Sean Whitfield - NURS - 3450 Learning Guide Module 2 (1) - Complete.docx

Module 2 Active Learning Guide - Chapters 6, 7, & 8 Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentrate on applying and analyzing knowledge to provide a context concerning the course and career skills. Students should...

Module 2 Active Learning Guide - Chapters 6, 7, & 8 Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentrate on applying and analyzing knowledge to provide a context concerning the course and career skills. Students should review the active learning guide before engaging with the module content, then work to complete the guide both during and after engaging with the content. An active learning guide is not the same as a study guide or a test blueprint. It serves as a guide to help the student navigate the course and content. The active learning guide is not a complete composite of the information needed for the exam but a guide to navigating the content delivery. The Sherpath Lessons that are included in the modules will also help you with grasping the material. They are interactive and thorough. Instructions Review the active learning guide before you begin reading and engaging with other content in the module. Looking at the questions beforehand will preview the information you will be learning, including the key concepts and takeaways. As you work through the module content, complete the active learning guide. Some questions may be reflective and require that you finish all content before responding. Students will turn in the completed learning guide by the end of the module. Faculty will review and award points and return them to students to review prior to the exam. There are 10 points possible for this learning guide. Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of our population. Evidence-Based Practice boxes contain a summary of pertinent current research related to chapter topics. Clinical Reasoning Case Studies are found in each chapter. The answers are available to you through the Elsevier Evolve Student Resource that you may register for (no additional cost). Legal Tips boxes are scattered throughout the text to give you important information on the legal aspects of women’s health. Cultural Consideration boxes give additional thoughtful material for the nurse to include in providing women and families with culturally competent care. Medication Guides are present for many medications that are used in women’s health. There are also Nursing Care Plans for many conditions. Much of women’s health nursing consists of educating our patients. To that end, there are many Teaching for Self-Management boxes throughout the text. Chapter 6 Reproductive System Concerns What are common causes of amenorrhea? Still, most commonly and most benignly, amenorrhea is a result of pregnancy. It can also result from anatomic abnormalities such as outflow tract obstruction. Amenorrhea can be caused by endocrine dysfunction such as anterior pituitary disorders, polycystic ovarian syndrome, hypothyroidism, or hyperthyroidism. Amenorrhea may result from chronic diseases such as type 1 diabetes, medications such as phenytoin (Dilantin), drug use (e.g., alcohol, opiates, marijuana, cocaine), or oral contraceptive use. Cyclic perimenstrual pain and discomfort (CPPD) includes what disorders? What are their definitions? Dysmenorrhea → pain that occurs during or shortly before menstruation, is one of the most common gynecologic problems in women of all ages. Many adolescents have dysmenorrhea in the first 3 years after menarche. Approximately 50% to 90% of women report some level of discomfort associated with menses, and approximately 15% report severe dysmenorrhea limiting their work and social activities Primary Dysmenorrhea → is a condition associated with the ovulatory cycle; it has no known pathology and manifests before 20 years of age, with a prevalence of approximately 75% (Mendiratta & Lentz, 2021). Research has shown that it arises from the release of prostaglandins with menses. During the luteal phase and subsequent menstrual flow, prostaglandin F2α (PGF2α) is secreted. Excessive release of PGF2α increases the amplitude and frequency of uterine contractions and causes vasospasm of the uterine arterioles, resulting in ischemia and cyclic lower abdominal cramps. Systemic responses to PGF2α include backache, weakness, diaphoresis, gastrointestinal (GI) symptoms (anorexia, nausea, vomiting, and diarrhea), and CNS symptoms (dizziness, syncope, headache, and poor concentration). Pain may begin a few days before menstruation and lasts from 48 to 72 hours (Tsonis, Gkrozou, Barmpalia, et al., 2021). Secondary Dysmenorrhea → menstrual pain that develops later in life than primary dysmenorrhea, typically after 25 years of age. It is associated with a pelvic pathology