Chapter 18 The Reproductive System and Drug Therapy

Chapter 18 The Reproductive System and Drug Therapy

Chapter 18 The Reproductive System and Drug Therapy Paradigm Publishing, Inc. 2 Chapter 18 Topics

Anatomy and Physiology of the Reproductive System Menopause Hypogonadism Erectile Dysfunction (ED) Contraception Infertility Sexually Transmitted Diseases (STDs) Herbal and Alternative Therapies Paradigm Publishing, Inc. 3

Anatomy and Physiology of the Reproductive System The Reproductive System It is responsible for procreation and fetal development Females produce ova from the ovaries; males produce sperm from the testes The ovum and sperm combine during fertilization to form an embryo HPA axis regulates male and female reproductive systems The pituitary gland releases FSH and LH, stimulating sex hormone production from the ovaries and testes Sex hormones: estrogen and progesterone (more in females), testosterone (more in males) Paradigm Publishing, Inc. 4

Anatomy and Physiology of the Reproductive System Sex Hormone Production and Control The male and female reproductive systems respond to a negative hormonal feedback loop system

Paradigm Publishing, Inc. 5 Anatomy and Physiology of the Reproductive System Female Reproductive System The ovaries, fallopian tubes, uterus, cervix, and vagina In response to FSH from the pituitary gland, the ovaries produce ova, which travel via fallopian tubes to the uterus Fertilization occurs if sperm is present; the zygote implants into the endometrial lining and develops into an embryo Embryo releases HCG (the pregnancy hormone) which causes progesterone and estrogen levels to rise If no fertilization, uterine lining sloughs off (menstruation) Menstrual cycle is regulated by FSH, LH, estrogen, and

progesterone; restarts about every 28 days Paradigm Publishing, Inc. 6 Anatomy and Physiology of the Reproductive System Female Reproductive Anatomy Paradigm Publishing, Inc. 7 Anatomy and Physiology of the Reproductive System

Fertilization and Implantation Paradigm Publishing, Inc. 8 Anatomy and Physiology of the Reproductive System Female Sex Hormone: Estrogen Significant production begins at puberty; tapers off during menopause (fifth decade, ages 4049) Primary female sex hormone; responsible for female sex characteristics such as breast enlargement Also regulates endometrial growth, cervical mucus production, bone health, cessation of height in girls

Hormone affects sodium retention, cholesterol levels, calcium use, carbohydrate metabolism, blood coagulation Levels rise during the days leading up to menstruation Indication (women): contraception, menopausal symptoms Paradigm Publishing, Inc. 9 Anatomy and Physiology of the Reproductive System Female Sex Hormone: Progesterone Referred to as progestin when produced in the body Hormone suppresses LH production, thickens cervical mucus, alters the endometrial lining to support embryo implantation, maintains pregnancy

Progesterone levels Affect insulin levels, glucose tolerance, fat deposition, body temperature; changes needed for pregnancy Rise in pregnancy; decline in menopause Indications (women): contraception, infertility, menopausal symptoms Paradigm Publishing, Inc. 10 Anatomy and Physiology of the Reproductive System Female Sex Hormone: HCG Presence indicates that an embryo has implanted in the uterus and a placenta has started to form Steep rise signals pregnancy; the body starts physiological

changes that prepare for and maintain pregnancy When present in measurable concentrations in the blood or urine, a diagnosis of pregnancy is made Home pregnancy tests measure HCG Paradigm Publishing, Inc. 11 Anatomy and Physiology of the Reproductive System Male Reproductive System Testes (testicles), epididymis, ductus deferens (vas deferens), seminal vesicles, prostate gland, urethra, penis It facilitates sexual reproduction and eliminates urine Sperm cells are made in the testes, mature in the

epididymis, then move through the ductus deferens During sex, sperm combine with semen (fluid produced by seminal vesicles) and are ejaculated through the urethra Sperm delivered into a womans vagina near the cervix; travel to the fallopian tubes to fertilize an ovum Continual production of male sex hormones Paradigm Publishing, Inc. 12 Anatomy and Physiology of the Reproductive System Male Reproductive Anatomy Paradigm Publishing, Inc.

