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Today’s Topics

This article provides an overview of the different phases of the menstrual cycle and explains various methods of contraception. It discusses fertility awareness, physiological and barrier methods, chemical methods including birth control pills, long-acting chemical methods, emergency contraception, operative sterilization, and abortion procedures.

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Today’s Topics

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  1. Today’s Topics Contraception Infertility Menstrual Disorders

  2. Phases of the Menstrual Cycle • Proliferative Phase (Follicular) 6-14d • High Estrogen and FSHdevelop follicle • Ovulation • Secretory Phase (Luteal) 15-26d • High Progesterone, Decreasing Estrogen • Ischemic Phase 27-28d • Menstrual Phase 1-6d

  3. The Menstrual Cycle Olds, S. London, M., Ladewig, P., Davidson, M. (2004). Maternal-newborn nursing & women’s health care.(7th ed.). Upper Saddle River, NJ.: Prentice Hall. (p. 211).

  4. Contraception begins with Fertility Awareness • Ovulation • Ovum can be fertilized w/in 48 hrs • Sperm viable for 72 hrs • Problem pinpointing ovulation • Basal Body Temperature (BBT)[chart] • Progesterone increases = BBT increases • Take temp when awakened • Temp drops .2-.3 F; 24-36 before ovulation • Rises .7-.8 after ovulation--sample

  5. Contraception begins with Fertility Awareness • Cervical Mucous (Spinbarkeit) • More abundant, thin clear, stretchy mucous at ovulation • Thickens and less amount until menses • Other Symptoms • Mittelschmertz • Increased libido • Bearing Down Pain

  6. Physiological Methods • Calendar • Keep records for 6-8 months • 18 days from end of SHORTEST cycle • 11 days from end of LONGEST cycle • Abstain during “fertile” times • BBT—website with calendar • Billings Method

  7. Barrier Methods • Male Condom • Hold onto ring when withdrawing • Female Condom • Diaphragm • Refit after each childbirth • Use with Contraceptive Jelly • Leave in for 6 hours AFTER intercourse • If repeat intercourse, use more spermicide • Cervical Cap • Leave in for 8-48 hours

  8. Chemical Methods • IUD—Prevents fertilization • Mirena-5 years, SKYLA-3 yrs • Paragard -10 years • Risk of PID, Heavier periods (paragard), perforation, dysmenorrhea • Teach to  string after each menses • Spermicides • May have to wait to dissolve • Reapply with repeat intercourse • Use with diaphragm/condom • Non-oxinol 9—Kills HIV and other STD’s

  9. Chemical Methods—BCP’s • Types • Combination P & E • Progesterone ONLY “minipill” • Phasic • Side effects (table 4-2, pg 63; 10th ed) • Estrogen effects: N/V, weight gain, headaches, breast tenderness, etc. • Progesterone effects: acne, breast tenderness, ↓ libido, depression, fatigue, hirsuitism, weight gain, etc. • Contraindications • Thrombophlebitis, CHD, Breast CA, SMOKER • Some antibiotics DECREASE effectiveness

  10. Long-Acting Chemical Methods • Implanon • Lasts up to 3 years • Flexible plastic rod the size of a matchstick that is put under skin in the upper arm • Chief side effect: irregular bleeding • Depo-Provera • Injection 4 x / yr • Prolonged amennorhea or uterine bleeding

  11. Newer Chemical Methods • Contraceptive Patch • ORTHO EVRA • Contraceptive Ring • NuvaRing • A helpful website • http://www.ultimatebirthcontrol.com/

  12. Emergency Contraception • Take 2 BCP’s at once and 2 more 12 hours later • Use within 72 hours after unprotected intercourse • Prevents implantation

  13. Operative Sterilization • Male Vasectomy • Outpatient • 81-91% reversal • Ice for pain, swelling • NOT immediate sterility—up to 36 ejaculations to rid ducts of all sperm • Sperm count to verify • Female Tubal Ligation • Can be done with C/sec • General Anesthesia or epidural if done after vaginal delivery • 20 minutes • Less successful reversals

  14. Outpatient Sterilization • Essure-small metallic implant that is placed into the fallopian tubes under hysteroscopic guidance • Induces scar tissue to form over the implant, blocking the fallopian tube and preventing fertilization of the egg by the sperm

  15. 99.8% effective • Oral contraceptives are often prescribed at least one month prior to insertion to induce endometrial atrophy and to prevent an undiagnosed pregnancy • Paracervical blocks are given to anesthetize the perineum • NSAIDs and Diazapam can be given during the procedure to minimize discomfort • Educate patients to use alternate contraceptive methods until a hysterosalpingogram is performed 3 months after placement to confirm complete blockage of fallopian tubes • 99.8% effective

  16. Abortion • ElectivePerformed at woman’s request • Therapeutic performed for reasons of maternal or fetal health • 1st trimester • Roe v. Wade • 2nd trimester • States decide

  17. RU-486 • Combination of 2 drugs • Mifepristone is an anti-Progesterone drug that stops the early pregnancy from growing. • Misoprostol is the second drug and causes the uterus to contract and an early pregnancy to be expelled.

  18. Procedure • Confirm Pregnancy Blood test or U/S • Take Mefipristone (1 pill) • 2-4 days later, Take Misoprostol • Come back to office in 2 weeks—U/S to confirm NO pregnancy

  19. Side Effects • Abdominal cramping pain, bleeding, nausea, vomiting, and diarrhea, which may be extreme in some cases. • Dilatation and Curettage (D&C) may be needed in rare cases.

  20. Plan B Levonorgestrel • Emergency contraception-not effective if already pregnant • Reduces risk of pregnancy when take after unprotected sex • With in 72 hours after intercourse • No prescription required for 17 years and older, prescription needed 16 yrs and younger

  21. Plan B • Levonorgestrel works by stopping ovulation, fertilization, or implantation, depending on where a woman is in her cycle. • Side effects • Nausea, abdominal pain, fatigue, headache and changes in menstural cycle

  22. Assess patient’s knowledge, lifestyle, preferences, any cultural taboos or implications • Take a thorough patient history to identify any factors that put a patient at high risk for complications and rule out certain contraceptives. Nurse’s Role in Birth Control Counseling • Provide handouts, demonstration, discuss advantages and disadvantages of each method, • Allow time for questions and feedback

  23. Infertility Inability of a couple to produce a living child as a result of a failure to conceive or inability to carry the conceived child to a viable state after 12 months of unrestricted sexual relations

  24. Categories • Primary Infertility • Never having conceived a child • Secondary Infertility • Has conceived by cannot conceive again or carry a pregnancy to viability after 1 year of unrestricted sexual relations

  25. Causes of Infertility by Couple • Female Factor 50% • Male Factor 35% • Unexplained 10% • Other 5%

  26. Causes of Infertility in Women • Endocrine Sources • Ovulatory Dysfunction 40% • Anovulation or oligo-ovulation • Hyperprolactinemia • Hyper- and hypo- thyroidism • Premature ovarian failure • Genetic Defects---Turner’s Syndrome (XO) • Excessive Exercise and Dieting • Polycystic Ovarian Syndrome Altered FSH:LH ratio • Severe Emotional Stress

  27. Causes of Infertility in Women • Non-endocrine Causes • Tubal & Uterine Factors 40% • Block tubes (PID, endometriosis) • Uterine Fibroids or malformed uterus • Unexplained 10% • Other 10%

  28. Causes of Infertility in Men • Sperm Factors • Too few, Too slow, Too many malformed • Injury, mumps, high fever, radiation, • Substance abuse: ETOH, cocaine, marijuana, cigarettes • Meds: cimetidine, chemo, sulfas, erythromycin, tetracycline

  29. Causes of Infertility in Men • Endocrine Factors • Klinefelter’s syndrome (XXY) • Low testosterone levels • Excessive Prolactin levels • Non-Endocrine Factors • Obstructed vas deferens • Varicoceles

  30. Female Fertility Work-Up • BBT • Cervical Mucous • Endometrial Biopsy- • adequacy of secretory tissue in LUTEAL phase--effect of progesterone by corpus luteum • 7 days BEFORE onset of menses • Can have cramping afterwards

