5PY022 Endocrine Study Pack

The Endocrine System

Student Study Guide

Facilitators Required References

Required:

Names: This study pack

Dr Sarah Jones Directed online material

(S.Jones4@[Link])
Medical Pharmacology and Therapeutics, Derek G.
Dr Mark Hewitt Waller and Anthony P. Sampson, 5th Edition, Elsevier
([Link]@[Link])
Available online
Dr Ayman Antoun [Link] 8
([Link]@[Link])
Optional:
Sarah Hughes
([Link]@[Link]) Key reference texts from the 5PY022 module guide to
cement your understanding include:

Pathology and Therapeutics for Pharmacists by Greene and

Harris; Rang and Dale’s Pharmacology; Aulton’s
Pharmaceutics: The Design and Manufacture of Medicines;
and the British National Formulary.

Learning Outcomes

This study pack covers the homeostatic, metabolic and therapeutic aspects of the
endocrine system.

1. Demonstrate an appreciation of the endocrine system.

2. Understand the importance of the physiological control of this system to
normal function, to pathological problems and to therapeutic solutions
3. Understand the key disease states that afflict this system, and which can be
treated by manipulating this system
4. Understand the formulation considerations relating to the effective delivery of
drugs to the endocrine system, and how products derived from the endocrine
system can be formulated to effectively treat myriad disease states

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Note: This study pack contains a high number of standard medical abbreviations, such
as ‘ACTH’, ‘PTH’ and so on. Ensure that you understand each abbreviation while
studying this pack.

Table of Contents

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The Endocrine System...........................................................................................................3

Control of endocrine hormone secretion....................................................................5
Hormones of the Anterior Pituitary.........................................................................6
Hormones of the Posterior Pituitary.......................................................................7
The Thyroid Gland........................................................................................... 7
Thyroid disorders......................................................................................... 9
The Adrenal Glands and the Hypothalamic Pituitary Adrenal (HPA) Axis...............11
Biosynthesis of adrenal corticosteroids..........................................................12
The Endocrine Pancreas and Diabetes Mellitus........................................................13
Factors regulating insulin secretion at a bodily level...............................................14
Stimulation of insulin secretion at a molecular level................................................15
Insulin and its targets........................................................................................ 16
The molecular mechanism of action of insulin.......................................................16
Type 1 Diabetes Mellitus (T1DM)........................................................................19
Insulin Therapy............................................................................................. 19
Pharmacokinetics.......................................................................................... 19
Preparations and Formulations........................................................................19
Rapid Acting.............................................................................................. 20
Short Acting............................................................................................... 20
Intermediate Acting..................................................................................... 21
Long Acting............................................................................................... 21
Biphasic Insulin.......................................................................................... 21
FORMULATION............................................................................................ 21
The Structure of Insulin and Peptide Analogues.................................................23
Type 2 Diabetes Mellitus (T2DM)........................................................................24
Further Definitions...................................................................................... 25
Type 2 Diabetes Mellitus - Management...........................................................25
Oral Hypoglycaemic Drugs..........................................................................26
The Female Reproductive System..........................................................................33
The Endocrine Control of the Menstrual Cycle......................................................33
Steroidal Contraceptives.................................................................................... 35
Oral Contraceptives.......................................................................................... 36
The Menopause and the Perimenopause.............................................................41
Hormone Replacement Therapy (HRT).............................................................42
Novel non-hormonal treatments for hot
flushes……………………………………………………….45
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The Endocrine System

Endocrinology is the branch of internal medicine which studies the endocrine system,
which is composed of a network of glands that work in concert to exert homeostatic control
over diverse body systems. Glands are physical structures within the body that secrete
hormones. There are two types:

 Exocrine glands: These secrete hormones onto epithelial surfaces via a duct
 Endocrine glands: These secrete hormones directly into the circulatory system

This study pack considers the endocrine system, which is an information signal system
similar to the nervous system, but it exerts its effects and mechanisms quite differently. For
example, the endocrine system's effects are slow to initiate, and prolonged in their response,
lasting from a few hours up to weeks. In contrast, the nervous system sends information very
quickly, and responses are generally immediate but short lived. Endocrine glands are
differentiated from other types of glands because they do not have ducts into which they
release hormones; they have high vascularity, and intracellular vacuoles or granules in
which hormones are stored prior to release. In contrast, exocrine glands, such as salivary
glands, sweat glands, and glands within the gastrointestinal tract, tend to be less vascular
and have ducts or a hollow lumen for the release of hormones.

The major endocrine glands are distributed throughout the vertebrate body – the names of
the main glands are shown in table 1, along with a few examples (there are many more!) of
the hormones they produce in humans.

Gland Hormone Gland Hormone

Pineal Melatonin Anterior pituitary Multiple - See below
Pancreas Insulin, Glucagon Posterior pituitary Multiple – See below
Thyroid Thyroxine Parathyroid Parathyroid hormone
Hypothalamus Multiple – See below GI tract Cholecystokinin
Adrenal Cortex Corticoids, androgens Ovaries / Testes Sex hormones
Adrenal medulla Nor- and Adrenaline Stomach Gastrin
Table 1: Examples of endocrine glands and examples of the hormones they produce

Once endocrine hormones pass into the blood stream, they then act at distal sights –
meaning that they act remotely, away from the gland from which they are released.
Endocrine hormones control many bodily functions such as the regulation of metabolism,

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stress responses, growth and development, reproduction, regulation of circulatory volume

and the control of blood glucose.

The physical locations of these glands are throughout the human body, as illustrated in
figure 1, and the hormones produced from these glands are classified either by their
intended target, or by their biochemical properties, as shown in table 2.

Figure 1: Endocrine glands

Table 2: Hormone classifications

[Link]

In addition to these glands, many other organs of the body, such as bone, kidney, liver, heart
and gonads, have secondary functions and can also release endocrine hormones - the
kidney, for example, secretes erythropoietin and renin.

Endocrine hormones exert an enormous range of effects within the body, and in addition to
their physiological effects their potency makes them a very important sources of both natural
products and of the medicines derived from them. They are among the most widely used
medicines that pharmacists dispense on a daily basis, and they are of immense value. The
downside of their potency, however, is that they can be highly damaging if used incorrectly
or excessively – several studies have shown that corticosteroid hormones, in particular, are
the leading cause of adverse effects (side effects) of all drug classes. It is therefore essential
that practicing pharmacists, as well as their healthcare professional colleagues, learn how to
use hormonal treatments safely and effectively, whilst minimising patient harm. While
prescribers are the ones who decide which hormones to use clinically, pharmacists are
heavily involved in patient counselling and advice to ensure that the products so prescribed
– whether delivered to the skin, by inhalation, by injection or by mouth or any other route -
are taken or used appropriately to maximise benefit and minimise the very real risks
associated with these treatments.

This subject matter is very diverse and covers practically all of the homeostatic functions
necessary for a normal, healthy existence. Studying all aspects of this in one study pack is

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simply not feasible, so some areas are necessarily only covered in brief detail. The aim now
is to review how the endocrine system is controlled, what the impacts are of altering that
control, and what pathological processes can either disrupt such control, or what processes
can be disrupted by medical interventions, for some of the most critical parts of the
endocrine system.

Signposting
Most of the material presented below describing the physiology and pathophysiology of
endocrine systems and their related disorders was covered during Pharmacy Stage 1
(4PY019) and is presented to refresh your understanding. Besides, to understand the
mechanisms of action of all drugs, we first need to have an in depth understanding of the
physiology and pathophysiology upon which these drugs impact.

Control of endocrine hormone secretion

There is a standard mechanism by which endocrine hormones are regulated and secreted,
which occurs in five main stages. This mechanism is ‘circular’, in that it regulates itself, so
any starting point is arbitrary. For the purposes of stage 1, the hypothalamus will be the
starting point in relation to the production of thyroid hormones.

Stage 1: The blood flowing through the hypothalamus is detected as being too low in the
level of thyroid hormones.

Stage 2: The hypothalamus detects this low level, and then synthesises the releasing factor
thyrotropin releasing hormone (TRH), which then passes to (in this case) the anterior
pituitary.

Stage 3: The pituitary is stimulated by the TRH to release thyroid stimulating hormone
(TSH), which is released directly into the blood stream, and is detected by the thyroid which
then increases the production of the two main thyroid hormones, T3 and T4 (explained
further below).

Stage 4: Levels of the thyroid hormones now increase in the blood

Stage 5: The increasing levels of thyroid hormones are now detected by the hypothalamus –
so, as a result of ‘negative feedback’, reduces the amount of releasing factors it produces –
and then the whole cycle is repeated in reverse and thyroid hormone production is reduced.

