Hormonal Contraception Overview

Hormonal Contraception

• Hormonal contraception uses hormones to prevent pregnancy by suppressing ovulation.
• Hormones are delivered orally, topically (patches, rings, or IUDs), implanted under the skin, or injected.
• The mechanism of action is similar for all forms of hormonal contraception.
• Hormones control the natural secretion of estrogen and progesterone through the hypothalamus, pituitary gland, and ovary.
• Oral contraceptives provide enough estrogen and/or progesterone to signal the hypothalamus that these hormones are not needed.
• This stops the release of GnRH, FSH, and LH, preventing ovulation and making it difficult for fertilization to occur.
• Combined oral contraceptives (OCs) contain synthetic estrogen and progestin.
• Progestin-only pills are preferred for breastfeeding women as they do not suppress lactation.
• Common side effects include breast enlargement, nausea, fluid retention, and weight gain.
• OCs can increase the risk of blood clots, leading to deep vein thrombosis.
• Medroxyprogesterone (Depo-Provera, DMPA) can cause amenorrhea and bloating.
• Some OCs can cause liver toxicity, indicated by elevated liver enzyme levels, yellowing of the skin and eyes, fatigue, dark urine, pale stools, and nausea.
• Hormonal contraceptives can promote the growth of hormone-sensitive cancers of the cervix, uterus, ovary, and breast.
• OCs containing drospirenone (Ocella, Yasmin, YAZ28) can increase serum potassium levels, potentially causing heart block and irregular heart rhythms.
• Hormonal contraception is not recommended for women with moderate to severe hypertension.
• Women should use an additional method of contraception during the first cycle, as OCs require a full cycle to become effective.
• Take OCs as prescribed to ensure effectiveness.
• OCs are effective only when taken exactly as prescribed.
• Take OCs once daily with food at the same time each day.
• Avoid smoking or nicotine use to reduce the risk of blood clots, heart attacks, and strokes.
• Missed doses can impact effectiveness, needing additional contraception if more than one dose is missed in a cycle.
• Inform healthcare providers about OC use due to potential drug interactions.
• Do not take over-the-counter medications without consulting a healthcare provider.
• Report any signs of liver toxicity, including yellowing of the skin or eyes, dark urine, or pale stools.
• Hormonal contraceptives should not be used during pregnancy as they can interrupt pregnancy and cause birth defects.
• Lactating women should not use hormonal contraceptives as they interfere with lactation and can harm infants.
• Examples of OCs include drospirenone, ethinyl estradiol (Yasmin), and Ortho-Novum.
• Progestin-only medication example: Depo-Provera (DMPA) given by injection.

Menopausal Hormone Replacement Therapy (HRT)

• Perimenopausal HRT replaces naturally secreted estrogen and progesterone with hormones.
• Low-dose estrogen increases blood estrogen levels, reducing perimenopausal symptoms and suppressing FSH levels.
• HRT helps with hot flashes, night sweats, and sleep disturbances.
• HRT increases the risk of myocardial infarction and is not recommended for long-term therapy.
• HRT drugs increase the risks of blood clotting, thrombophlebitis, and thrombi and emboli formation.
• These clotting risks increase with age and are greater with cigarette smoking.
• Potential health problems associated with increased clotting include heart attack, stroke, pulmonary embolism, and deep vein thrombosis.
• Assess for Homan's sign to check for possible clots.
• HRT, similar to OCs, promotes the growth of hormone-sensitive cancers of the cervix, uterus, ovary, and breast.
• HRT is also linked to liver impairment, gallbladder disease, and pancreatitis.
• Take HRT drugs exactly as prescribed regarding dosage and timing to prevent excessive uterine bleeding.
• Quit or reduce smoking while taking HRT to reduce clotting risks.
• Check the roof of the mouth and whites of the eyes for yellowing, indicating potential liver impairment.
• Seek immediate medical attention if experiencing chest pain, difficulty breathing, leg swelling, or stroke symptoms.
• Taking HRT for extended periods increases the risk of certain cancers. Discuss the optimal treatment duration with your healthcare provider.
• Examples of HRT/MRT include conjugated equine estrogen, conjugated estrogen plus progestin (Prempro).

