Hormones

1. Hormones Ana H. Corona, MSN, FNP-C Nursing Instructor November 2007

2. Hormonal contraceptives • Hormonal contraceptives alter the normal menstrual cycle, inhibiting ovulation, altering the endometrial lining, and thickening cervical mucus.

3. Mechanism of Action • Effects of Estrogen – Ovulation inhibited by suppression of follicle stimulating hormone (FSH) and luteinizing hormone (LH)–Endometrial lining altered making the endometrium less receptive to implantation  • Effects of Progestin – Cervical mucus thickened, hampering sperm transport–Suppression of midcycle LH peak prevents ovulation– Decreases cilia movement within the fallopian tube

4. Advantages of Hormonal contraceptives • Decreased dysmenorrhea, • Decreased menstrual blood loss, • Reliability• Requires addition of condom for STI protection or as back-up with user error•  • Side effects may include nausea, vomiting, breast tenderness, breakthrough bleeding, headaches, mood changes, decreased libido, or weight change

5. Serious Health Issues • Advise hormonal contraceptive users not to smoke • Teach reportable symptoms of possible complications: • Abdominal pain (severe) • Chest pain› Headache (severe) • Eye problems (blurred, double vision) • Severe leg pain, redness, and swelling • Shortness of breath • Worsening depression • Jaundice

6. Contraindications • HX of MI, stroke, blood clot; estrogen promotes blood clotting • HX of breast or female reproductive cancer; tumors may be hormonally provoked • DM with vascular involvement; estrogen promotes blood clotting • Impaired liver function; OCs are metabolized through the liver and use may adversely affect existing liver disease • Suspected or confirmed pregnancy • Uncontrolled HTN; increased risk for cardiovascular complications • Smoker over 35 years of age; increases the risk for cardiovascular complications • History of migraine headaches (with aura); increased risk for stroke • Major surgery planned with immobilization; increased risk for deep vein thrombosis

7. HRT • Current guidelines by the U.S. Food and Drug Administration (FDA) recommend HRT use only for moderate to severe menopausal symptoms at the lowest effective dose for the shortest period of time, noting the risk/benefit ratio for each woman•  • If HRT prescribed solely for vaginal/vulvar symptoms, local hormone therapy should be considered. • Alternatives to HRT should be considered if HRT used for sole purpose of osteoporosis prevention

8. Oxytocin (pitocin) • Oxytocin is a hormone used during the late stage of pregnancy to induce labor (contractions). • It is often used to induce labor in difficult pregnancies or pregnancies at risk for complications (e.g., preeclampsia, eclampsia, diabetes). • This drug may also be used during pregnancy to test the heartbeat of the fetus; and to remove the afterbirth (placenta) and control bleeding of the womb (uterus) after childbirth.

9. Side Effects • Nausea, vomiting, cramping, and stomach pain may occur. Serious side effects: irregular heartbeat, dizziness, lightheadedness, swelling, severe bleeding (after childbirth), seizures, headache, blurred vision, one-sided weakness. Serious side effects in the newborn: irregular heartbeat, yellowing eyes or skin, bleeding in the eyes, seizures. An allergic reaction to this drug is unlikely but may occur.

10. Q1 • Estrogen replacement therapy has been shown to do which of the following? a. Increase the risk of ovarian cancer b. Provide protection against coronary heart disease c. Increase levels of low-density lipoprotein d. Decrease levels of high-density lipoprotein e. Prevent rheumatoid arthritis

11. A1 • The answer is b. estrogen replacement therapy is useful in the prevention of osteoporosis and in protecting women against atherosclerotic vascular disease including coronary artery disease (angina, nonfatal and fatal myocardial infarction) and cerebrovascular disease. Postmenopausal estrogen users have decreased levels of total and low-density lipoprotein (LDL) and increased levels of high-density lipoprotein (HDL). Triglyceride levels are usually mildly increased in users estrogen alone. The addition of progestins such as medroxyprogesterone acetate (Provera), recommended in postmenopausal estrogen users who retain their uteruses to counter the proliferative effects of estrogen on the endometrium, can reverse some of these beneficial effects. Postmenopausal estrogen intake has not been shown to significantly increase the risk of ovarian cancer in women. direct protective or beneficial effect of estrogen on rheumatoid arthritis in postmenopausal women.

