THE NURSE’S ROLE IN WOMEN’S HEALTH CARE

The Nurse's Role in Women's Health Care

• Women are active participants in healthcare and need information about their bodies, health promotion, self-care, and treatment options
• Cultural competence is essential to empower women
• Nurses must understand cultural practices, past experiences, and individual goals
• Nurses offer support, knowledge, and caring behaviors

Health People 2030 Goals and Strategies Related to Women

• Aims for preventative care, screening, and accessibility to healthcare for women
• Increase mammograms in women over 40 to reduce breast cancer
• Increase Pap Tests in women over 21 to reduce cervical cancer deaths
• Reduce vertebral/hip fractures in older women with osteoporosis
• Reduce sexually transmitted infections and pelvic inflammatory disease

Preventative Health Care for Women

• Focuses on preventing or early identification of disease
• Can prevent disabling conditions or reduce severity
• Includes screenings that are not diagnostic but identify the need for further testing

Breast Care

• Three approaches for early breast cancer detection: monthly breast self-examination (BSE), annual professional breast examination, and mammography as appropriate
• All women after age 20 should perform BSE monthly, ideally 1 week after the beginning of their menstrual period
• BSE is supplementary to professional examinations
• Mammography uses low-dose x-rays to visualize breast tissue and can detect tumors early
• The American Cancer Society recommends an annual mammogram for women aged 40 and older

Vulvar Self-Examination

• Women over 18 (or younger if sexually active) should perform a monthly examination of the external genitalia
• Aims to identify lesions or masses indicating infection or malignancy

Pelvic Examination

• Not all women require annual pelvic exams
• When scheduled, it should be between menstrual periods
• Patient teaching includes no douching or intercourse 48 hours before the exam
• The exam identifies tumors, abnormal discharge, infections, and unusual pain
• External genitalia is inspected for signs of problems
• A speculum is used to visualize the cervix and vagina

Pap Test

• Screens for vaginal and cervical tissue changes
• Guidelines for routine Pap Tests in sexually active women: ages 21-29 every 3 years, ages 30-65 every 5 years, over age 65 no screening if negative for the previous 10 years
• Pap tests and human papillomavirus (HPV) co-screening are often done together
• After the Pap test, an internal bimanual examination is performed to evaluate the organs

Menstrual Cycle Disorders

• Nurses' roles vary depending on the disorder's cause and treatment
• Examples include teaching about medications and providing emotional support

Amenorrhea

• Absence of menstruation
• Normal before menarche, during pregnancy, and after menopause
• Classified as primary (failure to menstruate by age 16 or age 14 without secondary sex characteristics) or secondary (cessation for at least 3 cycles or 6 months in women with a previous pattern)

Abnormal Uterine Bleeding

• Bleeding too frequent, long in duration, or excessive in amount
• Metrorrhagia: intermenstrual bleeding
• Menorrhagia: excessive menstrual bleeding
• Common causes include bleeding disorders, pregnancy complications, lesions, breakthrough bleeding, endocrine disorders, and failure to ovulate or respond to hormones
• Treatment depends on the cause

Menstrual Cycle Pain

• Mittelschmerz: pain around ovulation, usually harmless and treated with mild analgesics
• Dysmenorrhea: painful menses or cramps
• Primary Dysmenorrhea: no evidence of pelvic abnormality, usually in young women who have not been pregnant, characterized by heavy flow, pain beginning hours before menstruation and lasting 72 hours, and normal pelvic examination results
• Secondary Dysmenorrhea: identifiable pathological condition including endometriosis, IUD use, pelvic inflammatory disease, uterine polyps, or ovarian cysts
• Treatment for Dysmenorrhea involves identifying the cause

Endometriosis

• Presence of tissue resembling the endometrium outside of the uterus
• Can cause pain, pressure, inflammation, and dyspareunia
• Treatment is medical or surgical

Premenstrual Disorders

• Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are associated with abnormal serotonin response to estrogen changes
• PMDD criteria include symptoms occurring between ovulation and menstruation, improving between menstruation and ovulation, not present in the week after menstruation, and at least five symptoms including depressed mood, anxiety, sensitivity to rejection, irritability, decreased interest in activities, difficulty concentrating, lethargy, appetite changes, sleep changes, feeling overwhelmed, breast tenderness, bloating, weight gain, and headaches
• Treatment includes diet rich in complex carbohydrates and fiber, stress management, exercise, oral contraceptives, diuretics, SSRIs, short-acting anti-anxiety medications, and CAM therapies

Gynecological Infections

• Vaginal infections are a common reason for women to seek healthcare
• The nurse plays a key role in educating women about vaginal health and preventing sexually transmitted infections

Sexually Transmitted Infections (STIs)

• Incidence is increasing worldwide
• Commonly transmitted through intimate sexual contact
• Risk factors include frequent sexual contact with multiple partners and unprotected sexual activity
• At-risk populations: young, single, urban, poor, male, and homosexual
• Assessment of risk factors uses the 5 Ps: past STI's, partners, practices, prevention, and pregnancy
• Four key factors contribute to STI spread: unprotected sex, antibiotic resistance, treatment delay, and sexual behavior patterns/permissiveness

