Anabolic steroids oestrogens

6.4.3 Anabolic steroids oestrogens

Anabolic steroids have some androgenic activity but they cause less virilisation than androgens in women. They are used in the treatment of some aplastic anae- mias (section 9.1.3). Anabolic steroids have been given

Anti-oestrogens

for osteoporosis in women but they are no longer The anti-oestrogens clomifene (clomiphene) and tam- advocated for this purpose.

oxifen (section 8.3.4.1) are used in the treatment of The protein-building properties of anabolic steroids

female infertility due to oligomenorrhoea or secondary have not proved beneficial in the clinical setting. Their

amenorrhoea (e.g. associated with polycystic ovarian use as body builders or tonics is quite unjustified; some

disease). They induce gonadotrophin release by occu- pying oestrogen receptors in the hypothalamus, thereby

athletes abuse them. interfering with feedback mechanisms; chorionic

Endocrine

gonadotrophin is sometimes used as an adjunct. Patients should be warned that there is a risk of multiple

pregnancy (rarely more than twins). Indications osteoporosis in postmenopausal women

NANDROLONE

syst

CLOMIFENE CITRATE

(but not recommended, see notes above); aplastic

anaemia (section 9.1.3) (Clomiphene Citrate)

em

Cautions cardiac and renal impairment, hepatic Indications anovulatory infertility—see notes above impairment (Appendix 2), hypertension, diabetes

Cautions see notes above; polycystic ovary syndrome mellitus, epilepsy, migraine; monitor skeletal matura-

(cysts may enlarge during treatment), ovarian hyper- tion in young patients; skeletal metastases (risk of

stimulation syndrome, uterine fibroids, ectopic hypercalcaemia); interactions: Appendix 1 (anabolic

pregnancy, incidence of multiple births increased steroids)

(consider ultrasound monitoring), visual symptoms Contra-indications severe hepatic impairment,

(discontinue and initiate ophthalmological examina- prostate cancer, male breast cancer, pregnancy

tion); breast-feeding (Appendix 5) (Appendix 4) and breast-feeding, acute porphyria

CSM Advice. The CSM has recommended that clomifene (section 9.8.2)

should not normally be used for longer than 6 cycles (pos- Side-effects

sibly increased risk of ovarian cancer) acne, sodium retention with oedema,

virilisation with high doses including voice changes hepatic disease (Appendix 2), (sometimes irreversible), amenorrhoea, inhibition of

Contra-indications

ovarian cysts, hormone-dependent tumours or abnormal uterine bleeding of undetermined cause,

spermatogenesis, premature epiphyseal closure; pregnancy (exclude before treatment; Appendix 4) abnormal liver-function tests reported with high

doses; liver tumours reported occasionally on pro- Side-effects visual disturbances (withdraw), ovarian longed treatment with anabolic steroids

hyperstimulation (withdraw), hot flushes, abdominal Dose

discomfort, occasionally nausea, vomiting, depres- sion, insomnia, breast tenderness, headache, inter-

. See below menstrual spotting, menorrhagia, endometriosis, Deca-Durabolin c

convulsions, weight gain, rashes, dizziness, hair loss (Organon) AU

Injection Dose (oily), nandrolone decanoate 50 mg/mL, net price 1-mL amp = £3.29

50 mg daily for 5 days, starting within about 5 days of

Excipients include arachis (peanut) oil, benzyl alcohol (see Excipients,

onset of menstruation (preferably on 2nd day) or at

p. 2)

any time (normally preceded by a progestogen- Dose by deep intramuscular injection , 50 mg every 3 weeks

induced withdrawal bleed) if cycles have ceased;

6.5.1 Hypothalamic and anterior pituitary hormones and anti-oestrogens BNF 57 second course of 100 mg daily for 5 days may be given

used in the treatment of infertility in women with proven in absence of ovulation; most patients who are going

hypopituitarism or who have not responded to clomi- to respond will do so to first course; 3 courses should

fene, or in superovulation treatment for assisted con- constitute adequate therapeutic trial; long-term

ception (such as in vitro fertilisation). cyclical therapy not recommended—see CSM advice, above

The gonadotrophins are also occasionally used in the treatment of hypogonadotrophic hypogonadism and Clomifene (Non-proprietary) A associated oligospermia. There is no justification for

Tablets , clomifene citrate 50 mg, net price 30-tab their use in primary gonadal failure. pack = £11.35

Chorionic gonadotrophin has also been used in delayed Clomid c (Aventis Pharma) A puberty in the male to stimulate endogenous testo-

Tablets , yellow, scored, clomifene citrate 50 mg. Net sterone production, but has little advantage over testo- price 30-tab pack = £8.80

sterone (section 6.4.2).

