41. Drugs Used in Men’s and Women’s Health



Drugs Used in Men’s and Women’s Health


Objectives



Key Terms


leukorrhea (image) (p. 642)


sexually transmitted infections (image image) (p. 642)


dysmenorrhea (image) (p. 647)


Vaginitis


image http://evolve.elsevier.com/Clayton


Secretions from the vagina usually represent a normal physiologic process, but if the discharge becomes excessive, it is known as leukorrhea, an abnormal, usually whitish, vaginal discharge that may occur at any age. It affects almost all females at some time in their lives. Leukorrhea is not a disease but a symptom of an underlying disorder. The most common cause is an infection of the lower reproductive tract, but other physiologic and noninfectious causes of vaginal discharge are well known (Box 41-1).



The most common organisms causing the infectious type of leukorrhea are Candida albicans, Trichomonas vaginalis, and Gardnerella vaginalis (Box 41-2). Occasionally, C. albicans infections of the mouth, gastrointestinal tract, or vagina may develop as secondary infections during the use of broad-spectrum antibiotics, such as penicillins, tetracyclines, and cephalosporins.



Pathogens that are commonly transmitted by sexual contact are called sexually transmitted infections (STIs). In some diseases, such as gonorrhea, syphilis, chlamydia, and genital herpes simplex virus, and in human papillomavirus (HPV) infection, sexual transmission is the primary mode of transmission. The medications used to treat these infections are found in Table 41-1. In other diseases, such as giardiasis, shigellosis, and the hepatitis viruses, other important nonsexual means of transmission also exist. Unfortunately, the true incidence of STIs is not known in the United States because of large numbers of unreported cases.



Table 41-1


Causative Organisms and Products Used to Treat Genital Infections















































































































































CAUSATIVE ORGANISM GENERIC NAME BRAND NAME DRUG MONOGRAPH, NURSING IMPLICATIONS
Vulvovaginitis
Candida albicans (fungus) butoconazole vaginal cream Gynazole l; Mycelex-3 (p. 760)
clotrimazole vaginal cream, vaginal tablets Gyne-Lotrimin, Mycelex-7 (p. 760)
fluconazole oral tablets Diflucan (p. 760)
itraconazole oral capsules Sporanox (p. 766)
miconazole vaginal cream, suppositories Monistat 3, 7 (p. 760)
terconazole vaginal cream, suppositories Terazol 7, Terazol 3 (p. 760)
tioconazole vaginal ointment Vagistat (p. 760)
Trichomonas vaginalis (protozoa) metronidazole oral tablets Flagyl (p. 757)
tinidazole oral tablets Tindamax (p. 758)
Bacterial vaginosis (formerly known as Gardnerella vaginalis [bacteria]) metronidazole oral tablets, vaginal gel Flagyl; MetroGel-Vaginal (p. 757)
tinidazole oral tablets Tindamax (p. 758)
clindamycin vaginal cream Cleocin (p. 754)
Gonorrhea
Neisseria gonorrhea (bacteria) ceftriaxone Rocephin (p. 736)
cefotaxime Claforan (p. 736)
ceftizoxime Cefizox (p. 736)
azithromycin Zithromax (p. 740)
doxycycline Vibramycin (p. 750)
Syphilis
Treponema pallidum (spirochete) penicillin G, benzathine Bicillin L-A (p. 743)
tetracycline Tetracycline (p. 750)
doxycycline Vibramycin (p. 750)
azithromycin (resistance reported) Zithromax (p. 740)
Genital Herpes
Herpes simplex genitalis (virus) acyclovir oral capsules Zovirax (p. 770)
famciclovir oral tablets Famvir (p. 777)
valacyclovir oral tablets Valtrex (p. 786)
Chlamydiae
Chlamydia trachomatis (chlamydia) azithromycin Zithromax (p. 740)
doxycycline Vibramycin (p. 750)
erythromycin Erythromycin (p. 740)
levofloxacin Levaquin (p. 746)
ofloxacin Floxin (p. 746)


Image


Data from Centers for Disease Control and Prevention (CDC), Workowski KA, Berman SM: Sexually transmitted diseases treatment guidelines, MMWR Morb Mortal Wkly Rep 55(RR-11):1-94, 2006; Centers for Disease Control and Prevention (CDC): Update to CDC’s sexually transmitted diseases treatment guidelines, 2010: fluoroquinolones no longer recommended for treatment of gonococcal infections, MMWR Morb Mortal Wkly Rep 56:332-336, 2007.