Androgens

• Male sex hormones are produced under the influence of the anterior pituitary gland.
• Androgens, including testosterone and related hormones, are synthetic or natural hormones that develop and maintain male sex organs at puberty.
• Androgens contribute to the development of secondary sex characteristics in men (facial hair, deep voice, body hair, body fat distribution, muscle development).
• Androgens promote anabolic (tissue-building) processes.
• Androgens are steroid hormones synthesized from cholesterol in the adrenal gland.
• Androgens are used to treat hypogonadism, hypopituitarism, eunuchism, cryptorchidism, oligospermia, and general androgen deficiency in males.
• Testosterone is the most commonly used androgen.
• Androgens can help in the development of skeletal muscle cells.
• Common side effects include edema due to sodium retention, acne, hirsutism, male pattern baldness, mouth irritation, diarrhea, nausea, and vomiting.
• Long-term high-dose androgen therapy can lead to liver tumors, liver cancer, and hepatitis.
• Other adverse reactions include jaundice, decreased sperm count, gynecomastia, and impotence.
• Androgens can interact with anticoagulants, antidiabetic agents, and other drugs.
• Corticosteroids given with androgens increase the risk of edema.
• Barbiturates decrease the effectiveness of androgens due to increased liver breakdown.
• Take androgens as instructed by your healthcare provider.
• Do not increase the dose without consulting your doctor, as response may take several months.
• Report any new or worrisome symptoms, including fluid retention, breast enlargement, shortness of breath, excessive stimulation, prolonged or painful erections, impotence, urinary retention, and jaundice.
• If taking sublingual or buccal androgens, avoid eating, drinking, smoking, or chewing tobacco until the drug is dissolved for optimal absorption.
• Check cholesterol and monitor liver function tests.
• If using a topical gel, prevent contact with women and children to avoid accidental absorption.
• Examples of androgens include testosterone cypionate (Andro-Cyp), Dehydroepiandrosterone (DHEA), and Androstenedione.
• Synthetic androgens can be used for women, such as danazol for endometriosis (causes endometrial tissue atrophy, decreases FSH and LH, leading to amenorrhea and anovulation).

Anabolic Steroids

• Anabolic steroids are synthetic drugs with the same uses and actions as androgens.
• They can be used as replacement therapy for testosterone deficiency.
• Anabolic steroids are primarily used to treat hypogonadism, hypopituitarism, eunuchism, cryptorchidism, oligospermia, and general androgen deficiency in males.
• Side effects are similar to those of androgens, including edema, acne, hirsutism, male pattern baldness, mouth irritation, diarrhea, nausea, and vomiting.
• Anabolic steroids can increase the effects of anticoagulants, antidiabetic agents, and other drugs.
• Patient teaching is the same as for patients taking androgens.

Phosphodiesterase (PDE) Inhibitors

• Penile erection involves the release of nitric oxide in the corpus cavernosum during sexual stimulation.
• PDE inhibitors enhance smooth muscle relaxation and blood flow to the corpus cavernosum, facilitating erections.
• Common side effects include headache, hypotension, and dyspepsia.
• PDE inhibitors potentiate the hypotensive effects of nitrates, making their concurrent use contraindicated.
• Tadalafil (Cialis) is also contraindicated for use with nitrates, nitric oxide, or alpha-adrenergic blockers.
• Sildenafil citrate (Viagra): The recommended dose is 50 mg taken approximately 1 hour before sexual activity, but can be taken 30 minutes to 4 hours beforehand.
• Tadalafil (Cialis): It should not be used in patients with unstable angina, recent stroke, life-threatening heart failure, uncontrolled hypertension, or recent myocardial infarction. The recommended dose is 10 mg before sexual activity (range 5-20 mg; not to exceed one dose in 24 hours).
• Vardenafil (Levitra): The recommended dose is 10 mg taken 1 hour before sexual activity (range 5-20 mg; not to exceed one dose daily). This drug should not be used with nitrates due to the risk of dangerously low blood pressure.
• Medications alone are not sufficient for erections; sexual stimulation is necessary.
• Examples of PDE inhibitors include sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil (Levitra).

