Female Reproductive Drugs

14. Considering common concerns of teenage girls, which oral contraceptive benefit does the nurse realize would be most likely to motivate use?

Dysmenorrhea relief

Dysmenorrhea

Dysmenorrhea, also called cyclic pelvic pain (CPP), is pelvic pain associated with the menstrual cycle. Other symptoms that may occur with the menstrual cycle are uterine cramping, lower back pain, abdominal cramps, changes in bowel patterns, increased bowel movements, & nausea & vomiting Primary dysmenorrhea is diagnosed when there is no apparent underlying pathology Secondary dysmenorrhea, there is an underlying cause for the pelvic pain. Conditions that may cause secondary dysmenorrhea are urinary tract infections (UTIs), PID, irritable bowel syndrome (IBS), uterine leiomyomata (fibroids), & endometriosis.

Carcinogenesis

ESTROGEN CAN CAUSE CANCER Long-term use of CHCs may increase the risk for breast cancer in younger women, but the risk is minimal. There is also an increased risk for benign liver tumors. Risk for cervical cancer is slightly increased, which is thought to be because CHCs change cervical epithelium, making it more susceptible to the high-risk pathogenic strains of human papillomavirus (HPV) & because condoms may be used less frequently in prevention of STIs. Women who use hormonal methods of contraception have a greatly reduced risk for ovarian & endometrial cancers. Nursing Process: Patient-Centered Collaborative Care Obtain a record of the patient's drug, supplement, and complementary and alternative medicine (CAM) use. Obtain baseline vital signs that include temperature, pulse, and respirations; blood pressure (BP); weight; and height. Calculate BMI, and report any abnormal findings. Obtain a complete menstrual history that includes age at menarche, menstrual pattern, cycle length, duration, & amount of bleeding and the first day of the last menstrual period (LMP). A detailed history of the menstrual cycle in reproductive-age and climacteric women should be considered as another vital sign. Determine pregnancy status. Obtain a family medical history specific to contraindications for CHCs and progestin contraceptives. Obtain a family history of premenopausal breast cancer. Assess for domestic violence, intimate partner violence, & past or recent sexual abuse/assault. Obtain a medical history, assessing for history of allergies to drugs, smoking, hypertension, & the contraindications to CHCs

8. A patient is taking a combined hormonal contraceptive 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. estrogen deficiency. b. progestin deficiency. c. excess progestin. d. excess of estrogen.

Excess progestin.

Guidelines for Missed Doses of Oral Contraceptives

Guidelines for Missed Doses of Oral Contraceptives 1) Combined Hormonal Contraceptives One Tablet Take the tablet as soon as the missed dose is realized. Take the next tablet as scheduled. Two Tablets Take 2 tablets as soon as the missed dose is realized and 2 tablets the next day. Use a back-up method of contraception for the rest of the cycle. Three Tablets Discontinue the present pack and allow for withdrawal bleeding. Start a new package of tablets 7 days after the last tablet is taken. Use another form of contraception until tablets have been taken for 7 consecutive days. 2) Progestin-Only Pills One or More Tablets Take the tablet as soon as the missed dose is realized, and follow with the next tablet at the regular time plus use a back-up method of contraception for 48 hours. 3) Absolute Contraindications Pregnancy (known or suspected) Venous thrombosis history or risk factors Vascular disease, including coronary artery disease and cerebrovascular accident (CVA) and past or current history of deep venous thrombosis (DVT) or pulmonary embolism Liver disease, including cirrhosis, viral hepatitis, & benign or malignant liver tumors Undiagnosed vaginal bleeding or known or suspected endometrial cancer Breast cancer Tobacco use of more than 15 cigarettes per day in a patient older than 35 years of age Cautious Use Hypertension with associated vascular disease Hypertension with blood pressure greater than 160/100 Hyperlipidemia Diabetes mellitus complicated by neuropathy, retinopathy, nephropathy, or vascular disease Diabetes mellitus for more than 20 years' duration Postpartum fewer than 3 weeks Lactation fewer than 6 weeks Age greater than 35 years & smoking fewer than 15 cigarettes per day Hypercoagulation disorders Prolonged immobility Use of drugs that affect liver enzymes (e.g., anticonvulsants, rifampin)

Pharmacologic Therapy for Perimenopausal & Menopausal Symptoms Hormone Therapy

HT is used only for the relief of symptoms related to menopause, most commonly hot flashes, vaginal dryness, & associated sleep disorders. 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. The nurse should determine whether the patient has had a hysterectomy in the past prior to administration of HT. It is the estrogen component in HT that relieves the symptoms of menopause Contraindications Pregnancy, h/o 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. Lifestyle factors such as smoking, known to enhance the risk of thromboembolism, should be considered in the treatment decision. The patient with a history of fibroid tumors is not started on HT for a full year after the last menstruation, because estrogen would likely result in tumor growth. Other Drugs for Menopausal Symptoms SSRIs and SNRIs reduce the number and severity of vasomotor symptoms in women. SSRIs also have the added benefit of reducing depression, which may relieve the irritability and mood changes associated with menopause. Gabapentin is an antiseizure drug that reduces the number and severity of nocturnal vasomotor symptoms in menopausal women. It should be administered in a single dose at bedtime. Clonidine, a drug used for hypertension, also reduces the number & severity of vasomotor symptoms in women. Blood pressure must be monitored at regular intervals, & the drug is discontinued if hypotension occurs.

