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Endogenous Estrogens

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Synthesized from cholesterol in ovarian follicles; basic chemical structure of a steroid Estradiol: principal and most active

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Exogenous Estrogens

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Synthetic Steroidal: conjugated estrogens, estradiol transdermal Non-steroidal: diethylstilbestrol (no longer available in U.S.)

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Estrogen Indications

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Treatment or prevention of disorders that result from estrogen deficiency Atrophic vaginitis, hypogonadism, oral contraception (given with a progestin), uterine bleeding, vasomotor spasms of menopause ("hot flashes"), osteoporosis, breast cancer or prostate cancer, ovarian failure or castration

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Estrogen Contraindications

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Any estrogen-dependent cancer, undiagnosed abnormal vaginal bleeding, pregnancy, active thromboembolic disorder or history

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Estrogen Adverse Effects

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Thrombolytic events: most serious Nausea: most common Hypertension, thrombophlebitis, edema, vomiting, diarrhea, constipation, abdominal pain, photosensitivity, chloasma, amenorrhea, breakthrough uterine bleeding, tender breasts, fluid retention, headaches

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Estrogens and HRT: The North American Menopause Society (2010)

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Supports initiating hormonal therapy around the time of menopause to treat menopause-related symptoms and to treat or reduce the risk of certain disorders (e.g., osteoporosis, fractures) Hormone replacement is not recommended for women with histories of endometrial cancer In women with breast cancer, estrogen therapy has not been proven safe and might raise recurrence risk

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Continuous Combined Hormone Replacement Therapy

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Use of estrogen therapy alone has been associated with an increased risk of endometrial hyperplasia, a possible precursor of endometrial cancer Addition of continuously administered progestin to an estrogen regimen reduces the incidence of endometrial hyperplasia associated with unopposed estrogen therapy

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Progestin Indications

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Treatment of functional uterine bleeding caused by hormonal imbalance, fibroids, uterine cancer Treatment of primary and secondary amenorrhea Adjunctive and palliative treatment of some cancers and endometriosis, alone or in combination with estrogens to prevent conception, prevention of threatened miscarriage Alleviation of PMS symptoms

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Megestrol (Megace) MUST KNOW

answer

Progestin drug

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Megestrol (Megace) Indications MUST KNOW

answer

Adjunct therapy for treatment of breast cancer and endometrial cancers Management of anorexia, cachexia, or unexplained weight loss in AIDS patients To stimulate appetite and promote weight gain in cancer patients

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Megestrol (Megace) Adverse Effects MUST KNOW

answer

Liver dysfunction Cholestatic jaundice Thrombophlebitis Thromboembolic disorders such as PE Nausea and vomiting Amenorrhea and spotting Edema Weight gain or loss

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Estrogen and Progestin Nursing Implications

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Take the smallest dose needed and give deep IM doses/rotate sites Give oral doses with meals to reduce GI problems

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Estrogen and Progestin Patient Education

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Self-administration of meds and what to do if a dose is missed Sunburn prevention: wear sunscreen or avoid sunlight Instruct patients to report weight gain Complete annual follow-up exams, including PAP smear and breast exam (self or mammogram)

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Contraceptive Drugs

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Medications used to prevent pregnancy Oral medications: monophasic, biphasic, triphasic forms (triphasic most closely duplicates the normal hormonal levels of the female cycle) Newer extended-cycle products Most contain estrogen-progestin combinations

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Other contraceptive forms

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Long-acting injectable form of medroxyprogesterone (Depo-Provera) Transdermal contraceptive patch Intra-vaginal contraceptive ring

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Contraceptive Drug Mechanism of Action

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Prevent ovulation by inhibiting the release of gonadotropins and increasing uterine mucous viscosity, resulting in: (1) Decreased sperm movement and fertilization of the ovum (2) Possible inhibition of implantation of a fertilized egg (zygote)

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Contraceptive Drug Drug Effects

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Improve menstrual cycle regularity Decrease blood loss during menstruation Decrease incidence of functional ovarian cysts and ectopic pregnancies

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Contraceptive Drug Indications

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Primarily used to prevent pregnancy Treatment of endometriosis and hyper-menorrhea Production of cyclic withdrawal bleeding Post-coital emergency contraception

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Contraceptive Drug Adverse Effects

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Estrogen-related effects: hypertension, thromboembolism, possible PE, MI, and stroke, alterations in lipid and carbohydrate metabolism, increases in serum hormone concentrations Edema, dizziness, headache, depression Nausea, vomiting, diarrhea Increased appetite, increased weight Breast changes

