Module 2: Reproductive Health & Sexually Transmitted Diseases

antidiuretic hormone (ADH), oxytocin

What two hormones does the posterior portion of the pituitary gland secrete?

andrenocorticotropic hormone (ACTH), prolactin, thyroid stimulating hormone, follicle stimulating hormone (TSH), follicle stimulating hormone, luteinizing hormone

What five hormones does the anterior portion of the pituitary gland secrete?

hypothalamic-pituitary-ovarian axis

monthly cycle of hormone secretion and actions

endogenous hormones

hormones produced naturally in the body

females: predominant ones are estrogen and progesterone

males: predominant one is testosterone

combined hormonal contraceptives (CHC)

-Contain a synthetic version of estrogen and progestin

-have generations of progestin

inhibit ovulation by preventing formation of dominant follicle; suppress luteinizing hormone surge

What is the action of CHCs?

oral, transdermal, transvaginal

What are three routes of delivery for CHCs?

Advantages of CHCs

-Ease of use

-High degree of effectiveness

-Relative safety

Differentiation of CHCs

-Strength of estrogen component

-Type of progestin used

-Whether estrogen or progesterone (and androgen) activity predominate

least amount of hormonal therapy while maintaining effectiveness

What is the current goal in regards to CHCs?

Monophasic contraceptives

Estrogen and progestin remain at a consistent level

multiphasic contraceptives

Estrogen and progestin may fluctuate throughout the cycle

delays

Extended use and continuous use CHC ___ menstruation

every 3 weeks

How often does ethinyl estradiol and norelgestromin transdermal patch need to be changed?

leave in for 3 weeks, take out for one week

How often does Ethinyl estradiol and etonogestrel transvaginal contraception need to be changed?

1. circulation

2. thrombosis

Progestin-Only Contraceptives: Benefits

-provides relative safety

-reduced risk of (1) disorders

-deep (2) is high risk if only estrogen

-increased levels of estrogen increase the levels of thrombin in the body, which affects the clotting cascade

progestin-only oral contraceptive pills

-called the minipill

-taken continuously without break for withdrawal bleeding

1. cervical mucus

2. endometrial

3. peristalsis

4. luteinizing

Action of Progestin-Only Oral Contraceptives

-alter (1), making it thick and viscous, which blocks sperm penetration

-interfere w/(2) lining, which makes implantation difficult

-decrease (3) in fallopian tubes, slowing transport of ovum

-interfere w/(4) hormone surge and inhibits ovulation

Depot medroxyprogesterone acetate (DMPA)

-A progestin-only hormonal contraceptive given by intramuscular or subcutaneous injection every 11-13 weeks

-highly effective, long-acting

-side effects: anovulation, amenorrhea

1. follicle stimulating

2. luteinizing

Action of DMPA

-Thickens cervical mucus

-Thins uterine endometrium

-Decreases fallopian tube motility

-Inhibits (1) hormone and (2) hormone, preventing formation of a dominant follicle

Progestin implant

-Single-rod device that contains etonogestrel

-Implanted in inner side of upper nondominant arm

-Removed no later than 3 yrs after insertion

-May be replaced w/new implant

-Contains radiopaque barium for easy location

Side effects of Progestin-Only Contraceptives

-Irregular bleeding and spotting

-Depression, mood changes, fatigue

-Decreased sexual desire, wt. gain

Preventing Fertilization w/CHC (1/2)

-2-5 pills at one time within 72 hrs

-"Emergency contraception" or "morning after pill"

Preventing Fertilization w/CHC (2/2)

-After unprotected vaginal intercourse

-After failure of a contraceptive method

-Raises estrogen & progestin levels to delay or prevent ovulation

-Interferes w/tubal transport of embryo, egg, and sperm

-Reduces pregnancy risk by 75%

-May cause nausea

withdrawal bleeding

-Pseudomenstruation occurring during monthly during 7-day hormone-free period

-Mimics normal 28-day menstrual cycle

(CHCs have 21 day packs + 7 days pill-free)

primary amenorrhea

absence of menses by age of 14 wo secondary sex characteristics or the absence by age 16 w/secondary sex characteristics

Chromosomal alterations

Endocrine disorders

Abnormalities in reproductive organs

What are three causes of primary amenorrhea

secondary amenorrhea

absence of a spontaneous menstrual period for 6 months in women who have had their period in the past

