Drugs Affecting Female Reproductive Systems

Adverse Effects/Abortifacients

Abdominal cramping Heavy uterine bleeding Perforated uterus or uterine rupture Headache, nausea, vomiting, diarrhea, diaphoresis, backache, and rash

Pharmacokinetics/ESTROGEN

Absorbed through the GI tract and undergoes extensive hepatic metabolism Excreted in the urine ; Estrogens cross the placenta and enter breast milk.

Therapeutic Actions & Indications/Oxytocics

Actions Affect neuroreceptors sites to stimulate contractions of the uterus ; effective in the gravid uterus ; Oxytocin, a synthetic form of the hypothalamic hormone, also stimulates the lacteal glands in the breast to contract, promoting milk ejection in lactating women. ; Oxytocics are indicated for the prevention and treatment of uterine atony after delivery. This is important to prevent postpartum hemorrhage. Indications Prevention and treatment of uterine atony after delivery

Therapeutic Actions & Indications/Fertility Drugs

Actions Directly or by stimulating the hypothalamus to increase FSH and LH levels, leading to ovarian follicular development and maturation of ova Fertility drugs also may be used to stimulate multiple follicle development for the harvesting of ova for in vitro fertilization. Menotropins also stimulate spermatogenesis in men with low sperm counts and otherwise normally functioning testes. Indications Infertility in men and women

Therapeutic Actions & Indications/ESTROGEN

Actions Protecting the heart from atherosclerosis Retaining calcium in the bones Maintaining the secondary female sex characteristics Indications Hormone replacement therapy (HRT)= when ovarian activity is blocked or absent Palliative and preventive therapy during menopause when many of the beneficial effects of estrogen are lost, to treat female hypogonadism and ovarian failure, to prevent postpartum breast engorgement, as part of combination contraceptives, to slow bone loss in osteoporosis, and for palliation in certain cancers that have known receptor sensitivity

Assessment: History and Examination Assess for contraindications or cautions: History of allergy to any fertility drug to avoid hypersensitivity reactions; current status of pregnancy and lactation, which are contraindications or cautions to the use of the drug; primary ovarian failure, which would not respond to these agents; thyroid or adrenal dysfunction due to effects on the hypothalamic-pituitary axis; ovarian cysts, which could be stimulated and become larger as a result of the drug's stimulatory effects; idiopathic uterine bleeding, which could reflect an underlying medical problem that could be exacerbated by the stimulatory effects of the drug; thromboembolic diseases, which could increase the patient's risk for thrombus formation; and respiratory diseases, which would be exacerbated by the effects of the drug. • Perform a complete physical assessment to establish baseline status before beginning therapy and during therapy to monitor for any potential adverse effects. • Perform a psychological assessment to determine teaching and support needs as these patients are often very stressed, anxious, and can experience bouts of depression which the nurse will need to be ready to address.

Assessment: History and Examination • Assess skin and lesions; orientation, affect, and reflexes; and blood pressure, pulse, respiration, and adventitious sounds to determine cardiac function and perfusion and to detect changes in blood flow or thromboemboli. • Complete or assist with pelvic and breast examinations and ensure collection of specimen for Pap smear to establish a baseline of GU health and detect early changes as a result of drug therapy. • Monitor the results of laboratory tests, such as renal and hepatic function studies, to evaluate for possible dysfunction that might interfere with metabolism and excretion of the drug; and check hormonal levels as indicated to determine the effectiveness of therapy and reduce the risk of ovarian hyperstimulation.

Contraindications & Cautions/ESTROGEN

Breast feeding, metabolic bone disease= because of the bone-conserving effect of estrogen, which could exacerbate the disease; with renal insufficiency, which could interfere with the renal excretion of the drug and increase the risk for potential adverse effects on fluid and electrolyte balance; and with hepatic impairment, which could alter the metabolism of the drug and increase the risk for adverse effects, including those on the liver and GI tract.

Therapeutic Actions & Indications/Fertility Dru

Cetrorelix inhibits premature LH surges in women undergoing controlled ovarian stimulation by acting as a GnRH antagonist. Chorionic gonadotropin is used to stimulate ovulation by acting like GnRH and affecting FSH and LH release. Follitropin alfa and follitropin beta are FSH molecules; they are injected to stimulate follicular development in the treatment of infertility and for harvesting of ova for in vitro fertilization. Menotropins, a purified gonadotropin (similar to FSH and LH), are also used to stimulate spermatogenesis. The urofollitropin now available is a less toxic form of human urofollitropin which used to be prepared from the urine of postmenopausal women and was associated with many immune reactions. Urofollitropin is used to stimulate follicle development and induce ovulation

Clinically Important Drug-Drug Interactions/Estrogen Receptor Modulators

Cholestyramine reduces the absorption of raloxifene. Highly protein-bound drugs such as diazepam (Valium), ibuprofen (Motrin), indomethacin (Indocin), and naproxen (Naprosyn), may interfere with binding sites Warfarin taken with raloxifene may decrease the prothrombin time; patients using this combination must be monitored closely.

