36.2: Hormonal, Contraception, and Infertility Drugs
By the end of this section, you should be able to:
- 36.2.1 Identify the characteristics of the hormonal therapy, contraception, and infertility drugs used to treat female reproductive disorders.
- 36.2.2 Explain the indications, actions, adverse reactions, and interactions of hormonal therapy, contraception, and infertility drugs used to treat female reproductive disorders.
- 36.2.3 Describe nursing implications of hormonal therapy, contraception, and infertility drugs used to treat female reproductive disorders.
- 36.2.4 Explain the client education related to contraception, hormonal therapy, and infertility drugs used to treat female reproductive disorders.
Hormonal Drugs
Hormonal drugs are derived from natural sources or manufactured to mimic the body’s hormones. Hormonal drugs can be used for numerous conditions from contraception to menopause. They can replace the body’s natural hormones when insufficient amounts are produced. They can also simulate or produce a state that is necessary for a specific reason. Contraception is an example in which hormonal drugs are used to create an environment that is not conducive to fertilization and implantation of an egg in the uterus.
Estrogens
Estrogen is produced in the body in four types: estrone (E1), estradiol (E2), estriol (E3), and estetrol (E4) (Hariri & Rehman, 2023). Indications for the use of estrogen include hormone replacement therapy (HRT) during menopause to relieve signs and symptoms such as vaginal dryness, hot flashes, mood swings, and painful intercourse. One type of estrogen, estradiol , can also be used as HRT for hypogonadism and ovarian failure (medical or physiological). Estradiol is available in a multitude of types and combinations, and dosages vary with the indication and use, the administration method, and its combined form (DailyMed, Estradiol , 2021; Hariri & Rahman, 2023).
Estrogen s are administered in several ways. If administered orally, they are absorbed well from the gastrointestinal tract, metabolized by the liver, and excreted in urine. Depending on the dose, estrogens can inhibit or promote ovulation. Other positive effects include preservation of calcium and phosphorus and stimulation of bone growth.
Table 36.1 lists two forms of estrogen therapy that are synthetic but identical to the body’s natural hormone and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Estradiol
( Estrace , Divigel , Estraderm Transdermal ) |
For postmenopausal symptoms:
Oral: Initial dose: 0.5–2 mg orally once daily. Adjust dose as necessary to control symptoms, using lowest effective dose. Transdermal extended release (ER): Initial dose: 0.0375–0.05 mg/24 hours applied topically twice weekly. Maintenance dose: 0.025–0.1 mg/24 hours applied topically twice weekly. Transdermal (applied once weekly): Available as 0.025 mg/day, 0.0375 mg/day, 0.05 mg/day, 0.06 mg/day, 0.075 mg/day, or 0.1 mg/day of estradiol. Transdermal spray: Initial dose: 1 spray (1.53 mg of estradiol) once daily in the morning to the forearm. Maintenance dose: 1–3 sprays once daily. Vaginal cream: 2–4 g daily administered vaginally with applicator for 1–2 weeks, then gradually reduce to half initial dosage for similar period. Maintenance dose of 1 g 1–3 times a week may be used. Parenteral: Estradiol cypionate (Depo-estradiol): 1–5 mg intramuscularly every 3–4 weeks. Estradiol valerate (Delestrogen): 10–20 mg intramuscularly every 4 weeks. |
|
Estropipate
( Improvera , Ortho-Est ) |
For menopause:
0.75–6 mg orally daily. For female hypogonadism/primary ovarian failure: 1.5–9 mg orally daily for the first 3 weeks of a theoretical cycle, followed by a rest period of 8–10 days. For prevention of osteoporosis: 0.75 mg orally for 25 days of a 31-day cycle per month. |
Adverse Effects and Contraindications
Adverse effects of estrogens are related mostly to the retention of fluids. Migraine headaches, bloating, weight gain, mood depression, stroke, and cardiovascular disease are known adverse reactions and can be life-threatening.
