Transcript 12_Womens Health and Sexuality_Reproduction and Uterine

DRUGS AFFECTING
WOMEN’S HEALTH,
SEXUALITY AND
REPRODUCTION
Physiology
• Female sex hormones are responsible for:
– Female sexual characteristics,
– Developing the female reproductive
system, and
– Maintaining pregnancy.
• The two types of female sex hormones are
estrogen and progestin.
• Both are steroidal compounds that the ovaries
begin to secrete at puberty and that the
placenta secretes during pregnancy.
Pathophysiology
• Functional
– Pregnancy prevention
– Hormone replacement therapy
(menopause)
• Non-functional
– Hypogonadism
– Post-menopausal osteoporosis treatment
– Hormone replacement therapy
(hysterectomy)
– Cancer of the ovaries, uterus, cervix or
breast
Menstrual
Cycle
Estrogens
• Many different types of exogenous estrogen
exist.
• Routes of administration may be oral,
intramuscular (IM), transdermal, or topical
(as vaginal creams).
• Most of these estrogens are used for
correction of low endogenous estrogen or to
suppress ovulation in birth control products
when combined with progestins.
Prototype drug: conjugated
estrogen (Premarin)
Estrogen Contraindications
Estrogens are contraindicated in:
• Known pregnancy
• Estrogen-dependent cancers (often breast or
ovarian)
• Undiagnosed abnormal genital bleeding
• Blood clot disorders
Conjugated Estrogen: Core Drug
Knowledge
• Pharmacotherapeutics
– Used primarily in hormone replacement
therapy
• Pharmacokinetics
– Metabolism: liver. Excreted: kidneys.
• Pharmacodynamics
– Stimulates the development of the female
sex organs and secondary female sexual
characteristics
Conjugated Estrogen: Core Drug Knowledge
• Contraindications and precautions
– Black Box warning in the labels indicates that
the drug increases the risk of cardiovascular
events.
• Side effects
– Breakthrough bleeding, headache, nausea,
vomiting, bloating, abdominal cramps
• Adverse effects
– Increases the risk of stroke and coronary heart
disease
• Drug interactions
– No important drug interactions are associated
with conjugated estrogen.
Conjugated Estrogen: Planning and
Interventions
• Maximizing therapeutic effects
– Administer conjugated estrogen cyclically.
• Minimizing adverse effects
– Monitor for signs of thrombophlebitis and
thromboembolus (blood clots)
– In women with a uterus, the combination
of estrogen and progestin should always
be used to minimize the risk of
endometrial cancer.
Conjugated Estrogen: Teaching,
Assessment, and Evaluation
• Patient and family education
– Teach patients and their families about the
therapeutic purpose of estrogen.
– Don’t smoke. It increases your risk for blood
clots.
– Provide instruction on how to take the estrogen.
• Ongoing assessment and evaluation
– If the patient is a prepubescent girl, evaluate for
normal sexual development with estrogen
therapy, and monitor the patient’s growth as
appropriate.
Should we treat menopause as a medical
disease?
• Menopause is when the menstrual cycle
stops. It usually occurs naturally, most often
after age 45. Menopause happens because
the woman's ovaries stop producing the
hormones estrogen and progesterone.
• A woman has reached menopause when she
has not had a period for one year.
Reference:
http://www.nlm.nih.gov/medlineplus/menopause.html
Menopause
• Generally starts in the mid- to late-50’s
• Changes and symptoms can start several years
earlier. They include:
– A change in periods - shorter or longer, lighter
or heavier, with more or less time in between
– Hot flashes and/or night sweats
– Trouble sleeping
– Vaginal dryness
– Mood swings
– Trouble focusing
– Less hair on head, more on face
Hormone Replacement Therapy
Pros
Cons
Before & during
menopause, levels of
hormones go up & down.
HRT also has risks. It
can increase the risk of
breast cancer, heart
disease, and stroke.
This can cause symptoms
such as hot flashes &
vaginal dryness. Some
women take hormone
replacement therapy
(HRT), to relieve these
symptoms.
HRT may also protect
against osteoporosis.
If HRT is used, it should
be the lowest dose that
helps and for the
shortest time needed.
http://www.nlm.nih.gov/medline
plus/hormonereplacementtherap
y.html
Progestins
• Progestins consist of progesterone and its
derivatives.
• Through stimulation or inhibition, they
regulate secretion of pituitary gonadotropins.
• Progestins also inhibit spontaneous uterine
contractions.
Prototype drug:
Medroxyprogesterone
(progesterone)
Progesterone: Core Drug Knowledge
• Pharmacotherapeutics
– Helps produce normal menstrual cycles
• Pharmacokinetics
– Administered: oral or IM. Metabolism:
liver. Excreted: kidneys.
