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NR566 / NR 566 Final Exam Study Guide (2022/2023) Chamberlain
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NR 566 / NR566 Final Exam Study Guide
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Week five: Chapter 50, 51, 52, 53, 82Hormone Replacement Therapy
Selective Estrogen Modulators are drugs that activate estrogen receptor modulators in some
tissues and block them in others
o By blocking estrogen receptors tamoxifen protects against breast cancer and
postmenopausal osteoporosis and has a favorable effect on serum lipids ( ↓ LDL)
o Hormone replacement therapy increases risk for endometrial cancer and
thromboembolism
o HRT in women >65 years old increases the risk for dementia
o Ex. Tamoxifen, Toremifene, Raloxifene, Bazedoxifene
Raloxifene does not block ERs (estrogen receptors) in endometrium so does not
pose risk for uterine cancer
Bazedoxifene recommended for prevention osteoporosis in postmenopausal
women with a uterus
o What are common vasomotor symptoms associated with menopause that HRT helps
reduce? hot flashes, (menopause S+S)
When do they appear after stopping HT? 4 days
those with severe symptoms before starting HRT are at highest risk for
intolerable symptoms when they stop
o What factors increase risk for harm with HRT? personal or family history of breast
cancer, cardiovascular disease
o To keep risk low, HT should be used in LOWEST dosage and for SHORTEST time
needed (often <5 years) to accomplish treatment goals. Long-term HRT should be
avoided as most risks outweigh benefits.
Chapter 50: Estrogens and Progestins
Hormone replacement therapy: estrogen, progestin
o Do not need to read/study Management of female sex interest-arousal disorder
Progestins
What are some non-contraception uses for progestin? menopausal hormone therapy,
dysfunctional uterine bleeding, amenorrhea, endometrial hyperplasia and carcinoma, corpus
luteum deficiency syndrome, early pregnancy, in vitro fertilization
Hydroxyprogesterone acetate (Makena) is approved for preventing preterm birth in women with
singleton pregnancy and something preterm delivery - BOOK
If estrogen levels are adequate, treatment with progestin for 5-10 days will be followed by
withdrawal bleeding in women with amenorrhea. If estrogen levels are low, may need to induce
endometrial proliferation with an estrogen before giving the progestin.
o before progestin treatment, estrogen levels must be adequate
Excessive dysfunctional uterine bleeding can be stopped by administering progestin for 10-14
days
How do we establish regular monthly cycle in dysfunctional uterine bleeding? Two methods:
cyclic therapy- oral dosing 10-14 days after period for 10 days OR progestin first 10 days of each
month
What is only approved indication for long-term progestin use? endometrial CA
When are progestins contraindicated? undiagnosed abnormal vaginal bleeding, coag issues, active
thrombophlebitis, breast CA, liver dx
What are some side effects of progestins? irregular bleeding, spot more, amenorrhea, different
volume and cycle lengths
, First generation progestins (ethynediol diacetate, norethindrone) have lower risk for thrombosis
than with other progestins like drospirenone and desogestrel which have greatest risk for
thrombosis
Estrogen
What side effects can occur with estrogen use? higher pulse- HA, nausea, increased risk for
thromboembolism
o take with food and at night
o nausea diminishes over time (try taking in AM after a bit)
o estrogen dose can be changed (high to low dose)
o combined oral contraceptives: HTN (lower estrogen dose)
What is the black box warning for estrogen?
o Endometrial cancer risk is increased in women with a uterus who take unopposed
estrogen
IF you have a uterus- need progestin to get rid of lining
o Estrogen may increase the risk for DVT and stroke and PE
o Estrogen is not indicated for cardiovascular disease or dementia and may increase the risk
for dementia in women aged 65 years and older
Endometrial cancer evaluation should occur if patient has what symptom? persistent or recurrent
vaginal bleeding
What education do provide to reduce cardiovascular risk when taking estrogen?
o Avoid smoking, perform regular exercise, decrease intake of saturated fats, and take
appropriate drugs to treat hypertension, diabetes, and high cholesterol
Why may transdermal estrogen therapy be preferred for some patients? less nausea
When are estrogens contraindicated? In pregnant women. Estrogens may decrease milk supply if
used in breastfeeding women.
o also in DVTs, MI, stroke history, geriatrics
Avoid use in women who have breast cancer as can promote the growth of existing breast
carcinoma.
Relative contraindication COC if have migraines, epilepsy, HTN, cardiac disease, diabetes,
gallbladder disease.
Estrogens are inappropriate for geriatric patients.
Hormone Therapy
How do COC reduce fertility? (Estrogen vs progestin MOA)
o Estrogen suppresses the release of follicle stimulating hormone from the pituitary and
thereby inhibits follicular maturation
o Progestin acts in the hypothalamus and pituitary to suppress the midcycle luteinizing
hormone surge, which normally triggers ovulation. Progestin also thickens the cervical
mucus (creates barrier to penetration of sperm) and alteration of the endometrium (keeps
it from building up/thickening), making it less hospitable for implantation
What is recommended HT for women with intact uterus vs. hysterectomy? Intact uterus:
combination (estrogen and progestin- not just estrogen by itself); Hysterectomy: use estrogen
(don’t have to worry about effects of estrogen on uterus)
Which are preferred for contraception during lactation (early on) and migraines? Migraines:
progestin (higher pulse- HA, higher risk for embolism with estrogen)
estrogen early on decreases mild supply
What is the difference between dose tapering and day tapering of hormone therapy?