Contraindications for estrogens include hormone-positive breast cancer, undiagnosed uterine bleeding, and active or history of thrombophlebitis or thromboembolism. Pregnancy and breastfeeding are also contraindications because estrogens cross the placenta and enter breast milk. Estrogens must be used cautiously in conditions that are affected or exacerbated by fluid retention, such as migraine headaches with an aura, renal or cardiac dysfunction, and hypertension. Obesity and age greater than 35 are circumstances when estrogens should be used cautiously, if at all.
Table 36.2 is a drug prototype table for estrogens featuring conjugated estrogen . It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Estrogen (hormone) Mechanism of Action Replaces estrogen normally produced by the body |
Drug Dosage
HRT: 0.3–0.625 mg/day orally (25 days on and 5 days off). Female hypogonadism: 0.3 mg or 0.625 mg daily orally (25 days on and 5 days off). Female castration or primary ovarian failure: 1.25 mg orally daily (25 days on and 5 days off). Palliative treatment of breast cancer: 10 mg orally 3 times daily. Palliative treatment of prostate cancer: 1.25–2.5 mg orally 3 times daily. |
|
Indications
To replace hormones during menopause To manage primary ovarian failure To manage abnormal uterine bleeding related to hormone imbalance To relieve symptoms of low estrogen in young females who do not produce enough estrogen naturally (hypogonadism) Therapeutic Effects Decreases symptoms of menopause (vaginal dryness, hot flashes, night sweats, mood changes, weight gain, trouble sleeping, and thinning hair) Palliative treatment in advanced prostate cancer or male breast cancer |
Drug Interactions
Ketoconazole Barbiturates Carbamazepine Phenytoin Penicillin Tetracyclines Rifampin St. John’s wort False unicorn root Red clover Wild yams Food Interactions Grapefruit and grapefruit juice |
|
Adverse Effects
Weight gain Nausea Bloating Headaches Photosensitivity Intolerance of contact lenses Breast tenderness Depression Increased risk of stroke Heart attack Deep vein thrombosis and other thrombotic events Breast and ovarian cancer |
Contraindications
Undiagnosed abnormal uterine bleeding Female breast cancer Active or history of thrombophlebitis or thromboembolic problems (deep vein thrombosis, pulmonary embolism) Active or history of cardiovascular disease or arterial thromboembolic diseases (stroke, heart attack) Pregnancy Estrogen-dependent neoplasia Known anaphylactic reaction, angioedema, hypersensitivity Hepatic impairment or disease Protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders Caution: Older than 35 years Smoking |
FDA Black Box Warning
Estrogen
Estrogen (both estrogen alone or estrogen-progestin combinations) can significantly increase the risk of cardiovascular events such as stroke and heart attack in postmenopausal clients .
It can significantly increase the risk of invasive breast cancer in postmenopausal clients.
It should not be used to prevent dementia as part of hormone replacement therapy.
Progestins
Progestins include progesterone and its derivatives. They can function as both a stimulant and an inhibitor to manage the secretion of pituitary gonadotropins. One of the properties of progestins is their ability to prevent follicular maturation and ovulation. They accomplish this by inhibiting the secretion of pituitary gonadotropins and decreasing LH secretion. Progestins thicken cervical mucus, which hinders sperm migration and changes the endometrium to decrease the likelihood that an egg can be implanted. These properties make progestins an excellent contraceptive medication. Progestins are metabolized by the liver and excreted in urine.
Progesterone is used for several reasons. It can be added to estrogen in postmenopausal HRT to reduce the risk of endometrial cancer. It is also used for amenorrhea and for dysfunctional uterine bleeding. It can be administered orally, intramuscularly, intrauterine, and as a gel, depending on the intended effect of the drug. Progesterone dosage for HRT varies, as does the number of days it is used per month.
Desogestrel, drospirenone, medroxyprogesterone, norethindrone, and levonorgestrel are progestins. Desogestrel and drospirenone are used only in combination form for contraception.
Table 36.3 lists common progestins and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Desogestrel/ethinyl estradiol
( Cyclessa , Mircette ) |
150 mcg of desogestrel/30 mcg of ethinyl estradiol orally once daily (on specific days as instructed; inactive tablets are included and should be taken as directed). |
|
Drospirenone/ethinyl estradiol
( Syeda , Yasmin , YAZ ) |
3 mg of drospirenone/0.02 or 0.03 mg of ethinyl estradiol orally once daily (as per instructions depending on specific brand name or package; inactive tablets are included and should be taken as directed). |
|
Medroxyprogesterone
( Depo-Provera , Provera ) |
Intramuscular:
150 mg/mL every 3 months.
