✅EXAM 1 Flashcards
Menopause
Transitional process as women move from reproductive yeas to non-reproductive years
Starts 40’s ends 50’s.
Typically treat symptoms.
- permanent cessation of menses, similar symptoms as peri-menopause.
Perimenopause
Cycles become longer or shorter, irregular, insomnia, hot flashes, irritability, headaches, memory lapse, decreased libido, vaginal dryness, joint aches and pains.
HRT
Hormonal Replacement Therapy.
For menopause symptoms.
Premarin
Class:HRT
for symtoms of menopause, CONJUGATED ESTROGENS, vagainal dryness/atrophy
-Develops and maintains female genital system, breat and secondary sex characteristics.
Contraindications: known allergy, any history of VTE, abnormal vaginal bleeding, current breast feeding, active thrombolytic disorder (stroke, thrombophlebitis, hypercoaguable states)
Think about the “Pre” in preMENOPAUSE
ADVERSE EFFECTS OF TAKING ESTROGEN
Thromboembolic events! Transdermal and vagdermal less risk
Nausea/vomiting/diarrhea/constpation, photosensitivity, HTN/thrmbophlebtis, chloasm (a pigmentation disorder of the skin characterized by darker skin patches that primarily affect the face and other sun-exposed areas.)/ hirstuism(is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back)/slope is, tender breast/fluid retention/headache
Estrogen interactions
Can decrease activity of oral anticoagulants
-use of rifampin and ST. John’s wart can decrease effectiveness of estrogen
-cant take Tricycle Antidepressants (TCA) … can be toxic with estrogen
- smoking can increase risk of thrombosis
SSRI
Selective serotonin reuptake inhibitors are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions; ITS ALSO USED TO TREEAT MENOPAUSE.
Clonidine
Reduces vaso motor symptoms (hot flashes), sedative effect, its an anti hypertensive ;must monitor bp cuz it can cause hypotension
Gabapentin
May relieve vasomotor symptoms, should be limited to those who cant take HRT, may cause drowsiness
Soy, red clover, black cohosh
Some herbal meds can increase estrogen; so pts should becareful if they cant take estrogen. Like. Those with breast CA and liver disease, Vit E, primrose, st.johns wart, ginseng and melatonin
-Help decrease hot flashes.
Women’s Health Initiative (WHI)
1991 HRT was found to have increased risk of Breast Ca, Heart disease, stroke, blood clots. Decreased risk of Hip Fx and Colon Ca. Study DC’D because of alarming results
2008 Statement by North American Menopause Society HRT beneficial for women close to the onset on menopause to relieve symptoms/decrease bone loss. However risk benefit ratio decreases with advancing age
Menarche
The start of spontaneous menstruation
Ends at Menopause
Successful contraception is essential for health and well-being of women in their child-bearing years
Control of symptoms of menopause and continued sexual health essential for older women
CHC
Combined-hormone contraception are estrogen-progestin combination products
-contain SYNTHETIC ESTROGEN (ethinyl estradiol) and PROGESTIN
Estrogen: prevents formation of dominant follicle, preventing ovulation, prevents LH surge, stabilizes uterine endometrium, inhibits proliferation and secretory changes, decreases irregular and/or heavy menstruation
Mestranol: is used in older products or products with high concentrations of estrogen (higher doses or mestranol only in certain circumstances).
Estrogen
We prefer low estrogen products.. lower possible dose
Higher doses put them in higher risks of venous thrombosis embolism.. mitral infractions, bloood clots
Make sure they dont have history of strokes or. Heart attacks/ Lower Estrogen products with estradiol are preferred now Use the lowest dose possible Higher doses of estrogen are associated with MI, VTE and strokes
Progestin
Natural or synthetic hormone with progesterone-like effects
-most are derivatives of testosterone (androgen steroid)
-balance estrogen effects
-makes endometrium less favorable for implantation
-suppress LH surge prevent ovulation and pregnancy.
Progesterone
Naturally occurring hormone produced in ovaries.
Progestin’s in CHC
When we have newer generations of meds… they are more effective than older ones.. and have less side effects
We would prop able use ne’er ones
Increase in weight, edema, male pattern type hair growth, depressing, increase in lipids, develop inability to metabolize glucose.. when on progesterone.