12. Q2 • There are five postmenopausal patients in the clinic. Each patient has one of the conditions listed below, and each patient wishes to begin hormone replacement therapy today. Which patient would probably be started on therapy at the time of this visit? a. Mild essential hypertension b. Liver disease with abnormal liver function tests c. Malignant melanoma d. Undiagnosed genital tract bleeding e. Treated Stage III endometrial cancer

13. Q2 • The answer is a. Absolute contraindications to postmenopausal hormone replacement therapy include the presence of estrogen-dependent tumors (breast or uterus), active thromboembolic disease, undiagnosed genital tract bleeding, active severe liver disease, and malignant melanoma. Past or current history of hypertension, diabetes, or biliary stones does not automatically disqualify a patient for hormone replacement therapy.

14. Q3 • A 62-year-old woman presents for annual examination. Her last menstrual period was 9 years ago, and she has been reluctant to use postmenopausal hormone replacement because of a strong family history of breast cancer. She now complains of diminished interest in sexual activity. Which of the following is the most likely cause of her complaint? a. Decreased vaginal length b. Decreased ovarian function c. Alienation from her partner d. Untreatable sexual dysfunction e. Physiologic anorgasmia

15. A3 • The answer is b. Sexuality continues despite aging. However, there are physiologic changes that must be recognized. Diminished ovarian function may lower libido, but estrogen replacement therapy (ERT) may help. Sexual dysfunction can be physiologic, e.g., from lowered libido. As with younger patients, however, lowered libido is in most cases treatable. Because aging does not alter the capacity for orgasm or produce vaginismus, a further evaluation should be initiated if these symptoms persist after a postmenopausal woman is placed on ERT.

16. Q4 • Which of the following is an absolute contraindication to the use of combination oral contraceptive pills? a. Varicose veins b. Tension headache c. Seizure disorders d. Obesity and smoking in women over 35 years of age e. Mild essential hypertension

17. A4 • The answer is d.Absolute contraindications to the use of BCP include (1) thromboembolic disorders, DVT,CVA,MI, or conditions predisposing to these conditions]; (2) markedly impaired liver function; (3) known or suspected carcinoma of the breast; (4) undiagnosed abnormal genital malignancies; (5) undiagnosed abnormal genital bleeding; (6) known or suspected bleeding; (7) known or suspected pregnancy; (8) a history of obstructive jaundice in pregnancy; (9) congenital hyperlipidemia; and (10) obesity in women who are smokers and over age 35. Relative contraindications to the use of the birth control pill require clinical judgment and informed consent. These include (1) migraine headaches; (2) hypertension; (3) uterine leiomyomas; (4) gestational diabetes; (5) elective surgery; and (6) seizure disorders.

18. Q5 • Use of the birth control pill decreases which of the following lab results? a. Glucose tolerance b. Binding globulins c. High-density lipoprotein (HDL) cholesterol d. Triglycerides e. Hemoglobin concentration

19. 5 • The answer is a. Combination-type oral contraceptives are potent systemic steroids that may cause many detectable alterations in metabolic function, such as increases in binding globulins, bromsulphalein retention, triglycerides and total phospholipids, and a decrease in glucose tolerance. Thus, the benefits of birth control pills must be weighed carefully against the added risks in patients with diabetes, cardiovascular disease, or liver disease. The pill modestly increases HDL cholesterol levels, but should have no direct effect on hemoglobin concentration. In fact, since bleeding volume is generally diminished in birth control pill users, hemoglobin concentration often increases in these patients.

20. 6 In combination birth control pills, the contraceptive effect of the estrogenic component is primarily related to: a. Conversion of ethinyl estradiol to mestranol b. Atrophy of the endometrium c. Suppression of cervical mucus secretion d. Suppression of luteinizing hormone (LH) secretion e. Suppression of follicle-stimulating hormone (FSH) secretion

21. 6 The answer is e.The two estrogenic compounds used in oral contraceptives are ethinyl estradiol and its 3-methyl ether, mestranol. To become biologically effective, Mestranol must be demethylated to ethinyl estradiol, because mestranol does not bind to the estrogenic cytosol receptor. The degree of conversion of mestranol to ethinyl estradiol varies among individuals; however, it is estimated that ethinyl estradiol is about 1.7 times as potent as the same weight of mestranol. The estrogenic component of birth control pills was originally added to control irregular endometrial desquamation resulting in undesirable vaginal bleeding. However, these estrogens imposed possible risks that would not be inherent in the progestational component alone. For example, thrombosis, the most serious side effect of the pill, is directly related to the dose of estrogen. The higher the estrogen dose, the more likely there will be thrombotic complications.