Subcutaneous: 104 mg/0.65 mL every 3 months. |
|
Norethindrone
( Camila , Ortho Micronor ) |
2.5–10 mg orally daily. |
|
Levonorgestrel
( Alesse , Introvale , Lessina ) |
1.5 mg orally as soon as possible within 72 hours of unprotected sexual intercourse or known or suspected contraceptive failure. |
Adverse Effects and Contraindications
Adverse effects, contraindications, and precautions for progesterone are similar to those of estrogen and include weight gain, nausea, bloating, headaches, visual disturbances, rash, and acne. Contraindications for progestin are hypersensitivity, pregnancy/lactation, history of thrombotic events, sexually transmitted disease (STD), pelvic inflammatory disease, endometriosis, undiagnosed uterine bleeding, cardiac/renal/liver disease, and hormone-sensitive cancers. Caution should be used with clients who have any condition that can be affected by fluid retention (migraine headache, cardiac/renal disease, seizure disorder), diabetes, hyperlipidemia, or clinical depression.
Table 36.4 is a drug prototype table for progestins featuring norethindrone. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Progestin (hormone) Mechanism of Action Inhibits secretion of FSH and LH Inhibits follicle maturation and ovulation |
Drug Dosage
2.5–10 mg orally daily. |
|
Indications
To prevent pregnancy (contraceptive) To treat primary and secondary amenorrhea To treat functional uterine bleeding To treat female hypogonadism Therapeutic Effects Palliative treatment of certain cancers (inoperable breast, prostate) Decreases symptoms of menopause Delays progression of osteoporosis |
Drug Interactions
Barbiturates Carbamazepine Phenytoin Penicillin Tetracyclines Rifampin St. John’s wort False unicorn root Red clover Wild yams Food Interactions Grapefruit/grapefruit juice |
|
Adverse Effects
Weight gain Nausea Bloating Headaches Visual disturbances Rash Acne Breakthrough bleeding/spotting Fluid retention/edema Chloasma (hyperpigmentation of skin) Alopecia Venous thromboembolism |
Contraindications
Hypersensitivity Pregnancy/lactation History of thrombotic events STD Pelvic inflammatory disease Endometriosis Undiagnosed uterine bleeding Cardiac/renal/liver disease Hormone-sensitive cancers Caution: Any condition that can be affected by fluid retention (migraine headache, cardiac/renal disease, seizure disorder) Diabetes Hyperlipidemia Clinical depression |
FDA Black Box Warning
Progesterone
In combination with estrogen, progesterone can significantly increase the risk of ovarian cancer.
Progesterone should not be used to prevent cardiovascular disease in postmenopausal clients.
Link to Learning
Hormone Replacement Therapy
Hormone replacement therapy was once commonly used to treat common menopausal symptoms, but large clinical trials have shown health risks. The Mayo Clinic discusses hormone replacement therapy and whether it is right for certain clients.
Contraceptives
Contraceptives are a group of medications, generally natural or synthetic hormone preparations, used to prevent pregnancy. Hormonal contraceptive medications work at distinct stages within the female (ovarian) reproductive system and use a variety of methods to interrupt the normal cycle of hormone release, egg fertilization, and/or implantation. Hormonal contraceptives can be oral, topical, vaginal, injectable, or implantable.
One important fact concerning all contraceptives, except male and female condoms, is that they do not prevent sexually transmitted infections (STIs). Therefore, client education about this topic is crucial. Another major consideration about contraceptives is that none of them is 100% effective in preventing pregnancy. There is a risk that sexual intercourse, even with the use of contraceptives, can lead to pregnancy (Britton et al., 2020).