13. Which information will the nurse include when teaching a patient about denosumab?

Increase calcium and vitamin D in your diet

Drugs Used to Promote Fertility

Infertility is defined as the inability to conceive a child after 12 months of unprotected sexual intercourse. Women older than 35 years may be considered infertile after 6 months of attempting pregnancy. Infertility is considered primary infertility if a couple has never conceived or has never carried a pregnancy to term. Secondary infertility describes a couple who has conceived & brought a pregnancy to term but is unable to conceive afterward Drugs Used to Promote Fertility - Clomiphene citrate (CC) Uses : Ovulation stimulant Contraindications: Pregnancy, undiagnosed vaginal bleeding, depression, fibroids, hepatic dysfunction, thrombophlebitis, primary pituitary or ovarian failure Side Effects: Breast discomfort, fatigue, dizziness, depression, anxiety, nausea, vomiting, constipation, increased appetite, headache, flatulence, multiple gestation, hot flashes, fluid retention

5. An 18-year-old woman calls the clinic office & tells the triage nurse that she had sex last night & the condom broke. She is concerned about unintended pregnancy. Which statement made by the triage nurse is the best advice for this patient? a. Levonorgestrel (systemic) progestin is available over the counter. b. You should make an appointment with the provider for a prescription of ulipristal acetate. c. You have time to wait a few days to make a decision. d. The provider can insert an intrauterine device. I will make an appointment for you.

Levonorgestrel (systemic) progestin is available over the counter.

Female Reproductive Drugs

Medications that affect the reproductive system include hormones that stimulate puberty, such as estrogen & progesterone in females & testosterone in males. These hormones are also used to replace a hormonal deficiency (male or female) or prevent pregnancy in women (oral contraceptives). Estrogens are hormones needed for growth & maturation of the female reproductive tract & secondary sex characteristics. Estrogens block bone resorption & reduce low-density lipoprotein (LDL) levels. At high levels, estrogens suppress the release of a follicle-stimulating hormone (FSH) needed for conception. Medication Classification: Estrogens Conjugated equine estrogens: Premarin Other Medications: - estradiol: Estrace, Vagifem - estradiol hemihydrate: Estrasorb Estrogens uses ■ Contraception ■ Relief of moderate to severe postmenopausal symptoms, such as hot flashes, mood changes ■ Prevention of postmenopausal osteoporosis ■ Treatment of dysfunctional uterine bleeding ■ Treatment of moderate to severe symptoms of vulvar atrophy ● Route of administration: - oral, transdermal, intravaginal, IM, & IV ■ Transdermal therapy reduces incidents of nausea & vomiting ■ A smaller dose can be prescribed that reduces fluctuation of blood estrogen levels & risk of complications Disadvantages of transdermal: Skin reactions, menstrual cramps, some bleeding issues Adverse Effects Nursing Interventions/Client Education Endometrial & ovarian cancers when prolonged estrogen is the only postmenopausal therapy Embolic events: MI, pulmonary embolism, DVT, stroke Potential risk for estrogen-dependent breast cancer › Rule out estrogen-dependent breast cancer prior to starting therapy. › Encourage clients to examine their breasts regularly. › Also, obtain yearly breast exams by a provider, & receive periodic mammograms. › Administer progestins along with estrogen. Instruct clients to report persistent vaginal bleeding if they have an intact uterus. Advise clients to have an endometrial biopsy every 2 years & yearly pelvic exam. › Women over 60 have increased risk of myocardial infarction & coronary heart disease (CHD) › Encourage clients to avoid all nicotine (vasoconstrictor) products. - Do not apply on breasts/waistline as it feeds cancer - Monitor for masses, lumps & abnormal bleeding › Monitor for pain, swelling, warmth, or erythema of lower legs. › Teach clients how to reduce risk of cardiovascular disease. Contraindications/Precautions Client or family history of heart disease. Abnormal vaginal bleeding that is undiagnosed. Breast or estrogen-dependent cancer. History or risk of thromboembolic disease. - Dysmenorrhea TOO MUCH ESTROGEN: BLOOD CLOTS!!! ESTROGEN SUPPRESSES FSH, PREVENTING PREGNANCY DO YOU HAVE A H/O DVT/DIABETES/CAD/ATRIAL FIBRILLATION? IF YES, THEY'RE NOT CANDIDATES FOR ESTROGEN. CHECK FOR CALF PAIN, CHEST PAIN, ABDOMINAL PAIN, CHECK BACK OF CALF ● Use cautiously during breastfeeding because estrogens decrease quantity & quality of milk & may be excreted in breast milk. ● Use cautiously in prepubescent girls. If administered, monitor bone growth & check periodically for early epiphyseal plate closure

Pharmacologic Management of Irregular Bleeding

NSAIDs can be used for the treatment of menorrhagia (regular uterine bleeding greater than 80 mL or lasting more than 7 days) NSAIDs block the production of prostaglandin, which decreases both excessive bleeding & uterine cramps. Common NSAIDs used for menorrhagia are mefenamic acid, ibuprofen, and naproxen sodium Major side effect: GI bleed, take with food

