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NUR259 Female & Male Reproductive Therapy

Terms in this set (56)

Menarche
the start of spontaneous menstruation
Goals in Female Reproductive Therapy
1. successful contraception for women of child bearing years
2. control symptoms of menopause and continued sexual health for older women
CHC
combined hormone contraceptives (estrogen and progestin)
Estrogen
-prevents formation of dominant follicle/ovulation

-prevents LH surge

-stabilizes endometrium

-inhibits proliferation/secretory changes

-**decreases irregularity, heaviness, and cramping**
Progestin
-most are from testosterone (androgen steroid)

-balance effects of estrogen

-make endometrium less favorable

-suppress LH surge and prevent ovulation
Risks Associated with HIGH Doses of Estrogen
(use lowest dose possible, estradiol is preferred now)

1. MI
2. VTE
3. Stroke
Progestin Generations
higher efficacy, fewer effects on lipids/CHO metabolism, fewer androgenic side effects
CHC side effects
1. Increased Estrogen: cyclic breast changes, dysmenorrhea, menorrhagia, chloasma, VTE

2. Decreased Estrogen: amenorrhea, spotting

3. Increased Progestin: weight gain, depression, fatigue, decreased libido

4. Decreased Progestin: break through bleeding, headaches

Most women experience lighter, shorter, and decreased cramps
CHC Routes
1. Oral (most common)
2. Transvaginal
3. Transdermal

NO SQ/IM in USA

transvaginal and transdermal have fewer GI and cardiac risks, and less non compliance with daily dosing
Oral CHC
-effective 99.3% or 92% of the time

advantages:
-decreased blood loss
-decreased cramps
-elimination of mittelshmerz
-reduction of ovarian cysts, BBDs, PID, ectopic pregnancy, endometrial and ovarian cancer
3 Types of Oral CHC
1. Monophasic (non phasic), fixed ratio of estrogen:progestin

2. Biphasic

3. Triphasic: newest forms, lowest amounts of estrogen and progestin, the ratios change during 3 phases of the cycle, HAVE THE LEAST SIDE EFFECTS ex: Ortho Tri-CyclenLo (can be used to treat acne)
New Generation Progestin
Yasmin/YAZ: high risk hyperkalemia, fib, vtach, monophasic
Oral CHC Cycle Length
21 or 28 days

inactive pills or no pills for 7 days

last 7 days are decreasing amounts of estrogen and withdrawal bleeding occurs (not true menses)

Loestrin Fe, Micerette (help prevent anemia and headaches associated with estrogen withdrawal, reduce side effects of withdrawal bleeding, NOT withdrawal bleeding itself)
CHC that reduce withdrawal bleeding (withdrawal bleeding is not necessary)
1. Extended Cycle Products: shortened period of inactive pills, reduces number of withdrawal bleeding days
ex: Loestrin 24, YAZ, Beyaz

2. Continuous Dosing Products: 91 day regimen with 84 days active and 7 days inactive (withdrawal bleeding only 4x a year) SEASONALE/JOLESSA, or 28 day cycle with no withdrawal bleeding (LYBREL)
Ortho Evra Transdermal Patch
-worn on stomach, butt, outer arm or upper torso
- 3 weeks on, 1 week off for withdrawal bleeding
-similar advantages to oral form

disadvantages:
1. skin irritation
2. menstrual cramps
3. change in vision/contact lens issues
4. not as effective in women over 198lb
5. weight gain/weight loss, N
6. increased risk of VTE

*do NOT use in women over 35 or women that smoke, increased risk of VTE
NuvaRing (and special considerations)
-2 inch dwelling ring with estrogen and progestin

-inserted during first 5 days of menstruation

-middle or upper third of vagina

-indwelling for 3 weeks, removed for 1 for withdrawal bleeding

SPECIAL CONSIDERATIONS
-use back up method for first seven days after insertion!!!
-if it falls out must be put back within 3 hours, if not then use back up method for seven days

-increased VTE risk, vaginal irritation, discharge or infection, risks increased if patient smokes
Reasons to use Progestin ONLY pills
For women who can't take estrogen because:

