Care of Women with Reproductive Disorders

1. Care of Women with Reproductive Disorders P. Maloney MSN/Ed,RN

3. External Structures • Vulva-name given to the external female genitalia. • The vulva is composed of the following structures: • Mons pubis-rounded mound of fatty tissue that protects the symphysis pubis. Covered with hair. • Labia majora-2 elongated , raised folds of skin that enclose the vulvular cleft.

4. External Structures • Labia minora-soft folds of skin within the labia majora. • Clitoris-located at the top of the vulvular cleft, made of erectile tissue,highly sensitive to touch. • Urethral meatus- external opening of the urethra of the urinary bladder. • Perineum-flat muscular surface between the vagina and the anus.

5. Female External Structures

6. Internal Structures • Vagina-muscular tube lined with membranous tissue with ridges called rugae. • Uterus-(womb) is a hollow pear-shaped organ with a thick muscular wall. Capable of expanding to accommodate a growing fetus. Lower opening is the cervix which dialates during labor to allow for delivery of infant.

7. Internal Structures • 2 fallopian tubes that branch outward at the top of the uterus, pathway for the ovum (egg), from the ovary to the uterus. • 2 ovaries, one located near the end of each fallopian tube. Almond shaped glands, excrete estrogen and progesterone into the bloodstream. • Bony pelvis-located at the base of the hips, supports pelvic organs.

8. Internal Structures

9. Accessory Organs • Breasts or mammary glands, located on the upper chest. • Composed of fibrous, adipose, and glandular tissue and are responsible for lactation (milk production).

10. Female Reproductive Cycle • Ovarian Cycle: (2 phases) • Follicular Phase-first 14 days of a 28 day cycle. Follicle-stimulating hormone (FSH) & Luteinizing hormone (LH) stimulate the maturing of the immature ova in preparation for fertilization. Ovulation takes place when estrogen peaks about 14 days before the next cycle.

11. Ovarian Cycle • Luteal phase-15th to 28th days of the cycle. LH and progesterone are the primary hormones in this phase. Blood supply to the uterus increases in preparation for possible implantation of a fertilized ovum. If fertilization and implantation do not occur, the lining of the uterus will degrade and be shed during menstruation, and the cycle begins again.

12. Sexual Maturation • Puberty-the period of sexual maturation, usually occurs between the ages of 9 and 17. • Involves a period of accelerated growth, hips begin to widen, breasts begin to develop and axillary and pubic hair appears. • Puberty is completed by the onset of the menstrual cycle. • Menarche menstruation- the first menstrual cycle.

13. Changes That Occur with Aging • Menopause-occurs when menses completely ceases for 12 months. • After menopause: • Female organs atrophy • Loss of elasticity • Dryness of vaginal membranes • Reduction in bone mass • Internal organs may sag, or prolapse into the vagina

14. Menstruation • May be abnormal for the first year. • Regular cycle is usually every 28 days. • Menstrual blood consists of shed endometrial tissue, blood mucous, and vaginal and cervical cells. • Amount of actually blood loss is only 40 -80 ml. • Flow may be heavy at first but gradually reduces.

15. Menstruation • Mild cramping may occur. • Mood swings may be associated with hormonal changes. • Mittelschmerz-sharp pain in the right lower quadrant, sometimes felt midcycle around the time of ovulation.

16. Normal Vaginal Discharge • Vagina is moist, warm, & dark, good medium for microorganisms. • Normal vaginal discharge has an off-white color and is without odor. • If vaginal discharge develops an odor or change in consistency, or causes irritation or burning, a healthcare provider should be consulted.

17. Contraception and Fertility • Many women start sexual relationships and risk pregnancy before they are ready to have children. • Some women give birth and do not want to have more children. • Many sexually active women of childbearing age are concerned about regulating, planning, or preventing pregnancy.

18. Contraceptive Options • Women should make an informed decision concerning methods of reliable birth control. • Nurses are responsible for providing comprehensive education concerning the advantages, limitations, and side effects of various contraceptive devices.