Nursing Process: Patient-Centered Collaborative Care

Obtain a complete obstetric and gynecologic history that includes gravida, parity, abortion (spontaneous, therapeutic, or elective); age at first and last pregnancy; time frame between pregnancies; complications during pregnancy, delivery, and postpartum; genetic anomalies and health of children; time since the last Papanicolaou (Pap) test; history of abnormal Pap testing; history of gynecologic and/or sexual infections; gynecologic problems and/or surgeries; and gynecologic anomalies. Obtain a complete sexual history that includes sexual expression and sexual risk practices, history of STIs & treatment, & past or present sexual abuse &/or assault. Recognize the need for periodic reassessment of baseline data and side effects. Most patients should be seen 1 to 3 months after beginning a contraceptive regimen. Nursing Diagnoses Knowledge, Deficient regarding reproduction, reproductive health, and self-care Decisional Conflict related to contraception methods Decisional Conflict with the partner regarding the contraceptive method choice and/or family planning Knowledge, Deficient regarding contraceptive method(s) and appropriate use Fear related to contraceptive method side effects Infection, Risk for Decisional Conflict related to a discrepancy between cultural and/or religious beliefs & the choice of contraception Planning Patients with contraindications to hormonal contraception will be determined by evaluation of risk-benefit. The patient will understand the difference between combined hormonal contraceptives & progestin contraceptives and their various routes of administration. The patient will verbalize understanding of the bleeding patterns associated with both types of contraceptives by reporting menstrual changes that occur. The patient will choose a contraceptive method suitable for her lifestyle and health status. The patient will understand the benefits, risks, & alternatives Starting method, dosing schedule, and use of contraceptive method chosen will be explained at the patient's level of understanding. For reporting symptoms of dangerous cardiovascular side effects to the health care provider, explain the ACHES acronym: abdominal pain (severe); chest pain or shortness of breath; headaches (severe), dizziness, weakness, numbness, or speech difficulties; eye disorders, which includes blurring or loss of vision; and severe leg pain or swelling in the calf or thigh. The patient will take oral contraceptives as prescribed & will report side effects that occur. The patient will place the contraceptive patch as prescribed & will report adverse side effects that occur. The patient will demonstrate and report comfort with placement of the transvaginal ring & will report adverse side effects that occur. The patient will be aware of the specific scheduling needed for progestin-only pills. The patient will understand initiation & scheduling of DMPA injections & the need for weight-bearing exercises and calcium supplementation. The patient will be given time to ask questions related to reproductive health, method choice, benefits and risks, alternatives, & use of the method. Follow-up appointments will be scheduled as needed. Patient Teaching Remind patients that these drugs should be used only under the direction of a qualified health care provider. Advise patients that concurrent use of some drugs and herbal products decreases the effectiveness of hormonal contraceptives. Patients should use a second form of contraception during use of these drugs and herbal supplements and possibly as long as 7 days after discontinuing counteracting drugs. Patients will understand that hormonal methods of contraception do not prevent transmission of STIs or the pathogen that causes HIV infection & AIDS. If a patient is at risk for STI or HIV infection, condoms should be used concurrently with the CHC method, and safe-sex practices should be discussed. Inform patients regarding proper condom use. Patient Teaching Counsel patients not to smoke tobacco because of increased cardiovascular risks. Advise patients to use a barrier method of contraception as needed during the first 7 days of contraception use if the method is started 5 days or more after the first day of the menstrual period. Instruct patients on how to use barrier methods properly. Teach patients about how to manage missed pills. Provide instruction for missed POPs and on patch, ring, and injection methods. Review instructions for emergency contraception. Advise patients to report any effects from hormonal contraception to their provider so therapy can be adjusted to suit patient needs. Encourage patients not to discontinue use of the method until an adequate trial time frame has been completed, which should be at least 3 to 6 months. Counsel patients that health care professionals should be advised of CHC use before surgery in which immobilization for an extended period may be needed. Encourage patients to report any irregular bleeding or BTB. A change in dose or type of hormonal contraceptive method may be advised. Advise patients to always report use of hormonal contraceptives when seeing a health care provider because of possible synergistic or antagonistic responses to other drugs and therapies. Advise nursing mothers that the use of CHCs may decrease the quantity & quality of breast milk. Advise patients that rare but serious side effects can occur, including VTE, MI, CVA, and retinal vein thrombosis. Encourage patients to notify their health care provider immediately if any of these symptoms occur. Advise patients that menstrual flow may be less in amount and duration because of thinning of the endometrial lining with CHCs and progestin contraceptives. Advise patients of menstrual changes that can occur at the start of combined estrogen-progestin contraception use, when changing types of hormonal contraception products, and with progestin contraceptives. Determine whether the patient wears contact lenses, and discuss how to handle alterations in the shape of the cornea and dry eyes caused by decreased tearing. Counsel patients who experiences post-CHC amenorrhea that 95% of women have regular periods within 12 to 18 months. Advise her that those who participate in endurance fitness activities may have increased post-CHC amenorrhea. Advise patients of a possible decrease in libido caused by an alteration in vaginal secretions & decreased levels of testosterone. Ensure that patients understand the ability to return to fertility after discontinuing a hormonal contraception product & the time frame in which pregnancy can be expected. Ensure a safe transition between contraceptive methods if a change in method is desired.