22. 7 • In addition to effective contraception, health benefits for women taking oral contraceptives include a decreased incidence of which of the following? a. Lung cancer b. Benign breast disease c. Hypertension d. Cervical cancer e. Pelvic inflammatory disease

23. 7 The answer is b. OCP offer many noncontraceptive health benefits. Women who are using Combination OCP are less likely to develop cancer of the endometrium than women who do not use OCP, probably because the formulations contain a progestogen as well as an estrogen. Since progestogens counteract the stimulatory action of the estrogen on target tissues, women who take OCP rarely have endometrial hyperplasia and appear to have a lower incidence of nonmalignant cystic disease of the breast. Secondary to the antiestrogenic action of progestin, there is a reduction in the amount of blood loss at the time of endometrial shedding; thus, the development of iron-deficiency anemia is less likely. Users of OCP are at higher risk for cervical neoplasia, there is no evidence that the OCP are the causative factor in this increased risk.

24. 8 • Which of the following mechanisms best explains the contraceptive effect of birth control pills that contain both synthetic estrogen and progestin? a. Direct inhibition of oocyte maturation b. Inhibition of ovulation c. Production of uterine secretions that are toxic to developing embryos d. Impairment of implantation hyperplastic changes of the endometrium e. Impairment of sperm transport due to uterotubal obstruction

25. 8 The answer is b. The marked effectiveness of the combined oral contraceptive pill, which contains a synthetic estrogen and a progestin, is related to its multiple antifertility actions. The primary effect is to suppress gonadotropins at the time of the midcycle LH surge, thus inhibiting ovulation. The prolonged progestational effect also causes thickening of the cervical mucus and atrophic (not hyperplasic) changes of the endometrium, thus impairing sperm penetrability and ovum implantation respectively. Progestational agents in oral contraceptives work by a negative feedback mechanism to inhibit the secretion of LH and, as a result, prevent ovulation. They also cause decidualization and atrophy of the endometrium, hence making implantation impossible. In addition, cervical mucus, which at ovulation is thin and watery, is changed by the influence of progestational agents to a tenacious compound that severely limits sperm motility. Progestins do not prevent irregular bleeding. Estrogen in birth control pills enhances the negative feedback of the progestins and stabilizes the endometrium to prevent irregular menses. Oral contraceptives have no direct effect on oocyte maturation, and do not cause uterotubal obstruction.

26. 9 • An 18-year-old college student who has recently become sexually active is seen for severe primary dysmenorrhea. She does not want to get pregnant, and has failed to obtain resolution with heating pads and mild analgesics. Which of the following medications is most appropriate for this patient? a. Prostaglandin inhibitors b. Narcotic analgesics c. Oxytocin d. Oral contraceptives e. Luteal progesterone

27. 9 The answer is d.Conservative measures for treating dysmenorrhea include heating pads, mild analgesics, sedatives or antispasmodic drugs, and outdoor exercise. In patients With dysmenorrhea there is a significantly higher than normal concentration of prostaglandins in the endometrium and menstrual fluid. Prostaglandin synthase inhibitors such as indomethacin, naproxen, ibuprofen, and mefenamic acid are very effective in these patients. However, for patients with dysmenorrhea who are sexually active, oral contraceptives will provide needed protection from unwanted pregnancy and generally alleviate the dysmenorrhea. The OCPs minimize endometrial prostaglandin production during the concurrent Administration of estrogen and progestin.

28. 10 • IN EVALUATING THE EFFECTIVENESS OF IV PITOCIN FOR A CLIENT WITH SECONDARY DYSTOCIA, THE NURSE SHOULD EXPECT: • A PAINLESS DELIVERY • CERVICAL EFFACEMENT • INFREQUENT CONTRACTIONS • PROGRESSIVE CERVICAL DILATION

29. 10 • Answer D is correct. The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin.