1st Generation norethindrone, norethindrone acetate, ethynodiol
2nd Generation Noresthisterone and levonorgestrel (LNG)- most common
3rd Generation Desogestrel, gestodene, norgestimate
CHC
Side effects depends on amount of estrogen and type of progestin
When theres increased estrogen… cyclic Brest changes, dysmenorrhea (painful menstration; cramps), menorrhagia (abnormally heavy bleeding at menstration), chloasma, VTE
-When there’s decreased estrogen,… amenorrhea, spotting
When theres increased progestin….weight gain, depression, fatigue decreassed libido
When theres decreased progestin… break through bleeding, headaches.
The less estrogen, the better to avoid VTE ect.
Women taking CHC, most experience lighter, shorter and decreased cramps.
Can be given orally, transvaginal, transdermal.
Transdermal and transvaginal have less N/V, heart and circulatory risks, and non-compliance with daily dosing
NO SQ or IM in the USA
ORAL CHC
ORALLY IS MOST COMMON world-wide
-99.3% effective if absolute correct use (means women takes the pill the same time every day and never miss a pill.)
-92% effective with typical use (occasionally missing a pill )
Advantages:
- deceased blood loss
-decreased cramps
- elimination of mittelshmerz (pain on ovulation)
Reduction of ovarian cysts, benign breast disorders, PID, ectopic pregnancy, endometrial and ovarian CA.
Most are 21 or 28 day packs 21 days of active pills and either no pills for 7 days or inactive pills for 7 days
The last 7 days are decreasing the amount of estrogen and cause the withdrawal bleeding. (not true menses)
Loestrin FE- provides Iron during withdrawal bleeding to prevent anemia (sometimes women will experience anemia, s this will prevent it.
Mircette- has 2 days FE+ and 5 days of low dose estrogen may help prevent headaches associated with estrogen withdrawal/ 5days of extremely low estrogen; the low dose will help with that.
Monophonic (non-phasic) Oral CHC
A fixed ratio of estrogen: progesterone
-older one, during the whole 28 days in pack.. they get the same amount of estrogen.
Biphasic Oral CHC
Fixed amount of estrogen but less progestin in begining of cycle: this allows for normal physiologic process of menstration without ovulation. Progestin is going to change depending on day of the month(ex: ortho-novum)
Triphasic Oral CHC
Low amount of estrogen and progestin, the ratios change during 3 phases in the cycle. It changes to mimic natural cycle. Commonly used. Have the least side effects.
Ex: Ortho Tri-CyclenLo (can also be used to treat acne)
Four Phasic Oral CHC
Four diff ratios of estrogen and progesterone.
Yasmin
A monophasic pill with ethinyl estradiol and drospirenone ( similar to spiromolactone)
A potassium spearing.. holds on to more potassium, which increases renal failure and vfibs. / Contraindicated in liver, kidney or adrenal insufficiency Contraindicated for long-term use with NSAIDS, K+ sparing diuretics, ACE, ARBS. May increase K+ levels
CHC that reduces withdrawal bleeding
Withdrawal bleeding not necessary (not necessary)
Extended cycle products: shortened period of inactive pills reduces number withdrawal bleeding days.
Ex: loestrin 24, YAZ, Beyaz
Continuous dosing products:
1. Seasonale (jolessa) 91 day regimen w/ 84 days active and 7 days inactive: withdrawal bleeding 4 time a years; some people prefer that & some doesnt.
- Lybreel: 28 day cycle NO withdrawal bleeding
Ortho-Evra transdermal patch
Patch worn on stomach, buttocks, outer arm or upper torso; ROTATE SITE to revert irritation, keep integrity of patch (don’t cut), and keep areas clean and dry.
Worn for 3 weeks, 1 week allows for withdrawl bleeding; SIMILAR ADVANTAGES TO ORAL form.
Disadvantages: skin irritation, mensstural cramps, Change in vision or inability to wear contact lens., not as effective in women over 198 pounds (women weigh over that, its going to change the ability to absorb efficiently. ), Increaased risk for VTE, do not use if women are over 35 and smoke will increase risk of VTE
NuvaRing
Has COMBINE HORMONE
Take. It out for a week for withdrawal.