13 Anatomy and Physiology of the Reproductive System Male Sex Hormone: Testosterone Primary androgen in males; responsible for sperm production and maturation of male genitalia Also responsible for secondary sexual characteristics during puberty: pubic hair, increased libido, bone and muscle development, fat distribution Testosterone levels decline with age, initiating changes Decreased testicular size Muscle weakness Reduced bone density Decreased energy, mood, and libido Paradigm Publishing, Inc.

14 Menopause About Menopause Permanent cessation of menstruation; the absence of menses for at least 12 months Process begins with perimenopause (for 3 to 5 years) Menstrual cycles become erratic; hormone levels fluctuate; fertility declines During menopause Ovarian follicle activity stops; estrogen levels drop 40 to 60%; progesterone levels fall dramatically Paradigm Publishing, Inc.

15 Menopause About Menopause (continued) Lack of estrogen causes vasomotor spasms, irregular menstrual bleeding, vaginal dryness and atrophy Also causes mood swings and memory impairment Some women take HRT (estrogen supplements) to mitigate the impact of declining estrogen during menopause Menopause is associated with osteoporosis (bone thinning) and increased risk for heart disease and stroke Paradigm Publishing, Inc. 16

Menopause Hormone Replacement Therapy (HRT) Indication: relief from menopausal symptoms For years, HRT was prescribed as a method that offered protection against heart disease, stroke, and osteoporosis New research studies indicate that HRT increases the risks of breast, endometrial, and ovarian cancers in women The current standard of practice for HRT is to use the lowest dose necessary for the shortest time possible Paradigm Publishing, Inc. 17 Menopause HRT: Estrogen and Progesterone

Estrogen Estrogen products usually are ethinyl estradiol, from natural or equine (horse) sources Conjugated estrogens are sodium salt forms of estrogen from pregnant mare urine Progesterone Progesterone products are synthetic agents or natural Estrogen and progesterone are taken in combination to reduce risk of endometrial cancer Indication: relief of menopausal symptoms Paradigm Publishing, Inc. 18 Menopause

HRT: Estrogen and Progesterone (continued) Route: oral or transdermal patch Natural-source HRTs are specially compounded in the pharmacy and are often used topically; may produce fewer short-term side effects Side Effects (common): dizziness, abdominal pain or bloating, diarrhea, nausea, headache, hair loss, depression Side Effects (other): dark skin patches on face (melasma) Cautions: contraindicated in patients with a history of breast, endometrial, or ovarian cancer; patients with cardiovascular disorders should probably avoid Paradigm Publishing, Inc. 19 Your Turn

Question 1: How does a patient know if she is in menopause? Answer: She is in menopause if she has not menstruated for at least twelve months. Question 2: How is the route of administration different between synthetic hormone replacement products and natural-source hormone replacement products? Answer: Synthetic hormone products are taken orally or applied as a transdermal patch, whereas natural-source products are often used topically on the skin. Paradigm Publishing, Inc. 20 Hypogonadism Hypogonadism

Underproduction of testosterone in males Associated with obesity and Type 2 diabetes Andropause: decline in androgen (testosterone) production that occurs with age Symptoms (for both): fatigue, low sexual desire, weakness, ED, poor sleep, depression, irritability, memory loss Testosterone Indication (common, males): hypogonadism May also be used in females to treat metastatic breast cancer or, occasionally, as an adjunct to HRT Paradigm Publishing, Inc. 21 Hypogonadism

Testosterone (continued) Testosterone is a controlled substance (Schedule III); can be used as a physical performance enhancement drug Produces larger muscle mass, improves strength and speed Testosterone and related compounds are called anabolic steroids Technicians: testosterone products require special storage, labeling, and handling Some states also require the patients medical diagnosis be written on the face of the prescription Paradigm Publishing, Inc. 22 Erectile Dysfunction

About ED Failure to initiate or maintain an erection until ejaculation Also called male impotence Studies show that 40 to 50% of patients with heart disease have ED Other causes include testosterone deficiency, high BP, alcoholism, cigarette smoking, diabetes with microvascular problems, psychological factors, and medications Paradigm Publishing, Inc. 23 Erectile Dysfunction Drugs that Can Cause ED

Alcohol Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) Cimetidine Clonidine Methyldopa Nicotine Spironolactone Thiazide diuretics Ketoconazole Paradigm Publishing, Inc.