This is a fundamentally important point to understand. The hypothalamus monitors

hormone levels in the blood, and if the level is too low, it secretes releasing factors as a
result of what is known as ‘positive feedback’ – more hormone is produced because more
is needed. Conversely, once the level of the hormone starts to get too high, ‘negative
feedback’ occurs and the secretion of releasing factors is reduced and the production of the
hormone falls. This mechanism is common to the endocrine system and is how hormone
production is regulated and controlled to ensure homeostasis within the body.

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Signposting
Watch the following video which should refresh your understanding of the hypothalamus
and pituitary gland, material which you have covered in Pharmacy Stage 1 (4PY019)
Hypothalamic Pituitary Axis | Endocrine System ([Link])

Hormones of the Anterior Pituitary

Secretion of hormones from the anterior pituitary, alternatively designated the
adenohypophysis, is largely regulated by the release from the hypothalamus of “releasing
factors”. These factors reach the pituitary via the blood stream, specifically the hypophyseal
portal system. The secretion of the releasing factors from the hypothalamus is the
mechanism which causes the pituitary gland to release its own hormones, which in turn
control the release of hormones from the rest of the endocrine system. The names of these
releasing factors which originate from the anterior pituitary gland are shown in table 3, along
with the subsequent pituitary hormone produced and the target gland and subsequent
action(s).

Table 3. Hormones released by the anterior pituitary gland, associated releasing factors,
targets and effects.

Hormones of the Posterior Pituitary

The posterior pituitary, alternatively designated the neurohypophysis, consists largely of

nerve terminals of nerve cells which originate in the supraoptic and paraventricular nuclei of
the hypothalamus. The axons of these neurons form the hypothalamic-hypophyseal tract
and terminate in close proximity to the capillaries of the posterior pituitary. Peptides, such as
vasopressin and oxytocin, are synthesized in the hypothalamic nuclei, pass down these
axons into the posterior pituitary, where they are stored and eventually secreted.

The Thyroid Gland

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Thyroid hormones are synthesised within the thyroid gland, and the two most physiologically
important hormones produced are tri-iodothyronine (with three iodine molecules attached,
hence often abbreviated as ‘T3’) and thyroxine (with 4 iodine molecules, so abbreviated T4,
and also known as tetra-iodothyronine). The synthesis and secretion of both T3 and T4 are
regulated by thyroid-stimulating hormone (TSH), alternatively referred to as thyrotropin.
Figure 2 recapitulates material from your first year regarding thyroid hormone biosynthesis
and Figure 3 illustrates how T3 and T4 exert their physiological effects.

Figure 2. Thyroid hormones, triiodothyronine (T3) and thyroxine (T4) are synthesized by
iodination of tyrosine (T) residues on thyroglobulin within the lumen of the thyroid follicle

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Figure 3: The mechanism of action of T3 and T4

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Signposting
The following video discusses thyroid function, thyroid diseases, symptoms and
treatment.

[Link]

Thyroid disorders

Hyperthyroidism (thyrotoxicosis): An overactive thyroid can lead to a syndrome of a high

metabolic rate, increased skin temperature, sweating, sensitivity to heat, tremor, tachycardia
and weight loss, despite an increase in appetite. There are a number of treatment options:

Radio-iodine: Radioactive iodine can be injected to be taken up selectively by the thyroid,

where the radioactive decay then causes cell damage. This can eventually lead to the
opposite condition, hypothyroidism, hence this option tends to be used only once drugs have
become ineffective.

Carbimazole is a thioureylene which decreases the synthesis of thyroid hormones by

inhibiting the enzyme thyroperoxidase. As such, this reduces the iodination of thyroglobulin
in addition to preventing the conversion of iodide into iodine (Figure 4). Furthermore, as
highlighted above, thyroperoxidase assists in coupling events in the follicle lumen.

Figure 4: The mechanism of action of carbimazole.

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Propylthiouracil is a thyroperoxidase inhibitor used when carbimazole is ineffective.

Iodine given in high doses decreases the vascularity of the thyroid gland and reduces
hormone secretion, but this effect tends to be transient. For this reason, it is not used long-
term but is given for 10-14 days prior to thyroidectomy to reduce the hormone release
caused by the physical handling of the gland by a surgeon.

Beta-Blockers, such as propranolol or atenolol, are used to treat the symptoms of Grave’s
disease, but do not affect the thyroid gland directly.

Grave’s Disease is caused by diffuse, toxic goitre. It is an auto-

immune disease, where thyroid stimulating immunoglobulins are
directed at the TSH receptor (increasing thyroxine secretions).
This condition leads to a characteristic sign of protruding
eyeballs, as shown in figure 5. Toxic nodular goitre is caused
by a benign neoplasm or adenoma developing in the thyroid
gland.

Hypothyroidism (also known as myxoedema) is an auto-immune or drug-induced condition

which leads to a low metabolic rate, slow speech, lethargy, bradycardia, sensitivity to cold,
mental impairment and characteristic thickening of the skin. Hashimoto’s thyroiditis is a
chronic autoimmune disease directed against thyroglobulin and thyroid tissue. Cases of
thyroid hormone deficiency at birth (occurrence rate of 1 in 3,000 to 4,000 births), leads to
growth retardation and mental deficiency. Thyroxine (T4) or levothyroxine given orally mimic
the effects of endogenous hormones and are the treatment of choice as maintenance
therapy. Liothyronine (T3) can be given by injection in emergencies, as it has a quicker
onset, but a reduced duration of action compared with T4.

The impact of iodine deficiency on public health, especially in regions such a Khazakstan,
has led to the introduction of iodised salt in order to ensure sufficient dietary iodine intake to
maintain normal thyroid hormone levels.

The Adrenal Glands and the Hypothalamic Pituitary Adrenal (HPA) Axis

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The two adrenal glands are located above the kidneys in capsules of fat and consist of two
separate endocrine organs – the adrenal cortex is the outer layer, which wraps around the
adrenal medulla. The adrenal cortex hormones known collectively as
adrenocorticosteroids, and these have two distinct classes of action:

 Glucocorticoid activity – these hormones influence carbohydrate and protein

metabolism and have potent anti-inflammatory effects. These are derived from the
zona fasciculata of the adrenal cortex.
 Mineralocorticoid activity – these hormones affect water and electrolyte balance
and are derived from the zona glomerulosa of the adrenal cortex.

In addition, the zona reticularis produces pre-cursor to the androgens. Figure 6 illustrates
the anatomical layout of the adrenal glands

Figure 6: The anatomical structure and function of the adrenal glands.

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Biosynthesis of adrenal corticosteroids

The hypothalamus releases corticotrophin releasing factor (CRF) and this stimulates the
anterior pituitary to release adrenocorticotrophic hormone (ACTH), which then stimulates
glucocorticoid production in the adrenal cortex (endogenous). This cyclical control of steroid
production is known as the hypothalamo-pituitary-adrenal axis (HPA), with negative and
positive feedback (higher or lower levels of natural steroids) detected in the blood by the
hypothalamus (Figure 7). If a natural or synthetic steroid (exogenous) is given to a patient,
this exerts a negative feedback effect on the hypothalamus, which will in turn reduces
production of ACTH, which means that the body will reduce natural production of hormones
such as hydrocortisone (cortisol). This is the reason why corticosteroid treatment must not
be stopped abruptly but should be tailored over time to enable the hypothalamus to stimulate
normal (endogenous) steroid production once again.

Figure 7: Regulation of synthesis and secretion of glucocorticoids. The HPA Axis.

Mineralocorticoids are not controlled in the same way, as they are subject to the renin-
angiotensin system

Signposting
You have briefly covered the HPA axis in your Respiratory pack (5PY022) when
examining the unwanted effects of glucocorticoid treatment. With this new
information, re-visit your respiratory pack and consider once again how
sudden withdrawal from long-term treatment with medications such as
prednisolone can cause acute adrenal crisis. You have also covered this during
the endocrine lectures of 4PY019

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The Endocrine Pancreas and Diabetes Mellitus

Unlike other endocrine glands covered in this workbook, the endocrine pancreas, which
secretes the hormone insulin, is not regulated by pituitary hormones. Blood glucose is the
most important factor in the stimulation of insulin secretion. Therefore firstly, we shall
examine how the body controls blood glucose levels.

Signposting
The following video provides an excellent account of the control of blood glucose. It also
introduces you to the aetiology and pathophysiology of Type 1 and Type 2 diabetes, all of
which we shall cover in more detail during the following sections. Do beware however!
The pathophysiology of Type 2 diabetes is complex and associated with both insulin
resistance and impaired insulin secretion which you will cover in detail later.

[Link]

There are some central tenets regarding the control of blood glucose which you should
always bear in mind.

