NR 566 Final Exam Study Guide
Week 5
Prevention of osteoporosis with hormone replacement therapy (p. 433)
Hormone therapy (HT) reduces postmenopausal bo... [Show More] ne loss & thereby decreases the risk for
osteoporosis & related fractures. Unfortunately, when HT is stopped, bone mass rapidly decreases by
approximately 12%. Hence to maintain bone health, HT must continue lifelong. As a result, the risk
for harm is increased. Accordingly, alternative treatments are preferred. Effective alternatives to HT
include raloxifene (Evista) & bisphosphonates like alendronate (Fosamax), calcitonin (Miacalcin), &
teriparatide (Forteo). All patients should practice primary prevention of bone loss by ensuring
adequate intake of calcium & vitamin D, performing regular weight-bearing exercise, & avoiding
smoking & excessive alcohol use.
When and when not to use progestin for hormone replacement therapy and why (pp. 430-433)
Goals for noncontraceptive uses of progestins are to counteract endometrial hyperplasia caused by
unopposed estrogen during hormone therapy; management of dysfunctional uterine bleeding,
amenorrhea, & endometriosis; & support of pregnancy in women with corpus luteum deficiency.
Progestins are also used in in vitro fertilization cycles & to prevent prematurity in women at high risk
for preterm birth.
Progestins are contraindicated in the presence of undiagnosed abnormal vaginal bleeding. Relative
contraindications include active thrombophlebitis or a history of thromboembolic disorders (DVT,
CVA), active liver disease, & carcinoma of the breast. Progestins should not be prescribed for women
who have undergone hysterectomy.
Local vs. systemic estrogen options and why one would be chosen over the
other (p. 428) Local estrogen options:
Transdermal: Transdermal estradiol is available is 4 formulations:
• Emulsion (Estrasorb): Applied once daily to the top of both thighs & the back of both
calves.
• Spray (Evamist): Applied once daily to the forearm.
• Gels (EstroGel, Elestrin, Divigel): Applied once daily to one arm, from the shoulder
to the wrist or to the thigh (Divigel).
• Patches (Alora, Climara, Estraderm, Menostar, Vivelle-Dot): Applied to the skin of the
trunk (but not the breast).
Intravaginal: Estrogens for intravaginal administration are available as inserts, creams, &
vaginal rings. All are used primarily for the treatment of vulval & vaginal atrophy associated
with menopause. NOTE: Femring is also used for systemic effects to control hot flashes & night
sweats.
• Inserts (Imvexxy, Vagifem, Yuvafem)
• Creams (Estrace Vaginal, Premarin Vaginal)
• Vaginal rings (Estring, Femring)
Systemic estrogen options:
Oral: Owing to convenience, the oral route is used more than any other. The most active
estrogenic compound— estradiol—is available alone & in combination with progestins.
Parenteral: Although estrogens are formulated for IV & IM administration, use of these routes is
rare. IV administration is generally limited to acute, emergency control of heavy uterine
bleeding.
Transdermal estrogen therapy has fewer adverse effects (p. 428)
Compared with oral formulations, the transdermal formulations have 4 advantages:
• The total dose of estrogen is greatly reduced (because the liver is bypassed).
• There is less nausea & vomiting.
• Blood levels of estrogen fluctuate less.
• There is a lower risk for DVT, PE, & CVA.
Management of oral contraceptives (OCs)
-How to change patient from one combination oral contraceptive to another. (p. 441)
When one combination OC is being substituted for another, the change is best made at the beginning of
a new cycle.
-How to initiate treatment (when in the cycle is it best to start- may vary based on type of
contraceptive) (p. 442)
Most 28-day cycle products are taken in a repeating sequence consisting of 21 days of an active pill
followed by 7 days on which either no pill is taken, an inert pill is taken, or an iron-containing pill is
taken. The sequence is begun on either the first day of the menstrual cycle or the first Sunday after
the onset of menses. With the first option, protection is conferred immediately, so no backup
contraception is needed. With a Sunday start, which is done to have menses occur on weekdays
rather than the weekend, protection may not be immediate, so an alternate form of birth control
should be used during the first 7 days of the pill pack. With both options, each dose should be taken
at the same time every day (with a meal or at bedtime). Successive dosing cycles should commence
every 28 days even if there is breakthrough bleeding or spotting.
Unlike combination OCs, whose administration is cyclic, progestin-only OCs are taken continuously.
Use is initiated on day 1 of the menstrual cycle, & one pill is taken daily thereafter. A backup
contraceptive method should be used for the first 7 days.
-What teaching needs to be done? (p. 442)
Educate patient on proper protocol for missed doses (depending on medication
type & cycle): For products that use a 28-day cycle, the following
recommendations [Show Less]
