Gonadal Hormones
Objectives
1 Describe gonads and their function.
3 Identify the uses of estrogens and progestins.
4 Compare the adverse effects seen with the use of estrogen hormones with those seen with androgens.
Key Terms
gonads (
) (p. 612)
testosterone (
) (p. 612)
androgens (
) (p. 612)
ovaries (
) (p. 612)
estrogen (
) (p. 612)
progesterone (
) (p. 612)
The Gonads and Gonadal Hormones
http://evolve.elsevier.com/Clayton
The gonads are the reproductive glands—the testes of the male and the ovaries of the female. In addition to producing sperm, the testes produce testosterone, the male sex hormone. Testosterone controls the development of the male sex organs and influences characteristics such as voice, hair distribution, and male body form. Androgens are other steroid hormones that produce masculinizing effects.
The ovaries produce estrogen and progesterone. These are hormones that stimulate maturation of the female sex organs. They influence breast development, voice quality, and the broader pelvis of the female body form. Menstruation is established because of the hormone production of the ovaries. Estrogen is responsible for most of these changes. Progesterone is thought to be associated mainly with body changes that favor the implantation of the fertilized ovum, continuation of pregnancy, and preparation of the breasts for lactation.
Nursing Implications for Gonadal Hormones
Assessment
History.
Ask the patient to describe the current problem that initiated this visit. How long have the symptoms been present? Is this a recurrent problem? If so, how was it treated?
Reproductive History.
Ask the patient to describe the following, as appropriate: age of menarche; usual pattern of menses (i.e., duration, number of pads used, last menstrual period); number of pregnancies, live births, miscarriages, and abortions; vaginal discharges, itching, infections, and how treated; and breast self-examination routine (if not being performed regularly, explain the correct procedure). Male patients should be asked whether testicular self-examinations are performed (if not being performed regularly, explain the correct procedure). As appropriate, obtain information regarding impotence, sterility, or alterations in libido.
History of Prior Illnesses.
Any indication of hypertension, heart or liver disease, thromboembolic disorders, or cancer of the reproductive organs is of particular concern.
Medication History.
Obtain a detailed history of all prescribed medications, including oral contraceptives, over-the-counter medications, including herbal medicines (e.g., dong quai, black cohosh), and any street drugs (e.g., “muscle-building” steroids). Ask patients if they understand why each is being taken. Tactfully determine if the prescribed medications are being taken regularly and if not, why not?
Smoking History.
Does the person smoke?
Physical Examination
Psychosocial.
Patients requiring androgen therapy may need to be encouraged to discuss feelings relating to sexuality, sterility, or altered libido.
Life Span Considerations
Diabetes Mellitus
Patients with diabetes mellitus who receive gonadal hormones may experience alterations in the blood glucose levels. Parameters should be established and a written record for glucose monitoring maintained for reporting to the physician or health care provider.
Most gonadal hormones are prescribed to patients for prolonged self-administration. Therefore, planning should stress patient education specific to the type of gonadal hormone prescribed and its intended actions, including monitoring of common and serious adverse effects. Ensure that the patient understands the dosage and specific time schedule for administration of the prescribed medication.
Implementation
Obtain baseline data for subsequent evaluation of therapeutic response to therapy (e.g., weight, vital signs, and blood pressure in sitting, lying, and standing positions). Assist with the physical examination.
Patient Teaching
Expectations of Therapy.
Discuss the expectations of therapy with the patient (e.g., degree of pain relief, frequency of use of therapy, relief of menopausal symptoms, sexual maturation, regulation of menstrual cycle, sexual activity, maintenance of mobility, activities of daily living and/or work).
Smoking.
Explain the risks of continuing to smoke, especially when the patient is receiving estrogen or progestin therapy. (The incidence of fatal heart attacks, thromboembolic disorders, and stroke is increased for women older than 35 years.) Provide smoking cessation education.
Physical Examination.
Stress the need for regular periodic medical examinations and laboratory studies.
Fostering Health Maintenance.
Discuss medication information and how it will benefit the course of treatment to produce an optimal response. Seek cooperation and understanding of the following points so that medication adherence is increased: name of medication; dosage, route, and times of administration; and common and serious adverse effects. If estrogen has been prescribed for the purpose of delaying the advancement of osteoporosis, stress the importance of adhering to the regimen to achieve the maximum effect.
