Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Chapter 34 Women’s Health Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Female Reproductive Functions Female sex steroid hormones Estrogens Progestins Pituitary gonadotropin hormones Follicle-stimulating hormone (FSH) Luteinizing hormone (LH) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Female Reproductive Functions (cont’d) Female sex steroid hormones and pituitary gonadotropin hormones promote: Development of primary and secondary sex characteristics Start of menses and regulation of menstrual cycle Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Estrogens Three major endogenous estrogens Estradiol (principal and most active) Estrone Estriol Synthesized from cholesterol in ovarian follicles Basic chemical structure of a steroid Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Exogenous Estrogenic Drugs–Synthetic Steroidal Conjugated estrogens, estradiol transdermal, estropipate, many others Nonsteroidal Diethylstilbestrol No longer available in the United States Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Estrogens (cont’d) Responsible for: Development and maintenance of the female reproductive system Development of female secondary sex characteristics Shaping of body contours and development of the skeleton Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Estrogens: Indications Treatment or prevention of disorders that result from estrogen deficiency Atrophic vaginitis Hypogonadism Oral contraception (given with a progestin) Uterine bleeding Vasomotor spasms of menopause (“hot flashes”) Osteoporosis Breast or prostate cancer Ovarian failure or castration Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Estrogens: Contraindications Any estrogen-dependent cancer Undiagnosed abnormal vaginal bleeding Pregnancy Active thromboembolic disorder or history Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Estrogens: Adverse Effects Thrombolytic events—most serious Nausea—most common Hypertension, thrombophlebitis, edema Vomiting, diarrhea, constipation, abdominal pain May cause photosensitivity, chloasma Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Estrogens: Adverse Effects (cont’d) Amenorrhea, breakthrough uterine bleeding Tender breasts, fluid retention, headaches Others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Estrogens and HRT: The North American Menopause Society (NAMS) 2010 Supports initiating HT (hormonal therapy) around the time of menopause to treat menopause-related symptoms and to treat or reduce the risk of certain disorders (e.g., osteoporosis, fractures) Hormone replacement is not recommended for women with histories of endometrial cancer In women with breast cancer, estrogen therapy has not been proven safe and might raise recurrence risk Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Continuous Combined Hormone Replacement Therapy Use of estrogen therapy alone has been associated with an increased risk of endometrial hyperplasia, a possible precursor of endometrial cancer Addition of continuously administered progestin to an estrogen regimen reduces the incidence of endometrial hyperplasia associated with unopposed estrogen therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Progestins Synthetic derivatives of progesterone hydroxyprogesterone (Hylutin) levonorgestrel (Plan B) medroxyprogesterone (Provera, Depo-Provera) megestrol (Megace) norethindrone acetate (Aygestin) norgestrel (Ovrette, Ovral) progesterone (Prometrium) etonogestrel implant (Implanon) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Progestins: Indications Treatment of functional uterine bleeding caused by: Hormonal imbalance Fibroids Uterine cancer Treatment of primary and secondary amenorrhea Adjunctive and palliative treatment of some cancers and endometriosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Progestins: Indications (cont’d) Alone or in combination with estrogens to prevent conception Prevention of threatened miscarriage Alleviation of PMS symptoms Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Progestins: Indications (cont’d) megestrol (Megace) Adjunct therapy for treatment of breast and endometrial cancers Management of anorexia, cachexia, or unexplained weight loss in AIDS patients To stimulate appetite and promote weight gain in cancer patients Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Progestins: Adverse Effects Liver dysfunction—cholestatic jaundice Thrombophlebitis, thromboembolic disorders, such as PE Nausea, vomiting Amenorrhea, spotting Edema, weight gain or loss Others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Contraceptive Drugs Medications used to prevent pregnancy Oral medications Monophasic, biphasic, and triphasic forms Triphasic form most closely duplicates the normal hormonal levels of the female cycle Newer extended-cycle products Most contain estrogen-progestin combinations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs (cont’d) Other contraceptive forms available Long-acting injectable form of medroxyprogesterone (Depo-Provera) Transdermal contraceptive patch Intravaginal contraceptive ring Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Mechanism of Action Prevent ovulation by inhibiting the release of gonadotropins and increasing uterine mucous viscosity, resulting in: Decreased sperm movement and fertilization of the ovum Possible inhibition of implantation of a fertilized egg (zygote) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Other Drug Effects Improve menstrual cycle regularity Decrease blood loss during menstruation Decrease incidence of functional ovarian cysts and ectopic pregnancies Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Indications Primarily used to prevent pregnancy Other uses: Treatment of endometriosis and hypermenorrhea Production of cyclic withdrawal bleeding Postcoital emergency contraception Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Adverse Effects Drawbacks to the use of these drugs include: Hypertension Thromboembolism, possible PE, MI, stroke Alterations in lipid and carbohydrate metabolism Increases in serum hormone concentrations These effects are caused by the estrogen component Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Adverse Effects (cont’d) May also cause: Edema, dizziness, headache, depression, nausea, vomiting, diarrhea, increased appetite, increased weight, breast changes, many others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Interactions Drugs that decrease effectiveness of oral contraceptive drugs Antibiotics Barbiturates Isoniazid Rifampin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Contraceptive Drugs: Interactions (cont’d) Drugs that may have reduced effectiveness if given with oral contraceptives Beta blockers, warfarin, tricyclic antidepressants, vitamins, hypnotics, anticonvulsants, theophylline, and antidiabetic drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Osteoporosis Low bone mass Increased risk of fractures Primarily affects women 20% with this condition are men Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Osteoporosis: Risk Factors Caucasian/Asian descent Slender body build Early estrogen deficiency Smoking Alcohol consumption Low-calcium diet Sedentary lifestyle Family history Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Prevention of Osteoporosis Calcium supplements and vitamin D may be recommended for women at high risk for osteoporosis Current recommendations are that women, especially those older than age 60, consider taking calcium and vitamin D supplements for bone health Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question While taking a history of a 68-year-old female patient who is receiving estrogen therapy as part of palliative treatment for advanced breast cancer, which assessment finding would be of most concern to the nurse? The patient is on transdermal opioids for cancer pain. The patient smokes 1 pack of cigarettes a day. The patient drinks a glass of wine one evening a week. The patient has a history of osteoporosis. Correct answer: B Rationale: Smoking should be avoided during estrogen therapy because it adds to the risk for thrombosis. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis Bisphosphonates alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), zoledronic acid (Reclast) Selective estrogen receptor modifiers (SERMs) raloxifene (Evista) tamoxifen (Nolvadex) Hormones calcitonin (Calcimar) teriparatide (Forteo) denosumab (Prolia) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis (cont’d) Bisphosphonates Work by inhibiting osteoclast-mediated bone resorption, thus preventing bone loss SERMs Stimulate estrogen receptors on bone and increase bone density Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis (cont’d) calcitonin (Calcimar) Directly inhibits osteoclastic bone resorption teriparatide (Forteo) Only drug that stimulates bone formation Derivative of parathyroid hormone Action similar to natural parathyroid hormone Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis (cont’d) denosumab (Prolia) Monoclonal antibody that blocks osteoclast activation, thereby preventing bone resorption It is given as a subcutaneous injection once every 6 months along with daily calcium and vitamin D Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis: Indications Bisphosphonates Both prevention and treatment of osteoporosis Bisphosphonates also used for glucocorticoid-induced osteoporosis and Paget’s disease Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis: Indications (cont’d) calcitonin (Calcimar) Treatment of osteoporosis Nasal spray (Miacalcin) most commonly used raloxifene (Evista) Prevention of postmenopausal osteoporosis teriparatide (Forteo) Treatment for those with highest risk of fracture (prior history of fractures) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis: Adverse Effects SERMs Hot flashes, leg cramps Increased risk of venous thromboembolism Teratogenic Leukopenia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis Adverse Effects (cont’d) Bisphosphonates Headache, GI upset, joint pain Risk of esophageal burns if medication lodges in esophagus before reaching the stomach Risk of osteonecrosis of the jaw Possible severe (incapacitating) bone, joint, or muscle pain Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy for Osteoporosis Adverse Effects (cont’d) calcitonin Flushing of the face, nausea, diarrhea, and reduced appetite teriparatide Chest pain, dizziness, hypercalcemia, nausea, and arthralgia denosumab Infections Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A 60-year-old woman is taking a bisphosphonate. She calls the clinic and tells the nurse that her stomach has been bothering her and wants to know what she should do. The nurse will instruct her to: take this medication with milk. take this medication with breakfast. remain upright in a sitting position for at least 10 minutes after taking this medication. stop the medication and to come in for an evaluation. Correct answer: D Rationale: Bisphosphonates (e.g., alendronate) are to be taken exactly as prescribed; that is, the drug is taken at least 30 minutes before the first morning beverage, food, or other medication and with at least 6 to 8 oz of water. Emphasize the importance of remaining upright for at least 30 minutes after taking the medication to prevent esophageal and GI adverse effects. Esophageal irritation, dysphagia, severe heartburn, and retrosternal pain must be reported to the prescriber immediately to help prevent severe reactions. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Fertility Drugs Various medical techniques used to treat infertility Includes in vitro fertilization and medication therapy (ovulation stimulation) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Fertility Drugs (cont’d) clomiphene (Clomid, Serophene) Nonsteroidal ovulation stimulant Blocks estrogen receptors in the uterus and brain, resulting in a false signal of low estrogen levels Increases production of Gn-RH, FSH, and LH As a result, maturation of ovarian follicles is stimulated, leading to ovulation and increased chance of conception Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Fertility Drugs (cont’d) menotropins (Pergonal) Standardized mixture of FSH and LH Stimulates development of ovarian follicles, leading to ovulation May also be given to men to stimulate spermatogenesis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Fertility Drugs (cont’d) chorionic gonadotropin alfa (Ovidrel) Recombinant form of human chorionic gonadotropin Causes rupture and ovulation of mature ovarian follicles, and maintenance of corpus luteum Used to stimulate ovulation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Fertility Drugs: Indications Used primarily to induce ovulation in anovulatory patients Also may be used to promote spermatogenesis in infertile men Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Fertility Drugs: Adverse Effects Tachycardia, hypovolemia, DVT Dizziness, headache, flushing, depression, restlessness, anxiety, nervousness, fatigue Nausea, bloating, constipation, vomiting, anorexia Urticaria, ovarian hyperstimulation, multiple pregnancy, blurred vision, diplopia, photosensitivity, breast pain Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Uterine Stimulants Medications used to alter uterine contractions Used to: Promote labor Prevent the start or progression of labor Postpartum use: reduce the risk of postpartum hemorrhage Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Stimulants (cont’d) Also called oxytocics Oxytocin (hormonal drug) Prostaglandins Ergot derivatives Progesterone antagonist mifepristone (RU-486) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Stimulants (cont’d) oxytocin (Pitocin)—synthetic form Used to induce labor at or near full-term gestation, and to enhance labor when contractions are weak and ineffective Other uses Prevent or control postpartum uterine bleeding Complete an incomplete abortion (after miscarriage) Promote milk ejection during lactation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Stimulants (cont’d) Prostaglandins Natural hormones Cause potent contraction of myometrium, smooth muscle fibers of the uterus Used to induce labor by softening the cervix and enhancing uterine muscle tone dinoprostone (Prostin E3) and misoprostol (Cytotec) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Stimulants (cont’d) Ergot alkaloids Increase force and frequency of uterine contractions Used after delivery of the infant and placenta to prevent postpartum uterine atony and hemorrhage methylergonovine (Methergine) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Stimulants (cont’d) Progesterone antagonist mifepristone (Mifeprex) Stimulates uterine contractions to induce abortion Given with a prostaglandin drug for elective abortions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Stimulants: Adverse Effects Hypotension or hypertension, chest pain Headache, dizziness, fainting Nausea, vomiting, diarrhea Vaginitis, vaginal pain, cramping Leg cramps, joint swelling, chills, fever, weakness, blurred