such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids). Women with secondary dysmenorrhea often have other symptoms that may suggest the underlying cause. For example, heavy menstrual flow with dysmenorrhea suggests a diagnosis of leiomyomata, adenomyosis, or endometrial polyps. Pain associated with endometriosis often begins a few days before menses but can be present at ovulation and continue through the first days of menses or start after menstrual flow has begun. In contrast to primary dysmenorrhea, the pain of secondary dysmenorrhea is often characterized by dull lower abdominal aching that radiates to the back or thighs. Often women experience feelings of bloating or pelvic fullness. In addition to a physical examination with a careful pelvic examination, diagnosis may be assisted by ultrasound examination, dilation and curettage (D&C), endometrial biopsy, or laparoscopy. Treatment is directed toward removal of the underlying pathology. Many of the measures described for pain relief of primary dysmenorrhea are also helpful for women with secondary dysmenorrhea. Premenstrual Syndrome → Approximately 75% of women experience premenstrual symptoms at some time in their reproductive lives, with approximately 30% reporting severe symptoms (Callahan & Caughey, 2018; Mendiratta & Lentz, 2021). Establishing a universal definition of premenstrual syndrome (PMS) is difficult, given that so many symptoms have been associated with the condition and at least two different syndromes have been recognized: PMS and premenstrual dysphoric disorder (PMDD). PMS is a complex, poorly understood condition that includes one or more of a large number (more than 150) of physical and psychologic symptoms beginning in the luteal phase of the menstrual cycle, occurring to such a degree that lifestyle or work is affected, and followed by a symptom-free period. Symptoms include fluid retention (abdominal bloating, pelvic fullness, edema of the lower extremities, breast tenderness, and weight gain), behavioral or emotional changes (depression, crying spells, irritability, panic attacks, and impaired ability to concentrate), premenstrual cravings (sweets, salt, increased appetite, and food binges), headache, fatigue, and backache. Premenstrual Dysphoric Disorder → is a more severe variant of PMS in which women have marked irritability, dysphoria, mood lability, anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed (Mendiratta & Lentz, 2021). The most common symptoms are those associated with mood disturbances, and PMDD is listed as a condition in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (American Psychiatric Association [APA], 2013). A diagnosis of PMS is made when a specific group of symptoms consistent with PMS occurs in the luteal phase and resolves within a few days of menses onset. These symptoms can be physical and/or behavioral and include breast tenderness, bloating, headache, irritability, anxiety, and depression (Mendiratta & Lentz, 2021). For a diagnosis of PMDD, the following criteria must be met (APA, 2013):  Five or more affective and physical symptoms are present in the week before menses and begin to improve in the follicular phase of the menstrual cycle.  At least one of the symptoms is marked affective lability, marked irritability or anger, depressed mood or feelings of hopelessness, self-deprecating thoughts, or anxiety.  One or more of the following additional symptoms is present: decreased interest in usual activities; subjective difficulty concentrating; lethargy; marked change in appetite (overeating, food cravings); hypersomnia or insomnia; feeling overwhelmed; physical symptoms of breast tenderness, muscle pain, bloating, weight gain.  Symptoms interfere markedly with work or interpersonal relationships.  Symptoms are not caused by an exacerbation of another condition or disorder.  Symptoms are not caused by physiologic effects of a substance or a specific medical treatment.  These criteria must be confirmed by prospective daily ratings for at least two menstrual cycles.  The occurrence of symptoms must be confirmed, evidenced through daily ratings. Describe some common treatments, teaching, and interventions for primary dysmenorrhea. Care Management The application of heat to the lower abdomen in the form of a wrap or heating pad as well as soaking in warm water can reduce discomfort. The heat minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia. Physical exercise has also been found to help alleviate pain (McKenna & Fogleman, 2021). Relaxation training, biofeedback, transcutaneous electrical nerve stimulation (TENS), breathing exercises, hypnotherapy, imagery, desensitization, and herbs and essential oils are also used to decrease menstrual discomfort, although evidence is insufficient to determine their effectiveness (Ferries- Rowe et