Pharmacological Advaancements for Women's Reproductive Health Transitions

Women experience major reproductive health transitions across their lifespan including menarche, childbearing, and menopause [1]. Although these transitional phases and the accompanying hormonal changes are considered normal [1], for some women these transitions can lead to disruptive symptoms and challenging health considerations [2,3]. Two new pharmacological treatments for women experiencing difficult reproductive health transitions have recently been approved by the FDA and are now available. To effectively support women through reproductive transitions, health care providers must be knowledgeable about these new pharmacological options. As members of the health care team, nurses play a pivotal role in implementing the plan of care when new medications are prescribed for women experiencing challenging reproductive health transitions [4].

One of the new medications is Zuranolone, the first oral medication for treating postpartum depression (PPD) [5]. PPD, one of the most prevalent mental health complications of childbirth, affects up to 1 in 7 women [3]; however, it often goes untreated. Although PPD most often presents within the first few weeks to months after delivery, it can occur anytime within a year after birth or even during pregnancy [3]. There are multiple risks for PPD including psychological, obstetric, hormonal, biological, and social factors [6]. The stigmatization of mental health conditions is a significant barrier to obtaining needed treatment: many mothers may experience shame and fear of judgment which can delay or even prevent them from seeking help. When PPD is not adequately screened for and treated, it can lead to suicide, which is the leading cause of death for women with PPD [7]. Additionally, PPD affects the child’s health, altering emotional and intellectual development [8]. Effective and timely treatment is essential and may often include a pharmacological agent.

Zuranolone is a positive allosteric modulator of gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter in the brain. Enhancing the activity of GABA is known to create a calming effect, as GABA controls the hyperactive neurons linked with anxiety and fear [6]. Zuranolone is unique in its rapid onset, thus patients have the potential to feel better in a matter of days rather than weeks. In the case of PPD, where time is of the essence for mother-child bonding and the mother’s mental and physical health, a rapid onset medication is favorable [6].

Nurses working with postpartum women have the opportunity to appropriately screen for and identify those who may be experiencing PPD. Many women are concerned about starting a new medication while postpartum, especially because of safety concerns for their newborn, and may look to nurses for confirmation that this medication is a good option for them. Nurses can help women with PPD consider drug therapy for treatment by making them aware of it as an option and educating them about the potential benefits to both mother and child. Education will include instructions on how to take the medication (for 14 days only, in the evening with a high fat food), strategies to support adherence to drug therapy, not driving for 12 hours after each dose, and review of potential side effects and drug interactions (Zuranolone is metabolized by CYP450) [9]. Shared decision-making is important for lactating women as there is limited data about medication safety during breastfeeding [10]. Another nursing imperative is providing counseling regarding the need for contraception while taking this medication due to potential fetal harm [11]. By providing education and supporting patients with both pharmacological decision-making and destigmatization of maternal mood disorders, nurses are instrumental in providing high quality care for patients experiencing PPD.

Another reproductive health transition is menopause. The menopause transition can be prolonged and challenging, with an average duration of ten years [12,13]. The most prevalent symptoms during the menopause transition are vasomotor symptoms (VMS) which affect over 80% of women [12,13]. VMS can be debilitating, leading to diminished sleep quality, changes in mood, along with decreased quality of life, interpersonal relationships, libido, job satisfaction, and workplace productivity; thus, negatively impacting both physical and psychosocial well-being [15]. Hormone therapy with estrogen +/progesterone is the gold standard for treating VMS, however not all women are candidates for hormone therapy. Unfortunately, older non-hormonal or nonpharmacological options are less effective [16,17].

A recently approved selective neurokinin 3 receptor (NK3R) antagonist, Fezolinetant, offers a novel nonhormonal approach to the treatment of VMS. VMS are believed to occur as a result of hypersecretion of neurotransmitters from the KNDy (kisspeptin/ nuerokininB/dynorphin) neurons. Fezolinetant blocks the activation of the KNDy neurons, resulting in a decrease in neurotransmitter secretion and thus fewer VMS [14,17].

Here again nurses can be instrumental in identifying potential candidates for this non-hormonal option and providing education to support decisionmaking. In addition to providing education regarding dosing instructions (e.g., setting reminders to take pills on time and swallowing pills intact), nurses should also conduct a thorough health and medication history to assess for conditions and drug interactions that could lead to higher concentrations of Fezolinetant and necessitate dose reductions. Furthermore, providing instructions about the need for blood work in the first nine months (due to the potential for transient elevations in liver enzymes) and monitoring those levels is a key nursing responsibility [18].

In the past, there has been a lack of focus on women’s health studies for decades due to discrimination in funding [19]. However, now that promising pharmacological treatment options are available for women suffering from PPD or VMS, women’s health care providers are equipped with a more comprehensive arsenal to effectively manage complications during childbearing and menopausal transitions. Nurses are in a unique position to support women during these reproductive life transitions. Early recognition is crucial to managing PPD effectively and decreasing the symptom burden of VMS. For women experiencing PPD or troublesome VMS, being able to discuss treatment options will lead to individualized plans of care that best meet their treatment goals. By assessing individuals experiencing distressing symptoms, counseling them about symptom management options, and monitoring response to treatment, nurses are key members of the women’s health care team.

Mary Fischer PhD MSN WHNP-BC MSCP Assistant ProfessorTan Chingfen Graduate School of NursingUMass Chan Medical School mary.fischer@umassmed.eduAudrey O’Neill, RN PMHNP-DNP Candidate in the Tan Chingfen Graduate School of NursingUMass Chan Medical School. audrey.oneill@umassmed.edu

David Runyan, FNP-BC, RN, NRP DNP Candidate in the Tan Chingfen Graduate School of NursingUMass Chan Medical School. David.Runyan@umassmed.edu.

Teri Aronowitz, PhD, APRN, FNP-BC, FAAN Professor & Associate Dean of Research & InnovationTan Chingfen Graduate School of NursingUMass Chan Medical School. terese.aronowitz@umassmed.edu