Genital Herpes

• Caused by herpes simplex virus (HSV)
• Characterized by recurrent episodes of painful vesicular eruptions
• HSV-1 is usually acquired in infancy, HSV-2 usually acquired sexually
• Manifestations include vesicles on the cervix, labia, rectum, vulva, vagina, skin, glans penis, foreskin, penile shaft, mouth, and anus
• Vesicles rupture into painful ulcers with edema and tenderness
• Initial lesions last 3-10 days, recurrent lesions last 7-10 days
• Primary infection may be accompanied by fever, malaise, myalgia, dysuria, and leukorrhea
• The virus becomes dormant and can be triggered by illness, fatigue, injury, or stress
• Recurrences are typically less painful and shorter
• Diagnosis is based on physical examination and patient history, confirmed by tissue cultures or serologic testing
• Treatment focuses on symptom management: good hygiene, loose-fitting cotton undergarments, keeping lesions clean and dry, sitz baths, local anesthetics, systemic analgesics, and abstinence from sexual contact
• Antiviral medications manage outbreaks and prevent future ones
• Nursing interventions include keeping lesions clean and dry, washing hands after touching lesions, wearing loose clothing, sitz baths, avoiding intercourse during outbreaks, encouraging barrier methods, informing partners and healthcare providers, and providing support.

Syphilis

• Caused by the spirochete Treponema pallidum
• High rates in men who have sex with men
• Transmission occurs through sexual contact during primary, secondary, and latent stages
• Spread through contact with infectious lesions and needle sharing
• Prenatal transmission is possible
• Four stages: primary, secondary, latent, and tertiary
• Symptoms include chancres (painless ulcers) in primary syphilis, skin rashes in secondary syphilis, moist lesions, enlarged lymph nodes, fever, fatigue, infections of the eyes, bones, liver, or meninges, dementia, pain or loss of sensation in the legs, aortic destruction, and destructive masses in any organ
• Diagnostic tests include the Venereal Disease Research Laboratory (VDRL) slide test, rapid plasma reagin (RPR) test, and gonorrhea screening
• Treatment aims to eradicate all syphilitic organisms.

Syphilis

• Caused by Treponema pallidum, a spirochete
• Transmitted through direct contact with a syphilitic lesion
• Stages: Primary, Secondary, Latent, Tertiary
• Primary Stage: Chancre develops at site of infection
• Secondary Stage: Generalized rash, flu-like symptoms, Condyloma lata, and alopecia
• Tertiary Stage: Neurosyphilis, cardiovascular syphilis, and gummatous syphilis
• Diagnosis: Darkfield microscopy, serologic testing, and cerebrospinal fluid analysis.
• Treatment involves penicillin G
• Previous damage cannot be reversed
• All stages of syphilis should be treated
• Appropriate antibiotic treatment before 18th week of pregnancy prevents fetal infection
• Treatment after 18th week of pregnancy cures both mother and fetus
• Neurosyphilis should be monitored for at least 3 years
• Syphilis should be treated in the earliest stage possible, can be cured in late stages but is more difficult

Gonorrhea

• Caused by: Neisseria gonorrhoeae, a gram-negative diplococci bacterium
• Transmitted by: Sexual contact
• Most common in: Adolescents and young adults
• Affects: Genital, rectal, oral, and eye mucosa
• Clinical Manifestations:
  • Males: Urethritis, dysuria, purulent discharge, edema
  • Females: May be asymptomatic, greenish yellow discharge, urinary frequency, pain, and fever
  • Other: Pharyngitis, tonsillitis, rectal burning, and purulent rectal discharge
• Diagnosis: Culture from the site of infection
• Medical Management:
  • Treatment: Ceftriaxone IM or Cefixime oral, Ciprofloxacin, Ofloxacim, Levofloxacin
  • Coexisting chlamydial infection: Doxycycline or tetracycline
  • All partners must be treated:
• Nursing Interventions:
  • Monitor for drug interactions
  • Good handwashing
  • Follow-up visits
  • Advise against sexual intercourse until cured
  • Advise loose, absorbent underclothes
  • Sitz baths to decrease discomfort
  • Discuss alternative birth control methods
  • Encourage notifying partners
  • Inform patients about potential sterility

Trichomoniasis

• Caused by: Trichomonas vaginalis, a protozoan
• Transmitted by: Sexual intercourse
• Clinical Manifestations:
  • Males: May be asymptomatic, urethritis, dysuria, frequent urination, pruritis, purulent discharge
  • Females: May be asymptomatic, profuse malodorous discharge, pruritus, vaginal edema, dysuria, frequent urination, spotting, menorrhagia, dysmenorrhea
• Diagnosis: Microscopic examination of vaginal discharge
• Medical Management: Metronidazole oral for 7 days or single large dose
• Nursing Interventions:
  • Advise against alcohol during treatment
  • Inform about urine discoloration
  • Counsel against douches, sprays, and powders
  • Teach about disinfection of applicators and toilet area
  • Encourage loose-fitting clothing and cotton underwear
  • Schedule follow-up visits
  • Contact sexual partners for treatment

Candidiasis

• Caused by: Candida albicans and Candida tropicalis
• Often occurs: During diabetes or when resistance is lowered by diseases
• Predisposing factors: Radiation, immunosuppressant drugs, hyperalimentation, antibiotic therapy, oral contraceptives
• Clinical Manifestations:
  • Newborn: Diaper rash, nail edema, "milk-curd" lesions in mouth
  • Adult Female: Cheesy vaginal discharge, pruritus, vulvovaginitis
  • Adult Male: Penile infection with purulent exudate
  • Systemic: Chills, fever, malaise
• Diagnosis: Gram stain of specimens from vagina, penis, pus, or mouth
• Medical Management:
  • Manage underlying conditions
  • Discontinue antibiotics and oral contraceptives
  • Nystatin for superficial candidiasis, topical amphotericin B for skin and nail infections
• Nursing Interventions:
  • Emphasize use of prescribed ointments, sprays, and creams
  • Teach vaginal suppository insertion technique
  • Encourage sexual partners to seek examination and treatment
  • Teach good handwashing techniques
  • Encourage treatment during pregnancy to prevent neonatal infection

