Lecture Sixteen: Care of the Client Experiencing Reproductive Dysfunctions

1. Lecture Sixteen: Care of the Client Experiencing Reproductive Dysfunctions NURS 2208 Fall 2002 T. Dennis RNC, MSN

2. Reproductive Dysfunctions Discuss the female menstrual and reproductive cycles. Identify common terms associated with reproductive dysfunctions. Discuss the clinical manifestations and therapeutic management of reproductive dysfunctions. Identify data to be included in the assessment of a client with reproductive disorders. Formulate appropriate nursing diagnoses. Select appropriate nursing interventions for a woman with reproductive dysfunction.

3. Education Nurses should provide girls and women with clear information about menstrual issues, such as use of pads and tampons (including warnings regarding deodorant and absorbency); vaginal spray and douching practices; self-care comfort measures during menstruation, such as maintaining good nutrition, exercising, and applying heat and massage.

4. Menstruation (pg.40) Menarche: Beginning of menstrual and reproductive function in the female. Average age 12 years. Menstrual cycle: cyclic buildup of the uterine lining, ovulation, and sloughing of the lining occurring approximately every 28 days in non-pregnant females. Menorrhagia: Excessive or profuse menstrual flow. Hygiene: Tampons (change frequently regardless of blood flow), pads (change frequently), vaginal sprays (unnecessary and may cause irritation) and douching (sometimes used to treat vaginal infections but contraindicated for hygiene purposes, may contribute to endometriosis).

5. Amenorrhea (pg. 42) Suppression or absence of menstruation. Primary : 1) occurs when menstruation has not been established by age 18. 2) may be caused by congenital anomalies, or absence or imbalance of hormones. Secondary: 1) occurs when an established menses of 3 months ceases. 2) common causes pregnancy, lactation, hormonal imbalances, poor nutrition, stressful life events, etc. Treatment is dictated by causative factors. Once the underlying factors have been addressed, menses returns to the normal pattern.

6. Dysmenorrhea Usually begins at or a day before, the onset of menses and disappears by the end. Treatment: Hormone therapy (eg., oral contraceptives), nonsteroidal anti-inflammatory drugs, or prostaglandin inhibitors (ibuprofen, aspirin, naproxen) can alleviate dysmenorrhea. Primary: cramps without underlying disease process. Secondary: associated with pathology of the reproductive tract and usually appears after menstruation has been established. Includes: endometriosis, pelvic inflammatory disease (PID), Self-care measures include: improving nutrition, exercising, applying heat, and getting extra rest. Avoid salt intake during menstruation, use a heating pad on the abdomen, daily exercise such as walking.

7. Premenstrual Syndrome (PMS) (pg. 43) Occurs most often in women over thirty. Symptoms include: irritability, depression, migraines, vertigo, rhinitis, nausea, vomiting, abdominal bloating, urinary retention, acne, weight gain, and mammary swelling and tenderness. Symptoms occur 2 to 3 days before the onset of menstruation and subside as menstruation starts, with or without treatment. Medical management usually includes progesterone agonists and prostaglandin inhibitors. Self-care measures include: improving nutrition (taking vitamin B complex (especially B6) and E supplements), and avoiding methylxanthines, found in chocolate and caffeine, undertaking a program of aerobic exercise, and participating in self-care support groups.

8. Menopause (pg. 58-60) The time when menses cease. Current median age is 51.3 years but may occur between ages 45 to 52. Perimenopause: a normal life transition that begins with the first signs of change in the menstrual cycles and ends 6 to 12 months after menopause. Perimenopause is marked by irregular menstrual cycles and hot flashes, shorter and lighter menses, occasional missed periods, abnormal FSH levels, increased vaginal dryness, and night sweats. Menopause is the single day that marks the last naturally occurring menstrual period. The date is determined in retrospect one year from the last period. So contraception must be used for that year.