Clinically Important Drug-Drug Interactions/ESTROGEN

Drugs that enhance hepatic metabolism Corticosteroids (so patients taking both drugs should be monitored very closely.) If estrogens are given in combination with drugs that enhance their hepatic metabolism (e.g., barbiturates, rifampin, tetracyclines, phenytoin), serum estrogen levels may decrease NO SMOKING (Nicotine increased the risk for development of thrombi and emboli) Patients should be discouraged from drinking large quantities of grapefruit juice if they are taking estrogens St. John's wort can affect the metabolism of estrogens and can make estrogen-containing contraceptives less effective. This combination should be discouraged.

Drugs Used to Treat Disorders of the Female Reproductive System

Estrogen and Progestins Estrogen Receptor Modulators Fertility Drugs Oxytocics Abortifacients Ocolytics

Adverse Effects/Estrogen Receptor Modulators

GI upset- nausea, vomiting Changes in fluid balance: headache, dizziness, and visual changes & mental health changes Estrogen receptor stimulation: hot flashes, skin rash, edema, and vaginal bleeding

CLASSIFICATION/Oxytocics

Stimulate contraction of the uterus, much like the action of the hypothalamic hormone oxytocin, which is stored in the posterior pituitary. These drugs include methylergonovine (Methergine), and oxytocin (Pitocin)

CLASSIFICATION/Estrogen Receptor Modulators

Two available estrogen receptor modulators are raloxifene (Evista) and toremifene (Fareston). The long-term effects of these two drugs are still being studied.

Tocolytics

Uses Relax the uterine smooth muscle and prevent contractions leading to premature labor and delivery Usually reserved for use after 20 weeks of gestation; neonate has a chance of survival outside the uterus Prototype Only one in US: Ritodrine (Yutopar); withdrawn because of serious side effects

Pharmacokinetics/Fertility Drugs

Well absorbed, treated like endogenous hormones within the body, undergoing hepatic metabolism and renal excretion Drugs that are available in injectable form include : cetrorelix, chorionic gonadotropin, chorionic gonadotropin alpha, follitropin alfa, follitropin beta, menotropins, ganirelix, and urofollitropin. Clomiphene is available as an oral agent.

Therapeutic Actions & Indications/Progestins

-transform the proliferative endometrium into a secretory endometrium -inhibit the secretion of FSH and LH -prevent follicle maturation and ovulation, -inhibit uterine contractions, and may have some anabolic and estrogenic effects. Contraceptives= mechanism is not known circulating progestins and estrogens "trick" the hypothalamus and pituitary and prevent the release of gonadotropin-releasing hormone (GnRH), FSH, and LH, thus preventing follicle development and ovulation. Treatment of primary and secondary amenorrhea Fertility protocols

Therapeutic Actions & Indications/Abortifacients

Actions Stimulate uterine activity Dislodge any implanted trophoblast and preventing implantation of fertilized egg Indications Termination of pregnancy at 12-20 weeks

Therapeutic Actions & Indications/Estrogen Receptor Modulators

Actions not hormones Modulating effects on estrogen receptors Used to stimulate specific estrogen receptors to increase bone mineral density Indications Postmenopausal osteoporosis Raloxifene = Used therapeutically to stimulate specific estrogen receptor sites, which results in an increase in bone mineral density without stimulating the endometrium in women; reduces risk of invasive breast cancer in postmenopausal women with osteoporosis who are at high risk for invasive breast cancer toremifene (Fareston) Used as an antineoplastic agent because of its effects on estrogen receptor sites (see Chapter 14) for treatment of advanced breast cancer in postmenopausal women with estrogen receptor-positive and estrogen receptor-unknown tumors

Contraindications & Cautions/ESTROGEN

Allergies to avoid hypersensitivity reactions Pregnancy due to the risk of serious fetal defects. Idiopathic vaginal bleeding, breast cancer, and estrogen dependent cancer=all of which could be exacerbated by the drug; thromboembolic disorders including cerebrovascular accident, or with heavy smokers because of the increased risk of thrombus and embolus development; or with hepatic dysfunction, because of the effects of estrogen on liver function.