Osteoporosis

Osteoporosis is a progressive, debilitating skeletal disease that affects older men and women. - Women older than 50 years are at greatest risk because the loss of estrogen during menopause is directly related to loss in BMD. The loss of bone structure & "porous bone" fragility lead to an increased risk for fractures. Osteoporosis has significant morbidity & mortality in the US. The most serious fracture site is the hip, & hip fracture is the second most common reason for older women to be placed in nursing homes, exceeded only by Alzheimer disease. Osteopenia (low BMD) or osteoporosis (a severe decline in BMD). The World Health Organization (WHO) defines osteopenia & osteoporosis by translating the results of the DXA scan into a T score. Normal BMD is a T score of −1 or greater. Osteopenia is defined by a T score of −1 to −2.5, & Osteoporosis is defined by a T score of −2.5 or less.

Progestin Contraceptives

Progestin contraceptives do not contain estrogen The estrogen component of contraceptives increases the risk of circulatory disorders. Advantages of progestin contraceptive: - relative safety, ease of use, spontaneity of sexual intercourse, & reversibility. Because the estrogen component is missing, these products have a higher incidence of irregular bleeding & spotting as well as the possibility of depression, mood changes, decreased libido, fatigue, & weight gain. Progestin contraceptives do not protect women against STIs. Women who cannot take estrogen but may be candidates for progestin contraceptives include patients with a personal or strong family history of VTE or heart disease, breastfeeding patients, smokers older than 35 years of age, & women with uncontrolled hypertension Women who have an untoward response to estrogenic effects such as chloasma, migraine headaches, or changes in lipid profiles may also be candidates for progestin contraceptives. Progestin-Only Oral Contraceptive Pills Minipill 1) it alters cervical mucus, making it thick and viscous, which blocks sperm penetration 2) it interferes with the endometrial lining, which makes implantation difficult 3) it decreases peristalsis in the fallopian tubes, slowing the transport of ovum; and 4) in approximately 50% of cycles, it interferes with the LH surge, inhibiting ovulation. Patients should be instructed to take the minipill daily within a 3-hour window. If the minipill is taken more than 3 hours late, a back-up contraceptive method should be used for 48 hours. There are no placebo pills in a pack of progestin-only pills. All 28 pills contain active hormones, so the patient continuously takes one active pill daily Depot Medroxyprogesterone Acetate (Depo-Provera injection) Depot medroxyprogesterone acetate (DMPA) is a highly effective, long-acting injectable progestin with theoretic & typical use efficacy rates of 99% & 97%, respectively. This makes DMPA one of the most effective hormonal methods of contraception. Injectable progestin is administered in a flexible dosing schedule every 11 to 13 weeks The DMPA vial or prefilled syringe should be vigorously shaken just prior to administration to ensure a uniform drug suspension. DMPA 150 mg/1 mL is given by deep IM injection into the ventral gluteus or deltoid muscle. ****The site should not be massaged after injection, & the injection site must be documented so that sites can be rotated****.IF 1 TO 2 DOSES ARE MISSED, OK DOUBLE UP- MORE: START CYCLE AGAIN. The patient is given a personalized calendar for subsequent doses & should return for another injection within 13 weeks. If the patient is late for her injection (e.g., 13 weeks and 1 day), pregnancy should be ruled out before she receives another injection. Women taking DMPA should be instructed to increase calcium & vitamin D intake to the daily recommended allowance for their age & to participate in regular weight-bearing exercises. The most common side effects include initially irregular uterine bleeding or spotting. Menstruation may cease about 1 year after starting. Side effects include breast tenderness and an increase in depression. The drug is contraindicated in cases of undiagnosed vaginal bleeding and known or suspected pregnancy. Caution in giving to women who are at risk for or have a history of postpartum depression. Women taking DMPA have a slower return to fertility than those using other hormonal methods of contraception. Progestin Implant A progestin implant is a single-rod device that contains 68 mg of etonogestrel; it is implanted in the inner side of the upper nondominant arm. It needs to be removed no later than 3 years after the date of insertion; it may be replaced with a new implant at the time of removal. The progestin implant contains barium, a radiopaque substance that can help locate the device on two-dimensional radiography, ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) scanning if necessary. The progestin implant may not be as effective in women who have a body mass index (BMI) greater than 30 (obese) or who are on drugs that induce liver enzymes.

2. A 54-year-old menopausal patient comes into the gynecology office and is interested in hormone therapy. Which are indications for prescribing hormone therapy? (Select all that apply.) a. Relief of hot flashes b. Prevention of breast cancer c. Prevention of cardiovascular disease d. Prevention of osteoporosis in a high-risk patient e. Relief of vaginal dryness

Relief of hot flashes Relief of vaginal dryness Prevention of osteoporosis in a high-risk patient

Oral Combined Hormonal Contraceptives

Safer than straight Estrogen Combination products containing norethindrone & ethinyl estradiol Combination products containing levonorgestrel (LNG) & ethinyl estradiol (EE) Route & Dosage Oral: 1 tablet PO daily from the 21-tablet package: 1 tablet daily for 21 consecutive days followed by 7 days off. A new course begins on the eighth day after a tablet is taken. 28-tablet package: 1 tablet daily without interruption taken at the same time each day Uses & Considerations Estrogen & progestin combination used for contraception & for treatment of moderate acne vulgaris in females 15 years & older who have achieved menarche, are unresponsive to topical treatments, have no contraindications to CHC use, & plan to stay on therapy for 6 months or longer. Contraindications: History of or current thrombophlebitis, DVT, PE, CVA, CAD, valve disease, hypertension, diabetes mellitus with vascular involvement, migraines in women >35 y, cancers, neoplasms, and tumors. Cardiovascular side effects are increased in women who smoke, especially those >35 y and in those who use CHCs Extended-Use Combined Hormonal Contraceptives - A continuous-dosing CHC pill that contains EE & LNG is a 91-day regimen of pills. - This regimen includes 84 days of active pills & 7 days of inert pills. This drug causes withdrawal bleeding to occur just four times per year.