Synthetic forms of estrogen and progestin are the hormones used in contraceptive drugs. These drugs contain either an estrogen-progestin combination or progestin alone. Estrogen works by the negative feedback loop to decrease the secretion of LH and FSH from the anterior pituitary gland. With lower levels of LH and FSH, a dominant follicle will not develop, and a mature egg will not be released from the follicle (Britton et al., 2020; Casey, 2022; Cooper et al., 2020).
Progestin thickens the cervical mucous and prevents sperm from reaching the egg. It also changes the endometrium so that the environment of the uterus is less favorable for egg implantation. Refer to the previous section regarding hormones for specific information about estrogen and progestin.
The combination oral contraceptives (COC) and progestin-only contraceptives (POP) make up two types of oral contraceptive pills. The third type is a continuous or extended-use pill, which means the pills are taken without any pause for an indefinite time. This contraceptive regimen allows for increased ovulation suppression and medication adherence, is more satisfactory for the user, and decreases both scheduled and breakthrough bleeding over time (Britton et al., 2020; Casey, 2022; Cooper et al., 2020).
Clinical Tip
Dealing with Side Effects of Birth Control Methods
The most frequent side effects of all birth control methods are nausea and breakthrough bleeding. Instructing the client to take the medication before going to bed is one of the best ways to manage nausea so that the client is asleep when the worst of the nausea occurs. Eating small meals frequently, avoiding spicy and greasy foods, and drinking ginger ale or clear liquids are other ways to alleviate nausea. The nausea should go away after about 3 months.
Breakthrough bleeding can be frustrating to the client. However, this should also subside after 3 months. Some clients may have only spotting and some may have times of heavy bleeding other than their period (if contraceptive method allows for monthly cycle to continue).
There is no way to determine which client will have which side effects. Every individual’s experience is different. The body is adjusting to new levels of hormones, and this process takes about 3 months. Emotional support to the client is also important. Some clients may need to try more than one contraceptive pill or method to find the best fit for their situation.
Oral and Injectable Contraceptives
Oral contraceptives are pills that contain either a combination of estrogen and progestin or progestin alone. Oral contraceptives are prescribed based on a client’s medical history, needs, and risk factors. Combined oral contraceptives (COCs) contain estrogen and progestin in varying dosages. The type of progestin varies with each COC depending on the individual client’s needs and medical status. There are three different categories of COCs. Monophasic contraceptive pills contain a fixed ratio of estrogen and progestin. Biphasic COCs contain a fixed dose of estrogen with a varying dose of progestin. Triphasic COCs contain low doses of both estrogen and progestin with a varying dose of estrogen (Britton et al., 2020; Casey, 2022; Mayo Clinic, 2023a; Cooper et al., 2020).
Injectable contraceptives are hormones that are injected, usually intramuscularly, at specific intervals to provide the same birth control protection as oral contraceptives (Britton et al., 2020; Casey, 2022; Cooper et al., 2020).
Table 36.5 lists common forms of COCs and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Monophasics | |
|
Estradiol levonorgestrel
( Aviane ) |
20 mcg estradiol/0.10 mg levonorgestrel orally (21 active pills and 7 inactive pills). |
|
Ethinyl estradiol desogestrel
( Apri 28 ) |
30 mcg ethinyl estradiol/0.15 mg desogestrel orally (21 active pills and 7 inactive pills). |
| Biphasics | |
|
Levonorgestrel and ethinyl estradiol
( Seasonique ) |
13-week supply of tablets:
|
| Triphasics | |
|
Desogestrel/ethinyl estradiol
( Mircette ) |
Days 1–21: 0.02 mg ethinyl estradiol/0.15 mg desogestrel (21 tablets).
Day 22–23: Inactive tablets (2 tablets). Day 24–28: 0.01 mg ethinyl estradiol (5 tablets). |
Progestin-only contraceptives are used when estrogen is not appropriate for the client’s situation. For instance, the client may have significant risk factors such as obesity, smoking, hypertension, and age over 35 years. These are also commonly used by clients who are breastfeeding, as they have less effect on the breast milk supply than oral contraceptives containing estrogen. Medroxyprogesterone, norethindrone, and levonorgestrel are progestin-only contraceptives. The injectable contraceptive medroxyprogesterone is administered intramuscularly or subcutaneously (Britton et al., 2020; Casey, 2022; Cooper et al., 2020).
