Chapter 18
The Reproductive System and
Drug Therapy
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Chapter 18
Topics
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Anatomy and Physiology of the Reproductive System
Menopause
Hypogonadism
Erectile Dysfunction (ED)
Contraception
Infertility
Sexually Transmitted Diseases (STDs)
Herbal and Alternative Therapies
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Anatomy and Physiology of the Reproductive System
The Reproductive System
• It is responsible for procreation and fetal development
• Females produce ova from the ovaries; males produce
sperm from the testes
• The ovum and sperm combine during fertilization to form
an embryo
• HPA axis regulates male and female reproductive systems
• The pituitary gland releases FSH and LH, stimulating sex
hormone production from the ovaries and testes
 Sex hormones: estrogen and progesterone (more in
females), testosterone (more in males)
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Anatomy and Physiology of the Reproductive System
Sex Hormone
Production
and Control
• The male and
female
reproductive
systems
respond to a
negative
hormonal
feedback loop
system
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Anatomy and Physiology of the Reproductive System
Female Reproductive System
• The ovaries, fallopian tubes, uterus, cervix, and vagina
• In response to FSH from the pituitary gland, the ovaries
produce ova, which travel via fallopian tubes to the uterus
• Fertilization occurs if sperm is present; the zygote implants
into the endometrial lining and develops into an embryo
• Embryo releases HCG (the pregnancy hormone) which
causes progesterone and estrogen levels to rise
• If no fertilization, uterine lining sloughs off (menstruation)
• Menstrual cycle is regulated by FSH, LH, estrogen, and
progesterone; restarts about every 28 days
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Anatomy and Physiology of the Reproductive System
Female
Reproductive
Anatomy
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Anatomy and Physiology of the Reproductive System
Fertilization and Implantation
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Anatomy and Physiology of the Reproductive System
Female Sex Hormone: Estrogen
• Significant production begins at puberty; tapers off during
menopause (fifth decade, ages 40–49)
• Primary female sex hormone; responsible for female sex
characteristics such as breast enlargement
 Also regulates endometrial growth, cervical mucus
production, bone health, cessation of height in girls
• Hormone affects sodium retention, cholesterol levels,
calcium use, carbohydrate metabolism, blood coagulation
• Levels rise during the days leading up to menstruation
• Indication (women): contraception, menopausal
symptoms
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Anatomy and Physiology of the Reproductive System
Female Sex Hormone: Progesterone
• Referred to as progestin when produced in the body
• Hormone suppresses LH production, thickens cervical
mucus, alters the endometrial lining to support embryo
implantation, maintains pregnancy
• Progesterone levels
 Affect insulin levels, glucose tolerance, fat deposition,
body temperature; changes needed for pregnancy
 Rise in pregnancy; decline in menopause
• Indications (women): contraception, infertility,
menopausal symptoms
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Anatomy and Physiology of the Reproductive System
Female Sex Hormone: HCG
• Presence indicates that an embryo has implanted in the
uterus and a placenta has started to form
• Steep rise signals pregnancy; the body starts physiological
changes that prepare for and maintain pregnancy
• When present in measurable concentrations in the blood
or urine, a diagnosis of pregnancy is made
 Home pregnancy tests measure HCG
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Anatomy and Physiology of the Reproductive System
Male Reproductive System
• Testes (testicles), epididymis, ductus deferens (vas
deferens), seminal vesicles, prostate gland, urethra, penis
• It facilitates sexual reproduction and eliminates urine
• Sperm cells are made in the testes, mature in the
epididymis, then move through the ductus deferens
• During sex, sperm combine with semen (fluid produced by
seminal vesicles) and are ejaculated through the urethra
• Sperm delivered into a woman’s vagina near the cervix;
travel to the fallopian tubes to fertilize an ovum
• Continual production of male sex hormones
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Anatomy and Physiology of the Reproductive System
Male Reproductive Anatomy
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Anatomy and Physiology of the Reproductive System
Male Sex Hormone: Testosterone