Advantages of CHC

Shorter, lighter periods Decreased blood loss and uterine cramps, elimination of mittelschmerz (mid-cycle pain usually associated with ovulation), Reduction of symptoms in many forms of benign breast disorders, and prevention of physiologic ovarian cysts. Reduce the incidence of pelvic inflammatory disease (PID), ectopic pregnancy, endometrial and ovarian cancer risk, and deaths from colorectal cancer. CHC products do not reduce the incidence of sexually transmitted infections Route of Delivery Most women are familiar with oral contraception, in which a pill is ingested daily that is absorbed by the gastrointestinal (GI) tract and metabolized by the liver. However, CHC products can also be administered through transvaginal & transdermal routes. The advantage of these alternative sites is avoiding GI absorption and the initial metabolism by the liver, or the first-pass effect. Side effects such as nausea and vomiting, heart & circulatory risks, & non-adherence with a daily dosage regimen can be avoided. Side Effects Low-dose CHCs greatly reduce the risk for dangerous side effects. The higher dose of estrogen increased risk for venous thromboembolism (VTE), myocardial infarction (MI), and stroke. Increased estrogenic activity may include side effects such as cyclic breast changes, dysmenorrhea (painful periods), menorrhagia (heavy periods), chloasma (hyperpigmentation of the skin) Decreased estrogenic activity can cause amenorrhea (absence of periods) or spotting at certain points in the cycle. Increased progestational activity can cause weight gain, depression, fatigue, and decreased libido, and a lack of progestational activity may cause breakthrough bleeding (BTB) and headaches BTB is an episode of bleeding that occurs during the active pill cycle of CHCs. Side effects primarily caused by an excess of estrogen include nausea, vomiting, dizziness, fluid retention, edema, bloating, breast enlargement, breast tenderness, chloasma (slightly more in dark-skinned patients on higher-dose tablets who are exposed to sunlight), leg cramps, decreased tearing, corneal curvature alteration, visual changes, vascular headache, & hypertension. Side effects primarily caused by estrogen deficiency include vaginal bleeding (BTB, 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; and dyspareunia (painful sexual intercourse) secondary to atrophic vaginitis. Side effects primarily caused by an excess of progestin include 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 Side effects primarily caused by progestin deficiency include dysmenorrhea, bleeding late in the cycle (days 15 to 21), heavy menstrual flow with clots, or amenorrhea. There may also be changes in laboratory values, including thyroid & liver function, blood glucose, & triglycerides.

Other Methods of Contraception

Spermicides Spermicides are chemical agents that inactivate sperm before they can travel through the cervix & into the upper genital tract. The most common spermicide is nonoxynol-9, which is infused into carrying agents—jellies & creams, foams, suppositories, & films—& is also impregnated into over-the-counter (OTC) sponges used for birth control. Some of the carrying agents contain a short-acting spermicide, whereas others adhere to the vaginal mucosa to provide extended spermicidal action. Spermicide can cause vulvo-vaginal abrasions & altered vaginal flora, which can increase susceptibility to pathogens. Emergency Contraception Emergency contraception (EC) can prevent pregnancy after unprotected sex. There are several options: Under the supervision of a health care provider, taking 2 to 5 CHCs at one time Using Plan B One-Step, an over-the-counter progestin-only EC taken as a single pill, within 72 hours; Using Next Choice, an over-the-counter progestin-only EC taken in two doses (12 hours apart), within 72 hours Using ulipristal acetate, a prescription-only drug taken as a single tablet within 5 days of unprotected sex Inserting a copper-releasing IUD to prevent implantation of a fertilized egg within 5 to 7 days of unprotected sex EC is intended to be used one time in the event that a condom breaks, a diaphragm or a cervical cap is displaced, or doses of a hormonal contraception method are missed. EC is indicated in the event of sexual assault. The only documented contraindication to EC is an established pregnancy. Women should be instructed that EC is most effective when taken within 24 hours after unprotected sex.

Transvaginal Contraception

The ethinyl estradiol & etonogestrel transvaginal ring is a 2-inch flexible indwelling ring that is inserted into the vagina. These rings are a combination of estrogen & progesterone The transvaginal ring remains in place for 3 weeks. The patient inserts the ring during the first 5 days of the menstrual cycle and removes the ring after 3 weeks, remains "ring-free" for 1 week (for withdrawal menses), and then inserts a new ring. Backup contraception is recommended during the first 7 days after the first ring is placed. After this, contraceptive effects are expected to be continuous provided the ring is correctly inserted If the ring slips out, it can be rinsed with lukewarm water & reinserted into the vagina. It should be reinserted within 3 hours after becoming dislodged; if the ring remains out for more than 3 hours, additional contraception is required until the ring has been in place for 7 days. Possible side effects include vaginal discharge, irritation, or infection. ' Other associated risks are the same AND increased in patients who smoke.