24 Erectile Dysfunction Drugs for ED: PDE-5 Inhibitors First-line drug therapy; typically listed in the top 50 drugs dispensed in pharmacies Mechanism of Action: relax smooth muscle in penis which eases blood flow to the area, facilitating erection Route: oral; taken one hour or more prior to sexual activity Side Effects: headache, heartburn, nausea, flushing Side Effects (severe): priapism (seek medical attention) Cautions: patients should not take with alpha blockers or nitrates; can interact with several other medications Paradigm Publishing, Inc.

25 Erectile Dysfunction Drugs for ED: Alprostadil A prostaglandin that is a second-line drug therapy Mechanism of Action: relaxes smooth muscle in penis, blood flow increases and causes an erection Route: intracavernosal injection into base of penis or urethral insertion of pellet Side Effects: pain or burning in the penis, urethra, or testes Cautions: interacts with several other medications Paradigm Publishing, Inc. 26

Erectile Dysfunction Drugs for ED: Yohimbine Third-line drug therapy Mechanism of Action: blocks alpha-2 receptors and enhances parasympathetic nervous system effects Route: oral Side Effects: BP changes, nervousness, irritability, tremor, dizziness, nausea, headache, skin flushing Cautions: contraindicated in patients taking antidepressants; should probably be avoided in patients with hypertension Paradigm Publishing, Inc. 27

Contraception About Contraception The prevention of pregnancy through artificial means Four approaches to birth control Physical or pharmacologic barriers that prevent sperm and egg from coming into contact Drug therapy that prevents ovulation from occurring Drug therapy that prevents implantation of a fertilized egg in the uterus Abstinence from intercourse during days in menstrual cycle when conception is likely (rhythm method) High pregnancy rate Paradigm Publishing, Inc. 28

Contraception Condoms, Diaphragms, and Other Barrier Methods Methods that form a physical barrier preventing sperm from entering the uterus through the cervix They are put in place prior to intercourse, left for a specific amount of time, then removed Male condom and female condom (latex and polyurethane are best); only method that lowers risk of STD transmission Diaphragms and cervical caps (rubber, latex, silicone) are bordered with a rounded ring; fit over cervix inside vagina Work best when used with a spermicide (kills sperm) Are prescription items; fitted to a womans anatomy Paradigm Publishing, Inc. 29

Contraception Oral Contraceptives Contain ethinyl estradiol (synthetic estrogen) and one of several synthetic progesterones (progestin or progestins) Indication: manipulate hormones to prevent ovulation and change cervical mucus texture Mechanism of Action (estrogen): suppress production of LH (hormone that triggers ovulation) Mechanism of Action (progesterone): suppress production of LH, thicken cervical mucus (impedes sperm travel) Route: oral; taken daily to maintain a steady and elevated hormone level Paradigm Publishing, Inc. 30

Contraception Oral Contraceptives (continued) Some oral products contain only progestin or progestins Less hormones reduce side effects (headaches, high BP) Products used if oral contraceptives not appropriate, such as women who are older than age 35, have high BP or heart disease, have clotting disorders, or smoke Missed doses more quickly affect failure rate Combination oral contraceptives come in monophasic, biphasic, and triphasic dosing regimens Extended oral regimens: menstrual cycle every 3 or 4 months Paradigm Publishing, Inc. 31

Contraception Emergency Oral Contraceptives Plan B and Preven are taken within 72 hours of intercourse, with second dose 12 hours later Both prevent ovulation, alter tubal transport of sperm and ovum, or inhibit implantation Both do not work if fertilized egg has implanted (i.e., patient is already pregnant) OTC product; kept behind the counter; patient must be 18 years old Only a pharmacist or prescriber can order Paradigm Publishing, Inc. 32 Contraception

Oral Contraceptives: Side Effects and Cautions Side Effects (common): weight gain, nausea, vomiting, bloating, increased appetite, fatigue, headaches, edema Side Effects (other): breakthrough bleeding (blood flow in the middle of a menstrual cycle) can occur Cautions: Avoid in patients with clotting disorders, heart or cerebral vascular disease; smokers run higher risk of heart attack, blood clots, stroke; weigh benefits/risks if history of breast and reproductive system cancers; many drug interactions, reducing effectiveness Technician: special packaging and dispensing regulations Paradigm Publishing, Inc. 33 Contraception

Transdermal Contraceptives Adhesive patches that deliver estrogen and progesterone in a steady supply through the skin Mechanism of Action: alter the menstrual cycle, prevent follicle maturation and ovulation, thicken cervical mucus Route: transdermal; one patch is applied each week for 3 weeks and then left off for 1 week during menstruation Side Effects: breast tenderness, headache, application site irritation, nausea, menstrual cramps, abdominal pain Cautions: if patch detaches, follow instructions to reapply or replace and for use of backup birth control Paradigm Publishing, Inc. 34 Contraception

Vaginal Contraceptives The vaginal ring is a combination birth control that contains synthetic estrogen and progesterone It is inserted into the vagina every 3 weeks, then removed for 1 week while menstruation occurs The sponge is made of a latex porous material that is infused with a spermicide that kills sperm on contact Inserted 12 to 24 hours prior to intercourse, then left in place for 6 hours after intercourse Side Effects (vaginal ring): headache, nausea, vaginal secretion, vaginitis, bloating, cramps, weight gain Paradigm Publishing, Inc. 35 Contraception

Vaginal Contraceptives (continued) Side Effect (sponge): vaginal irritation Cautions (vaginal ring) When stored in the pharmacy, vaginal ring must be refrigerated to maintain potency; also, technicians should warn patients to refrigerate until use If the vaginal ring is removed or expelled, follow instructions for replacing and backup birth control Caution (sponge) If sponge is left in vagina more than 24 hours, higher risk of bacterial infection and toxic shock syndrome Paradigm Publishing, Inc. 36 Contraception

Injections, Implants, and Intrauterine Devices Three contraception methods with hormonal therapy that are used to prevent pregnancy for months to years Medroxyprogesterone (Depo-Provera) is injected every 3 months; etonogestrel (Implanon) is implanted for 3 years Both agents administered by healthcare provider Both inhibit ovulation, thicken cervical mucus, and change the endometrium to inhibit implantation Many kinds of IUDs are available; placed into the uterus by healthcare provider every 5 years Most contain progesterone which alters endometrium Paradigm Publishing, Inc. 37 Contraception

Injections, Implants, and Intrauterine Devices (continued) Side Effects (medroxyprogesterone, common): menstrual irregularity, abdominal pain, weight changes, dizziness, headache, weakness, fatigue, nervousness Side Effects (etonogestrel, common): menstrual bleeding, weight gain, mood swings Side Effects (IUDs, common): septicemia, pelvic infection, uterus perforation, vaginitis, tubal damage, abnormal menstrual bleeding, anemia, cramping, backaches Cautions: Injections, implants, and IUDs should not be used during pregnancy Paradigm Publishing, Inc. 38

Contraception Mifepristone and Misoprostol Indication: taken to terminate a uterine pregnancy during the first 49 days of pregnancy; requires 3 physician visits to determine gestational age of embryo Mifepristone is only supplied to physician offices that abide by strict monitoring and therapy guidelines Pharmacies do not dispense Home Pregnancy Tests Tests measure the presence of HCG in the urine; can be used on day one of a missed period HCG can be detected 6 to 8 days after conception Paradigm Publishing, Inc. 39

Your Turn Question 1: What is a restriction of PDE-5 inhibitors? Answer: Patients should not take them if they are already taking nitrates or alpha blockers. Question 2: A patient wants to take a contraceptive to prevent pregnancy. She does not want to have to remember to take or use it regularly. What are the likely contraceptive options the healthcare prescriber will suggest? Why? Answer: The healthcare provider probably will suggest contraceptive injections, implants, or IUDs. These three contraceptive methods use hormonal therapy to prevent pregnancy for months to years. Paradigm Publishing, Inc. 40

