Endocrine System: Diabetes, Steroids, Thyroid and Contraception for the GPhC

Scope and time budget

Diabetes dominates, but the area also covers thyroid, steroids, bone health and sex hormones. Contraception links to the law and to the reproductive domain.

What is tested

• Type 2 diabetes. The drug pathway with metformin, SGLT2 inhibitors and GLP-1 agonists.
• Insulin. Types, regimens, injection technique and hypoglycaemia.
• Acute complications. Diabetic ketoacidosis and sick-day rules.
• Monitoring. Complications of the foot, kidney and eye, and HbA1c.
• Thyroid disease. Levothyroxine, carbimazole and interactions.
• Corticosteroids. Adrenal suppression, steroid cards and tapering.
• Adrenal conditions. Adrenal insufficiency and Cushing's syndrome.
• Bone health. Osteoporosis and bisphosphonate counselling.
• Menopause. Hormone replacement therapy.
• Combined hormonal contraception. Assessment with the UK Medical Eligibility Criteria.
• Progestogen-only and long-acting methods. Counselling and suitability.
• Emergency contraception. Options, windows and supply.
• Sex hormone therapy. Androgen therapy and the boundaries of gender-affirming care.
• Pituitary and calcium disorders. Principles and drug safety.

UK guideline anchors

• Units. HbA1c in mmol/mol, glucose in mmol/L and insulin in units.
• NICE type 2 diabetes (to confirm). Metformin first line and a target HbA1c of 48 mmol/mol, or 53 mmol/mol when taking a drug that can cause hypoglycaemia.
• Emergency contraception (checked). Copper IUD within 5 days (120 hours), levonorgestrel within 3 days (72 hours) and ulipristal acetate within 5 days (120 hours).
• UKMEC. FSRH eligibility categories for hormonal contraception.
• BNF. Doses, adjustment in renal impairment and interactions.

Diabetes: drugs, devices and safety

Diabetes appears in several guises. Type 2 pathway questions follow NICE: metformin is first line, with further agents chosen by patient factors such as cardiovascular disease, heart failure, kidney function and weight. We recall the standard HbA1c target as 48 mmol/mol, or 53 mmol/mol for people taking a drug that can cause hypoglycaemia, but confirm it against the NICE guideline. Insulin questions test product identification, injection technique, rotating sites, storage and the recognition and treatment of hypoglycaemia. Insulin is also one of the framework's high-risk drug groups, and doses are in units, not milligrams.

Sick-day rules matter. During vomiting, diarrhoea or fever, patients on certain diabetes and cardiovascular medicines are advised to adjust or pause them, and those on insulin should keep taking it and monitor glucose and ketones more often. Diabetic ketoacidosis is a medical emergency, and a pharmacist should recognise the warning signs and refer.

Steroids, thyroid and bone

Long-term oral corticosteroids suppress the adrenal axis. Know why they should not be stopped abruptly, why a steroid treatment card matters, and how doses are increased during intercurrent illness under medical advice. For thyroid disease, know that levothyroxine is taken on an empty stomach, separated from iron, calcium and some antacids, and that carbimazole carries a warning about signs of infection and a sore throat. For osteoporosis, know bisphosphonate counselling: take with water, upright, before food, and report swallowing difficulty or chest pain.

Contraception and menopause

Endocrine items include contraception and hormone replacement. Combined hormonal methods are assessed against the UK Medical Eligibility Criteria from the FSRH, which grade conditions by risk. Emergency contraception windows are checked: copper intrauterine device within 5 days (120 hours), levonorgestrel within 3 days (72 hours) and ulipristal acetate within 5 days (120 hours). Weight and enzyme-inducer adjustments should come from the BNF and FSRH guidance. For menopause, know the benefits and risks of hormone replacement and the importance of an individual assessment.

Counselling points that earn marks

• Insulin. Rotate injection sites, store unopened pens in a fridge and in-use pens at room temperature, never share pens, and always carry a fast-acting sugar source.
• Metformin. Take with or after food to reduce stomach upset, and report vomiting or dehydration.
• Levothyroxine. Empty stomach, consistent timing, and separate from iron and calcium.
• Corticosteroids. Carry the steroid card, do not stop suddenly, and tell any clinician treating you.
• Bisphosphonates. Swallow whole with a full glass of water, stay upright, and wait before food.

Children and endocrine disease

Type 1 diabetes in children, growth and puberty, and paediatric thyroid disease can all appear, with doses from the BNFc. Insulin doses in children are individual and in units, so the question is more likely to test recognition of hypoglycaemia, sick-day management and school or carer counselling than a dose calculation.

Three typical traps

1. The unit trap. Insulin is dosed in units. Converting units to milligrams, or confusing strengths such as 100 units/mL and 500 units/mL, is a safety error.
2. The sick-day trap. Patients on insulin should not stop it during illness, while other diabetes and cardiovascular medicines may be paused. Read which drug the question is about.
3. The window trap. Emergency contraception windows differ by method. Choose the option that fits the time since unprotected sex and the patient's weight and medicines.

How to revise it

1. Draw the T2DM pathway. Start from metformin and branch by comorbidity.
2. Learn insulin as a table. Type, onset, peak, duration, timing and storage.
3. Drill sick-day rules. Which medicines to pause, which to continue and when to seek help.
4. Memorise the contraception windows. And the weight and enzyme-inducer checks to confirm in the BNF.
5. Mix questions. Combine diabetes, steroids and thyroid in thirty-item sets.

Continue with infection and genito-urinary and reproductive health. See also high-yield topics and the hub.