• Primary androgen in males; responsible for sperm
production and maturation of male genitalia
• Also responsible for secondary sexual characteristics
during puberty: pubic hair, increased libido, bone and
muscle development, fat distribution
• Testosterone levels decline with age, initiating changes
 Decreased testicular size
 Muscle weakness
 Reduced bone density
 Decreased energy, mood, and libido
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Menopause
About Menopause
• Permanent cessation of menstruation; the
absence of menses for at least 12 months
• Process begins with perimenopause (for 3 to 5 years)
 Menstrual cycles become erratic; hormone levels
fluctuate; fertility declines
• During menopause
 Ovarian follicle activity stops; estrogen levels drop 40 to
60%; progesterone levels fall dramatically
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Menopause
About Menopause (continued)
• Lack of estrogen causes vasomotor spasms, irregular
menstrual bleeding, vaginal dryness and atrophy
 Also causes mood swings and memory impairment
• Some women take HRT (estrogen supplements) to mitigate
the impact of declining estrogen during menopause
• Menopause is associated with osteoporosis (bone
thinning) and increased risk for heart disease and stroke
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Menopause
Hormone Replacement Therapy (HRT)
• Indication: relief from menopausal symptoms
• For years, HRT was prescribed as a method that offered
protection against heart disease, stroke, and osteoporosis
• New research studies indicate that HRT increases the risks
of breast, endometrial, and ovarian cancers in women
• The current standard of practice for HRT is to use the
lowest dose necessary for the shortest time possible
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Menopause
HRT: Estrogen and Progesterone
• Estrogen
 Estrogen products usually are ethinyl estradiol, from
natural or equine (horse) sources
 Conjugated estrogens are sodium salt forms of estrogen
from pregnant mare urine
• Progesterone
 Progesterone products are synthetic agents or natural
• Estrogen and progesterone are taken in combination to
reduce risk of endometrial cancer
• Indication: relief of menopausal symptoms
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Menopause
HRT: Estrogen and Progesterone (continued)
• Route: oral or transdermal patch
• Natural-source HRTs are specially compounded in the
pharmacy and are often used topically; may produce fewer
short-term side effects
• Side Effects (common): dizziness, abdominal pain or
bloating, diarrhea, nausea, headache, hair loss, depression
• Side Effects (other): dark skin patches on face (melasma)
• Cautions: contraindicated in patients with a history of
breast, endometrial, or ovarian cancer; patients with
cardiovascular disorders should probably avoid
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Your Turn
Question 1: How does a patient know if she is in menopause?
Answer: She is in menopause if she has not menstruated for
at least twelve months.
Question 2: How is the route of administration different between
synthetic hormone replacement products and natural-source
hormone replacement products?
Answer: Synthetic hormone products are taken orally or
applied as a transdermal patch, whereas natural-source
products are often used topically on the skin.
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Hypogonadism
Hypogonadism
• Underproduction of testosterone in males
 Associated with obesity and Type 2 diabetes
• Andropause: decline in androgen (testosterone)
production that occurs with age
• Symptoms (for both): fatigue, low sexual desire, weakness,
ED, poor sleep, depression, irritability, memory loss
Testosterone
• Indication (common, males): hypogonadism
 May also be used in females to treat metastatic breast
cancer or, occasionally, as an adjunct to HRT
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Hypogonadism
Testosterone (continued)
• Testosterone is a controlled substance (Schedule III); can
be used as a physical performance enhancement drug
 Produces larger muscle mass, improves strength and
speed
• Testosterone and related compounds are called anabolic
steroids
• Technicians: testosterone products require special storage,
labeling, and handling
 Some states also require the patient’s medical diagnosis
be written on the face of the prescription
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Erectile Dysfunction
About ED
• Failure to initiate or maintain an erection until ejaculation
• Also called male impotence
• Studies show that 40 to 50% of patients with heart disease
have ED
• Other causes include testosterone deficiency, high BP,
alcoholism, cigarette smoking, diabetes with microvascular