30. 11 • Mary W.'s baby has just been delivered, and he weighs 9 lb 10 oz. After the delivery, the nurse notices that Mary is chilly and that her fundus has relaxed. The nurse administers the oxytocin that the physician orders. The nurse knows that it has had the expected effect when • A) the uterus becomes firm. • B) Mary states that she feels warmer now. • C) Mary falls asleep. • D) the baby cries.

31. 11 • The correct answer is A. Oxytoxic medications such as Pitocin, Methergine, and Ergotrate are administered to stimulate uterine contractility and reverse fundal relaxation in the postdelivery client

32. 12 • THE PHYSICIAN HAS ORDERED AN INTRAVENOUS INFUSION OF PITOCIN FOR THE INDUCTION OF LABOR. WHEN CARING FOR THE OBSTETRIC CLIENT RECEIVING INTRAVENOUS PITOCIN, THE NURSE SHOULD MONITOR FOR: • MATERNAL HYPOGLYCEMIA • FETAL BRADYCARDIA • MATERNAL HYPERREFLEXIA • FETAL MOVEMENT

33. 12 • Answer B is correct. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect.

34. 13 • A CLIENT WITH A MISSED ABORTION AT 29 WEEKS GESTATION IS ADMITTED TO THE HOSPITAL. THE CLIENT WILL MOST LIKELY BE TREATED WITH: • MAGNESIUM SULFATE • CALCIUM GLUCONATE • DINOPROSTONE (PROSTIN E.) • BROMOCRYSTINE (PARDEL)

35. 13 • Answer C is correct. The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk.

36. 14 • WHILE ASSESSING THE POSTPARTAL CLIENT, THE NURSE NOTES THAT THE FUNDUS IS DISPLACED TO THE RIGHT. BASED ON THIS FINDING, THE NURSE SHOULD: • ASK THE CLIENT TO VOID • ASSESS THE BLOOD PRESSURE FOR HYPOTENSION • ADMINISTER OXYTOCIN • CHECK FOR VAGINAL BLEEDING

37. 14 • Answer A is correct. If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.

38. 15 • Which of the following conditions can result from using HRT for management of menopause? A) Colorectal cancer B) Improved visual acuity C) Osteoporosis D) Urogenital atrophy E) Vasomotor flushes

39. 15 (B) Improved visual acuity. Evidence suggests that estrogen therapy improves visual acuity, perhaps by causing a beneficial effect on lacrimal fluid. Postmenopausal women who use hormone Replacement therapy (HRT) have been found to have a markedly reduced risk for macular degeneration, a cause of painless central visual loss in elderly patients. The increased prevalence of keratoconjunctivitis sicca in menopausal women is often symptomatically relieved by HRT.

40. 16 • Which of the following is NOT a potential adverse effect of HRT in the management of menopause? A) Abdominal bloating B) Breast tenderness C) Fluid retention in extremities D) Uterine bleeding E) Weight gain

41. 16 (E) Weight gain. Weight gain has been absolved as an adverse effect of HRT. The Rancho Bernardo and Postmenopausal Estrogen/Progestogen Intervention studies found no significant weight difference between women who did and did not use hormones. Uterine bleeding, abdominal bloating, breast tenderness, weight gain, and fluid retention in extremities are common adverse effects of HRT, which can decrease patient compliance and lead to discontinuance of therapy

42. 17 • Which of the following is NOT a contraindication • to postmenopausal HRT? A) Chronically impaired liver function B) Endometrial adenocarcinoma C) History of breast cancer D) Hypertriglyceridemia E) Impaired glucose tolerance

43. 17 (E) Impaired glucose tolerance. Low-dose Postmenopausal HRT has been shown to improve peripheral insulin resistance, prevent hyperinsulinemia, and reduce the risk for type 2 diabetes mellitus. In fact, the cardiovascular benefits of HRT may significantly help patients with diabetes mellitus. Estrogen is metabolized in the liver; therefore, HRT is contraindicated in patients with chronically impaired liver function. Endometrial adenocarcinoma is almost always an estrogen-sensitive cancer, and HRT is accordingly contraindicated. Breast cancer also is often an estrogen- sensitive cancer. After primary treatment of the breast cancer, metastatic cells may still be present and susceptible to exogenous hormones. Hypertriglyceridemia and pancreatitis can be precipitated by HRT administration in women with triglyceride levels between 250 and 750 mg/dL.