6. A 48-year-old patient arrives at the clinic to discuss her perimenopausal symptoms. She states that her last menstrual period was 8 months ago, & before that, her periods had been irregular. What is the most important nursing advice to give this patient? a. Hormone therapy is only used for hot flashes and vaginal dryness. b. The patient should be using some form of contraception to avoid pregnancy. c. The patient should have a dual-energy X-ray absorptiometry scan to test for osteopenia. d. At this time, herbal supplementation is probably best to relieve her perimenopausal symptoms.

The patient should be using some form of contraception to avoid pregnancy.

11. The nurse is counseling a 62-year-old patient with a T score of −2.0 after her dual-energy X-ray absorptiometry scan. What is the best advice for this patient?

The patient should supplement her diet with 1200 mg of calcium with vitamin D 600 IU orally once daily.

Menopause

The perimenopausal period includes the years before the natural cessation of spontaneous menstruation Menopause is the 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. Postmenopause is the stage when the body adapts to a new hormonal environment. The production of estrogen & progesterone from the ovaries decreases during the late premenopausal and early postmenopausal periods ****CHOLESTEROL LEVELS RISE IN MENOPAUSE****(LDL)

Cardiovascular Risk

There is an increased risk for hypertension & arterial blood clot complications such as MI, pulmonary embolus, & cerebrovascular accident (CVA) in women using CHCs compared with women who are not using CHCs. Cardiovascular risks are increased in - Women older than 35 years who smoke - Women older than 45 years - Women with hypertension that is undiagnosed or uncontrolled by drugs.

Ethinyl Estradiol and Norelgestromin Transdermal Patch

This is a weekly form of CHC patch that delivers the medications every 24 hours through a transdermal system. The system is a thin plastic patch placed on the skin of the buttocks, stomach, upper outer arm, or upper torso. The patch is placed once a week for 3 weeks in a row. The fourth week is patch-free to allow for withdrawal bleeding. The patch should be placed on clean, dry skin; placement on or near the breasts should be avoided because of the estrogen component, and the site of the patch placement should be rotated to avoid skin irritation. If the patch partially or completely detaches from the skin, a new patch should be placed. When used correctly, the patch protects against pregnancy on a monthly basis. Advantages of the Transdermal Patch The patch works in a similar manner to CHC pills by inhibiting ovulation, thickening cervical mucus to prevent sperm penetration, & preventing a fertilized egg from implanting in the uterus. The patch avoids the first-pass effect (through the liver). Advantages include not having to remember to take a pill daily. As with CHC products, the ability to become pregnant returns quickly when the pill is discontinued. Menstrual flow, cramping, acne, iron-deficiency anemia, excess body hair, premenstrual symptoms, & vaginal dryness are all lessened with the patch. The patch reduces the risk for ovarian & endometrial cancers, PID, breast & ovarian cysts, ectopic pregnancy & osteoporosis (loss of bone mass) that predisposes women to fractures. Disadvantages of the Patch Disadvantages of the patch include skin reaction at the site of application, menstrual cramps, & a change in vision or the inability to wear contact lenses; it is not as effective for women who weigh more than 198 lb. The EE & norelgestromin 766 transdermal patch carries a boxed warning stating that it exposes women to higher levels of estrogen, thereby increasing the risk for venous thromboembolism (VTE) Women who are older than 35 years & smoke should not use the transdermal patch. Other side effects include - temporary irregular bleeding, - weight gain or loss, breast tenderness, & nausea.

Drugs That Interact With Combined Hormonal Contraceptives

Use a higher-dose pill or an alternative form of contraception (if the drug is continuous). Use a back-up method for the duration of treatment plus 7 days (if drug is short term). Anticonvulsant Drugs Carbamazepine Hydantoins (ethotoin, mephenytoin, phenytoin) Succinimide anticonvulsants (ethosuximide) Antituberculin Drugs Rifampin Antibiotics Amoxicillin Ampicillin Doxycycline Metronidazole Minocycline Neomycin Nitrofurantoin Penicillin Tetracycline Barbiturates Phenobarbital Primidone Hypnotics & Sedatives Benzodiazepines Migraine Drugs Topiramate Drugs That May Increase Combined Hormonal Contraceptive Activity Acetaminophen Ascorbic acid Fluconazole

12. The nurse is instructing a patient on the use of depot medroxyprogesterone acetate. Which statements are correct?

You should increase your intake of calcium You can expect some irregular bleeding at first You can use depot medroxyprogesterone acetate if you are breastfeeding.