Drugs Used for Infertility

• Management of infertility depends on the cause.
• Supplemental hormone therapy may be used to restore and maintain ovulation if infertility is due to altered ovarian function.
• Drugs used to induce ovulation:
  • Clomiphene citrate (Clomid) (ovulatory stimulant)
  • Bromocriptine (Parlodel) (dopamine promoter)
• Progesterone:
  • Injection
  • Vaginal jelly
• Clomiphene citrate (Clomid) and bromocriptine (Parlodel) can increase the risk of multiple births.
• Progesterone can be continued until 10-12 weeks gestation, when the placenta takes over hormone production.
• Reducing psychological stress can improve the emotional climate and enhance the likelihood of conception.
• Educate couples regarding the timing of ovulation and appropriate coital techniques. Sexual intercourse timed to the days preceding and at ovulation is optimal.
• The placenta takes over hormone production around 3 months of gestation.

Vaginal Suppositories

• Vaginal suppositories can be used for medication delivery.
• Medications for yeast infections, vaginal dryness, spermicides, and antifungals can be administered through vaginal suppositories.
• Reiterate the importance of hand washing before and after medication application.
• Heat can be applied through douches, perineal irrigations, and sitz baths.
• Excessive douching can alter normal vaginal flora.
• Use vaginal suppositories at bedtime.
• Remain lying down for at least 30 minutes after insertion to allow absorption and prevent loss of medication.
• Refrain from sexual intercourse or use a condom to prevent medication loss.

Bisphosphonates

• Bisphosphonates are used to prevent and manage osteoporosis.
• Pamidronate sodium (Aredia) is used to delay bone metastases and reduce skeletal problems in patients with advanced breast cancer.
• Bisphosphonates bind to calcium in the bone and prevent osteoclasts from destroying bone cells and resorbing calcium.
• Common side effects include headache, esophageal reflux, and nausea.
• Jawbone necrosis (osteonecrosis) can occur with tooth extraction or other invasive dental procedures in which the jawbone is damaged.
• Take bisphosphonates early in the morning, right after breakfast, and drink a full glass of water.
• Remain upright (sitting, standing, or walking) for at least 30 minutes after taking these drugs to prevent esophageal irritation and reflux.
• Inform the dentist or oral surgeon about bisphosphonate use before a tooth extraction or invasive dental procedure involving the jawbone.
• Report any swelling, pain, redness, or other signs of infection in the gums that may indicate osteonecrosis.

Radiation Therapy

• Can be used to cure or control cancer that has spread to local lymph nodes or to treat tumors that cannot be removed surgically.
• Can also be used to slow the growth of malignant tumors.
• Can be delivered externally or internally.
• Normal cells can tolerate radiation only up to a certain amount before irreversible damage occurs.
• Treatment plans are designed to minimize the radiation dose to normal structures.
• Meticulous planning and recording of the doses are essential.
• External radiation adverse effects include fatigue and skin reactions such as erythema, pruritus, dryness, infection, and pain.
• Keep the skin dry and pat the skin dry with an absorbent towel after bathing.
• Do not apply lotions, ointments, creams, or powders to the area.
• Avoid direct sunlight, heat, or cold to the radiated area.
• Maintain a high-protein, high-calorie diet to promote healing and tissue regeneration.
• Drink 2 to 3 L of fluid per day to maintain hydration.
• Internal radiation for cervical cancer involves placing an applicator containing radioactive material in the vagina.
• Keep the patient on strict bed rest and prevent the applicator from dislodging by instructing the patient not to turn or raise the head of the bed more than 45 degrees.
• Do not give a complete bed bath while the applicator is in place.
• Encourage active range-of-motion (ROM) exercises with both arms and mild foot and leg exercises to minimize complications of immobility.
• Use antiembolism stockings or pneumatic compression boots to prevent blood stasis in the lower extremities.
• Monitor vital signs every 4 hours and be alert for elevations in temperature, pulse, and respirations.
• Report a temperature higher than 100°F (37.7°C) to the patient’s health care provider.
• Assess for and report any rash or skin eruption, excessive vaginal bleeding, or vaginal discharge.
• Maintain an accurate intake and output record.
• Encourage the patient to consume at least 3 L of fluid intake daily.
• An indwelling urinary catheter can be used to reduce bladder size and decrease the effects of radiation on the bladder.
• Monitor the catheter's patency and ensure that it continues to drain well.
• Monitor the patient’s dietary intake and encourage low-residue selections to minimize peristalsis and bowel movement, which may lead to dislodgment of the applicator.
• Check the position of the applicator every 4 hours.
• Keep long-handled forceps and a special lead container in the patient’s room for use by the radiologist, should the implant become dislodged.
• Never touch a dislodged applicator or materials.
• Check any bed linens, dressings, or pads that have been changed for the patient with a radiation safety officer before they are removed from the patient’s room.
• After the applicator is removed, an indwelling catheter is usually removed, and a douche and enema commonly are prescribed.
• Encourage the patient to ambulate and gradually resume activities.
• Delay sexual intercourse for 7 to 10 days.
• Instruct the patient to notify the health care provider of nausea, vomiting, diarrhea, frequent or painful urination, or a temperature higher than 100°F (37.7°C).