al., 2020; Tsonis et al., 2021) (Fig. 6.1). Exercise helps relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia. It also releases endogenous opiates (specifically β-endorphins), suppresses prostaglandins, and shunts blood flow away from the viscera, resulting in reduced pelvic congestion. One specific exercise that nurses can suggest is pelvic rocking. In addition to maintaining good nutrition at all times, specific dietary changes can help to modify some of the systemic symptoms associated with dysmenorrhea. A decreased intake of salt and refined sugar 7 to 10 days before the expected menses may reduce fluid retention. Natural diuretics such as asparagus, cranberry juice, peaches, parsley, or watermelon may help reduce edema and related discomforts. A low-fat vegetarian diet and vitamin E intake may also help to minimize dysmenorrheal symptoms (Mendiratta & Lentz, 2021). It is noteworthy that some research has found that missing breakfast and low caloric intake may be associated with primary dysmenorrhea (Tsonis et al., 2021). Medications used to treat primary dysmenorrhea include prostaglandin synthesis inhibitors, primarily nonsteroidal antiinflammatory drugs (NSAIDs) (Mendiratta & Lentz, 2021) (Table 6.1). NSAIDs are most effective if started several days before the menses or at least by the onset of bleeding. All NSAIDs have potential GI side effects including nausea, vomiting, and indigestion as well as potential hematologic sequelae and nephrotoxicity. Women taking NSAIDs should be instructed to report dark-colored stool because this may be an indication of GI bleeding. It is recommended that women take NSAIDs for 72 hours or less to prevent adverse effects. OCPs are associated with less severe primary dysmenorrhea and are an appropriate choice for women who want to use a contraceptive agent (Dickey & Seymour, 2021). The benefits of their use are attributed to decreased prostaglandin synthesis associated with an atrophic decidualized endometrium. Combined OCPs, which contain both estrogen and progesterone, are effective in relieving symptoms of primary dysmenorrhea for approximately 70% to 80% of women. Extended-cycle OCPs have been shown to be effective for the relief of primary dysmenorrhea (McKenna & Fogleman, 2021). OCPs are a particularly good choice for therapy because they combine contraception with a positive effect on dysmenorrhea, menstrual flow, and menstrual irregularities. Adolescents may benefit from use of the long-acting injectable contraceptive (depot medroxyprogesterone acetate), but more research is needed. Because OCPs have side effects (e.g., risk of venous thromboembolism), women may not wish to use them for dysmenorrhea. OCPs may be contraindicated for some women. (See Chapter 8 for a complete discussion of OCPs.) Hormonal intrauterine devices (IUDs) have been demonstrated to decrease dysmenorrhea. Specifically, levonorgestrel IUDs have been associated with fewer reports of dysmenorrhea (Dickey & Seymour). Alternative and complementary therapies are increasingly popular and used in developed countries. Therapies such as acupuncture, acupressure, biofeedback, desensitization, hypnosis, massage, Reiki, relaxation exercises, and therapeutic touch have been used to treat pelvic pain (Fisher, Hickman, Adams, & Sibbritt 2018; Tsonis et al., 2021). Herbal preparations have long been used for managing menstrual problems including dysmenorrhea, though limited evidence of their benefits exists (Tsonis et al.). However, it is essential that women understand that these therapies are not without potential toxicity and may cause drug interactions. Vitamin D has been shown to reduce the symptoms of dysmenorrhea and PMS (Bahrami, Avan, Sadeghnia, et al., 2018). Aerobic exercise (50 minutes of exercise three times a week) has also been shown to improve primary dysmenorrhea (Tsonis et al.). Table 6.2 lists some alternative and complementary therapies. Give 4 nursing diagnoses for a woman who is experiencing endometriosis: Diagnosis Related to: Acute Pain Inflammation and tissue irritation Impaired Fertility Adhesions around the uterine tubes Deficient Knowledge Lack of patient education Anxiety Chronic pain and uncertainty about the future What education does a woman experiencing endometriosis need? Be specific with what you would teach (not just topics). Counseling and education are critical components of nursing care for clients with endometriosis. Women need an honest discussion of treatment options, with review of the potential risks and benefits of each. Because pelvic pain is a subjective, personal experience that can be frightening, support is important. Sexual dysfunction resulting from dyspareunia is common and may necessitate referral for counseling. Support groups for women with endometriosis may be found in some locations. Patient