o dose tapering: daily dose but the dosage amount is gradually reduced (gradual reduction
of the dose)
o day tapering: daily dose that is the same but the days between the doses is gradually
reduced (gradual reduction of the days between doses)
, o Only taper down estrogen dosage because lowering of progestin might permit estrogen to
stimulate endometrial growth which increases risk for endometrial hyperplasia (pre-
cancerous potentially)
What are symptoms of excess estrogen vs progestin?
o estrogen: nausea, breast tenderness, edema
o progestin: appetite increases, depression, fatigue
COC should be avoided in women older than 35 years old who smoke. What is preferred tx then?
progestin only pills, IUD or diaphragm
o NO estrogen or combined oral contraceptives (have estrogen)
What are some other contraindications for COC? pregnant women, breast cancer, abd liver
function, thrombophlebitis
What is the black box warning for estrogen and progestin therapy? May increase risk for breast
cancer.
o NOT indicated for cardiovascular disease or dementia and may increase risk of dementia
in women aged 65 and older.
How long is Nexplanon effective and when it should be removed? FDA approved for 3 years but
can be used up to 5 years
o subdermal progestin
Chapter 51: Birth Control
Monotherapy
Combination therapy
o Do not need to read/study emergency contraceptives or drugs for medical abortion
Birth Control
High estrogen oral contraceptives are reserved for women taking drugs that induce CYP450 or
P3A4
o CYP450 meds may include Amiodarone, Fluoroquinolones, Diltiazem, Valproic Acid,
etc. Those drugs can decrease effectiveness of oral contraceptives by decreasing hormone
levels. May be noted if breakthrough bleeding occurs.
o OC may decrease effectiveness of warfarin leading to decreased INR levels so may need
to increase Coumadin dosage.
o OC may increase glucose levels so may need to increase dosage of diabetic medications.
o OC can impair hepatic metabolism of theophylline, tricyclic antidepressants, diazepam,
and chlordiazepoxide leading to reduces (hepatic and renal) clearance which increases
risk of toxicity.
How does monophasic differ from biphasic, triphasic, etc. regarding hormone levels?
o monophasic: doses of estrogen and progastrin remain constant throughout cycle
o others fluctuate to match our normal hormone levels
o triphasic: have different colors (not placebos) because of the changing levels
How educate start date of hormone therapy (28-day regimen) if patient wants to avoid getting
period on weekend vs patient who wants to start on date which pregnancy protection conferred
immediately?
o weekend: avoid period on weekend: start on a Sunday (first period usually Tuesday and
finish by Friday)
o avoid additional protection: 1st Sunday after your period- no backups needed then (you
aren’t close to your ovulation)
How educate patient how take birth control if only wants one period every three months? (HINT
extended use)
, o Use four 28-day packets of monophasic pills and take active pills only, discard placebo
pills in the first 3 packets and continue to the next packet. Do not take placebo pills till
reach 4th packet.
o For those on combination OC that use extended cycle, up to 56 days can be missed with
little or no increased risk for pregnancy provided that pills had been taken continuously
for the prior 3 weeks.
Which birth control methods are the most effective? Nexplanon, IUD, Depo
What are the CDC recommendations to educate patient regarding if miss one or more COC pills?
o Refer to package insert for individual drugs as may vary, but in general:
o During FIRST week:
If ONE or MORE pills are missed, take 1 pill as soon as possible and the n
continue the pack. Use an additional form of contraception for 7 days.
o During SECOND or THIRD week:
If ONE or TWO pills are missed, take 1 pill as soon as possible and then
continue with active pills in the pack but skip the placebo pills and go straight to
a new pack once all the active pills have been taken.
If THREE or MORE pills are missed, follow the same instructions given for
missing one or two pills, but use an additional form of contraception for 7 days.
Taking a PROGESTIN pill even 3 hours late can reduce their effectiveness and use of back up
protection or emergency contraception is recommended if unprotected sexual intercourse
occurred.
o higher failure rates and not as effective as combo pills
o someone who takes progestin only: lactating, migraines, lots of side effects with combo
What are the recommendations to educate if miss progestin OC pill? take as soon as you
remember and use back up for at least 2 days
o If ONE pill is missed, it should be taken as soon as remembered and backup
contraception should be used for at least 2 days. The pills should be resumed as
scheduled on the next day.
o If TWO pills are missed, the regimen should be restarted, and backup contraception
should be used for at least 2 days.
o If TWO or MORE pills are missed and no menstrual bleeding occurs, a pregnancy test
should be done.
Patch may help improve compliance as only need to change patch once weekly for first 3 weeks,
then no patch 4th week (to have cycle)
o When is back-up protection needed when patch is used? If the patch has been off longer
than 24 hours.
Chapter 52: Androgen
Hormone replacement therapy: testosterone
Therapy effects (therapeutic vs adverse)
Monitoring needs
Contraindications
Androgens
What does androgen deficiency lead to? infertility/sterility. Does androgen replacement restore
fertility? NO
Testosterone is major endogenous androgen. What are normal natural levels of testosterone in
men vs women?
o Men produce 2.5 - 10 mg testosterone daily by the Leydig cells of the testes
o Women produce 300 mcg with half production from both ovaries and adrenal glands (10-
40x less testosterone than men)
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