Table 36.6 lists common progestin-only contraceptives and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Medroxyprogesterone
( Provera , Depo-Provera ) |
Amenorrhea:
5–10 mg orally daily for 5–10 days.
Contraception: 150 mg/1 mL intramuscularly every 3 months; 104 mg/0.65 mL subcutaneously. Adjunct cancer treatment (endometrial or renal carcinoma): 400–1000 mg intramuscularly weekly. May decrease to 400 mg intramuscularly monthly depending on client response. Used only as adjunctive and palliative treatment for advanced inoperable cases. |
|
Norethindrone acetate
( Aygestin , Finzala ) |
Amenorrhea:
2.5–10 mg Aygestin orally daily for 5–10 days.
Contraception: 24 chewable active Finzala tablets with 1 mg norethindrone acetate/20 mcg ethinyl estradiol along with 4 nonhormonal placebo tablets. 1 tablet orally daily. |
|
Levonorgestrel
( Plan B One-Step ) |
Contraception: 1.5 mg orally as soon as possible within 72 hours of unprotected sexual intercourse or contraceptive failure. |
|
Ulipristal acetate
( Ella ) |
Contraception: 30 mg orally as soon as possible within 5 days (120 hours) after unprotected sex or contraceptive failure. |
Link to Learning
Contraceptive Options
Birth Control Methods is a client education site that discusses birth control options and resources for obtaining them.
Intrauterine and Implanted Contraceptives
In addition to oral and injectable contraceptives, intrauterine devices (IUDs) and implanted contraceptive devices are available. The advantages to these forms of contraception are their long-term effects and ease of use. They do not require remembering to take daily pills or scheduling appointments for injections. However, they do have side effects, like any hormonal medication. Additionally, because they are inserted into the body, risks of infection and migration (moving) or dislodgement of the devices exist (Andersen & Spanfeller, 2022; Britton et al., 2020; Casey, 2022; Madden, 2023).
IUDs have become the most commonly used contraceptive method in the world and are among the most effective types of contraceptives. IUDs are small T-shaped devices that are placed inside the uterus via the cervix. Five types of IUDs are used in the United States. Four of them are hormonal. They release small amounts of progestin (levonorgestrel) into the body. They also have a positive effect of making monthly periods lighter. Further, these IUDs may decrease the risk of ovarian, endometrial, and cervical cancers (Andersen & Spanfeller, 2022; Casey, 2022; Madden, 2023).
The fifth type is copper. It works by stimulating the body’s immune response, creating an unfavorable uterine environment for the sperm, and preventing pregnancy. It may initially increase bleeding with periods and between periods; however, the bleeding should lessen to an acceptable level. Hormonal IUDs can last for 3–8 years, depending on the specific hormone and dose, and the copper type lasts for 10 years (Andersen & Spanfeller, 2022; Britton et al., 2020; Casey, 2022; Madden, 2023).
Another type of birth control method is the implanted device. The device comes as a single soft, radiopaque, flexible implant (4 cm in length × 2 mm in diameter) that contains 68 mg etonogestrel, 15 mg barium sulfate, and 0.1 mg magnesium stearate. It comes with the insertion device in the package. The contraceptive is implanted under the skin of the inner upper arm. It has the same action, use, contraindications, and side effects as any other contraceptive containing levonorgestrel. The primary risk is infection or dislodgement of the implant. This device lasts for 3 years and is a highly effective contraceptive method (Britton et al., 2020; Casey, 2022; DailyMed, Nexplanon , 2022).
Table 36.7 lists the four hormonal IUD types and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Levonorgestrel
( Kyleena Liletta Mirena Skyla ) |
Intrauterine 19.5 mg. Intrauterine 52 mg (20.1 mcg/day). Intrauterine 52 mg (20 mcg/day). Intrauterine 13.5 mg. |
Adverse Effects and Contraindications
Contraindications include active STI or recent pelvic infection, pregnancy, cancer of the cervix or uterus, or unexplained vaginal bleeding. Hormonal IUDs should not be used by clients who have had breast cancer.