• Pharmacodynamics
– External progesterone affects the body in
ways similar to those of endogenous
progesterone.
Progesterone: Core Drug Knowledge
• Contraindications and precautions
– Hypersensitivity and known cardiovascular
disease. Blood clots, or cerebral hemorrhage
– Case reports of fetal abnormalities when taken
during pregnancy
– Photosensitivity may occur
• Drug interactions
– No known drug interactions are associated with
progesterone
Adverse Effects
• Common Adverse Effects
– Menstrual disorders (breakthrough bleeding,
spotting, etc.)
– Breast tenderness
– Weight changes
– Nausea
– Mental depression or Mood changes
• Serious Adverse Effects
• Progesterone may increase the risk of breast and
ovarian cancer when given in combination with
estrogen to postmenopausal women
Progesterone: Teaching, Assessment, and
Evaluation
• Patient and family education
– Instruct patients and their families on the
therapeutic and adverse effects of progesterone.
– Teach patients how to perform breast selfexamination.
• Ongoing assessment and evaluation
– Monitor premenopausal women taking
progesterone for return of normal menstrual
flow and cessation of abnormal bleeding.
Oral Contraceptives
• Contain estrogen + progesterone or just
progesterone
• Oral contraceptives are given to prevent pregnancy.
• Inhibit ovulation by suppressing the gonadotropins
FSH and LH
• Oral contraceptives should be prescribed with the
smallest effective dose of estrogen possible.
• Oral contraceptives are known to interact with
penicillins and tetracycline, St. John’s Wort and
other drugs.
Other forms of contraceptive
• Emergency Oral contraceptives
– Levonorgestrel (Plan B)
– Used after unprotected intercourse to prevent
ovulation
– Does not cause a spontaneous abortion (SAB)
• Transdermal – topical estrogen/progestin skin patch
• Vaginal Ring (NuvaRing) – estrogen/progestin ring
worn around the cervix and left in place for 3 weeks
for slow release of medication
Other forms of contraceptives
• Implanted Contraceptives (Implanon)
– Progestin rod implanted under the skin on the arm
– 99% effective for up to 3-years
• Intrauterine System Contraceptive
– T-shaped units filled with levonorgestrel (a
progestrin) left in the uterus
– Recommended for women who have already had a
child. More risk for pregnancy, pelvic inflammation
– Remain in place for 5 years
– Also used as a treatment for abnormal bleeding
due to fibroids
Drugs Affecting
Uterine Motility
Challenge Question
Which of the following hormones is responsible for uterine
contractions?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: D – Oxytocin is the naturally occurring hormone
responsible for uterine contractions.
Physiology
Contractions and related changes
• The induction of labor is related to oxytocin.
• Oxytocin receptors that are located in the
endometrium increase during labor and
reach peak levels at birth.
• Prostaglandins also have a role in preparing
the uterus for labor and delivery.
Pathophysiology
• Occasionally, uterine function does not
proceed normally.
• Two main categories of obstetric situations
require drug administration to initiate the
onset of contractions:
– Labor that does not begin at term
(delayed labor)
– Pregnancy that is detrimental to the
patient or her fetus (dangerous
pregnancy)
Pathophysiology
• Pregnancy that is detrimental to the patient
or her fetus (dangerous pregnancy):
– Gestational or chronic hypertension
•Pre-eclampsia or eclampsia
– Post-term gestation (late)
– Premature Rupture of the Membranes
(Amniotic sac) near term with lung
maturity in fetus
– Severe Intrauterine Growth Restriction
Oxytocics
• Oxytocic drugs are synthetic forms of the
endogenous posterior pituitary hormone
oxytocin.
• They produce uterine contractions and milk
ejection for breast-feeding.
Prototype drug: oxytocin (Pitocin)
Oxytocin: Core Drug Knowledge
• Pharmacotherapeutics
– Given by continuous IV drip infusion to initiate
or augment (improve) labor contractions
• Pharmacokinetics
– Administered: IV. Onset: immediate.
Elimination: liver, kidneys, and mammary
glands.
• Pharmacodynamics
– Synthetic, exogenous oxytocin has the same
effects on the body as natural, endogenous
oxytocin.
Oxytocin: Core Drug Knowledge (cont.)
• Contraindications and precautions
– Cephalopelvic disproportion and unfavorable fetal
positions. Can cause mechanical harm to the fetus.
• Side effects
– Nausea, vomiting, uterine hypertonicity
• Adverse effects
– Cardiac arrhythmias
– Fatal water toxicity has occurred due to its effects on
the renal system
• Drug interactions
– Sympatho-mimetic drugs
Oxytocin: Teaching, Assessment and
Evaluation
• Patient and family education
– Educate the patient and family about the rationale
for oxytocin use.
– Explain that the patient and fetus will be monitored
closely.