9. Menopause (pg. 58-60) Psychological aspects: Menopause in the past has had a negative connotation. New research and treatments have diminished some negative aspects. Physical aspects: Age of onset may be influenced by overall health, nutritional, cultural, lifestyle and genetic factors. Onset occurs when estrogen levels become so low menstruation stops. Generally ovulation stops 1 to 2 years before menopause. 2 to 4 years prior to menopause changes in cycles may occur. Uterine endometrium, myometrium, cervical glands, fallopian tubes and ovaries atrophy. A vasomotor disturbance known as hot flashes occurs.

10. Menopause (pg. 58-60) Long range physical changes include Osteoporosis. Osteoporosis is a decrease in bony skeletal mass. Associated with decreased estrogen levels causing imbalances in bone formation and resorption. Weight gain Increased risks for coronary artery disease, hypertension, and strokes.

11. Menopause (pg. 58-60) Medical Therapy may include Hormone replacement therapy (HRT): administration of hormones, usually estrogen and progestin, to alleviate the symptoms of menopause. Benefits: Stops hot flashes and night sweats ? incidence of coronary artery disease Prevention and treatment of bone loss Improved bladder and vaginal tone May improve memory Risks: ? risk of gallbladder disease, venous thrombosis, endometrial cancer, breast cancer and systemic Lupus Dosage: Estrogen is given the first 25 days of the month then progestin is added during the last twelve days.

12. Menopause (pg. 58-60) Prevention and treatment of osteoporosis: Prevention is the primary goal of care. Calcium intake of 1200 to 1500 mg per day for clients > 50 years of age. Calcium supplements are most efficient when taken with a meal and when single doses do not exceed 500mg. Participation in regular exercise program. Fosamax (alendronate) inhibits bone resorption and increases bone mass. Recommended for women who cannot take estrogen. Must be taken on an empty stomach with water at least 30 minutes before any other fluid, food or medicine.

13. Menopause (pg. 58-60) Alternative and Complementary Therapies: Diet rich in calcium and vitamins, E, D, and B complex. Phytoestrogens include carrots, yams and soy products. Avoid caffeine, alcohol and spicy foods. Begin weight bearing exercise: walking, jogging, running. Practice relaxation techniques Herbal remedies may include ginseng to relieve symptoms of hot flashes, headaches and fatigue. Keeping a cool environment and drinking cool fluids may alleviate hot flashes. Kegel exercises are important in maintaining vaginal and bladder tone. Vaginal lubricants may alleviate vaginal dryness (decreased libido may occur).

14. Endometriosis (pg. 63) Condition characterized by the presence of endometrial tissue outside the uterine cavity. Can be found in the vagina, lungs, cervix, central nervous system and GI tract. Most common location is the pelvis. Tissue responds to the hormonal changes of the menstrual cycle and bleeds in a cyclic fashion. Results in inflammation, scarring of the peritoneum, and formation of adhesions. Most common symptom of endometriosis is pelvic pain.

15. Endometriosis (pg. 63) Treatment: Medical, surgical intervention or both. Laser vaporization under laparoscopic examination. Hysterectomy with bilateral salpingo-oophorectomy. Mild disease: NSAIDS and analgesics. Other medications include: oral contraceptives, progestins, antiprogestins, and gonadotrophin-releasing hormones (GnRH). Danazol is an antiprogesterone treatment that is frequently used: suppresses GnRH which suppresses ovulation and causes amenorrhea. Side effects include: hirsutism, acne, weight gain and vaginal bleeding.

16. Danazol Danacrine: 400 mg po bid Therapeutic classification: Hormones Pregnancy category: X Indication: Treatment of moderate endometriosis that is unresponsive to conventional therapy. Adverse reactions: amenorrhea, weight gain, voice changes, decreased breast size. Caution: Pregnancy should be avoided while on this medication.

17. Endometriosis (pg. 63) Nursing Assessment: Thorough history Understanding of condition Diagnosis: Pain related to peritoneal irritation secondary to endometriosis Ineffective Individual Coping related to depression secondary to infertility. Nursing Plan: Explain condition, symptoms, treatment alternatives, and prognosis. Review medication knowledge. Review need to make choices considering not postponing pregnancy. Support the client by being nonjudgmental.

18. Toxic Shock Syndrome (pg. 64) Associated with the use of super-absorbent tampons. Causative organism is staphylococcus aureus. Common signs: fever, desquamation of skin (especially the palms of hands and soles of feet), rash, hypotension, dizziness, vomiting, diarrhea, and disorders of the central nervous system. Treatment includes: hospitalization with supportive therapy including intravenous therapy to maintain blood pressure. Severe cases may require renal dialysis, administration of vasopressors, and intubation. Education: Change tampons every 3 to 6 hours and avoid use of super-absorbent tampons. Alternate tampons and pads and use only pads overnight.

19. Pelvic Inflammatory Disease (PID) (pg. 72) An infection of the fallopian tubes (salpingitis) that may or may not be accompanied by a pelvic abscess; may cause infertility secondary to tubal damage. Disease is more common in women who have had multiple sexual partners, a history of PID, early onset of sexual activity, a recent gynecologic procedure, or an intrauterine device. Causative organisms include: Chlamydia trachomatis and neisseria gonorrhoeae. Symptoms include: bilateral sharp cramping pain in the lower quadrants, fever, chills, purulent vaginal discharge, irregular bleeding, malaise, nausea, and vomiting. Possible to be asymptomatic and have normal lab values.

20. Pelvic Inflammatory Disease (PID) (pg. 72) Clinical therapy: Diagnosis consists of a clinical examination to define symptoms, blood tests, and culture for Chlamydia and GC. Direst abdominal tenderness with palpation, adnexal tenderness, and cervical and uterine tenderness with movement. Laparoscopy may be used to obtain cultures and confirm diagnosis. Hospitalization with intravenous administration of antibiotics. Sexual partner should also be treated.

21. Pelvic Inflammatory Disease (PID) (pg. 72) Nursing Assessment: Thorough history (IUD) Alert to risk factors for condition Symptoms of lower abdominal pain, malaise, foul smelling discharge Diagnosis: Pain related to peritoneal irritation Knowledge deficit related to lack of information about possible infertility Nursing Plan: Explain condition, symptoms, treatment alternatives, and prognosis. Review medication knowledge. Discuss signs and symptoms of PID and stresses the importance of early detection. Support the client by being nonjudgmental.

22. Abnormal Uterine Bleeding (pg.74) Dysfunctional uterine bleeding (DUB): characterized by anovulatory cycles with abnormal uterine bleeding that does not have an identifiable cause. Oligomenorrhea: scanty or infrequent menstrual flow Polymenorrhea: occurring with abnormal frequency Menorrhagia: excessive bleeding Metrorrhagia: spotting or breakthrough bleeding Menometrorrhagia: irregular and excessive menstrual flow Intermenstrual bleeding: bleeding between menses

23. Abnormal Uterine Bleeding (pg.74) Diagnosis is made by excluding organic causes Lab tests: Pap smear, thyroid function studies, pregnancy test and possible endometrial biopsy. Goals of treatment: control bleeding, prevent or treat anemia, prevent endometrial hyperplasia or cancer, and restore quality of life. Pharmacologic treatment for women desiring pregnancy includes clomiphene citrate or gonadotrophins to induce ovulation. Reproductive tract diseases that cause bleeding problems include: Abnormal pregnancy (threatened, missed or incomplete abortion, ectopic pregnancy), 2) Endometrial, cervical , or ovarian cancer, 3) Uterine lesions (fibroids, polyps, adenomyosis), 4) Cervical lesions (polyps, cervicitis, herpes, or chlamydia.

24. Ovarian Masses (pg. 74) Between 70 to 80% of ovarian masses are benign. No relationship exists between ovarian masses and ovarian cancer. Symptoms: sensation of fullness or cramping in the lower abdomen, dyspareunia (painful sexual intercourse), irregular bleeding, or delayed menstruation. May be asymptomatic and mass noted on routine pelvic exam. Diagnosis: made on the basis of a palpable mass with or without tenderness and other related symptoms. Clinical management: observation for a month or two (most cysts will resolve and are harmless), oral contraceptives may be prescribed to suppress ovarian function, A repeat pelvic exam is done to determine effectiveness of treatment. Surgery is not always necessary.

25. Uterine Masses (pg. 75) Fibroid tumors (leiomyomas) are among the most common benign disease entities affecting women. Develop when smooth muscle cells are present in whorls and arise from uterine muscle and connective tissue. Size varies from 1 to 2 cms to size of a ten week fetus. Client is frequently asymptomatic. Symptoms include: lower abdominal pain, fullness or pressure, menorrhagia, metrorrhagia, or increased dysmenorrhea. May be palpated on pelvic exam. Ultrasound can assist and confirm diagnosis. Initial treatment: increase the frequency of pelvic exams to every 3 to 6 months. Treatment if mass is increasing in size or symptoms: surgery (myomectomy, D&C, hysterectomy). Majority of these masses require no treatment and will shrink after menopause.

26. Endometrial Cancer (pg. 75) Most commonly a disease of the postmenopausal client. Hallmark sign: vaginal bleeding in postmenopausal women not treated with hormone replacement therapy. Diagnosis: made by endometrial biopsy or post-hysterectomy pathologic examination of the uterus. Treatment: Total Abdominal Hysterectomy (TAH) and bilateral salpingo-oophorectomy. Radiation therapy may be indicated, depending on the staging of the cancer. TAH or TVH: Discharge teaching should include 1) no menstruation will occur, 2) Intercourse should be avoided for 4 to 6 weeks, 3) may be temporary loss of vaginal sensation if TVH, 4) heavy lifting should be avoided for 2 months.

27. Ovarian Cancer (pg. 1543) Causes more deaths than any other cancer of the female reproductive system due to advanced disease process at diagnosis. Occurs more frequently in women between 55 and 65 years old. Risk factors: family history, increasing age and high fat diet. Risk reducing factors: Breast feeding, multiple pregnancies, oral contraceptive use, and early age at first birth. Clinical manifestations: usually asymptomatic in early stages, increased abdominal girth, bowel and bladder dysfunction, pain, menstrual irregularities, and ascites. Classified as Stage I, II, and III. Treatment: total abdominal hysterectomy, chemotherapy, and radiation.

28. Cervical Cancer (pg. 1540) An increased risk of cervical cancer is associated with low economic status, early sexual activity (before 17), multiple sexual partners, infection with HPV (human papilloma virus), and smoking. Widespread use of the Pap test is attributed with the decrease in cervical cancer over the past 40 years. Progression from normal cervical cells to dysplasia and on to cervical cancer appears to be related to repeated injuries to the cervix. Clinical manifestations: may be asymptomatic, leukorrhea, intermenstrual bleeding. Classified as Class I,II, III, IV, and V. Diagnosis: pap test, colposcopy, and biopsy. Treatment: repeat Pap test, laser, cautery, cryosurgery, surgery, radiation. (Pap smears and pelvic exams should be preformed annually beginning at age 18 or when sexually active.)

29. Pelvic Relaxation (pg. 77) Cystocele: the downward displacement of the bladder, which appears as a bulge in the anterior vaginal wall. Classified as mild to severe. Corrected surgically with an anterior colporrhaphy. Rectocele: weakening between the rectum and vagina. Corrected surgically with a posterior colporrhaphy. Contributing factors include: childbearing, obesity, genetic predisposition and increased age. Symptoms: stress incontinence, loss of urine when coughing, sneezing, laughing or sudden exertion. Vaginal fullness, a bulging out of the vaginal wall, and/or a dragging sensation. May have to push upward vaginally to be able to urinate completely. Treatment: Kegel exercises, estrogen improves condition of vaginal mucous membrane, vaginal pessary may be used if surgery is no indicated. Pessary: a device inserted into the vagina to function as a supportive structure for the uterus.

30. Uterine Prolapse (pg. 1548) The downward displacement of the uterus into the vaginal canal. Rated by degrees: 1) First degree; cervix rests in the lower part of the vagina, 2) Second degree; cervix is at the vaginal opening, 3) Third Degree; uterus protrudes through the introitus. Symptoms: a feeling of something coming down, dyspareunia, backache, bowel or bladder problems, stress incontinence and tissue irritation to the protruding cervix. Therapy: Kegel exercises, pessary, surgery (vaginal hysterectomy with an anterior and posterior repair).

31. Questions?