Nursing Administration

● Instruct clients to take the medication at the same time each day (e.g., at bedtime). ● Apply estrogen patches to the skin of the trunk. Avoid the breasts & waistline. ● Instruct clients to report menstrual changes: dysmenorrhea, amenorrhea, breakthrough bleeding, &/or breast changes. ● Encourage clients to perform monthly breast self-exams & annual gynecologic & breast exams with the provider. ● Advise clients to notify the provider of any swelling or redness in legs, shortness of breath, or chest pain. ● Discontinue prior to Combined Hormonal Contraceptives All combined hormonal contraceptives (CHCs) contain a synthetic version of estrogen & progestin. Ethinyl estradiol (EE) is the most commonly used synthetic estrogen Progestins are natural or synthetic hormones that have progesterone-like effects. - Progesterone is the naturally occurring sex hormone produced in the ovaries of women Not only do progestins have contraceptive properties, they serve to balance out the effects of estrogen. The combination of estrogen & the selected progestin also has an effect on the uterine endometrium, therefore the lowest effective dose that successfully prevents conception should be used. Mechanism of Action The estrogen component of CHC products inhibits ovulation by preventing the formation of a dominant follicle. When a dominant follicle does not mature, estrogen remains at a consistent level and is unable to reach the peak level needed to stimulate the luteinizing hormone (LH) surge. The progestin component also suppresses the LH surge. When the LH surge is suppressed, ovulation is prevented, & pregnancy does not occur. Any cycle in which ovulation does not occur, whether induced by drugs or naturally occurring, is called an anovulatory cycle. The estrogen component of CHC products also stabilizes the uterine endometrium, inhibiting proliferation & secretory changes & decreasing the occurrence of irregular or heavy bleeding. The progestational effects of progestin change the endometrium to make it less favorable for implantation of a fertilized ovum. In addition, progestins have an effect on the quantity & viscosity of the cervical mucus, making it thick & hostile to sperm penetration

10. 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."

"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."

Premenstrual Syndrome

- Premenstrual syndrome (PMS) comprises a collection of cyclic physical symptoms & perimenopausal mood alterations. - Symptoms increase in the 2 weeks before menstruation & subside after menses begins. - These physical, emotional, & behavioral symptoms interfere to varying degrees with a woman's ability to function.

COMPLEMENTARY & ALTERNATIVE THERAPIES

- St. John's wort may decrease the level of contraceptive hormones in the bloodstream, reducing the effectiveness of combined hormonal contraceptives (CHCs). This may result in breakthrough bleeding and/or spontaneous ovulation - Chasteberry extract should be used with caution with CHCs or hormone therapy, as it may alter contraceptive hormone levels in the body & can make them less effective. Other herbal remedies that may alter the effectiveness of contraceptive hormones include Dong-quai, black cohosh, & red clover.

1. The nurse is preparing a teaching plan for combined hormonal contraceptive use. Which information should the nurse include in the teaching plan? (Select all that apply.) a. The patient should report abdominal pain, chest pain, headaches, blurred vision & visual disturbances, & severe leg pain. b. Combined hormonal contraceptives are safe for smokers older than 35 years who smoke fewer than 20 cigarettes per day. c. Combined hormonal contraceptive use will not protect patients from sexually transmitted infections. d. The pills can be missed but not for more than 12 hours. e. Vaginal spotting after starting combined hormonal contraceptives is a sign that the method is not effective in preventing pregnancy.

- The patient should report abdominal pain, chest pain, headaches, blurred vision & visual disturbances, & severe leg pain. - Combined hormonal contraceptive use will not protect patients from sexually transmitted infections.

7. A patient has been prescribed clomiphene citrate therapy by her doctor. The patient asks the nurse, "How does my new medicine work?" What can the nurse say to convey the mechanism of action of clomiphene citrate therapy to this patient? (Select all that apply.) a. This drug works by stimulating the ovaries, increasing the chance of ovulation. b. This drug increases circulating progesterone levels. c. This drug usually does not work on the first cycle. d. This drug helps the ovaries form multiple follicles.

- This drug works by stimulating the ovaries, increasing the chance of ovulation. - This drug increases circulating progesterone levels. - This drug helps the ovaries form multiple follicles.

Pharmacologic Treatment of Premenstrual Syndrome

1) Antidepressant Drugs PMS is improved with selective serotonin reuptake inhibitors (SSRIs). Symptom relief includes a decrease in irritability, mood swings, fatigue, tension, & breast tenderness. SSRIs block the reuptake of serotonin into nerve terminals in the central nervous system (CNS), regulating serotonin use by the brain. The most commonly used SSRIs are fluoxetine & sertraline, paroxetine, citalopram, and escitalopram. V enlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI) has also demonstrated relief in patients with severe PMS symptoms, but is not considered a first-line agent. 2) Hormonal Therapy Long-term suppression of ovulation has been shown to decrease cyclic physical discomforts and to normalize mood variations in some women. Caution should be used with progestin-only products because they may exacerbate symptoms of depression

Pharmacologic Management of Dysmenorrhea

1) NSAIDs: block pain by preventing synthesis of prostaglandins. The mechanism of drug action is the inhibition of cyclooxygenase (COX). The COX enzyme converts arachidonic acid into prostaglandins, which cause constriction of the uterine arterioles, necrosis of the endometrial lining, uterine contractions, and menstrual pain. The most commonly used NSAIDs for relief of pain associated with dysmenorrhea include naproxen sodium, diclofenac potassium, ibuprofen, naproxen, celecoxib, & mefenamic acid. GI upset is a common side effect of NSAIDs, so most drugs in this category should be taken with food & water. NSAIDs can also be taken with an antacid or calcium supplement to prevent GI upset. NSAIDs should not be taken for more than 10 days. 2) Combined Hormonal Contraceptives CHCs are effective in the treatment of dysmenorrhea. CHCs reduce the thickness of the uterine endometrium, cause atrophy of the uterine lining, limiting the occurrence of dysmenorrhea and the amount of bleeding during menstruation.

