N497 Reproductive System: Alterations and Pathologies

• Week 6 self-study notes on reproductive alterations

Reproductive Health Alterations

• Reproductive health alterations include menopause, benign prostatic hyperplasia (BPH), sexually transmitted infections (STIs), infertility, and the impact of STIs on fertility.

Gender Inclusive Language

• The material references female and male sexes when explaining conditions.
• A PDF guide is provided for gender-inclusive language encountered in nursing.

Class Objectives

• Understand hematologic system anatomy and physiology, and how chronic illness affects overall systemic functioning.
• Explain the pathophysiology, health risk factors, lab evaluation, and in-depth assessment of the body in relation to reproductive health alterations, BPH, menopause, STIs, and infertility.
• Prioritize patient conditions related to assessment and clinical manifestations.

Pathologies of the Reproductive System

• Involve structure and functioning of organs in the system.
• Impacts reproduction and fertility.
• Impacts urinary system functioning.

Aging in Females

• Ovaries reduce the number of maturing follicles, leading to a gradual decline in fertility.
  • Estrogen levels drop, triggering menopause around age 51.
• The uterus loses muscle and eventual cessation of menstrual cycle occurs.
• Fallopian tubes shrink in length and lose ciliated epithelia and mucosa.
• The vagina loses elasticity, shortens in length, and reduces vaginal secretions.
  • This increases the risk of tears, bleeding, and infection.
• The opening of the cervix has reduced cervical secretions.

Aging in Males

• Secretions from the seminal vesicles and prostate gland decrease, leading to a reduced volume of ejaculate.
  • Benign prostatic hypertrophy may compress the urethra, making urination difficult.
• Reduced testosterone levels can cause shrinking and erectile dysfunction of the penis.
• Testicular mass reduces, which leads to a reduction in sperm and testosterone secretion.
  • Sperm ducts become less elastic.

Female Menopause: Perimenopause

• A transitional period between reproductive and non-reproductive years lasts 2 to 8 years.
• Women note variability in the frequency and quality of flow 5-10 years before menopause.
• Ovaries still function, but this reduces.
• Symptoms depend on the sensitivity of the target tissue receptors.
• Symptoms begin with a lengthening of the menstrual cycle, which correlates with anovulatory cycles.

Menstrual and (An)ovulation Cycles

• Pregnancy is possible during perimenopause because one may still be ovulating.
• The body undergoes complex hormonal changes during each menstrual cycle, leading to ovulation.
  • Ovulation is when a mature egg is released from the ovary.
• After ovulation, the corpus luteum produces progesterone, which supports possible early pregnancy.
• The corpus luteum breaks down and stops producing progesterone if conception doesn't occur, which starts a period.
• A woman does not ovulate during an anovulatory cycle, and cannot get pregnant.

Other Common Reasons for Anovulation

• Being overweight or obese
• Experiencing high stress
• Being underweight
• Exercising too much
• Hormonal imbalances involving thyroid stimulating hormone (TSH) and prolactin are common reasons for anovulation.
• Polycystic ovary syndrome (PCOS) can cause anovulation.
• Common during hormonal transition periods.
• A girl's first few periods are usually anovulatory.
• The first few periods after stopping birth control are often anovulatory, as is the time during perimenopause.
• Many women also have an anovulatory cycle after miscarriage or childbirth.

Menopause

• The point in a woman's life when she is no longer fertile and menstrual periods stop.
• Absence of menstrual periods for 12 months defines menopause.
• The average age for natural menopause is 51, but can occur earlier or later.
• Considerations for Menopause:
  • Women who smoke tend to start menopause earlier, which is average of 2 years sooner than nonsmokers.
  • Tends to be genetically predetermined and unaffected by age at menarche, childbearing, use of oral contraceptives, socioeconomic status, or race.
  • Thinner women experience earlier menopause
  • Irregular menses in the early 40s
  • Alcohol consumption leads to later menopause.

Menopause: Ovarian Changes

• Estradiol levels remain normal to slightly elevated until about 1 year before menopause.
• Accelerated follicular loss occurs around 37-38 years until the supply depletes.
• This correlates with an increase in Follicular Stimulating Hormone (FSH) and a decrease in inhibin.
• Inhibin B usually keeps FSH levels down.