 Glucose is the obligatory source of energy for the adult brain

 The physiological control of blood glucose reflects the need to maintain adequate
‘fuel supplies’ in the face of intermittent food intake and variable metabolic demands.
 Energy (glucose) that is required immediately is made available by feeding and
excess calories are stored as glycogen or fat.
 During fasting, these energy stores are mobilised in a regulated manner.
 The most important regulatory hormone is insulin - increased blood glucose
stimulates insulin secretion, while reduced blood glucose reduces insulin secretion

The control of insulin secretion shall be covered both at (i) the bodily and physiological
level and (ii) the cellular and molecular level. In doing so, we shall identify pharmacological
targets for the treatment of Diabetes Mellitus.

Once insulin is secreted and enters the blood stream it will act on key targets “insulin
responsive tissues” to mediate its effects. Insulin’s targets and its molecular mechanism of
action shall also be covered.

The Endocrine Pancreas

The pancreas contains both endocrine and exocrine tissue, the latter of which constitutes
99% of the weight of the pancreas and is arranged into numerous small masses known as
acini. The principal function of the exocrine pancreas is the production of digestive enzymes,
released when required into a series of progressively larger ducts.

The endocrine pancreas refers to those cells within the pancreas which synthesise and
secrete hormones and is composed of approximately a million cell clusters designated as

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the Islets of Langerhans. Islets are composed of 4 main cell types, each of which produces
a different endocrine product.

 cells secrete glucagon - increases blood glucose during fasting by breaking down
glycogen into glucose.
  cells secrete insulin - decreases blood glucose after a meal by facilitating glucose
uptake into tissues and promotes the synthesis of glycogen from glucose.
  cells - secrete somatostatin which inhibits the secretion of glucagon and insulin
from and cells, respectively.
 PP cells (cells) - secrete pancreatic polypeptide, the function of which is unknown.
 cells – also secrete amylin (amyloid polypeptide- which delays gastric emptying and
opposes insulin by stimulating glycogen breakdown in striated muscle.

Factors regulating insulin secretion at a bodily level

Blood glucose is the most important factor stimulating insulin production. However, amino-
and fatty- acids, gastrointestinal (GIT) hormones and incretins such as glucagon-like peptide
1 (GLP-1) and gastric inhibitory peptide (GIP - also known as glucose-dependent
insulinotropic polypeptide) also enhance insulin secretion. Incretins also inhibit pancreatic
glucagon secretion from cells and slow the rate of absorption of digested foods by
decreasing gastric emptying. Parasympathetic nerves can also act on muscarinic receptors
to stimulate insulin secretion, and sympathetic nerve fibres acting on 2 adrenoceptors can
inhibit insulin secretion (Figure 8).

Figure 8: Factors regulating insulin secretion at a bodily level

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Stimulation of insulin secretion at a molecular level

A number of molecular events lead to the secretion (exocytosis) of insulin from pancreatic 
cells (Figure 9), which are central to the mechanisms of action of some of the drugs used in
Type 2 diabetes.

The sequence is as follows:

 After an increase in blood glucose, glucose enters the pancreatic β cell via the
glucose transporter, GLUT2.
 Glucose is phosphorylated by glucokinase to glucose 6-phosphate (G6P), which is
subsequently metabolized via glycolysis and the TCA cycle, increasing intracellular
levels of ATP and decreasing ADP.
 The consequential increase in the ATP/ADP ratio results in inhibition of the ATP-
sensitive K+ channel (alternatively designated the inwardly rectifying K+ channel
KIR6.2). K+ accumulates within the cell and the cell becomes slightly more positive.
This leads to a partial membrane depolarization and triggers the activation of voltage-
gated Ca2+ channels.
 Ca2+ now moves into the pancreatic  cell. The rise in intracellular Ca2+ stimulates
exocytosis of secretory granules containing insulin.

A pancreatic  cell

Figure 9: Stimulation of insulin secretion at a molecular level.

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The sulphonylurea group of antidiabetic medications bind to sites on the ATP-sensitive

K+ channel (SUR1-sulphonylurea receptor) to inhibit channel conductance, resulting in
membrane depolarization, and Ca2+ entry, thereby promoting insulin release.

Insulin and its targets

When circulating levels of glucose increase, insulin is secreted by the pancreas in the
manner described and it then promotes the uptake and storage of glucose (as well as amino
and fatty acids) into insulin-responsive tissue including skeletal muscle and adipose tissue.
Insulin also inhibits hepatic glucose output and promotes hepatic glycogen formation (insulin
converts glucose to glycogen), see Figure 10a. The overall consequence of insulin secretion
is the rapid movement of nutrients from the blood into tissues to be used to meet the energy
and metabolic demands of the body. If insulin levels or responsiveness of tissues to insulin
action are inadequate, hyperglycaemia ensues.

The molecular mechanism of action of insulin

Within insulin responsive tissue, insulin binds to receptors on insulin responsive target cells.
Figure 10b provides an account of activation of the insulin receptor. Cellular events
triggered by activated insulin receptors have both short- and long-term actions - short term
are the immediate metabolic effects and include recruiting glucose transporters, such as
GLUT-4, to the plasma membrane so that glucose can now move into the cell. GLUT-4 is an
insulin-sensitive glucose transporter present in muscle and fat cells. There is also activation
of the enzyme glycogen synthase to promote glycogen synthesis, and both gluconeogenesis
(the ability of the liver to make glucose de novo) and glycogen breakdown are inhibited.
These immediate metabolic effects are generally governed by kinase and phospholipase
enzymes. Figure 11 provides a more detailed account of the how activation of the insulin
receptor produces these immediate metabolic events. It must also be remembered that
occupied receptors aggregate into clusters which are subsequently internalised into vesicles,
resulting in downregulation of the receptor at the membrane. Ultimately, these receptors are
recycled back to the plasma membrane. Long-term actions of insulin receptor activation
promote gene expression and the synthesis of key enzymes involved in the regulation of
blood glucose, and cell growth and division.

Figure 10a. Insulin Responsive Tissue. Figure from Raffa, R.B et al., Netter’s Illustrated Pharmacology

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Figure 10b: The Insulin Receptor expressed on insulin-responsive target cells.

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Figure 11: The metabolic activity of insulin.

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Type 1 Diabetes Mellitus (T1DM)

In summary, type I diabetes mellitus is caused primarily by a T-cell mediated autoimmune

response leading to the destruction of the pancreatic β cells that produce insulin. The
stimulus for this autoimmune response is still unknown. Pancreatic β cell destruction can
occur over a number of years, but after significant destruction (∼90%) the onset of the
symptoms of polyuria, polydipsia, and polyphagia can be abrupt. Increased urine volume is
caused by osmotic diuresis resulting from increased concentrations of urinary glucose and
ultimately ketone bodies. Thirst and hunger are compensatory responses. Ketone bodies are
the product of fat metabolism. As the body is unable to uptake, use and store glucose, it
perceives itself as in a state of starvation and resorts to breaking down fat which can fuel
skeletal muscle. Unfortunately, ketone bodies are toxic to the brain, an organ which
exclusively uses glucose for its source of energy.

The development of diabetes mellitus is characterized by weight loss in the untreated patient
and the premature cessation of growth in children. At the onset of symptoms, insulin levels
are lower than normal and eventually become negligible, requiring replacement to prevent
metabolic acidosis (ketosis), which can lead to diabetic coma and premature death if
untreated. The goal of insulin replacement is the carefully controlled maintenance of blood
glucose to prevent or delay the onset of long-term diabetic complications.

Signposting
You may wish to revisit the initial video to refresh your understanding of the pathophysiology, signs
and symptoms of Diabetes Mellitus

Insulin Therapy

Insulin therapy is an essential treatment for Type 1 diabetes and eventually a valuable
component for the treatment of many patients with Type 2.

Pharmacokinetics

The administration of exogenous insulin must be parenteral, since insulin is a peptide and
consequently is quickly destroyed in the GI tract. Insulin is therefore routinely administered
subcutaneously. Hyperglycaemic emergencies, such as diabetic ketoacidosis, may warrant
IV administration. Once absorbed, insulin has a very short half-life (T 0.5 = approximately 10
minutes), as it is inactivated enzymatically in the liver and kidney and 10% is excreted in the
urine. Renal impairment reduces insulin dosage requirements.

Preparations and Formulations

The very short half-life of insulin has prompted the search for longer acting formulations.
However, it is also of paramount importance to avoid the wide fluctuations in plasma insulin

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concentration which can be associated with subcutaneous injections, which can potentially
lead to low blood glucose levels.
Ultimately, the aim of insulin therapy is to the mimic endogenous patterns of insulin
secretion. Basal levels of insulin are secreted throughout the night and between meals, and
insulin secretion is stimulated in response to a meal, returning to basal levels after 2-4 hours
(Figure 12)

Figure 12: Endogenous patterns of insulin secretion

Figure 12: Endogenous patterns of insulin secretion.