Contraindications & Cautions/Progestins

Allergies, pregnancy, idiopathic vaginal bleeding, breast or genital cancer, history of thromboembolic disorders, PID, sexually transmitted disease, endometriosis, or pelvic surgery

Contraindications & Cautions/Oxytocics

Allergy to oxytocics to avoid hypersensitivity reactions early pregnancy which could be compromised by uterine stimulation. Cephalopelvic disproportion unfavorable fetal position, complete uterine atony

Contraindications & Cautions/Abortifacients

Allery to avoid hypersensitivity reactions ;After 20 weeks from the last menstrual period, which would be too late into the pregnancy for an abortion; Asthma, hypertension, or adrenal disease Acute vaginitis or scarred uterus which could be exacerbated by the drug effects, and with acute vaginitis (inflammation of the vagina) or scarred uterus, which could be aggravated by the uterine contractions. Active PID or acute CV, hepatic, renal, or pulmonary disease, which could be exacerbated by the effects of these drugs They are not recommended for use during lactation because of the potential for serious effects on the neonate. If these drugs are to be used by a lactating mother, another method of feeding the baby should be used.

Prototype Summary: Dinoprostone Indications: Termination of pregnancy 12 to 20 weeks from the first day of the last menstrual period; evacuation of the uterus in the management of missed abortion or intrauterine fetal death; management of nonmetastatic gestational trophoblastic disease; initiation of cervical ripening. Actions: Stimulates the myometrium of the pregnant uterus to contract, evacuating the contents of the uterus. Pharmacokinetics: RouteOnsetPeakDuration Intravaginal 10 min 15 min 2-3 h T1/2: 5 to 10 hours; metabolized in the tissue and excreted in the urine. Adverse Effects: Headache, paresthesias, hypotension, vomiting, diarrhea, nausea, uterine rupture, uterine or vaginal pain, chills, diaphoresis, backache, fever.

Assessment: History and Examination • Assess for contraindications or cautions: History of allergy to any abortifacient or prostaglandin preparation to avoid hypersensitivity reactions; active pelvic inflammatory disease, which could be exacerbated by the increased uterine activity; cardiac, hepatic, pulmonary, or renal disease problems, which could be exacerbated by the effects of the drug; history of asthma, which predisposes the patient to hypersensitivity reactions; hypotension, hypertension, and epilepsy, which require cautious use of the drug; and scarred uterus or acute vaginitis, which could be exacerbated by the strong uterine contractions. • Perform a psychological assessment to determine teaching and support needs as these patients are often very stressed, anxious, and can experience bouts of depression which the nurse will need to be ready to address.

Prototype Summary: Raloxifene Indications: Prevention and treatment of osteoporosis in postmenopausal women. Actions: Increases bone mineral density without stimulating the endometrium; modulates effects of endogenous estrogen at specific receptor sites. Pharmacokinetics: RouteOnsetPeakDuration PO Varies 4-7 h 24 h T1/2: 27.7 hours; metabolized in the liver and excreted in the urine. Adverse Effects: Venous thromboembolism, hot flashes, skin rash, nausea, vomiting, vaginal bleeding, depression, light-headedness.

Assessment: History and Examination • Assess for contraindications or cautions: History of allergy to any sex hormone or component of the drug product to avoid hypersensitivity reactions; current status related to pregnancy and lactation due to adverse effects on the fetus and neonate; hepatic dysfunction that might interfere with drug metabolism; CV disease, breast or genital cancer, renal disease, or metabolic bone disease, which could be exacerbated by estrogen use; history of thromboembolism or smoking, which may increase the patient's risk for embolic conditions; idiopathic vaginal bleeding or pelvic disease, which could represent an underlying problem that could be exacerbated with the use of these drugs; and history of asthma or epilepsy, which could be exacerbated by progestin use. • Perform a physical assessment to establish a baseline status before beginning therapy and during therapy to determine the effectiveness of therapy and evaluate for any potential adverse effects.

Prototype Summary: Oxytocin Indications: To initiate or improve uterine contractions for early vaginal delivery; to stimulate or reinforce labor in selected cases of uterine inertia; to manage inevitable or incomplete abortion; for second-trimester abortion; to control postpartum bleeding or hemorrhage; to treat lactation deficiency. Actions: Synthetic form stimulates the uterus, especially the gravid uterus; causes myoepithelium of the lacteal glands to contract, resulting in milk ejection in lactating women. Pharmacokinetics: RouteOnsetPeakDuration IV Immediate Unknown 60 min IM 3-5 min Unknown 2-3 h T1/2: 1 to 6 minutes; metabolized in the tissue and excreted in the urine. Adverse Effects: Cardiac arrhythmias, hypertension, fetal bradycardia, nausea, vomiting, uterine rupture, pelvic hematoma, uterine hypertonicity, severe water intoxication, anaphylactic reaction.