Still need to use back up contraception, its not that effective.
2 inch inwelling ring that contains estrogen/progesterone.
-interred in the first 5 days of menstration into the middle or upper 3rd of vagina, indweling for 3 weeks, removed for 1 week for withdrawal bleeding.
- 1st seven days after insertion you have to use back-up-method
-if falls out, must be put in within 3hours .. if not, you must use back up method for 7 days.
-has increased risk for VTE, vaginal irritation, discharge or infection. (Risk increases in pt smokes)
Progestin only Pills
There are some women that cannot take estrogen because of increase blood clots or VTE. If someone already has a blood clot, not going to put them. On estrogen.
Ex: pt with lupus cant go on estrogen.
Women who cant take estrogen and can take progestin only pills:
-history of VTE
-Heart disease
-breast feeding
-smokers
- over 35
-HTN
- or this who experience HA, chloasma, lipid changes
Side effects:
-higher incidence or irregular bleeding
-fatigue
-decreased libido
-depression/mood changes
- weight gain
Can be given orally, IM, SQ or implantable.
Oral examples of progestin only
Micronor, Nor QD, Aygestin
PLAN B
Injectable progestin only
Ex: Depo-Provera
-Prevents ovulation
-Injected every 11-13 weeks
-an ovulation and amenorrhea
If pt late for injection: they need a pregnancy test before injection/13 weeks and 1 day must be ruled out for pregnancy.
-risk of decreased bone density and should be stopped after 2years of continuous use
MUST increase intake of Ca+ and vit D. (Estrogen holds on to calcium and prevents osteoporosis… the progestin counter interacts and should intake calcium and vitamin D)
Implantable progestin only
Ex: Nexeplon similar to Implanon
-inserted for up to 3 years
Nexeplon contains barium (radioactive) can be seen on X-RAY, US, CT scan and MRI.
-not used to be in women with BMI >30
-99.6% effective …because its implanted inside you!
Considerations for Contraceptives
Missed dose:
-miss 1 tab, take as soon as you remember.
-missed 2 tabs (yesterday and today), take 2 as soon as realize and 2 the next day; use back up for rest of cycle.
-missed 3 tabs; forgets it.. just start a new pack
Some drugs decrease effectiveness.. for example, Abx can counter interact with birth control pills; use back up contraception.
Emergency Contraception
Used to prevent pregnancy after unprotected intercourse. SHOULD NOT be used as birth control. Used in 24hrs after unprotected sex
1. CHC in documented effected regimen (has to be prescribed)
2. Plan B (progestin only)
3. Inserting copper-releasing IUD
Can be taken if condom breaks, diaphragm or cervical cap dislodged, dose of CHC missed, sexual assault.
MUST not be taken if already pregnant, should be taken within 24hrs of unprotected sex
Calcitonin
Directly inhibits osteoclastic bone reabsorption/ gives calcium back to the bone
- its a treatment for osteoporosis
Contraindications:
- drug allergy or allergy to salmon.
Adverse effects:
- flushing of the face, N/D (nausea or diarrhea), and decreased appetite.
Teriparatide (Forteo)
Acts similar to the parathyroid hormone.
- treats osteoporosis by modifying body’s metabolism of calcium and phosphorus (review relationship btwn -horrors and calcium)
- treats osteoporosis.
Contraindications
- drug allergy
Adverse effects:
Chest pain, dizziness, hypercalcemia, nausea, arthralgia (pain in joint)
Bisphophonate Class alendronate (Fosamax)
This is VERY acidic. Commonly use to treat and prevent osteoporosis.
Inhibits osteoclast-mediated bone reabsorption, which in turn indirectly enhance mineral bone density.
Contraindications:
Hypocalcemia, esophageal dysfunction (the med is acidic; can get stuck in esophagus and causes burns) pt has to sit up or stand for 30 mins after dosing
Adverse effects:
HA/GI upset/joint paint. Risk for esophageal burns, if lodged in esophagus, drink full glass of H2O,sit up for 30 mins after.