The formulations and analogues of insulin used therapeutically vary in the timing of their
peak effect and duration of action and can be classified as rapid-acting, short-acting,
intermediate-acting and long-acting.

Rapid Acting
o Insulin Aspart (NovoRapid®) and Insulin Lispro (Humalog®)
o Onset of action is 15 min
o Duration of action 2-5 hours
o Mimics the effects of insulin which is produced to cope with a meal
o Administered immediately before or just after a meal

Short Acting
o Soluble insulin (Actrapid®)
o Onset of action is 30-60 min
o Duration of action up to 8 hours
o Injected approximately 15-30 minutes before a meal

Soluble insulin produces a rapid and short-lived effect. Longer acting preparations are
made by precipitating insulin with protamine or zinc.

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Intermediate Acting
o Isophane Insulins (eg. Insulatard®, Humalin I®)
o A suspension of insulin with protamine
o Onset of action is 1-2 hours, max effects 4-12 hours
o Duration of action 16-35 hours
o Injected OD or BD

Long Acting

Insulin zinc suspensions

These formulations are finely divided amorphous solids or relatively insoluble crystals which
are injected as a suspension from which insulin is slowly absorbed.
Protamine zinc + insulin (rarely used, drawback of binding with soluble insulin when mixed in
the same syringe)

Insulin Glargine (Lanctus®), injected OD

Insulin Detemir (Levemir®), injected BD
Reach a steady-state level after 2-4 days

Biphasic Insulin
o Mixture of rapid or short acting with intermediate-acting insulin
o NovoMix®30 (30% insulin aspart, 70% insulin aspart protamine)

Question

What is/are the advantage(s) of prescribing a patient a biphasic insulin?

FORMULATION

The drugs covered in this study pack have will include a number of tablet formulations
(pioglitazone and ulipristal) as well as oral solutions and powders (metformin). Refer back to
your previous study packs to refresh your memory on these dosage forms.

Note: modified release formulations will be revisited in much more detail next year.

The remaining drugs, including the insulins above, are in the form of injectable solutions (or
suspensions). You have covered solutions and suspensions previously in the GI study pack,

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but since they are to be injected a number of additional factors must be considered. These
include:

 Sterility – Since these formulations are administered

parenterally, they must be sterile and free from
contamination.
 Stability – As with other solutions, stability of your
API in water (or other solvents) is of key concern. If
stability is a problem, it is often possible to overcome
by using alternative solvents (other than water) or to
formulate the product as a powder for reconstitution
prior to administration.
 Isotonicity – Refer to your L4 physicochemical
properties study pack. Isotonicity with the site of injection is crucial. A related factor to
this is API/excipient concentration.
 pH – The pH of the solution/suspension is a very important factor since this may elicit
pH changes at the site of administration and lead to irritation.
 Local effects – Of course, following the administration of a solution/suspension,
before it can distribute around the systemic circulation, it has the possibility of
initiating local effects at the site of injection. For example, some compounds are
vasoconstrictive, meaning they restrict blood supply and slow drug
diffusion/distribution.


Signposting

You will learn much more about the importance of sterility and asepsis in the next study
pack (imaginatively entitled “sterility and asepsis”).

Don’t forget to relate what you learn in your solutions/aseptics practical class back to these
considerations and how they would ultimate affect the patient.

It is also important to realise that devices play a large part in

the delivery of insulins (and other drugs). Insulin pens are
now widely used and deliver metered doses in a safe and
convenient format.

Signposting

Medical devices (including insulin pens, intrauterine devices, etc.) will be covered next
year when we revisit these body systems in more detail.

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5PY022 Endocrine Study Pack

The Structure of Insulin and Peptide Analogues

Insulin for clinical use was once either porcine or bovine, but there was always a danger that
administration would induce an immune response. Modern insulin preparations are now
almost entirely made by recombinant DNA technology. Insulin is a peptide and modification
of its amino acids has generated both short- and long-acting analogues (Figure 13)

 Insulin lispro (Humalog®) – an insulin analogue in which a Lys (K) and Pro (P) are
switched. It acts more rapidly but for a shorter time than natural insulin thus enabling
patients to inject themselves immediately before a meal.
 Insulin glargine (Lantus®) – A long-acting analogue in which 2 Arginines (R) extend
the B chain. Additionally, Asparagine Asn 21 (N) is substituted with a Glycine (G) on
the A chain. It is designed to provide a constant basal supply of insulin and mimic
physiological post-absorptive basal insulin secretion. It forms a micro precipitate at
the physiological pH of subcutaneous tissue, and absorption from the subcutaneous
injection site is therefore prolonged.
 Insulin aspart (Novorapid®) - Insulin aspart is a rapid-acting insulin analogue. The
substitution of Pro 28 to Asp reduces its propensity to form hexamers and gives it a
higher rate of absorption following subcutaneous administration.

Figure 13: Structures of insulin and insulin peptide analogues. The amino acid
sequences of the 21-amino acid A chain and the 30-amino acid B chain of human insulin are
shown. There are two interchain disulphide bridges - the intrachain disulphide in the A chain
of insulin are indicated. Residues in beef or pork insulin that differ from those in human
insulin are shown above or below the A and B chain sequences. Also depicted are the amino
acids in Insulin Glargine, Insulin Lispro and Insulin Aspart that differ from those in unmodified
insulin.

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5PY022 Endocrine Study Pack

Figure from Wecker, L. (Ed) Brody’s Human Pharmacology: Molecular to Clinical

[Link]
43/figure-432

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5PY022 Endocrine Study Pack

Type 2 Diabetes Mellitus (T2DM)

Type 2 diabetes mellitus is commonly diagnosed during middle-age but can occur at any
age, and epidemiological studies are indicating a disturbing increase in the incidence of
obesity, and associated type 2 diabetes mellitus, occurring in children. As with Type 1
diabetes mellitus, there is a genetic predisposition, but Type 2 diabetes mellitus is much
more strongly influenced by other risk factors, including obesity and a sedentary lifestyle.

Type 2 Diabetes Mellitus is associated with both insulin resistance and impaired insulin
secretion. Insulin resistance precedes overt disease and often goes undetected. The
following series of events explains both insulin resistance and impaired insulin secretion.

1. A diet high in sugars and carbohydrates may precipitate elevated insulin levels.
You will recall that blood glucose is the most important factor in the stimulation of
insulin secretion
2. The tissues upon which insulin exerts its effects become unresponsive following
bombardment of their respective insulin receptors with elevated blood insulin levels
owing to;
a) Down-regulation of the insulin receptor (a loss of insulin receptors from the cell
surface). Remember, insulin receptors internalize following ligand binding.
b) Impaired signalling mechanisms which recruit the transporter GLUT-4 (Please
refer back to Figure 11 and see Figure 14)
3. Insulin sensitive tissues are now unresponsive and resistant to the effects of
insulin. Glucose can no longer enter the cell leading to a further rise in blood glucose.
4. In an attempt to drive glucose uptake into cells, the pancreatic  cells (which respond
to elevations in blood glucose) produce yet more insulin which results in
hyperinsulinaemia.
5. Gradually, the  cells of the pancreas become depleted of insulin (supply cannot
keep up with demand) and impaired insulin secretion ensues.

Figure 14 Signalling components of insulin resistance

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5PY022 Endocrine Study Pack

Further Definitions

Impaired glucose tolerance (IGT) is a pre-diabetic state of hyperglycaemia that is

associated with insulin resistance and carries an increased risk of cardiovascular pathology.
IGT may precede type 2 diabetes mellitus by many years and may often go undetected.
Detection of IGT is difficult because fasting blood glucose and insulin levels can be near
normal. However, 2 hours after a glucose challenge (a fasting patient is given a large
quantity of glucose as an oral solution to drink) above-normal levels of blood sugar and
insulin are observed in cases of IGT. See Figure 15. Observe and rationalise the differences
in blood glucose and insulin levels between Type1 and Type 2 diabetes, impaired glucose
tolerance and a non-diabetic individual, following a glucose challenge.

Figure 15 From Wecker, L. (Ed) [Link]

pharmacology-5th/chapter-43/figure-431

Signposting
Pharmacists are commonly involved in preparing glucose solutions for the glucose
tolerance test. For a description of fasting blood glucose and oral glucose tolerance
tests, please visit the following website.