• Ongoing assessment and evaluation
– Throughout induction, monitor continually for
evidence of adverse maternal or fetal effects.
Challenge Question
Which of the following can be severe adverse effects of
oxytocin?
A. Water intoxication
B. Uterine rupture
C. Impaired fetal oxygenation & CNS damage
D. Premature ventricular contractions and other cardiac
arrhythmias
ANSWER: All of the above!
Tocolytics
• Drugs that inhibit uterine activity are classified as
tocolytics.
• Tocolytics should be used with corticosteroids
to prevent respiratory complications in the
premature newborn.
• Preterm labor is the medical complication
requiring the administration of tocolytics.
• Tocolytics are used when true labor begins after 20
weeks’ gestation and usually before completion of
the 34th gestational week.
Prototype drug: terbutaline (Brethine)
Terbutaline: Core Drug Knowledge
• Pharmacotherapeutics
– Off-label to control preterm labor in pregnancies
of 20 to 34 weeks
• Pharmacokinetics
– Administered: SC or oral. Onset of action is
faster when given SC.
• Pharmacodynamics
– Cholinergic beta-receptor agonist that inhibits
contractility of uterine smooth muscle.
Terbutaline: Core Drug Knowledge (cont.)
• Contraindications and precautions (many)
– Contraindicated before the 20th week of pregnancy
– Cannot use for longer than 48-72 hours d/t high risk of
maternal cardiovascular events
• Side effects
– Nausea, and vomiting
– Tachycardia, hypotension, dyspnea, nervousness,
transient hyperglycemia,
• Adverse effects
– pulmonary edema, cerebral and myocardial ischemia,
• Antidote for terbutaline
– Beta adrenergic antagonist propanolol (Inderal)
Terbutaline: Planning and Interventions
• Maximizing therapeutic effects
– Begin drug therapy as soon as possible after
preterm labor is diagnosed.
• Minimizing adverse effects
– Closely monitor the patient’s fluid status and
avoid fluid overload.
– If the patient demonstrates signs of adverse
effects, the dosage of terbutaline should be
decreased.
Terbutaline: Teaching, Assessment, and
Evaluation
• Patient and family education
– Educate the patient and family about the therapeutic
and adverse effects of the drug.
– Have patient lie on her left side for better blood flow
to the fetus.
• Ongoing assessment and evaluation
– Monitor the maternal heart rate, FHR, and maternal
blood pressure and fluid status throughout
terbutaline therapy.
– Listen to lungs for signs of pulmonary edema
Magnesium Sulfate
• Pharmacotherapeutics
– A trace mineral used to correct electrolyte
imbalances (orally) and in obstetrics to prevent
seizures associated with pre-eclampsia/eclampsia, a
disorder of pregnancy-induced hypertension.
– Rarely can be used as a tocolytic
• Pharmacokinetics
– Absorbed orally, IM and intravenously (IV drip)
• Pharmacodynamics
– CNS and muscular system depressant producing
peripheral neuromuscular blockade.
– Antagonizes calcium.
Magnesium Sulfate
Side Effects
Adverse Effects
Minor
Serious
– Headache
Circulatory collapse
– Hypo-reflexia
Respiratory depression
– Weakness
Pulmonary edema
– Thirst
Cardiac depression
– Flushing
Cardiac arrhythmias esp.
– Sweating
– Hypotension
with overdosage
Magnesium Sulfate
• Maximizing therapeutic effects/
• Minimizing adverse effects
– Monitor serum magnesium levels
– Monitor cardiac functioning
– Place on bedrest
– Keep calcium gluconate at bedside to use as an
antidote if needed
• Ongoing assessment and evaluation
– Vital signs esp. blood pressure
– Check deep tendon reflexes
NCLEX STYLE QUESTION #1
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NCLEX STYLE QUESTION #9
NCLEX STYLE QUESTION #10
Ms. Lopez has an IV infusion of magnesium sulfate
following delivery. What would indicate to the nurse that
the patient is having a serious adverse reaction to the
medication?
A. Difficulty breathing
B. Decreased deep tendon reflexes
C. Flushing
D. A drop in her blood pressure
ANSWERS:
1. D – Leg pain may be a sign of a blood clot
2. C – Osteoporosis can result from long-term use of
progestin
3. D – Progesterone is used with estrogen to reduce
the risk of endometrial cancer
4. D – A 25 year old with primary ovarian failure is
the only safe option.
5. B – Oral contraceptive pills suppress ovulation.
ANSWERS:
6. B – A tocolytic (used to stop or slow labor)
7. D – a 25 year old with diabetes.
8. C – Premature birth is avoided for 24-hours
9. C – Oxytocin is the hormone responsible for the
induction of labor.
10. A – Difficulty breathing. Respiratory distress and
pulmonary edema can be serious adverse
events with magnesium sulfate infusions.