Reproductive Medication
Reproductive Medication Indications for Reproductive Hormone Therapy
Menopause
Pathophysiology
During menopause, estrogen levels begin to decline, leading to:
Gradual menstrual irregularity.
Complete cessation of menses and fertility.
Effects on Client Health
Absence of estrogen results in:
Increased risk of atherosclerosis.
Potential development of high blood pressure.
Loss of bone mass increases risk for osteoporosis.
Weakening of the urethra causes urinary incontinence.
Gender-Affirming Care
Description
Hormonal therapy aimed at:
Suppressing body’s sex hormones.
Administration of cross-sex hormones for secondary sex characteristic development.
Reproductive Hormone Therapy (HRT)
Components of HRT
Includes:
Estrogen therapy.
Progesterone therapy.
Testosterone therapy.
Anti-androgens (androgen blockers).
Menopause and Andropause
HRT alleviates symptoms such as:
Hot flashes, night sweats, mood swings, vaginal dryness (for menopause).
Decreased sexual desire, erectile dysfunction (for andropause (individuals with low testosterone levels)).
Infertility
Used to regulate reproductive cycles and increase mature egg production.
Contraception
Hormonal contraceptives are utilized to prevent pregnancy.
Other Hormone-Related Conditions
HRT benefits in treating:
Hypogonadism.
Osteoporosis.
Classes of Medications
Estrogen Therapy
Examples: Estrogens/Estradiol
Mechanism of Action
Estrogen binds to specific estrogen receptors in tissues including:
Reproductive organs.
Breasts.
Hypothalamus.
Pituitary gland.
Effects on the Body
Produces secondary sex characteristics in females, such as:
Development of breast tissue.
Thickening of uterine lining for pregnancy preparation.
Regulation of the menstrual cycle.
Maintenance of vulvar and vaginal mucosal health.
Prevention of osteoclast activity, thus inhibiting bone loss.
Increases levels of HDL (good cholesterol) and decreases LDL (bad cholesterol).
Indications for Use
Used for:
Moderate to severe menopause manifestations.
Correction of hormonal imbalance, e.g., clients with uterine bleeding or oophorectomy.
Gender-affirming care.
Contraindications
History of or risk for:
Thromboembolic events.
Cancer (breast, vaginal, cervical, endometrial).
Undiagnosed vaginal bleeding.
Liver disease, hypertension, gallbladder disease.
Diabetes mellitus, heart disease, migraine headaches, kidney dysfunction.
Drug interactions affecting effectiveness.
Side Effects
Common side effects can include:
Nausea, hypertension, edema, urticaria, oily skin.
Gynecomastia, breast tenderness, vomiting, anorexia, weight changes.
Amenorrhea, dysmenorrhea, loss of libido, hypercalcemia, leg cramps.
Hyperglycemia, erectile dysfunction, testicular atrophy.
Adverse Effects
Increased risk for endometrial, breast, and ovarian cancers; cardiovascular disease.
Client Education
Teach about medication purpose, administration method, potential side/adverse effects.
Special instructions for transdermal patch placement (lower abdomen or trunk).
Importance of smoking cessation.
Progesterone Therapy
Example: Medroxyprogesterone acetate
Mechanism of Action
Induces changes to the endometrial lining secretions.
Effects on the Body
Thickening of the uterine lining; lighter or no menstruation during treatment.
Indications for Use
Treatment of pain from endometriosis, dysfunctional uterine bleeding, HRT, endometrial carcinoma. Also used for:
Maintaining pregnancy with naturally low progesterone.
Preventing pregnancy.
Contraindications
Medication interactions:
Rifampin, ritonavir, phenobarbital, carbamazepine, primidone, phenytoin, St. John’s wort.
Side Effects
Common side effects include breakthrough bleeding, nausea, constipation, edema, headache.
Adverse Effects
Serious adverse effects: thromboembolic disorders, hypersensitivity reactions (anaphylaxis, angioedema).
Client Education
Purpose, method of administration, side effects, special instructions.
Instruct breast self-exams due to increased cancer risk.
Report leg/chest pain, leg edema, vision changes, severe headache, shortness of breath.
Estrogen/Progesterone Combination Therapy
Description
Used to relieve severe menopause symptoms and prevent postmenopausal osteoporosis.
Common Medications
Conjugated estrogen and medroxyprogesterone acetate; transdermal combination of estradiol and norethindrone.