Chlamydia

• Caused by: Chlamydia trachomatis, a gram-negative, intracellular bacterium
• Causes: Cervicitis, urethritis, epididymitis, salpingitis
• Most common STI in the US: Responsible for 20-30% of PID cases
• High incidence: Young, promiscuous, low-income, unmarried women, and those with history of STIs
• Transmitted: vaginal, anal, or oral sex
• Clinical Manifestations:
  • Males: Scanty exudate, burning, pruritus, urinary frequency, dysuria
  • Females: Cervicitis (vaginal pruritus, pain, fever, discharge, irregular bleeding), PID
• Diagnosis:
  • Direct fluorescent antibody test: (less specific, may produce false positives)
  • Culture:
  • Nucleic Acid Amplification Test (NAAT): (gold standard)
• Medical Management:
  • Treatment: Tetracycline, doxycycline, azithromycin, ofloxacin
  • Pregnancy: Erythromycin (amoxicillin if intolerant)
  • Follow-up: Return if symptoms persist, treat partners, encourage condom use
  • Concurrent gonococcal infection: Treat both infections
• Nursing Interventions:
  • Address depression, anger, fear, and guilt
  • Consider education, income, language, insurance, and support network
  • Focus on prevention

Family Planning

• Advances in drug therapy and family planning technology offer a range of options for pregnancy prevention or planning
• Birth control planning involves moral, religious, cultural, and personal values
• Methods selection based on health, effectiveness, cost, lifestyle, ease of use, age, and pregnancy history
• Compliance and couple's preference are important considerations
• Nurses educate and guide about available choices, advantages, disadvantages, side effects, and long-term effects
• Contraception is intended to reduce unplanned pregnancies
• Contraceptive methods: Surgical, hormonal, barrier, and behavioral

Temporary Hormonal Methods

• Combined Birth Control Pills:

  • Contains: Estrogen and progesterone
  • Mechanism: Prevents ovulation, alters endometrium and cervical mucus, and tubal transport
  • Effectiveness: 99% (failure due to irregular or incorrect use)
  • Side Effects: Weight gain, nausea, spotting, breakthrough bleeding, post-pill amenorrhea, breast tenderness, headache, melasma, irritability, nervousness, depression, decreased libido
  • Complications: Benign liver tumor, gallstones, MI, thromboembolism, stroke (higher risk in smokers over 35)
  • Contraindications: Cardiovascular or liver disease, hypertension, breast or pelvic cancer, diabetes, sickle cell anemia
  • Patient Education:
    • Correct pill use
    • Take at the same time daily
    • Report cramps, edema, chest pain
    • Regular checkups (weight, BP, Pap smear, hematocrit)
    • Review danger signs of drug
    • Drug interaction with phenytoin, phenobarbital, antibiotics (ampicillin)
    • Not recommended for women over 35
    • Discourage smoking

• Morning-After Pill:

  • Contains: Norgestrel and ethinyl estradiol
  • Mechanism: Creates a hostile uterine lining and alters tubal transport
  • Effectiveness: 98.4%
  • Side Effects: Nausea for 1-2 days, does not prevent ectopic pregnancy
  • Patient Education:
    • Take two doses within 72 hours of intercourse
    • Repeat if vomiting occurs
    • Take the second dose 12 hours after the first
    • Menses should begin within 2-3 weeks
    • Start an ongoing method of contraception immediately after menses

• Progestin-Only Pills (POPs):

  • Taken: Daily, no pill-free days
  • Advantages: Preferred for breastfeeding women, does not suppress lactation, inhibits ovulation, thickens cervical mucus, alters uterine lining, lower cardiovascular risk than combined pills
  • Side Effects: Menstrual changes, breakthrough bleeding, prolonged cycles, or amenorrhea, increased risk of functional ovarian cysts and ectopic pregnancy
  • Patient Education:
    • Use alternative contraception when starting POPs or if a pill is missed
    • Take at the same time every day
    • Keep track of menses and undergo pregnancy testing if 2 weeks late

Barrier Methods

• Diaphragms:

  • Description: Dome-shaped latex caps with a flexible metal ring, fitted to cover the cervix
  • Mechanism: Mechanical barrier to sperm
  • Effectiveness: 87% (failure due to improper fitting or placement)
  • Side Effects: Allergy to latex or spermicide
  • Patient Education:
    • Demonstration and practice with insertion and removal
    • Empty bowel and bladder before insertion
    • Cleaning and storage instructions, check for holes or deterioration
    • Refitting after pregnancy, weight loss, or gain
    • Not suitable if severe pelvic relaxation present

• Cervical Caps:

  • Description: Rubber thimble-shaped shields covering the cervix, held in place by suction
  • Mechanism: Mechanical barrier to sperm
  • Effectiveness: Similar to diaphragms
  • Side Effects: Allergy to rubber or spermicide, cervical irritation, or erosion from suction
  • Patient Education:
    • Practice with insertion and removal
    • Cleaning, storage, and inspecting for damage
    • Use with abnormalities of vaginal canal but not with cervical inconsistencies or PID

• Condoms:

  • Male:

