EEMT Disease Interactions

The use of androgenic anabolic steroids is contraindicated for male patients with carcinoma of the breast or prostate. Circulating androgens can be converted in peripheral tissues to estrogens and dihydrotestosterone, which may act as promoters of tumor growth in the breast and prostate, respectively. Likewise, androgenic agents may cause enlargement of the prostate and should be used cautiously in patients with or predisposed to prostatic hypertrophy.

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Androgenic anabolic steroids may cause sodium and water retention, particularly when given in high dosages or for prolonged periods. Therapy with these agents should be administered cautiously in patients who have preexisting problems with fluid overload or are at risk for developing edema. The manufacturers consider the use of androgenic agents to be contraindicated in patients with severe cardiac, renal and/or hepatic dysfunction.

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When treated with androgenic anabolic steroids, patients with metastatic breast cancer may develop hypercalcemia due to osteolysis. Frequent determination of urine and serum calcium levels is recommended during therapy with androgenic agents. If hypercalcemia occurs, therapy should be stopped. The development of hypercalcemia may indicate progression of metastases to the bone.

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Androgenic anabolic steroids may adversely affect serum lipids, including lowering HDL and elevating LDL levels. These changes can be marked, particularly with the 17-alpha-alkyl derivatives (i.e., fluoxymesterone, methyltestosterone, oxandrolone, oxymetholone, and stanozolol), and may significantly impact the risk of atherosclerosis and coronary artery disease. Patients with preexisting hyperlipoproteinemia may require closer monitoring during therapy with androgenic agents, and adjustments made accordingly in their lipid-lowering regimen. Androgen therapy should be administered cautiously in patients with coronary artery disease or a history of ischemic heart disease.

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The use of androgenic anabolic steroids may be associated with development of cholestatic hepatitis and jaundice. Other, more serious hepatotoxicities such as peliosis hepatis and hepatocellular neoplasms are rare but may occur with prolonged use or high dosages. These latter toxicities may be fatal and often not recognized until they become life-threatening. Patients with preexisting liver diseases should be monitored more closely during therapy with anabolic steroids if they are used. If liver function declines or toxicity occurs, therapy should be withdrawn and the cause investigated.

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Androgenic anabolic steroids may cause polycythemia when given in high dosages or for prolonged periods. Patients with preexisting polycythemia may experience worsening of their condition. Frequent monitoring of clinical status and hemoglobin and hematocrit levels is recommended if androgen therapy is administered to these patients.

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Androgenic anabolic steroids may cause suppression of clotting factors II, V, VII, and X, and an increase in prothrombin time. Androgen therapy should be administered cautiously in patients with bleeding disorders.

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The use of estrogens is contraindicated in patients with undiagnosed, abnormal vaginal bleeding. Prolonged (> 1 year), unopposed estrogen use (i.e. estrogen without concomitant progestin therapy) has been associated with a significant, dose-related risk of endometrial carcinoma. The risk may be offset substantially by the addition of a progestin but may not be completely abolished. Prior to initiating estrogen therapy, appropriate diagnostic tests should be performed in patients with abnormal vaginal bleeding to rule out endometrial malignancy. The same applies if recurrent or persistent bleeding develops during estrogen therapy.

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The use of estrogens is generally contraindicated in patients with known or suspected estrogen-dependent neoplasia such as breast and endometrial cancer, since it may stimulate tumor proliferation. High dosages of estrogens may be used for the palliative treatment of inoperable, metastatic breast cancer, but only in appropriately selected men and postmenopausal women.

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When treated with an estrogen, patients with breast cancer and bone metastases may develop severe hypercalcemia, in which case the drug should be stopped and measures be taken to reduce serum calcium levels.

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The risk of myocardial infarction and strokes, including those associated with oral contraceptive use and some estrogen use, is increased in patients with hypertension. Moreover, estrogens (and progestogens) may elevate blood pressure and worsen the hypertension, thus compounding the risk. Clinically significant blood pressure increases have been reported during estrogen therapy, particularly in patients receiving high dosages or treated with oral contraceptive combinations having high progestational activity. These effects also increase with duration of therapy and patient age. Therapy with estrogens should be administered cautiously in patients with preexisting hypertension. Patients should be monitored for changes in cardiovascular status, and their antihypertensive regimen adjusted or estrogen therapy withdrawn as necessary. In patients requiring contraception, alternative methods should be considered for those who are hypertensive, over age 35, and smoke.

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The use of estrogens is considered by manufacturers and some authorities to be contraindicated in patients with active thrombotic or thromboembolic disorders. The use of estrogen-containing oral contraceptives is additionally deemed contraindicated in patients with a history of such disorders and/or current cerebrovascular or coronary artery disease. Females with a history of migraines with aura are at an increased risk for stroke and this stroke risk may be further increased in females who have migraines with aura with use of combination oral contraceptives. Hypercoagulability and changes in various clotting factors and blood components have been observed in women receiving estrogen therapy. Although the clinical significance of these effects is unknown, epidemiological data suggest it may be dose-dependent. The risk is probably slight with the use of newer, low-dose oral contraceptives in the absence of known risk factors (e.g., smoker, particularly over the age of 35; hypertension; hyperlipidemia; obesity; diabetes; age over 40). However, a much more significant risk has been reported with higher dosages, such as those used to treat prostate or metastatic breast cancer or those used in older formulations of birth control pills. Therapy with estrogens should be administered cautiously in the lowest effective dosage and only after careful consideration of risks and benefits. Estrogens should be avoided in patients with a history of thrombotic and thromboembolic disorders associated with estrogen use, except when used in the treatment of breast or prostatic malignancy.