Risks
Combination therapy increases the thromboembolism and cardiac event risk compared to estrogen therapy alone.
Testosterone Therapy
Examples: Depo-Testosterone, Androgel
Mechanism of Action
Testosterone binds to androgen receptors; also converted to estradiol via aromatization, binding to estrogen receptors.
Effects on the Body
Increases male secondary sex characteristics, muscle/bone mass, fat distribution, cognition, and cell production.
Indications for Use
Treats delayed puberty, hypogonadism, palliative care for androgen-responsive breast cancers, gender-affirming care for transgender men, low sex drive in males and females.
Contraindications
Includes pregnancy, lactation, breast or prostate cancer, uncontrolled heart failure, myocardial infarction or stroke in past 6 months, obstructive sleep apnea.
Caution in diabetes, cardiovascular disease, hypertension, kidney/liver impairment, hypercalcemia, obesity.
Side Effects
In males: voice deepening, acne, facial hair, erectile dysfunction, breast growth, generalized edema.
In females: clitoral enlargement, libido changes, decreased breast size, generalized edema.
Adverse Effects
Include: deep vein thrombosis, liver toxicity, stroke, suicidal thoughts, pulmonary embolism.
Client Education
Cover medication purpose, administration, side/adverse effects, prescription parameters, special instructions.
Location for transdermal patches (upper arm, back, abdomen, thigh).
Location for oral medication (gums above an upper incisor by applying pressure with a finger for 30 seconds, alternate sides of mouth).
Hand washing after application and proper oral application techniques.
Report DVT symptoms: unilateral swelling, redness, calf pain.
Caution against fetal harm; discontinue if pregnancy is suspected.
Classes of Medications: Gonadotropin-Releasing Hormone Analogues
GnRH Analogues
Description
Regulate GnRH by acting on the HPG axis to prevent LH and FSH release from the pituitary gland.
Examples: GnRH agonists and antagonists.
GnRH Agonists
Example: Leuprolide
Mechanism of Action
Overstimulation of the GnRH receptors leads to desensitization, causing them to stop working.
Effects on the Body
Initial estrogen/testosterone surge followed by decreased hormone levels.
Indications for Use
Prostate cancer, gender-affirming care, endometriosis, uterine fibroids, precocious puberty, infertility.
Contraindications
Pregnancy, breastfeeding, hypersensitivity.
Side Effects
Children: injection site pain, weight changes, mood changes, skin rash, acne vulgaris, seborrhea, vaginal discharge, vaginal hemorrhage, vaginitis.
Adults: hot flashes, fatigue, decreased libido, headaches, dependent edema, hyperlipidemia, hyperglycemia, etc.
Adverse Effects
Serious: myocardial infarction, liver toxicity, GI bleeding, stroke, seizures, pulmonary embolism, + prolonged QT interval.
Client Education
Teach purpose, administration, side/adverse effects, prescription parameters, special instructions.
Seek emergency treatment for chest pain, severe symptoms.
Emphasize non-hormonal contraceptive use during therapy.
GnRH Antagonists
Example: Relugolix
Mechanism of Action
Blocks pituitary GnRH receptors to prevent LH and FSH release.
Effects on the Body
Lowers testosterone in men and estrogen in women, reduces menstrual blood loss in fibroids.
Gender-affirming care: delays manifestations of puberty.
Indications for Use
Prostate cancer, endometriosis, gender-affirming care.
Contraindications
Breast cancer history, osteoporosis, thromboembolic disease, gallbladder diease, uncontrolled hypertension.
Side Effects
Hot flashes, gynecomastia, fatigue, weight gain, irregular bleeding, erectile dysfunction, hypertension, fluid retention.
Adverse Effects
Rare: venous thrombosis, liver disease, hypersensitivity.
Fetus: harmful.
Client Education
Teach purpose, method, and administration with specific instructions on reporting serious symptoms (chest pain, palpitations).
Classes of Medications: Anti-Androgens
Anti-Androgen Antagonists (Blockers)
Examples: Spironolactone, progesterone
Mechanism of Action
Bind to androgen receptor (such as hair follicles or testes), blocking testosterone and DHT action.
Effects on the Body
Reduced masculine secondary sexual characteristics.
Indications for Use
Conditions including acne, hirsutism, PCOS, BPH, precocious puberty, gender-affirming care.
Contraindications
Hypersensitivity, liver impairment, wasting disease, severe depression, Dubin-Johnson Syndrome, Rotor Syndrome, thromboembolism, renal issues, hyperkalemia.