Understanding of Endometriosis Definition. Signs and Symptoms. Causes. Risk Factors. Management of Signs and Symptoms Pain Managment. Diet Modifications. Treatments/Interventions Medication. Surgical Options. Alternative Medications/Therapies. Fertility Alterations. Challenges to conceiving. Family Planning. IVF. Mental Health Support Counseling. Support Groups. Medical Adherence Signs and Symptoms Tracking. Routine Checks. Define abnormal uterine bleeding (AUB)→ is any form of uterine bleeding that is irregular in amount, duration, or timing and is not related to regular menstrual bleeding but is defined as menstrual blood loss of 80 mL or greater. What are the general categories of causes (see box 6.1)? Box 6.1 Possible Causes of Abnormal Uterine Bleeding Pregnancy-Related Conditions Threatened or spontaneous miscarriage Retained products of conception after elective abortion or miscarriage Ectopic pregnancy Placenta previa/placental abruption Trophoblastic disease Lower Reproductive Tract Infections Cervicitis Endometritis Myometritis Salpingitis Benign Anatomic Abnormalities Adenomyosis Leiomyomata Polyps of the cervix or endometrium Neoplasms Endometrial hyperplasia Cancer of cervix or endometrium Hormonally active tumors (rare) Vaginal tumors (rare) Malignant Lesions Cervical squamous cell carcinoma Endometrial adenocarcinoma Estrogen-producing ovarian tumors Testosterone-producing ovarian tumors Leiomyosarcoma Trauma Genital injury (accidental, coital trauma, sexual abuse) Foreign body Lacerations Systemic Conditions Adrenal hyperplasia and Cushing disease Blood dyscrasias Coagulopathies Hypothalamic suppression (from stress, weight loss, excessive exercise) Polycystic ovarian syndrome Thyroid disease Pituitary adenoma or hyperprolactinemia Severe organ disease (renal or liver failure) Iatrogenic Causes Medications with estrogenic activity Anticoagulants Exogenous hormone use (oral contraceptives, menopausal hormone therapy) Selective serotonin reuptake inhibitors Tamoxifen Intrauterine devices Herbal preparation (e.g., ginseng) Describe the physical changes a woman experiences during menopause and explain the cause for that change. Change Cause Bleeding Degenerating corpus luteum function. Obese women are more likely to have dysfunctional uterine bleeding and endometrial hyperplasia because women with more body fat have higher circulating levels of estrone. This occurs because the estrogen that is stored in the body’s fat cells is converted into estrone that is available to the estrogen receptors within the endometrium. Genitourinary Syndrome of Menopause The vagina and urethra are estrogen-sensitive tissues, and low levels of estrogen can cause atrophy of both. Aging. vaginal pH increases, the growth of Lactobacillus can be depressed, and other bacteria tend to multiply. This combination of factors can lead to vaginitis or urinary tract infections or both. Vasomotor Instability Vasomotor instability in the form of hot flashes or flushes is a result of fluctuating estrogen levels and is the most common disturbance of the perimenopausal years, occurring in up to 75% of women having natural menopause (Monteleone et al., 2018; NAMS, 2022c; Pace & Secor, 2019) and 90% of women who have a surgical menopause. Osteoporosis Lower levels of estrogen. Estrogen key in bone health, regulating bone turnover and keeping bone density. Coronary Heart Disease Estrogen has a favorable effect on circulating lipids, decreasing LDL and total cholesterol and increasing HDL. It has a direct antiatherosclerotic effect on arteries. Postmenopausal women are at risk for coronary artery disease because of changes in their lipid metabolism: a decline in serum levels of HDL cholesterol and an increase in LDL levels. What education does a woman experiencing menopause need about these topics? Topic Brief Summary of Teaching Sexual Health Nonirritant vaginal lubricants (e.g., Restore, Slippery Stuff) can aid in providing relief from painful intercourse. It may be applied directly to the vulva and the penis. Vaginal lubricants may be water based or silicone based and may be useful to decrease sexual discomfort and increase sexual pleasure (Cason, 2022). Nurses must offer all women accurate information on matters such as appropriate contraception, sexuality, and the physiology of menopause as well as support and nonjudgmental guidance. Women need advice about contraception because ovulation may not cease for a year after the last menstrual cycle, and menopausal women can still become pregnant. Muscle tone around the reproductive organs decreases after menopause. Kegel exercises (see Chapter 4 for more detailed information) strengthen these muscles, improve tone, and, if practiced regularly, help prevent a prolapsed uterus and stress incontinence. This is a low-cost, effective, noninvasive