1. History of VTE
2. Heart disease
3. Breast feeding
4. Smokers
5. Over 35
6. HTN
7. those who experience HA, chloasma, lipid changes
Progestin ONLY side effects
-higher incidence of irregular bleeding
-fatigue
-decreased libido
-depression/mood changes
-weight gain
Progestin ONLY
oral, SQ, IM, or implantable

oral examples: Micronor, Nor QD, Aygestin
IM example: DEPO-PROVERA
Depo-Provera
progestin ONLY, injected every 11-13 weeks,

anovulation and amenorrhea,

if patient is late for injection (13 weeks and 1 day!), must be ruled out for pregnancy (GIVE TEST)

risks of decreased bone density
should be stopped after 2 years of continuous use
patient should increase intake of calcium and vitamin D
Implantable Progestin ONLY
Nexeplon (similar to Implanon)

inserted for up to 3 years

Nexeplon contains barium (radioactive ,can be seen on tests)

NOT for women with BMI over 30

99.6% effective
Missing Doses of Contraceptives
miss 1 tab: take as soon as remember

miss 2 tabs: take 2 as soon as remember and 2 the next day, use back up for the rest of the cycle

miss 3 tabs: discard pack
Emergency Contraception
methods: CHC in documented effective regimen, Plan B (Progestin ONLY) or inserting a copper IUD
Indications for Emergency Contraception
condom breaking, diaphragm or cervical cap dislodged, dose of CHC missed

should be taken within 24 hours!!
Tocolytic Therapy
therapy to stop pre term labor of women, has cervical changes and no contraindications

ex: terbutaline, magnesium sulfate
Terbutaline (beta 2 agonist)
slows frequency and strength of uterine contraction

-2nd and 3rd trimester, usually single use
-decrease use in US due to effects on maternal and fetal CV systems


adverse effects: PALPITATIONS, tremors, malaise, weakness, dyspnea, tachycardia, high SBP, hypoglycemia
Magnesium Sulfate (calcium agonist, CNS depressant)
-used more often, preferred because it doesn't have the CV effects that terbutaline does

-decreases contraction

-increases uterine perfusion, good for fetus

-less CV effects

-loading dose over 20 min, then maintenance dose

adverse effects: flushing, increased warmth, perspiration, dizziness, N, HA

magnesium toxicity: respiratory depression, confusion, cardiac arrest, circulatory collapse
Oxytocin
-induces labor, increases uterine contraction

-S/E: HTN, dysrhythmias, uterine hyperstimulation

-A/E: seizures, H2O intoxication if given in electrolyte free solution
Menopause
starts mid 40s, ends mid 50s

typically will treat symptoms

peri menopause: cycles can become longer or shorter, irregular, insomnia, hot flashes, irritability, HA, memory lapse, decreased libido, vaginal dryness, joint aches and paints

menopause: permanent cessation of menses, similar symptoms
Premarin
indications: HRT for menopause symptoms (moderate to severe vasomotor symptoms, dryness/atrophy)

MOA: develops and maintains female genital system, breast and secondary sex characteristics

contraindications: KDA, any estrogen dependent cancers, breast cancer, undiagnosed abnormal vaginal bleeding, pregnancy, lactation, active thrombolytic disorder (stroke, thrombophlebitis, hypercoaguable states)

A/E: THROMBOLYTIC EVENTS, nvd, constipation, photosensitivity, HTN/thrombophlebitis, amenorrhea, breakthrough bleeding, chloasma, hirstuism, alopecia, tender breasts, fluid retention, HA

interactions: decrease activity of oral anticoagulants, concurrent use of rifampin and St. John's wart can decrease effectiveness, use with TCA can cause toxicity of TCA, smoking can increase risk of thrombosis
Other Therapies for Menopause
SSRI, clonidine, gabapentin, soy/red clover/black cohosh
WHI
large research program to assess possible detrimental effects of HRT

1991 HRT was found to have increased risk of breast cancer, heart disease, stroke, blood clots; decreased risk of hip fracture and colon cancer, study discontinued because of alarming events

2008 HRT beneficial for women close to the onset of menopause to relieve symptoms/decrease bone loss; however risk benefit ratio decreases with increasing age
Osteoporosis
low bone mass, increase fracture risk

-nearly 40% of women in US over 50 will develop osteoporotic fracture

-risk factors for post menopause osteoporosis:
1. white/asian descent
2. slender build
3. early estrogen deficiency
4. smoking/ETOH/low calcium diet/sedentary lifestyle/FH
Calcitonin
MOA: directly inhibits osteoclastic bone reabsorption, treats osteoporosis

contraindications in pts with allergy to salmon

A/E: flushing of the face, N/D, decreased appetite
Forteo
MOA: treats OP, acts similar to parathyroid, modulates body's metabolism of calcium and phosphorus

