Women's Reproductive Health and Menopause PDF

University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING...

University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Learning Module in NCM 106 PHARMACOLOGY Prepared by: John Ian L. Lamasan, M.A.N., R.N. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM NCM 106: PHARMACOLOGY MODULE 3 DRUGS AFFECTING IN THE BODY SYSTEM Module Overview This module is designed for nursing students to have a comprehensive introduction to the concepts, principles of Pharmacology and to Integrate knowledge of physical, social, natural and health sciences and humanities in nursing pharmacology Module Outcomes At the end of the module the learner should be able to: 1. Provide appropriate health education related to drug therapy. 2. Evaluate compliance and response of client to the medications prescribed. 3. Use available clinical evidence that can ensure safe medication administration. 4. Document client’s condition/response/ outcomes related to drug therapy. 5. Manage resources (human, physical, financial, time) efficiently and effectively in safe drug administration. Use appropriate communication/ interpersonal techniques/strategies to ensure a working relationship with the client and/or support system in medication administration. Ensure intra-agency, inter-agency, multidisciplinary and sectoral collaboration in medication administration. Assume personal responsibility to keep abreast with current trends in nursing pharmacology Exemplify love for country in the service of the Filipinos. Discuss various technological advances in ensuring safe medication administration Manifest professionalism and excellence in planning for safe medication practice. Module Content: a. Reproductive System b. Pregnancy and Pre-term labor drugs c. Labor and Delivery and Neonatal drugs d. Postpartum and Newborn drugs e. Women’s Reproductive Health and Menopause f. Men’s Reproductive Health and Reproductive Disorders g. Infertility and Sexually Transmitted Infections A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM WOMEN’S REPRODUCTIVE HEALTH AND MENOPAUSE Women have specific health care needs throughout their reproductive and postreproductive life cycle. Women’s reproductive life cycle begins with menarche, the start of spontaneous menstruation, and continues through menopause, the permanent cessation of menstruation. Successful contraception is essential to the health and well-being of sexually active women of reproductive age. Successful adaptation to menopause, control of menopausal symptoms, and continued sexual wellness is essential to the health and well-being of older women. ESTROGEN-PROGESTIN COMBINATION PRODUCTS All estrogen-progestin combination products (also known as combined hormone contraception [CHC] products) contain a synthetic version of estrogen and a compound known as progestin. Ethinyl estradiol (EE) is the most commonly used synthetic estrogen found in CHC products. An older form of estrogen, mestranol, is found in higher-dose (≥50 mcg) oral combination products. Mestranol is converted into ethinyl estradiol in the body. Progestins are natural or synthetic hormones that have progesterone-like effects. Progesterone is the naturally occurring sex hormone produced in the ovaries of women. Progestogen refers to any synthetically produced progesterone compound. The term progestin will be used to describe the compound used in CHC products. Not only do progestins have contraceptive properties, they serve to balance out the effects of estrogen. COMBINED ORAL CONTRACEPTION PRODUCTS  Most commonly used methods of reversible contraception in the world.  Ease of use, high degree of effectiveness, and relative safety.  92% to 99.3% effective for contraception. TYPES OF COMBINED ORAL CONTRACEPTION PRODUCTS Monophasics, or nonphasic pills- provide a fixed ratio of estrogen to progestin throughout the menstrual cycle. Biphasics or phasic pills- the amount of estrogen is fixed throughout the cycle, but the amount of progestin varies; reduced in the first half to provide for some proliferation of the endometrium and increased in the second half to promote secretory development of the endometrium. This simulates the normal physiologic process of menstruation while still inhibiting ovulation. Triphasics- are the newest form of phasic COC products delivering low doses of both hormones with minimal side effects, including breakthrough bleeding. With triphasics, the amount of either estrogen or progesterone varies throughout the cycle in different ratios during three phases. EXTENDED-CYCLE COC PRODUCTS Loestrin 24 Fe is a 24-day monophasic hormonal regimen of 20 mcg of ethinyl estradiol tablets and 1 mg of norethindrone acetate, plus 4 ferrous fumarate tablets. It provides 24 days of active hormonal therapy and 4 days of hormone-free pills containing an iron supplement. CONTINUOUS DOSING COC PRODUCTS Seasonale (Jolessa) is a continuous dosing combined hormone contraception pill. The 91-day regimen includes 84 days of active pills and 7 days of inert pills. ORTHO-EVRA TRANSDERMAL PATCH The Ortho-Evra patch is aweekly form of combined hormone contraception, consisting of 750 mcg of ethinyl estradiol and 6 mg of the progestin norelgestromin (NGMN) delivered through a transdermal system. It is a thin plastic patch placed on the skin of the buttocks, stomach, upper outer arm, or upper torso. The patch is placed once a week for 3 weeks in a row. The fourth week is patch-free to allow for withdrawal bleeding. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM The patch works in a similar manner to COC pills by inhibiting ovulation, thickening cervical mucus to prevent sperm penetration, and preventing a fertilized egg from implanting in the uterus. Advantages:  Not having to remember to take a pill daily.  Less menstrual flow and cramping, acne, iron-deficiency anemia, excess body hair, premenstrual symptoms, and vaginal dryness with the patch.  Reduces the risk for ovarian and endometrial cancers, PID, breast cysts, ovarian cysts, and osteoporosis (loss of bone mass predisposing the patient to fractures).  Fewer occurrences of ectopic pregnancy. Disadvantages: - Skin reaction at the site of application, menstrual cramps, and a change in vision or the inability to wear contact lenses. - Not as effective for women who weigh more than 198 lb. - Exposes patients to higher levels of estrogen. - Increased risk for venous thromboembolism (VTE). - Other side effects include temporary irregular bleeding, weight gain or loss, breast tenderness, and nausea. - NUVARING TRANSVAGINAL CONTRACEPTION NuvaRing is a 2-inch–diameter flexible indwelling ring inserted into the vagina. It is nonbiodegradable, transparent, and colorless to almost colorless. NuvaRing releases 15 mcg of EE and 120 mcg of the progestin etonogestrel per day, similar to the quantities of estrogen and progestin found in lower-dose COC products. PROGESTIN-ONLY CONTRACEPTION PRODUCTS Do not contain estrogen. The estrogen component of contraceptives increases the risk of circulatory disorders. Allow contraception to be available for women who cannot take estrogen- progestin combination products. PROGESTIN-ONLY ORAL CONTRACEPTION PILL  Alteration in cervical mucus, making it thick and viscous, which blocks sperm penetration.  Interference with the endometrial lining, which makes implantation difficult.  Decreased peristalsis in the fallopian tubes, slowing the transport of ovum.  In approximately 50% of cycles, interference with the LH surge inhibiting ovulation. DEPO-PROVERA  Highly effective, long-acting injectable progestin in the form of depot- medroxyprogesterone acetate  With a theoretical and typical use efficacy rate of 99% and 97%, respectively.  One of the most effective hormonal methods of contraception at 97% to 99%.  Convenient dosing schedule.  Responsible for thickening of the cervical mucus, thinning of the uterine endometrium, and decrease in fallopian tube motility.  Inhibits both FSH and LH secretion from the anterior pituitary gland.  No protection against STIs.  May cause a loss of bone mineral density. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM IMPLANTABLE PROGESTINS  Nexplanon is a single-rod device containing 68 mg of the progestin etonogestrel; it is placed in the same location as Implanon.  Contains barium, a radio-opaque substance that can help locate the device on two- dimensional x-ray, ultrasound, magnetic resonance imaging (MRI) and computed tomography (CT) scanning if necessary.  Nexplanon may not be as effective in women who have a BMI greater than 30 (obese) or are on medications that induce liver enzymes. OTHER METHODS OF CONTRACEPTION SPERMICIDES Spermicides are chemical agents that inactivate sperm before they can travel through the cervix and into the upper genital tract. The most common form of spermicide is nonoxynol-9. BARRIER METHODS Both male and female condoms are available over-thecounter without a prescription. The female condom is a polyurethane (plastic) pouch with flexible rings at each end. It is inserted deep into the vagina like a diaphragm. The ring at the closed end holds the pouch in the vagina. The ring at the open end stays outside the vulva. Male condoms are available in latex, lambskin, and polyurethane. Latex condoms offer very good protection against STIs and HIV. INTRAUTERINE CONTRACEPTION Intrauterine devices (IUDs) and intrauterine systems (IUSs) are safe methods of contraception with high patient satisfaction rates. ParaGard T 380A  It releases copper, which primarily interferes with the contractions within the uterus impeding sperm migration.  A secondary effect is an inflammation of the endometrium, which also obstructs sperm motility and prevents implantation in the rare case that conception should occur  It should be inserted up to day 7 of the menstrual cycle, and can remain in place for up to 10 years. Mirena levonorgestrel-releasing intrauterine system (LNG-IUS)  It causes cervical mucus to become thicker so sperm cannot enter the upper reproductive tract or reach the ovum.  It impairs sperm migration by changing the uterotubal fluid.  Alterations in the endometrium prevent implantation in the rare case that conception occurs with the device in place. The LNG-IUS may also suppress ovulation. Both the ParaGard and the LNG-IUS can be inserted as early as 6 weeks postpartum. There are no contraindications with breastfeeding women and intrauterine contraception. Contraindications to the LNG-IUS are known or suspected pregnancy, uterine anomalies, and risk for acquiring an STI. The LNG-IUS may be effective at preventing endometrial cancer and invasive cervical cancer. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM MEDICAL ABORTION Refers to the termination of pregnancy that is less than 63 days from the first day of the LMP, or less than 9 weeks’ gestation.  Methotrexate is a medication that stops the pregnancy in the uterus. It may also be used to treat an early ectopic pregnancy that is encapsulated and less than 3 cm in size.  Mifepristone, first marketed as RU486, is an anti-progestin that blocks the hormone progesterone. Without progesterone, the lining of the uterus breaks down, ending support for the embryo.  Misoprostol is given to cause the uterus to contract and expel the products of conception. MENOPAUSE It refers to the transitional process experienced by women as they move from the reproductive years into the nonreproductive stage of life. Stages 1. Perimenopause or Premenopause - Includes the years before the natural cessation of spontaneous menstruation. - Women may experience short cycles (less than every 25 days), long cycles (more than every 35 days), heavy bleeding, light bleeding, or periods of longer or shorter duration. - Women may start to skip periods or abruptly stop menstruating altogether. - Oligomenorrhea (very scant periods) or menorrhagia is common. - Most common symptoms are hot flashes (caused by a surge in LH levels) and vaginal dryness (caused by estrogen withdrawal). Other symptoms include insomnia, headaches, irritability, anxiety or other variations in mood, cognitive difficulties, memory lapses, joint aches, and decreased libido. 2. Menopause - Refers to the permanent end of spontaneous menstruation caused by cessation of ovarian function. - It is documented as having occurred once a woman has stopped menstruating for 1 year. 3. Postmenopause - It is the stage when the body adapts to a new hormonal environment. - The production of estrogen and progesterone from the ovaries decreases during the late premenopausal and early postmenopausal periods. PHARMACOLOGIC AND COMPLEMENTARY AND ALTERNATIVE THERAPY FOR PERIMENOPAUSAL AND MENOPAUSAL SYMPTOMS COMPLEMENTARY ALTERNATIVE MEDICINE Soy has been made available in many over-the-counter nutritional supplements; however, natural soy products are considered more effective at treating hot flashes Red clover extract is also used to treat hot flashes, although research studies using red clover extract are inconclusive. Actaea racemosa, or black cohosh, is used in the over-thecounter preparations of Remifemin and Estroven. Limited studies show that black cohosh may decrease hot flashes. St. John’s wort may be helpful for menopausal women experiencing mild depression or mood alterations. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Ginseng may improve sleep, mood changes, and sense of well-being, while valerian is thought to help with insomnia. BIOIDENTICAL HORMONE THERAPY It includes estrogen-like compounds that have been derived from plants. These compounds are biochemically similar or identical to those produced by the ovaries. The most common commercially available compounds are estrone, estradiol, estriol, testosterone, and micronized progesterone. The route of administration can be oral,sublingual, implantable, injectable, or in vaginal suppository form. Pellet therapy is a form of bioidentical hormones, usually estradiol and estriol, aswell as progesterone and testosterone, implanted subcutaneously, in unnoticeable areas. Usually one pellet is placed and has a duration of 4 to 6 months. A new pellet is then inserted. HORMONE THERAPY Hormone therapy (HT) is used only for the relief of symptoms related to menopause, most commonly hot flashes, vaginal dryness, and associated sleep disorders. HT includes estrogen-progestin therapy (EPT) for use with women who have an intact uterus, and estrogen therapy (ET) for use with women who have had a hysterectomy. HT is available in oral preparations, transdermal applications, and vaginal preparations. Vaginal preparations are creams, suppositories, or rings. All vaginal preparations contain estrogen only and are very effective in treating vaginal dryness. Three types of estrogens are used in HT products: Natural or biological estrogens (including bioidentical estrogens) are derived from plants, minerals, or animals and are composed of estrones and estradiols. CEE are mixtures of natural estrogens isolated from the urine of pregnant mares. Although CEEs are derived from nonhuman sources, they are naturally occurring estrogens. Synthetic estrogens include ethinyl estradiol and mestranol, which are both the same estrogens found in CHC products. OTHER DRUGS FOR MENOPAUSAL SYMPTOMS Selective serotonin reuptake inhibitors (SSRIs) reduce the number and severity of vasomotor symptoms in women. SSRIs also have the added benefit of reducing depression, which may relieve irritability and mood changes associated with menopause. Clonidine (Catapres, Kapvay), a medication used for hypertension, also reduces the number and severity of vasomotor symptoms in women. Gabapentin (Neurontin) is an antiseizure medication that reduces the number and severity of vasomotor symptoms in menopausal women. OSTEOPOROSIS It is a progressive, debilitating skeletal disease that affects older men and women. Women older than 50 years are at greatest risk since the loss of estrogen during menopause is directly related to loss in bone mineral density. Hormone Therapy is no longer recommended for the treatment of osteoporosis but should be considered as a preventive measure in postmenopausal women who are at risk. bisphosphonates, which can reduce the breakdown of bone microstructure, and selective estrogen receptor modulators (SERMs). SERMs are a new class of synthetic estrogens. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Medications Menostar (estradiol transdermal system) is 14 mcg of 17-β estradiol in a transdermal, once-a- week patch used for prevention of postmenopausal osteoporosis. Alendronate (Fosamax) is a bisphosphonate used to treat osteopenia and osteoporosis. Ibandronate sodium (Boniva) is a once-a-month bisphosphonate indicated for the treatment and prevention of osteoporosis in postmenopausal women. Risedronate (Actonel) is also available in a daily or weekly dose. It has similar directions for use and side effects as the bisphosphonates. Reclast is a bisphosphonate that is administered IV in a 5-mg dose yearly. The IV dose should be administered over 15 minutes. Raloxifene (Evista) is a SERM that increases bone mineral density, decreases bone turnover, and reduces vertebral fractures. Evista is taken orally once a day in 60-mg tablet. Teriparatide (Fortéo) is a parathyroid hormone used for treatment of postmenopausal osteoporosis. It is administered 20 mcg subQ on a daily basis. Salmon calcitonin (e.g., Fortical, Miacalcin) is composed of calcitonin, a naturally occurring hormone that regulates calcium in the body and promotes bone metabolism. It is delivered via intranasal spray in a 200-IU dose administered daily. Denosumab (Prolia) is an osteoclast inhibitor used in women who are at a high risk for osteoporotic fracture, have had a fracture, or have not had improvement in T-score after using the bisphosphonates for osteoporosis. A 60-mg dose is given subcutaneously every 6 months. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Activity 1. CASE ANALYSIS (Analyse and Share) Instructions: 1. Read and analyse the scenario provided. 2. Answer the questions asked. 3. Write your answers in the box provided. Scenario: TA (gravida 3, para 1) is ready to leave the hospital after delivery of a healthy baby. TA had developed gestational hypertension during her pregnancy, but she had no prior history of hypertension. She plans to breastfeed for 3 months. She desires contraception and asks about hormonal contraceptive methods. Questions: TA asks whether she can take combination birth control pills while breastfeeding. Are other CHC methods available for TA besides the pill? What CHC start method is best for TA? A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan