NURS 6521 Week 10: Women’s and Men’s Health

Sample Answer for NURS 6521 Week 10: Women’s and Men’s Health Included After Question

NURS 6521 Week 10: Women’s and Men’s Health 

Breast cancer is not just a disease that strikes at women. It strikes at the very heart of who we are as women: how others perceive us, how we perceive ourselves, how we live, work, and raise our families—or whether we do these things at all. 

–Debbie Wasserman Schultz 

This sentiment that Schultz expressed is true for many disorders associated with women’s and men’s health such as hormone deficiencies, cancers, and other functional and structural abnormalities. Disorders such as these not only result in physiological consequences but also psychological consequences such as embarrassment, guilt, or profound disappointment for patients. For these reasons, the provider-patient relationship must be carefully managed. During evaluations, patients must feel comfortable answering questions so that you, as a key health-care provider, will be able to diagnose and recommend appropriate treatment options. Advanced practice nurses must be able to educate patients on these disorders and help relieve associated stigmas and concerns. 

This week, as you examine women’s and men’s health issues, you focus on treatments for hormone deficiencies and cancer. You also explore preventive services for women’s and men’s health. 

Learning Objectives 

By the end of this week, students will: 

  • Evaluate the strengths and limitations of hormone replacement therapy 
  • Evaluate treatments for hormone deficiencies 
  • Analyze preventive services for women’s and men’s health 
  • Analyze drug treatments for cancer patients 
  • Evaluate implications of cancer drug treatments on patients 
  • Understand and apply key terms, concepts, and principles related to prescribing drugs to treat disorders associated with women’s and men’s health 

Photo Credit: Comstock/Stockbyte/Getty Images 

NURS 6521 Week 10: Women's and Men's Health 
NURS 6521 Week 10: Women’s and Men’s Health

Learning Resources 

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. 

This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below. 

Required Readings 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

  • Chapter 33, “Prostatic Disorders and Erectile Dysfunction” (pp. 527-544)
    This chapter examines the causes, pathophysiology, and drug treatment of four disorders: prostatitis, benign prostatic hyperplasia, prostate cancer, and erectile dysfunction. It also explores the importance of monitoring patient response and patient education.  

 

  • Chapter 34, “Overactive Bladder” (pp. 545-564)
    This chapter describes the causes, pathophysiology, diagnostic criteria, and evaluation of overactive bladder. It also outlines the process of initiating, administering, and managing drug treatment for this disorder.  

 

  • Chapter 55, “Contraception” (pp. 959-970)
    This chapter examines various methods of contraception and covers drug interactions, selecting the most appropriate agent, and monitoring patient response to contraceptions.  

 

  • Chapter 56, “Menopause” (pp. 971-994)
    This chapter presents various options for menopausal hormone therapy and examines the strengths and limitations of each form of therapy.  

 

  • Chapter 57, “Osteoporosis” (pp. 985-994)
    This chapter covers various options for treating osteoporosis. It also describes proper dosages, potential adverse reactions, and special considerations of each drug.  

 

  • Chapter 58, “Vaginitis” (pp. 995-1006)
    This chapter examines various causes of vaginitis and explores the diagnostic criteria and methods of treatment for the disorder.  

 

Roberts, H. & Hickey, M. (2016). Managing the menopause: An update. Maturitas, 86(2016), 53-58. https://doi.org/10.1016/j.maturitas.2016.01.007  

Note: Retrieved from the Walden Library databases. 

 

This article provides an update on treatments on Vasomotor symptoms (VMS), genito-urinary syndrome of menopause (GSM), sleep disturbance, sexual dysfunction and mood disturbance are common during the menopause transition. 

 

Lunenfeld, B., Mskhalaya, G., Zitzmann, M., Arver, S., Kalinchenko, S., Tishova, Y., & Morgentaler, A. (2015). Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. Aging Male, 18(1), 5-15. doi: 10.3109/13685538.2015.1004049 

Note: Retrieved from the Walden Library databases. 

Mäkinen, J. I., & Huhtaniemi, I. (2011). Androgen replacement therapy in late-onset hypogonadism: Current concepts and controversies—A mini-review. Gerontology, 57(3), 193–202. 

Note: Retrieved from the Walden Library databases. 

 

This article examines the role of testosterone levels in the development of hypogonadism. It also explores health issues that are impacted by testosterone levels and the role of testosterone replacement therapy. 

 

Drugs.com. (2012). Retrieved from http://www.drugs.com/ 

 

This website presents a comprehensive review of prescription and over-the-counter drugs including information on common uses and potential side effects. It also provides updates relating to new drugs on the market, support from health professionals, and a drug-drug interactions checker. 

 

U.S. Preventive Services Task Force. (2014). The Guide to Clinical Preventive Services: Section 2. Recommendations for Adults. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2.html 

 

This website lists various preventive services available for men and women and provides information about available screenings, tests, preventive medication, and counseling.  

 

Optional Resources 

Refer to the Optional Resources listed in Week 1. 

 

Discussion: Hormone Replacement Therapy 

In recent years, hormone replacement therapy has become a controversial issue. When prescribing therapies, advanced practice nurses must weigh the strengths and limitations of the prescribed supplemental hormones. If advanced practice nurses determine that the limitations outweigh the strengths, then they might suggest alternative treatment options such as herbs or other natural remedies, changes in diet, and increase in exercise. 

Consider the following scenario: 

  • As an advanced practice nurse at a community health clinic, you often treat female (and sometimes male patients) with hormone deficiencies. One of your patients requests that you prescribe supplemental hormones. This poses the questions: How will you determine what kind of treatment to suggest? What patient factors should you consider? Are supplemental hormones the best option for the patient, or would they benefit from alternative treatments? 

To prepare: 

  • Review Chapter 56 of the Arcangelo and Peterson text, as well as the Roberts and Hickey (2016), Lunenfeld et al (2015), and Makinen and Huhtaniemi (2011) articles in the Learning Resources. 
  • Review the provided scenario and reflect on whether or not you would support hormone replacement therapy. 
  • Locate and review additional articles about research on hormone replacement therapy for women and/or men. Consider the strengths and limitations of hormone replacement therapy. 
  • Based on your research of the strengths and limitations, again reflect on whether or not you would support hormone replacement therapy. 
  • Consider whether you would prescribe supplemental hormones or recommend alternative treatments to patients with hormone deficiencies. 

With these thoughts in mind: 

By Day 3 

Post a description of the strengths and limitations of hormone replacement therapy. Based on these strengths and limitations, explain why you would or why you would not support hormone replacement therapy. Explain whether you would prescribe supplemental hormones or recommend alternative treatments to patients with hormone deficiencies and why. 

By Day 6 

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who provided a different rationale than you did, in one or more of the following ways: 

  • Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library. 
  • Validate an idea with your own experience and additional research. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! 

Submission and Grading Information 

Grading Criteria  

 

To access your rubric: 

Discussion Rubric 

 

Submission 

Post by Day 3 and Respond by Day 6 

 

To participate in this Discussion: 

Week 10 Discussion 

 

 

Assignment:
Cancer and Women’s and Men’s Health  

The American Cancer Society estimates that by the end of 2012, more than 226,000 women will be diagnosed with breast cancer and more than 241,000 men will be diagnosed with prostate cancer (American Cancer Society, 2012a; American Cancer Society 2012b). With such prevalence of women’s and men’s cancers, patient education and preventive services are essential. In clinical settings, advanced practice nurses must assist physicians in educating patients on risk factors, preventive services, and for patients diagnosed with cancer, on potential drug treatments. The clinical implications of women’s and men’s cancer greatly depend on early detection, which is primarily achieved through preventive services. In this Assignment, you consider the short-term and long-term implications of cancer and drug treatments associated with women’s and men’s health, as well as appropriate preventive services. 

To prepare: 

  • Select a type of cancer associated with women’s or men’s health such as breast, cervical, or ovarian cancer in women and prostate cancer in men. 
  • Locate and review articles examining the type of cancer you selected. 
  • Review the U.S. Preventive Services Task Force article in the Learning Resources. Think about available preventive services that providers might recommend for patients at risk of this type of cancer. 
  • Select two of the following factors: genetics, gender, ethnicity, age, or behavior. Reflect on how these factors might impact decisions related to preventive services. 
  • Consider drug treatment options for patients diagnosed with the type of cancer you selected including short-term and long-term implications of the treatments. 

By Day 7 

Write a 2- to 3- page paper that addresses the following: 

  • Describe available preventive services that providers might recommend for patients at risk of the type of cancer you selected. 
  • Explain how the factors you selected might impact decisions related to preventive services. 
  • Describe drug treatment options for patients diagnosed with the type of cancer you selected. Explain the short-term and long-term implications of these treatments. 

 

Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting. 

 

Submission and Grading Information 

To submit your completed Assignment for review and grading, do the following:  

  • Please save your Assignment using the naming convention “WK10Assgn+last name+first initial.(extension)” as the name.  
  • Click the Week 10 Assignment Rubric to review the Grading Criteria for the Assignment. 
  • Click the Week 10 Assignment link. 
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK10Assgn+last name+first initial.(extension)” and click Open 
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database. 
  • Click on the Submit button to complete your submission. 

Grading Criteria  

 

To access your rubric: 

Week 10 Assignment Rubric 

 

Check Your Assignment Draft for Authenticity 

 

To check your Assignment draft for authenticity: 

Submit your Week 10 Assignment draft, and review the originality report 

 

Submit Your Assignment by Day 7 

 

To submit your Assignment: 

Week 10 Assignment 

 

 

Week 10 Quiz 

This week’s Quiz covers the content you have explored this week. The Quiz may include the following topics: 

  • Drug classifications by indication—contraceptives, hormones (female and male), obstetrics and gynecology, urogenital system 
  • Drug dosage calculations 
  • Drug interactions 
  • Drugs to treat osteoporosis, overactive bladder, sexually transmitted diseases, and also for use during pregnancy and lactation 

By Day 7 

You have 100 minutes to complete this 41-question Quiz. 

This quiz is a test of your knowledge in preparation for your certification exam. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this quiz. You are expected to comply with Walden University’s Code of Conduct. 

Submission and Grading Information 

Submit Your Quiz by Day 7 

 

To submit your Quiz: 

Week 10 Quiz 

 

 

Week In Review 

This week week you evaluated treatments for hormone deficiencies including the strengths and limitations of hormone replacement therapy. You also analyzed preventive services for women and men’s health and drug treatments for cancer patients, including implications of those treatments on the patients. 

Next week you will examine the practice of prescribing off-label drugs to children and strategies for making off-label drug use safer for children from infancy to adolescence. 

Next Week 

 

Go to next week: 

A Sample Answer For the Assignment: NURS 6521 Week 10: Women’s and Men’s Health

Title: NURS 6521 Week 10: Women’s and Men’s Health

1 month ago  

JOEL PIERRE  

RE: Discussion – Week 10  

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Week 10: Hormone Replacement Therapy 

Introduction 

Hormone therapy (HT) for postmenopausal women refers to drug treatment involving the hormones estrogen and progestin for managing symptoms related to menopause.  Goals of therapy include reducing the severity and frequency of the vasomotor and associated genitourinary symptoms and thereby improving the patients quality of life (Arcangelo, Peterson, Wilbur, & Reinhold, (Eds.), 2017). Hormone replacement therapy (HRT) is rampantly debatable in recent years. Advanced Practice Nurses have responsibility for prescribing medications including supplemental hormones. Therefore, they need to consider the strengths and limitations of hormonal therapies prescribed. If the specialist determines that the limitations outweigh the strengths, they should suggest alternative options of treatment such as the use of herbs, change of diet, exercise or other natural remedies.  

Scenario 

In this case, advanced practice nurses serving at community health clinic often encounter treating female and sometimes male patients with hormone deficiencies. In one situation, a patient requested to be prescribed with supplemental hormones. At this point, the APN must determine what kind of treatments to suggest, patient factors to consider, best treatment options for the patient or the possibility for alternative treatments.  

Strengths and limitations of HRT 

For many women below the age of 60 years, the benefits of hormone replacement therapy outweigh the limitations. Hormone therapy (HT) for postmenopausal women refers to drug treatment involving the hormones estrogen and progestin for managing symptoms related to menopause(Arcangelo, Peterson, Wilbur & Reinhold, 2017). Goals of therapy include reducing the severity and frequency of the vasomotor and associated genitourinary symptoms and thereby improving the patients quality of life (Arcangelo, Peterson, Wilbur, & Reinhold, (Eds.), 2017). The benefits include a reduction in vasomotor symptoms that improve within four weeks of treatment such as frequency of hot flushes (Arcangelo, Peterson, Wilbur & Reinhold, 2017). They enhance the quality of life such as sleep improvement, a decrease in muscle aches and pain. HRT can improve mood and reduce symptoms of depression especially from menopause chronicles (Willacy & Payne, 2018). Also, research shows that HRT improves vaginal dryness and sexual function alongside improving on symptoms of urinary frequency. 

 Replacement of hormones leads to the reduction of osteoporosis risk such as preventing osteoporotic fractures in women and increasing bone mineral density (BMD) (Arcangelo, Peterson, Wilbur & Reinhold, 2017). HRT is FDA-approved to relieve these symptoms and potentially improve the quality of life for post-menopausal women (Arcangelo, Peterson, Wilbur & Reinhold, 2017).  Prematurely menopausal women, less than 40-years-old, who are prescribed HRT until their approximate natural menopause age can potentially reduce the known risks associated with early menopause.  These risks include coronary artery disease, osteoporosis, declines in cognitive function, and early death (Willacy & Payne, 2018). HRT helps in reducing cardiovascular diseases such as coronary heart disease if it begins within the ten years of menopause. Estrogens control the level of cholesterol depending on dose and androgen. They reduce the risk of patients contracting colorectal cancer. Other benefits of the therapy include reduction of osteoplastic resorption, maintenance, and enhancement of muscle strength, mass, and connective tissue, increase skin thickness, elasticity, and hydration, reduce the risk of Alzheimer’s disease and dementia, and stabilize hormonal fluctuations. (Arcangelo, Peterson, Wilbur & Reinhold, 2017)  

The limitations of HRT are significant, and they include thromboembolic disease, pulmonary embolism, gallbladder disease, stroke, breast, and endometrial cancer. Most of the HRT concerns were raised by WHI and Million Women Study (MWS). However, for menopause women, it results in a favorable benefit-risk ratio. In this case, oral HRT increases VTE risk along with other factors such as age, obesity, history, smoking, and immobility. Oral HRT or combined process results to stroke especially on dosage-related. Nurses need to regulate prescription to control the disease (Willacy & Payne, 2018). Further, combined HRT increases the risk of breast cancer, endometrial cancer, and ovarian cancer. In women with a uterus, estrogen-only increases the risk of endocrine cancer. 

My support for HRT 

HRT provides an improvement in the quality of life for many women and prevention of complications related to early menopause (Willacy & Payne, 2018). It is a valuable therapy for many women. However, it may also present serious risks for others.  As an NP provider, I would determine to find the balance between the risks and benefits for each individual patient. Based on the analysis of the benefits and limitations of HRTs, I will support the process of hormonal replacement especially among women. The treatment options are numerous, and others have been proven not to be disastrous. Also, the benefits of the therapy outweigh the limitations which can be treated using other effective interventions (Willacy & Payne, 2018).  

Recommendation 

For patients that seek hormonal replacements, I recommend undergoing sufficient screening and testing depending on their factors such as age, gender, and history of past diseases. In some cases, I will recommend men to undergo such therapies in emergency cases (Willacy & Payne, 2018). Women who are suitable in hormonal imbalance can also withstand the hormone replacement therapy. I would prescribe supplemental hormones for the right patient and at the right time using evidenced-based guidelines.  There are many women who face moderate to severe symptoms related to this disorder(Arcangelo, Peterson, Wilbur & Reinhold, 2017).  Many others face early menopause which places them at high risk of complications related to adequate hormone levels.  Both groups should have the option of weighing out the risks and benefits of HRT with their provider.   

Conclusion 

Healthcare providers should conduct a proper analysis and assessment of the patient before arriving at such conclusions. However, other alternative treatment options can be recommended if the therapy becomes unsuitable. 

 

References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Willacy, H., & Payne, J. (2018, January 29). Hormone Replacement Therapy. Retrieved January 28, 2019, from patient info: https://patient.info/doctor/hormone-replacement-therapy-including-benefits-and-risks 

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Week 10- Hormone Replacement Therapy  

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Hormones 

               Hormones are chemicals that are created and released by the endocrine glands (Huether & McCance, 2017). Their role is to convey regulatory messages among the cells and organs, and they are also integrated in the central nervous system (Huether & McCance, 2017). They are classified and released by specific glands, and excretion of specific hormones can decrease with age (Huether & McCance, 2017). This post will explain the mechanism of action of hormones, explore hormone replacement therapies (the benefits and risks), discuss the support or lack of support for HRT, and explore supplemental hormone therapies or alternative treatments. 

The Mechanism of Action Hormones 

               As hormones are secreted by specific endocrine organs, they affect the target cells through a negative or positive feedback system (Huether & McCance, 2017). The role of the hormone is to maintain a homeostatic internal environment (Huether & McCance, 2017). The excretion of hormones usually occur in response to an altered cellular environment or in response to the need to maintain the level of another hormone or substance through direct (obvious changes occur) or permissive (facilitates the maximal performance of a cell) mechanisms to obtain the homeostatic environment (Huether & McCance, 2017). 

Hormone Replacement Therapy 

               Hormone Replacement Therapy (HRT) is utilized in both men and women to negate the impact of the decrease in hormone production. In menopausal women, estrogen and progestin can be utilized to improve or decrease the symptoms of menopause, with timing being a crucial component of the efficacy of treatment (Arcangelo, Peterson, & Reinhold, 2017). Strengths of estrogen and progestin treatments include decreasing the intensity or occurrences of night sweats and occurrences of wakefulness, reduce sleep latency, decrease the occurrences of hot flashes, and improve the overall quality of sleep (Arcangelo, Peterson, & Reinhold, 2017). The weaknesses, or risks of HRT, include increased risks of endometrial hyperplasia (can result in endometrial cancer), venous thromboembolism (which can be mitigated by the form of HRT prescribed), Chronic Heart Disease, stroke, and pulmonary embolism (Arcangelo, Peterson, & Reinhold, 2017). Breast Cancer can be caused by HRT and is usually correlated with the use of Progestin (Liu, Chen, & Hwang, 2016). Treatment with progestin should be limited to 3-5 years and estrogen to 7 years to minimize the risk of developing the risks. 

Support or Not to Support HRT 

               The decision for the utilization of hormone replacement therapy would be based on the individual patient. The risk factors would be taken into consideration in the process. The patient who has had a past medical history of stroke or any event resulting from an issue with clotting would be less likely to be prescribed the HRT. A familial history of associated cancers and strokes, myocardial infarction, etc. would also be taken into consideration. The timing of the symptoms would be considered due to the impact on the efficacy of treatment. The severity of the symptoms would also help determine the risk versus the benefits. 

Supplemental Hormone or Alternative Treatment 

               Alternative treatments include diet, exercise, acupuncture, and vitamins (Bavendar, 2018). Improving the quality of the individual’s diet has been recommended to improve the symptoms of menopause. Increasing the intake of fruits and vegetables are indicated (Bavendar, 2018). Aerobic exercising, such as swimming and running, can reduce hot flashes (Bavendar, 2018). Acupuncture can increase hormone production (Bavendar, 2018). And Vitamin E in addition to Black Coosh can help with symptoms (Bavendar, 2018). Caution is advised with black coosh due to the increased possibility of hepatic toxicity (Bavendar, 2018). 

Summary 

               Hormones assist with maintenance of a homeostatic environment in the body. As an individual ages, the hormone production can decrease, resulting in a variety of undesired symptoms. Hormone replacement therapy has helped improve some of the symptoms; however, there are many risks associated with hormone replacement therapy. The decision to utilize or not utilize HRT would have to be determined after a risk/ benefit analysis takes place. If the risk outweighs the benefits, alternative treatments such as diet, exercise, and vitamins can be utilized. 

 

References 

Arcangelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins. 

Bavendar, K. L. (2018). Hormonal Havoc: Alternative Therapies to Hormone Replacement. Jounal of the Council on Nutrition of American Chiropractic Association, 18-23. 

Huether, S. E., & McCance, K. L. (2017). Understanding Pathophysiology. S. Louis, Missouri: Elsivier. 

Liu, J.-Y., Chen, T.-J., & Hwang, S.-J. (2016). The Rik of Breast Cancer in Women Using Menopausal Hormone Replacement Therapy in Taiwan. International Journal of Environmental Research and Public Health, 1-6. 

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Collette Dillon  

Week Ten- Hormonal replacement therapy  

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NURS 6521- Advanced Pharmacology 

INITIAL POST  

Benefits and Risk of Hormonal Replacement Therapy.  

There are many risks and benefits that go along with the usage of hormonal replacement therapy. Take for instance, according to Sood, Faubion, Kuhle, Thielen, and Shuster (2014) menopausal hormone therapy (MHT) can have great benefits for those females who are under the age of 60 but are within ten years of menopause. Women who used this form of replacement therapy are said to experience fewer progression of disorder such as atherosclerotic disease, which in turn lower the cardiovascular risk factors and it’s mortality rate (Scood et al., 2014). Other advantages of MHT are that it helps to decrease other disorders such as osteoporosis, and cognitive declined (Scood, et al., 2014). MHT works by reducing certain symptoms that such as hot flashes, irritability, problems with sleep and trouble with a concentration that are associated with menopause (Scood, et al., 2014).  It is believed that estrogen by itself lower the risk of developing breast cancer, compare to when treatment consists of a combination of estrogen and progestogen (Scood, et al., 2014). When the combination of estrogen and progestogen are used beyond five years the chances of developing breast cancer increase. Estrogen-only hormonal replacement therapy is mainly used in females who have a hysterectomy done, while the combination of estrogen and progestogen is used for those with an intact uterus (Scood, et al., 2014). Combination hormonal therapy of estrogen and progestogen is the preferred method of treatment for women who have had endometrial ablation due to the increase due to the continuous risk of endometrial cancer (Scood, et al., 2014).  The form of estrogen use also makes a difference,  “because, in contrast, oral estrogen, low-dose transdermal estrogen appears to be linked to a lower risk of cholecystitis, stroke, and deep venous thromboembolism”, Scood, et al., 2014). “Oral estrogens increase the hepatic production of sex hormone-binding globulin with the associated lowering of free testosterone, potentially adversely affecting sex drive and sexual responsiveness. Oral estrogens also stimulate other hepatic enzymes, which can affect the cardiovascular, thrombotic, and vascular systems”, (Scood, et al., 2014). The primary purpose of progestogen is hormonal replacement therapy is to protect against the development of endometrial cancer or to prevent overproduction of endometrial cells (Scood et al, 2014). While there are great benefits to this form of hormonal therapy there are also negative implications if used in the wrong group of females. This form of therapy is not indicated for females who have pre-existing conditions such as stroke, coronary artery disease and who are at risk for deep vein thrombosis among other (Scood, et al., 2014).  

Other Alternatives Treatments Away from Hormonal Replacement Therapy 

 As a clinician, careful history of the patient’s health history and current health history and the patient’s preference must be taken into consideration before the initiation of hormonal replacement therapy. Based on some of the risk factors such as stroke, heart attacks, and breast cancer that are associated with the use of hormonal replacement therapy, as a clinician, the student would choose lifestyle modifications first and other means to control symptoms of pre-menopause and use hormonal replace therapy as last resort. According to the American Cancer Society (2017), the soy-based product consists of phytoestrogens which have a similar characteristic as estrogen is effective in control some menopausal symptoms and is safer than estrogens that are used in pre-menopausal. There are medications such as venlafaxine, catapres, and gabapentin that are not hormonal and are effective in control hot flashes.  It is believed that antidepressant such as venlafaxine reduced hot flashes by working on the certain neurotransmitter in the hypothalamus which plays a role be body heat regulation. When the medication is administered serotonin, level increased which cause the desensitization of the receptor in the hypothalamus that is responsible for heat (American Cancer Society, 2017).  Some adverse reactions from venlafaxine are insomnia, nausea, constipation  (American Cancer Society). According to Zagaria, (2010) catapres is effective in relieving hot-flashes because it reduces “central adrenergic outflow which is responsible for blood flow to cutaneous vessels” (Zagaria, 2010). Side effects include tiredness, hypotension, and dizziness, among others. Some researchers also believe that acupuncture can also help relieve pre-menopausal symptoms. Other ways that might help to alleviate some symptoms is to limit alcohol consumption and quit smoking and maintaining ideal body weight and trying to eat well-balanced meals that consist of whole grains, beans and green leafy vegetables (dark) among other modifications (American Cancer Society, 2017). There are also many other herbal products that are being explored to see how they can alleviate premenopausal symptoms, to prevent the use of hormonal replacement therapy whenever possible.  

While there are great benefits that are associated with hormonal replacement therapy, there are also negative aspects that go along with its usage, therefore careful assessment must be done prior to initiating this form of treatment. Working with the mental health population the student has seen where the initiation of growth hormone therapy in kids can lead to such things as increased aggression and other behavioral issues. There have been several cases where patients on the behavioral health unit for kids are being admitted because parents reported increase physical aggressive behaviors in the children who did not have any prior incidents of aggression but started once they were placed on growth hormones.  In circumstances whenever hormonal replacement therapy must be used, it must be used for the shortest amount of time and smallest possible effective dose.  

 

 

References  

 

American Cancer Society (2017). Menopausal -hormone therapy after breast cancer. Retrieved  

from  

https://www.cancer.org/cancer/breast-cancer/living-as-a-breast-cancer- 

survivor/menopausal-hormone-therapy-after-breast-cancer.html 

Sood, R., Faubion, S. S., Kuhle, C. L., Thielen, J. M., & Shuster, L. T. (2014). Prescribing  

menopausal hormone therapy: an evidence-based approach. International Journal of  

Women’s Health, 6, 47-57. doi:10.2147/IJWH.S3834 

Zagaria, A. M (2010). Hot flashes and night sweats. Retrieved from  

https://www.uspharmacist.com/article/hot-flashes-and-night-sweats 

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1 month ago  

Lindsey Steele  

Week 10 Discussion  

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When prescribing hormone replacement medications to patients, it is important to consider whether the benefits will out weigh the adverse affects. There are many issues to consider before prescribing these types of medications. The patient would need to have a true deficit before these types of medications would need to be prescribed. Age and overall physical health are other considerations that need to be taken into consideration.  

Menopause is the final menstruation period in the reproductive life of a woman. The term is often used to encompass the years prior and after this event. This occurs usually between 45 years of age to 52 years of age. During this time, the ovarian follicles decline along with the secretion of estrogen and progesterone by the ovaries. These changes cause the menstruation cycle to become irregular (Copestead and Banasik, 2013). The lack of estrogen causes endometrial growth to decline and eventually stop permanently. Some of the more common symptoms associated with the condition are vaginal dryness, depression, sleep disturbance, and vasomotor symptoms such as hot flashes (Santoro et al, 2015). Many have noted body contour changes, increased wrinkling of skin, as well as joint and muscle aches. 

 Management of the symptoms will become important during the transition. Patients experiencing depression during this time may need medication to help manage this condition in conjunction with any hormone replacement or supplements. For moderate to severe vasomotor symptoms the use of hormone therapy has been found to be effective (Roberts and Hickey, 2016). Hormone therapy comes in oral, vaginal creams, vaginal tablets, vaginal rings, and transdermal patches. Picking the best option for each patient will be based on symptoms, age, medication preference, and patient ability. Patients experiencing night sweats and hot flashes have found symptom decreases with estrogen plus progestin. In patients experiencing predominately or only vaginal dryness, use of topical vaginal creams may be more fitting to their needs. With loss of libido, testosterone may be supplemented. Testosterone supplementation may increase the risk of hepatocellular neoplasm, edema, and elevation of cholesterol levels. Patients starting hormone therapy after the age of 65 have an increased risk of developing dementia (Arcangelo et al, 2017). 

Hormone therapy functions by decreasing genitourinary and vasomotor symptoms of menopause by increasing estrogen levels, or other hormone levels, in the body. For women who still have a uterus, progestins should be included to prevent the formation of endometrial hyperplasia or cancer. Patients with clotting disorders or history of stroke should be prescribed transdermal patch due to the lowered risk of developing venous thrombosis this this form of medication.  Those at high risk of hepatic injury or who have impaired hepatic function should be prescribed transdermal and creams rather than oral hormone therapies. Patients who may not want to apply or be able to remember to apply a daily cream may need to have a vaginal tablet or ring prescribed. Vaginal medications do not appear to need progestin added with decreased risk of endometrial hyperplasia or cancer associated with their use. Some may still be utilizing contraceptive medications that will need to be balanced with the hormone therapy. There has been a correlation of the use of estrogen with progestin and an increase in invasive breast cancer, PE, stroke, and coronary events. While these conditions increased in patients taking hormone therapy, there were decreased incidents of hip fracture and colorectal cancer (Arcangelo et al, 2017). These medications should not be taken with alcohol due to the increased levels of estrogen from the body’s metabolization of the alcohol. Patients who smoke may need a higher dose than those who do not. Patients taking barbiturates, rifampin, and phenytoin may have decreased estrogen levels while corticosteroid use increases estrogen levels.  

Some patients may not want to use hormone therapy and decide to start taking supplements to ease their symptoms. The largest risk of supplement taking is that many supplements are not fully regulated or studied to determine their effectiveness. This means that the dosage of the medication may not be the same as what the product claims or that it contains only that supplement. Another issue is that the effects of the supplement are not fully studied so the possible interaction with other medications that a patient is taking may not be known. The supplement may also cause issues with various organ systems that patients may not be aware of as well as not fully understood due to lack of study. Patients who take supplements should be encouraged to share what those supplements are with their providers.  

The most studied supplement that is used for menopause is black cohosh. This supplement contains flavonoids, glycosides, aromatic acids, and other constituents. Studies of black cohosh have failed to yield any effect on LH, FSH, SHBG, prolactin, or estradiol serum levels. The exact function of the supplement is not fully understood but may have estrogenic activity, while none have yet to be found in animal studies. The supplement is thought to improve vasomotor symptoms in menopausal women. There have been documented cases of hepatic failure in women who have used this supplement without clarity of whether the black cohosh was a cause of the liver failure or not. There have been no found interactions with medications in relation to the use of this supplement (Geller and Studee, 2005).  

Each patient and their needs will need to be evaluated before prescribing any hormone therapy. Each form of medication will fit some need better than others based on patient symptom severity and current conditions.  

 

Arcangelo, V., Peterson, A., Wilbur, V., and Reinhold, J. (2017) Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lipincott Williams and Wilkins 

Copestead, L. and Banasik, J. (2013). Pathophysiology (5th ed.). St. Louis, MO: Elsevier Inc.  

Geller, S. and Studee, L. (2005). Botanical and dietary supplements for menopausal symptoms: What works, what doesn’t. Journal of Women’s Health. 14(7): 634-649 

Santoro, N., Epperson, N., and Mathews, S. (2015). Menopausal symptoms and their management. Endocrinology Metabolism Clinics of North America. 44(3): 497-515 

Roberst, H. and Hickey, M. (2016). Managing the menopause: An update. Maturitas: The European Menopause Journal. Retrieved from: https://www.maturitas.org/article/S0378-5122(16)30007-X/fulltext 

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Determination of hormone therapy (HT) for patients experiencing menopause depends on several factors.  Determining the patients age, symptoms and past medical history is a strong determinant of the options available.  Menopause affects women from age 40 to 58, and is due to a decrease in estrogen, mainly estradiol and progesterone (Arcangelo, Peterson, Wilbur & Reinhold, 2017). The dose, delivery system and duration of treatment for HT should be individualized to relieve symptoms (Roberts & Hickey, 2016). 

Role of Estrogen 

Estrogrens are a class of steroidal hormones and has major effects on many body systems.    Estradiol, the most potent estrogen hormone in the circulation, is involved in a wide variety of vital physiological functions that range from the development and maintenance of reproductive organs to the regulation of cardiovascular, musculoskeletal, immune, and central nervous system homeostasis (Yaşar, Ayaz, User, Güpür, & Muyan, (2016). Estrogen receptors are located on the membrane, mitochondria, and nucleus of cells, estradiol interacts with each receptor with different effects of cell to regulate growth, differentiation and death.  As a decrease in estrogen occurs with menopause the results are the symptoms that are experienced.  

Associated symptoms 

Symptoms most commonly associated with menopause are hot flashes, night sweats, chills, perspiration are classed as vasomotor symptoms (VMS), which often resolve.   There are also genitourinary (GU) symptoms such as vaginal dryness, itching, burning and dyspareunia (Arcangelo, Peterson, Wilbur & Reinhold, 2017). 

Past medical History 

A thorough medical history is required to determine if HT would be beneficial or detrimental.  Depending on the history and the symptoms being experienced determines necessity, route, strength and duration.  Adverse effects should be thoroughly discussed with each patient and the goals of HT should be identified.  Patients with a history of estrogen dependent cancer, thromboembolic disease, liver disease, hypertension or smoking should consider an alternative to HT therapy.  Patients with an intact uterus will also require concurrent administration of progesterone along with an estrogen replacement.  

Drug Therapy 

It is important to discuss with the patient the goals of drug therapy, dosages and routes, alternative therapy, length of treatment and adverse effects.  Routine screening such as mammograms, routine lab work and yearly gynecological exams are encouraged, goals of low dose and short duration should be clearly communicated.   For healthy patients experiencing VMS requesting HT, an oral or transdermal approach may be offered.  Conjugated equine estrogen (CEE) along with bazedoxifene at the lowest dosage has proven efficacy with moderate to severe VMS, acting as an estrogen agonist/antagonist by reducing the incidence of endometrial hyperplasia and bone loss.  Patients have reported a decrease in VMS after 12 weeks of therapy.  Side effects include nausea, vomiting, weight changes, hypertension, breast tenderness and changes in libido, patients should be encouraged to report any adverse effects to discuss options to minimize those effects. 

 Transdermal patches may also be an option for patients at risk for venous thromboembolism, due to the absence of experiencing the first-pass hepatic metabolism, there are also less adverse effects associated with this route. 

 For patients experiencing GU associated symptoms low-dose vaginal creams or gels have greater efficacy over oral or transdermal applications, with similar but less systemic effects.  Vaginal dosing may be in the form of a cream, gel or tablet, estradiol strengths and dosage vary depending on the form.  The concurrent use of progesterone for patients with an intact uterus may be indicated but are safe used alone in patients without a uterus.  

For patients in which HT is contraindicated, alternate options are available selective serotonin reuptake inhibitors (SSRI) and selective serotonin-norepinephrine reuptake inhibitors (SSNRI) are options.  Paroxetine decreases VMS by restoring serotonin and norepinephrine in the hypothalamus, which is required for thermoregulation, which is affected by the fluctuating levels of estrogen producing the VMS.  The therapeutic effects are seen within four weeks with adverse effects of nausea, dizziness, dry mouth, nervousness, and sexual dysfunction (Arcangelo, Peterson, Wilbur & Reinhold, 2017).  Therapy is contraindicated with concurrent use of monoamine oxidase inhibitors (MAOI) and is known to alter platelet effects when taken with nonsteroidal anti-inflammatory drugs (NSAIDS).  

 

 

 

References: 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Roberts, H. & Hickey, M. (2016).  Managing the menopause: An update. Maturitas. 86(2016), 53-58. https://doi.org/10.1016/j.maturitas.2016.01.007. 

Yaşar, P., Ayaz, G., User, S. D., Güpür, G., & Muyan, M. (2016). Molecular mechanism of estrogen-estrogen receptor signaling. Reproductive medicine and biology, 16(1), 4-20. doi:10.1002/rmb2.12006 

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1 month ago  

Kristin Pullins  

Week 10 Initial Discussion  

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Week 10 HT.docx 

 

Week 10 Discussion: Hormone Replacement Therapy  

      Estrogen is produced by the ovaries and affects the bones, teeth, brain, eyes, vasomotor, heart, colon and urogenital system (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Estrogen stimulates the growth of egg follicles, stimulates the growth of the vagina/vagina wall/ vaginal acidity/ lubrication, contracts and grows the fallopian tubes, enhances and maintains the uterine lining and contraction, regulates the flow and thickness of uterine secretions, and is responsible for breast growth and nipple pigmentation (Nichols, 2018).  Estrogen also is responsible for smaller/shorter bones, a wider pelvis, narrower shoulders, increased fat around the hips and thighs, increased sensitivity to insulin, finer/ more permanent hair, a smaller voice box with a high-pitched voice, and suppress oil gland activity (Nichols, 2018).  Estrogen also helps maintain body temperature, improves the thickness and quality of the skin, preserves bone strength and prevents bone loss, and regulates cholesterol production in the liver (Nichols, 2018).  Progesterone is only produced when there is an empty ovarian follicle following ovulation (Nichols, 2017).  If the egg is fertilized, progesterone stimulates the development of blood vessels in the endometrium as well as stimulating the endometrium glands to secrete nutrients to nourish the egg (Nichols, 2017).  Progesterone also prepares and preserves the tissue lining for implantation and throughout the pregnancy (Nichols, 2017).  Progesterone is also secreted by the placenta following conception (Nichols, 2017).    

 

Hormone therapy 

       Estrogen hormone therapy minimizes vasomotor and genitourinary symptoms that are due to estrogen deficiency (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Night sweats, hot flashes, awakening at night, sleep latency and overall sleep patterns are improved with hormone therapy (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Hormone therapy has also been proven to have a protective role on cognition and mood (Hiroi, et.al, 2016).  Combination estrogen and progestin is often used in woman with an intact uterus and estrogen is used alone with woman that have no uterus (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Micronized progesterone is also available and should be considered when choosing a progestin replacement (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).    

      While estrogen and combination estrogen/progestin is beneficial in symptom reduction in the majority of users, use is limited.  Long-term use increases the chance of breast cancer, coronary heart disease, and venous thromboembolism (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Combination therapy should be limited to five years or less and estrogen should be limited to seven years (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Even with the limitations, since half of all postmenopausal women suffer severe symptoms affecting their everyday life, not treating symptoms is a bigger risk than the side effects of treatment (Holm, Aaltonen, Heikkinen and Tiihonen, 2014).    

       I would fully support hormone therapy, as long as the patient was fully educated on the potential side effects and limitations and still wanting to proceed.  I have seen many co-workers go through menopause and suffer from major hormonal changes monthly myself so I know how disrupting hormones, or lack thereof, can be to your life.  When managed correctly, taken at a low dose and used for a short-term, side effects can be limited.  The proper follow up care must also be in place and followed as well.  When a woman presents in my clinic with complaints of menopause symptoms I would likely encourage lifestyle and dietary changes to start with.  If that was not working well, then the option of hormone therapy could be explored.  I might encourage the patient to seriously consider this option before it was intiated and she was fully educated but would never tell a patient that it was a bad idea, unless of course hormone therapy was contraindicated.    

 

 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).   

     Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott      

     Williams & Wilkins.  

Hiroi, R., ….Bimonte-Nelson, H. A. (2016, December 8). Benefits of Hormone Therapy   

     Estrogens Depend on Estrogen Type: 17β-Estradiol and Conjugated Equine Estrogens Have      

    Differential Effects on Cognitive, Anxiety-Like, and Depressive-Like Behaviors and Increase   

    Tryptophan Hydroxylase-2 mRNA Levels in Dorsal Raphe Nucleus Subregions. Frontiers in      

    Neuroscience, 10(12), 517-523. doi: 10.3389/fnins.2016.00517 

Holm, E., Aaltonen, K., Heikkinen, A. M., and Tiihonen, M. (2014, August). From systemic   

     hormone therapy to vaginal estrogen – A nationwide register study in Finland, 2003–  

      2013. Maturitas, 78(4), 293-297. https://doi.org/10.1016/j.maturitas.2014.05.006 

Nichols, H. (2018, January). Everything You Need to Know About Estrogen. Retrieved   

      from https://www.medicalnewstoday.com/articles/277177.php 

Nichols, H. (2017, February). Progesterone and progestin: How do they work? Retrieved   

      from https://www.medicalnewstoday.com/articles/277737.php  

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1 month ago  

Chuck Weiss  

Main Discussion  

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Scenario 

            As an advanced practice nurse at a community health clinic, you often treat female (and sometimes male patients) with hormone deficiencies. One of your patients requests that you prescribe supplemental hormones. This poses the questions: How will you determine what kind of treatment to suggest? What patient factors should you consider? Are supplemental hormones the best option for the patient, or would they benefit from alternative treatments? 

Androgen Deficiency 

 

            Patients come in to a provider’s office for many different things.  Having the ability to have an open discussion with the patient is very important.  Male patients tend to be the most difficult to treat because they tend to be less forward about medical problems.  Androgen deficiency is one of these topics.  This week we learn about hormone replacement therapy in both men and women, medications that can be taken, and is it necessary to treat the deficiency or can it be left alone.  It is important to realize that even if it doesn’t affect the patient medically it may have indirect effects that need to be taken care of.   

            Androgens in men are the hormones that give men their male characteristics.  When a male patient has Androgen deficiency it means that he is not producing enough hormones like testosterone which is needed for health and male characteristics.  Signs and symptoms of Androgen deficiency in men include loss of libido and infertility, as well as shrinkage of testicles, penis and prostate, fatigue, depression, anxiety, and a decrease in masculinization. (Androgen, 2018) One of the causes of a decease in testosterone in a male patient could come from the testes.  Such medical conditions like underdeveloped testes, trauma to the testes, complications from mumps, side effects from chemotherapy or radiation, as well as Klinefelter’s syndrome. (Bahsin, S. 2018)   

            Diagnosis of this disease is done by completing a thorough physical as well as a full health history.  Also, two different testosterone levels are completed by the patient.  These are done first thing in the morning after the patient has been fasting.  Levels are not checked on healthy males.  Once a positive diagnosis has been made, treatment options are discussed. It’s important to discuss with the patient different options, and if any treatment is needed at all. Not all men qualify for Testosterone Replacement therapy (TRT).  Some cases can be rectified medically or monitored over time.  “TRT therapy does not work on all patients, so as a clinician you have to decide if the patient will benefit from the treatments or will it be more problematic.”  (Sherman, C. 2010 para. 6)  

Testosterone Replacement Therapy (TRT) 

Testosterone replacement therapy is the most common treatment for men with low levels of testosterone in their bodies.  Testosterone comes in multiple different forms, gel, oral, or intramuscular injections.  Side effects include increased red blood cell count, enlarged prostate and breasts, possible sleep apnea, and acne.  “The guideline recommends diverse formulations and routes of administration, including: Intramuscular testosterone enanthate or cypionate: 75-100 mg weekly, or 150-200 biweekly, a transdermal patch: One to two 5-mg patches applied daily to back, thigh, or upper arm, gel formulation: 5-10 g of 1% testosterone gel daily to cover skin.  Buccal tablets can be prescribed at 30 mg applied to buccal mucosa every 12 hours, and finally subcutaneous pellets can be used by implanting them every three to six months.” (Sherman, C. 2010 para. 8)   

Research has shown that treatment for low testosterone levels increases a patient’s hemoglobin as well as bone density, it also slightly increases a patient’s libido and levels the testosterone in a patient.  But the side effects may greatly outweigh the benefits.  If your patient is thinking about fathering a child, it is important to know that TRT can suppress pituitary hormones that drive the production of sperm. (Androgen, 2018)  Another concern is older men have a natural decrease in hormone levels.  In these cases, TRT is not recommended because there is no provable benefit to taking testosterone.   

Conclusion 

In conclusion, treating a patient for a hormone deficiency is difficult.  It is important to factor in the patient’s medical history as well as their physical evaluation.  What type of treatments are available and if the patient would benefit from the therapy or would the risks outweigh the benefits.  With Androgen deficiency finding the cause is most important.  As nurse practitioners it is our job to take all these variables into consideration and decide what would be best for the patient.  Just because it might make the patient feel better doesn’t always mean that it will be the healthiest.   

             

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1 month ago  

Brandy Barrett  

Week 10 Initial Post  

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Nurs 6521: Advanced Pharmacology 

Week 10: Hormone Replacement Therapy 

             

            Hormone replacement therapy is a course of treatment that providers often select for the individual whose body is no longer producing a particular hormone or not making enough of the hormone.  Menopause is a disorder that is connected to an age-related loss of ovarian function that causes a decrease in estrogen secretion by the ovarian follicular unit (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p 971).  Women can also be sent into early menopause if their ovaries are removed during a hysterectomy.  The start of menopause usually begins around age 47 and continues for an average of 5-8 years (Roberts & Hickey, 2016, p. 53).  If the body is not producing the needed amount of estrogen, the individual will have uncomfortable symptoms.  

             A person may experience some or all of the symptoms that accompany menopause.  The systemic symptoms include hot flashes, insomnia, mood changes, irritability, sleep disturbance, and memory atrophy. In addition to those symptoms, the local symptoms are urogenital atrophy, vaginal dryness, dyspareunia, and sexual dysfunction (Garrido Ovarzun & Castelo-Branco, 2017, p. 11). Going back to the scenario if my patient came to me asking for supplemental hormones because of the side effects it would depend on the symptoms and the severity of those symptoms before I decided if I would prescribe hormone replacement therapy. Hormone replacement therapy is not suggested for every individual. 

            Before prescribing hormone replacement therapy, the provider needs to weigh the benefits and risk of the patient being on this therapy and how compliant the patient will be with the regimen.  There are contraindications to hormone therapy. So it is essential to get an accurate health history from the patient and to do a physical.  Hormone replacement therapy should be avoided in a patient with known or suspected breast cancer, endometrial cancer, untreated hypertension, acute liver disease, thromboembolic disease, pregnancy (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.976.  There are much more health issues that would warrant avoiding hormone replacement. Roberts & Hickey 2016, also states that hormone therapy should be avoided in patients with unexplained vaginal bleeding, coronary heart disease, and stroke (p. 54). Hormone replacement is one form of treatment for menopause, but patients can also do non-hormonal options as well.  According to Arcangelo et al. 2017, regimens containing estrogen with or without progestin added is an option as well as non-hormonal options like selective serotonin reuptake inhibitors (SSRIs), and gabapentin can be used as therapy (p.972). Non-hormonal treatment is good for vasomotor symptoms (VMS).  Other interventions may be necessary in combination with troublesome menopausal symptoms.  When using an SSRI escitalopram is the first choice because it is well tolerated and reduces the frequency, severity, the interference associated with VMS improves the quality of life, improves sleep and does not affect sexual function when used for VMS (Roberts & Hickey, 2016, p. 56).   

            The patient should understand the absolute risk related to HT.  It should be understood that these risks are smaller in healthy women but as we see many health conditions complicate using HT and is not recommended.  HT puts the patient at an increased risk for cancer especially breast cancer.  Studies showed that there was no increase of breast cancer found with estrogen alone however after stopping a combination HT therapy there is an increased risk of breast cancer for eight years after stopping the treatment (Roberts & Hickey, 2016, p.55).   

 

 

Summary 

            In conclusion, HT can be beneficial when used correctly and with the right patient.  When used in the for the ideal patient HT can make embarrassing and uncomfortable symptoms tolerable for the individual.  Just like with all medication there are side effects and adverse effects with HT.  One of the major issues with HT is that it can increase the chances of developing breast cancer.  Non-hormonal treatments are helpful, but they do not address all of the symptoms that accompany menopause.  If my patient was in her 40s-50s with no contraindicating health concerns and the symptoms were affecting her quality of life, I would prescribe HT therapy for her. Of course, I would start at the lowest suggested dose.  However, I would try non-hormonal treatment first if the patient fit the profile for it. If the patient were started on HT, I would start with only estrogen because it had less risk alone keeping in mind that HT is only recommended for a short period.  See an example of a hormone replacement medication and non-hormone replacement medication below.Medications  

Hormone Replacement Therapy  

Estradiol- treatment of moderate to severe vasomotor symptoms associated with menopause 

Action- modulates pituitary secretion of gonadotropins; follicle-stimulating hormone 

Pharmacokinetics- absorbed through the GI tract, widely distributed, protein binding 50-80%, broken down by liver, eliminated through urine, unknown half-life  

Frequent side effects- anorexia, nausea, swelling of breast, peripheral edema marked by swollen ankles and feet 

Contraindicated in hepatic impairment and pregnancy 

(Kizior, 2018, p.442-445) 

Non-Hormonal Therapy  

Escitalopram- treatment of major depressive disorder; vasomotor symptoms associated with menopause 

Action- blocks uptake of neurotransmitter serotonin at neuronal presynaptic mebreane; increase availabitiy at postsynaptic receptor sites 

Pharmacokinetics- well after PO administration, protein binding 56%, broken down by the liver, mainly eliminated in feces; lesser amount eliminated in urine. Half-life 35hrs  

Frequent side effects- nausea, dry mouth, drowsiness, insomnia, and diaphoresis 

Monitor for suicidal ideations 

(Kizior, 2018, p.438) 

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1 month ago  

jennifer stromgren  

Week 10 Discussion  

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Strengths and Limitations of Hormone Replacement Therapy 

Hormone replacement therapy medications containing female hormones to replace the ones the body no longer makes after menopause ( Mayo Clinic, 2018). Hormone therapy has been proven to prevent bone loss and reduction of fractures in postmenopausal women ( Mayo Clinic, 2018). Hormone therapy can reduce symptoms such as, hot flashes, night sweats and vaginal dryness ( Mayo Clinic, 2018). Hormone replacement therapy has the potential to cause heart disease, stroke, blood clots and breast cancer ( Mayo Clinic, 2018). Women with a uterus taking Ostrogen are at a high risk for endometrial cancer ( Willacy, 2018). 

Hormone Replacement Therapy 

As an advanced practice nurse, prior to prescribing hormone replacement therapy i would take into consideration treating mild menopause symptoms versus the increased risks in which may be caused by medications. I would speak in depth with the patient regarding their feelings on hormone replacement. Patients that are at a higher risk of developing complications from medication might benefit from alternative therapy to include, black cohosh which may help with hot flashes, it is derived from the buttercup family and behaves similarily to serotonin in the brain and regulates boy temperature ( Cappellani, 2018). St Johns Wort helps with mood swings and depression ( Cappelloni, 2018). Yoga and acupuncture may also benefit individuals whom do not want to take hormone replacement therapy. 

Supplemental Hormones 

I would prescribe supplemental hormones at low doses and depending on the patients symptoms, there are many hormone replacement medications that may help individuals that are suffering from mild side effects of menopause to severe effects. Oral hormone replacement therapy which includes conjugated equine estrogen ( Premarin) is used to treat menopause symptoms such as hot flashes and vaginal changes and prevent osteoporosis ( Drugs.com, 2018). When estrogen therapy is prescribed in women whom still have a uterus premarin should be considered as it reduces the risk of endometrial cancer ( Drugs.com, 2018). After menopause most endogenous estrogen is produced by conversion of androstenrdione, secreted by the adrenal cortex to estrone in the peripheral tissues ( Drugs.com, 2018). Estrogens act through binding to nuclear resceptor in estrogen-responsive tissues ( Drugs.com, 2018). Circulating estrogen modulate the pituitary secretion of gonadotropins, luteinizing hormone and FSH through a negative feedback mechanism ( Drugs.com, 2018). There are no pharmacodynamics data for premarin ( Drugs.com, 2018). Conjugated estrogens are water-soluable and are absorbed from the gastrointestinal tract after release from the drug formulation ( Drugs.com, 2018). 

Combonation products such as, CEE and medroxyprogestrone have androgenic and anabolic effects that have been noted but the drug is apparently devoid of significant estrogenic activity ( Drugs.com, 2018). While parenterally administered MPA inhibits gonadtropin production, which in turn prevents follicular maturation and ovulation ( Drugs.com, 2018). 

Transdermal menopause hormone therapy such as estradiol, is a form of estrogen ( Drugs.com, 2018). Estrogens act through binding to nuclear recesptors in estrogen- responsive tissues ( Drugs.com, 2018). Estrogens are widely distributed in the body and are generally found in higher concentrations in the sex hormone target organs ( drugs.com, 2018). Side effects may include, headache, breakthrough bleeding and irritation of the applicaiton site ( Arcangelo, Peterson, Wilbur, & Reinhold, 2017). 

Other related options such as ospemifene work in the same manner as estrogen. Side effects may include hot flashed and vaginal discharge ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). 

Progestrone 

Progestrone is a female hormone important for the regulation of ovulation and menstruation ( Drugs.com, 2018). Progestrone transforms proliferative endometrium into secondary endometrium ( Drugs.com, 2018). Progestrone is extensilvely bound to plasma proteins, primarily albumin and cortisol binding protein ( Drugs.com, 2018). Progestrone metabolites which are excreted in the bile may undergo entherohepatic recycling or may be excreted in the feces ( Drugs.com, 2018). 

Molecular Mechanism of Estrogen 

Estradiol as the main circulating estrogen hormone, regulates many tissue and organ functions ( Yasar, et al, 2016). The effects of E2 cells are mediated by the transcription factors and estrogen receptor and ERb that are encoded by distinct genes ( Yasar, et al, 2016). 

Reference 

Arcangelo, V.P., Peterson, A.M., Wilbur, A.M. & Reinhold, J.A. (2017). Pharmacotherapeutics for advanced practice: A practical approach. (4th ed). Lipincott, Williams & Wilkins 

Cappelloni, L. (2018). Alternative for Treating Menopause. Retrieved from: https;//www.healthline.com.health/menopause/alternative-treatments 

Drugs.com (2018). Estradiol. Retrieved from: https://www.drugs.com/pro/estradiol.html 

Drugs.com. (2018). Medroxyprogestrone. Retrieved from: https://www.drugs.com/pro/medroxyprogestrone.html 

Drugs.com. (2018). Premarin. Retrieved from: https://www.drugs.com/pro/premarin.html 

Drugs.com. (2018). Progestrone. Retrieved from: https;//www.drugs.com/pro/progestrone.html 

Mayo Clinic. (2018). Hormone Therapy. Retrieved from; https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/ART-20046372 

Willacy, H. (2018). Hormone Replacement Therapy. Retrieved from: https://www.patient.info/doctor/hormone-replacement-therapy-including-benefits-and-risks 

Yasar, P., Ayaz, G., Damla, S., Gupur, G. & Muyan, M. Molecular mechanism of estrogen-estrogen receptor signiling. Reproductive Medicine and Biology;2018 

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1 month ago  

Marie Lucien  

Hormone Replacement Therapy  

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Hormone Replacement Therapy 

            To substitute the natural hormones when the body does not make enough is known as hormone replacement therapy (HRT). Hormone replacement therapy may be given when the thyroid gland does not produce enough thyroid hormone, or when the pituitary gland does not make enough growth hormone. Nevertheless, HRT is mostly given to women after menopause to replenish the hormones estrogen and progesterone that are no longer generated by the body. Depending on the women point of view HRT might be not welcome. Like some say, it is detestable, whereas others say they cannot live without it. The decision to initiate HRT is a personal decision made between the patient and their provider.  More importantly, it is crucial that you acquired knowledge before determine that is the right decision for your health even your provider encourage you to take it. Hormone therapies should be saved as a last resort option in difficult and severe cases where the alternative therapies have not provided relief for the patient (Bavender, 2018). 

History of hormone replacement 

            Hormone replacement therapy was viral until 2002 when the Women’s Health Initiative (WHI) released the results from their randomized control trial that was cut short due to the high risks they found associated with HRT. Specifically, it was shown that women who used HRT containing estrogen plus progestin had a 26% increased risk of invasive breast cancer, a 29% increased risk for myocardial infarction or death from coronary heart disease, a 41% increased risk of stroke, and a 200% increased risk of blood clots. The benefits found were a 33% decreased risk of hip fracture, 37% reduces the risk of colorectal cancer, and relief of menopausal symptoms. They concluded that the chances of HRT outweighed the benefits. 

            In woman’s life, the hormones fluctuate all day every day placing her on a situation which changes from one extreme to another. The estrogen rollercoaster called menstruation. A decline of ovarian purpose, whether occurring naturally or through medical intervention, results in a rapid halt of the estrogen rollercoaster causing the termination of menstruation known as menopause. Most women are between the ages of 40-50 when they experience menopause, and some of the most common symptoms include hot flushes, night sweats, vaginal dryness, and sleep disturbances.  These symptoms interrupt women’s lives causing them to seek treatment options from their health care provider. In old-style medical settings physicians habitually recommend hormone replacement therapy (HRT). However, after the results of 2002, Women’s Health Initiative (WHI) study acknowledged the high risks associated with HRT, women began searching for alternative treatment options. CBHT does not carry the safety warnings mandated by the FDA for estrogen-products after the discontinuation of the Women’s Health Initiative. Due to marketing, media promotion, and even high-profile celebrity endorsements many women as Oprah Winfrey, who stated, “After one day on bioidentical estrogen, I felt the veil lift”. Today, CBHT remains fervently debated and in the news and recent data suggests that CBHT use (Abernethy, 2015). 

            Study uncovers that women draw upon a range of “push” and “pull” motivations in their decision to use CBHT. Importantly, we find that women are not only seeking alternatives to conventional pharmaceuticals, but alternatives to traditional care where their menopausal experience is solicited, their treatment goals are heard, and they are engaged as agents in managing their menopause (Abernethy, 2015). The significance of this finding goes beyond understanding why women choose CBHT.  Although CBHT does not carry the safety warnings mandated by the FDA for estrogen-products after the discontinuation of the Women’s Health Initiative, women who are experiencing the menopause symptom, are not willing to continue with that deplorable discomfort when they can manage alternative treatment for relieving and manageable of their daily activities. Making menopause treatment decisions of all kinds would benefit from greater shared decision-making in the clinical context in which they are explicitly invited to share their experiences, priorities, and preferences (Bavender, 2018).  It would also provide an opportunity for clinicians to discuss the pros and cons of conventional HT, CBHT, and other approaches to managing menopause (Thompson, Ritenbaugh, & Nichter, 2017). 

Resources and limitations of HRT 

            HRT is one of the FDA-approved treatments for relief of menopausal symptoms including night sweats, sexual problems and difficulty sleeping. If the signs are so great, HRT will help almost immediately when it comes to relieving vasomotor symptoms and helping with mood and sleep issues. Women are often prescribed estrogen or estrogen with progestin. Thus, HRT can help improve a woman’s quality of life including vasomotor and urogenital symptoms, relieving joint pains, insomnia, and better control of menopausal symptoms. 

HRT also benefits women by maintaining bone mineral density which reduces the risk of osteoporotic fractures. Furthermore, some evidence suggests that HT may improve muscle mass and strength (Abernethy, 2015). 

Purposes for supporting HRT 

            As a future provider, I support the use of HRT for menopausal women as this causes great relief to women whose lives are made sad by the symptoms of menopause. Menopause can spiral a woman into depression with the possibility of suicidal ideation. I would also recommend the use of therapy and natural remedies for patients that are at high risk for adverse effects of HRT. Remedies as black cohosh (Actaea racemosa, Cimicifuga racemosa). This herb has received quite a bit of scientific attention for its possible impact on hot flashes. Red Clover, Dong Quai, Ginseng, Kava, Evening Primrose Oil. Those remedies should use with caution and take them to the attention of your provider to prevent contraindication (McNeil, 2017). 

            Also, when speaking about HRT, we cannot forget about men. Some physicians are saying that male menopause (andropause) does exist with symptoms of tiredness, depression and lack of libido.  Andropause does not affect all men, and doctors acknowledge that with age, men have testosterone deficiencies, including erectile dysfunction or low libido, should be screened for low testosterone (Abootalebi, Kargar, & Aminsharifi, 2017). Those with active symptoms should be considered for therapy (McNeil, 2017). The selection of hormone replacement therapy for men is similar to women; they should have a talk with their provider, discuss the risks and benefits and tailor the treatment based on their needs (Abootalebi, Kargar, & Aminsharifi, 2017). However, my biggest reason for supporting HRT is that hundreds of evidence-based studies have proven that systemic hormone therapy (estrogen with or without progestogen) effectively helps such conditions as hot flashes, vaginal dryness, night sweats, and bone loss. These benefits can lead to improved sleep, and sexual relations, and a better quality of life (Abootalebi, Kargar, & Aminsharifi, 2017). 

The judgment to Prescribe HRT 

            The decision to prescribe HRT should be in collaboration with the provider and the patient, after informing the patient of the risks involved. Providers should initiate the lowest dose possible because the benefits of hormone therapy are dose-related (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The severity of the patient’s symptoms must be considered, as well as the age, medical history, and family history of the patient. Patients should also be given the choice of alternative treatment like acupuncture and natural remedies such as bioidentical HRT, as well as vitamins and supplements that can support the patient in managing symptoms and transitions associated with menopause (McNeil, 2017). Also, lifestyle changes should be suggested such as diet modification and food supplements. It is beneficial in lowering caffeine intake, exercising, and maintaining cooler body temperatures. There is no HRT that is right for all women, and very few women should be told they can never have HRT. Hormone therapy remains a valid treatment option for women who are significantly troubled by menopausal symptoms. The risks and benefits of such treatment vary according to age and medical history (Abernethy, 2015). It is often a personal decision for female patients to decide on whether to consider HRT as some women may feel they can manage menopausal symptoms with or without any replacement therapy. I was lucky by managing all my symptoms with natural remedies; I had great success. I was sweating so much that I went natural with my hair and able to water it couple times a day. I was so concerned about menopause that I was doing my research before it was started. Therefore, I knew all the choices that I had and chose what I thought was fit my medical condition.  Patient education plays a vital role when deciding on menopause treatment (McNeil, 2017). 

Conclusion 

            Depending on the women experience of menopause, the decision to use a particular hormone product must be base accordingly to age, risks, and health status. The decision should be making after fact-finding and thoughtful consultation with her provider to make the best treatment choice. As new therapies and guidelines are available, and as a woman’s body changes over time, reevaluation and adjustments should be made appropriately. Education is essential when approaching menopause to prevent overwhelmed when making a health decision. Last but not least, either men and women have to be knowledgeable when the moment comes. 

References 

Abernethy, K. (2015). Making sense of hormone replacement therapy. Nurse Prescribing, 13(9), 

            452-456 

Abootalebi, M., Kargar, M., & Aminsharifi, A. (2017). Assessment of the validity and reliability of a questionnaire on the knowledge and attitude of general practitioners about andropause. The Aging Male: The Official Journal of The International Society For The Study Of The Aging Male, 20(1), 60–64. https://doi-org.ezp.waldenulibrary.org/10.1080/13685538.2016.1188067 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A.  (Eds.). (2017).  

            Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins   

Bavender, K. L. (2018). Hormonal Havoc: Alternative Therapies to Hormone Replacement. Nutritional Perspectives: Journal of the Council on Nutrition, 41(3), 18–23. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=131588998&site=ehost-live&scope=site 

McNeil, M. (2017). Menopausal Hormone Therapy: Understanding Long-term Risks and Benefits. JAMA, 318(10), 911–913. https://doi-org.ezp.waldenulibrary.org/10.1001/jama.2017.11462 

Thompson, J. J., Ritenbaugh, C., & Nichter, M. (2017). Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making. BMC Women’s Health, 17, 1–18. https://doi-org.ezp.waldenulibrary.org/10.1186/s12905-017-0449-0 

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1 month ago  

Lindsay Ramirez  

Week 10 – Main Discussion Hormone Replacement Therapy  

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Week 10 

NURS 6521 

Hormone Replacement Therapy 

Menopause is a gradual and natural process in women where menstruation is permanently ceased as a result of the ovaries no longer producing estrogen (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Natural estrogen and progesterone in the body are one of two sex hormones in women and are responsible for female physical features and reproduction such as breast development, the growth of pubic hair, and regulation of the menstrual cycle (What Does Estrogen Do, 2014).  Estrogen also contributes to the control of cholesterol, bone health, mood, heart skin, and other tissues of the body (How Does Estrogen Work, 2014).  The decreased production of estrogen can lead to several physiologic manifestations and contribute to other disease processes.  The increased incidence of chronic disease in postmenopausal women appears to be influenced by decreased levels of estrogen or progesterone, and the management of symptoms associated with menopause including vasomotor symptoms and urogenital symptoms are often the focus of health care providers for this population (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 971). For this reason, many women seek care for hormone replacement therapy to treat or manage the physiologic symptoms of menopause.  Morbidity in postmenopausal women is largely impacted by the decline in estradiol production (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Some of the symptoms experienced most often resulting in vasomotor symptoms of insomnia, hot flashes and mood changes, as well as urogenital symptoms of vaginal dryness, itching, burning, and dyspareunia (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 972).  

Androgen replacement therapy is also utilized for males suffering from hypogonadism.  Hypogonadism is a term referring to the condition of decreased testosterone and is associated with hypogonadal symptoms of increased fat mass, decreased immune function and bone mineral density, loss of muscle mass and strength, decreased libido, erectile dysfunction, sweating, insomnia, and depression (Makinin & Huhtaniemi, 2011, p. 194).  Chronic illnesses, hypertension, coronary artery disease, obesity, depression, and diabetes are associated with the reduction of testosterone in middle-aged men (Makinin & Huhtaniemi, 2011, p. 195).  Late-onset hypogonadism is not simply an age-related decrease in testosterone but must also have three sexual symptoms in addition to low testosterone (Rivas, Mulkey, Lado-Abeal, & Yarbrough, 2014).  A clear diagnosis of hypogonadism usually indicates a need for androgen replacement therapy and is available in the form of gels and patches, intramuscular injections, subcutaneous pellets, and buccal tablets (Makinin & Huhtaniemi, 2011).   

Types of Drug Therapy 

Hormone therapy 

The goal of drug therapy in the treatment of hormone deficiencies is to minimize the symptoms and improve the quality of life for the patient.  In menopause, hormone therapy for women with an intact uterus combines estrogen and progestin, whereas estrogen alone is used in women who have no uterus (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Hormone replacement with estrogen regimens decreases the frequency and intensity of hot flashes, the frequency of night sweats, sleep disturbances, and urogenital symptoms.  There are several different hormone therapy products to treat the symptoms of menopause. Estradiol is a form of estrogen hormone used as hormone therapy for postmenopausal symptoms.  The oral form of this medication is 1 mg to 2 mg orally daily and should be cyclic, for example, three weeks on, one week off (Estradiol, n.d.).  The injectable for is 10 mg to 20 mg intramuscularly every 4 weeks, the topical gel is applied once a day as a thin layer, the spray is once a day to the inner surface of the forearm, the transdermal film and patches are applied weekly and the vaginal insert is 10 mcg intravaginally daily for 2 weeks, followed by 1 insert twice weekly (Estradiol, n.d.).  Estrogen therapies are widely distributed in the body, generally in higher concentrations in the sex hormone target organs (Estradiol, n.d.). They are metabolized mainly in the liver and excreted in the urine (Estradiol, n.d.).  These therapies should be used at the lowest effective dose, and for the shortest duration possible, typically limited to 3 to 5 years (Arcangelo, Peterson, Wilbur, & Reinhold, 2017 p. 975).   

Estrogen Agonist/Antagonist 

There is only one medication in this class of drugs, called ospemifene, that has been approved for the treatment of postmenopausal symptom management, mostly for the symptoms of dyspareunia (Arcangelo, Peterson, Wilbur, & Reinhold, 2017 p. 977).  The mechanism of action of this medication is that it binds to alpha and beta estrogen receptors and acts as an agonist in some tissues of the body, and an antagonist in others (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p.977).  This medication minimizes dyspareunia in vaginal tissues, has weak estrogen activity in the uterus that does not lead to endometrial hyperplasia, and may have antiestrogenic activity in breast tissue lacking the increased risk of breast cancer that has been noted with traditional hormone therapy (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 977).  Ospemifene is administered as an oral tablet with a dose of 60 mg daily and should be taken with food to maximize its absorption (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 977).  This medication is contraindicated in women with undiagnosed abnormal vaginal bleeding, women with known estrogen-dependent neoplasia, and women with a history of active thromboembolic disease (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 977).  The most common adverse events with ospemifene are vaginal discharge, muscle spasms, hot flashes, and there is an increased risk for venous thromboembolism (VTE) events, cardiovascular disease, and endometrial cancer with its use (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 977). 

