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Chapter 56 Drugs for Women’s Reproductive Health and Menopause Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 1 Estrogen-Progestin Combination Products (CHC) First generation Second generation Third generation New generation Drospirenone (DSRP): New-generation progestin derived from spironolactone Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Mechanism of Action Inhibits ovulation by preventing the formation of a dominant follicle Delivery: oral, transdermal, transvaginal Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 Combined Oral Contraceptive Products (COC) One of the most commonly used methods of reversible contraception in the world because of their ease of use, high degree of effectiveness, and relative safety Differentiated based on the strength of the estrogen component, type of progestin used, and whether estrogen or progesterone (and androgen) activity predominate Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Types of COC Monophasic Biphasic Triphasic Types of COC pills have also been categorized as “phasic” and “non-phasic” pills. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 New Generation Progestin Yasmin Femcon Fe Generess Fe Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Withdrawal Bleeding Pseudomenstruation 28-day oral contraception pills that provide medication during the 7-day hormone-free period: Estrostep Fe, Loestrin Fe 1.5/30, Loestrin Fe 1/20, Loestrin 24 Fe, and Generess Fe Researchers have established that a monthly episode of withdrawal bleeding is not necessary to maintain a healthy uterus. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Extended-Cycle COC Products Loestrin 24 Fe Yaz Beyaz Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Continuous Dosing COC Products Seasonale Seasonique LoSeasonique Lybrel Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Ortho-Evra Transdermal Patch Patch that is placed once a week for 3 weeks in a row Fourth week is patch-free to allow for withdrawal bleeding. Patch works in a similar manner to COC pills by inhibiting ovulation, thickening cervical mucus to prevent sperm penetration, and preventing a fertilized egg from implanting in the uterus. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 NuvaRing Transvaginal Contraception 2-inch–diameter flexible indwelling ring inserted into the vagina Non-biodegradable, transparent, and colorless or almost colorless Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Progestin-Only Contraception Products The progestin-only oral contraception pill (POP), also called the minipill Taken continuously, without a break for withdrawal bleeding Micronor, Nor-QD, Aygestin Ovrette Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Depo-Provera Highly effective, long-acting injectable progestin in the form of depot-medroxyprogesterone acetate (DMPA or MPA) Anovulation and amenorrhea Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Implantable Progestins Nexplanon Single-rod device that contains progestin etonogestrel Lasts 3 years Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Start Date and Dosing Schedules First-day start method Sunday start Quick start Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Side Effects Excess of estrogens Nausea, vomiting, dizziness Fluid retention, edema, bloating Breast enlargement, breast tenderness Chloasma Leg cramps Decreased tearing, corneal curvature alteration, visual changes Vascular headache Hypertension Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Side Effects (Cont.) Estrogen deficiency Vaginal bleeding (breakthrough bleeding, especially in the first few cycles after starting therapy) that lasts several days (usually during days 1 to 14) Oligomenorrhea (very scant periods) especially after long-term use Nervousness Dyspareunia (painful sexual intercourse) secondary to atrophic vaginitis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Side Effects (Cont.) Excess progestin Increased appetite, weight gain, oily skin and scalp, acne, depression, vulvovaginal candidiasis (vaginitis from the yeast microbe candida), excess hair growth, decreased breast size, and amenorrhea after cessation of use (1% to 2% of patients) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Side Effects (Cont.) Progestin deficiency Dysmenorrhea, bleeding late in the cycle (days 15 to 21), heavy menstrual flow with clots, or amenorrhea Changes in laboratory values, including thyroid and liver function, blood glucose, and triglycerides Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Nursing Process: Hormonal Methods of Contraception Assessment Nursing diagnoses Planning Nursing interventions Patient teaching Cultural considerations Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Other Methods of Contraception Spermicides Barrier methods Intrauterine contraception Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Emergency Contraception Combined hormone contraceptive pills Plan B ParaGard Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Menopause Transitional process experienced by women as they move from the reproductive years into the nonreproductive stage of life Perimenopause or premenopause Menopause Postmenopause Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 Perimenopause Most common symptoms are hot flashes (caused by a surge in LH levels) and vaginal dryness (caused by estrogen withdrawal). Other symptoms include insomnia, headaches, irritability, anxiety or other variations in mood, cognitive difficulties, memory lapses, joint aches, and decreased libido. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Menopause (Cont.) Permanent end of spontaneous menstruation caused by cessation of ovarian function This natural event is documented as having occurred once a woman has stopped menstruating for 1 year. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25 Postmenopause Stage when the body adapts to a new hormonal environment Production of estrogen and progesterone from the ovaries decreases Hormone therapy (HT) improves vasomotor symptoms and vaginal dryness and decreases risk of osteoporosis and osteoporotic fractures. Boxed warning: HT should be used only for the treatment of menopausal symptoms, at the lowest dose possible, for the shortest duration possible, usually less than 5 years. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Perimenopausal and Menopausal Symptoms Complementary and alternative medicine Natural soy and soy derivatives Red clover extract Actaea racemosa, or black cohosh Vitamin E Evening primrose oil St. John’s wort Ginseng Valerian Melatonin Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Perimenopausal and Menopausal Symptoms (Cont.) Bioidentical hormone therapy Estrogen-like compounds that have been derived from plants Custom-made for the patient under the direction of the health care provider Estrone, estradiol, estriol, testosterone, and micronized progesterone Tri-est and Bi-est Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Hormone Therapy (HT) HT includes: Estrogen-progestin therapy (EPT) for use with women who have an intact uterus Estrogen therapy (ET) for use with women who have had a hysterectomy (surgical removal of the uterus) Dosage forms Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Contraindications to Hormone Therapy Pregnancy History of endometrial cancer Personal history of breast cancer History of thromboembolic disorders Acute liver disease or chronic impaired liver function Active gallbladder or pancreatic disease Coronary artery disease (CAD) Undiagnosed vaginal bleeding Endometriosis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30 Other Drugs for Menopausal Symptoms SSRIs Clonodine Gabapentin Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Osteoporosis Progressive, debilitating skeletal disease that affects older men and women HT is no longer recommended for the treatment of osteoporosis but should be considered as a preventive measure in postmenopausal women who are at risk Bisphosphonates Selective estrogen receptor modulators (SERMs) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Osteoporosis (Cont.) Prevention Calcium Vitamin D Weight-bearing exercises Medications Menostar (estradiol transdermal system) Alendronate (Fosamax) Ibandronate sodium (Boniva) Risedronate (Actonel) Reclast Raloxifene (Evista) Teriparatide (Fortéo) Salmon calcitonin (e.g., Fortical, Miacalcin) Denosumab (Prolia) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33 Practice Question #1 Considering common concerns of teenage girls, which oral contraceptive benefit does the nurse realize would be most likely to motivate use? A. B. C. D. Protection against breast disease Dysmenorrhea relief Reduction in iron deficiency anemia Decreased risk of endometrial cancer Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Practice Question #2 A patient is taking Tri-Levlen and reports the most troubling side effect to be depression. The patient has also experienced weight gain. The nurse knows that these are usually associated with A. B. C. D. estrogen deficiency. progestin deficiency. excess progestin. excess of estrogen. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Practice Question #3 What information will the nurse include when teaching a patient about hormonal methods of contraception? A. “You will need to have at least two mammograms a year because you are now at an increased risk of developing breast cancer.” B. “You can expect your menstrual flow to be heavier and longer.” C. “Call your health care provider immediately if you experience severe abdominal pain, chest pain or shortness of breath, headaches, eye disorders, or severe leg pain or swelling.” D. “You may experience a possible increase in libido.” Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 Practice Question #4 The nurse identifies which condition as a contraindication to hormone replacement therapy? A. B. C. D. Diabetes mellitus Depression Renal failure Breast cancer within the last 5 years Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 37 Practice Question #5 Which information will the nurse include when teaching a patient about DepoProvera? A. Menstruation ceases one month after receiving Depo-Provera. B. Do not take Depo-Provera if you are breastfeeding. C. Increase calcium and vitamin D in your diet. D. Depo-Provera is administered once a week. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 38