CHORIONIC GONADOTROPHIN Anterior pituitary hormones

(Human Chorionic Gonadotrophin; HCG) A preparation of a glycoprotein fraction secreted by the pla-

Corticotrophins centa and obtained from the urine of pregnant women having

the action of the pituitary luteinising hormone Tetracosactide (tetracosactrin), an analogue of cortico-

Indications see notes above tropin (ACTH), is used to test adrenocortical function;

failure of the plasma cortisol concentration to rise after cardiac or renal impairment, asthma, epi- administration of tetracosactide indicates adrenocorti-

Cautions

lepsy, migraine; prepubertal boys (risk of premature cal insufficiency.

epiphyseal closure or precocious puberty) Contra-indications androgen-dependent tumours Both corticotropin and tetracosactide were formerly

Side-effects oedema (particularly in males—reduce tem used as alternatives to corticosteroids in conditions

dose), headache, tiredness, mood changes, gynaeco-

sys such as Crohn’s disease or rheumatoid arthritis; their

mastia, local reactions; may aggravate ovarian value was limited by the variable and unpredictable

hyperstimulation, multiple pregnancy therapeutic response and by the waning of their effect

ocrine with time. . By subcutaneous or intramuscular injection ,

Dose

End TETRACOSACTIDE according to patient’s response

Choragon c (Ferring) A Indications see notes above

6 (Tetracosactrin)

Injection , powder for reconstitution, chorionic Cautions

gonadotrophin. Net price 5000-unit amp (with sol- as for corticosteroids, section 6.3.2; impor-

vent) = £3.26. For intramuscular injection tant: risk of anaphylaxis (medical supervision; consult

product literature); interactions: Appendix 1 (corti- Pregnyl c (Organon) A costeroids)

Injection , powder for reconstitution, chorionic Contra-indications as for corticosteroids, section

gonadotrophin. Net price 1500-unit amp = £2.20; 6.3.2; avoid injections containing benzyl alcohol in

5000-unit amp = £3.27 (both with solvent). For sub- neonates (see under preparations)

cutaneous or intramuscular injection Side-effects as for corticosteroids, section 6.3.2 Dose

CHORIOGONADOTROPIN ALFA

. See under preparations below (Human chorionic gonadotropin) Synacthen c (Alliance) A Indications see notes above

Injection , tetracosactide 250 micrograms (as Cautions rule out infertility caused by hypothyroidism, acetate)/mL. Net price 1-mL amp = £2.93

adrenocortical deficiency, hyperprolactinaemia, Dose diagnostic (30-minute test), by intramuscular or intra-

tumours of the pituitary or hypothalamus venous injection , 250 micrograms as a single dose

Contra-indications ovarian enlargement or cyst Synacthen Depot c (Alliance) A (unless caused by polycystic ovarian disease); ectopic

Injection (aqueous suspension), tetracosactide pregnancy in previous 3 months; active thromboem- acetate 1 mg/mL, with zinc phosphate complex. Net

bolic disorders; hypothalamus, pituitary, ovarian, price 1-mL amp = £4.18

uterine or mammary malignancy

nausea, vomiting, abdominal pain; Dose diagnostic (5-hour test), by intramuscular injection , 1 mg

Excipients include benzyl alcohol (avoid in neonates, see Excipients

Side-effects

p. 2)

headache, tiredness; injection-site reactions; ovarian as a single dose

hyperstimulation syndrome; rarely diarrhoea, Note Formerly used therapeutically by intramuscular injection , in

depression, irritability, breast pain; ectopic pregnancy an initial dose of 1 mg daily (or every 12 hours in acute cases);

and ovarian torsion reported reduced to 1 mg every 2–3 days, then 1 mg weekly (or 500 micr- ograms every 2–3 days) but value was limited (see notes above)

Dose . By subcutaneous injection , according to patient’s

Gonadotrophins

response

Follicle-stimulating hormone (FSH) and luteinising Ovitrelle c (Serono) A hormone (LH) together (as in human menopausal

Injection , choriogonadotropin alfa, net price 6500- gonadotrophin), follicle-stimulating hormone alone

unit/0.5 mL (250-micrograms/0.5 mL) prefilled (as in follitropin), or chorionic gonadotrophin, are

syringe = £33.31