[Link]

Glycated haemoglobin (HbA1c) forms when red blood cells are exposed to glucose in the
plasma. The HbA1c test reflects average plasma glucose over the previous 8–12 weeks.
Unlike the oral glucose tolerance test, an HbA1c test can be performed at any time of the
day and does not require any special preparation, such as fasting.
HbA1c is a continuous risk factor for type 2 diabetes. This means there is no fixed point
when people are (or are not) at risk. The World Health Organization recommends a level of
48 mmol/mol (6.5%) for HbA1c as the cut-off point for diagnosing type 2 diabetes in non-
pregnant adults. For the purposes of this guidance, the range 42–47 mmol/mol (6.0–6.4%) is
considered to be 'high risk'.

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5PY022 Endocrine Study Pack

Impaired fasting glucose (IFG) is defined as a fasting plasma glucose between 6.1 and 6.9
mmol/l.

High risk is defined as a fasting plasma glucose level of 5.5–6.9 mmol/l or an HbA1c level of
42–47 mmol/mol (6.0–6.4%).

Type 2 Diabetes Mellitus - Management

The management plan for type 2 diabetes must be tailored to meet individual patient needs
and the stage of development of the condition. Non-pharmacological strategies include
dietary modifications (large proportion of food to consist of complex carbohydrates/high
fibre/low glycaemic index/low fat), weight loss (as required), and increased physical activity
(as tolerated).

Pharmacological approaches include the supplementation or promotion of endogenous

insulin secretion, antagonism of carbohydrate metabolism / absorption from the
gastrointestinal (GI) tract to reduce insulin resistance. The long-term treatment plan of most
type 2 diabetics will include pharmacological therapy, and approximately half will need
insulin supplementation.

Oral Hypoglycaemic Drugs

Biguanides (Metformin)

Pharmacodynamics – Metformin reduces hepatic glucose production (gluconeogenesis)

which is markedly increased in T2DM. It also increases glucose uptake and utilisation in
skeletal muscle, reduces carbohydrate absorption and reduces circulating levels of LDL and
VLDL.

Metformin does not cause hypoglycaemia, but it can cause dose-related side effects such as
anorexia, diarrhoeas, nausea and other GI-related effects. The most serious side effect is
the occurrence of lactic acidosis – this particularly likely in patients with reduced drug
eliminations or reduced tissue oxygenation, hence this drug should not be used in patients
with renal or hepatic disease. Metformin is, however, used in patients with compensated
heart failure, as it can improve outcomes for such patients.

Sulphonylureas (Chlorpropamide, Tolbutamide, Glipizide, Glibenclamide, Gliclazide)

Pharmacodynamics - The principal mechanism of action of the sulfonylureas is on

pancreatic  cells, by stimulating insulin secretion and thus reducing plasma glucose, but for
this reason, sulfonylureas are only effective if there are functional cells available.
Sulfonylureas are NOT used in T1DM or late-stage Type 2, when intracellular levels of
insulin have already been severely depleted.

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5PY022 Endocrine Study Pack

Signposting
To understand the mechanism of action of the sulfonylureas, please re-consult Figure 9
“Stimulation of insulin secretion at a molecular level”.

High affinity receptors for sulfonylureas (SUR1) are present on the inwardly rectifying
K+ channel, KIR6.2, the ATP-sensitive K+ channel in the pancreas. Like the rise in intracellular
levels of ATP, following glucose metabolism in pancreatic beta cells and the consequential
inhibition of the KIR6.2 channel, sulfonylureas block the outflux of K +. The resulting partial
membrane depolarization triggers activation of voltage-gated Ca2+ channels, Ca2+ entry and
exocytosis of secretory granules containing insulin.

Pharmacokinetics – Sulfonylurea drugs are usually well tolerated, and the most common
adverse effect is hypoglycaemia, which is related to the potency and duration of action
(highest with glibenclamide and lowest with tolbutamide). Long acting sulphonylureas are
best avoided in the elderly (who have reduced renal function) and patients with renal
impairment. A comparison of the pharmacokinetic properties of some commonly used
sulphonylurea drugs is shown in table 4.

Drug RP(a) Duration Pharmacokinetic Practice

and (T0.5 ) aspects considerations
Tolbutamide 1 6-12 hr  Some converted in  A safe drug and
(4 hr) the liver to the least likely to cause
weakly active hypoglycaemia
hydroxytolbutamide.  Contraindicated in
 Carboxylated to the liver failure
inactive compound.
Renal excretion
Glibencl 150 18-24 hr  Some is oxidised in  May cause
amide (10 hr) the liver to hypoglycaemia. The
moderately active active metabolite
products and accumulates in renal
excreted in the failure
urine. 50% is
excreted unchanged
in the faeces.
Glipizide 100 16-24 hr  Plasma levels peak  May cause
(7) in 1 hr. Most is hypoglycaemia. Has
metabolized in the a diuretic action
liver to inactive  Only inactive
products which are products
excreted in the accumulate in renal
urine. failure
 12% is excreted in
the faeces
a
RP – Relative Potency is relative to tolbutamide
Table 4: Pharmacokinetic Profiles of the Sulphonylureas

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5PY022 Endocrine Study Pack

Thiazolidinediones (or glitazones)

Pioglitazone and rosiglitazone are the only drugs of this class which have been used
clinically as earlier analogues induced hepatic toxicity. However, reports have implicated
pioglitazone with an increased incidence of heart failure (and it should therefore not be
used in patients with heart failure or a history of heart failure) and there also appears to be a
risk of bladder cancer. The marketing authorization for rosiglitazone has been
withdrawn.

Pharmacodynamics – Thiazolidinediones bind to the nuclear receptor PPARg (peroxisome

proliferator-activated receptor-g), see Figure 16. After ligand binding, PPARs form
heterodimers with retinoid X receptor-alpha (RXR-α), thereby undergoing conformational
changes, which facilitate their binding to the peroxisome proliferative response element
(PPRE) in the enhancer regions of target genes which are important in insulin signalling,
fat metabolism and fluid volume. The pharmacodynamic effects are summarised below.

 Thiazolidinediones reduce insulin resistance in insulin responsive tissue by increasing the

transcription of GLUT-4 glucose transporters, thus increasing glucose uptake, and
enhancing the effectiveness of endogenous insulin. Thiazolidinediones reduce the
amount of exogenous insulin needed to maintain a given level of blood glucose by
approximately 30%.

• Reduce hepatic glucose output

• Act on PPARγ in adipocytes promoting adipogenesis, predominantly in pre-adipocytes

from subcutaneous deposits where the increased transcription of transporters and
enzymes involved in fatty acid uptake and lipogenesis increases the deposition of lipid in
these adipocytes. The consequential reduction in the availability of fatty acids as an
energy source, thereby favours the utilisation of glucose

• Reduction in small dense LDL (atherogenic)

• Effect on blood glucose is slow in onset, the maximal effect achieved after 1-2 months of
treatment

Common Unwanted Effects

However, as stated previously, thiazolidinediones enhance the expression of those genes

which are important in fat metabolism and fluid volume and this can result in some common
unwanted effects. Differentiation of adipocytes and an increase in lipogenesis contribute to
unwanted weight gain (1-4 kg). Promotion of amiloride-sensitive Na+ reabsorption in the
renal collecting ducts contributes to the adverse effect of fluid retention in which plasma
volume can increase up to 500 ml with a concomitant reduction in haemoglobin
concentration.

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5PY022 Endocrine Study Pack

Figure 16: Thiazolidinediones - Mechanism of action

Glucosidase inhibitors (acarbose)

Acarbose is an inhibitor of the intestinal enzyme glycoside hydrolase, or glucosidase.

Inhibition of this enzyme leads to delays in carbohydrate absorption, thereby reducing the
postprandial increase in blood glucose. Common side effects include flatulence, loose
stools, diarrhoea and abdominal pain/bloating.

Incretin mimetics (exenatide)

Incretins are endogenous GI peptides which stimulate insulin secretion from pancreatic b
cells and include glucagon-like peptide 1 and gastric inhibitory peptide. Incretins also inhibit
pancreatic glucagon secretion from  cells. Incretins slow the rate of absorption of digested
foods by decreasing gastric emptying. Exenatide is a synthetic
version (a mimetic) of extendin-4, a peptide isolated from the
saliva of the Gila monster – a lizard which disables its prey by
inducing a state of hypoglycaemia. Like insulin, exenatide must
be subcutaneously administered as it is a peptide.

The Glucagon-Like Peptide-1(GLP-1) Receptor Agonists

The class of incretin mimetics has grown considerably since the introduction of exenatide
and is now referred to as the GLP-1 receptor agonists. There are different indications for
different GLP-1 receptor agonists.