  31. Female Fertility Work-Up • Hystersalpingogram- • Dye instilled in uterus—Watch flow through fallopian tubes • Moderate discomfort • Laparoscopy • General Anesthesia • 6-8 months after Hysterosalpingogram • Referred shoulder pain • Evaluate for endometriosis, adhesions, tumors, cysts

  32. Male Fertility Work-Up • Sperm adequacy tests • Count • Motility • Morphology • Abstain for 2 days—Bring into lab within 1 hour after collection

  33. Couple Tests • Post-Coital Tests • 1-2 days prior to expected ovulation • Couple has intercourse • Go to MD within 4-6 hours • Aspirate cervical mucous from os • Evaluate mucous/sperm • Motility and Number

  34. Infertility Trx--Medications • Pg 200-203; 10th edition • Clomid-Estrogen Antagonist (po) • Take on days 5-9 • Induces Ovulation • Pergonal, Humegon or Repronex (hMG) • IM • Direct effect on pituitary,stimulate FSH/LH

  35. Infertility Treatments/Medications • Fertinex, Follistim and Gonal F • purified FSH given SQ • Start on day 2-4 of menstrual cycle • Watch growth of follicles via U/S and serum estradiol levels • Give hCG IM when follicles/levels OK • Have intercourse within 2 days

  36. Egg Retrieval

  37. Infertility Trx • Artificial Insemination • 1-2 days BEFORE ovulation • Fresh semen placed at cervical os • In-Vitro Fertilization (IVF) • Stimulate ovum production—Harvest eggs • Sperm and Egg meet in Test tube • Fertilized ovum transferred into uterus

  38. Infertility Trx • Gamete Intrafallopian Transfer (GIFT) • Sperm and egg transferred separately into fallopian tube where fertilization can occur • Go past cervical mucous • Zygote Introfallopian Transfer (ZIFT) • Fertilized zygote transferred into fallopian tube and then travels back into uterus to implant

  39. Other Alternatives • Adoption • Surrogate

  40. Nurse’s Role in Infertility Trx • Highly Sensitive Issue • Self-Esteem/Body Image • Marital Relations • Expensive

  41. Menstrual Cycle & Disorders • Menarche • Age at which menses begins • Usually about 13 y/o, range 10-16 • Menopause • Time when periods stop; 50-51 y/o • Initially periods are irregular, painless and anovulatory—BUT can get pregnant • Peri-menopausal period

  42. PreMenstrual Syndrome (PMS) • Affects 30-40% of all women • Three criteria need to be met • Symptoms occur in the luteal phase (after ovulation and 4-10 days before menses starts) • About 1 week w/o symptoms in follicular phase • Symptoms sever enough to interfere with life

  43. Characteristic Symptoms • Fluid Retention/ Bloating • Anxiety/Irritability • Agitation/ Arguementative • Depression/Crying • Lethargy • Panic Attacks • Accident Prone • Decreased concentration • Food Cravings • Salt & Sweets • Breast tenderness • Headaches/dizziness

  44. Causes of PMS • Unknown • Interaction between Estrogen and Progesterone--Progesterone Deficiency • Prolactin & Prostaglandin Excess • ? Role of Endorphins • Nutritional Deficiency—Mg ++

  45. Treatments • Track symptoms • BCP’s, Progesterone • Prostaglandin Inhibitors • Efamol • Mefenamic Acid 250mg/day in luteal phase • Danazol & Xanax less effective

  46. Toxic Shock Syndrome • Pyrogenic exotoxins from Staph. Aureus • 15-24 y/o, using tampons • Three Principal Clinical Manifestations • Sudden onset high Fever > 102 • HYPOtension, systolic < 90mm Hg • Rash—diffuse, macular, desquamation of palms and soles • Other S/S

  47. Treatment • Early dx is critical • IV fluid—trx dehydration • Antibiotics • Platelets • Meds for skin rash and hypotension

  48. Nursing Education Pg 104; 10th edition “Client Self-Care—Prevention of TSS”

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