19. Oral Contraceptives • Most popular method of reversible hormonal contraception. • Effective if used properly. • Offer relief from breast tenderness, bloating, and PMS symptoms. • Abstinence is the only 100% effective method of birth control.

20. Oral Contraceptives The “Pill” Oral Contraceptives Combination of synthetic estrogen and progestin, hormones prevent ovulation and thicken cervical mucus, making it difficult for sperm to travel upward. Based on a 28 day cycle with 7 hormone free days that result in monthly menstruation.

21. Oral Contraceptives • Prescription required. • Must be taken faithfully. • Not recommended for women older than 35 who smoke. • Contraindicated for women with a history of heart or liver disease, breast or uterine cancer, or blood clots. • 97% to 99.9% effective.

22. Intrauterine Device (IUD) IUD Examples of IUD’s • Small, sterile, flexible plastic device inserted into the uterus by a physician. • Can be a copper device or a device containing the hormone levonorgesterel (minera). Can provide protection up to 5 yrs.

23. IUD’s Side Effects/Precautions: • May increase menstrual flow or cause cramping or low back pain • Increased incidence of PID with multiple sex partners. • Patient must check placement by feeling for string once each month. • Must be removed by health care provider. • Up to 99% effective.

24. Male Condom Condom Assorted Condoms • A sheath commonly made of latex that is placed over the erect penis before intercourse. • Oil-based lubricants such as petroleum jelly can cause latex to break down and reduce effectiveness.

25. Male Condom • Precautions: • Leave space at the tip for seman to collect rather than being forced upward out of the condom. • Store in a cool, dry place and do not keep excessively long to avoid breakage. • Handle carefully to avoid spilling semen and possibly introducing it into the vagina.

26. Male Condom Effectiveness: • 88% -98% if used properly. • Use of spermicide increases effectiveness to 98%-99%.

27. Diaphragm How diaphragm works Diaphragms • A rubber dome-shaped cup that fits snugly over the cervix. • Spermacide is applied to the cervical side of the diaphragm and it is inserted into the vagina so that the fitted ring holds it securely in place.

28. Diaphragm • Precautions: • Diaphragm must be fitted professionally and should be refitted annually. • Should be refitted with a gain or loss of 7-10 lbs. and after pregnancy. • Effectiveness is 82%-94%.

29. Injectable Contraceptives (Depa-Provera) • Synthetic timed-release progesterone is injected q 12 weeks to prevent ovulation. • Injections must be given in clinic or office. • Must be repeated q12 weeks to remain effectiveness. • 99.7% effective

30. Emergency Contraception How Method Works “Morning-after” pill • Taken orally the day following intercourse, it induces menses and prevents implantation in the uterus. • Should not be used as a routine for of contraception. • 97%-99.9% effective

31. Legal and Ethical Consideration Although the “morning after” contraceptive pill can be sold over the counter in most states, there has been considerable unwillingness by certain pharmacists to provide it. The pharmacists’ claim that dispensing the pill is against their religious principles. It may not be ethical for pharmacists’ to withhold the medication from a woman because of the pharmacists’ personal belief.

32. Infertility • Primary infertility-the inability of the couple to conceive a child after at least 1 year of active, unprotected sexual relations without contraceptives. • Secondary infertility-the inability to conceive after having once conceived, or the inability to maintain a pregnancy long enough to deliver a viable infant.

33. Factors contributing to infertility • Problems with ovulation • An abnormal pathway between the cervix and the fallopian tube • Abnormality in the endometrium or the uterus • Tumors in the reproductive tract • Vaginal or cervical environment that is inhospitable

34. Diagnosis of Infertility • Obtain a detailed health history • Serum prolactin levels and endocrine evaluations, semen analysis & chromosome analysis • Tests for tubal patency or other possible abnormalities

35. Emotional Impact • The emotional impact of infertility is intense. • Psychological intervention may be necessary. • Couples may not be able to focus, increased tension, blaming each other.