Tissue Selective Estrogen Complex (TSEC) 

This class of medications describes a combination of continuous-combined estrogen (CCE) and bazedoxifene, an estrogen agonist/antagonist that is used for the treatment of moderate to severe vasomotor symptoms (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 977).   It is marketed under the brand name DuaveeThis drug works similar to the other estrogen agonist/antagonist in its effects with a further reduction in bone mineral density loss, a reduction in vasomotor symptoms, and does not increase risk of venous thromboembolism (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 978).  The recommended dosage is a combination of 20 mg of bazedoxifine and 0.45 mg or 0.625 mg conjugated equine estrogen (CEE) by mouth daily (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 978).  This medication should be avoided in patients with a history of venous thromboembolic disorder, history of an arterial thromboembolic disorder, history of or current breast cancer, hepatic impairment, and protein C and S or antithrombin deficiency that would predispose a woman to a blood clot (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 978).   

SSRIs, SNRIs, and Gabapentin 

Nonhormonal options such as the selective serotonin reuptake inhibitors (SSRIs), selective serotonin-norepinephrine reuptake inhibitors (SNRIs), and gabapentin are available treatment options for menopause as vasomotor symptoms may be due to the disruption of the thermoregulatory system that is regulated by consistent concentrations of serotonin and norepinephrine (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 972).  SSRIs and SNRIs improve vasomotor symptoms by reestablishing the neurotransmitters in the thermoregulatory center of the hypothalamus (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 978).  
The dosage of these medication varies with each agent.  Improvement in symptoms with the use of these medications can take several weeks of therapy (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 978).  The most common adverse effects of SSRIs and SNRIs are nausea, dizziness, dry mouth, nervousness, constipation, and sexual dysfunction (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 978).   

Gabapentin is an anticonvulsant that has been used to treat vasomotor symptoms associated with menopause, although the exact mechanism of action is unknown (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 979).  The prescribed dosage of gabapentin for postmenopausal women starts at 600 mg to 900 mg in divided doses daily with a maximum total daily dose of 2.7 g (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 979).  Improvement of symptoms may not be observed for several weeks. Adverse events associated with gabapentin are somnolence, fatigue, dizziness, rash, and peripheral edema (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 979).   

How would I determine what kind of treatment to suggest? Patient factors to consider?  

            I would determine the type of treatment based on the severity of symptoms in my patient, the desired goals of therapy, and I would weigh the benefits and risks of treatment.  It is also important to consider whether a woman has had a history of estrogen-dependent cancer (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 979).  Factors to consider when deciding the type of treatment to suggest include whether or not a woman is suffering from vasomotor symptoms, genitourinary syndrome of menopause (GUSM), or both.  I would have to consider whether or not the patient has any contraindication to hormone therapy or if they are opposed to taking hormone therapy.  If this is the case, I would then suggest taking an SSRI/SNRI, gabapentin, or clonidine.  If a patient does not have contraindications and is open to taking hormone therapy, I would prescribe oral, transdermal, or a combination form of hormone therapy. If a patient also has symptoms of GUSM, I would suggest vaginal lubricants and moisturizers and continued sexual intercourse if there was a contraindication or unwillingness to use hormone therapy.  I would prescribe vaginal estrogen of low dose oral or transdermal estrogen or the medication ospemifene.  Hormone therapy should be discontinued after symptoms resolve, usually one to three years after menopause, with use beyond three to five years not recommended due to an increased risk of breast cancer (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 980).  Women treated with hormone therapy should have annual health visits to evaluate symptoms, complete a breast exam, monitor for vaginal bleeding, a pelvic exam with pap smear, lipid panel, and blood pressure screening (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).   

Strengths and Limitations of Hormone Replacement Therapy 

Strengths of hormone replacement therapy center around minimization of the symptoms associated with menopause.  For some women, these symptoms may be very disruptive to their quality of life.  One limitation of hormone therapy is that the benefits of therapy can take up to several weeks and may require continued dose adjustment (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 981).  There are potential adverse effects as a result of hormone therapy, some may be minimal side effects such as nausea, while others may be more serious such as venous thromboembolism.  Studies have shown that women who use hormone replacement therapy containing estrogen plus progestin had a 26% increased risk of invasive breast cancer, a 29% increased risk for myocardial infarction or death from coronary heart disease, a 41% increased risk of stroke, and a 200% increased risk of blood clots (Bavender, 2018, p. 18).  These studies share that benefits include a 37% decreased risk of colorectal cancer, and relief of menopausal symptoms, stating that the risks of hormone replacement therapy outweighed the benefits (Bavender, 2018, p. 18).   

            In terms of androgen replacement therapy, some preparations have associated unfavorable side effects such as increased liver enzymes, cholestasis, peliosis of the liver, and liver tumors (Makinin & Huhtaniemi, 2011, p. 195).  Additionally, the disadvantage of oral androgen preparations is their short duration of action due to first-pass metabolism in the liver whereas the long duration of action of injectables prevents rapid discontinuation due to potentially serious adverse effects (Makinin & Huhtaniemi, 2011). Testosterone is in some cases associated with adverse behavior such as excess libido and aggression, as well as gynecomastia and suppression of spermatogenesis (Makinin & Huhtaniemi, 2011, p. 200).   

Would I Prescribe Supplemental Hormones? 

            As the practitioner, I would discuss alternative therapies with my patient before prescribing hormone replacement therapy. I would prescribe supplemental hormones to my patient only after thoroughly reviewing the current and past medical history of the patient to determine whether or not this patient is a candidate for hormone replacement therapy.  I would want to respect the patient’s autonomy to make his or her own decision. I would discuss potential benefits, as well as risks, side effects, and adverse events that could be potential with each therapy.  If I felt that this patient would benefit from supplemental hormones and have an improved quality of life, I would consider prescribing supplemental hormones.  That being said, I would ensure the patient understood the risks, has realistic expectations of when and how the therapies work, and that education was provided on the specific course of treatment.  

Alternative Treatments 

Alternative treatments include diet and lifestyle changes, as well as complementary and alternative medications.  The reduction of refined carbohydrates, caffeine, and alcohol in the diet has been reported to result in minimizing hot flashes (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 981).  Smoking cessation and weight loss are recommended, and for genitourinary symptoms associated with menopause, regular sexual activity is encouraged (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 981).  Vaginal moisturizers and lubricants are also options for these associated symptoms of vaginal atrophy.  Herbal remedies such as soy, black cohosh, or phytoestrogens are used to manage vasomotor symptoms and foods containing soy, some nuts, oats, corn, wheat, flaxseeds, sunflower seeds, and chickpeas have been thought to provide some relief of vasomotor symptoms (Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 982).   

References 

 

Arcangelo, V.P., Peterson, A.M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach(4thed.). Ambler, PA: Lippincott Williams & Wilkins 

Bavender, K. (2018).  Hormonal havoc: Alternative therapies to hormone replacement. Journal of the Council on Nutrition, 41(3), 18-23. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=10&sid=50fb91b1-19c4-42d1-8585-e3d35c1b0e99%40sessionmgr102 

Estradiol. (n.d.). Retrieved January 28, 2017, from https://www.drugs.com/pro/estradiol.html 

Makinen, J.I., & Huhtaniemi, I. (2011). Androgen replacement therapy in late-onset hypogonadism: Current concepts and controversies – A mini-review. Gerontology, 57(3), 193-202.  

Rivas, A. M., Mulkey, Z., Lado-Abeal, J., & Yarbrough, S. (2014). Diagnosing and managing low serum testosterone. Baylor University Medical Center Proceedings,27(4), 321-324. doi:10.1080/08998280.2014.11929145 

What Does Estrogen Do? (2014). The Journal of Clinical Endocrinology & Metabolism,99(4). doi:10.1210/jc.2014-v99i4-31a 

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1 month ago  

Kaitlan Middlemas  

Week 10 Discussion Post  

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Hormone Replacement Therapy 

Kaitlan Middlemas 

Nurs 6521: Advanced Pharmacology 

Walden University 

January 29, 2019 

Strengths and limitations 

Menopausal hormone therapy reduces the frequency and severity of hot flashes and other symptoms such as sleep disruption, mood instability, difficulty concentrating and a reduced quality of life (Sood et al., 2014). In healthy women, menopausal hormone therapy (MHT) can provide excellent symptom relief that also poses low risks. If menopausal hormone therapy is withheld from symptomatic women risks may occur such as osteoporosis and cardiovascular disease. Even in low doses, menopausal hormone therapy preserves and improves bone density (Sood et al., 2014). Random clinical trials have shown that estrogen-containing menopausal hormone therapy may decrease coronary heart disease and mortality in women that are younger than 60 years of age and within 10 years of menopause. Menopausal hormone therapy has also been shown to decrease the development of type 2 diabetes when the hormone therapy contains oral conjugated equine estrogens (CEE) alone or with progestin (Sood et al., 2014).  

Hormone therapy should be used at the lowest effective dose and for the shortest duration possible (Arcangelo et al., 2017). “Evidence on the risk of breast cancer from MHT use is complex, but what is clear is that taking combination estrogen plus progestogen therapy for longer than 5 years is associated with an increase risk” (Sood et al., 2014). The current understanding is that the increased risk of breast cancer due to menopausal hormone therapy results from the menopausal hormone therapy promoting the growth of pre-existing cancers that may not have grown otherwise of may have been too small to diagnose (Sood et al., 2014). In one of the largest clinical trials, a combination estrogen-progestin pill (Prempro) increases the risk of heart disease, stroke, blood clots, and breast cancer (Mayo Foundation for Medical Education and Research, 2019). Other studies have shown that these risks vary, depending on the age of the patient. For example, if a patient is on hormone replacement therapy for more than 10 or 20 years from the onset of menopause, or at the age of 60 and older there is greater risks of heart disease, stroke, blood clots, and breast cancer. If hormone therapy is started before the age of 60 or within 10 years of menopause, the benefits seem to outweigh the risks (Mayo Foundation for Medical Education and Research, 2019). 

Support 

For me it would be a hard decision on whether I supported hormone replacement therapy and it would really be based off of the patient. If I had a patient who was less than 60 years of age or was within 10 years of menopause and had symptoms such as sleep disruption, mood instability, and a reduced quality of life and wanted to try hormone replacement therapy I would support them in doing so. If it would mean increasing their quality of life, I would support them. On the other hand, if I had a patient who was over the age of 60 and more than 10-20 years from the onset of menopause, I would not support them with their desire of taking hormone replacement therapy. At this point, the risks outweigh the benefits and it would not be in their best interest.  

Prescribing 

In patients with menopausal symptoms, especially hot flashes, estrogen therapy remains the gold standard. Women are started on a transdermal 17-beta estradiol because it has lower risks of VTE, stroke, and hypertriglyceridemia versus oral estrogens (Martin & Barbieri, 2018). In relieving menopausal symptoms, all types and routes of estrogen are effective. “In a meta-analysis of 24 trials of MHT in 3329 women, the frequency of hot flashes decreased more in those receiving MHT (weighted mean difference- 18 hot flashes per week compared with placebo; 95% CI-22.86 to -12.99; 75 percent reduction). The severity of hot flashes also decreased more with MHT compared with placebo” (Martin & Barbieri, 2018). Based off of data, it is suggested that started with lower doses of estrogen is recommended unless the patient has severe symptoms. The standard dose of estrogen is given daily and is conjugated estrogen 0.625 mg or its equivalent and 0.014 mg of estradiol is the lowest available dose (Marin & Barbieri, 2018). “All women with an intact uterus need a progestin in addition to estrogen to prevent endometrial hyperplasia, which can occur after as little as six months of unopposed ET. Women who have undergone hysterectomy should not receive a progestin, as there are no other health benefits other than prevention of endometrial hyperplasia and carcinoma” (Martin & Barbieri, 2018).  

Reference: 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins  

Martin, K., & Barbieri, R. (2018). Treatment of menopausal symptoms with hormone therapy. Retrieved from https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with-hormone-therapy?search=hormone%20replacement%20therapy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 

Mayo Foundation for Medical Education and Research (MFMER). (2019). Hormone therapy: Is it right for you? Retrieved from https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/art-20046372 

Sood, R., Faubion, S., Kuhle, C., Thielen, J., & Shuster, L. (2014). Prescribing menopausal hormone therapy: an evidence-based approach. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897322/ 

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Men and Prostate Cancer  

Collette Dillon 

Walden University  

February 2019 

 

 

 

 

 

 

 

 

 

 

 

The burden of disease related to cancer continues to expose cancer as a serious health concern in many healthcare systems. Prostate cancer is not a rare disorder in men. According to a study by (Grossman et al., (2018), men has an 11% cancer of being diagnosed with prostate cancer over their lifetime and 2.5% chance of mortality. While citing the 2017 report by the U.S. Preventive Services Task Force, (USPSTF) (Grossman et al., 2018) the median deceased age for men with prostate cancer is around 80. Like many other forms of cancer, men with prostate cancer do not experience the symptoms related to this chronic condition. As such, most men never know they suffer prostate cancer until they are screened. The purpose of this paper, therefore, is to explore the range of preventive services that are available for recommendation by healthcare providers to patients who are at risk of this type of cancer. In so doing, this paper is guided by the 2014 U.S. Preventive Services Task Force article that stipulates the population at risk and the risk factors associated with prostate cancer. The USPSTF develops recommendations concerning the effectiveness of preventive care services for patients who do not have commonly related symptoms of a disease. 

According to the USPSTF, screening is the primary preventive service that providers should recommend for patients who are at risk of prostate cancer (Ahrq.gov, 2019). This recommendation method of making an accurate diagnose of prostate cancer was rejected by USPSTF.   This recommendation follows the bulk of evidence showing that this form of screening results in the detection of asymptomatic prostate cancer. For instance, a long-term follow-up the trial in the European Randomized Study of Screening for Prostate Cancer (ERSPC) established that PSA-based screening prevented only 1.28 for every 1,000 men from death (Schröder et al., 2014). Furthermore, in the study that was conducted results showed that screening that was done mainly with PSA method of determining prostate cancer one decreased the metastasis of cancer in 3 men ranging between the age of 55 to 69 years old.  In many cases, PSA-based screening detects asymptomatic cancer in men who have tumors that progress slowly or do not progress for the man’s lifetime (Schröder et al., 2014). Based on this evidence, diagnostic results drawn from PSA-based screening are considered over-diagnosis. It is the recommendation of the USPSTF that the patient’s serum PSA should be measured. Additionally, the USPSTF recommends the use of active surveillance of low-risk prostate cancer. This way, the risks associated with the harms from prostate cancer screening are minimized.   

Prostate Cancer Treatment Options 

There many established treatments plan that patients with prostate cancer can choose from the base on the progression of cancer. According to the National Cancer Institute (2019), there are currently seven standard treatment options that are being utilized for the treatment of prostate cancer and they consist of;  “watchful waiting or active surveillance, surgery, radiation therapy, and radiopharmaceutical therapy, hormone therapy, chemotherapy, biologic therapy, and bisphosphonate therapy” (American Cancer Institute).  

Watchful or surveillance treatment – this form of treatment is used for older patients who are not showing any symptoms and signs of the disease and do have any other medical issues. Patients are closely observed and are not treated until they began to show. Test such as digital rectal examination, prostate-specific antigen (PSA) and biopsy among other tests are performed to see if the cancer was progressing. If there is the growth of cancer then treatment would begin (National Cancer Institute, 2019) 

Surgical treatment –  This treatment option is available only when the cancer is localized only in the prostate and the patient is in optimal health condition (American Cancer Institute, 2019). There are various surgical techniques that are used when this type of treatment is used. Some potential complications that can occur with this form of treatment are; uncontrol outflow of feces and urine and shrinkage in the size of men’s penis (National Cancer Institute, 2019).  

Radiation therapy and radiopharmaceutical therapy– this form of treatment uses extreme high beam energy in various forms to kill cancerous cells and inhibit their growth. There different kinds of radiation therapy that are used to treat prostate cancer based on stage and type of cancer (American Cancer Institute, 2019). Patients can experience impotence and increase the risk of developing bladder and gastrointestinal cancer (American Cancer Institute, 2019).  

Hormone therapy – this treatment consists of inhibiting the production of certain hormones in males that are believed to link with prostate cancer, in doing this the cancer cells are unable to grow (American Cancer Institute, 2019). There are also various types of hormonal therapies that are associated with this form of treatment. Some potential complication is diarrhea, bone weakness and lack of sex drive or desire (American Cancer Institute, 2019).   

Chemotherapy – chemicals are used to destroy cancerous cells and prevent their growth (American Cancer Institute, 2019). The medication can be administered by mouth or intravenously.  Chemotherapy treatment can cause nausea, vomiting, hair loss, low white blood, and low platelet count, among numerous other complications (American Cancer Institute, 2019).   

Biologic therapy –  consist of using man-made chemicals to increase or restore the body’s capacity to ward off cancer.  One of the type of therapy that is being used is “Sipuleucel-T in order to treat prostate if it began to spread to other regions of the body” (American Cancer Institute, 2019). 

Bisphosphonate therapy- this form of therapy is currently mainly being used to decrease bone disorders that occurs when prostate cancer is spread to the bone (American Cancer Institute, 2019.  Clinical researches are being done to see is this form of medication therapy can prevent and inhibit prostate cancer metastasis to bones (American Cancer Institute, 2019).  

Factors That Impact Treatment  

The age and gender are the main factors that may impact the decisions related to the preventive services. The USPSTF explains that reductions in prostate cancer mortality are very low after PSA-based screening (Ahrq.gov, 2019). The decision to establish prostate cancer among optimal age range of patients between 55 and 65 years at risk using PSA-based screening presents the patients to the risk of bleeding, fever, pain, transient urinary difficulties and infections (Schröder et al., 2014). Besides, the decision for preventive services is impacted by the risk of gender-related factors such as bowl and erectile dysfunction.  

To reach cancer cells in the body, Androgen Deprivation Therapy (ADT) drugs can be used. These drugs work by destructing the testicular function (Yoo, Choi, You & Kim, 2016). The luteinizing hormone-releasing hormones (LHRH) are medications that are used to prevent the testicles from making testosterone. The drugs are administered yearly or monthly depending on the type of drug used. Additionally, anti-androgens are drugs that are used to block the entry of androgen receptors to the cells. The anti-androgens are administered to men whose prostate cancer is hormone-sensitive meaning that their cancer responds to therapies of testosterone suppression. These medications consist of nilutamide, flutamide, and bicalutamide. These drugs block CYP17, an enzyme that makes adrenal androgens.  

The use of drugs to destroy the cancer cells, referred to as chemotherapy, is a pharmaceutical intervention that works through ending the ability of these cells to grow and divide. For prostate cancer, such drugs as docetaxel and cabazitaxel are recommended by the FDA and are used in combination with specific steroids (Nevedomskaya, Baumgart & Haendler, 2018). These drugs are taken daily, and the dosage depends on the risk of the patient and the cancer stage. The drugs used in chemotherapy are often costly, despite being regarded as the safest and most patient-sensitive method of managing prostate cancer.  

Short- Term and Long-Term Effects of Treatment Options 

Cancer therapies of all nature expose the patient to a range of side effects that border on the reduced functional activities of the body (Livi, Isidori, Sherris & Gravina, 2014). In the short term, the ADT drugs may cause severe allergic reactions as they induce flares that are characteristic of extremely low testosterone levels. The potential long-term complications for ADT consist of bone pain which include osteoporosis and osteopenia, anemia, psychological and cognitive effects which include depression, and memory loss, various sexual dysfunction, and cardiac disorders (Sountoulides and Rountos, 2013). According to Sountoulides and Rountos, 2013) these sides effects can be reduced by  “educating patients about treatment side effects and coping strategies may result in improved psychosocial and physical health for prostate cancer patients undergoing ADT”. Other means to reduce long term side effects include doing the ADT treatment intermittently and by reducing the number of intracellular androgens without decreasing circulating testosterone levels(Sountoulides and Rountos, 2013).  The short-term side effects of chemotherapy drugs include nausea, loss of appetite, swelling, vomiting, muscle aches and infections. On the other hand, the long-term effects of these treatments range from low blood cells levels, hair and nail changes, loss of vision and seizures. Some long- term effects of chemotherapy do show up until later and some early side effects might continue to linger. Some potential long-term side effect of chemotherapy is damage to some cardiac muscles, cognitive and memory loss, especially short-term, infertility, trouble with hearing, scaring of the lungs, liver damage, peripheral neuropathy and kidneys and bladder damage (Eldridge, 2018). In order, the decrease potential mortality rates from these long-term complications from chemotherapy patients are encouraged to follow up regularly with doctors who specialized in areas of the body that are impacted by chemotherapy.  

Conclusion 

In this paper, age and gender have been identified as the main factors that may impact the decisions related to the preventive services as outlined by the USPSTF. The main preventative service recommended is screening, though the PSA-based screening that was traditionally used for prostate cancer has been disapproved due to the possibility of overdiagnosis. The paper identifies ADT, anti-androgens, and chemotherapy as the drugs used in managing prostate cancer.  As evidenced, different forms of pharmacotherapy used for prostate cancer can provoke different side effects. Of more significance is the need for healthcare providers to explain to the patient the therapeutic workings of these treatments and the potential side effects that manifest because of these treatment methods.  

 

 

 

 

References 

Ahrq.gov. (2019). Section 2. Recommendations for Adults (continued) | Agency for Healthcare Research & Quality. Retrieved from https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2c.html#prostate 

American Cancer Institute (2019). Prostate cancer treatment an overview. Retrieved from  

https://www.cancer.gov/types/prostate/patient/prostate-treatment-pdq#section/_142 

Eldridge, L.(2018). Long- term side effects of chemotherapy. Retrieved from   

https://www.verywellhealth.com/long-term-side-effects-of-chemotherapy-2248994 

Grossman, D., Curry, S., Owens, D., Bibbins-Domingo, K., Caughey, A., & Davidson, K. et al.  

(2018). Screening for Prostate Cancer. JAMA, 319(18), 1901. doi: 10.1001/jama.2018.3710 

Livi, L., Isidori, A., Sherris, D., & Gravina, G. (2014). Advances in Prostate Cancer Research and Treatment. Biomed Research International, 2014, 1-3. doi: 10.1155/2014/708383 

Nevedomskaya, E., Baumgart, S., & Haendler, B. (2018). Recent Advances in Prostate Cancer Treatment and Drug Discovery. International Journal Of Molecular Sciences, 19(5), 1359. doi: 10.3390/ijms19051359 

Schröder, F., Hugosson, J., Roobol, M., Tammela, T., Zappa, M., & Nelen, V. et al. (2014). Screening and prostate cancer mortality: results of the European Randomized Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. The Lancet, 384(9959), 2027-2035. doi: 10.1016/s0140-6736(14)60525-0  

Sountoulides, P and Rountos, T. (2013).  “Adverse effects of androgen deprivation therapy for prostate cancer: prevention and management,” Urology, doi:10.1155/2013/240108. 

You, S., Choi, S., You, D., & Kim, C. (2016). New drugs in prostate cancer. Prostate International, 4(2), 37-42. DOI: 10.1016/j.prnil.2016.05.001