A/E: angina, nausea, dizziness, hypercalcemia, arthralgia
Fosamax
MOA: enhances bone mineral density to the MAX, treats and PREVENTS osteoporosis

contraindications: hypocalcemia, esophageal dysfunction, inability to sit upright or stand for 30 min after dosing

A/E: HA, GI upset, joint pain, RISK OF ESOPHAGEAL BURNS, DRINK FULL GLASS OF WATER NAD SIT UPRIGHT FOR 30 min example of old lady post colonoscopy
Menostar
estradiol transdermal patch; worry about estrogen side effects too, treats osteoporosis, ONLY for people who can't tolerate the other therapies, women who have intact uterus progestin recommended every 6-12months
Selective Estrogen Receptor Modulators (SERMs) Raloxifene
***worry about estrogen side effects again, but one thing it does is it actually decreases risk of breast cancer

***good choice for patients who had breast cancer and have osteoporosis


MOA: stimulates estrogen receptors on bones and increases bone density

A/E: hot flashes, leg cramps, thromboembolism, leukopenia
Androgens
allow for primary and secondary sex characteristics, primarily testosterone
Testosterone
androgenic activity (secondary sex characteristics)

anabolic activity (development of muscle and bone, inhibit protein catabolism)

erythropoietic effects
Risks of Testosterone
increase in LDL cholesterol, increase in triglycerides and resulting pancreatitis
Synthetic Derivatives of Testosterone
used for decreased libido and fatigue due to low serum levels of testosterone
Synthetic Derivatives of Testosterone Examples
1. testosterone propionate: oily solution lasting 2-3 days, administered every 2-4 weeks

2. methylestosterone/fluoxymesterone: effective with oral administration, buccal tablet or injectable

3. transdermal forms *risk of transfer to pregnant women or kids=BAD
Anabolic Steroids
build muscles, synthetic, not commonly used in USA, great potential for misuse in athletes and bodybuilders, Schedule III (need special script, can lead to psychological or physical dependence)

indications: anemia, hereditary angioedema, metastatic breast cancer, wasting syndrome due to HIV/cancer
Four Anabolic Steroid Products (available in US)
anadrol 50
oxandrin
winstrol
nandrolone
Androgen (testosterone) Uses
primary and secondary hypogonadism

treatment of oligospermia

inoperable breast cancer in women (counteract tumor enhancing estrogen activity, more palliative than curative)
Androderm
-transdermal patch used for HRT
-mimics natural circadian cycles of males

contraindications: severe renal/hepatic disease, male breast cancer, prostate cancer, genital bleeding
Androderm special considerations
-applied to SKIN only (vs. testoderm)

-contact with children=inappropriate enlargement of genitalia, premature development of pubic hair. advanced bone aging, increased libido, aggressive behavior

-baseline lab testing!!! (BUN, CR, LFT, CEs)!!!

-watch for weight gain and electrolyte disturbances
BPH
process begins at 30 years old, causes urinary outflow obstruction (frequency, dribbling, nocturia)
Proscar/Finesteride
MOA: reduces prostate size by inhibiting enzyme that converts testosterone to 5-alpha... (DHT), eases the passage of urine
Proscar additional effects
may increase hair growth in men

teratogenic in pregnant women and children, cannot even touch the pill, consider family taking care of pt on proscar, category X
Proscar Indications
androgenic alopecia in men, BPH to be reduced in 3-6 months, some men start to feel the effects after a couple of days
Sildenafil (Viagra)
MOA: inhibits 5-phosphodiesterase-> prolonged cGMP elevation = vasodilation, relaxation of smooth muscle, inflow of blood

*nitric oxide releases also contributes to the erectile effect
Sildenafil (Viagra) Indications
ED, take 1 hour before
Sildenafil (Viagra) Contraindications
do not use with nitrates, DANGEROUS HYPOTENSIVE EFFECT
Sildenafil (Viagra) A/E
hypotension, HA, dyspepsia, visual loss, PRIAPISM: EMERGENCY ERECTION LASTING LONGER THAN 4 HOURS, PENIS CAN BECOME NECROTIC AND NEED TO BE REMOVED
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