36. Assisted Reproduction • Reproductive therapy associated with many legal and ethical issues. • Ex. Risk of having multifetal pregnancy, freezing embryos for later use, surrogate mother.

37. Menopause • Defined by the World Health Organization as the cessation of menses for 12 consecutive months due to a decrease in estrogen production. • The perimenopausal period is the time around the actual cessation of the menstrual cycle. • S/S include: hot flashes, night sweats, low estrogen levels.

38. Risks of Menopause • Osteoporosis due to decrease in estrogen slows bone growth. • Increased risk for cardiovascular disease due to change in lipid metabolism. • Treatment may be hormone replacement therapy.

39. Health Screening • Primary prevention is designed to decrease the probability of becoming ill. • Secondary prevention is designed to focus on detection of specific at-risk diseases so that early treatment may be given. • Tertiary prevention minimizes the impact of already-diagnosed conditions.

40. Breast Self-Examination • Should be done monthly, about 1 week after menstruation begins, or on a specific date each month. • See figure 39-5 for self breast exam. • https://www.youtube.com/watch?v=E5SKi-mALbY

41. Common Gynecologic Tests • Pelvic exam-visual inspection of the external genitalia, vagina, and the cervix to obtain specimens such as a Pap smear. • Process: Inspection via the vaginal speculum; manual palpation through abdominal wall, vaginally, and rectally of internal organs.

42. Common Gynecologic Tests • Pap Smear-to obtain samples of cells and fluids for pathology/ cytology studies. • Process-exudate, mucous, and cells are obtained from surface with sterile swab or scraping tool and placed on a laboratory slide or into a preservative solution for pathology evaluation.

43. Common Gynecologic tests • Dilation & Evacuation (D &E)-to detect cause of excessive bleeding; to remove hypertrophied uterine lining, retained placenta, or tissue from an incomplete abortion. Done in the OR. • Process-the cervix is dilated and the interior of the uterus is cleansed by scraping, suction, or both.

44. Common Gynecologic Tests • Mammography-to screen breasts for abnormal growths, particularly cancer. • Process-a full-field digital mammography machine records images on a computer screen and can computer-enhance images for increased accuracy.

45. Surgical Procedures • Hysterectomy-removal of entire uterus, vaginally or abdominally. • Panhysterectomy-removal of entire uterus, fallopian tubes, and ovaries. • Radical hysterectomy-removal of uterus, tubes, ovaries, upper third of the vagina, and lymph nodes.

46. Surgical Procedures • Salpingectomy-removal of the fallopian tubes • Oophorectomy-removal of an ovary. • Vulvectomy-surgical excision of the labia, clitoris, perineal structures, femoral and inguinal lymphatic tissues.

47. Surgical Procedures • Salpingectomy-removal of the fallopian tubes • Oophorectomy-removal of an ovary. • Vulvectomy-surgical excision of the labia, clitoris, perineal structures, femoral and inguinal lymphatic tissues.

48. Menstrual Dysfunctions Premenstrual Syndrome- (PMS) • AKA ovarian cycle syndrome. • Presence of physical, psychological, or behavioral symptoms that occur regularly within the luteal phase of the menstrual cycle and disappear during the remainder of the cycle.

49. Menstrual Dysfunctions Signs & symptoms: • Weight gain, bloating • Irritability, changes in eating patterns • Fatigue, mood swings Management: • Lifestyle modifications • Diet high in B vitamins • Exercise, stress management • Avoidance of fatigue

50. Dysmenorrhea • Painful menstruation, 2 types: • Primary Dysmenorrhea • Secondary Dysmenorrhea • Primary dysmenorrhea-occurs 6-12 months after menarche. • Caused by the release of high levels of prostaglandins in the first 2 days of menstruation, causing uterine contractions that result in abdominal cramps.