Side Effects
Hot flashes, nausea, gynecomastia, erectile dysfunction, increased body hair, decreased insulin sensitivity, fatigue.
Adverse Effects
Serious: meningiomas, liver toxicity, thromboembolism, polyuria, polydipsia, postural hypotension, hyperkalemia.
Client Education
Teach medication purpose, administration, side/adverse effects.
Avoid potassium-rich foods and alcohol.
Stop 4 weeks prior to procedures increasing thrombosis risk.
5-ARIs
Example: Finasteride
Mechanism of Action
Block 5-alpha reductase enzyme, decreasing DHT.
Effects on the Body
Reduced prostatic DHT and serum PSA, alleviating urinary symptoms such as dribbling, frequency, and nocturia.
Indications for Use
BPH and androgenic alopecia treatments.
Contraindications
Prepuberty, pregnancy, hypersensitivity.
Side Effects
Orthostatic hypotension, dizziness, decreased libido, erectile dysfunction.
Adverse Effects
Increased risk for nonalcoholic fatty liver disease; potential prostate cancer incidence debated.
Client Education
Medication purpose, administration, potential effects.
Discontinuation can lead to hair loss.
Avoid blood donation while on medication and for 6 months after.
Physiology of the Ovarian Cycle
Contraceptive Use
Hormonal contraceptives improve health, aid pregnancy planning, and reduce maternal mortality.
Hormonal Contraceptives
Combined Estrogen-Progestin Contraceptives
Examples: Ortho Tri-Cyclen, Yaz.
Mechanism of Action: Prevent ovulation and pregnancy.
Contraceptive Patch
Examples: Norelgestromin and ethinyl estradiol transdermal.
Mechanism of Action: Delivers hormones (estrogen + progestin) to suppress ovulation.
Contraceptive Ring
Examples: Nuva Ring, Annovera.
Mechanism of Action: Provides contraception for a month.
Inserted into the vagina; contains a low-dose of estrogen & progestin hormones.
Effects on the Body:
Inhibit ovulation, thin the uterine lining, thicken the cervical mucous.
Indications for Use
Primary: Preventing pregnancy; secondary: acne, menstrual disorders, endometriosis.
Contraindications
Include pregnancy, certain cancers (breast, endometrial), cardiovascular issues, and some migraine types.
Avoid in clients older than 35 who smoke cigarettes & the first 21 days postpartum.
Side Effects
Include nausea, changes in appetite, bleeding, breast tenderness.
Transdermal Patch: redness, skin irritation, rash at the injection site.
Vaginal Ring: swelling, redness, irritation, burning, itching of the vagina; yellow or white vaginal discharge.
Adverse Effects
Include lethargy, severe headaches, dizziness, vision changes, jaundice, dark urine, light-colored stool.
Client Education
Topics include medication purpose and administration, importance of reporting severe adverse effects.
Progestin-Only Contraceptives
Examples: Norethindrone (Micronor, Drospirenone).
Injectable Progestin-Only Contraceptives: Medroxyprogesterone (Depo-Provera).
Implanted Progestin-Only Contraceptives: Etonogestrel (Nexplanon, NuvaRing).
IUD: Levonorgestrel (Mirena, Skyla, Kyleena).
Mechanism of Action: Suppress GnRH, LH, and FSH, inhibit ovulation.
Effects on the Body: Prevent sperm from reaching the egg; inhibit ovulation.
Indications for Use: Primary - pregnancy prevention; secondary - painful periods, irregular cycles, endometriosis.
Contraindications: Include pregnancy, breast cancer, unexplained bleeding, liver disease.
Avoid injectable contraceptives in clients with thrombophlebitis or cerebral vascular disease.
Side Effects: Irregular periods, breast tenderness, headaches, weight gain.
Adverse Effects: Include thromboembolism and bone density loss; ectopic pregnancy risk with IUDs.
Injectables: Angioedema, anaphylactic shock, facial palsy, syncope
Client Education: Medication purpose, method, effects, and special instructions.
Emergency Contraceptives
Example: Levonorgestrel (Plan B One-Step).
Mechanism of Action: Suppresses LH, inhibiting ovarian follicles; ulipristal works similarly but has a longer window.
Effects on the Body: Inhibit ovulation, preventing fertilization.