Causes of secondary amenorrhea

Pregnancy

Anovulation - cycle w/no ovulation

hypo/hyperthyroidism

Hyperprolactinemia

Extreme wt loss/anorexia

Polycystic ovarian syndrome

polycystic ovarian syndrome (POS)

disorder in metabolism of androgens and estrogens

side effects of medications for POS

anovulation, hirsutism (facial hair), menstrual irregularities, masculine qualities

menorrhagia

regular menstrual bleeding that lasts longer than 7 days and has a blood loss > 80 mL/day

metrorrhagia

irregular (outside of your normal cycle) menstrual bleeding that lasts longer than 7 days and has a blood loss > 80 mL/day

menometrorrhagia

combination of menorrhagia and metrorrhagia

intramenstrual bleeding

bleeding that occurs between menstrual periods and is usually like in nature (i.e. spotting)

dysfunctional uterine bleeding

-Irregular bleeding w/no organic pathology

-Estrogen combinations w/progestin may be used to normalize bleeding patterns

dysmenorrhea

Pelvic pain associated w/menstrual cycle

Accompanying Symptoms

-Uterine cramping, abdominal cramps, lower back pain

-Changes in bowel patterns, increased bowel movements

-N/V

Surge of prostaglandin early in the cycle

1. prostaglandin

2. cardiac

3. dysfunctional

4. endometrial

Pharmacologic Management of Irregular Bleeding

NSAIDs

-(1) is often the culprit of irregular bleeding

-Mefenamic acid (menorrhagia), ibuprofen, naproxen sodium - be cautious w/(2) patients

Combined Hormonal Contraceptives

-Decreases (3) uterine bleeding

-Suppresses (4) development

-Restores predictable bleeding pattern

-Reduces menstrual flow

-Progestins (synthetic progesterone)

endometriosis

endometrial tissue located outside the uterus

painful, bloody bowel movements; dyspareunia; infertility

Besides dysmenorrhea and pelvic/back pain, what are three S/S of endometriosis?

dyspareunia

painful intercourse

CHCs, progestin therapy, gonadotropin-releasing hormone agonists

What are three pharmacologic managements for endometriosis?

Gonadotropin-releasing hormone (GnRH)

A hormone released from the hypothalamus that triggers the anterior pituitary to secrete FSH and LH.

premenstrual syndrome (PMS)

Cyclic physical symptoms and perimenopausal mood alterations

Cues

Bloating

Mood changes

Fatigue

Edema

Constipation, diarrhea

Acne

Sleep pattern alterations

Decreased libido

Breast tenderness

Usually subsides during menses, occurs within 14 days of onset of menses

nonpharmacologic treatment of PMS

-Empathy and support from family and friends

-Exercise, dietary changes

-Stress-reduction exercises

pharmacologic treatment of PMS

-Antidepressant drugs - SSRIs

-Hormonal therapy

-Dospironolone (Derivative of spironolactone_

infertility

inability to conceive after 12 months of unprotected sexual intercourse

primary infertility

a couple who has never conceived/carried a pregnancy to term

secondary infertility

a couple who has conceived and brought a pregnancy to term, but is unable to conceive afterwards

Assessing Infertile Couple

-Complete health history

-Complete physical exams

-Pap testing, HPV testing, cultures for STI testing

-Lab tests, other diagnostic tests

-Semen evaluation

-Mental health evaluation

-Prolactin disorders, thyroid disorders

PAP testing, HPV testing, cultures for STI testing

What three tests may be done when assessing an infertile couple?

Clomiphene citrate and Bromicriptine (ergot derivative)

What two drugs may be used to induce ovulation (and thus, promote fertility)?

selective estrogen receptor modulator (SERM; competes for estrogen receptors within the hypothalamus and stimulates ovulation)

What's the MOA of clomiphene citrate?

breast discomfort, dizziness

What are two side effects of clomiphene citrate?

1. visual

2. pharmacologic

Clinical Judgment: Clients w/Infertility

Take Action

-instruct pt to report adverse effect such as abdominal pain or (1) disturbances

-ensure pt understands the risks, benefits, and alternatives to (2) therapy

menopause

Transitional process experienced by women as they move from reproductive years into nonreproductive stage of life

perimenopause stage

Ovarian follicles become depleted, causing estrogen to diminish

Cues of perimenopause stage

-Short or long cycles, heavy/light bleeding, periods of longer or shorter duration

-Skipped periods, abrupt stopping of periods, vaginal dryness, oligomenorrhea, menorrhagia, hot flashes

-Insomnia, headaches, irritability, anxiety, mood variation, cognitive difficulties, memory lapses, joint aches, decreased libido

menopause stage

-Permanent end of spontaneous menstruation caused by cessation of ovarian function

-Menstruation has stopped for 1 yr

premature ovarian failure

-Menopause before age 40

-May occur abruptly due to oophorectomy, ovarian function destroyed by radiologic procedures, severe infection, ovarian tumors, endometriosis

postmenopause

-Stage when body adapts to a new hormonal environment

-Production of estrogen and progesterone from ovaries decreases

-Surge of luteinizing hormone causes hot flashes, tachycardia, sleep disruption

hormone therapy

low daily doses of estrogen, either alone or in combination with progesterone, aimed at reducing the physical discomforts of menopause and perimenopause

1. intact

2. hysterectomy

3. menopausal

4. five years

Hormone therapy

-Estrogen-progestin for females w/an (1) uterus

-Estrogen for females w/a (2)

-Relieves hot flashes, vaginal dryness, and related sleep disorders

Boxed Warning:

Should only be used for the treatment of (3) symptoms, at the lowest dose possible, for the shortest duration possible, usually less than (4)

moderate to severe vasomotor symptoms of menopause and vaginal dryness/atrophy

What is the use of conjugated estrogens?

develops and maintains female genital system, breast, and secondary sex characteristics; increases synthesis of protein

What is the MOA of conjugated estrogens?

thromboembolism

What is the life-threatening effect of conjugated estrogens?