Drug Therapy for Leukorrhea and Genital Infections


See Table 41-1.


imageNursing Implications for Men’s and Women’s Health


Assessment

The following assessment questions apply to all age groups.


Female Reproductive History.

Assess for the following:



• Age of menarche


• Usual pattern of menses: Duration, number of pads used, last menstrual period


• Pain, discomfort, spotting between periods, or extended time of menstrual flow


• Number of pregnancies, live births, miscarriages, or abortions


• Vaginal discharges, infections, genital lesions, or warts. Describe color, odor, and amount of discharge; describe lesions or any itching. Is there pain with urination or sexual intercourse?


• Contraceptive methods used (e.g., oral contraceptives, intrauterine device, condoms, or spermicidal products)


• If taking oral contraceptives, what types? How long have oral contraceptives been used? Are they taken regularly? What, if any, adverse effects have been experienced?


• History of multiple sexual partners—male, female, or both. What type of protection is used during sexual intercourse?


• Is breast self-examination performed regularly? Have any abnormal findings been noted, such as lumps or discharge?


• Age of menopause


• Postmenopausal women: Has there been any vaginal bleeding?


• History and frequency of Papanicolaou (Pap) smears


• Reproductive problems (e.g., endometriosis, ovarian cysts, and uterine fibroids)


• History of STIs (e.g., chlamydia, syphilis, gonorrhea, yeast infections, genital herpes, human immunodeficiency virus [HIV]), genital warts (HPV). If so, when, and what was the treatment?


• If a prescription for oral contraceptive therapy is being requested, ask about any indication of hypertension, heart or liver disease, thromboembolic disorders, or cancer of the reproductive organs. Does the individual smoke?


Male Reproductive History.

Assess for the following:



• Pattern of urination. Has there been a recent change in the pattern of urination (e.g., difficulty initiating urine stream, need to strain to empty the bladder, frequency of nocturia, pain on urination, frequency, urgency, hematuria, incontinence, dribbling, or urinary retention)?


• Presence of a urethral discharge or genital or perianal lesions. Is there any swelling of the penis?


• Is there pain in the lower back, perineum, or pelvis?


• History of prostatitis, benign prostatic hyperplasia, or prostatic cancer


• Is testicular self-examination performed regularly? Have any abnormal findings been noted, such as lumps or masses?


• History of STIs (e.g., chlamydia, syphilis, gonorrhea, yeast infections, genital herpes, HIV, genital warts [HPV]). If so, when and what was the treatment?


• History of multiple sexual partners—male, female, or both. What type of protection is used during sexual intercourse?


• History of erectile dysfunction and description of pattern of altered erectile functioning


• History of arthralgia, fever, chills, malaise, pharyngitis, or oral lesions


• History of prior illnesses


• If erectile dysfunction has occurred, ask specifically about vascular disorders that may lead to changes in blood flow to the penis (e.g., stroke). Ask about smoking and the use of drugs that may affect the vascular system (e.g., antihypertensive agents).


• Has the individual had prostate surgery? If so, was the onset of the erectile dysfunction before or after the surgery?


• Other neurologic disorders (e.g., Parkinson’s disease and spinal cord injuries) may cause problems with sexual functioning. Has the individual had any other genitourinary conditions (e.g., testicular injury)?


• Endocrine disorders such as thyroid disease, adrenal disorders, and diabetes mellitus are also associated with sexual dysfunction. Does the patient have any of these illnesses?


History of Current Symptoms.

Ask the patient to describe the current problem or problems that initiated this visit. How long have the symptoms existed? Is there a recurrence of symptoms that were treated previously?


Medication History


Psychosocial.

STIs cause a high degree of anxiety. The intimate nature of the questioning required to obtain a sexual history may be embarrassing. Vaginal or urethral discharge may also be alarming to the patient seeking health care. When an STI diagnosis is suspected, explain the confidentiality policy of the facility before asking about sexual partners. (Many individuals do not return for followup appointments; there may be only one chance to obtain relevant information about contacts.)


Ask about lifestyle orientation (e.g., heterosexual, bisexual, or homosexual and number of partners). Has there been known contact with people with STIs? Are precautions used during sexual contacts?


Assess the level of anxiety present and adaptive responses and coping mechanisms used.


Laboratory and Diagnostic Studies


Physical Examination


Implementation


image Patient Teaching and Health Promotion

Instructions for Adolescents.

The rate of STIs is high in this age group, so it is important to do a thorough assessment of sexual activity and practices. For those who are sexually active, counseling regarding safe sex practices and voluntary testing and treatment should be offered. Medical care for STIs can be provided without parental consent or knowledge. Check individual state laws for those that allow testing and counseling for HIV. All adolescents should be taught thoroughly about alternatives for abstinence and about safe sexual practices.


Instructions for Women


• Refrain from using irritating substances such as deodorants, scented toilet paper, and perfumed soaps, sprays, and douches.


• Warm sitz baths may help relieve vaginal or perineal irritation.


• Douching should be avoided unless specifically prescribed by the health care provider. Douching alters the pH of the vagina and may encourage the growth of inappropriate organisms.


• Personal hygiene should include wiping from front to back after voiding and defecation, voiding before and after intercourse, cleansing genitals thoroughly before and after intercourse, and changing menstrual tampons or pads frequently. Avoid wearing underwear made of synthetic materials; cotton materials help prevent moisture accumulation.


• Contraceptive methods (e.g., oral and other hormonal contraceptives, intrauterine devices) or surgical procedures such as hysterectomy do not provide any protection against HIV or other STIs. It is necessary to use physical and chemical barriers (e.g., condoms, foam spermicides).


• Stress the need for an annual Pap smear to detect cervical cancer that originates from cervical intraepithelial neoplasia.


Instructions for Men


• Practice good personal hygiene. Keep the penis, scrotum, and perianal area thoroughly cleansed. Wash areas before and after intercourse. Urinate after intercourse. Wash hands well.


• Prostatitis is treated with antibiotics, anti-inflammatory agents, and stool softeners. The local application of heat with a sitz bath, drinking plenty of fluids, and adequate rest are also usually used for relief of the symptoms of prostatitis.


• Men need annual physical examinations after age 40, which includes a rectal examination to palpate the prostate.


• Discuss appropriate interventions for men with altered sexual function that may be treated with medications such as phosphodiesterase inhibitors or surgical intervention (e.g., penile prosthesis). Remind the patient of the need for consultation with a health care provider before using phosphodiesterase inhibitors. Although these drugs are readily available over the Internet, people with cardiovascular disorders are particularly susceptible to life-threatening consequences with their use.


• Latex condoms can be effective in reducing sexual transmission of HIV and some other STIs (e.g., gonorrhea, trichomonas, chlamydia), but condoms are not as effective against STIs transmitted by skin-to-skin contact such as herpes simplex virus, HPV, syphilis, and chancroid.


• Men having homosexual relationships and people who inject drugs should be vaccinated for hepatitis A. The frequent use of nonoxynol-9 spermicide during anal intercourse irritates the epithelial lining of the rectum, providing a portal of entry for HIV and other STIs.


Instructions for Women and Men


• When infections are present, abstain from sexual intercourse. Stress the need to prevent reinfection. When sexual practices are resumed, use latex condoms. Recent research demonstrates that vaginal spermicides containing nonoxynol-9 may not be effective in preventing cervical gonorrhea, chlamydia, or HIV infection. According to the Centers for Disease Control and Prevention, the role of spermicides, sponges, and diaphragms for preventing transmission of HIV has not been evaluated. A recent study indicates that the frequent use of nonoxynol-9 may actually increase the risk of HIV infection during vaginal intercourse because of irritation of vaginal tissues.


• Use sexual abstinence during the communicable phase of any disease. Remember that when having sex with an individual, one is also having sex with all previous sexual partners and thus should consider the infectious possibilities.


• If having sex with a partner with an unknown status or one infected with HIV or another STI, a new condom should be used for each insertive intercourse.


• It is advised that both partners be tested for STIs, including HIV, before the first sexual encounter.


• Practice safe sex, if not abstinence. Use latex condoms. Discuss proper techniques for applying, using, removing, and discarding condoms.


• Arrange for follow-up appointments with the health care provider and appropriate referrals for counseling or with social service department as needed.


• All sexual partners need to understand the importance of “partner services,” the documentation of all sexual partners for the purpose of providing evaluation and treatment to anyone who may have been exposed to an STI before the infected individual became clinically symptomatic. Cases of syphilis, gonorrhea, chlamydia, and AIDS are reported in every state.


Medications

For Women.


Teach the patient the proper way to apply medications topically or intravaginally using ointments, troches, or suppositories. It is imperative that proper cleansing of the genital area be done regularly using soap and water; rinse and dry well. Hands should be washed before and after the application or insertion of medications and before and after toileting. After every use, the vaginal applicator should be thoroughly washed with soap and water and then dried. After inserting a vaginal medication (cream or suppository), the woman should remain in a recumbent position for 30 minutes to allow time for drug absorption. A minipad can be worn to catch remaining drainage. (See Chapter 8, Figure 8-13 for proper administration of vaginal medication.)


With oral contraceptive therapy, teach not only the medication schedule and dosage but also what to do if a dose is missed, frequency of follow-up care, and common and serious adverse effects.


For Men and Women.


Teach the medication regimen and who must take the medications—both partners in a sexual relationship.


Fostering Health Maintenance


Written Record.

Enlist the patient’s aid in developing and maintaining a written record of monitoring parameters (e.g., blood pressure, pulse, weight, degree of relief from menstrual pain, menstrual cycle information for women on oral contraceptives). (See Self-Monitoring Drug Therapy Record on the Evolve imageWeb site at http://evolve.elsevier.com/Clayton.) For patients with STIs, a listing of the symptoms present and degree of relief obtained may be appropriate. 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 bring the completed form to follow-up visits. During follow-up visits, focus on issues that will foster adherence with the therapeutic interventions prescribed.



image Health Promotion


The consistent use of male latex condoms significantly reduces the risk of HIV infection, gonorrhea and chlamydia, herpes simplex virus in men and women, and HPV in women, but male condoms may be less effective in protecting against STIs transmitted by skin-to-skin contact (e.g., genital herpes, syphilis), because the infected areas may not be covered by the condom.


Drug Therapy for Contraception


Oral (hormonal) contraceptives (birth control pills) became available in 1960. They now represent one of the most common forms of artificial birth control in the United States. It is estimated that approximately one third of all women between 18 and 44 years of age use oral contraceptives.


Drug Class: Oral Contraceptives


Actions


Estrogens and progestins, to some extent, induce contraception by inhibiting ovulation. The estrogens block pituitary release of follicle-stimulating hormone (FSH), preventing the ovaries from developing a follicle from which the ovum is released. Progestins inhibit pituitary release of luteinizing hormone (LH), the hormone responsible for releasing an ovum from a follicle. Other mechanisms play a contributory role in preventing conception. Estrogens and progestins alter cervical mucus by making it thick and viscous, inhibiting sperm migration. Hormones also change the endometrial wall, impairing implantation of the fertilized ovum.


The progestin-only pills, or minipills, represent a common form of oral contraceptive therapy. Many adverse effects of combination-type contraceptives are caused by the estrogen component of the tablet. For those women particularly susceptible to adverse effects of estrogen therapy, the minipill provides an alternative. Women who might prefer the minipill are those with a history of migraine headaches, hypertension, mental depression, weight gain, and breast tenderness and those who want to breastfeed postpartum. The minipill is not without its disadvantages, however. Between 30% and 40% of women on the minipill continue to ovulate. Dysmenorrhea, manifested by irregular periods, infrequent periods, and spotting between periods, is common in women taking the minipill. Birth control is maintained by progestin activity on cervical mucus, uterine and fallopian transport, and implantation. There is a slightly higher incidence of both uterine and tubal pregnancies.