Assessment: History and Examination • Assess for contraindications or cautions: History of allergy to oxytocics to avoid hypersensitivity reactions; early status of pregnancy, which might lead to early onset of labor; current status of lactation; uterine atony, undesirable fetal position, and cephalopelvic disproportion, which could be compromised by the stimulatory effects of the drug; hypertension, which could be exacerbated due to the drug's effect on arteries; and history of cesarean birth, which could lead to uterine rupture or damage to previous surgical sites due to the drug's stimulatory effect on uterine contraction. • Perform a complete physical assessment to establish a baseline before beginning therapy and during therapy to evaluate drug effectiveness and to determine potential adverse effects. • Assess the patient's neurological status, including level of orientation, affect, reflexes, and papillary response.

Estrogens are important for the development of the female reproductive system and secondary sex characteristics. They affect the release of pituitary follicle-stimulating hormone (FSH) and luteinizing hormone (LH); cause capillary dilation, fluid retention, and protein anabolism and thin the cervical mucus; conserve calcium and phosphorus and encourage bone formation; inhibit ovulation; and prevent postpartum breast discomfort.

Estrogens also are responsible for the proliferation of the endometrial lining An absence or decrease in estrogen produces the signs and symptoms of menopause in the uterus, vagina, breasts, and cervix. Estrogens are known to compete with androgens for receptor sites; this trait makes them beneficial in certain androgen-dependent prostate cancers. Estrogens produce a wide variety of systemic effects, including protecting the heart from atherosclerosis, retaining calcium in the bones, and maintaining the secondary female sex characteristics

Implementation with Rationale • Provide warnings about the risk and hazards of multiple births so the patient can make informed decisions about drug therapy. • Offer support and encouragement to deal with low self-esteem, stress, anxiety, and possible depression issues associated with infertility. • Provide patient teaching about proper administration technique, appropriate disposal of needles and syringes, measures to avoid adverse effects, warning signs of problems, and the need for regular evaluation to enhance patient knowledge about drug therapy and to promote compliance.

Evaluation • Monitor patient response to the drug (ovulation). • Monitor for adverse effects (abdominal bloating, weight gain, ovarian overstimulation, multiple births). • Evaluate the effectiveness of the teaching plan (the patient can name the drug, dosage, adverse effects to watch for, and specific measures to avoid them). • Monitor effectiveness of comfort measures and compliance with the regimen.

Adverse Effects/Oxytocics

Excessive effects: uterine hypertonicity and spasm (uterine rupture ; postpartum hemorrhage, decreased fetal heart rate) GI upset (nausea) Headache; dizziness Blood pressure changes Water intoxication Methylergonovine can produce ergotism, manifested by nausea, blood pressure changes, weak pulse, dyspnea, chest pain, numbness and coldness in extremities, confusion, excitement, delirium, convulsions, and even coma Oxytocin has caused severe water intoxication with coma and even maternal death when used for a prolonged period.

Adverse Effects/ESTROGEN

GU tract (Genitourinary tract) breakthrough bleeding, menstrual irregularities, dysmenorrhea, amenorrhea, and changes in libido. Systemic effects of estrogens estrogens, including fluid retention, electrolyte disturbances, headache, dizziness, mental changes, weight changes, and edema. GI effects also are fairly common and include nausea, vomiting, abdominal cramps and bloating, and colitis. Potentially serious GI effects, including acute pancreatitis, cholestatic jaundice, and hepatic adenoma, have been reported with the use of estrogens

Nursing Diagnoses Nursing diagnoses related to drug therapy might include the following: • Disturbed body image related to drug treatment and diagnosis • Acute pain related to headache, fluid retention, or GI upset • Sexual dysfunction related to alterations in normal hormone control • Deficient knowledge regarding drug therapy • Risk for impaired tissue perfusion (cardiopulmonary, peripheral) related to increased risk for thrombus formation • Situational low self-esteem related to the need for fertility drugs Planning • The patient will receive the best therapeutic effect from the drug therapy. • The patient will have limited adverse effects to the drug therapy. • The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.

Implementation with Rationale • Assess the cause of dysfunction before beginning therapy to ensure appropriate use of the drug. • Complete a pelvic examination before each use of the drug to rule out ovarian enlargement, pregnancy, or uterine problems. • Check urine estrogen and estradiol levels before beginning therapy to verify ovarian function. • Administer with an appropriate dose of HCG as indicated to ensure beneficial effects. • Discontinue the drug at any sign of ovarian overstimulation and arrange for hospitalization to monitor and support the patient if this occurs. • Provide women with a calendar of treatment days, explanations of adverse effects to anticipate, and instructions on when intercourse should occur to increase the therapeutic effectiveness of the drug.

Implementation with Rationale • Administer drug as prescribed to prevent adverse effects; administer with food if GI upset is severe to relieve GI distress. • Provide analgesics for relief of headache as appropriate. • Strongly urge the patient to stop smoking to reduce the risk of thromboemboli. • Encourage the use of small, frequent meals to assist with nausea and vomiting. • Monitor for swelling and changes in vision or fit of contact lenses to monitor for fluid retention and fluid changes. • Arrange for at least an annual physical examination, including pelvic examination, Pap smear, and breast examination, to reduce the risk of adverse effects and to monitor drug effects.

Implementation with Rationale • Assess the patient periodically for changes in perfusion or signs of vessel occlusion because of the risk of thromboemboli. • Monitor liver function periodically for the patient on long-term therapy to evaluate liver function and ensure discontinuation of the drug at any sign of hepatic dysfunction. • Offer support and reassurance to deal with the drug and drug effects. • Provide thorough patient teaching, including steps to take if a dose is missed or lost, measures to avoid adverse effects, signs and symptoms that may indicate a problem, and the need for regular evaluation, to enhance patient knowledge about drug therapy and to promote compliance.

Implementation with Rationale • Administer via route indicated, following the manufacturer's directions for storage and preparation, to ensure safe and therapeutic use of the drug. • Confirm the age of the pregnancy before administering the drug to ensure appropriate use of the drug. • Confirm that abortion or uterine evacuation is complete by assessing vaginal bleeding and passing of tissue in the vaginal blood to avoid potential bleeding problems; prepare for dilation and curettage if necessary to stop excessive blood loss. • Monitor blood pressure frequently during and after administration to assess for adverse effects; discontinue the drug if blood pressure rises dramatically.

Implementation with Rationale • Monitor uterine tone and involution and the amount of bleeding during and for several days after use of the drug to ensure appropriate response to and recovery from the drug. • Provide support and appropriate referrals to help the patient deal with abortion or fetal death. • Provide patient teaching, including monitoring necessary during drug administration, comfort measures, signs and symptoms of adverse effects, measures to minimize or prevent adverse effects, danger signs and symptoms to report immediately, need for follow-up monitoring and evaluation, and sources for support and referrals to enhance patient knowledge about drug therapy and to promote compliance.

Implementation with Rationale • Ensure fetal position (if appropriate) and cephalopelvic proportions to prevent serious complications of delivery. • Regulate oxytocin delivery using an infusion pump between contractions if it is being given to stimulate labor to regulate dose appropriately. • Monitor blood pressure and fetal heart rate frequently during and after administration to monitor for adverse effects. Discontinue the drug if blood pressure rises dramatically. • Monitor uterine tone and involution and amount of bleeding to ensure safe and therapeutic drug use. • Discontinue the drug at any sign of uterine hypertonicity to avoid potentially life-threatening effects; provide life support as needed. • Monitor fetal heart rate and rhythm if given during labor to ensure safety of the fetus.

Implementation with Rationale • Provide nasal oxytocin at bedside with the bottle sitting upright. Have the patient invert the squeeze bottle and exert gentle pressure to deliver the drug just before nursing to achieve greatest therapeutic effect to stimulate milk "let down." • Provide patient teaching about administration technique for nasal oxytocin if indicated, required monitoring and assessments, danger signs and symptoms to report immediately, possible adverse effects, measures to be instituted to reduce the risk of adverse effects, safety and comfort measures, measures to promote effective breastfeeding as appropriate (for nasal administration of oxytocin), and ongoing need for continued monitoring and evaluation to enhance patient knowledge of drug therapy and to promote compliance.

Adverse Effects/Fertility Drugs

Increase risk of multiple births and birth defects Ovarian overstimulation (abdominal pain, distention, ascites, pleural effusion) Headache, fluid retention, nausea, bloating Uterine bleeding, ovarian enlargement Gynecomastia febrile reactions (possibly due to stimulation of progesterone release).

