Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 34 Women’s Health Drugs

2 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Female Reproductive Functions  Female sex steroid hormones  Estrogens  Progestins  Pituitary gonadotropin hormones  Follicle stimulating hormone (FSH)  Luteinizing hormone (LH)

3 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

4 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

5 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Exogenous Estrogenic Drugs– Synthetic  Steroidal  Conjugated estrogens, estradiol transdermal, many others  Nonsteroidal  Diethylstilbestrol  No longer available in the United States

6 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Estrogens Responsible for :  Development and maintenance of the female reproductive system  Development of female secondary sex characteristics

7 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Estrogens: Indications  Treatment or prevention of disorders that result from estrogen deficiency  Atrophic vaginitis  Hypogonadism  Oral contraception (given with a progestin)  Dysmenorrhea  “Hot flashes” of menopause

8 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Estrogens: Indications (cont’d)  Treatment or prevention of disorders that result from estrogen deficiency (cont’d)  Uterine bleeding  Palliative treatment of advanced breast and prostate cancer  Osteoporosis treatment and prophylaxis  Many other indications

9 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Estrogens: Contraindications  Any estrogen-dependent cancer  Undiagnosed abnormal vaginal bleeding  Pregnancy  Active thromboembolic disorder or history

10 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

11 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Estrogens: Adverse Effects (cont’d)  Amenorrhea, breakthrough uterine bleeding  Tender breasts, fluid retention, headaches  Others

12 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Estrogens and HRT  Currently there is controversy about whether or not hormone replacement therapy (HRT) is safe  Ongoing studies

13 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Progestins  Synthetic derivatives of progesterone  hydroxyprogesterone (Hylutin)  medroxyprogesterone (Provera)  megestrol (Megace)  etonogestrel implant (Implanon)  Many others

14 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Progestins: Indications  Treatment of functional uterine bleeding caused by:  Hormonal imbalance, fibroids, or uterine cancer  Treatment of primary and secondary amenorrhea

15 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Progestins: Indications (cont’d)  Palliative treatment of some cancers and endometriosis  Prevention of threatened miscarriage  Alleviation of PMS symptoms

16 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

17 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Progestins: Adverse Effects  Liver dysfunction—cholestatic jaundice  Thrombophlebitis, thromboembolic disorders, such as PE  Nausea, vomiting  Amenorrhea, breakthrough uterine bleeding, spotting  Edema, weight gain or loss  Others

18 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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 Triphasic form most closely duplicates the normal hormonal levels of the female cycle  Newer extended cycle products  Most contain estrogen-progestin combinations

19 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

20 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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)

21 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

22 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

23 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

24 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

25 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Contraceptive Drugs: Interactions  Drugs that decrease effectiveness of oral contraceptive drugs  Antibiotics, barbiturates, isoniazid, rifampin

26 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Contraceptive Drugs: Interactions (cont’d)  Drugs that may have reduced effectiveness if given with oral contraceptive drugs  Anticonvulsants, beta-blockers, hypoglycemic drugs, oral anticoagulants, theophylline, TCAs, vitamins, hypnotics

27 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Osteoporosis  Low bone mass  Increased risk of fractures  Primarily affects women  20% with this condition are men

28 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

29 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Therapy for Osteoporosis  Calcium supplements and vitamin D may be recommended for women at high risk for osteoporosis

30 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Therapy for Osteoporosis (cont’d)  Bisphosphonates  alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), zoledronic acid (Reclast)  Selective estrogen receptor modifier (SERM)  raloxifene (Evista)  Hormone  calcitonin  teriparatide (Forteo)

31 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

32 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

33 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

34 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Therapy for Osteoporosis: Indications (cont’d)  calcitonin (Calcimar)  Treatment of osteoporosis Nasal spray (Miacalcin) most commonly used 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)

35 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Therapy for Osteoporosis: Adverse Effects  SERMs  Hot flashes, leg cramps  Increased risk of venous thromboembolism  Contraindicated if patient is near age of menopause because of possible hot flashes  Leukopenia

36 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

37 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Fertility Drugs  Various medical techniques used to treat infertility  Includes in vitro fertilization and medication therapy (ovulation stimulation)

38 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Fertility Drugs (cont’d)  clomiphene (Clomid, others)  Nonsteroidal ovulation stimulant  Blocks estrogen receptors in the uterus and brain, resulting in a false signal of low estrogen levels

39 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Fertility Drugs (cont’d)  clomiphene (Clomid, others) (cont’d)  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

40 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Fertility Drugs (cont’d)  mentropins (Pergonal)  Standardized mixture of FSH and LH  Stimulates development of ovarian follicles, leading to ovulation  May also be given to men to stimulate spermatogenesis

41 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

42 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Fertility Drugs: Indications  Used primarily to induce ovulation in anovulatory patients  Also may be used to promote spermatogenesis in infertile men

43 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Fertility Drugs: Adverse Effects  Tachycardia, phlebitis, DVT  Dizziness, headache, flushing, depression, anxiety, nervousness, fatigue  Nausea, bloating, constipation, others  Ovarian hyperstimulation, multiple pregnancies, blurred vision, breast pain, others

44 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Uterine-Active Medications  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

45 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Uterine Stimulants  Also called oxytocics  Oxytocin (hormonal drug)  Prostaglandins  Ergot derivatives  Progesterone antagonist

46 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

47 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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 E 2 ) and misoprostol (Cytotec)

48 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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)

49 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

50 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Uterine Stimulants: Adverse Effects  Hypotension or hypertension, chest pain  Headache, dizziness, fainting  Nausea, vomiting, diarrhea  Vaginal pain, cramping  Leg cramps, joint swelling, chills, fever, weakness, blurred vision

51 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

52 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

53 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Uterine Relaxants  terbutaline (Brethine)  Beta-adrenergic drug  Stimulation of beta 2 -adrenergic receptors on the uterine smooth muscle  Results in relaxation of the uterus, thus stopping premature contractions  “Off-label” use  Magnesium sulfate IV also used to stop labor

54 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Uterine Relaxants: Adverse Effects  Palpitations, tachycardia, hypertension, others  Tremors, anxiety, insomnia, headache, dizziness, others  Nausea, vomiting, anorexia, bloating, diarrhea, constipation  Hyperglycemia, hypokalemia  Dyspnea, hyperventilation, others

55 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

56 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

57 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

58 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

59 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

60 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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 exams, including PAP smear and breast exam

61 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Follow specific administration guidelines carefully for IV administration of uterine relaxants or stimulants  Monitor patient’s vital signs and fetal condition during therapy

62 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

63 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

64 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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)

65 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Monitor for therapeutic responses  Monitor for adverse effects