Side effects include bleeding and spotting as the uterus adjusts to the IUD. Other adverse effects include abdominal pain, endometriosis, pelvic inflammatory disease (PID), and expulsion of the IUD. Extremely rare is the possibility that an IUD may cause uterine perforation.
For a copper IUD, the bleeding and spotting may last up to 6 months. The insertion of the IUD may be uncomfortable, and the client may experience some cramping and backache for a day or two after the procedure. The pain can be managed using ibuprofen or acetaminophen and heating pads. Other side effects include nausea, cramping, ovarian cysts, and mood changes. The most concerning complications of all IUDs are infection, expulsion, or perforation; however, the risk for these complications is extremely low (Andersen & Spanfeller, 2022; Britton et al., 2020; Casey, 2022; Madden, 2023).
Other Contraceptive Methods
Two other hormonal contraceptive methods are a transdermal patch and a vaginal ring . The patch contains an estrogen–progestin combination and is applied weekly for 3 weeks and left off for 1 week. The vaginal ring also contains a combination of estrogen–progestin and is inserted once and left in place for 3 weeks. The ring is removed for 1 week before a new ring is inserted. Both methods are based on a 4-week cycle (Britton et al., 2020; Casey, 2022).
In 2018 the FDA approved a new vaginal ring that is reused for a year (Center for Devices and Radiological Health, 2018). It is used according to the same cycle of 3 weeks in place and 1 week out. The difference is that between cycles it can be washed and stored and then reused.
Specific client teaching for the vaginal ring includes properly placing and removing the ring and properly disposing of the monthly ring or cleaning and storage of the yearly ring. If the ring is removed for more than 3 hours, clients should be advised to use a backup contraceptive method concurrently for 7 days (Britton et al., 2020; Casey, 2022).
Client teaching for the patch includes correct opening of the package; placing the patch on clean, dry skin on the buttocks, upper outer arm, lower abdomen, or upper body; pressing it firmly for 10 seconds; and not placing the patch on the breasts (Britton et al., 2020; Casey, 2022).
All contraceptive drugs, regardless of form, are derived from the hormones estrogen and progestin. Refer to Table 36.1 and Table 36.3 for information related to mechanism of action, indication, therapeutic effects, side effects, contraindications, and food and drug interactions.
Case Study
Read the following clinical scenario to answer the questions that follow.
Susan Lopez is a 34-year-old female who presents to the public health department for counseling regarding contraception. She is planning to be married, and she and her fiancé do not want children. Susan has been sexually active with three male partners including her fiancé. She has always insisted that the partners use condoms.
Social History
Tobacco use: Smokes e-cigarettes daily. Formerly smoked regular cigarettes, 1/2 pack per day. Total time smoking is 10 years.
Alcohol use: Occasional social drink, usually wine
Sexually active
Current Medications
None
| Vital Signs | Physical Examination | |
|---|---|---|
| Temperature: | 98.4°F |
|
| Blood pressure: | 128/78 mm Hg | |
| Heart rate: | 74 beats/min | |
| Respiratory rate: | 16 breaths/min | |
| Height: | 5'3" | |
| Weight: | 152 lb |
The nurse completes the initial assessment for Susan. Which finding is the most important regarding counseling about contraceptive medications?
- Answer
-
Smoking
After discussing all the options for contraception with Susan and considering that Susan does not want children, which method do Susan and the nurse think may be the best for her?
- Answer
-
Copper IUD
Initiating Contraceptives
The oral and transdermal methods can be initiated using a first-day start method, a quick start method, or a Sunday start method. All are equally effective. The first-day start method means the client starts the contraceptive on day 1 of their menstrual cycle and continues as directed. The quick start method means that the client starts the contraceptive immediately, regardless of the timing of their menstrual period. This is week one. The individual continues to take the pills or apply the patch as directed. One advantage of the quick start method is that the client can begin taking the medication the day they receive the medication. The Sunday start method means the client will start using the contraceptive on the first Sunday following the start date of their period. Then the client continues to take the pills or apply the patch as directed. A disadvantage of the Sunday start method is that clients may forget to start on the correct date and then must wait until after their next period to begin taking the medication (Britton et al., 2020; Casey, 2022; Cooper et al., 2020).