Clinically Important Drug-Drug Interactions/PROGESTINS

Interaction with barbiturates, carbamazepine, phenytoin, griseofulvin, penicillins, tetracyclines, or rifampin may reduce the effectiveness of progestins. Patients using any of these drugs should use another method of contraception if birth control is needed. St. John's wort can affect the metabolism of progestins and can make progestin-containing contraceptives less effective. This combination should be discouraged.

Adverse Effects/PROGESTINS

Intrauterine systems are associated with abdominal pain, endometriosis, abortion, PID, and expulsion of the intrauterine device. Vaginal use is associated with local irritation and swelling. Drospirenone, used in combination contraceptives, has antimineralocorticoid activity and can block aldosterone, leading to increased potassium levels.

Evaluation • Monitor patient response to the drug (palliation of signs and symptoms of menopause, prevention of pregnancy, decreased risk factors for coronary artery disease, palliation of certain cancers). • Monitor for adverse effects (liver changes, GI upset, edema, changes in secondary sex characteristics, headaches, thromboembolic episodes, breakthrough bleeding). • Monitor for potential drug-drug interactions as indicated. • Evaluate the effectiveness of the teaching plan (the patient can name the drug, dosage, adverse effects to watch for, specific measures to avoid them, and warning signs and symptoms). • Monitor the effectiveness of comfort measures and compliance with the regimen.

KEY POINTS Estrogens are hormones associated with the development of the female reproductive system and secondary sex characteristics; pharmacologically, estrogens are used to prevent conception, to stimulate ovulation in women with hypogonadism, and to a lesser extent to replace hormones after menopause. Progestins maintain pregnancy and are also involved with development of secondary sex characteristics. Progestins are used as part of combination contraceptives, to treat amenorrhea and functional uterine bleeding, and as part of fertility programs. Estrogen receptor modulators are used to stimulate specific estrogen receptors to achieve therapeutic effects of increased bone mass without stimulating the endometrium and causing other, less desirable estrogen effects.

Evaluation • Monitor patient response to the drug (evacuation of uterus). • Monitor for adverse effects (GI upset, nausea, blood pressure changes, hemorrhage, uterine rupture). • Evaluate the effectiveness of the teaching plan (the patient can name the drug, dosage, adverse effects to watch for, and specific measures to avoid them). • Monitor the effectiveness of comfort measures and compliance with the regimen.

KEY POINTS Oxytocic drugs act like the hypothalamic hormone oxytocin to stimulate uterine contractions and induce or speed up labor and to control bleeding and promote postpartum involution of the uterus. Abortifacients are drugs that stimulate uterine activity to cause uterine evacuation. These drugs can be used to induce abortion in early pregnancy or to promote uterine evacuation after intrauterine fetal death. Tocolytics are drugs that relax the uterine smooth muscle; they are used to stop premature labor in patients after 20 weeks of gestation. Hydroxyprogesterone caproate is the only drug available for this purpose.

Pharmacokinetics/Progestins

Levonorgestrel = only available in combination-for oral contraceptives or as uterine insert. It is also used as a "morning after" pill (Plan B, Plan B OneStep) Ulipristal (Ella) is only available as a postcoital or "morning after" contraceptive and is classified as a progesterone agonist/antagonist.

Assessment: History and Examination • Monitor vital signs, including pulse and blood pressure; auscultate lungs for evidence of adventitious sounds. • Assess labor pattern, including uterine contractions, cervical dilation and effacement, and fetal status, including fetal heart rate, rhythm, and position. Institute electronic fetal monitoring as appropriate. • Evaluate uterine tone, noting any indications of atony; assess fundal height and uterine involution, and amount and characteristics of vaginal bleeding. • Monitor the results of laboratory tests, including coagulation studies and complete blood count to evaluate hematological status.

Nursing Diagnoses Nursing diagnoses related to drug therapy might include the following: • Acute pain related to increased frequency and intensity of uterine contractions or headache • Excess fluid volume related to ergotism or water intoxication • Deficient knowledge regarding drug therapy Planning • The patient will receive the best therapeutic effect from the drug therapy. • The patient will have limited adverse effects to the drug therapy. • The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.

Assessment: History and Examination • Perform a complete physical assessment before beginning therapy to establish baseline status and during therapy to determine drug effectiveness and evaluate for any potential adverse effects. • Confirm date of last menstrual period and estimated duration of pregnancy to ensure appropriate use of the drug. • Assess vital signs, including skin and lesions; orientation and affect; and blood pressure, pulse, and respiration; and auscultate lung sounds, to monitor for vascular effects, including bleeding and hypersensitivity reactions. • Assist with or complete a pelvic examination, observe for vaginal discharge, and evaluate uterine tone to monitor effectiveness of the drug and the occurrence of adverse effects. • Monitor the results of laboratory tests, including complete blood count (e.g., leukocyte count, hemoglobin, and hematocrit), to monitor for excess bleeding, and urinalysis to monitor for potential infection or reaction to the procedure.

Nursing Diagnoses Nursing diagnoses related to drug therapy might include the following: • Acute pain related to uterine contractions or headache • Ineffective coping related to abortion or fetal death • Risk for injury related to increased risk for heavy vaginal bleeding • Risk for fluid volume deficit related to blood loss, diarrhea, and diaphoresis • Deficient knowledge regarding drug therapy Planning • The patient will receive the best therapeutic effect from the drug therapy. • The patient will have limited adverse effects to the drug therapy. • The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.

Assessment: History and Examination • Assess abdomen, including auscultation of bowel sounds and palpation of the liver, to identify abnormalities. Measure abdominal girth as indicated to evaluate for bloating. • Assess skin color, lesions, and texture; affect, orientation, mental status, and reflexes; and blood pressure, pulse, cardiac auscultation, edema, and perfusion, which will reflect circulatory status and show any changes associated with thromboembolism. • Complete or assist with pelvic and breast examinations. Ensure specimen collection for Pap smear; obtain a history of the patient's menstrual cycle to provide baseline data and to monitor for any adverse effects that could occur. • Arrange for ophthalmic examination (particularly if the patient wears contact lenses) because hormonal changes can alter the fluid in the eye and curvature of the cornea, which can change the fit of contact lenses and alter visual acuity. • Monitor the results of laboratory tests, including urinalysis and renal and/or hepatic function tests, to determine the need for possible dose adjustment and identify early indications of dysfunction.

Nursing Diagnoses Nursing diagnoses related to drug therapy might include the following: • Excess fluid volume related to fluid retention • Acute pain related to systemic side effects of GI pain and headache • Ineffective tissue perfusion (cerebral, cardiopulmonary, peripheral) related to changes in the blood vessels concerning drug therapy and risk of thromboemboli • Unbalanced nutrition: Less than body requirements related to GI distress associated with drug therapy • Risk for ineffective management of therapeutic regimen related to complexities of drug regimen • Deficient knowledge regarding drug therapy Planning • The patient will receive the best therapeutic effect from the drug therapy. • The patient will have limited adverse effects to the drug therapy. • The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.

Pharmacokinetics/Estrogen Receptor Modulators

Orally ; Raloxifene=Well absorbed in the GI tract, metabolized in the liver Excreted in the feces

Contraindications & Cautions/Oxytocics

Oxytocin is used during lactation because of its effects on milk ejection, but the baby should be evaluated for any adverse effects associated with the hormone. Caution should be used in patients with coronary disease and hypertension due to the effect of causing arterial contraction, which could raise blood pressure or compromise coronary blood flow, patients who have had previous cesarean births because of the effects on uterine contraction, which could compromise scars from previous procedures. Caution should be used in hepatic or renal impairment, which could alter the metabolism or excretion of the drug.

Contraindications & Cautions/Fertility Drugs

Primary ovarian failure (they only work to stimulate functioning ovaries Thyroid or adrenal dysfunction because of the effects on the hypothalamic-pituitary axis Ovarian cysts which could be stimulated and become larger due to the effects of the drugs; Pregnancy due to the potential for serious fetal effects idiopathic uterine bleeding which could represent an underlying problem that could be exacerbated by the stimulatory effects of these drugs; known allergy avoid hypersensitivity reactions. breastfeeding because of the risk of adverse effects on the baby thromboembolic diseases because of the risk of increased thrombus formation, as well as in women with respiratory diseases because of alterations in fluid volume and blood flow that could overtax the respiratory system.

CLASSIFICATION/Progestins

Progestins include drospirenone (Yasmin, Yaz), etonogestrel (Implanon), levonorgestrel (Mirena), medroxyprogesterone (Provera), norethindrone (Aygestin), norgestrel (generic), progesterone (Prometrium, and others), desogestrel (found in many contraceptive combinations), and ulipristal (Ella) used as a postcoital contraceptive.

Prototype Summary: Estradiol Indications: Palliation of moderate to severe vasomotor symptoms associated with menopause; prevention of postmenopausal osteoporosis; treatment of female hypogonadism, female castration, female ovarian failure; palliation of inoperable and progressing breast cancer and inoperable prostatic cancer. Actions: The most potent endogenous female sex hormone, responsible for estrogen effects on the body. Pharmacokinetics: RouteOnsetPeakDuration PO Slow Days Unknown Topical preparations are not generally absorbed systemically. T1/2: Not known; metabolized in the liver and excreted in the urine. Adverse Effects: Corneal changes, photosensitivity, peripheral edema, chloasma, hepatic adenoma, nausea, vomiting, abdominal cramps, bloating, breakthrough bleeding, change in menstrual flow, dysmenorrhea, premenstrual-like syndrome.

