chapter 34 women’s health drugs 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. 2

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


Three major endogenous estrogens Estradiol (principal and most active) Estrone Estriol

Synthesized from cholesterol in ovarian follicles Basic chemical structure of a steroid

Estrogens


Steroidal Conjugated estrogens, estradiol transdermal,

estropipate, many others Nonsteroidal

Diethylstilbestrol No longer available in the United States

Exogenous Estrogenic Drugs–Synthetic


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

Estrogens (cont’d)


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

Estrogens: Indications


Any estrogen-dependent cancer Undiagnosed abnormal vaginal bleeding Pregnancy Active thromboembolic disorder or history

Estrogens: Contraindications


Thrombolytic events—most serious Nausea—most common Hypertension, thrombophlebitis, edema Vomiting, diarrhea, constipation, abdominal pain May cause photosensitivity, chloasma

Estrogens: Adverse Effects


Amenorrhea, breakthrough uterine bleeding Tender breasts, fluid retention, headaches Others

Estrogens:Adverse Effects (cont’d)


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

Estrogens and HRT: The North American Menopause Society

(NAMS) 2010


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

Continuous Combined Hormone Replacement Therapy


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)

Progestins


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

Progestins: Indications


Alone or in combination with estrogens to prevent conception

Prevention of threatened miscarriage Alleviation of PMS symptoms

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

Progestins: Indications (cont’d)


Liver dysfunction—cholestatic jaundice Thrombophlebitis, thromboembolic disorders,

such as PE Nausea, vomiting Amenorrhea, spotting Edema, weight gain or loss Others

Progestins: Adverse Effects


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

Contraceptive Drugs


Other contraceptive forms available Long-acting injectable form of medroxyprogesterone

(Depo-Provera) Transdermal contraceptive patch Intravaginal contraceptive ring

Contraceptive Drugs (cont’d)


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)

Contraceptive Drugs: Mechanism of Action


Improve menstrual cycle regularity Decrease blood loss during menstruation Decrease incidence of functional ovarian cysts

and ectopic pregnancies

Contraceptive Drugs: Other Drug Effects


Primarily used to prevent pregnancy Other uses:

Treatment of endometriosis and hypermenorrhea Production of cyclic withdrawal bleeding Postcoital emergency contraception

Contraceptive Drugs: Indications


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

Contraceptive Drugs: Adverse Effects


May also cause: Edema, dizziness, headache, depression, nausea,

vomiting, diarrhea, increased appetite, increased weight, breast changes, many others

Contraceptive Drugs:Adverse Effects (cont’d)


Drugs that decrease effectiveness of oral contraceptive drugs Antibiotics Barbiturates Isoniazid Rifampin

Contraceptive Drugs:Interactions


Drugs that may have reduced effectiveness if given with oral contraceptives Beta blockers, warfarin, tricyclic antidepressants,

vitamins, hypnotics, anticonvulsants, theophylline, and antidiabetic drugs

Contraceptive Drugs:Interactions (cont’d)


Low bone mass Increased risk of fractures Primarily affects women 20% with this condition are men

Osteoporosis


Caucasian/Asian descent Slender body build Early estrogen deficiency Smoking Alcohol consumption Low-calcium diet Sedentary lifestyle Family history

Osteoporosis: Risk Factors


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

Drug Therapy for Prevention of Osteoporosis


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?

A. The patient is on transdermal opioids for cancer pain.

B. The patient smokes 1 pack of cigarettes a day.

C. The patient drinks a glass of wine one evening a week.

D. The patient has a history of 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)

Drug Therapy for Osteoporosis


Bisphosphonates Work by inhibiting osteoclast-mediated bone

resorption, thus preventing bone loss SERMs

Stimulate estrogen receptors on bone and increase bone density

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



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



Bisphosphonates Both prevention and treatment of osteoporosis Bisphosphonates also used for glucocorticoid-

induced osteoporosis and Paget’s disease

Drug Therapy for Osteoporosis:Indications


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)

Drug Therapy for Osteoporosis:Indications (cont’d)


SERMs Hot flashes, leg cramps Increased risk of venous thromboembolism Teratogenic Leukopenia

Drug Therapy for Osteoporosis:Adverse Effects


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

Drug Therapy for OsteoporosisAdverse Effects (cont’d)


calcitonin Flushing of the face, nausea, diarrhea, and reduced

appetite teriparatide

Chest pain, dizziness, hypercalcemia, nausea, and arthralgia

denosumab Infections

Drug Therapy for OsteoporosisAdverse Effects (cont’d)



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.


Various medical techniques used to treat infertility Includes in vitro fertilization and medication therapy

(ovulation stimulation)

Fertility Drugs


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

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



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



Used primarily to induce ovulation in anovulatory patients

Also may be used to promote spermatogenesis in infertile men

Fertility Drugs: Indications


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

Fertility Drugs: Adverse Effects


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

Uterine Stimulants


Also called oxytocics Oxytocin (hormonal drug) Prostaglandins Ergot derivatives Progesterone antagonist mifepristone (RU-486)

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



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)



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)



Progesterone antagonist mifepristone (Mifeprex) Stimulates uterine contractions to induce abortion Given with a prostaglandin drug for elective abortions



Hypotension or hypertension, chest pain Headache, dizziness, fainting Nausea, vomiting, diarrhea Vaginitis, vaginal pain, cramping Leg cramps, joint swelling, chills, fever,

weakness, blurred vision

Uterine Stimulants: Adverse Effects



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.


Used to stop labor that begins before term to prevent premature birth

Generally used after the 20th week of gestation

Uterine Relaxants:Tocolytics


Uterine contractions that occur between the 20th and 37th weeks of gestation are considered premature labor

Nonpharmacologic measures Bed rest, sedation, hydration

Uterine Relaxants:Tocolytics (cont’d)


indomethacin Nonsteroidal antiinflammatory agent Inhibits prostaglandin activity

nifedipine Calcium channel blocker Inhibits myometrial activity by blocking calcium influx

Uterine Relaxants


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.

Uterine Relaxants (cont’d)


Relief of menopausal symptoms, osteoporosis prevention

Estrasorb, applied as a lotion Adverse Effects

Nausea Diarrhea Abdominal pain Estrasorb remains on skin for 8 hours

Herbal Products: Soy


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

Nursing Implications



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.


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

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



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



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



Follow specific administration guidelines carefully for administration of uterine relaxants or stimulants

Monitor patient’s vital signs and fetal condition during therapy



Instruct patients taking fertility drugs to take the medication as ordered

Advise patients to keep a journal while on fertility drugs



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



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)



Monitor for therapeutic responses Monitor for adverse effects



chapter 34 women’s health drugs copyright © 2014 by mosby, an imprint of elsevier inc

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