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5PY022 Endocrine Study Pack

Signposting
Please consult the BNF for each GLP-1 receptor agonist listed below paying attention to the
indications. For instance, dulaglutide is used as a monotherapy in Type 2 diabetes mellitus if
metformin is inappropriate. Others such as lixisenatide are used in combination with oral
antidiabetic drugs (e.g., metformin, pioglitazone, or a sulfonylurea) or basal insulin, or both, when
adequate glycaemic control has not been achieved with these drugs. Liraglutide is also used as
an adjunct in weight management.

dulaglutide, exenatide, liraglutide, lixisenatide and semaglutide

You will have noticed that some GLP-1 receptor agonists, in addition to Type 2 diabetes
mellitus, are also used for the management of weight gain. NICE has (Tuesday 8 February
2022) issued draft guidance recommending semaglutide to adults with at least one weight-
related condition and a body mass index (BMI) of at least 35 kg/m 2, and exceptionally, to
people with a BMI of 30.0 kg/m 2 to 34.9 kg/m2. The rationale for this can easily be explained
by the multiple mechanisms of action of the GLP-1 receptor agonists. Please see Figure 17
below.

Figure 17: Multiple Mechanisms of Action of the Glucagon-Like Peptide-1(GLP-1)

Receptor Agonists. As with endogenous incretins GLP-1 receptor agonists bind to GLP-1
receptors to lower blood glucose by [Link] glucose-dependent insulin release from
pancreatic b cells, 2. Inhibiting glucagon from pancreatic a cells, 3. Slowing gastric
emptying thus delaying post prandial carbohydrate absorption and metabolism and 4. Acting
as an appetite suppressant, thus reducing oral consumption of carbohydrates. Figure
adapted from, [Link]

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5PY022 Endocrine Study Pack

It is also of note that the effect of GLP-1 receptor agonists is glucose-dependent, i.e. there is
more insulin release when glucose levels are elevated, but less when glucose levels are
normal. For this reason it is considered that GLP-1 receptor agonists have a lower risk of
producing hypoglycaemia compared to sulfonylureas, which chronically stimulate insulin
release independent of blood glucose concentration.

Signposting
Please visit Nova Nordisk who provide an elegant video summarising the mechanisms of action of
semaglutide in addition to peptide modifications to enhance plasma half-life.
[Link]

Gliptins (sitagliptin, vildagliptin)

These drugs are synthetic dipeptidylpeptidase-4 (DDP4) inhibitors which potentiate

endogenous incretins by competitively inhibiting this enzyme which breaks down incretins.
These agents are added to other orally active drugs to improve control in patients with
T2DM, and they are generally well tolerated and are weight-neutral. The mechanism of
action of the gliptins is shown in Figure 18.

Figure 18: Mechanism of action of the Gliptins

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The Sodium Glucose Co-Transporter 2 (SGLT-2) Inhibitors

Sodium-glucose co-transporter-2 inhibitors work by inhibiting SGLT-2 in the proximal

convoluted tubule of the kidney, to prevent reabsorption of glucose and facilitate its excretion
in urine. As glucose is excreted, plasma levels fall (Figure 19). This mechanism of action is
dependent on blood glucose levels. Thus, there is minimal potential for hypoglycaemia, and
no risk of overstimulation or fatigue of pancreatic beta cells. Because their mode of action
relies upon normal renal glomerular-tubular function, SGLT-2 inhibitor efficacy is reduced in
persons with renal impairment.

Canagliflozin, dapagliflozin, and empagliflozin, may be suitable for some patients when first-
line options are not appropriate. Additionally, canagliflozin and empagliflozin can be
beneficial in patients with type 2 diabetes and established cardiovascular disease.
Unfortunately, sodium glucose co-transporter 2 inhibitors are associated with a risk of
diabetic ketoacidosis.

Figure 19: Mechanism of Action of the SGLT-2 Inhibitors

The SGLT-2 (sodium-glucose co-transporter-2) mediates reabsorption of over 90% of filtered

glucose back into the body. The following points elucidate the mechanism of action of the
SGLT-2 inhibitors presented in Figure 19.

• Normally, the Na+/K+ ATPase pump removes Na+ from the S1 segment renal proximal
tubule.

• The sodium-glucose co-transporter-2 enables Na+ to move down it’s concentration

gradient bringing with it glucose into the S1 segment renal proximal tubule.

• Glucose is then reabsorbed into the blood via GLUT-2.

• SGLT-2 inhibitors work by inhibiting SGLT2 in the proximal convoluted tubule of the
kidney, to prevent reabsorption of glucose and facilitate its excretion in urine

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 5PY022 Endocrine Study Pack

• As glucose is excreted in the urine, plasma glucose levels fall.

The Female Reproductive System

Start here
Oestrogens and Progesterone are the main female steroid hormones which control the
female reproductive system. As with other steroid hormones, oestrogens and progestogens
act by influencing gene transcription. They passively diffuse into the cell and bind to their
cognate receptors either in the cytoplasm or the nucleus. The receptors are associated with
heat shock proteins (HSPs) when in their unbound state in the cytosol. HSPs dissociate
when the hormone binds to the receptor and the receptor forms dimers which translocate to
the nucleus. The steroid-receptor complex associates with hormone-response elements of
numerous oestrogen- or progesterone-responsive genes. Oestrogen binds to 2 specific
receptors (ER and ER), which have different tissue distributions. Progesterone also has 2
specific receptors, PR-A and PR-B. Steroid hormones are also responsible for some non-
genomic actions by binding to extra-nuclear steroid receptors.

Figure 20: Mechanisms of action of oestrogen and progesterone

The Endocrine Control of the Menstrual Cycle

Signposting
The endocrine control of the menstrual cycle was covered during Pharmacy Stage 1
(4PY019) and is presented to refresh your understanding. Besides, to understand the
mechanisms of action of all drugs, we first need to have an in depth understanding of the
physiology and pathophysiology upon which these drugs impact. Start by viewing this
elegant video depicting ovulation [Link]

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5PY022 Endocrine Study Pack

The endocrine control of the menstrual cycle is a complex physiological control system,
which relies on the Hypothalamic-pituitary-gonadal (HPG) axis and associated hormonal
fluctuations which correspond to physiological events as the cycle progresses. The following
phases describe the endocrine control of the menstrual cycle. In order to fully understand
this complex physiological control system, simultaneously refer to Figure 21 - The
Menstrual Cycle. Pay particular attention to Figure 21 (A & B), which depicts the
Hypothalamic- pituitary-gonadal- axis (HPG axis) and hormonal fluctuations which
correspond to physiological events.

Menstruation – Usually lasting from 3-6 days, this marks the beginning of the menstrual
cycle, during which the superficial layer of the endometrium is shed.

The Follicular Phase - The endometrium regenerates after menstrual flow ceases, and
gonadotrophin releasing hormone (GnRH) is secreted from the hypothalamus and stimulates
the anterior pituitary to release follicle stimulating hormone (FSH) and luteinising hormone
(LH). These act upon the ovaries to promote the development of small groups of follicles,
each of which contains an ovum (egg). One follicle will develop more rapidly than the others
to form the Graafian follicle (GF), which proceeds to secrete oestrogen (the remainder of the
ova degenerate).

The Proliferative Phase - Oestrogens are responsible for endometrial regeneration (from
day 5 or 6 to mid-cycle. The endometrium increases in thickness and vascularity, and at
peak oestrogen levels, there is a prolific cervical secretion of mucus (pH 8-9, therefore
alkaline), which is rich in protein and carbohydrate and which facilitates the entry of sperm to
the ovum. High endogenous oestrogen secretion just before mid-cycle sensitizes the LH-
releasing cells of the anterior pituitary to the action of GnRH, leading to a mid-cycle surge in
LH secretion. This, in turn, causes rapid swelling and rupture of the Graafian follicle resulting
in ovulation. If fertilisation now occurs, the fertilised ovum passes down the fallopian tube to
the uterus.

The Luteal Phase - The ruptured Graafian follicle proliferates and develops into the corpus
luteum, which now starts to secrete progesterone. Progesterone acts on the oestrogen-
primed endometrium to render the endometrium suitable for implantation of the fertilized
ovum, and the cervical mucous is thicker to hinder any sperm. Progesterone exerts negative
feedback on the hypothalamus and the pituitary, and thereby decreases the further synthesis
and release of LH. If fertilization and implantation do not occur, progesterone secretion stops
at the end of the cycle, triggering menstruation.

If fertilization and implantation does occur, the corpus luteum continues to secrete
progesterone, which then negatively feeds back to the hypothalamus and pituitary to prevent
further ovulation. This process is summarised in Figure 21.

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5PY022 Endocrine Study Pack

Figure 21: The Menstrual cycle: (A) The hypothalamic pituitary gonadal axis, (B) Hormonal
fluctuations and corresponding events, (C) The ovarian cycle.