    • Description: Thin sheath fitting over erect penis
    • Mechanism: Barrier to sperm
    • Effectiveness: 85% (failure due to tearing or slipping)
    • Advantages: Simple to use, no prescription required, offers protection against some STIs and HIV
    • Side Effects: Allergy to latex, decreased sensation
    • Patient Education:
      • Roll sheath along entire penis, leaving slack at the end
      • Avoid sharp objects that can tear the condom
      • Hold sheath in place when withdrawing to prevent emptying of sperm

  • Female:

    • Description: Double-ring system fitted into the vagina up to 8 hours before intercourse
    • Advantages: No prescription required, protects against HIV, CMV, and hepatitis B
    • Side Effects: No significant side effects
    • Patient Education:
      • Discuss insertion, lubrication, and method of removal
      • More expensive than male condoms### Intrauterine Devices (IUDs)

• Inserted into the uterus; they are flexible devices made of plastic or copper wire, usually attached to a string that protrudes into the vagina.

• Effectiveness: 97% to 88% effective.

• Most common type today is Progestasert, containing progestins.

• Side effects: Increased menstrual flow, intermenstrual bleeding, and cramping, especially during the early months of use.

• Possible complications: Ectopic pregnancy, pelvic infection, perforation of the uterus, infertility.

• Patient teaching: Discuss insertion and removal techniques, check for the string in the vagina after each period.

Rhythm Method

• Requires periodic abstinence during the fertile portion of the menstrual cycle.
• Effectiveness: 60% to 65% effective.
• Side Effects: Inaccurate or incomplete knowledge of the menstrual cycle.
• Patient education: Discuss methods to establish a baseline menstrual pattern and identify ovulation.

Tubal Sterilization

• Abdominal and vaginal surgical procedures that permanently prevent sperm and ovum from meeting.
• Effectiveness: Nearly 100% (99.6%) effective.
• Side effects: Bowel injury, hemorrhage, or infection.
• Patient education: Counsel regarding effects of the procedure on physiology and sexual performance.

Hysterectomy

• Surgical removal of the uterus.
• Effectiveness: 100% effective.
• Side effects: Bladder infection, vascular disorders, infection, hemorrhage, pain, psychological adjustment.
• Patient education: Assess understanding of the surgery, altered physiology, complications, and sexual performance.

Vasectomy

• Bilateral surgical ligation and resection of the ductus deferens.
• Sterilization is not immediate, usually takes about 1 to 3 months.
• Side effects: Hematoma, edema, psychological adjustment.
• Patient Education: Inform the patient that the procedure is usually done as an outpatient procedure and takes 15 to 30 minutes.

Infertility

• Defined as the inability to conceive after 1 year of sexual intercourse without birth control measures.
• If the woman is over the age of 35, the time is reduced to 6 months.
• An estimated 10% to 15% of couples are infertile.
• A woman's age has a significant bearing on her ability to conceive.
• Women are most fertile between ages 20 and 29.
• Fertility begins to decline after age 35.

Male Fertility

• Male fertility does not dramatically decrease with aging.
• Leading causes of male-related infertility: Damage to sperm production, longevity, or sperm motility issues.
• Additional male-related causes: Hormonal imbalances, anatomic abnormalities, and genetic defects.
• Lifestyle factors: Alcohol and drug use, smoking, exposure to environmental toxins, and some medications.

Female Fertility

• Female-related causes: Ovulatory issues, hormonal imbalances, and structural abnormalities.
• Ovulation-related disorders: Compromise most female-related cases of infertility.
• Hormonal imbalances: Problematic levels of estrogen, progesterone, and FSH.
• Structural abnormalities: Scarring from sexually transmitted infections or endometriosis, abnormalities in the shape and size of the uterus, uterine fibroid tumors, and blockages in the fallopian tubes.

Infertility Assessment & Diagnostic Tests

• Subjective and objective data: Physical examination and health histories for both partners.
• Specific testing: Rule out systemic diseases such as diabetes mellitus, neoplasms, hepatic and renal diseases, and viral conditions.
• Male testing: Semen analysis and endocrine imbalance testing.
• Female testing: Assessment of ovulatory functions, endometrial biopsy, hysterosalpingography, and hysterography.
• Male and female interaction studies: Huhner’s test, immunologic or immunoglobulin (antibody) testing, and testing for normalcy of sex chromosomes.

Medical Management of Infertility

• Depends on the cause.
• Ovarian function disorders: Supplement hormone therapy to restore and maintain ovulation.
• Structural abnormalities: Surgical correction.
• Hormonal imbalances: Pharmacologic treatment.
• Poor cervical mucus: Cauterization of the cervix or administration of estrogens.
• Intrauterine insemination: With the partner's or donor's sperm.
• In vitro fertilization (IVF): Removal of mature oocytes followed by fertilization in a Petri dish.
• Assisted reproductive technologies (ARTs): IVF, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), cryopreserved embryo transfer (CPE), and donor oocyte programs.

Nursing Interventions & Patient Teaching

• Provide emotional support and education throughout the infertility testing and treatment period.
• Recognize and deal with psychological and emotional factors.
• Encourage couples to participate in support groups and individual therapy.
• Give couples ample opportunity to plan what is financially realistic.
• Prognosis: The condition causing the infertility and the age of the woman are the primary deciding factors.
• Women over age 40 have reduced chances of achieving pregnancy.

Women's Health Care Overview

• Women are active participants in their healthcare and require information about their bodies, health promotion, self-care, and treatment options.
• Cultural competence is crucial for empowering women to feel confident about their healthcare.
• Nurses should understand patients' cultural practices, past experiences, and individual goals.
• Nurses provide support, knowledge, and caring behaviors to help women cope with screening tests or health problems.