Prototype Summary: Norethindrone Acetate Indications: Treatment of amenorrhea, abnormal uterine bleeding due to hormonal imbalance; treatment of endometriosis; component of some hormonal contraceptives. Actions: Progesterone derivative that transforms the proliferative endometrium into a secretory endometrium; inhibits the secretion of pituitary FSH and LH, which prevents ovulation; inhibits uterine contractions. Pharmacokinetics: RouteOnsetPeakDuration PO Varies Unknown Unknown T1/2: Unknown; metabolized in the liver and excreted in the feces and urine. Adverse Effects: Venous thromboembolism, loss of vision, diplopia, migraine headache, rash, acne, chloasma, alopecia, breakthrough bleeding, spotting, amenorrhea, fluid retention, edema, increase in weight.

Contraindications & Cautions/Estrogen Receptor Modulators

Raloxifene= Known allergy= prevent hypersensitivity pregnancy and lactation=because of potential effects on the fetus or neonate. Patients with history of venous thrombosis or smoking patients with a history of venous thrombosis or smoking because of an increased risk of blood clot formation if smoking and estrogen are combined.

Pharmacokinetics/Oxytocics

Rapidly absorbed after parenteral or oral administration; metabolized in the liver, and excreted in urine and feces IM OR IV Methylergonovine is administered as such directly after delivery and then continued in the oral form to promote uterine involution. Oxytocin is also used in a nasal form to stimulate milk "let down" in lactating women.

Pharmacokinetics/Abortifacients

Well absorbed, metabolized in the live and excreted in the urine Because of their effects on the uterus, they are used during pregnancy only to end the pregnancy. Mifepristone is administered orally and takes 5 to 7 days to produce the desired effect. Carboprost is available as an IM injection, with an onset of 15 minutes and a duration of 2 hours. Dinoprostone is given by intravaginal suppository, with an onset of effects in 10 minutes and a duration of effects of 2 hours.

CLASSIFICATION/ESTROGEN

estrogens and the progestins (the endogenous female hormone progesterone and its various derivatives). Estrogens that are available for use include estradiol (Estrace, Climara, and others), conjugated estrogens (Premarin), esterified estrogen (Menest), and estropipate (Ogen).

Contraindications & Cautions/Progestins

similar to those for estrogens. contraindicated in the presence of pelvic inflammatory disease (PID), sexually transmitted diseases, endometriosis, or pelvic surgery because of the effects of progestins on the vasculature of the uterus Drospirenone is contraindicated in patients who are at risk for hyperkalemia due to renal disorders, liver disease, adrenal dysfunction, or the use of other drugs that can affect potassium levels because of its antimineralocorticoid effects and the risk of hyperkalemia. caution in patients with epilepsy, migraine headaches, asthma, or cardiac or renal dysfunction because of potential exacerbation of these conditions.

CLASSIFICATION/Fertility Drugs

stimulate the female reproductive system. The following fertility drugs are in use: Cetrorelix (Cetrotide), chorionic gonadotropin (Pregnyl), chorionic gonadotropin alpha (Ovidrel), clomiphene (Clomid, and others), follitropin alfa (Gonal-F), follitropin beta (Follistim AQ), ganirelix (generic), menotropins (Pergonal), and urofollitropin (Bravelle)

CLASSIFICATION/Abortifacients

used to evacuate uterine contents via intense uterine contractions. These drugs include carboprost (Hemabate), dinoprostone (Cervidil, Prepidil Gel, Prostin E2), and mifepristone (RU-486, Mifeprex). Some serious name confusion has been reported with dinoprostone and other drugs.

Adverse Effects/PROGESTINS

vary with the administration route used ; Systemic effects are very similar to the adverse effects of estrogen Dermal patch contraceptives are associated with the same systemic effects, as well as local skin irritation Vaginal gel use is associated with headache, nervousness, constipation, breast enlargement, and perineal pain

Pharmacokinetics/Progestins

well absorbed, undergo hepatic metabolism, and are excreted in the urine cross the placenta and to enter breast milk. Etonogestrel, in addition to being available as a vaginal ring, NuvaRing, is available as a subdermal implant that may be left in place for up to 3 years and then must be removed. [Another implant could be placed at that time.]