problems, psychological factors, and medications
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Erectile Dysfunction
Drugs that Can Cause ED
• Alcohol
• Ketoconazole
• Antidepressants,
especially selective
serotonin reuptake
inhibitors (SSRIs)
• Methyldopa
• Cimetidine
• Thiazide diuretics
• Nicotine
• Spironolactone
• Clonidine
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Erectile Dysfunction
Drugs for ED: PDE-5 Inhibitors
• First-line drug therapy; typically listed in the top 50 drugs
dispensed in pharmacies
• Mechanism of Action: relax smooth muscle in penis which
eases blood flow to the area, facilitating erection
• Route: oral; taken one hour or more prior to sexual activity
• Side Effects: headache, heartburn, nausea, flushing
• Side Effects (severe): priapism (seek medical attention)
• Cautions: patients should not take with alpha blockers
or nitrates; can interact with several other
medications
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Erectile Dysfunction
Drugs for ED: Alprostadil
• A prostaglandin that is a second-line drug therapy
• Mechanism of Action: relaxes smooth muscle in penis,
blood flow increases and causes an erection
• Route: intracavernosal injection into base of penis or
urethral insertion of pellet
• Side Effects: pain or burning in the penis, urethra, or testes
• Cautions: interacts with several other medications
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Erectile Dysfunction
Drugs for ED: Yohimbine
• Third-line drug therapy
• Mechanism of Action: blocks alpha-2 receptors and
enhances parasympathetic nervous system effects
• Route: oral
• Side Effects: BP changes, nervousness, irritability, tremor,
dizziness, nausea, headache, skin flushing
• Cautions: contraindicated in patients taking
antidepressants; should probably be avoided in patients
with hypertension
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Contraception
About Contraception
• The prevention of pregnancy through artificial means
• Four approaches to birth control
 Physical or pharmacologic barriers that prevent sperm
and egg from coming into contact
 Drug therapy that prevents ovulation from occurring
 Drug therapy that prevents implantation of a fertilized
egg in the uterus
 Abstinence from intercourse during days in menstrual
cycle when conception is likely (rhythm method)
 High pregnancy rate
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Contraception
Condoms, Diaphragms, and Other Barrier Methods
• Methods that form a physical barrier preventing sperm
from entering the uterus through the cervix
• They are put in place prior to intercourse, left for a specific
amount of time, then removed
• Male condom and female condom (latex and polyurethane
are best); only method that lowers risk of STD transmission
• Diaphragms and cervical caps (rubber, latex, silicone) are
bordered with a rounded ring; fit over cervix inside vagina
 Work best when used with a spermicide (kills sperm)
 Are prescription items; fitted to a woman’s anatomy
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Contraception
Oral Contraceptives
• Contain ethinyl estradiol (synthetic estrogen) and one of
several synthetic progesterones (progestin or progestins)
• Indication: manipulate hormones to prevent ovulation and
change cervical mucus texture
• Mechanism of Action (estrogen): suppress production of
LH (hormone that triggers ovulation)
• Mechanism of Action (progesterone): suppress production
of LH, thicken cervical mucus (impedes sperm travel)
• Route: oral; taken daily to maintain a steady and
elevated hormone level
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Contraception
Oral Contraceptives (continued)
• Some oral products contain only progestin or progestins
 Less hormones reduce side effects (headaches, high BP)
 Products used if oral contraceptives not appropriate,
such as women who are older than age 35, have high
BP or heart disease, have clotting disorders, or smoke
 Missed doses more quickly affect failure rate
• Combination oral contraceptives come in monophasic,
biphasic, and triphasic dosing regimens
• Extended oral regimens: menstrual cycle every 3 or 4
months
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Contraception
Emergency Oral Contraceptives
• Plan B and Preven are taken within 72 hours of
intercourse, with second dose 12 hours later
• Both prevent ovulation, alter tubal transport of sperm and
ovum, or inhibit implantation
• Both do not work if fertilized egg has implanted (i.e.,
patient is already pregnant)
• OTC product; kept behind the counter; patient must be 18
years old
 Only a pharmacist or prescriber can order
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Contraception
Oral Contraceptives: Side Effects and Cautions
• Side Effects (common): weight gain, nausea, vomiting,
bloating, increased appetite, fatigue, headaches, edema
• Side Effects (other): breakthrough bleeding (blood flow in
the middle of a menstrual cycle) can occur
• Cautions: Avoid in patients with clotting disorders, heart or
cerebral vascular disease; smokers run higher risk of heart
attack, blood clots, stroke; weigh benefits/risks if history of
breast and reproductive system cancers; many drug
interactions, reducing effectiveness
• Technician: special packaging and dispensing regulations
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Contraception
Transdermal Contraceptives
• Adhesive patches that deliver estrogen and progesterone
in a steady supply through the skin
• Mechanism of Action: alter the menstrual cycle, prevent
follicle maturation and ovulation, thicken cervical mucus
• Route: transdermal; one patch is applied each week for 3
weeks and then left off for 1 week during menstruation
• Side Effects: breast tenderness, headache, application site
irritation, nausea, menstrual cramps, abdominal pain
• Cautions: if patch detaches, follow instructions to reapply
or replace and for use of backup birth control
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Contraception
Vaginal Contraceptives
• The vaginal ring is a combination birth control that
contains synthetic estrogen and progesterone
 It is inserted into the vagina every 3 weeks, then
removed for 1 week while menstruation occurs
• The sponge is made of a latex porous material that is
infused with a spermicide that kills sperm on contact
 Inserted 12 to 24 hours prior to intercourse, then left in
place for 6 hours after intercourse
• Side Effects (vaginal ring): headache, nausea, vaginal
secretion, vaginitis, bloating, cramps, weight gain
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Contraception
Vaginal Contraceptives (continued)
• Side Effect (sponge): vaginal irritation
• Cautions (vaginal ring)
 When stored in the pharmacy, vaginal ring must be
refrigerated to maintain potency; also, technicians
should warn patients to refrigerate until use
 If the vaginal ring is removed or expelled, follow
instructions for replacing and backup birth control
• Caution (sponge)
 If sponge is left in vagina more than 24 hours, higher
risk of bacterial infection and toxic shock syndrome
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Contraception
Injections, Implants, and Intrauterine Devices
• Three contraception methods with hormonal therapy that
are used to prevent pregnancy for months to years
• Medroxyprogesterone (Depo-Provera) is injected every 3
months; etonogestrel (Implanon) is implanted for 3 years
 Both agents administered by healthcare provider
 Both inhibit ovulation, thicken cervical mucus, and
change the endometrium to inhibit implantation
• Many kinds of IUDs are available; placed into the uterus by
healthcare provider every 5 years
 Most contain progesterone which alters endometrium
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Contraception
Injections, Implants, and Intrauterine Devices
(continued)
• Side Effects (medroxyprogesterone, common): menstrual
irregularity, abdominal pain, weight changes, dizziness,
headache, weakness, fatigue, nervousness
• Side Effects (etonogestrel, common): menstrual bleeding,
weight gain, mood swings
• Side Effects (IUDs, common): septicemia, pelvic infection,
uterus perforation, vaginitis, tubal damage, abnormal
menstrual bleeding, anemia, cramping, backaches
• Cautions: Injections, implants, and IUDs should not be
used during pregnancy
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Contraception
Mifepristone and Misoprostol
• Indication: taken to terminate a uterine pregnancy during
the first 49 days of pregnancy; requires 3 physician visits to
determine gestational age of embryo
• Mifepristone is only supplied to physician offices that
abide by strict monitoring and therapy guidelines
 Pharmacies do not dispense
Home Pregnancy Tests
• Tests measure the presence of HCG in the urine;
can be used on day one of a missed period
• HCG can be detected 6 to 8 days after conception
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Your Turn
Question 1: What is a restriction of PDE-5 inhibitors?
Answer: Patients should not take them if they are already
taking nitrates or alpha blockers.
Question 2: A patient wants to take a contraceptive to prevent
pregnancy. She does not want to have to remember to take or
use it regularly. What are the likely contraceptive options the
healthcare prescriber will suggest? Why?
Answer: The healthcare provider probably will suggest
contraceptive injections, implants, or IUDs. These three
contraceptive methods use hormonal therapy to prevent
pregnancy for months to years.
