Understanding Sexual Assault

Sexual Assault

• Sexual assault is defined as contact or behavior without explicit consent, including rape, unwanted touching, and oral/penetrating acts.
• Consent requires informed approval and freely given agreement, with only "yes" meaning yes, and is a choice as well as an ongoing process.
• Inability to consent/refuse can be due to factors like age, illness, disability, intoxication, being asleep, or coercion (weapons, misuse of authority).
• Tactics used can include physical force, drugs/alcohol, exploitation, intimidation, economic coercion, humiliating, misrepresentation, false promises, and grooming.
• Assessment involves physical injury evaluation (genitalia focus), psychological assessment, pregnancy assessment, STI evaluation/treatment/prevention, and forensic evaluation.
• Human trafficking involves the use of force, fraud, or coercion of a minor (under 18 years) into commercial sex.
• Risk factors include age, runaway history, sex abuse history, dysfunctional family, LGBTQ+ status, substance use, learning disabilities, high crime area, political corruption, and gender bias/discrimination.
• Red flags to look out for include someone else speaking for the patient, disorientation, no ID, fear, anxiety, PTSD, submission, and unexplained injuries.
• Other signs include sex in exchange for things, violence, discrepancies in age, self-inflicted injuries, addictions, chronic medical conditions, and recurrent STIs.
• Barriers to disclosure may include unfamiliarity with healthcare, lack of trust, financial concerns, nowhere to go, criminal records, disorientation, language barriers, illness, cultural/religious beliefs, and fear.
• Action to take includes keeping patients apart from family/friends.

Reporting Sexual Assault

• For children, report to police/CPS without needing consent.
• For adults, ask for consent before reporting; if declined, provide resources.
• Prevention, prosecution, and protection are key.

Intimate Partner Violence (IPV)

• IPV is a learned pattern of behaviors used to maintain power and control over a partner.
• Forms of IPV include physical, sexual, emotional, and psychological, and it affects everyone.
• Tactics involve threats, intimidation, name-calling, criticism, destruction of property/pets, reckless behavior, isolation, and interruption of support networks.
• Mandatory reporting concerns threaten confidentiality, limit autonomy, negates consent, and deters help-seeking.
• Pregnancy risks include preterm labor, low birth weight, future child abuse/femicide, miscarriage, and increased likelihood of substance abuse.
• Assessment involves routinely asking direct questions, documenting findings, and planning for patient safety, with referral to resources.

Pregnancy Loss

• Needs of women include access, presence, clear communication, discussion of subsequent pregnancies, individualized treatment, and hope grounded in medical information.
• Support should include postpartum follow-up, a strong support network, emotional support, and respect for grief.
• Addressing issues involves acknowledging and addressing depression, anxiety, or trauma.
• Empowerment consists of supporting patient control, giving resources, offering follow-up, and continuing the conversation realistically.
• Listen with empathy, understand, and believe the patient’s experience and remember their history from their perspective.
• A new baby is not a reset; life is different but possible with support.
• Women find ways to honor and remember babies and integrate grief in their own way.

Fertility Awareness-Based (FAB) Methods

• FAB methods are not always reliable for preventing pregnancy.
• The fertile window is 5 days before ovulation to 1 day after, requiring abstinence.
• A regular cycle, between 26-32 days, is necessary to use FAB methods.
• Factors affecting the cycle include stress, fatigue, illness, alcohol, sleep, and medications.
• Calendar Rhythm requires recording cycles for six months to calculate the fertile window.
• Subtract 18 from the shortest cycle and avoid unprotected sex starting that day.
• Subtract 11 from the longest cycle and unprotected sex can be started the next day.
• Billings (Cervical Mucus): Assess daily for spinnbarkeit, which is clear, stretchy mucus.
• Ovulation is said to occur 4 days after spinnbarkeit is first noticed.
• Spinnbarkeit help pick up sperm,
• Basal Body Temperature: Record morning temperature, as an increase indicates ovulation.

Contraception

• Hormone progesterone decreases just before the period starts with dropping temperature.
• Lactational Amenorrhea Method (LAM): Exclusive breastfeeding (≤4-6 hours between feedings) for it to work.
• Abstinence: Refrain from intercourse.
• Coitus Interruptus: Withdrawal method.
• When breastfeeding progestin-only methods are best and Estrogen can reduce milk production.
• Spermicide (Nonoxynol-9): Insert vaginally, use alone or with a barrier, leading to decreased spontaneity.
• Barrier Methods such as Male/Female Condoms protect against STIs (if used correctly).
• Contraceptive Sponge: OTC, contains spermicide, moistened with tap water. Can be left in place up to 24 hrs.
• Diaphragm/Cervical Cup: Fitted by provider, use with spermicide, increases UTI risk and must be left in place for at least 6 hours.
• Long-Acting Reversible Contraception (LARCs) are 99.9% effective and reversible.
• Nexplanon: Progestin implant, lasts up to 5 years.

Progestin and Copper IUDs

• Progestin IUDs (Mirena, Liletta, Kyleena, Skyla) release progestin and last 3-8 years.
• Side effects: bleeding, amenorrhea, weight gain, headaches, ovarian cysts, mood changes, breast tenderness, hair loss, fluid retention, PID.
• Copper IUD (ParaGard): No hormones and lasts up to 12 years.
• Creates inflammation toxic to sperm.
• Side effects: heavier longer menses, PID.
• Can be used for emergency contraception up to 5 days after intercourse.

Combined Oral Contraceptives

• Pills, Ring, Patch suppresses LH and FSH by blocking the pituitary gland in the hypothalamus to stop ovulation.
• Inhibits ovulation at the level of the hypothalamus, pituitary gland blocking GnRH, LH and FSH.
• Suppression of LH secretion blocks ovulation keeping the endometrium thin, and FSH secretion inhibits folliculogenesis.
• Improved bone density, decreased ovarian/colon cancer risk, and improved acne/hirsutism.
• The types include monophasic (same dose) and triphasic/multiphasic (tapered dose).
• Start with a low dose!.
• Side Effects include breakthrough bleeding, breast tenderness, elevated BP, headache, nausea, bloating, weight gain, skin/hair changes, increased DVT risk.
• Contraindications include pregnancy, HTN, thromboembolic disease, liver disease, estrogen-dependent cancer, >35 and smoking, undiagnosed uterine bleeding, gallbladder disease, DM, migraines with aura, epilepsy, and depression.

Emergency Contraception

• Plan B contains progestin, is OTC and must be taken within 72 hours of intercourse.
• Copper IUD: Insertion within 5 days of intercourse is an option.
• Combined Oral Contraceptives: Tapered dosing (off-label) and 2 doses should administered 12 hours apart.

Progestin-Based Contraception

• Think thins endometrium and thickens cervical mucus.
• Thin endometrium, prevents implantation, thickens cervical mucus.
• Benefits for breastfeeding as estrogen-based contraceptives reduce milk.
• Can be used for emergency contraception.
• Side Effects are bleeding, amenorrhea, weight gain, headache, ovarian cysts, mood changes (including depression), hair loss, and fluid retention.
• Optionsinclude Micronor (Mini-Pill), Opill and Depo Provera.
• Micronor (Mini-Pill): Must take at the same time daily.
• Opill: FDA approved OTC with no prescription needed.
• Depo Provera: IM injection every 3 months with decreased bone mineralization and delayed return to fertility. Its not recommended for individuals under 21.

Sterilization

• Tubal Ligation is an inpatient procedure using clips/ligates/cauterizes/bands/plugs on the fallopian tubes.
• Side effects involves burns, bowel perforation, pain, infection, and anesthesia effects.
• Salpingectomy (RRS): Removal of fallopian tubes which decreases ovarian cancer risk and ectopic pregnancy risk
• Side effects include infection, bowel perforation, pain, and anesthesia effects.

Vaginal & Vulvar Cancers

• Vaginal Cancer is rare and typically originates in the birth canal, often asymptomatic.
• Vulvar cancer affects the outer part of the genital area.
• The HPV vaccine (Gardasil 9) offers protection for vag and vulvar CA Risk Factors:
• Persistent HPV
• History of precancerous lesions
• Weak immune system
• Smoking
• Chronic vulvar issues
• Symptoms include abnormal bleeding, bloody stool/urine, persistent diarrhea/constipation, pelvic pain, skin changes, sores, lumps, itching, and burning.
• Diagnosis is via biopsy and Treatment involves Surgery, radiation, and chemotherapy.

Sexually Transmitted Infections (STIs)

• Chlamydia causes thin or mucopurulent discharge and is considered a "silent disease."
• Symptoms include discharge, cervical ectropion (glandular cells outside of the cervix), friable (sensitive) cervix, burning/frequency upon urination, and lower abdominal pain.
• Diagnosis: NAAT golden standard (cervical/vaginal swab).
• Treatment is by Azithromycin 1 gram, treat partners, and no intercourse for 7 days.
• Syphilis is known as "great pretender" because its rash can look like other things.
• Stages of Syphilis include Primary (chancre), Secondary (rash, condyloma), Latent (no symptoms), and Tertiary (neuro symptoms).
• Early/Primary stages present with chancre fever and weight loss along with single chancre, firm round painless sores where syphilis enters body lasts 3-6 weeks and heals regardless.
• Secondary- 6 weeks later condyloma skin rashes and/or mucous membrane lesions.
• Tertiary: affects internal organs and presents with neuro symptoms.
• Latent: no symptoms however it can be detected through serologic testing (RPR or VDRL).
• Diagnosis is RPR or VDRL, microscopic examination for spirochetes
• Treatment is Penicillin G. (PCN Benzathine) 2.4 million units IM.

Cervical Cancers

• 100% treatable if caught early.
• It is slow growing and initially presents with dysplasia (abnormal cell growth).
• Risks involve HPV infection, early sex activity, smoking, STDs, multiple partners, weakened immune system, DES in utero exposure, prolonged oral contraceptive use, and multiple childbirths.
• Symptoms include abnormal bleeding, watery/foul discharge, leakage of urine/feces, dyspareunia, changes in menstrual patterns, fatigue, pelvic/back/leg pain, and fistula formation
• Diagnosis: Pap smear, HPV testing. Treatment: Surgery, radiation, and chemo.
• HPV: Group of more than 150 related viruses, 12 (most common are strains 16 and 18) potential to cause cervical cancer
• The HPV vaccine Gardasil 9 is a form of Prevention.
• Diagnosis is via a Pap smear from the age of 21 upwards.

Herpes Simplex Virus (HSV)

• HSV1 & HSV2 can spread throughout body (lung, liver, brain, and kidney) HSV1:
• Spreads via direct contact such as sharing utensils and kissing. HSV2:
• Spreads via sexual contact.
• Symptoms: Vesicles (blisters) rupture, painful lesions, enlarged lymph nodes, and flu-like symptoms.
• Diagnosis requires NAAT (swab lesion) and serum testing. Treatment: No cure however Antivirals Valtrex, Acyclovir can manage outbreaks. Prophylactic antiviral in the 3rd trimester to prevent outbreaks during delivery.
• Prophylactic antiviral medication (acyclovir or valacyclovir) 3rd trimester (around 36 weeks) to reduce the chance of outbreak at delivery is helpful.

Menopause and Perimenopause

• Patho: Increased cortisol and increased androgen levels with a decrease in estrogen levels
• Normally estrogen levels are regulated by FSH and LH.

Diagnostic Testing and Screening

• Screening Tools: Mammography (breast masses), Pap smear (abnormal cervical cells).
• No Screening Tools: Endometrial, ovarian, vaginal, vulvar cancers.
• Diagnostic Test: Always biopsy.

Perimenopause

• Perimenopause is a 4-8 year transition with onset around 39-51 years of age.
• Hormonal shifts such as decreased estrogen and increased cortisol lead to Symptoms such as hot flashes, sweating, vaginal dryness, mood changes, and memory problems.

Menopause

• Menopause typically occurs around 40-58 (average 51).
• Indicated by a year since the last period resulting in Decreased ovarian hormone secretion with Symptoms: of hot flashes, night sweats, and vaginal thinning.
• Major Health Problems that can arise are Osteoporosis and heart disease.
• Bleeding Post-Menopause is a red flag for endometrial cancer.
• Vaginal Changes is a decline in estrogen which leads to vaginal atrophy, dryness, and thinning but can be treated with low-dose estrogen and lubricants.
• Induced Menopause: Surgical removal, CA treatment, and smoking.

Gynecological Cancers

• Endometrial Cancer begins in the lining of the uterus can be recognised from Heavy bleeding after menopause or between cycles.
• Diagnosis: Endometrial biopsy, transvaginal ultrasound, pelvic exam, D&C, and hysteroscopy. Risks :

• 50

• Obesity
• HRT
• Infertility treatments
• Ovarian Cancer is a deadly cancer and develops with Symptoms: (Usually develop if metastasized) Bloating, pelvic/abdominal pain, trouble eating, and urinary symptoms.
• Diagnosis: Pelvic exam, CT, MRI, ultrasound, blood tests ROMA marker (CA-125, HE4) along with menopausal status and biopsy Risks :
• Family history
• BRCA1/2 mutations
• History of breast cancer
• Nulliparity.

Pelvic Support Disorders (PFD)

• Causes: Weakened muscles/connective tissue, pregnancy, prolonged pushing, age (decreased estrogen), and injury.
• Types: Pelvic organ prolapse, bladder/bowel control issues.
• Risk Factors: Childbirth, obesity, chronic straining, aging, genetic predisposition, and prior surgeries.

Human Trafficking

• Sex trafficking is most lucrative.
• Mandated to report minors or those who are not competent and do not need to report competent adults
• Survivors may not disclose because: nowhere to go, past criminal record, no money and lack of trust Trauma informed care:
• Reduce re-trauma
• Highlight strengths and resilience
• Promote healing and recovery
• Develop health

Self Managed Medication Abortion

• Timeframe: FDA approved up to 10 weeks, can be used up to 12 weeks.
• The medications include Mifepristone and Misoprostol.
• Bleeding: Starts 30 minutes-24 hours after misoprostol, heavy for hours, moderate 1-2 weeks, and light spotting 3-4 weeks.
• Side Effects: Pain, bleeding, nausea, vomiting, fever, chills, and cramping.
• Follow-up: 7-14 days after mifepristone, serial beta HCG (if <10, no follow up), and ultrasound.

Surgical Abortion

1st Trimester:

• Within 14 weeks and 6 days the procedure Dilation & Curettage (D & C) – cervix is dilated via a cannula inserted to begin suction/curettage. 2nd Trimester
• Takes place between 15 weeks and 23 weeks 6 days using Dilation & Evacuation (D & E) or Induction of Labor.
• Side Effects: Bleeding (1-6 weeks), cramping, nausea, and diarrhea.
• Complications: Infection, fever, odor, hemorrhage, severe pain, and ongoing pregnancy symptoms.
• Contraindications: Hemodynamic instability, anemia, and thrombocytopenia.

Bacterial Vaginosis (BV)

• Symptoms include gray discharge, "fishy" odor, burning urination, itching/irritation potentially overlapping with a yeast Candida infection.

Sexual Assault Lecture – Forensic Nursing

• Safe Nurse collects forensic evidence, coordinate referrals, conduct interviews, furthermore photographs injuries.
• Consent requires words and overt actions of a competent individual.
• Intimate Partner Violence & Trafficking: Empowered trauma-informed care.
• Mandatory Reporting involves child abuse, elder abuse, and vulnerable adults provided they are not competent adults.

Osteoporosis

• Risk Factors: Menopause (decreased estrogen) and age.
• Evaluation: Bone density testing (every 1-2 years depending on risk).

Polycystic Ovary Syndrome (PCOS)

• Is characteristically hormone imbalance, increased follicular ovarian cysts, and increased androgen levels which Impact fertility
• Symptoms include irregular cycles, infertility, cysts, hirsutism, acne, weight gain, diabetes type 2, and cardiovascular disease.
• Diagnosis requires Hormones, pelvic ultrasound, and blood tests provided at least two symptoms are evident.

Endometriosis

• It is an abnormality where tissue similar to uterine lining grows outside the uterus.
• Diagnosis is not curable with Symptoms: being pain, menstrual irregularities, bleeding between periods, and infertility.

Premenstrual Syndrome (PMS) vs. Premenstrual Dysphoric Disorder (PMDD)

• Management includes Diet, exercise, sleep, and ibuprofen.
• PMDD or premenstrual Dysphoric Disorder is a severe form of PMS (5%) occurring 1-2 weeks before menstruation, and hormonal fluctuation is in serotonin.

Stroke Assessment

• Use FAST (Face, Arms, Speech, Time)
• Recognize stroke Symptoms: Numbness, confusion, trouble speaking/understanding, vision disturbance, difficulty walking/loss of balance, and dizziness.

Ovulation Cycle

• Follicular Phase (Day 1-14): FSH rises, egg matures, Estrogen rises to build uterine lining.
• Ovulation (Day 14): LH spike triggers egg release, Estrogen levels are high thickening cervical mucus.
• Luteal Phase (Day 15-28): Corpus luteum makes progesterone to maintain uterine lining.

Neonatal Sepsis

• Most common cause of Maternal GBS exposure is GBS in urine (systemic) is most dangerous. Presenting with Respiratory symptoms and unstable temperature. Treatment is IV antibiotics and extended observation (36-48 hours).

Fetal Presentation

Occiput Anterior (LOA) is ideal (Head facing down) but if Posterior it is “poopy”.

Necrotizing Enterocolitis (NEC)

• Inflammation of intestinal tissue (tissue death and perforation) which can Manifest 2-6 weeks after birth.

Amniotic Fluid Embolism (AFE)

• Amniotic fluid enters maternal circulation causing difficulty breathing, chest pain, tachycardia, hypotension, hypoxemia, confusion, agitation, seizures, and coagulopathy.

Gestational Diabetes

• Diagnostic criteria is if ≥2 values are elevated * Fasting ≥95 mg/dL * 1 hr ≥180 * 2 hr ≥155 * 3 hr ≥140