intervention to control symptoms. However, symptoms return if exercises are discontinued. Nutrition Calcium is an essential part of any therapeutic regimen for women with osteoporosis and women who want to prevent osteoporosis. The National Institutes of Health (NIH) (2022b) recommends 600 IU of vitamin D for healthy women up to 70 years of age and 800 IU for women 71 years of age and older. Sources of vitamin D include sunlight, food (e.g., fortified dairy products, fatty fish, liver, egg yolks), and supplements. Exercise Exercise alone cannot prevent or reverse osteoporosis, but data indicate that weight-bearing exercise, such as walking and stair climbing, may delay bone loss and increase bone mass at any age. Aerobics and strength training have positive effects on women’s health in midlife, including cardiorespiratory function, weight, bone density, and quality of life. Medications for Osteoporosis (general categories & functions) Calcitonin reduces the rate of bone turnover and stabilizes bone mass in women with osteoporosis and may have some analgesic effects. Although calcitonin can reduce the incidence of spinal fractures, no data are available about its use to protect against hip fractures. Calcitonin may be used with women who are at least 5 years postmenopausal and in whom estrogen is contraindicated or not tolerated. It is usually administered intranasally on a daily basis, though subcutaneous or intramuscular administration is also available. The medication is considered safe; however, side effects of nausea, vomiting, anorexia, and rhinitis (if used intranasally) have been reported (Merenda & Phelps, 2022). The nasal spray may be prescribed for women who cannot tolerate some of the other pharmacological therapies. Bisphosphonates are approved for prevention and treatment of osteoporosis, especially in reducing the incidence of spinal fractures. Side effects include GI problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcer. Depending on the medication used, the oral drugs may be taken daily or monthly. Some formulations contain vitamin D (Lobo, 2022a; Merenda & Phelps, 2022; Shoback et al., 2020). Alendronate reduces bone turnover and is taken daily by mouth. Ibandronate is available as an intravenous injection every 3 months and decreases bone breakdown; zoledronic acid is given intravenously yearly for treatment of osteoporosis and every 2 years for prevention (Lobo; Shoback et al.). What are risk factors for osteoporosis? The most well-defined risk factor for osteoporosis is the loss of the protective effect of estrogen associated with the cessation of ovarian function, particularly at menopause (NAMS, 2021j). Women at greatest risk are likely to be White or Asian, small-boned, and thin. Obese women have higher estrogen levels resulting from the conversion of androgens in adipose tissue; mechanical stress from extra weight also helps preserve bone mass. A family history of osteoporosis is common (Berman et al.). Inadequate calcium intake is a risk factor, particularly during adolescence and into the third and fourth decades, when peak bone mass is attained. An excessive caffeine intake increases calcium excretion, causing a systemic acidosis that stimulates bone resorption (Berman et al., 2019). Smoking is associated with earlier and greater bone loss and decreases estrogen production. Excessive alcohol intake interferes with calcium absorption and depresses bone formation. A greater intake of phosphorus than of calcium, which occurs with soft drink consumption, particularly cola drinks, may be a risk factor. Other risk factors include long-term or frequent steroid therapy and disorders such as hypogonadism, hyperthyroidism, and diabetes mellitus (Bone Health and Osteoporosis Foundation, nd). Review the section in your chapter regarding menopausal hormone therapy (MHT). What are the pros and cons that need to be considered when educating a patient about the use of MHT? Decision to Use Hormone Therapy All women considering ET or HT must understand that studies on HT are ongoing and there is still much to be learned. Nurses can provide current information and counseling to assist women in making decisions regarding HT use. Important teaching points include the following: For women taking HT for short-term (1 to 3 years) relief of menopausal discomforts who do not have increased risks for cardiovascular disease, the benefits may outweigh the risks. The decision to use HT should be made by the woman in consultation with her health care provider. If used, HT should be taken at the lowest effective dose for the shortest possible duration. When a woman decides to stop HT, symptoms will recur whether the medication is tapered or discontinued abruptly. NAMS makes no recommendation on how to discontinue the medication, although some clinicians recommend a gradual withdrawal. Older women who are taking or considering HT only for the prevention of cardiovascular disease should be counseled on other methods to reduce their risks of cardiovascular disease. Alternatively, beneficial cardiovascular effects may be associated with HT for younger, more recently menopausal women, but more research is needed in this area. Women who are taking HT only for the prevention of osteoporosis or other chronic conditions should be counseled regarding their personal risks and benefits in continuing the therapy. These women should be reassured that there are effective alternatives for long-term prevention. Bone density studies may also be indicated to determine the degree of risk in an individual woman (Bone Health and Osteoporosis Foundation, nd). Side Effects Side effects associated with estrogen use include headaches, nausea and vomiting, bloating, ankle and foot swelling, weight gain, breast soreness, brown spots on the skin, eye irritation with contact lenses, and depression. The type of estrogen used for postmenopausal ET is much less potent than ethinyl estradiol used in OCPs and has fewer serious side effects. Side effects that occur with ET may disappear with a change in estrogen preparation or a decrease in the dose prescribed. Complete the following: Case study: Reproductive system concerns. (2023). In Sherpath for Maternal newborn (Lowdermilk version) (12th ed.). Elsevier. Joy is a 47-year-old G2 P2 who is experiencing periods of hot flashes/flushes and night sweats and has difficulty sleeping at night. She has mild hypertension but does not take any hypertensive medications since she started a daily walking regimen 6 months ago. Joy feels that her menopausal symptoms are interfering with her quality of life. She made an appointment with the nurse practitioner at her gynecologist’s office to discuss natural or alternative therapies to help relieve her symptoms. Why do menopausal women experience hot flashes/flushes and night sweats? Hormonal changes are the reason. The decline in estrogen levels affects the hypothalamus causing it to not regulate body temperature. Hypoestrogenism results in hot flashes in almost all women. Why do these symptoms interfere with the women’s quality of life? They interfere due to the influence they have over their physical, emotional and social well being. What are comfort measures to help with hot flashes/flushes? Teaching For Self-Management Comfort Measures for Menopausal Symptoms Hot Flashes/Flushes During the Day  Wear layered clothing that “wicks” so you can take things off if you get warm.  Avoid “triggers” that bring on a flash/flush; these include vigorous exercise on hot days, spicy foods, red wine, caffeine, hot beverages, and alcohol.  Splash your face with cool water, drink ice water, or take a cool shower.  Try slow, deep breathing. At Night  Sleep in cotton night clothes, use cotton sheets, keep the room cool, and possibly sleep with a fan on.  Avoid heavy blankets that will make you too warm at night.  Keep a glass of water by the bed.  Avoid using electronic devices (smart phones, computers, other screens) for 30 minutes before bedtime. Chapter 7 Sexually Transmitted and Other Infections What are the 6 Ps that should be assessed regarding STIs (see box 7.2)? 1.Partners 2.Practices 3.Prevention of Pregnancy 4.Protection from STIs 5.Past history of STIs 6.Pregnancy Plans BOX 7.2 Five Ps Approach for Health Care Providers Obtaining Sexual Histories 1.Partners Are you currently having sex of any kind? What is the gender(s) of your partner(s)? 2.Practices To understand your risks for STIs, I need to ask more specific questions about the kind of sex you have had recently. What kind of sexual contact do you have, or have you had? Do you have vaginal sex, meaning “penis in vagina” sex? Do you have anal sex, meaning “penis in rectum/anus” sex? Do you have oral sex, meaning “mouth on penis/vagina” sex? 3.Protection from STIs Do you and your partner(s) discuss prevention of STIs and HIV? Do you and your partner(s) discuss getting tested? Additional question regarding condom use: What protection methods do you use? In what situations do you use condoms? 4Past history of STIs Have you ever been tested for STIs and HIV? Have you ever been diagnosed with an STI in the past? Have any of your partners had an STI? Additional questions for identifying HIV and viral hepatitis risk: Have you or your partner(s) ever injected drugs? Is there anything about your sexual health that you have questions about? 