Endometriosis: Interventions, Drug Therapy & Treatment

Endometriosis Interventions

• Treatment depends on patient wishes. Factors include patient age, desire for pregnancy, symptom severity, and the disease's extent and location.
• Treatment proceeds more rapidly if infertility is the reason for assessment.

Endometriosis: Drug Therapy

• Pain is managed using NSAIDs such as diclofenac (Voltaren).
• Endometriosis can be controlled, but not cured, with hormone therapy.
• Estrogen production can be inhibited to shrink endometrial tissue.
• Ovulation can be suppressed with progestin (medroxyprogesterone).
• Danazol (Cyclomen) is a synthetic androgen that atrophies ectopic endometrial tissue.
• Adverse effects of Danazol, weight gain, acne, hot flashes, hirsutism, and is expensive.

Endometriosis Treatment Options

• Initial steps include lifestyle changes, diet and exercise.
• Two Treatment levels: Prescription Drugs include Pain medication, Oral contraceptives, and Conservative surgery.
• Alternative medicines may control hormones through the use of herbal, phytoestrogenic and hormone-regulating supplements.
• Hormonal contraceptives such as birth control pills, patches, and vaginal rings control the hormones responsible for the buildup of endometrial tissue.
• Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists block ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation; this causes endometrial tissue to shrink
• Progestin-only contraceptives, such as an intrauterine device (Mirena), contraceptive implant or contraceptive injection (Depo-Provera), can halt menstrual periods and growth of endometrial implants to relieve signs and symptoms
• Danazol suppresses endometrium growth by blocking ovarian-stimulating hormone production and preventing menstruation. Danazol can cause serious side effects and can be harmful to a baby, so it may not be the first choice.

Endometriosis: Surgery

• Diagnostic laparoscopy is needed for a definitive diagnosis and may also remove lesions.
• Surgery includes hysterectomy, salpingectomy, oophorectomy, and endometrial implant removal.

Menopause Stages

• The first menstrual cycle usually occurs between ages 12-13 The peak fertility is around age 25, when estrogen levels are highest.
• Perimenopause: This is the period around 8-10 years before menopause, when estrogen is steadily declining and symptoms start to occur.
• Menopause: Ovaries stop releasing eggs and menstruation ceases for 12 consecutive months, typically around age 51.
• Postmenopause: The years following menopause, where estrogen levels continue to decline.

Menopause: Collaborative Care - Drug Therapy

• Standard hormone therapy includes estrogen for those without ovaries and estrogen and progesterone for those with a uterus
• Estrogen plus progestin increases the risk of breast cancer, stroke, heart disease, and emboli, yet people had fewer hip fractures and lower risk of developing colorectal cancer.
• Estrogen only(Premarin) increases risk of stroke and emboli, with less risk for hip fractures and no risk heart disease or breast or colorectal cancer
• HT therapy indicated for symptom management for less than 5 years.
• The lowest effective dose is administered for the shortest amount of time.

Menopause: Collaborative Care - Adverse Effects

• Estrogen: nausea, fluid retention, headache, and breast enlargement
• Progesterone: increased appetite, weight gain, irritability, depression, spotting, and breast tenderness
• Common estrogen regimen: daily dose, with increased dose for relief.
• Common progesterone regimen: 12 days each month on a continuous or cyclical regimen.
• SSRIs like paroxetine (Paxil), fluoxetine (Prozac), venlafaxine (Effexor XR), or gabapentin (Neurontin) may decrease hot flashes.
• Selective estrogen receptor modulators (SERMs), such as raloxifene (Evista) to prevent bone loss
• Bisphosphonates decreases osteoporosis risk
• Fossamax (alendronate) and Risedronate (Actonel) are examples of bisphosphonates.

Menopause - Collaborative Care: Lifestyle

• Avoid situations that fluctuate body temperature.
• Maintain a cool environment
• Avoid caffeine and alcohol.
• Wear loose clothing.
• Relaxation techniques may assist in minimizing effects
• Vitamin E may reduce hot flashes
• Cessation of smoking helpful
• Bone health maintained with a diet high in calcium, vitamin D, and complex carbohydrates and vitamin B complex
• Black cohosh herb can help with menopause symptoms.

Benign Prostatic Hyperplasia (BPH): Collaborative Care Goals

• Restore bladder drainage.
• Relieve symptoms.
• Prevent/treat complications

BPH - Mild Symptoms

• Watchful waiting is an option.
• Dietary changes are a component
• Avoid medications
• Restrict fluids in the evening.
• Adhere to a timed voiding schedule

BPH - Drug Therapy

• Alpha-Adrenergic receptor blockers
• Tamsulosin (Flomax) is a common Alpha-Adrenergic receptor blocker.
• Alpha-Adrenergic receptor blockers promote smooth muscle relaxation in the prostate to facilitate urinary flow.
• Improvement is expected in 2 to 3 weeks
• Side effects include orthostatic hypotension, dizziness, retrograde ejaculation, and nasal congestion.

BPH - Drug Therapy Continued

• 5α-Reductase inhibitors (inhibits type 2 isoenzyme)
• Finasteride (proscar) is a 5α-Reductase inhibitor.
• 5α-Reductase inhibitors decrease size of the prostate gland
• It takes about 6 months for noticeable improvement.
• Side effects include decreased libido, decreased volume of ejaculation, and erectile dysfunction.
• Dutasteride (Duragen) is a 5α-Reductase inhibitor that inhibits type 1 & 2 isoenzymes.
• May decreased libido.
• Adverse effects: Decreased volume of ejaculate, erectile dysfunction.

BPH: Minimally Invasive Therapy

• Transurethral needle ablation is a similar procedure to transurethral microwave therapy, but uses radiofrequency instead.
• Transurethral needle ablation is more precise.
• Pain is not typically an outcome.
• Complications include UTI, urinary retention, and irritative voiding symptoms with possible hematuria for 1 week.
• Transurethral microwave thermotherapy is an outpatient procedure.
• Microwaves are used to destroy prostate tissue.
• A Rectal T probe is an important safety measure.
• Complications: The procedure can cause urinary retention, dysuria, and hematuria, and may require a urinary catheter.
• Medications: bladder and pain medications may be used.
• Laser prostatectomy is an effective alternative to TURP.
• Compared to TURP, laser prostatectomy provides minimal bleeding and faster recovery time, and patients can stay on anticoagulants.

BPH: Invasive Therapy - Transurethral Resection (TURP)

• The obstructing prostate tissue is removed using a resectoscope inserted through the urethra.
• The outcome for 80% to 90% of patients is excellent.
• It is a relatively low risk procedure
• TURP is performed under spinal or general anesthesia and requires a hospital stay.
• The bladder is continuously irrigated with a three-way catheter for the first 24-36 hours to prevent mucus and blood clots.
• Complications include bleeding, clot retention, and dilutional hyponatremia.
• Patients must stop taking anticoagulants before surgery.

BPH: Post-Operative Care

• Routine postoperative care is given
• Postoperative bladder irrigation is performed to remove blood clots and ensure drainage of urine.
• Administer antispasmodics such as belladonna and opium.
• Teach Kegel exercises for continence control

BPH: Nursing Implementation

• Provide postoperative care
• Observe patient for signs of infection.
• Implement dietary interventions such as stool softeners to assist with straining
• Provide discharge instructions on the in-dwelling catheter
• Manage incontinence
• Instruct patient to drink 2 to 3 L of fluids per day
• Educate on signs and symptoms of UTI
• Prevent constipation
• Instruct patient to avoid heavy lifting
• Advise patient to refrain from driving and intercourse after surgery as directed.

Erectile Dysfunction (ED): Collaborative Care

• Oral drug therapy is the most common.
• Vacuum constriction devices may be used
• Intra-urethral devices are an option.
• Penile implants can assist with symptoms
• Sexual counseling can assist with underlying causes

Erectile Dysfunction: Drug Therapy

• Phosphodiesterase inhibitors are used in the treatment of erectile dysfunction (ED).
• Sildenafil (Viagra) was the first oral drug treatment for ED.
• Sildenafil (Viagra) causes relaxation of the smooth muscle in the corpora cavernosa (erectile tubes) of the penis, which permits the inflow of blood.
• Vardenafil (Levitra) is another drug in the family.
• Tadalafil (Cialis) another option but provides a longer duration of action.
• Sildenafil and tadalafil, under trade names Revatio® and Adcirca®, are also used to treat pulmonary hypertension.

Erectile Dysfunction: Drug action times

• Viagra: onset in 30 minutes, duration 4 hours
• Cialis (2.5mg-20mg daily): onset in 15 minutes, duration 36 hours
• Levitra: onset in 30 minutes, duration 5 hours

Infertility: Female Testing

• Ovulatory studies measure basal body temperatures.
• Tubal patency studies, involving visualization of the uterus and tubes
• Postcoital studies examine the environment of the cervix and number and motility of sperm.
• The cause of infertility is often not found

Infertility: Male factor

• Male factor infertility is related to the hypothalamic-pituitary system, testes and ejaculatory system
• Physical causes are either pretesticular, testicular, or post testicular
• Issues may be related to infection, medication, radiation, or substance use.
• History can include surgery, injuries, hot tubs, sexual practices, including masturbation (20x/day), weight training, tight undergarments, and stress levels.

Infertility: Treatments

• Intrauterine insemination (IUI): Sperm from either a partner or a donor is inserted directly into the uterus.
• Assisted Reproductive Technology (ART): One method is in vitro fertilization (IVF), where a mature oocyte is removed from a uterus, fertilized with sperm, and the embryo is transferred to the uterus.
• Infertility is emotionally and financially exhausting for couples.