Indications for Use: Prevent pregnancy after unprotected intercourse; effective within specific timeframes post-intercourse (up to 5 days).
Contraindications: Pregnancy, hypersensitivity, liver disease.
Side Effects: Changes in menstrual flow, headaches, nausea.
Adverse Effects: Potential toxicity risk.
Client Education: Importance of timing for effectiveness and reporting vomiting after dose.
Infertility
Pathophysiology
Focus on female infertility involving:
Hormonal imbalance or tissue response issues to estrogen/progesterone.
Primary causes include anovulation, hormonal imbalance, age, uterine structural problems, blocked tubes, hyperprolactinemia.
Effects on Client Health
Psychological, emotional, and financial distress can accompany infertility.
Medications to Treat Infertility
Gonadotropins
Examples: hMG, Menopur, Repronex.
Indications include stimulating ovaries for twinning or IVF when ovulation does not occur.
Gonadotropins facilitate follicle maturation and ovulation.
No significant side effects, but abdominal discomfort may occur.
Ovulation Stimulants
Example: Clomiphene citrate.
Mechanism: Stimulates anterior pituitary to release LH/FSH for follicle maturation.
Indications: Anovulatory or oligo-ovulatory infertility treatment.
Risks: Ovarian hyperstimulation syndrome, symptoms: nausea, abdominal pain, shortness of breath.
Risk Factors: Being younger than 35, PCOS, elevated estrogen levels, large follicle counts.
Medications for Preterm Birth or Preeclampsia & Eclampsia
Glucocorticoids
Examples: Betamethasone, Dexamethasone.
Mechanism of Action: Trigger anti-inflammatory changes in target cells.
Effects: Delay labor to mature fetal lungs.
Indications for Use: For clients in preterm labor between 24-34 weeks.
Contraindications: Hypersensitivity, chorioamnionitis, and heart blocks.
Side Effects: May cause hyperglycemia in mothers, hypoglycemia in newborns.
Adverse Effects: None expected from short-term single-use therapy.
Client Education: Cover purpose, administration, effects.
Magnesium Sulfate (High-Alert!)
Mechanism of Action: CNS depression by inhibiting calcium and acetylcholine.
Effects: Reduces neuromuscular irritability; prevents seizures in preeclampsia/eclampsia.
Indications: Used for seizure prevention in preeclampsia/eclampsia, neuroprotective for fetus.
Contraindications: Known hypersensitivity and heart block.
Side Effects: Common are flushing and warmth.
Adverse Effects: Potential magnesium toxicity; additional serious effects include flaccid paralysis, hypothermia.
Client Education: Cover purpose, administration, side/adverse effects, and special instructions.
Medications for Termination of Pregnancy
Examples: Mifepristone, Misoprostol.
Mechanism of Action: Mifepristone blocks progesterone; Misoprostol induces uterine contractions and cervical dilation.
Effects on the Body: Uterine contractions & cervical ripening to induce medical abortion of the fetus.
Indications of Use: For termination of pregnancy up to 10 weeks.
Contraindications: Adrenal failure, ectopic pregnancy, inherited porphyria.
Side Effects: Mostly from Misoprostol; cramping, bleeding, nausea.
Adverse Effects: Anemia, heavy bleeding, risk of ectopic pregnancy.
Erectile Dysfunction
Pathophysiology
Disorder characterized by inability to obtain or maintain an erection.
Result of deficiencies in vascular, neurological, psychological, and endocrine systems.
Nitric oxide (NO) increases cGMP levels in penile tissue for vasodilation; in ED, PDE-5 causes rapid decrease in cGMP, hindering erection.
Effect on Health of Client
ED can damage relationships, mental health, and self-esteem.
Medication Therapy for Erectile Dysfunction
PDE-5 Inhibitors
Example: Sildenafil.
Mechanism of Action: Inhibits PDE-5, delaying breakdown of cGMP.
Effects on the Body: Causes smooth muscle relaxation, enhances blood flow to the penis.
Indications for Use: Treatment of erectile dysfunction.
Contraindications: Use with nitrates or nitroglycerin, severe hypotension, or post recent heart issues.
Caution in clients with a history of angina or myocardial infarction.
Side Effects: Flushing, headache, dizziness, dyspepsia.
Adverse Effects: Rarely, priapism, myocardial infarction, vision and hearing loss.
Client Education: Importance of sexual stimulation for effectiveness, time medication approximately 1 hour before intercourse, report any prolonged erections or vision changes.