Health People 2030

• Goals and strategies related to women include preventive care, screening, and increased access to healthcare.
• Increase mammograms in women over 40 to reduce the rise in breast cancer.
• Increase Pap tests in women over 21 to reduce cervical cancer deaths.
• Reduce the occurrence of vertebral/hip fractures in older women with osteoporosis.
• Reduce the occurrence of sexually transmitted infections and pelvic inflammatory disease.

Preventative Healthcare for Women

• Preventative healthcare aims to prevent or identify disease early.
• Preventative healthcare can prevent disabling conditions or reduce the severity of others.
• Preventative care includes interventions specific to women’s health (e.g., cervical cancer), conditions prevalent in women (e.g., breast cancer), and common conditions in the general population (e.g., hypertension, colorectal cancers).

Breast Care

• Early detection of breast cancer requires:
  • Monthly breast self-examination (BSE)
  • Annual professional breast examination
  • Mammography as appropriate
• Nurses educate women about the benefits of these examinations and teach BSE techniques.
• BSE should be performed by all women over 20, ideally a week after the start of the menstrual period.
• Professional breast examinations are a supplement to BSE and are part of annual gynecological examinations, with increased frequency for high-risk women.
• Mammograms use low-dose x-rays to visualize breast tissue and detect tumors early.
• The American Cancer Society recommends an annual mammogram for women 40 and older. High-risk individuals may start earlier.

Vulvar Self-Examination

• Women over 18 (or younger if sexually active) should perform monthly examinations of their external genitalia.
• The goal is to identify lesions or masses that may indicate infection or malignancy.
• Techniques involve systematic inspection with a hand mirror in good light and palpation of the vulva and mons pubis.
• Report abnormal findings to a healthcare provider:
  • Painful or inflamed areas
  • Ulcerations
  • Sores
  • Changes in skin color

Pelvic Examination

• Pelvic exams aren't recommended for all women annually.
• If recommended, schedule it between menstrual periods.
• Patient teaching includes:
  • No douching or intercourse 48 hours before the exam
  • The purpose is to identify:
    • Tumors
    • Abnormal discharge
    • Infections
    • Unusual pain
• The healthcare provider inspects the external genitalia and uses a speculum to visualize the cervix and vagina for anomalies.

Pap Test

• Screens for changes in vaginal and cervical tissues, which may be precancerous.
• Guidelines for sexually active women:
  • Ages 21-29: Every 3 years
  • Ages 30-65: Every 5 years
  • Over 65: No screening necessary with negative results for the previous 10 years.
• Pap tests and HPV co-screening are often done together.
• After the Pap test, the healthcare provider may perform a bimanual examination to assess the organs. This allows palpation of the cervix, uterus, and ovaries.

Menstrual Cycle Disorders

• The nurse's role depends on the disorder's cause and treatment.
• Examples: Teaching about medications, providing emotional support.

Amenorrhea

• The absence of menstruation.
• Normal before menarche, during pregnancy, and after menopause.
• If not normal, classified as:
  • Primary: Failure to menstruate by age 16 or by age 14 without secondary sex characteristics.
  • Secondary: Cessation of menstruation for at least three cycles or six months in a woman who previously had regular menstruation.
• Medical management includes thorough health history, physical examination, and lab tests. Treatments target the underlying cause.

Abnormal Uterine Bleeding

• Bleeding that is too frequent, long-lasting, or excessive.
• Metrorrhagia: Intermenstrual bleeding.
• Menorrhagia: Excessive menstrual bleeding.
• Common causes:
  • Bleeding disorders
  • Pregnancy complications
  • Lesions
  • Breakthrough bleeding
  • Endocrine disorders
  • Failure to ovulate or respond to hormones.
• Treatment depends on the identified cause.

Menstrual Cycle Pain

• Mittelschmerz: Pain around ovulation, near the menstrual cycle. Mild analgesics can alleviate it.
• Teach patients that mittelschmerz is harmless.

Dysmenorrhea

• Painful menstrual cramps.
• Occurs after the onset of menses and is spasmodic.
• Discomfort in the lower abdomen that may radiate to the back or legs.
• Some women experience diarrhea, nausea, and vomiting.
• More common in young women without prior pregnancies.
• Types:
  • Primary: No identified pelvic abnormality.
  • Secondary: Identifiable pathological condition.
• Primary dysmenorrhea:
  • Heavy menstrual flow
  • Pain begins a few hours before menstruation starts and lasts up to 72 hours.
  • Normal pelvic examination results.
• Secondary dysmenorrhea:
  • Often caused by:
    • Endometriosis
    • Intrauterine devices (IUDs)
    • Pelvic inflammatory disease
    • Uterine polyps
    • Ovarian cysts
• Treatment involves identifying the cause and may include:
  • Prostaglandin-inhibitor drugs (e.g., ibuprofen, naproxen)
  • Heat application to the lower abdomen or back
  • Oral contraceptives

Endometriosis

• Presence of tissue that resembles the endometrium outside the uterus.
• Clinical manifestations:
  • Lesions may cause pain, pressure, and inflammation in adjacent organs.
  • Pain can be sharp or dull.
  • Dyspareunia (painful intercourse).
• Treatment:
  • Medical or surgical
  • Medications (e.g., danazol)
  • Surgical treatments:
    • Hysterectomy
    • Laser ablation
• Prognosis: No effect on pregnancy once achieved.