Chemotherapy

• Chemotherapy drugs are used to reduce the size or slow the growth of cancer.
• Most chemotherapeutic agents work by interfering with the cells’ replication process (ability to multiply or reproduce), damaging the cell, and causing cellular death.
• Malignant and normal cells are affected by chemotherapy, with rapidly multiplying cells (hematopoietic system, hair follicles, and GI system) being most affected.
• Common side effects result from the destruction of normal cells in these systems, including thrombocytopenia, leukopenia, weight gain, alopecia, nausea, and vomiting.
• Nephrotoxicity is a common adverse effect.
• Chemo brain can occur, with mental changes for a short period of time or years after treatment.
• Leukopenia (a reduction in the number of circulating white blood cells) increases infection risk.
• Treat nausea and vomiting with antiemetics such as prochlorperazine and serotonin antagonists such as granisetron and ondansetron (Zofran).
• Epoetin alfa (Procrit) can be used to raise erythrocyte counts and correct anemia.
• Assess the mouth for stomatitis (inflammation of the oral mucosa), which can lead to swallowing problems and systemic infections.
• Assess the skin for rashes or eruptions, which may indicate infection.
• Clean skinfolds twice a day with soap and water to prevent bacterial flourishing.
• Administer drugs orally whenever possible.
• Limit subcutaneous or intramuscular injections due to the risk of abscesses in patients with neutropenia.
• Assess pulmonary function for changes in breath sounds, elevated respiratory rate and rhythm, labored breathing, and pain during inspiration or expiration.
• Assess urinary and bowel function.
• Monitor for decreased urinary output, changes in the odor or color of the urine, hematuria, or glycosuria.
• Assess for urinary frequency, urgency, or pain.
• Avoid urinary catheterizations in neutropenic patients to reduce the risk of urinary tract infection.
• Monitor for diarrhea or constipation.
• Prescribe a stool softener to prevent straining.
• Perform regular, gentle mouth care.
• Use water-soluble moisturizers to prevent skin dryness.
• Use an electric razor to shave and prevent cuts.
• Encourage deep breathing and coughing exercises and physical activity.
• Use an incentive spirometer to maximize ventilatory capacity.
• Instruct the patient to report any changes in bowel pattern.
• Provide education about hair loss, which can begin within a few days or weeks of treatment and may be rapid and complete.
• Provide education about scalp protection, such as using gentle shampoos, avoiding hair dryers, curling irons, permanents, and hair coloring, and protecting the scalp.
• Examples of chemotherapy include cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF), or doxorubicin and cyclophosphamide.

Hormonal Therapy for Cancer Patients

• Estrogen can promote the growth of breast cancer cells if the cells are estrogen receptor positive.

• Hormonal therapy removes or blocks the source of estrogen, promoting tumor regression.

• Estrogen deprivation can occur by destroying the ovaries through surgery, radiation, or drug therapy.

• Hormonal therapy can block or destroy the estrogen receptors.

• Hormonal therapy is used to treat recurrent or metastatic cancer and as an adjuvant to primary treatment.