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Infertility
About Infertility
• Infertility is the inability to achieve pregnancy after one
year of regular, unprotected sexual intercourse
 Up to 10% of the U.S. population face fertility issues
• Problems with infertility may lie in the female’s, male’s, or
both reproductive systems
• Causes (women): PID, hormonal imbalance, anatomic
problems, PCOS, endometriosis
• Causes (men): infectious diseases, anatomic problems,
immunologic factors, lifestyle factors that inhibit sperm
(tight clothes, hot tubs, high alcohol/caffeine intake)
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Infertility
Drugs for Infertility
• ART: specialized practice that matches drug therapy and
other treatment to the specific cause for infertility
• Ovulation induction: process of using hormones to
stimulate ovaries to produce and release multiple ova
• Artificial insemination: process that introduces semen
containing sperm into a woman’s uterus during ovulation
• In vitro fertilization: eggs are artificially fertilized with
sperm, then placed into woman’s uterus for implantation
• These agents usually dispensed by specialty pharmacies
due to their high cost and specialized use
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Infertility
Home Ovulation Tests
• Ovulation tests are used to identify the 24- to 48-hour
period when ovulation occurs
 Identification of peak ovulation period improves
chances of pregnancy
• Home ovulation predictor kits measure either body
temperature or hormonal fluctuation to predict ovulation
• Urine test kits detect the LH surge that occurs prior to
ovulation
 Includes 5–7 tests
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Sexually Transmitted Diseases (STDs)
About STDs
• Infections that affect the reproductive system in males and
females that are transmitted through sexual contact
• Caused by bacteria (can be cured) and by viruses (cannot
be cured, only treated for symptoms)
• Chlamydia: infection caused by organism with qualities of
both bacteria and viruses; most common STD in U.S.
• Gonorrhea: gram-negative bacterial infection; if untreated,
can affect the heart, brain, eyes, pharynx, and joints
• Syphilis: bacterial infection; if untreated, can affect the
CNS and CV systems; has four stages
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Sexually Transmitted Diseases (STDs)
About STDs (continued)
• Vaginosis: inflammation and infection of the vaginal
mucosa; caused by bacteria or by yeast-like fungus
• Genital herpes: viral infection caused by the herpes
simplex virus; not curable and usually recurs
• HPV: virus causing wart-like lesions appears in genital
region; virus is closely linked to cervical cancer in women
 A vaccine to prevent HPV is available for young women
• AIDS: viral infection transmitted through exchange of
bodily fluids (sexual activity, blood transfusion)
 Immune system cannot fight infection; patient dies
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Sexually Transmitted Diseases (STDs)
Disease Treated
Drugs of Choice
AIDS
NRTIs, NNRTIs, PIs, and enfuvirtide
Chlamydia
Doxycycline, azithromycin, or erythromycin
Genital herpes
Acyclovir, valacyclovir, or famciclovir
Gonorrhea
Ceftriaxone or a fluoroquinolone
HPV
Imiquimod, podofilox, or other therapies
Syphilis
Penicillin, doxycycline, or tetracycline
Vaginosis: bacterial Metronidazole, clindamycin
Vaginosis: yeast
Vaginal candidiasis products
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Herbal and Alternative Therapies
• Soy (isoflavone or phytoestrogen) is a plant source of
protein taken for some menopausal symptoms
 Can cause stomach upset, diarrhea, bloating, nausea,
constipation, and insomnia; can worsen migraines
• Black cohosh is a plant product with estrogenic effects
taken for menopausal symptoms
 Avoid for patients with liver disease and in those who
are pregnant or breast-feeding
• Evening primrose oil taken for menopause or PMS
• Wild yam (Mexican yam) is a phytoestrogen similar to soy
with mild estrogenic effects
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Summary
• Estrogen and progesterone are hormonal therapies for
menopausal symptoms
• The hormone testosterone is used for hypogonadism
• PDE-5 inhibitors are used for erectile dysfunction
• Estrogen and progesterone are hormonal therapies used
in oral, transdermal, vaginal, and IUD contraceptives
• ART matches drug therapy to specific causes for infertility
• Antibiotics are used to treat bacterial STDs, and antivirals
are used to treat viral STDs
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