Link to Learning
How to Provide Quality Counseling for Contraception
This position statement from American College of Obstetricians and Gynecologists provides information about client-centered contraceptive counseling. It highlights the importance of recognizing health disparities and bias that can occur when counseling clients on contraceptive use and recommends a shared decision-making approach through client-centered contraceptive counseling.
Infertility Drugs
Infertility drugs constitute a highly specialized class of drugs. The content in this chapter is intended to give the reader an introduction to the topic. Infertility can occur for numerous reasons that are beyond the scope of this chapter to detail. Some causes of infertility are related to impaired hormone secretion from the reproductive system and the thyroid. Other causes include blockages or conditions that require surgical intervention to resolve. This chapter will cover only the drugs used to promote fertility.
Some clients cannot become pregnant without exogenous treatment, meaning they will need medications administered to assist their body’s reproductive system to ovulate and for the egg to mature. Some medications directly stimulate the follicles and ovulation; others stimulate the hypothalamus to increase the secretion of FSH and LH, which then lead to follicle and ovary development and maturation.
These medications are typically used only for clients who have functioning ovaries and who have been unable to become pregnant after at least 1 year of trying. However, if a client is over age 35, fertility drugs are generally used after 6 months of trying. The other purpose of infertility drugs is for people who want multiple follicles developing in order to harvest ova for in vitro fertilization.
One important aspect of fertility treatment is the complex schedule for taking each medication and when intercourse should take place to increase the chance of egg fertilization. Additionally, provider appointments may not be easy to facilitate if the client lives a distance from the clinic or is limited by their personal situation in scheduling appointments at the clinic. Further, if the client is self-administering injections, they will need instructions and supplies.
Table 36.9 lists common infertility drugs and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Clomiphene
( Clomid ) |
50–100 mg orally daily. Timing and length of therapy are dependent on individual client situations. |
|
Cetrorelix acetate
( Cetrotide ) |
0.25 mg subcutaneously once daily during the early- to mid-follicular phase.
0.25 mg subcutaneously on either stimulation day 5 (morning or evening) or day 6 (morning) and continued daily until the day of human chorionic gonadotropin (hCG) administration. |
|
Human chorionic gonadotropin (hCG)
( Ovidrel ) |
5000–10,000 USP (U.S.) units intramuscularly 1 day following the last dose of menotropin. 250 mcg subcutaneously 1 day following the last dose of the follicle-stimulating agent. |
|
Follitropin
( Follistim AQ , Gonal-F , Gonal-F RFF ) |
Follistim AQ:
50 international units subcutaneously daily for at least the first 7 days; dosage adjusted weekly based on ovarian response.
Gonal-F: Dosing depends on individual situation. |
|
Menotropin
( Menopur ) |
Initial dose : 225 international units subcutaneously on cycle day 2 or 3; adjust dose after 5 days and subsequent adjustments made per ovarian response. |
Adverse Effects and Contraindications
Adverse effects of infertility drugs include a significant risk of multiple births and birth defects. Ovarian overstimulation is another side effect that is manifested by abdominal pain, distention, ascites (fluid accumulation in the abdomen), and pleural effusion. Headache, fluid retention, ovarian enlargement, uterine bleeding, nausea, and fever are additional side effects.
Infertility drugs are contraindicated when the client has primary ovarian failure, thyroid or adrenal dysfunction, ovarian cysts, or idiopathic uterine bleeding or is pregnant. Clients with respiratory issues or who are breastfeeding should use caution before deciding to take fertility medications.