• Tamoxifen (an antiestrogen drug) blocks the estrogen receptor sites of malignant cells, inhibiting the growth-stimulating effects of estrogen.

• Tamoxifen is the first-line treatment for metastatic breast cancer in post-menopausal, estrogen receptor–positive women with or without lymph node involvement.

• Letrozole, like tamoxifen, interferes with the hormone estrogen, which feeds breast cancer cells. Tamoxifen blocks estrogen receptors on the cells, whereas letrozole inhibits the creation of estrogen.

• Fulvestrant (Faslodex) is used for women with advanced breast cancer who no longer respond to tamoxifen. It slows cancer progression by destroying estrogen receptors in the breast cancer cells and is given intramuscularly on a monthly basis.

• Aromatase inhibitor drugs, which interfere with the enzyme that synthesizes endogenous estrogen, are used to treat advanced breast cancer in postmenopausal women with disease progression. These drugs include anastrozole (Arimidex), letrozole (Femara), exemestane (Aromasin), and aminoglutethimide (Cytadren).

• Other drugs that may be used to suppress hormone-dependent tumors include megestrol, diethylstilbestrol, and fluoxymesterone.

Hormonal Contraception

• Hormonal contraception uses hormones to prevent ovulation, making it highly effective when used correctly.
• Hormonal contraceptives can be taken orally, applied topically, implanted under the skin, or injected.
• The mechanism of action for all forms of hormonal contraception is the same: controlling estrogen and progesterone levels.
• Estrogen and progesterone in contraceptives communicate to the hypothalamus that these hormones are not needed, suppressing GnRH, FSH, and LH secretion.
• This ultimately prevents ovulation, thickens cervical mucus, and makes the uterine lining unsuitable for pregnancy.
• Combined oral contraceptives (OCs) are most effective and contain a synthetic estrogen and progestin.
• Progestin-only pills are preferred for breastfeeding women as they do not suppress lactation.
• Common side effects of oral contraceptives include breast enlargement, nausea, fluid retention, weight gain, and vaginal bleeding.
• OCs can increase the risk of blood clots, leading to deep vein thrombosis.
• Medroxyprogesterone (Depo-Provera) can cause amenorrhea and bloating.
• Some OCs can cause liver toxicity, indicated by elevated liver enzymes, yellowing of the skin and eyes, tiredness, and changes in urine and stool color.
• Estrogen and progestin in OCs can promote the growth of hormone-sensitive cancers.
• OCs containing drospirenone can increase serum potassium levels, potentially leading to heart problems.
• Hormonal contraceptives are contraindicated for women with moderate to severe hypertension.
• During the first cycle, an additional method of contraception should be used with OCs.
• OCs are only effective when taken exactly as prescribed.
• It is crucial to avoid smoking or nicotine use while taking OCs to reduce the risk of blood clots.
• Missed OC doses can reduce effectiveness, requiring an additional contraceptive method.
• Inform other healthcare providers about OC use due to potential drug interactions.
• Avoid over-the-counter medications without consulting the healthcare provider who prescribed the contraceptive.
• Notify your healthcare provider immediately about any signs of liver toxicity.
• Hormonal contraception is not recommended during pregnancy or breastfeeding.

Menopausal Hormone Replacement Therapy (HRT)

• HRT involves replacing naturally secreted estrogen and progesterone with hormones during perimenopause.
• Low-dose estrogen in HRT increases blood estrogen levels, reducing perimenopausal symptoms and suppressing FSH levels.
• HRT can reduce hot flashes, night sweats, and sleep difficulties.
• HRT increases the risk of myocardial infarction and is not recommended for long-term use.
• Estrogen and progesterone in HRT increase the risk of blood clots, thrombophlebitis, and thrombi formation.
• These risks increase with age and are significantly higher for smokers.
• Potential health problems associated with increased clot formation include heart attack, stroke, pulmonary embolism, and deep vein thrombosis.
• Assess patients for Homan's sign to detect potential clots.
• HRT can promote the growth of hormone-sensitive cancers like cervical, uterine, ovarian, and breast cancers.
• HRT is contraindicated for women at high risk of these cancers.
• HRT can cause liver impairment, gallbladder disease, and pancreatitis.
• Take HRT drugs exactly as prescribed to avoid excessive uterine bleeding.
• Quit or reduce smoking while taking HRT to decrease the risk of blood clots.
• Monitor for yellowing of the skin, eyes, and mouth, which may indicate liver impairment.
• Seek immediate medical attention for chest pain, difficulty breathing, leg swelling, or stroke symptoms.
• Discuss the optimal duration of HRT with your healthcare provider to minimize cancer risks.

Androgens

• Androgens are male hormones produced under the influence of the anterior pituitary gland.
• Testosterone and other related hormones are called androgens.
• Androgens are responsible for developing and maintaining male sex organs, secondary sex characteristics (e.g., facial hair, deep voice, body hair), and promoting muscle growth.
• Androgens are synthesized from cholesterol in the adrenal gland and are primarily used to treat hypogonadism, hypopituitarism, eunuchism, cryptorchidism, oligospermia, and general androgen deficiency.
• The most common androgen is testosterone.
• Common side effects of androgens include edema, acne, hirsutism, male pattern baldness, mouth irritation, diarrhea, nausea, and vomiting.
• Long-term, high-dose androgen therapy can lead to liver tumors, liver cancer, and hepatitis.
• Other adverse reactions include jaundice, decreased sperm count, gynecomastia, and impotence.
• Androgens can increase the effects of anticoagulants, antidiabetic agents, and other medications.
• Corticosteroids can increase the risk of edema when co-administered with androgens.
• Barbiturates reduce the effectiveness of androgens due to increased liver breakdown.
• Take androgen medications as instructed and avoid increasing the dose without consulting a healthcare provider.
• Report any new or troublesome symptoms, including fluid retention, breast enlargement, shortness of breath, excessive stimulation, prolonged erections, impotence, urinary retention, and jaundice.
• Ensure proper absorption of sublingual or buccal forms by avoiding eating, drinking, smoking, or chewing tobacco until the drug dissolves.
• Monitor cholesterol levels and liver function tests regularly.
• Avoid contact of topical androgen gels with women and children to prevent accidental absorption.

Anabolic Steroids

• Anabolic steroids are synthetic drugs with similar uses and actions as androgens.
• They are primarily used as replacement therapy for testosterone deficiency.
• Anabolic steroids cause similar side effects to androgens, including edema, acne, hirsutism, male pattern baldness, mouth irritation, diarrhea, nausea, and vomiting.
• Anabolic steroids can increase the effects of anticoagulants, antidiabetic agents, and other medications.
• Patient teaching for anabolic steroid use is the same as for androgens.

Phosphodiesterase (PDE) Inhibitors

• PDE inhibitors are used to treat erectile dysfunction (ED).
• During sexual stimulation, nitric oxide is released in the corpus cavernosum, leading to erection.
• PDE inhibitors enhance smooth muscle relaxation and blood flow to the corpus cavernosum, facilitating erection.
• Common side effects include headache, hypotension, and dyspepsia.
• PDE inhibitors can potentiate the hypotensive effects of nitrates, contraindicating their use in patients using nitrates.
• Tadalafil (Cialis) is contraindicated for concurrent use with nitrates, nitric oxide, or alpha-adrenergic blockers.
• The recommended dose of sildenafil citrate (Viagra) is 50 mg taken 1 hour before sexual activity.
• Tadalafil (Cialis) is contraindicated for patients with unstable angina, recent stroke, life-threatening heart failure, uncontrolled hypertension, or recent myocardial infarction.
• The recommended dose of tadalafil is 10 mg taken before sexual activity.
• Vardenafil (Levitra) is not to be used with nitrates due to the risk of unsafe blood pressure decrease.
• PDE inhibitors require sexual stimulation to be effective.

Medications for Infertility

• Infertility management depends on the cause.
• Hormonal therapy may be used to induce ovulation in cases of impaired ovarian function.
• Clomiphene citrate (Clomid) and bromocriptine (Parlodel) are used to stimulate ovulation.
• Progesterone is used to support pregnancy in some cases.
• Clomiphene citrate and bromocriptine can increase the risk of multiple births.
• Progesterone may be continued until the placenta is functioning and can produce hormones at around 10 to 12 weeks of gestation.
• Reducing psychological stress can improve the emotional climate and increase the chances of pregnancy.
• Educate couples about ovulation timing and appropriate coital techniques.

Vaginal Suppositories

• Vaginal suppositories are used to deliver medication directly to the vagina.
• Medications used in vaginal suppositories include those for yeast infections, vaginal dryness, spermicides, and antifungals.
• Hand washing before and after medication application is essential.
• Douching should be done sparingly, as excessive douching can disrupt normal vaginal flora.
• Administer vaginal suppositories at bedtime.
• Remain recumbent for at least 30 minutes after insertion to allow absorption and prevent loss of medication.
• Avoid intercourse or use a condom for the duration of the medication course.

Bisphosphonates

• Pamidronate sodium (Aredia) is used to delay bone metastases and reduce skeletal problems in patients with advanced breast cancer.
• Bisphosphonates work by binding to calcium in bone, preventing osteoclasts from destroying bone cells.
• Common side effects include headache, esophageal reflux, and nausea.
• Jawbone necrosis (osteonecrosis) can occur with tooth extraction or dental procedures in patients taking bisphosphonates.

Nursing Implications for Bisphosphonates

• Take bisphosphonates early in the morning, right after breakfast, with a full glass of water.
• Remain upright (sitting, standing, or walking) for at least 30 minutes after taking bisphosphonates to prevent esophageal irritation and reflux.
• Inform dentists or oral surgeons about bisphosphonate use before any dental procedures, especially extractions.
• Report any swelling, pain, redness, or signs of infection in the gums, which could indicate osteonecrosis.

Radiation Therapy

• Used to cure or control cancer that has spread to lymph nodes or to treat tumors that cannot be surgically removed.
• Can also slow the growth of malignant tumors.
• Can be delivered externally or internally.
• Normal cells have a tolerance limit for radiation before irreversible damage occurs.
• Treatment plans are designed to minimize radiation exposure to normal structures.

Nursing Implications for External Radiation

• Adverse effects include fatigue and skin reactions like erythema, pruritus, dryness, infection, and pain.
• Keep the radiated skin dry.
• Do not apply lotions, ointments, creams, or powders to the radiated area unless prescribed.
• Protect the area from direct sunlight.
• Maintain a diet high in protein and calories to promote healing and tissue regeneration.
• Encourage fluid intake (2-3 liters per day) unless contraindicated.

Nursing Implications for Internal Radiation

• Applicators containing radioactive material are placed in the vagina for cervical cancer treatment.
• Place "Radiation in Use" sign on the patient's door.
• Keep the patient on strict bed rest, preventing turning from side to side or onto the abdomen.
• Do not raise the head of the bed more than 45 degrees.
• Limit bed baths and linen changes to avoid dislodging the applicator.
• Encourage active range-of-motion (ROM) exercises for both arms, and mild foot and leg exercises to prevent complications from immobility.
• Monitor vital signs every 4 hours, especially for elevated temperature, pulse, and respirations.
• Report temperature exceeding 100°F (37.7°C) to the health care provider.
• Assess for and report rash, skin eruption, excessive vaginal bleeding, or vaginal discharge.
• Maintain an accurate intake and output record, encouraging 3 liters of fluid intake daily.
• Place an indwelling urinary catheter to reduce bladder size and minimize radiation effects on the bladder.
• Monitor catheter patency and drainage.
• Encourage low-residue diet to minimize peristalsis and bowel movements, which can dislodge the applicator.
• Check the applicator's position every 4 hours.
• Keep long-handled forceps and a lead container in the room for the radiologist in case of dislodgement.
  • Never touch dislodged applicators or materials as they are radioactive.
• Check bed linens, dressings, and pads for radiation before disposal.
• After applicator removal, an enema and douche are usually prescribed.
• Precautions are no longer needed after applicator removal.
• Encourage ambulation and gradual return to activities.
• Sexual intercourse is usually delayed for 7-10 days.
• Instruct the patient to report nausea, vomiting, diarrhea, frequent or painful urination, or temperature higher than 100°F (37.7°C).

