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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)
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
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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.
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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.
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Types of COC
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
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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.
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New Generation Progestin



Yasmin
Femcon Fe
Generess Fe
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Withdrawal Bleeding
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
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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.
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Extended-Cycle COC Products
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

Loestrin 24 Fe
Yaz
Beyaz
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8
Continuous Dosing COC Products
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Seasonale
Seasonique
LoSeasonique
Lybrel
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9
Ortho-Evra Transdermal Patch
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

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
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
2-inch–diameter flexible indwelling ring
inserted into the vagina
Non-biodegradable, transparent, and
colorless or almost colorless
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11
Progestin-Only Contraception
Products
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The progestin-only oral contraception pill
(POP), also called the minipill
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

Taken continuously, without a break for withdrawal
bleeding
Micronor, Nor-QD, Aygestin
Ovrette
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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
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Nexplanon
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Single-rod device that contains progestin
etonogestrel
Lasts 3 years
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14
Start Date and Dosing Schedules
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

First-day start method
Sunday start
Quick start
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15
Side Effects
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Excess of estrogens
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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.
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Side Effects (Cont.)

Estrogen deficiency
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


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.
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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
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
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
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
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
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Spermicides
Barrier methods
Intrauterine contraception
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21
Emergency Contraception
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
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Combined hormone contraceptive pills
Plan B
ParaGard
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22
Menopause



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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
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
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.
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Postmenopause
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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
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Complementary and alternative medicine
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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
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27
Perimenopausal and Menopausal
Symptoms (Cont.)

Bioidentical hormone therapy
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

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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
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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
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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
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

SSRIs
Clonodine
Gabapentin
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31
Osteoporosis

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
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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.)
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Prevention
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Calcium
Vitamin D
Weight-bearing exercises
Medications
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Menostar (estradiol transdermal system)
Alendronate (Fosamax)
Ibandronate sodium (Boniva)
Risedronate (Actonel)
Reclast
Raloxifene (Evista)
Teriparatide (Fortéo)
Salmon calcitonin (e.g., Fortical, Miacalcin)
Denosumab (Prolia)
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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