Table 36.10 is a drug prototype table for infertility drugs featuring clomiphene. Clomiphene is a selective estrogen receptor modulator (SERM) with both estrogen antagonist and agonist effects that increase gonadotropin release as well as increase production of FSH and LS. The ultimate effect is ovarian follicular growth (Carson & Kallen, 2021). The table lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Infertility drug Mechanism of Action Stimulates ovarian reproductive system |
Drug Dosage
50–100 mg orally daily. Timing and length of therapy are dependent on individual client situations. |
|
Indications
Treatment of ovulatory dysfunction in clients desiring pregnancy Therapeutic Effects Creates reproductive environment conducive to pregnancy |
Drug Interactions
No significant interactions Food Interactions Alcohol |
|
Adverse Effects
Ovarian hyperstimulation syndrome (OHSS) Ovarian enlargement Vasomotor flushes Abdominal-pelvic discomfort/distention/bloating Nausea and vomiting Breast discomfort Visual symptoms (blurred vision, lights, floaters, waves, unspecified visual complaints, photophobia, diplopia, scotomata, phosphenes) Headache Abnormal uterine bleeding Intermenstrual spotting, menorrhagia Significant risk of multiple births and birth defects |
Contraindications
Hypersensitivity Pregnancy Uncontrolled thyroid or adrenal dysfunction Organic intracranial lesion such as pituitary tumor Abnormal uterine bleeding Ovarian cysts Liver disease |
Nursing Implications
The nurse should do the following for clients who are taking hormone therapy, contraceptives, or infertility drugs:
- Assess client’s baseline health status to include medical history, physical exam, and complete medication history, including herbal remedies and over-the-counter (OTC) medications.
- Assess for factors that increase the client’s risk of adverse effects including personal and family history of cardiovascular disease (myocardial infarction, cerebral vascular accident, hypertension, and thrombotic events including venous thromboembolism and pulmonary embolism).
- Assess smoking history and alcohol use.
- Assess pregnancy and lactation status (for contraceptive use).
- Assess for presence of or risk of sexually transmitted infection (for clients obtaining contraception).
- Assess client’s emotional status and support system.
- Identify any factors that may affect the client’s ability to adhere to the medication regime.
- Obtain serum and urine specimens as ordered.
- Assist with gynecological exam as needed.
- Assess baseline sexual development for prepubescent clients taking hormone therapy.
- Obtain baseline vital signs and weight and monitor at each follow-up appointment.
- Assess client’s understanding of the drugs to be used—actions, side effects, contraindications, administration method, and schedule–and provide instruction as indicated.
- Provide information in a calm, supportive, nonjudgmental manner.
- Assist the client with their choice of contraceptive method according to individual needs and preferences.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a hormone therapy, contraceptive, or infertility drug should:
- Understand the purpose, effect, and side effects of the medication(s).
- Be able to follow the drug schedule (daily, cyclical).
- Be able to self-administer drug as ordered (topical, transdermal, oral, injection).
- Verbalize the importance of taking medications at the same time and what to do for missed doses.
- For clients using contraceptives, understand the need for using a barrier or nonhormonal birth control method to prevent pregnancy when beginning contraception and any time 3 or more consecutive doses of oral contraceptive are missed. The alternate method should generally be used for a minimum of 7 days.
- For clients using contraception, understand that it does not protect against STIs, so barrier methods (condoms) must be used to prevent the spread of infections.
- For clients with transdermal patches or vaginal rings, understand what to do when they are dislodged or removed during the active time.
- For clients with an implanted contraceptive device, understand the potential complications of infection and migration of the device.
- Report problems such as breakthrough bleeding and any intolerable side effects to the health care provider.
- Avoid prolonged exposure to sunlight (hormone therapy).
- Recognize any change in vision and/or problems with contact lenses (hormone therapy).
- Initiate smoking cessation in the manner most suited to the client (medication, support group, etc.).
- Clients taking infertility medications should understand the possibility of multiple births.
- Dispose of any sharps in a safe manner.
- Clients taking infertility medications should be able to follow the schedule for sexual intercourse as determined to maximize chances for pregnancy success.
- Report new health problems to the health care provider in a timely manner.
- Notify the health care provider immediately of chest pain and/or shortness of breath; any pain, swelling, and/or redness in calves; severe headache; signs and symptoms of stroke; and any significant change in mood (depression).
- Notify the health care provider before taking any new medication or OTC/herbal remedies.
- Maintain follow-up appointments.
The client taking a hormone therapy, contraceptive, or infertility drug should not:
- Smoke because of the increased risk of blood clots (hormone therapy, contraceptives).
- Discontinue or alter the dose of the medication without consulting with their health care provider.