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Contraceptive Drug Contraindications (Drugs that *decrease effectiveness of oral contraceptive drugs*)

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Antibiotics Barbiturates INH Rifampin

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Contraceptive Drug Contraindications (Drugs that *may have reduced effectiveness if given with oral contraceptive drugs*)

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Beta blockers Warfarin Tricyclic antidepressants Vitamins Hypnotics Anticonvulsants Theophylline Anti-diabetic drugs

question

Drug Therapy for Prevention of Osteoporosis

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Calcium supplements and vitamin D may be recommended for women at high risk Current recommendations are that women, especially those older than age 60, consider taking calcium and vitamin D supplements for bone health

question

Biphosphonates

answer

Osteoporosis drugs Work by inhibiting osteoclast-mediated bone reabsorption, thus preventing bone loss MUST KNOW: alendronate (Fosamax), ibandronate (Boniva)

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Biphosphonate Indications

answer

Both prevention and treatment of osteoporosis Glucocorticoid-induced osteoporosis and Paget's disease

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Biphosphonate Adverse Effects

answer

Headache, GI upset, joint pain Risk of esophageal burns if medication lodges in esophagus before reaching stomach Risk of osteonecrosis of the jaw Possible severe (incapacitating) bone, joint, or muscle pain

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Biphosphonate Nursing Implications

answer

Ensure that patients have no esophageal abnormalities Instruct patients to take meds upon rising in the morning with a full glass of water and 30 minutes before eating Emphasize that patients should sit upright for at least 30 minutes after taking the meds

question

Selective Estrogen Receptor Modifiers

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Osteoporosis drugs Stimulate estrogen receptors on bone and increase bone density

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Selective Estrogen Receptor Modifier Adverse Effects

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Hot flashes, leg cramps, increased risk of venous thromboembolism Teratogenic, leukopenia

question

Selective Estrogen Receptor Modifier Nursing Implications

answer

Instruct patient that meds will need to be discontinued 72 hours before and during any prolonged immobility (such as surgery or a long trip)

question

Monoclonal Antibody

answer

Osteoporosis Drugs Given as a subcutaneous injection once every 6 months along with daily calcium and vitamin D

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Hormones

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Osteoporosis Drugs

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Fertility Drugs

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Treat infertility through ovulation stimulation MUST KNOW: menotropin (Pergonal)

question

Menotropin (Pergonal) MUST KNOW

answer

Fertility Drug Standardized mixture of FSH and LH

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Menotropin (Pergonal) Mechanism of Action MUST KNOW

answer

Stimulates development of ovarian follicles, which leads to ovulation May also be given to men to stimulate spermatogenesis

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Fertility Drug Indications

answer

Used primarily to induce ovulation in anovulatory patients Also used to promote spermatogenesis in infertile men

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Fertility Drug Adverse Effects

answer

Tachycardia, hypovolemia, DVT Dizziness, headache, flushing, depression, restlessness, anxiety, nervousness, fatigue Nausea, bloating, constipation, vomiting, anorexia Urticaria, ovarian hyper-stimulation, multiple pregnancy, blurred vision, diplopoa, photosensitivity, breast pain

question

Fertility Drug Nursing Implications

answer

Instruct patient to take meds as ordered Patient should keep a journal while on fertility drugs

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Uterine Stimulants

answer

Medications used to alter uterine contractions MUST KNOW: oxytocin (Pitocin)

question

Uterine Stimulant Indications

answer

Promote labor Prevent start or progression of labor Postpartum use: reduce risk of postpartum hemorrhage

question

Oxytocin (Pitocin) MUST KNOW

answer

Uterine stimulant Synthetic form, hormonal drug Used to induce labor at or near full-term gestation Enhance labor when contractions are weak and ineffective Other: Prevent or control postpartum uterine bleeding, complete an incomplete abortion (after miscarriage), promote milk ejection during lactation

question

Uterine Stimulant Adverse Effects

answer

Hypotension or hypertension, chest pain Headache, dizziness, fainting Nausea, vomiting, diarrhea Vaginitis, vaginal pain, cramping Leg cramps, joint swelling, chills, fever, weakness, blurred vision

question

Uterine Relaxants: Tocolytics

answer

Used to stop labor that begins before term or to prevent premature birth (if bed rest does not work) Generally used after the 20th week of gestation (premature labor)

question

Uterine Relaxant or Stimulant Nursing Implications

answer

Follow specific administration guidelines carefully for administration Monitor patient's vital signs and fetal condition during therapy

question

Herbal Products: Soy Indications

answer

Relief of menopausal symptoms Used to prevent osteoporosis

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Herbal Products: Soy Adverse Effects

answer

Nausea Diarrhea Abdominal pain

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Nursing Implications: Assessment