vision Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A woman in labor is on an oxytocin infusion. The nurse notes that her contractions are close to 100 seconds apart and are lasting 1.25 seconds. The mother’s blood pressure has increased to 130/98, and the fetal heart rate decreases during the contractions. The woman states, “Wow, this medicine is sure hurrying things along!” The nurse’s next action(s) will be to: continue to monitor the labor, which is progressing nicely. offer comfort measures during the contractions. stop the infusion, administer oxygen, have her lie on her left side, and notify the physician immediately. take the patient to the delivery area because delivery is imminent. Correct answer: C Rationale: These are signs of hyperstimulation of the uterus from the oxytocin. Fetal compromise may occur if the infusion is not stopped. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Uterine Relaxants: Tocolytics Used to stop labor that begins before term to prevent premature birth Generally used after the 20th week of gestation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Relaxants: Tocolytics (cont’d) Uterine contractions that occur between the 20th and 37th weeks of gestation are considered premature labor Nonpharmacologic measures Bed rest, sedation, hydration Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Uterine Relaxants indomethacin Nonsteroidal antiinflammatory agent Inhibits prostaglandin activity nifedipine Calcium channel blocker Inhibits myometrial activity by blocking calcium influx Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Uterine Relaxants (cont’d) When indomethacin and nifedipine are ineffective and delivery is proceeding, corticosteroids (betamethasone or dexamethasone) are administered to the mother to promote lung maturity in the fetus between 24 to 34 weeks of gestation. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Herbal Products: Soy Relief of menopausal symptoms, osteoporosis prevention Estrasorb, applied as a lotion Adverse Effects Nausea Diarrhea Abdominal pain Estrasorb remains on skin for 8 hours Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Nursing Implications Assess baseline vital signs, weight, blood glucose levels, renal and liver function studies Assess whether the patient smokes Assess history and medication history Assess contraindications, including potential pregnancy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A woman has not taken her oral contraceptive since Monday. It is now Wednesday morning. What should she do now to prevent pregnancy? Take the two missing doses as soon as possible. Continue the drug as if no doses were missed. Start over with a new monthly pack of oral contraceptives. Resume the drug but also use a second form of birth control. Correct answer: D Rationale: Missed doses will reduce the effectiveness of the oral contraceptive, so another form of pregnancy prevention will be needed. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Before giving any uterine stimulants, assess the mother’s vital signs and fetal heart rate Uterine relaxants are used when premature labor occurs between the 20th and 37th weeks of gestation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) For bisphosphonates, ensure that patients have no esophageal abnormalities and can remain upright or in a sitting position for 30 minutes after the dose Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Estrogens and progestins Take the smallest dose needed Give IM doses deep in large muscle masses, and rotate sites Give oral doses with meals to reduce GI problems Teach patients about correct self-administration and what to do if a dose is missed Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Estrogens and progestins (cont’d) Increased susceptibility to sunburn may occur—advise patients to wear sunscreen or avoid sunlight Instruct patients to report weight gain Advise patients to complete annual follow-up examinations, including PAP smear and breast examination Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Follow specific administration guidelines carefully for administration of uterine relaxants or stimulants Monitor patient’s vital signs and fetal condition during therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Instruct patients taking fertility drugs to take the medication as ordered Advise patients to keep a journal while on fertility drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Bisphosphonates Instruct patients to take medication upon rising in the morning, with a full glass of water, and 30 minutes before eating Emphasize that patients should sit upright for at least 30 minutes after taking the medication Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) SERMs Instruct patients that the medication will need to be discontinued 72 hours before and during any prolonged immobility (such as surgery or a long trip) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Monitor for therapeutic responses Monitor for adverse effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc.