Estrogens, Progestins, Estrogen Receptor Modulators, Preconception

Estrogen examples

Estradiol, conjugated estrogens, estropipate

Estrogen indications

HRT, menopausal symptom relief, combination contraception, osteoporosis prevention, selected cancer palliation

Estrogen reproductive effects

Develop female reproductive system and secondary sex characteristics

Estrogen pituitary effects

Affects FSH/LH release and can inhibit ovulation

Estrogen vascular effects

Causes capillary dilation and fluid retention

Estrogen cervical effect

Thins cervical mucus

Estrogen bone effect

Conserves calcium/phosphorus and promotes bone formation

Estrogen postpartum effect

Can prevent postpartum breast discomfort/engorgement

Estrogen contraindications

Undiagnosed atypical vaginal bleeding, breast/estrogen-dependent cancer, thromboembolic history

Additional estrogen contraindications

Heavy smoking, pregnancy/breastfeeding, metabolic bone disease, kidney insufficiency, liver impairment

Estrogen adverse effects

Breakthrough bleeding, menstrual irregularities, dysmenorrhea, amenorrhea

Estrogen systemic adverse effects

Libido/mental/weight changes, fluid retention, edema, headache, dizziness

Estrogen GI adverse effects

Nausea, vomiting, abdominal cramps, bloating, colitis

Estrogen interactions

Drugs increasing liver metabolism, corticosteroids, anticoagulants, thyroid medications, oral diabetes drugs

Estrogen food/herbal interactions

Grapefruit juice and St. John's wort

Progestin examples

Drospirenone, etonogestrel, levonorgestrel, medroxyprogesterone, norethindrone, progesterone, ulipristal

Progestin indications

Contraception, amenorrhea, functional uterine bleeding, emergency contraception, selected cancers

Progestin endometrial effect

Transforms proliferative endometrium into secretory endometrium

Progestin pituitary effect

Inhibits FSH/LH secretion

Progestin ovulation effect

Prevents follicle maturation and ovulation

Progestin uterine effect

Inhibits uterine contractions

Progestin precautions

Endometriosis/pelvic surgery, liver/adrenal disease, epilepsy, migraines, asthma, cardiac/kidney dysfunction

Progestin hyperkalemia risk

Some progestins can increase potassium, especially with kidney impairment or potassium-affecting drugs

Progestin bone risk

May decrease bone mineral density

Progestin adverse effects

Headache, nervousness, constipation, breast enlargement, perineal pain

IUD adverse effects

Abdominal pain, worsened endometriosis, abortion, PID, expulsion

Estrogen + progestin risks

Increased thrombosis, breast cancer, and dementia risk

Progestin drug interactions

Barbiturates, carbamazepine, phenytoin, griseofulvin, penicillins, tetracyclines, rifampin

Progestin herbal interaction

St. John's wort may reduce effectiveness

Estrogen receptor modulators

Nonhormonal drugs that selectively stimulate or block estrogen receptors

SERMs purpose

Provide beneficial estrogen effects while limiting unwanted effects

Raloxifene

Prevents/treats postmenopausal osteoporosis and reduces breast cancer risk

Ospemifene

Treats moderate/severe dyspareunia and vaginal dryness from postmenopausal vulvovaginal atrophy

Estrogen receptor modulator contraindications

Allergy, pregnancy/lactation, venous thrombosis history, smoking, premenopausal use

Estrogen receptor modulator adverse effects

GI upset, fluid changes, hot flashes, edema, vaginal discharge, endometrial polyps, muscle spasms

Ospemifene boxed warning

Increased endometrial cancer and cardiovascular adverse-event risk

SERM interactions

Highly protein-bound drugs, warfarin, concurrent systemic estrogens

Preconception care

Prior-to-pregnancy care that identifies and modifies biomedical, behavioral, and social risks

Preconception folic acid

400–800 mcg/day depending on risk

Preconception lifestyle

Healthy diet, exercise, healthy weight

Preconception vaccines: influenza

Give if pregnancy is planned during flu season

Preconception vaccines: rubella

Give if nonimmune before pregnancy

Preconception vaccines: varicella

Give if nonimmune before pregnancy

Preconception vaccines: Tdap

Ensure adult tetanus/diphtheria/pertussis vaccination is up to date

Pregnancy teratogenic risk: isotretinoin

Isotretinoin/Accutane is a major pregnancy risk

Other pregnancy risk factors

Alcohol misuse, antiepileptics, diabetes, folate deficiency, hepatitis B, HIV/AIDS

Additional pregnancy risk factors

Rubella, obesity, STIs, smoking, hypertension

Preconception partner assessment

Assess both partners' immunizations, medical conditions, reproductive health, sexuality, nutrition, lifestyle

Genetic preconception assessment

Assess genetic disorders and carrier status

Psychosocial preconception assessment

Assess psychosocial issues, medications/drugs, and support system

Healthy pregnancy outcome strategies

Exercise/weight maintenance, folic acid, chronic disease management, and hazard education

Environmental pregnancy hazards

Metals, herbs, medications, tobacco, and other teratogens