Premenstrual Disorders

• Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are associated with an abnormal serotonin response to estrogen fluctuations during the menstrual cycle.
• Criteria for diagnosing PMDD:
  • Symptoms occur between ovulation and the onset of menstruation.
  • Symptoms improve between menstruation and ovulation.
  • Symptoms are absent the week after the menstrual period.
  • Five or more of the following symptoms typically occur regularly:
    • Depressed mood
    • Anxiety, tension, feeling “on edge”
    • Increased sensitivity to rejection
    • Irritability
    • Decreased interest in usual activities
    • Difficulty concentrating
    • Lethargy
    • Change in appetite (food cravings)
    • Change in sleep habits
    • Feeling overwhelmed
    • Physical symptoms (breast tenderness, bloating, weight gain, headaches).
• Diagnosis is based on established symptoms for more than three months.
• Treatment:
  • Diet rich in complex carbohydrates and fiber
  • Stress management
  • Exercise
  • Medical management:
    • Oral contraceptives
    • Diuretics
    • Selective serotonin reuptake inhibitors (SSRIs)
    • Short-acting anti-anxiety medications
    • Complementary and alternative medicine (CAM) therapies.
• Patient teaching:
  • Monitor symptoms
  • Stress management
  • Reduce caffeine, simple sugars, and salty foods
  • Regular exercise
  • Prevention of hypoglycemia

Gynecological Infections

• Vaginal infections are a common reason for women to seek healthcare.
• Nurses play a key role in educating women about vaginal health and preventing sexually transmitted infections (STIs).
• Community-based education in schools and churches is essential for primary prevention.
• Three classes of gynecological infections:
  • Toxic shock syndrome
  • Sexually transmitted infections (STIs)
  • Pelvic inflammatory disease

Sexually Transmitted Infections (STIs)

• The incidence of infections transmitted through sexual activity continues to rise globally.
• These infections are usually transmitted during intimate sexual contact but can have other routes of transmission (e.g., from an infected mother to her newborn).
• They can occur with or without symptoms and have long periods of asymptomatic infectivity.
• Any sexually active person can be at risk for an STI.
• People with frequent sexual contact with multiple partners and who engage in unprotected sex are at increased risk.
• Those most at risk often include:
  • Young
  • Single
  • Urban
  • Poor
  • Male
  • Homosexual.
• Assess risk factors for STIs using the "5 Ps":
  • Past STIs
  • Partners
  • Practices
  • Prevention
  • Pregnancy
• STIs are among the world's most communicable diseases. The main factors responsible for their spread include:
  • Unprotected sex
  • Antibiotic resistance
  • Treatment delays
  • Sexual behavior patterns and permissiveness (accepting casual sex and sex with multiple partners).

Types of STIs:

Genital Herpes

• Caused by the herpes simplex virus (HSV).
• Infectious viral disease with recurrent episodes of painful, erythematous, vesicular eruptions (blisters) on or in the genitalia or rectum.
• Two forms:
  • HSV type 1: Usually acquired in infancy during feeding or kissing by adults.
  • HSV type 2: Usually acquired sexually after puberty, affecting the genital or anal regions.
• Clinical Manifestations:
  • Fluid-filled vesicles appear 2 to 14 days after exposure.
  • In women, vesicles usually occur on the cervix, labia, rectum, vulva, vagina, and skin.
  • In men, vesicles occur on the glans penis, foreskin, and penile shaft.
  • Lesions may appear on the mouth and anus.
  • Vesicles rupture and become shallow, painful ulcers, with redness, swelling, and tenderness.
  • Lymph nodes may be affected.
  • Initial lesions last 3 to 10 days, recurring lesions last 7 to 10 days.
  • Primary infection may be accompanied by fever, malaise, muscle aches (myalgia), painful urination (dysuria), and leukorrhea (vaginal discharge) in women.
  • Urination may be painful if urine contacts active lesions.
  • After the initial outbreak subsides, the virus becomes dormant but can be triggered by illness, fatigue, injury, or stress.
  • Recurring outbreaks are usually less painful and shorter in duration.
  • Frequency of outbreaks varies, with some individuals never experiencing an outbreak and others having frequent episodes.
• Diagnostic Tests:
  • Diagnosis is based on physical examination and patient history.
  • Confirmed by identifying the virus in tissue cultures.
    • Cultures are more positive during primary infections than recurring infections.
  • Asymptomatic disease can be identified through serological (blood) testing.
• Medical Management:
  • Treatment focuses on symptom management.
  • Maintain good genital hygiene and wear loose-fitting cotton undergarments.
  • Keep lesions clean and dry.
  • Frequent sitz baths soothe the area and reduce inflammation.
  • Pain relief may require local anesthetics (e.g., lidocaine) or systemic analgesics (e.g., codeine, aspirin).
  • Abstain from sexual contact during active outbreaks.
  • Transmission can occur even without symptoms.
  • Antiviral medications can manage the initial outbreak, subsequent outbreaks, or prevent future outbreaks as suppressive therapy.
  • Medications do not cure the disease but reduce symptom severity and shorten outbreak duration.
• Nursing Interventions and Patient Teaching:
  • Keep genital lesions clean and dry.
  • Wash hands after touching lesions.
  • Wear loose, absorbent clothing.
  • Sitz baths for comfort and to improve urination and bowel elimination.
  • Avoid sexual intercourse during an active outbreak.
  • Encourage barrier methods (e.g., condoms) even during asymptomatic periods.
  • Inform future sexual partners and healthcare providers about latent or recurring infections.
  • Educate patients about the role of stress, poor nutrition, and insufficient rest in recurrences.
  • Annual Pap tests for women.
  • Provide nonjudgmental support and refer to local herpes support groups.

Syphilis

• Caused by the spirochete bacterium Treponema pallidum.
• High rates of primary syphilis in men who have sex with men (MSM), accounting for 82% of cases.
• The third most frequently reported communicable disease.
• Transmitted through sexual contact during primary, secondary, and latent stages (tertiary stage is non-contagious).
• Can be spread through contact with infectious lesions and sharing needles among drug users.
• Prenatal infection from mother to fetus is possible.
• The organism thrives in warm areas of the body and can be killed by soap and water.
• The spirochete penetrates intact skin and mucous membranes of the genital organs, rectum, and mouth.
• Clinical Manifestations:
  • Syphilis has four stages: primary, secondary, latent, and tertiary.
  • Signs and symptoms:
    • Chancre (painless erosion or papule that ulcerates with a scooped-out appearance) in primary syphilis.
    • Skin rashes in secondary syphilis.
    • Moist, raised, gray to pink lesions on the genital or perirectal skin.
    • Enlarged lymph nodes
    • Fever
    • Fatigue
    • Infections of the eyes, bones, liver, or meninges
    • In late stages:
      • Dementia
      • Pain or loss of sensation in the legs
      • Destruction of the aorta
      • Destructive inflammatory masses in any organ
      • Cardiovascular syphilis (affecting the heart and blood vessels)
      • Neurosyphilis (affecting the central nervous system)
      • Spinal cord degeneration
      • Partial paralysis
      • Various psychoses
• Diagnostic Tests:
  • Venereal Disease Research Laboratory (VDRL) slide test.
  • Rapid plasma reagin (RPR) test.
  • All patients should be checked for gonorrhea as well (often coexists with syphilis).
• Medical Management:
  • Goal: Eradicate all syphilitic organisms.

Syphilis

• Caused by Treponema pallidum, a spirochete
• Transmitted through direct contact with a syphilis sore during sexual activity
• Syphilis can be cured with penicillin
• If left untreated, syphilis can cause serious health problems, including death
• Syphilis can be treated in all stages but is more difficult to manage in late stages
• Neurosyphilis should be monitored with periodic serologic testing, clinical evaluations, and cerebrospinal fluid examinations

Gonorrhea

• Caused by Neisseria gonorrhoeae, a gram-negative bacterium
• Transmitted through sexual contact
• The highest incidence of gonorrhea occurs in adolescents and young adults
• Gonorrhea can infect the mouth, throat, and eyes
• Treatment is usually given without waiting for culture results
• The drug of choice is Ceftriaxone or Cefixime
• All sexual contacts must be treated to prevent reinfection

Trichomoniasis

• Caused by the protozoan parasite Trichomonas vaginalis
• Transmitted through sexual intercourse
• Most men and women are asymptomatic
• Treating with oral metronidazole (Flagyl)

Candidiasis (Thrush)

• Caused by the Candida species, a fungus
• Often occurs when glucose levels are high or immunity is weakened
• Can be treated with topical antifungal medications, such as nystatin or amphotericin B
• Infected individuals may display signs of scaly skin, erythematous rash, and exudates
• Pregnant women should be treated to prevent infection of the newborn

Chlamydia

• Caused by Chlamydia trachomatis, a bacterium
• The most common sexually transmitted infection (STI) in the US
• Can be transmitted through vaginal, anal, or oral sex
• Most women are asymptomatic
• Treated with antibiotics, such as doxycycline, azithromycin, or erythromycin
• Sexual partners must be treated to prevent reinfection

Family Planning

• Advances in drug therapy and family planning technology have made a range of options available for individuals wishing to prevent or plan conception
• Family planning involves moral, religious, cultural, and personal values
• The nurse's role is to educate and guide patients concerning available choices, advantages, disadvantages, side effects, and long-term effects of different methods
• Contraception does not always prevent pregnancy
• Contraceptive methods can be categorized as surgical, hormonal, barrier, and behavioral
• Patients should be informed of the side effects and contraindications of each method
• Patients should be encouraged to seek more information and follow-up care.

Contraceptive Methods

• Combined Birth Control Pills: contain estrogen and progesterone, prevents ovulation, 99% effective if used correctly
• Morning-after pill (Combined pill): contains norgesterel and ethinyl estradiol, 98.4% effective, prevents ovulation
• Progestin-only pills: taken daily, preferred for breastfeeding women, inhibits ovulation
• Diaphragm: dome-shaped latex cap that covers the cervix, 87% effective if used correctly
• Cervical caps: rubber thimble-shaped shields that cover the cervix, effectiveness similar to diaphragm
• Male Condoms: thin rubber sheath that fits over the penis, 85% effective if used correctly
• Female Condoms: double-ring system that fits into the vagina, protects against HIV, cytomegalovirus, and hepatitis B

IUDs

• IUDs are small, flexible devices made of plastic or copper wire, inserted into the uterus to prevent pregnancy.
• They work by causing an inflammatory response in the endometrium, preventing implantation.
• IUDs must be inserted by a healthcare provider and require no additional equipment after insertion.
• They are highly effective, with a success rate ranging from 97% to 88%, with most failure due to undetected expulsion.
• The most common type of IUD used today is Progestasert, which contains progestins.
• Common side effects include increased menstrual flow, intermenstrual bleeding, and cramping, especially during the early months of use.
• Potential complications include ectopic pregnancy, pelvic infection, uterine perforation, and infertility.

Rhythm Method

• The rhythm method involves abstaining from intercourse during the fertile portion of the menstrual cycle.
• It requires strong motivation and self-control but aligns with all religious doctrines.
• Effectiveness rates range from 60% to 65%, with failure primarily due to difficulty in determining ovulation and irregular menstrual cycles.
• Potential side effects include inaccurate or incomplete knowledge of the menstrual cycle.

Tubal Sterilization

• Tubal sterilization involves surgical procedures that permanently prevent sperm and ovum from meeting.
• Techniques include crushing, ligating, clipping, or plugging the fallopian tubes.
• It is highly effective, with a success rate of nearly 100% (99.6%).
• Failure is typically due to recanalization of fallopian tubes or incorrect ligation.
• Potential complications include bowel injury, hemorrhage, or infection.

Hysterectomy

• Hysterectomy is the surgical removal of the uterus, resulting in 100% effectiveness.
• Potential complications include bladder infection, vascular disorders, infection, hemorrhage, pain, and psychological adjustment.

Vasectomy

• Vasectomy is a bilateral surgical procedure that ligates and resects the ductus deferens.
• Sterilization is not immediate; it typically takes 1 to 3 months for the procedure to be fully effective.
• Men should return to their physician for semen analysis to verify the absence of sperm.
• Until confirmation, alternative birth control methods are required.
• Potential complications include hematoma, edema, and psychological adjustment.

Infertility

• Infertility is defined as the inability to conceive after 1 year of unprotected intercourse.
• The timeframe is reduced to 6 months for women over 35.
• Primary infertility refers to couples who have never conceived.
• Secondary infertility refers to couples who have conceived previously but are now unable to do so.
• Approximately 10% to 15% of couples experience infertility.
• A woman’s age significantly impacts her fertility, with peak fertility between ages 20 and 29.
• Fertility declines after age 35 and is minimal as menopause approaches.

Male Fertility

• Male fertility does not dramatically decrease with aging.
• Causes of male infertility include:
  • Damage to sperm production, longevity, or motility issues.
  • Structural abnormalities and low motility of sperm.
  • Excessive heat exposure of the testicles.
  • Hormonal imbalances, anatomic abnormalities, and genetic defects.
  • Lifestyle factors such as alcohol and drug use, smoking, exposure to environmental toxins, and certain medications.
  • Illnesses like cancer and related treatments.

Female Fertility

• Female infertility causes include:
  • Ovulation-related disorders.
  • Hormonal imbalances affecting estrogen, progesterone, and FSH levels.
  • Structural abnormalities such as scarring from sexually transmitted infections, endometriosis, uterine abnormalities, uterine fibroids, and fallopian tube blockages.
  • Lifestyle factors like increasing age, smoking, excessive alcohol use, athletic training, obesity, or being underweight.

Assessment, Diagnostic Tests, & Medical Management of Infertility

• Assessment of couples includes physical examination, health histories, and specific testing to rule out systemic diseases, genetic defects, and disorders of the testes.
• Diagnostic testing can be stressful and expensive, with male testing often simpler and less costly than female testing.
• Male testing includes semen analysis and endocrine imbalance testing.
• Female testing focuses on ovulation and reproductive organ function, including:
  • Assessment of ovulatory functions.
  • Endometrial biopsy.
  • Hysterosalpingography and hysterography.
• Male and female interaction studies include the Huhner’s test, immunologic testing for spermicidal antibodies, and sex chromosome testing.
• Management of infertility depends on the cause.
• Hormonal therapy to induce ovulation may be attempted using drugs like clomiphene citrate (Clomid) and bromocriptine (Parlodel), which increase the risk of multiple births.
• Surgical correction may be considered for structural abnormalities, fibroid tumors, and scar tissue.
• Hormonal imbalances can be treated pharmacologically with progesterone.
• Poor cervical mucus may be addressed through cauterization or estrogen administration.
• Improving overall health can help, especially if debilitation or chronic illness is present.
• Reducing psychological stress can enhance emotional well-being.
• Education about ovulation timing and coital techniques may be indicated.
• Intrauterine insemination with the partner’s or donor's sperm is an option if other measures fail.
• In vitro fertilization (IVF) is used for fallopian tube obstruction, decreased sperm count, and unexplained infertility.
• IVF involves egg retrieval, fertilization in a Petri dish, and embryo transfer into the uterus.
• Assisted reproductive technologies (ARTs) have expanded rapidly since the first IVF baby was born in 1978.
• ARTs include IVF, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), cryopreserved embryo transfer (CPE), and donor oocyte programs.

Nursing Interventions & Patient Teaching

• Nurses provide emotional support and education throughout the infertility testing and treatment process.
• Important considerations include:
  • Addressing the psychological and emotional factors associated with infertility.
  • Encouraging participation in support groups and individual therapy.
  • Providing information and emotional support during treatment.
  • Assisting couples in planning financially realistic approaches, as IVF treatments can be expensive (between $10,000 and $15,000 per cycle in the United States).

Prognosis

• The condition causing infertility and a woman's age are key factors influencing the outcome of infertility treatments.
• Women over 40 have reduced chances of achieving pregnancy.
• An estimated 50% of couples undergoing diagnostic testing and treatment for fertility can conceive.

Test your knowledge on women's health care, including preventative measures, early detection methods, and important examinations. This quiz covers key topics such as breast self-examinations, mammograms, and menstrual disorders. Empower yourself with the facts and best practices for women's health.