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Baseline VS, weight, blood glucose levels, renal and liver function studies, smoking, medical and gestational history (i.e., gravida and parity) Contraindications, including potential pregnancy Fetal heart rate, uterine activity (relaxation and contraction)

question

Androgens

answer

Testosterone Anabolic steroids

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Testosterone

answer

Androgen Responsible for normal development and maintenance of primary and secondary male sex characteristics

question

Testosterone Mechanism of Action

answer

Development of bone and muscle tissue Inhibition of protein catabolism (metabolic breakdown) Retention of various electrolytes Stimulates the production of blood cells

question

Testosterone Drugs

answer

Several synthetic derivatives are available (oral and transdermal forms) Long-term dosage forms can last from 2-3 days to 2-4 weeks

question

Anabolic Steroids

answer

Androgen Anabolic activity: synthesis of tissue and increasing tissue formation Schedule III, great potential for misuse by athletes

question

Anabolic Steroid Adverse Effects

answer

Liver dysfunction (e.g., peliosis)

question

Androgen Mechanism of Action

answer

Stimulation of normal growth and development of the male sex organs Development and maintenance of male secondary characteristics Stimulate increased synthesis of body proteins, aiding in formation of muscular and skeletal proteins

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Androgen Adverse Effects

answer

Fluid retention

question

Androgen Inhibitors

answer

5-Alpha-Reductase Inhibitors Alpha1-Adrenergic Blockers Androgen Receptor Blockers Gn-RH Analogs

question

5-Alpha-Reductase Inhibitors

answer

Androgen Inhibitor MUST KNOW: finasteride (Proscar)

question

5-Alpha-Reductase Inhibitor Mechanism of Action

answer

Block the effects of endogenous androgens

question

5-Alpha-Reductase Inhibitor Indications

answer

Used to treat benign prostatic hyperplasia (BPH) May also be used for treatment of male-pattern baldness (minoxidil)

question

5-Alpha-Reductase Inhibitor Drug Effects

answer

Results in alleviation of symptoms of BPH

question

5-Alpha-Reductase Inhibitor Adverse Effects

answer

Loss of libido, loss of erection, ejaculatory dysfunction May cause PSA concentrations to decrease

question

Alpha1-Adrenergic Blocker Indications

answer

Androgen Inhibitor Used for symptomatic relief of obstruction caused by BPH

question

Androgen Receptor Blocker Mechanism of Action

answer

Androgen Inhibitor Block the activity of androgen hormones at target tissue (prostate) receptors

question

Gn-RH Analog Indications

answer

Androgen Inhibitor Used to treat prostate cancer

question

Drugs for the Treatment of Erectile Dysfunction

answer

MUST KNOW: sildenafil (Viagra), tadalafil (Cialis) Viagra= first oral drug for treatment of ED

question

Drugs for the Treatment of Erectile Dysfunction Mechanism of Action

answer

Recall discussion of pulmonary hypertension drugs

question

Drugs for the Treatment of Erectile Dysfunction Adverse Effects

answer

Headache, flushing, dyspepsia, chest pain Hypotension, unexplained visual loss Priapism In men with preexisting cardiovascular disease, especially those taking nitrates: lower BP substantially and may cause serious adverse effects

question

Herbal Products: Saw Palmetto Indications

answer

Used for treatment of BPH and alopecia

question

Herbal Products: Saw Palmetto Adverse Effects

answer

GI upset Headache Back pain Dysuria

question

Nursing Implications: Assessment

answer

Complete history, including history of and current meds urinary elimination problems, potential contraindications, drug interactions (e.g., erectile dysfunction drugs) Renal, liver, and CVS function PSA level and perform digital rectal exam before beginning any drugs for treatment of prostate disease Baseline VS, weight, height, serum electrolyte levels

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Nursing Implications: General Considerations

answer

Follow exact instructions for SL, buccal, and PO forms Transdermal Testoderm patches are applied to the scrotal skin Transdermal Androderm patches are applied to the skin on the body, never to scrotal skin Educate patients on proper administration techniques for each drug Monitor for therapeutic and adverse effects

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