4. A 39-year-old patient who smokes one pack of cigarettes (20) per day asks about a contraception method that is best for her. She is normotensive & has used combined hormonal contraceptives in the past. She is in a monogamous relationship and has had two children with no complications during pregnancy. She is not planning any more pregnancies. The nurse determines that which method would be best for this patient? a. Combined hormonal contraceptives b. A levonorgestrel intrauterine system c. Progestin-only pills d. Levonorgestrel (systemic) progestin

A levonorgestrel intrauterine system

Endometriosis

Abnormal location of endometrial tissue outside the uterus. The tissue is known as ectopic endometrial implants. It is a common cause of dysmenorrhea, chronic pelvic pain, & infertility. Pharmacologic Management of Endometriosis Pharmaceutic treatment strategies for endometriosis include drugs that decrease the amounts of circulating estrogen & limit or eliminate menstruation. This interrupts internal bleeding & irritation associated with the ectopic endometrial implants & may even cause them to recede. Combined Hormonal Contraceptives - Suppress gonadotropin-releasing hormone (GnRH) release - Prevent ovulation, & cause atrophy of the uterine lining ***actions thought to relieve pelvic pain by causing a regression of the endometrial implants. Progestin Therapy Norethindrone acetate may be taken at 5 mg PO daily for 2 weeks, then increasing the dose by 2.5 mg every 2 weeks until a dose of 15 mg per day is reached & continued for 6 to 9 months.

Oral Bisphosphonate

Alendronate is a bisphosphonate used to treat osteopenia & osteoporosis Daily or weekly dose. Once-a-week dosing has made this a first-line therapy. For prevention of osteoporosis, the oral weekly dose is 35 mg. For treatment, the oral weekly dose is 70 mg. Alendronate must be taken with 8 ounces of water 30 minutes before ingesting any food, liquids, or drug, and the patient must remain upright for 30 minutes or longer to prevent Esophagitis!!! Common side effects include abdominal pain & acid reflux. Alendronate is also available with added vitamin D for enhanced absorption of calcium. Ibandronate Risedronate Zoledronic acid Side Effects of Oral Bisphosphonate The side effects of oral bisphosphonates include nausea, abdominal or stomach pain, difficulty swallowing, esophageal inflammation, reflux, & ulcers. Injectable Bisphosphonates do not have the GI side effects, and it can be easier for the patient to schedule a quarterly or yearly injection than to remember to take a daily or weekly pill. Oral Bisphosphonates should not be taken with aspirin, NSAIDs, or antacids. Contraindications to Bisphosphonates: - esophageal abnormalities - delayed emptying of the esophagus - inability to sit or stand for 30 minutes after oral ingestion - hypocalcemia. Nursing Interventions Encourage sufficient intake of calcium and vitamin D throughout the lifespan by either dietary intake or supplementation. The recommended daily requirement of calcium for women aged 19 to 50 years is 1000 mg/day, whereas women older than 50 years need 1200 mg/day. Calcium should be taken in divided doses and with adequate vitamin D to enhance absorption. The recommended daily allowance of vitamin D is 600 IU/day for women aged 19 to 70 years and 800 IU/day for women older than 70 years. All calcium preparations, with the exception of calcium citrate, should be taken with food. Smoking cessation should be encouraged because smoking interferes with vitamin D absorption. Alcohol consumption should be limited to one drink per day because alcohol reduces GI absorption of calcium. Weight-bearing exercise includes walking, jogging, low-impact aerobics, weight training, and yoga; these strengthen the bones, increase muscle strength, and enhance balance. Caution should be used in patients who are prescribed drugs that cause hypotension or dizziness. The patient should be assessed for fall risk, and the prevention of falls should be part of the nurse's health care teaching.

Irregular or Abnormal Uterine Bleeding

Amenorrhea is the absence of menses Primary amenorrhea is defined as no menses by age 14 years without secondary sex characteristics or no menses by age 16 years with secondary sex characteristics. Secondary amenorrhea is the absence of a spontaneous menstrual period for 6 consecutive months in women who have experienced menstrual cycles in the past. Pregnancy is the most common reason a patient may experience amenorrhea, & breastfeeding or menopausal patients also may not menstruate, therefore secondary amenorrhea is a symptom of these normal physiologic processes. Other causes of secondary amenorrhea include anovulatory cycles (cycles without ovulation), hypothyroidism or hyperthyroidism, & hyperprolactinemia (high levels of the hormone prolactin, which stimulates lactation). Extreme weight loss & anorexia can also cause amenorrhea.

3. A 24-year-old patient tells the nurse that she would like to use the progestin-only pill for contraception. Nursing evaluation of this patient as a candidate for the progestin-only pill includes what? a. Obtaining an obstetric history to make sure that the patient has given birth in the past b. Obtaining a gynecologic history to ensure that the patient has regular periods c. Assessing patient reliability in taking an oral pill daily d. Interviewing the patient about past smoking habits

Assessing patient reliability in taking an oral pill daily

9. The nurse identifies which condition as a contraindication to hormone replacement therapy? a. Diabetes mellitus b. Depression c. Renal failure d. History of breast cancer

Breast cancer within the last 5 years

15. What information will the nurse include when teaching a patient about hormonal methods of contraception?

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."