Estradiol transdermal system
Ex: menostar
Once a week patch used for prevention of post-menopausal osteoporosis.
- low does estrogen
- reserved for those who are unable to tolerate other therapies
-women who still have their uterus intact, progestin recommended every 6-12 mos.
Selective Estrogen Receptor Modulator (raloxifene)
Stimulates estrogen receptors on bone and increases bone density.
-prevents post menopausal osteoporosis
Contraindications :
Drug allergy, pregnant or may become pregnant. Thrombosis disorder
Adverse effects:
Hot flashes/leg cramps/thrombosis-embolism, leukopenia
- decrease the chances of breast cancer
Testes
Pair of oval glands located in scrotal sac
- produce male sex hormones
Seminiferous Tubules
Channels to the testes
- site of spermatogenesis
Androgens
Primarily TESTOSTERONE (anabolic steroid)
- controls the development and Maintance of male primary and secondary sex characteristics.
- helps maintain muscle mass
-are the hormones that give men their ‘male’ characteristics. Androgen deficiency means the body has lower levels of male sex hormones, particularly testosterone, than is needed for good health. are the hormones that give men their ‘male’ characteristics. Androgen deficiency means the body has lower levels of male sex hormones, particularly testosterone, than is needed for good health. are the hormones that give men their ‘male’ characteristics. Androgen deficiency means the body has lower levels of male sex hormones, particularly testosterone, than is needed for good health.
Testosterone
Is a type of androgen
-produced from interstitial cells btwn the seminiferous tubules.
Anabolic activity: involved in development of bone and muscle tissue, and inhibits protein catabolism or break down of protein.
- increases RBCs… (erythropoietin effects) usually used for people who have low rbcs (not really used for this anymore; we have other medications)
Indications: who takes them? Patients with….
- primary and secondary HYypogonadism ( if they dont have their testes, dont have the hormones to respond to/A failure of the gonads, testes in men and ovaries in women, to function properly.
Production of a man’s testosterone and a woman’s estrogen are inhibited.)
- treatment of oligospermia (they’re not producing sperm)
-inoperable breast Ca in women (counter act tumor enhancing estrogen activity)
Synthetic Derivatives of Testostrone
We can use synthetic testosterone to improve the way hormones work. If we combine esters with testosterones, leads to poor PO absorption
- we use testosterone for decrease in libido and fatigue (ex: if males feels like they are losing muscle mass, and libido.. have to becareful with using this because it is not reccomended for those with normal levels of testosterones because it’ll increase the side effects.)
Example medications:
Testosterone propionate: an oily solution that last 2-3 days and it is administered every/q 2-4wks
Methyltestosterone/fluoxymestrone: effective w/ oral admin, buccal tab or injectable.
Anabolic Steroids
Synthetic drugs that mimics the natural hormone
-can be a huge risk of abuse and dependence (used with body builders or athletes… and not used in the US unless they have low levels)
- possesses high anabolic activity (he anabolic state is one where the body builds and repairs muscle tissue as opposed to a catabolic state that involves the process of breaking down tissue to replenish depleted energy levels of the body.)
- increases muscle mass VERY SIGNIFICANTLY
Indications: used for patients who have anemia, hereditary angioedema (swelling of face, lips; it’s cmmon for those who have this hereditary trait, it just happens), metastatic breast Ca, wasting syndrome due to HIV
Schedule III drug: needs to have a DEA # to keep track of it; can lead to psychological or physical dependence.
Four products available in US:
- anadrol-50
-oxandrin
-winstrol
-nandrolone
Androderm
A TRANSDERMAL PATCH is used when hormonal replacement therapy is the indication/ do have low testosterone levels.
There are two types:
1. Androderm patch: applied to skin (not scrotal)
2. Testoderm: always applied to scrotal skin ( think of “testo” for teste).. always rotate site
Pt should wash their hands and cover treated area as transfer to others can occur e; especially Prego women and children.