Chemotherapy

• Used to reduce the size or slow the growth of cancer.
• Most agents interfere with cell replication, causing cell damage and death.
• Affects both malignant and normal cells, particularly rapidly multiplying cells like those in the hematopoietic system, hair follicles, and GI system.

Common Side Effects of Chemotherapy

• Thrombocytopenia
• Leukopenia
• Weight gain
• Alopecia (hair loss)
• Nausea and vomiting
• Nephrotoxicity (kidney damage)
• Chemo brain (mental changes)

Treatment of Common Side Effects of Chemotherapy

• Nausea and vomiting: treated with antiemetics like prochlorperazine, and serotonin antagonists like granisetron and ondansetron (Zofran).
• Anemia: Epoetin alfa (Procrit) helps raise erythrocyte counts.

Nursing Interventions for Cancer Therapy

• Assess the mouth for stomatitis, which can lead to swallowing problems and infections.
• Assess the skin for rashes or eruptions, which may indicate infection.
• Administer drugs orally whenever possible, minimizing subcutaneous or intramuscular injections to reduce abscess risk in neutropenic patients.
• Assess pulmonary function for signs of infection, including changes in breath sounds, elevated respiratory rate and rhythm, labored breathing, and pain during inspiration or expiration.
• Assess urinary and bowel function for decreased urinary output, changes in urine odor or color, hematuria, glycosuria, urinary frequency, urgency, or pain.
• Avoid urinary catheterizations in neutropenic patients.
• Monitor stool characteristics (color, consistency, blood), and record bowel movement dates.
• Prescribe stool softeners to prevent straining.

Patient Teaching for Chemotherapy

• Emphasize the importance of performing regular but gentle mouth care.
• Use water-soluble moisturizers to prevent dry skin.
• Advise patients to shave with an electric razor to prevent cuts.
• Encourage deep breathing and coughing exercises, as well as physical activity.
• Use an incentive spirometer to maximize ventilatory capacity.
• Instruct patients to report any changes in bowel patterns.
• Discuss potential for hair loss, which may begin within days or weeks of treatment (drug-induced alopecia is temporary).
• Provide educational materials and sessions with a hair stylist regarding scalp protection.

Examples of Chemotherapy Drugs

• Cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF)
• Doxorubicin and cyclophosphamide

Hormonal Therapy for Cancer

• Estrogen can promote the growth of breast cancer cells if the cells are estrogen receptor positive.
• Hormonal therapy removes or blocks estrogen sources, promoting tumor regression.

Actions and Uses of Hormonal Therapy

• Estrogen deprivation can occur through oophorectomy (ovarian removal), radiation, or drug therapy.
• Hormonal therapy can block or destroy estrogen receptors.
• Used to treat recurrent or metastatic cancer and as an adjuvant to primary treatment.

Tamoxifen

• An antiestrogen drug, blocks the estrogen receptor sites of malignant cells, inhibiting estrogen's growth-stimulating effects.
• First-line treatment for metastatic breast cancer in postmenopausal, estrogen receptor-positive women with or without lymph node involvement.

Letrozole

• Interfere with estrogen production.
• Blocks estrogen receptors on cells, while letrozole inhibits estrogen creation.

Fulvestrant (Faslodex)

• Used for women with advanced breast cancer who no longer respond to tamoxifen.
• Destroys estrogen receptors in breast cancer cells, slowing cancer progression.
• Given intramuscularly monthly.

Aromatase Inhibitor Drugs

• Interfere with the enzyme that synthesizes endogenous estrogen.
• Used for advanced breast cancer in postmenopausal women with disease progression.
• Include anastrozole (Arimidex), letrozole (Femara), exemestane (Aromasin), and aminoglutethimide (Cytadren).

Additional Drugs for Hormone-Dependent Tumors

• Megestrol
• Diethylstilbestrol
• Fluoxymesterone

Test your knowledge on hormonal contraception and its effects with this quiz. It covers mechanisms of action, recommendations for breastfeeding women, potential risks, and important instructions for use. Understand the implications of hormonal contraceptives during pregnancy and after childbirth.