Written Record.
Plan to teach the individual to monitor vital signs and weight daily. Enlist the patient’s aid in developing and maintaining a written record of monitoring parameters (e.g., blood pressure, pulse, daily weight, degree of pain relief, menstrual cycle information, breakthrough bleeding, nausea, vomiting, cramps, breast tenderness, hirsutism, gynecomastia, masculinization, hoarseness, headaches, sexual stimulation). (See Self-Monitoring Drug Therapy Record on the Evolve
Web site at http://evolve.elsevier.com/Clayton.) Complete the Premedication Data column for use as a baseline to track response to drug therapy. Ensure that the patient understands how to use the form and instruct the patient to take the completed form to follow-up visits. During follow-up visits, focus on issues that will foster adherence to the therapeutic interventions prescribed.
Drug Therapy with Gonadal Hormones
Drug Class: Estrogens
Actions
The natural estrogenic hormone released from the ovaries is comprised of several closely related chemical compounds—estradiol, estrone, and estriol. The most potent is estradiol. It is metabolized to estrone, which is half as potent. Estrone is further metabolized to estriol, which is considerably less potent. Estrogens are responsible for development of the sex organs during growth in utero and for maturation at puberty. They are also responsible for characteristics such as growth of hair, texture of skin, and distribution of body fat. Estrogens also affect the release of pituitary gonadotropins; cause capillary dilation, fluid retention, and protein metabolism; and inhibit ovulation and postpartum breast engorgement.
Uses
Estrogen products are used for relief of hot flash symptoms of menopause; for contraception; for hormone replacement therapy after an oophorectomy, in conjunction with appropriate diet, calcium, and physical therapy for the treatment of osteoporosis; for treatment of severe acne in females; and to slow the disease progress (and minimize discomfort) in patients with advanced prostatic cancer and certain types of breast cancer.
Postmenopausal women with an intact uterus are at an increased risk of developing endometrial cancer with the use of estrogens alone. If estrogen therapy is indicated, it should be accompanied by progestin therapy to reduce the risk of endometrial cancer. There is no evidence that “natural” estrogens are more or less hazardous than “synthetic” estrogens at equi-estrogenic dosages.
Results of a controlled study, the Women’s Health Initiative (WHI), have indicated that hormone replacement therapy is associated with a small increase in the risk of cardiovascular disease (Rossouw et al, 2002). In the WHI estrogen plus progestin study, there was a 29% increase in the incidence of heart disease in postmenopausal women receiving hormone replacement therapy compared with those receiving placebo. The number of coronary heart disease events (e.g., myocardial infarctions) per 10,000 patient-years of exposure to hormone replacement therapy was 37 compared with 30 in women receiving placebo. In the WHI estrogen-alone study, estrogen replacement therapy did not affect the incidence of coronary heart disease.
Two other major studies are currently under way that may provide much more information for women, hormone therapy and heart disease. The Kronos Early Estrogen Prevention Study (KEEPS) is following women ages 42 to 58—a decade younger, on average, than WHI participants. They are also healthier, with lower body mass indexes, lower cholesterol and blood pressure levels, and fewer smokers, about one-fourth the average baseline risk for heart disease. All are regularly monitored for atherosclerotic plaque and other signs of coronary artery disease. KEEPS will increase our knowledge about menopausal hormone therapy by helping determine whether hormone therapy prevents or delays the onset of heart disease. The KEEP study is scheduled to end in 2012.
The second study, the Early versus Late Intervention Trial with Estradiol (ELITE), compares estrogen’s effects in two groups of women—those within 6 years of menopause and those at least 10 years past menopause. The women enrolled in the study are being monitored for the development of atherosclerosis. ELITE is scheduled to end in 2013.
Therapeutic Outcomes
The primary therapeutic outcomes expected from estrogen therapy are as follows:
Nursing Implications for Estrogen Therapy
Premedication Assessment
Availability, Dosage, and Administration
See Table 39-1.
Medication Safety Alert
The use of estrogens during early pregnancy is contraindicated. Serious birth defects have been reported, and it has been found that the female offspring have an increased risk of developing vaginal or cervical cancer later in life.
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