Contraindications:
Pts with these conditions, cant take it:
- severe renal cardiac or hepatic disease
- male breast Ca
- prostate Ca
-allergy to drug
-genital bleeding (because they may have cancer and we dont want to increase hormones)
Do NOT allow children to exposed to it, can cause inappropriate enlargement of genitalia, premature development of pubic hair, advanced bone aging, increased libido , aggressive behavior.
Nurse considerations:
- baseline lab testing BUN/Cr, LFT(LIVER FUNCTION TEST), CE’s (cardiac enzymes), Lipids
When giving testosterones, can increase their lipids and cholesterol, as well… have to be mind ful… can increase for heart attack and stroke.
Watch for weight gain or electrolyte disturbances (biggest concerns are potassium and magnesium).
Benign Prostatic Hyperplasia (BPH)
When the prostate gets bigger; doesn’t always mean its cancerous;
- it starts to close off urinary tract; if urine doesnt go out, that means urinary retention, which leads to renal failure.
-Androgens maintain secondary health characteristics, growth and Maintenance of the prostate , often leads to prostate enlargement (BPH)
-Process begins at 30 yrs old
Causes urinary outflow obstruction:
-frequent urination
-dribbling
-nocturnal (utilizing bathroom at night)
5-Alpha Reductase inhibitor (proscar) finesteride
BRAND NAME: proscar
GENERIC NAME: fineesteride
Mode of action: REDUCES prostate size by inhibiting the enzyme that converts testosterone to 5-alphadihydotesterone (DHT), and eases the passage of urine.
/ helps prostate shrink and open up urinary tract to help urination flow.
Additional Effects:
- may increase hair growth in men (sometimes you would see men take his for baldness and increase hair growth)
- it’s TERATOGENIC in pregnant women and children
Indications (therapeutic uses):
- Androgenic alopecia in men
- BPH shrinks prostate in 3-6 mos.
Contraindicated:
-hypersensitivity (if allergic to meds, shouldn’t take it)
- pregnant women ( DO NOT HANDLE) category X
Erectile Dysfunction (ED)
10 million men experience ED
- 20% of men 65 or older experience it; usually starts in late 40s
Treatment:
Sildenafil (Viagra)
Vardenafil (Levitra)
Tadalafil (Cialis)
-You may see women taking Slidenafil for pulmonary artery hypertension.
- all erectile dysfunction drugs ends in “-afil”
Sildenafil
Brand Name: Viagra
Inhibits the enzyme phosphodiesterase, that causes the build up. Of guanosine monophosphate, which then causes the relaxation of smooth muscle in the penis and permits the penis to have an erection/ cause blood flow into the penis.
- Viagra needs to be taken 1 hr before intercourse and needs sexual simulation to make the erection happen.
Contraindicated:
-People who are on Nitrates.(people put it underneath their tongue if they’re having chest pain) its the ONLY true contraindication to ED drugs. If they’re on the nitrates, they should nOT be getting ED medications.
-can cause hypotensive effects because of vasodialation.
Adverse effect
- hypotension
-dyspepsia (indigestion)
-priapism (erection lasting than 4 hours.. this is a medicAl emergency, if they dont get help, this will lead to a necrotic penis and needs to be removed.)
-visual loss
Labor and delivery medications
- Oxytocin (Pitocin)
-Terbutaline - Magnesium Sulfate
Oxytocin
BRAND NAME: Pitocin
-used to induce labor (a week or so pass their due date, utilize pitocin to induce)
- increases uterine contractility (we have to make sure cervix is dilated)
Side effects: HTN, dysrhythmias, hypercontraction of uterus
Adverse reaction: seizures, water intoxication
Terbutaline
To STOP preterm labor; if its too soon to give birth, use terbutaline. / decreases. Uterine contractions to stop pre-term labor
Side effects: tachycardia in mother and fetus
Magnesium Sulfate
Can be used for pre-termlabor to decrease contractions
-may be safer than terbutaline because increases blood flow to uterus, less tachycardia
Can be used for pre-eclampsia (Htn, spilling protein into the urine ; A potentially dangerous pregnancy complication characterized by high blood pressure.
Pre-eclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. It can lead to serious, even fatal, complications for both mother and baby.)
Autonomic Nervous System
There are two:
Sympathetic: fight or flight
Parasympathetic: rest and digest.