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The use of oral contraceptives is contraindicated in patients with liver tumors. An increased risk of benign hepatic adenomas and hepatocellular carcinomas has been associated with long-term, oral estrogen- progestin contraceptive use of at least 4 years and 8 years, respectively. Although these tumors are rare and have not been reported with other types of estrogen or progestogen therapies, any preparation containing estrogens and/or progestogens should probably be avoided in patients with existing tumors of the liver. Hepatic hemangiomas and nodular hyperplasia of the liver have been reported with isolated estrogen therapy.

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The metabolic effects of androgenic anabolic steroids may lower blood glucose. Decreased glucose tolerance and increased insulin resistance have also been reported. Patients with diabetes mellitus should be monitored more closely during therapy with androgenic agents, and their antidiabetic regimen adjusted accordingly.

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Androgenic anabolic steroids decrease urinary excretion of calcium, which may result in hypercalcemia. Therapy with androgenic agents should be administered cautiously in patients with hypercalcemia, disorders of bone metabolism such as hyperparathyroidism, or renal dysfunction. Some manufacturers consider the use of androgenic anabolic steroids to be contraindicated in patients with hypercalcemia.

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The use of exogenous estrogens may induce or exacerbate symptoms of angioedema, particularly in women with hereditary angioedema. Close monitoring is recommended when prescribing these agents to patients predisposed to angioedema.

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A two- to four-fold increase in risk of gallbladder disease has been noted in women receiving postmenopausal estrogen therapy. The risk for gallbladder disease may be less for premenopausal women using oral contraceptives containing low-dose estrogens and/or progestins. Therapy with estrogens should be administered cautiously in patients with preexisting gallbladder disease.

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Estrogens influence the metabolism of calcium and phosphorus. Intestinal absorption and retention of calcium are increased, which may occasionally result in hypercalcemia. Therapy with estrogens should be administered cautiously in patients with preexisting hypercalcemia, renal dysfunction, or metabolic bone diseases that are associated with hypercalcemia.

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Although estrogens have generally favorable effects on plasma lipids, including increases in HDL and decreases in total cholesterol and LDL, they have also been associated with significant elevations in triglyceride levels, particularly when high dosages are used. Severe hyperlipidemia is known to sometimes cause pancreatitis. Patients with preexisting hyperlipidemia may require closer monitoring during estrogen therapy, and adjustments made accordingly in their lipid-lowering regimen.

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Estrogens are primarily metabolized by the liver. Patients with impaired hepatic function may be at increased risk for adverse effects associated with estrogen administration due to decreased drug clearance. Therapy with estrogens should be administered cautiously in patients with liver disease. In addition, clinicians should be aware that estrogen therapy may affect liver function tests. Increased sulfobromophthalein retention has been reported with the use of estrogen-containing oral contraceptives and may be expected with larger doses of estrogens.

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The use of exogenous estrogens may occasionally cause chloasma, especially in women with a history of chloasma gravidarum. Women with a tendency to chloasma should avoid exposure to the sun or ultraviolet radiation while taking combination oral contraceptives.

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The use of oral contraceptives has been associated with an increased incidence of depression. It is uncertain whether this effect is related to the estrogenic or the progestogenic component of the contraceptive, although excess progesterone activity is associated with depression. Patients with a history of depression receiving estrogen and/or progestogen therapy should be followed closely. The manufacturer of medroxyprogesterone recommends monitoring patients who have a history of depression and to not re- administer medroxyprogesterone if depression recurs.

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Estrogens and progestogens may cause fluid retention, particularly when given in high dosages or for prolonged periods. Therapy with these agents should be administered cautiously in patients who have preexisting problems with excess fluid. In addition, patients with conditions that may be adversely affected by fluid accumulation, such as asthma, epilepsy, migraine, and cardiovascular or renal dysfunction, should be observed for exacerbation of their condition during estrogen and/or progestogen therapy.

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Impaired glucose tolerance has been observed in some patients administered oral contraceptives and appears to be related primarily to the estrogen dose. However, progestogens can increase insulin secretion and produce insulin resistance to varying degrees, depending on the agent. Patients with diabetes mellitus should be monitored more closely during therapy with estrogens and/or progestogens, and adjustments made accordingly in their antidiabetic regimen.

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Estrogens and progestogens may cause retinal thrombosis. Oral contraceptives should be discontinued if there is unexplained partial or complete loss of vision; onset of proptosis or diplopia; papilledema; or retinal vascular lesions. Therapy with these agents should be administered cautiously in patients who have preexisting ocular problems and appropriate diagnostic and therapeutic measures should be instituted. Contact lens wearers who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist.

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When administering estrogen and/or progestogen therapy in patients with thyroid disorders, clinicians should be aware that these hormones may affect thyroid function tests. Changes have mostly been reported with the use of combination oral contraceptives. Specifically, thyroid-binding globulin (TBG) may be increased, resulting in elevated circulating total thyroid hormone, as measured by PBI (protein-bound iodine), T4 by column or radioimmunoassay, or T3 by radioimmunoassay. Free T3 resin uptake may be decreased. On the contrary, a decrease in TBG and, consequently, thyroxine concentration, has been reported by the manufacturers of the progestin-only (norethindrone) oral contraceptives.

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When androgenic anabolic steroids are used in patients with thyroid disorders, clinicians should be aware that these agents may affect thyroid function tests. Specifically, thyroid-binding globulin levels may be decreased, resulting in lower total T4 serum levels and increased resin uptake of T3 and T4. Free thyroid hormone levels remain unchanged, however.

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