Steroidal Contraceptives

Oral hormonal contraceptives (colloquially known as “the pill”) are the most widely used form
of contraception and contain either a combination of a synthetic oestrogen with synthetic
progesterone or progesterone alone. The most simplistic mechanism of action for their
contraceptive utility can be explained by the fact that elevated circulating levels of synthetic

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5PY022 Endocrine Study Pack

oestrogen and progesterone prevent the precise cyclic pattern of the hormonal events of the
menstrual cycle which are outlined above.

Oral Contraceptives

The Combined Pill

 Combined hormonal contraceptives (often called the “combined oral contraceptive
pill” or COCP) contain a synthetic oestrogen and a synthetic progesterone.
 Since the combined oral hormonal contraceptive was introduced, the dose of the
oestrogen component has been reduced to minimise unwanted side effects such as
thromboembolism, hypertension and migraines.
 “Second generation” combined hormonal contraceptives have a lower oestrogen
content than “first generation” combined oral contraceptives, the latter of which are
no longer in use.
 Constituents of the second generation of COCP. The predominant oestrogen
included in second generation combined pills is ethinylestradiol (an oestrogen which
is alkylated at C17 to slow its metabolism). Some contain mestranol, which is
metabolised in the liver to ethinylestradiol. The progesterone may be norethisterone
or levonorgestrel, testosterone analogues which also possess residual androgenic
activity.
 “Third generation” oral combined hormonal contraceptive pills contain modified
progestogens which have less androgenic activity, including desogestrel or
gestodene, which are more potent, but probably cause a greater risk of
thromboembolism than do second generation hormones.
 Regimen: The COCP regimen is taken cyclically to mimic the natural menstrual
cycle. This usually involves taking the active pill for 21 consecutive days out of 28,
followed by a pill-free period to 28 days to enable a withdrawal menstrual bleed.
Some women have difficulty following this regiment, and some packs of the pill
therefore contain ‘dummy’ placebo pills to be taken from days 22-28. These are
usually designated as the ‘ED’ version – the two versions of the COCP Microgynon
30 are shown in Figure 22.

Figure 22: Packet of 3 x 21 x active tablets Microgynopn (left) and packets of 3 x 28

Microgynon 30ED tablets – 21 active tablets and 7 dummy pills for the drug-free period.

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5PY022 Endocrine Study Pack

Mechanisms of Action of the COCP

 The exogenous oestrogen in the COCP

inhibits the release of FSH, thereby inhibiting
development of the follicle development.
 The exogenous progesterone inhibits the
release of LH.
 The lack of follicular development, combined
with the inhibitory effects of negative feedback
from exogenous progesterone, prevents
ovulation.
 Together, the exogenous oestrogen and
progesterone make the endometrium
unsuitable for implantation.
 Exogenous progesterone also makes
cervical mucus inhospitable to sperm.

Drawbacks. Although usually well tolerated, the COCP can cause weight gain, nausea,
mood changes and skin pigmentation.

Serious unwanted effects are rare. A proportion of women develop reversible

hypertension, and there is a small risk of thromboembolism with the third generation of pill.
There is conflicting evidence both for and against the risk of breast cancer.

Benefits of treatment with the COCP. These extend beyond simply preventing pregnancy.
They can decrease irregular periods and inter-menstrual bleeding, reduces heavy menstrual
bleeding (menorrhagia) and pain associated with menses (dysmenorrhoea). They can also
reduce pre-menstrual tension, and they are generally extremely effective for these
conditions.

The Progesterone-only pill (POP)

 The POP is an alternative to the COCP for women in whom oestrogen is
contraindicated (at risk of hypertension, cardiac disease or thromboembolism) and
whose BP increases during treatment with the COCP.
 Constituents. Contains progestogens such as norethisterone, levonorgestrel, or
ethynodiol.
 Regimen: In contrast to the COCP, these hormones are taken every day, without a
cyclical break.

Mechanisms of Action of the POP

 The contraceptive effect is a result of alterations made to cervical mucous, making

it thicker, less copious and more hostile to sperm.

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5PY022 Endocrine Study Pack

 Exogenous progesterone will also produce an asynchronous development of the

endometrium, which renders the endometrium less receptive to implantation of the
fertilised ovum.
 The POP is less reliable than the combined pill. Low dose progesterone inhibits
ovulation in only 50% of cycles, and its contraceptive actions rely on the effects
mentioned above. At higher doses, inhibition of follicular development and ovulation
become more significant.

Drawbacks. Irregular bleeding is a common occurrence.

For a thorough review of the unwanted effects of oestrogens and progesterones and their
clinical implications please refer to Figure 24.

The Pharmacokinetics of the female sex hormones

Like endogenous oestrogen and progesterone,

their synthetic derivatives are highly lipid soluble
and so are rapidly and completely absorbed from
the gut following oral administration. However,
synthetic drugs are metabolised more slowly and
are less susceptible to first pass metabolism. For
this reason, they have greater oral bioavailability
and longer half-lives. Both the COCP and POP
are metabolised by hepatic cytochrome p450
enzymes. Metabolised conjugates may undergo
enterohepatic cycling (Figure 23).
Figure 23: Enterohepatic circulation

As such, each microgynon pill contains only 30 micrograms of ethinylestradiol – such a low
dose is made possible because the enterohepatic recycling is responsible for maintaining
effective plasma concentrations with such low dose formulations.

While it is desirable to minimise the dose of oestrogen (to avoid thromboembolism), any
increase in the clearance of the COCP or the POP (which can include episodes such as
vomiting or diarrhoea) may lead to contraceptive failure. Moreover, any increase in the
metabolism of the COCP or the POP can reduce their efficacy and lead to contraceptive
failure. As previously stated, both the COCP and POP are metabolised by hepatic
cytochrome p450 enzymes. Thus, care must be taken if co-administered with enzyme
inducing drugs which INCREASE the activity of p450 enzymes and thus enhance the
breakdown and metabolism of the COCP and the POP. Such enzyme inducing drugs include
anti-convulsants (carbamazepine, barbiturates, and phenytoin), anti-retroviral drugs
(nelfinavir, nevirapine, ritonavir) and antibiotics such as rifampicin and rifabutin.

There is some controversy regarding the co-administration of antibiotics. As

pharmacists, we have a duty of care when issuing drugs to patients to ensure that they are
fully warned about dangers or problems that may occur. In the past, this has led to
recommendations to use barrier contraceptive methods in patients on broad-spectrum

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5PY022 Endocrine Study Pack

antibiotics. However, with the exception of rifampicin-like drugs, there is a lack of scientific
evidence supporting the ability of commonly prescribed antibiotics to either reduce blood
levels and/or the effectiveness of oral contraceptives (DeRossi & Hersh 2002). Despite the
evidence, many pharmacists still advocate the use of barrier contraception during the course
of antibiotics, and often for the rest of the cycle as well. An additional important point to
consider is that all antibiotics can cause nausea, vomiting and diarrhoea, which in turn can
enhance the clearance of the COCP and the POP. In the event of this adverse reaction,
barrier methods of contraception should be used.

DeRossi, S.S., Hersh, E.V., (2002) Antibiotics and oral contraceptives. Dent. Clin.
North. Am. 46(4):653-664

Signposting
Progesterone-only contraceptives can also be administered parentally or via an intra-uterine
device. Please refer to Pages 516-517 of Waller & Sampson, Chapter 45 Female
Reproduction. Specifically;

 Parental progesterone only contraceptives

 Intra-uterine progesterone only device

Please also refer to Emergency Contraception which can be found on this

page.

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5PY022 Endocrine Study Pack

Figure 24: Adverse effects associated with the oestrogen and progestogen components of
the COCP

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5PY022 Endocrine Study Pack

The Menopause and the Perimenopause.

Signposting: During Pharmacy Stage 1 (4PY019) you covered symptoms and hormonal
changes of the menopause which included changes to the menstrual cycle, vasomotor symptoms,
urogenital changes and alterations in bone density. Please resit this material to refresh your
memory.

The menopause, also referred to as the climacteric, is the point in a woman's life where she
ceases to be capable of childbearing, and it is usually thought to occur once she has not had
a withdrawal bleed (period) for 1 year. For most women, menopause happens around age
50, although some women stop having periods in their mid-40s while others continue well
into their 50s. Figure 25 indicates physiological differences within the female reproductive
organs between the menopause and the perimenopause.

Perimenopause is the process of change

that leads up to menopause. It can start
as early as the late 30s or as late as the
early 50s, and usually lasts from 2 to 8
years. Women may have irregular periods
or other symptoms during this time. A key
physiological feature of the
perimenopause / menopause is a decline
in levels of oestrogen as a consequence
of the natural depletion of ovarian follicles
(Figure 25). Progesterone levels also fall
if ovulation does not occur. These
hormones provide negative feedback to
the hypothalamus and pituitary, - an
absence of this negative feedback
mechanism will therefore lead to elevated
levels of LH and FSH, which can be used
as an indication of menopause.
Figure 25: Physiological features of the
perimenopause and postmenopause.