Uses


There are two types of oral contraceptives: the combination pill, which contains both an estrogen and a progestin, and the minipill, which contains only a progestin. The combination pills are subdivided into fixed combination or monophasic (Table 41-2), biphasic (Table 41-3), triphasic and quadriphasic (Table 41-4) products. The monophasic combination pills contain a fixed ratio of estrogen and progestin given daily for 21 days, beginning on day 5 of the menstrual cycle. The biphasic product contains a fixed dose of estrogen and a progestin dose on days 1 to 10 that is lower than that on days 11 to 21 of the menstrual cycle. The triphasic combination pills provide three concentrations of estrogen and progestin, and the quadriphasic pills provide four concentrations of hormones. The purpose of the variable concentrations is to provide contraception with the lowest necessary dose of hormones. Most of the combination pills are also packaged in 28-tablet containers. The last 7 tablets are inert but are supplied so that there is no break in the routine of taking 1 tablet daily. The progestin-only products (Box 41-3, p. 651) are packaged in units of 28 tablets. All tablets contain active hormone; 1 tablet should be taken daily at approximately the same time each day.



image Table 41-2


Monophasic Oral Contraceptives

























































































































































































































































































































































PRODUCT PROGESTIN (mg) ESTROGEN (mcg) OTHER INGREDIENTS (mg)
Altavera (28) levonorgestrel, 0.15 ethinyl estradiol, 30 —
Alesse (28) levonorgestrel, 0.1 ethinyl estradiol, 20 —
Apri (28) desogestrel, 0.15 ethinyl estradiol, 30 —
Aviane (28) levonorgestrel, 0.1 ethinyl estradiol, 20 —
Balziva (28) norethindrone, 0.4 ethinyl estradiol, 35 —
Beyaz (28) — ethinyl estradiol, 20 drospirenone, 3
Brevicon (28) norethindrone, 0.5 ethinyl estradiol, 35 —
Cryselle (21, 28) — ethinyl estradiol, 30 norgestrel, 0.3
Desogen (28) desogestrel, 0.15 ethinyl estradiol, 30 —
Femcon Fe (chewable tablets) norethindrone, 0.4 ethinyl estradiol, 35 ferrous fumarate, 75
Gianvi (28) — ethinyl estradiol, 20 drospirenone, 3
Jolessa (91) levonorgestrel, 0.15 ethinyl estradiol, 30 —
Junel 21 Day 1/20 (28) norethindrone acetate, 1 ethinyl estradiol, 20 —
Junel 21 Day 1.5/30 (28) norethindrone acetate, 1.5 ethinyl estradiol, 30 —
Junel Fe 1.5/30 (28) norethindrone acetate, 1.5 ethinyl estradiol, 30 ferrous fumarate, 75
Junel Fe 21 Day 1/20 (28) norethindrone acetate, 1 ethinyl estradiol, 20 ferrous fumarate, 75
Kelnor 1/35 (28) ethynodiol diacetate, 1 ethinyl estradiol, 35 —
Lessina (21, 28) levonorgestrel, 0.1 ethinyl estradiol, 20 —
Levora (28) levonorgestrel, 0.15 ethinyl estradiol, 30 —
Loestrin-21 1/20 (21) norethindrone acetate, 1 ethinyl estradiol, 20 —
Loestrin Fe 1/20 (28) norethindrone acetate, 1 ethinyl estradiol, 20 ferrous fumarate, 75
Loestrin-21 1.5/30 (21) norethindrone acetate, 1.5 ethinyl estradiol, 30 —
Loestrin-24 Fe* (28) norethindrone acetate, 1 ethinyl estradiol, 20 ferrous fumarate, 75
Loestrin Fe 1.5/30 (28) norethindrone acetate, 1.5 ethinyl estradiol, 30 ferrous fumarate, 75
Loryna — ethinyl estradiol, 20 drospirenone, 3
Low-Ogestrel (28) — ethinyl estradiol, 30 norgestrel, 0.3
Lo/Ovral (21, 28) — ethinyl estradiol, 30 norgestrel, 0.3
Lutera (28) levonorgestrel, 0.1 ethinyl estradiol, 20 —
Lybrel (28),† levonorgestrel, 0.09 ethinyl estradiol, 20 —
Microgestin Fe 1/20 (28) norethindrone acetate, 1 ethinyl estradiol, 20 ferrous fumarate, 75
Microgestin Fe 1.5/30 (28) norethindrone acetate, 1.5 ethinyl estradiol, 30 ferrous fumarate, 75
Modicon (28) norethindrone, 0.5 ethinyl estradiol, 35 —
MonoNessa (28) — ethinyl estradiol, 35 norgestimate, 0.25
Necon 0.5/35 (21, 28) norethindrone, 0.5 ethinyl estradiol, 35 —
Necon 1/35 (21, 28) norethindrone, 1 ethinyl estradiol, 35 —
Necon 1/50 (21, 28) norethindrone, 1 mestranol, 50 —
Nordette (28) levonorgestrel, 0.15 ethinyl estradiol, 30 —
Norinyl 1 + 35 (28) norethindrone, 1 ethinyl estradiol, 35 —
Norinyl 1 + 50 (28) norethindrone, 1 mestranol, 50 —
Nortrel 0.5/35 (21, 28) norethindrone, 0.5 ethinyl estradiol, 35 —
Nortrel 1/35 (21, 28) norethindrone, 1 ethinyl estradiol, 35 —
Ocella (28) — ethinyl estradiol, 30 drospirenone, 3
Ogestrel 0.5/50 (28) — ethinyl estradiol, 50 norgestrel, 0.5
Ortho-Cept (28) desogestrel, 0.15 ethinyl estradiol, 30 —
Ortho-Cyclen (28) — ethinyl estradiol, 35 norgestimate, 0.25
Ortho-Novum 1/35 (28) norethindrone, 1 ethinyl estradiol, 35 —
Ortho-Novum 1/50 (28) norethindrone, 1 mestranol, 50 —
Ovcon-35 (28) norethindrone, 0.4 ethinyl estradiol, 35 —
Ovcon-50 (21, 28) norethindrone, 1 ethinyl estradiol, 50 —
Ovral (28) — ethinyl estradiol, 50 norgestrel, 0.5
Portia (21, 28) levonorgestrel, 0.15 ethinyl estradiol, 30  
Previfem (28) — ethinyl estradiol, 35 norgestimate, 0.25
Quasense (91) levonorgestrel, 0.15 ethinyl estradiol, 30 —
Reclipsen (28) desogestrel, 0.15 ethinyl estradiol, 30 —
Safyral (28) — ethinyl estradiol, 30 drospirenone, 3
Seasonale‡ (91) levonorgestrel, 0.15 ethinyl estradiol, 30 —
Solia (28) desogestrel, 0.15 ethinyl estradiol, 30 —
Sprintec (28) — ethinyl estradiol, 35 norgestimate, 0.25
Sronyx (28) levonorgestrel, 0.1 ethinyl estradiol, 20 —
Syeda (28) — ethinyl estradiol, 30 drospirenone, 3
Yasmin (28) — ethinyl estradiol, 30 drospirenone, 3
Yaz* — ethinyl estradiol, 20 drospirenone, 3
Zarah (28) — ethinyl estradiol, 30 drospirenone, 3
Zenchent norethindrone, 0.4 ethinyl estradiol, 35 —
Zeosa norethindrone, 0.4 ethinyl estradiol, 35 —
Zovia 1/35 E (21, 28) ethynodiol diacetate, 1 ethinyl estradiol, 35 —
Zovia 1/50 E (21, 28) ethynodiol diacetate, 1 ethinyl estradiol, 50 —


Image


*Take one active tablet daily for 24 days, followed by four inert tablets.


†Take one active tablet daily for 28 days, followed by a new cycle of active tablets. These products contain no inert tablets.



image Table 41-3


Biphasic Oral Contraceptives





























PRODUCT PROGESTIN (mg) ESTROGEN (mcg) OTHER INGREDIENTS (mg)
Amethia

—
Azurette

—
Camrese

—
Kariva* (28)

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Jul 11, 2016 | Posted by in NURSING | Comments Off on 41. Drugs Used in Men’s and Women’s Health

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