Hormones

• Estradiol is produced by the ovaries.
• Estrogen includes estradiol, estrone, and estriol. Estradiol is the most potent and plentiful of the three.
• Estrogen matures reproductive organs, development of secondary sex characteristics, long bone closure, regulates menstrual cycle and endometrial regeneration.
• Estrogen has metabolic effects on bones, liver, blood vessels, brain and CNS, kidneys, and skin.
  • After menopause, ovarian estradiol and estrone production decreases, raising osteoporosis susceptibility.
• Increased FSH stimulation accelerates follicular loss, and declining inhibin production disrupts the negative feedback influence over pituitary secretion of FSH.
• Inhibin-A and inhibin-B are secreted by the gonads and inhibit the production of follicle-stimulating hormone (FSH) by the pituitary gland.
• Follicle-stimulating hormone helps mature ovarian follicles in women, and supports sperm growth and development in men.
• A woman cannot continue her reproductive cycle with FSH release, as her ovaries will not release an egg.
• Purposes of FSH test:
  • Menopause testing: A doctor may order the test after an irregular menstrual cycle or no period. High FSH indicates menopause.
  • Female fertility testing: FSH levels might be high or low, depending on the cause of ovulating.
  • Male fertility testing: High FSH levels in men can mean the testicles are not functioning properly.

Menopause: Uterine Changes

• Proliferative growth of the endometrium occurs.
• Longer estrogen exposure and greater thickness of the endometrium means half of all women experience dysfunctional uterine bleeding that is heavy and unpredictable.

Menopause: Systemic Changes

• Vasomotor flashes are characterized by a rise in skin temperature, dilation of blood vessels, increased blood flow in the hands, increased skin conductance, transient increase in heart rate, and perspiration.
• Dizziness, nausea, headaches, or palpitations may accompany the flush.
• Flushes vary in frequency, intensity, and duration and experienced for 1 to 15 years, and average 1-5 years.
• Rapid changes in estrogen levels can increase emotional stress and cause unpredictable mood swings, weight gain, migraine headaches, and insomnia.
• Lower estrogen levels will decrease skin thickness and diminish skin elasticity, increasing skin dryness and wrinkling.

Menopause: Breast Tissue Changes

• Breast tissue becomes involuted.
• Fat deposits and connective tissue increase.
• Breasts are reduced in size and firmness.

Menopause: Urogenital Changes

• Ovaries shrink, uterus atrophies, and the vagina shortens, narrows, and loses elasticity.
• Lubrication in the vagina diminishes, and vaginal pH increases.
  • Higher risk of vaginitis.
• Cervix atrophies, cervical os shrinks, vaginal epithelium atrophies, and labia major/minora become less prominent.
• Some pubic hair is lost.
• Urethral tone declines which increases urinary frequency/urgency, UTIs and incontinence occurs.
• Regular sexual activity and orgasm may diminish some of these changes.
• Sexually active women have less vaginal atrophy.

Menopause: Skeletal and Cardiac Changes

• Skeletal: Bone mass is lost, increasing brittleness/porosity and possibly causing osteoporosis, mainly in lumbar spine and femoral neck.
• Cardiac: Risk of coronary heart disease increases significantly from high LDL and decreased HDL cholesterol.

Estrogen Deficiency

• Estrogen deficiency is indicated by hot flashes, night sweats, and atrophy of the vagina.
• Dyspareunia secondary to poor lubrication and incontinence can result.
• Emotional lability, a change in sleep patterns, and decreased REM sleep can indicate estrogen deficiency.
• An increased fracture rates, especially of vertebral bodies but also of the humerus, distal radius, and upper femur, can result.
• Decreased high-density lipoproteins and increased low-density lipoproteins.
• Diminished collagen content of skin and breast tissue changes.

Signs and Symptoms of Estrogen Deficiency

• Perform MSK assessments for potential fractures.
• Conduct CV assessments for increased risk of cardiovascular disease.
• Perform mental health assessment for issues such as self, body image, confidence and stress.
• Potential incontinence, infections are possible as a result of a GU assessment which can impact self-esteem and cause isolation.

Male Menopause

• Known as andropause, involves aging-related hormonal changes in men.
• As men age, testosterone and androgen levels steadily decline, as early as age 40.
• Symptoms include loss of libido, fatigue, decreased muscle mass/strength, depression, decreased bone mineral density, and anemia.
• Males experience a gradual decline in testosterone, sperm production does not stop, and not all experience low testosterone/sperm production.
• The term "menopause” only pertains to the female condition when the ability to reproduce is halted.
• Testosterone is the male sex hormone that is needed for growth of body hair, building strong bones/muscles, and sperm.
• Testosterone levels decline with age due to lifestyle factors and is inaccurately referred to as male menopause but is known as testosterone deficiency syndrome/late-onset hypogonadism.

Benign Prostatic Hyperplasia (BPH)

• Occurs mainly in older men.
• Aging and the amount of testosterone decreases but a small amount of estrogen remains.
  • Higher proportion of estrogen promotes prostate cell growth.
• Dihydrotestosterone (DHT), a male hormone that promotes prostate cell growth, produced and accumulated at high levels in prostate.
• Is the most common problem for men over 50, and symptoms increase with age.
• Risk factors:
  • Age 40 and older
  • Family history
  • Conditions such as obesity, heart/circulatory disease, and type 2 diabetes
  • Lack of physical exercise
  • Erectile dysfunction

BPH Symptoms

• Lower urinary tract symptoms may include urinary frequency, the inability to delay urination, trouble starting/ a weak urine stream, dribbling after urination, frequent urination during periods of sleep, urinary retention/incontinence, pain after ejaculation/urination and unusual colour/smell of urine.
• BPH symptoms commonly caused by blocked urethra and bladder overworked by trying to pass urine through the blockage.
• Potential complications:
  • Acute/chronic urinary retention
  • Blood in the urine
  • UTIs
  • Bladder/kidney damage
  • Bladder stones.

Diagnosis of BPH

• Symptoms history, digital rectal examination that determines prostate enlargement, cystoscopy, and transrectal ultrasonography is needed.
• Lab values: Prostate specific antigen (PSA) is elevated.

Sexually Transmitted Infections (STIs)

• STIs can be bacterial, viral, or parasitic.
• Bacteria: Chlamydia, gonorrhea, syphilis, chancroid, and genital mycoplasmas.
• Protozoa: Trichomoniasis.
• Viruses: HIV, herpes simplex virus types 1/2, cytomegalovirus, viral hepatitis A/B and human papillomavirus (primary cause of cervical neoplasms).
• Parasites: Pediculosis (may/may not be sexually transmitted) and scabies (may/may not be sexually transmitted).

Infertility

• Infertility means a woman has unsuccessfully attempted to become pregnant for 1 year without the use of contraceptives.
• Subfertility is prolonged time to conceive, while sterility is the inability to conceive.
• Primary infertility means a woman has never been pregnant before.
• Secondary infertility occurs when a woman has been pregnant in the past.
• Infertility increases with the age, particularly past 40.
• Diagnosis and treatment need emotional, psychological, and financial investment over a period of time.
• Infertility is a diminished ability to conceive.
  • If younger than 35, no conception after 12 months with sexual activity.
  • If older than 35, and has not become pregnant after six months.
• Nearly 16% of Canadian couples experience infertility.
• Delaying pregnancy until nearly 40 causes fertility decrease and increases the prevalence of diseases such as endometriosis and ovulatory dysfunction.

Causes of Infertility

• Male causes account for 30%.
• Female causes account for 40%.
• Combination factors account for 20%.
• There is no specific cause in 10% of cases.
• Sperm and mucus may not be compatible.
• Each needs testing with donor mucus and sperm to determine the issue and test for potential interventions:
  • Wash sperm and artificially inseminate.

Causes of Infertility: Women

• Age, decreasing after 35.
• Problems producing eggs.
• Experiencing an STI like chlamydia.
• Problems in the uterus or the fallopian tubes.
• Having Endometriosis.
• Hormonal imbalances.
• Early menopause--before age 40.

Causes of Infertility: Men and Women

• Post cancer treatments like chemo/radiation.
• Chronic illnesses such as diabetes.
• Tobacco and alcohol use
• Being underweight or overweight.

Causes of Infertility: Men

• Poor "quality" sperm count: poor motility, dead
• Low sperm count or lack of sperm

Factors Affecting Infertility in Women

• Ovarian factors: Developmental abnormalities, Primary/Secondary Anovulation, etc.
• Tubal/Peritoneal Factors: Developmental anomalies, Inflammation, Tubal adhesions, endometriosis, and PID.
• Uterine Factors: Developmental anomalies, endometrial/myometrial tumors, Vaginal-Cervical Factors.
• Other: Nutritional deficiencies, thyroid dysfunction, obesity, and Idiopathic condition.

Pelvic Inflammatory Disease

• Is an acute inflammatory process caused by infection involving the upper genital tract
• Polymicrobial infection starts with chlamydia or gonorrhea that develops after infected cervix ascends to the uterus and induces changes which facilitate invasion of other microorganisms.
• Manifestations range from sudden, severe abdominal pain to asymptomatic cervicitis that may develop before PID.
• Pain worsens with walking, jumping, or intercourse, and symptoms are more likely to develop during or immediately after menstruation.
• Also includes dysuria and irregular bleeding, and increased vaginal discharge.
• Ectopic pregnancy is a potential complication.

Factors Affecting Infertility in Men

• Hypospadius - Opening of urethra is on underside of penis.
• Testicular atrophy
• Variococele- varicose vein on spermatic vein in groin prevent surgically if wanted.
• Retrograde ejaculation

Male infertility

• Hypospadias results in lower sperm counts likely from ejaculatory disturbances, and fixed in childhood.
  • Adult men may have sexual dysfunction as a result of the procedure.
• Testicular Atrophy occurs in patients with steroid use, trauma, testicular torsion.
• Varicocele occurs when there is Enlargement of veins which causes the temperature of the testicie too high and impacts sperm development.
• Retrograde ejaculation-- semen enters the bladder instead of emerging through the penis during orgasm.
  • Sperm can be collected and washed, then artificially inseminated.