Infertility About Infertility Infertility is the inability to achieve pregnancy after one year of regular, unprotected sexual intercourse Up to 10% of the U.S. population face fertility issues Problems with infertility may lie in the females, males, or both reproductive systems Causes (women): PID, hormonal imbalance, anatomic problems, PCOS, endometriosis Causes (men): infectious diseases, anatomic problems, immunologic factors, lifestyle factors that inhibit sperm (tight clothes, hot tubs, high alcohol/caffeine intake) Paradigm Publishing, Inc. 41

Infertility Drugs for Infertility ART: specialized practice that matches drug therapy and other treatment to the specific cause for infertility Ovulation induction: process of using hormones to stimulate ovaries to produce and release multiple ova Artificial insemination: process that introduces semen containing sperm into a womans uterus during ovulation In vitro fertilization: eggs are artificially fertilized with sperm, then placed into womans uterus for implantation These agents usually dispensed by specialty pharmacies due to their high cost and specialized use Paradigm Publishing, Inc. 42

Infertility Home Ovulation Tests Ovulation tests are used to identify the 24- to 48-hour period when ovulation occurs Identification of peak ovulation period improves chances of pregnancy Home ovulation predictor kits measure either body temperature or hormonal fluctuation to predict ovulation Urine test kits detect the LH surge that occurs prior to ovulation Includes 57 tests Paradigm Publishing, Inc. 43

Sexually Transmitted Diseases (STDs) About STDs Infections that affect the reproductive system in males and females that are transmitted through sexual contact Caused by bacteria (can be cured) and by viruses (cannot be cured, only treated for symptoms) Chlamydia: infection caused by organism with qualities of both bacteria and viruses; most common STD in U.S. Gonorrhea: gram-negative bacterial infection; if untreated, can affect the heart, brain, eyes, pharynx, and joints Syphilis: bacterial infection; if untreated, can affect the CNS and CV systems; has four stages Paradigm Publishing, Inc. 44

Sexually Transmitted Diseases (STDs) About STDs (continued) Vaginosis: inflammation and infection of the vaginal mucosa; caused by bacteria or by yeast-like fungus Genital herpes: viral infection caused by the herpes simplex virus; not curable and usually recurs HPV: virus causing wart-like lesions appears in genital region; virus is closely linked to cervical cancer in women A vaccine to prevent HPV is available for young women AIDS: viral infection transmitted through exchange of bodily fluids (sexual activity, blood transfusion) Immune system cannot fight infection; patient dies Paradigm Publishing, Inc. 45

Sexually Transmitted Diseases (STDs) Disease Treated Drugs of Choice AIDS NRTIs, NNRTIs, PIs, and enfuvirtide Chlamydia Doxycycline, azithromycin, or erythromycin Genital herpes Acyclovir, valacyclovir, or famciclovir

Gonorrhea Ceftriaxone or a fluoroquinolone HPV Imiquimod, podofilox, or other therapies Syphilis Penicillin, doxycycline, or tetracycline Vaginosis: bacterial Metronidazole, clindamycin Vaginosis: yeast Vaginal candidiasis products

Paradigm Publishing, Inc. 46 Herbal and Alternative Therapies Soy (isoflavone or phytoestrogen) is a plant source of protein taken for some menopausal symptoms Can cause stomach upset, diarrhea, bloating, nausea, constipation, and insomnia; can worsen migraines Black cohosh is a plant product with estrogenic effects taken for menopausal symptoms Avoid for patients with liver disease and in those who are pregnant or breast-feeding Evening primrose oil taken for menopause or PMS Wild yam (Mexican yam) is a phytoestrogen similar to soy with mild estrogenic effects

Paradigm Publishing, Inc. 47 Summary Estrogen and progesterone are hormonal therapies for menopausal symptoms The hormone testosterone is used for hypogonadism PDE-5 inhibitors are used for erectile dysfunction Estrogen and progesterone are hormonal therapies used in oral, transdermal, vaginal, and IUD contraceptives ART matches drug therapy to specific causes for infertility Antibiotics are used to treat bacterial STDs, and antivirals are used to treat viral STDs Paradigm Publishing, Inc.

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