Hormone Replacement Therapy (HRT)

Once menopausal (which may be natural or surgically-induced) ovarian function decreases

and oestrogen levels fall. This can lead to some unpleasant symptoms, such as hot flushes
and night sweats (vasomotor symptoms), atrophy of the urogenital organs (including vaginal
dryness) and osteoporosis, as well as sleep disturbance, memory loss, brain fogging and the
development of cardiovascular disease.

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Hormone replacement therapy (HRT).

 HRT involves the cyclic or continuous administration of low doses of one or more
oestrogens with or without a progestogen.
 Oestrogen ONLY preparations. There is a risk of endometrial and ovarian cancer
since oestrogen causes endometrial hyperplasia within these tissues. For this
reason, oestrogen-only preparations are ONLY used in post-hysterectomy women,
who have considerably lower levels of circulating oestrogen
 Oestrogen and Progestogen preparations. Progesterone is known to inhibit
endometrial hyperplasia and counteracts the hyperplasic effects of the oestrogen
component. Thus, the risk of developing endometrial and ovarian cancers is reduced.
However, there may be a small increased risk of developing breast cancer.
 Although somewhat controversial, HRT is thought to be beneficial in the short term to
address some of the problems associated with the menopause which can be
debilitating.
 However, alternative treatments for osteoporosis are usually recommended.
 HRT does not prevent coronary heart disease or protect against a decline in
cognitive function, it should not be prescribed for these purposes.
 Experience of treating women over 65 years with HRT is limited.

Tibolone is a synthetic compound with weakly oestrogenic, progestogenic and androgenic

properties – it activates progestogenic and androgenic effects in the endometrium and can
prevent post-menopausal symptoms and bone loss. It can cause vaginal bleeding, and so is
not used within 12 months of a last period. It has a similar side profile to other HRT
preparations.

Raloxifene is a selective oestrogen (oestrogen) receptor modulator (SERM) with anti-

oestrogenic effects on breast tissue and the uterus, while being pro-oestrogenic on bone and
lipid metabolism. It is useful for preventing post-menopausal osteoporosis but does not affect
vasomotor symptoms. It may have beneficial effects in reducing oestrogen-receptor positive
breast cancer.

Signposting: The following video provides an account of some of the more common
symptoms of the menopause. [Link]
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Signposting: Please refer to the summaries below which identify some of the more
common symptoms associated with the menopause, the “pros and cons” of HRT
usage, therapeutic and unwanted effects.

The Menopause and HRT-the Pros and Cons

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By now you have probably realised that the menopause can be a most troublesome time, a
situation which is compounded by the fact that HRT is not without side effects. Whether a
woman should take HRT is therefore not as straight forward as one might think. These
issues and guidelines will be addressed in the following years of your course. For your
interest, some brief guidelines are presented below in “so what do we ladies do?”

So, what do we ladies do?

“Current recommendations specify that HRT use should be restricted mainly
to moderate or severe menopausal symptoms alleviation. It should not be
used as a means of chronic disease prevention and it is advisable to restrict
treatment administration to the shortest period and lowest dosage possible
to control symptoms effectively”

Please visit the BNF and NICE Guidelines and Risks associated with HRT,
the link is provided below.

[Link]

Some major points include,

• HRT may be used in women with early natural menopause (before

the age of 45) since they are at risk of osteoporosis.
• For early menopause, HRT can be given until the approximate age of
natural menopause (until aged 50 years).
• Alternatives to HRT should be given if osteoporosis is the main
concern.

HRT INCREASES THE RISK OF

• Venous thromboembolism and stroke

• Endometrial cancer (reduced by concomitant use of progesterone),
breast cancer and ovarian cancer
• There is an increased risk of coronary heart disease in women who
start HRT more than 10 years after the menopause

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Vaginal oestrogen

Oestrogen cream, usually estradiol, or pessaries can be used to treat vaginal atrophy,
painful sexual intercourse and relieve urinary frequency and painful/difficult urination.

Signposting
Look back at the Gastrointestinal and Special Senses packs to refresh your memory on
the formulation of creams and pessaries.

Some formulations may cause considerable systemic absorption and an oral progesterone
may be warranted to prevent endometrial hyperplasia.

Novel non-hormonal treatments for hot flushes: there is hope!

Neurokinin B, the guilty neuropeptide which mediates hot flushes.

The specific and central mechanism by which sex steroid hormone deficiency induces hot
flushes remained elusive until discovery of the neuropeptide, Neurokinin B (NKB), a
hypothalamic neuropeptide which binds preferentially to neurokinin 3 receptors (NK3R).

Fig 26: NMR data : A helical structure is induced in NKB, in presence of perdeuterated
dodecyl phosphocholine (DPC) micelles, a membrane model system. The conformation
adopted by NKB in the presence of DPC micelles represents a structural motif typical of
neurokinin-3 selective agonists. Amino acid sequence: H-Asp-Met-His-Asp-Phe-Phe-Val-
Gly-Leu-Met-NH2

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Signposting
The Truth About the Menopause BBC iPlayer: Dr Julia Prague from Imperial
College London. [Link]
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ihtJav9lsNX9PnFQllIhxh4pKkGWcXyKqXEjBLMkVVS7QYS4rp8QdlHpVvNVgMqxO5kH6Jy_wmyt9g03BDfH-
0ZHfonlqt_zJdZlvC7LZ3Es1R50AUPBP5g25lEBCNx7Bh6l9EtnFtmXkOCiMAES54WyAWHxqU15_epjwHBX7TnXpaqdvv

Targeting the missing link between oestrogen feedback and control over GnRH
release:

 Prior to the menopause, increases in oestrogen will cause a negative feedback effect
on GnRH neurons resulting in a suppression of GnRH secretion and subsequent
inhibition of LH and FSH. The arcuate nucleus (Arc) is now recognised as the nodal
point for controlling this negative feedback effect.

 Within the arcuate nucleus, a subpopulation of hypothalamic neurons colocalize

three neuropeptides, namely kisspeptin, neurokinin B (NKB), and dynorphin,

collectively termed KNDy neurons. Animal studies suggest they interact to affect
pulsatile GnRH release (KNDy hypothesis).

 Ovarian failure causes an increase in both kisspeptin neuronal size and gene
expression and hypertrophy of the arcuate nucleus. There is also a marked
increase in hypothalamic NKB gene expression in post menopausal women.
All considered due to a loss of negative feedback from oestrogen.
• So, in the absence of oestrogen, increased kisspeptin and NKB signalling will result
in hypersecretion of GnRH (Figure 27).

KNDy neurons

Figure 27: Schematic diagram showing the relationship between KNDy neurons and the
neuroendocrine circuits controlling LH secretion in postmenopausal women. Degeneration of

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ovarian follicles results in loss of oestrogen.

How does this relate to body temperature regulation?

• KNDy neuron project some of their axons to the MnPO (Median preoptic area of the
hypothalamus).
• The MnPO nucleus is considered a central hub in the thermoregulation in mammals,
receiving input from and projecting to the autonomic thermoregulatory pathway.
• The MnPO nucleus has also been demonstrated to express NK3R mRNA, the
primary receptor for NKB (Figure 28)

Figure 28: Published in Frontiers in Neuroendocrinology 2013

Modulation of body temperature and LH secretion by hypothalamic KNDy (kisspeptin,
neurokinin B and dynorphin) neurons: A novel hypothesis on the mechanism of hot
flushes Naomi E. Rance, Penny A. Dacks, Melinda A. Mittelman-Smith, Andrej A.
Romanovsky, Sally J Krajewski-Hal

A NK3R Antagonist, recently MHRA approved.

Fezolinetant (ESN364) (Veoza), antagonises NKB at neurokinin 3 receptors. Early research
demonstrated that infusion was shown to reduce hot flush frequency by 93% in women
suffering from more than 49 moderate to severe hot flushes a week, whilst additional
improvements in sleep and quality of life were reported. Current formulation is a once daily
“non-hormonal” pill.

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Signposting

A marked increase in bone loss occurs after the menopause which can lead to
osteoporosis. Please consult Waller & Sampson Chapter 42: Calcium
metabolism and metabolic bone disease. Specifically,

1. Regulation of Calcium Metabolism Page 479-480.

2. Osteoporosis, prevention of osteoporosis and treatments
for established osteoporosis Page 485-486

It will help if you refresh your knowledge of parathyroid hormone and

calcium homeostasis covered during the Endocrine Cycle of Pharmacy
Stage 1 (4PY019)

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