1. corticosteroids

2. anticoagulants; oral hypoglycemics

3. antidepressants

Conjugated Estrogens: Drug-Drug Interactions

-Increase effects of (1)

-Decreased effects of (2) and (2)

-Toxicity w/some (3)

SSRIs, Gabapentin, Clonidine, Bremelanotide

What are four drugs for menopausal symptoms?

reduces depression, irritability, mood changes

Besides reducing vasomotor symptoms, what effect does SSRIs have when used for menopausal symptoms?

bremelanotide

Menopausal drug that increases sexual desire

vasomotor symptoms

hot flashes and night sweats

osteoporosis

-Decreased bone mineral density and increased risk of fractures because of alterations in bone microarchitecture

-Progresses silently for decades until fractures occur

resorbed; formed

With osteoporosis, old bone is being ____ faster than new bone is being ____ → bone loses density

spine, femoral neck, and wrist

What are the three most common sites for osteoporosis-related fractures?

dual energy x-ray absorptiometry (DEXA)

a noninvasive procedure that measures bone density

osteopenia

-thinner than average bone density

-BMD of -1.5 to -2.5

osteoporosis BMD

-2.5 or lower

risk factors of osteoporosis

Genetic

Anthropometric

Hormonal and metabolic

Dietary

Lifestyle

Concurrent

Illness and trauma

Drugs (hormonal replacement therapy)

1. 6-12 months

2. breast

3. pelvic

A patient on hormone therapy should have a medical follow-up every (1), including a BP check, (2) examination and a (3) examination.

1. 1200 mg

2. cessation

3. alcohol

4. hypotension

5. fall

Nursing Interventions for Osteoporosis

-women older than 50 years old need (1) of calcium/day

-calcium should be taken w/food

-smoking (2)

-limit (3) consumption

-weight-bearing exercise

-caution in patients who are prescribed drugs that cause (4)

-assessment for (5) risk

biphosphonates

-alendronate, ibandronate, risedronate

-drugs for osteoporosis

action of testosterone

Controls development and maintenance of sexual processes, accessory sexual organs, cell metabolism, and bone/muscle growth

1. androgen

2. replacement

3. puberty

Testosterone: Indications

-(1) deficiency, specifically hypogonadism

-(2) therapy for testicular failure in adult males

-delayed (3) in adolescents

buccal, nasal, transdermal, parenteral

What are four routes of delivery for testoserone?

Drug Interactions of Testosterone

-Oral anticoagulants, calcitonin, parathyroid hormones

-Antidiabetic agents, corticosteroids

-Barbiturates, phenytoin, phenylbutazone

Caution of Testosterone

-HTN, CAD, seizures

-Hypercholesterolemia, renal disease

-infants, prepubertal children, older males

BPH, prostate cancer, men w/breast cancer, hepatic dysfunction

What are four contraindications for testosterone therapy?

Increase protein synthesis in cells resulting in anabolism, especially in muscles

Development and maintenance of masculine characteristics

What is the action of anabolic steroids?

dehydroepiandrosterone (DHEA)

-testosterone precursors

-available OTC as nutritional supplements

-given to women in menopause to balance levels of estrogen and testosterone

doping medications

-Human chorionic gonadotropin (hCG)

-Tetrahydrogestrinone (THG)

1. liver

2. affect

Clinical Judgment: Androgens

Concept: Hormonal regulation

Recognize Cues:

-monitor weight, BP, (1) and thyroid function, blood lab results

-assess pt's expressive (2) during therapy

Analyze Cues

-self-concept, weight gain

Generate Solutions

The patient will maintain a positive self-concept during long-term treatment.

block synthesis/action of androgens

What's the action of antiandrogens?

1. benign prostatic hyperplasia

2. endometriosis

3. puberty

4. virilization

Antiandrogens: Uses

-(1)

-Advanced prostatic cancer

-(2)

-male baldness pattern

-Acne, hirsutism, precocious (3) in boys

-(4) syndrome in women

benign prostatic hyperplasia

-benign growth of cells within the prostate gland

-bladder outflow obstruction

S/S of BPH

Trouble urinating, nocturia, starting/stopping stream of urine, erectile dysfunction, low amounts of semen, hematuria, incontinence, urinary retention

Drugs Used for Treatment of BPH

5-alpha-reductase inhibitors,

Alpha-adrenergic blocking agents,

Phosphodiesterase-5 inhibitors

bacterial vaginosis, chlamydia, gonorrhea, syphilis

What are four common bacterial STIs?

bacterial vaginosis

-healthy bacteria in vagina replaced w/anaerobic bacteria

-thin white discharge w/strong fishy odor

metronidazole and tinidazole; clindamycin

What are three treatments for bacterial vaginosis?

chlamydia

A sexually transmitted disease, the most common in developed countries, caused by a bacterium

Often producing no symptoms, it can cause infertility, pelvic inflammatory disease, ectopic pregnancies, and infertility if left untreated.