5Pregnancy intention Do you think you would like to have (more) children in the future? How important is it to you to prevent pregnancy (until then)? Are you and your partner(s) using contraception or practicing any form of birth control? Would you like to talk about ways to prevent pregnancy? To guide your learning about common STIs and other vaginal infections, complete the following table. STI Signs/symptoms How diagnosed/treatment/prevented Patient education Chlamydia Abnormal Discharge. Burning Sensation During Urination. For diagnosis of chlamydia in women, the CDC recommends the nucleic acid amplification test (NAAT) using urinary, vaginal, or endocervical specimens (CDC, 2021a). The NAAT is the most sensitive test for these specimens and has been cleared by the US Food and Drug Administration (FDA) for client self-collected or clinician-collected vaginal swabs in a clinical setting. An NAAT is also recommended by the CDC for rectal and oropharyngeal screening among persons engaging in receptive anal or oral intercourse. The CDC recommendations for treatment of urethral, cervical, and rectal chlamydial infections are azithromycin, levofloxacin, or doxycycline (CDC, 2021a). Azithromycin is often prescribed when compliance may be a problem because only one dose is needed. If the woman is pregnant, azithromycin or amoxicillin is used. Pregnant women should be retested in approximately 4 weeks to determine if treatment was effective (test of cure). In addition, all pregnant women who have a chlamydial infection should be retested 3 months after treatment (CDC). Women who have a chlamydial infection and are also infected with HIV should be treated with the same regimen as clients who are not infected with HIV. Because chlamydia is often asymptomatic, the woman should be cautioned to take all medication prescribed. All exposed sexual partners should also be treated. Nonpregnant women treated with doxycycline or azithromycin do not have to be retested unless symptoms continue, adherence was in question, or reinfection is suspected. Gonorrhea Women → Asymptomatic. Menstrul Irregularities. Pelvic/lower abdominal pain. Longer menses. Specific diagnosis of infection with N. gonorrhoeae can be obtained by testing an endocervical, vaginal, rectal, oropharyngeal, or conjunctival gonococcal infection or urinary specimens. Culture and nonculture tests (nucleic acid hybridization tests and NAATs) are available for the detection of N. gonorrhoeae. NAATs and point-of-care (POC) NAATs allow for the widest array of FDA-cleared specimen types including endocervical and vaginal swabs (can be clinician or client collected), urine swabs, and pharyngeal swabs (CDC, 2021a). NAAT sensitivity for detecting N. gonorrhea from urogenital and nongenital anatomic sites is superior to culture but varies by NAAT type, and the CDC recommends that product inserts for each NAAT manufacturer be consulted. Management of a client with gonorrhea is straightforward; with appropriate antibiotic therapy, the cure is usually rapid. Single-dose efficacy is a major consideration in selecting an antibiotic regimen for women with gonorrhea. Previously the CDC recommended a dual therapy for gonorrhea, but this has been found to have potential harm and thus no longer is a treatment recommendation (CDC, 2021a). Now the treatment of choice for uncomplicated urethral, endocervical, and rectal infections in pregnant and nonpregnant women is ceftriaxone (an injectable cephalosporin); this is now the only CDC-recommended treatment regimen for gonorrhea (CDC). Another important consideration is the high percentage of women with coexisting chlamydial infections. If a chlamydial infection is suspected and has not been ruled out, the recommendation is to treat with doxycycline in addition to ceftriaxone. Pregnant women should be treated with ceftriaxone plus treatment for chlamydia if suspected and not ruled out. Gentamicin use during pregnancy is cautioned because of risk of teratogenic effects, nephrotoxicity, or ototoxicity. Women who are not able to follow the treatment guidelines because of allergy or other conditions should be referred to an infectious disease specialist or an STI clinical expert for management (CDC). Women with HIV should receive the same treatment regimen as women who do not have HIV. Gonorrhea is a highly communicable disease, and to reduce complications and transmission, it is recommended that medication be given at the visit and that it be directly observed (directly observed therapy [DOT]) (CDC, 2021). It is important to notify partners if a woman is diagnosed with a gonorrheal infection. Recent (past 30 days) sexual partners should be examined and treated with appropriate regimens if positive for gonorrhea. Most treatment failures result from reinfection. The woman must be informed of this as well as of the consequences of reinfection in terms of chronicity, complications, and potential infertility. To address disease transmission, women are counseled to use condoms with sexual intercourse to prevent future STIs. They should be instructed to abstain from all sexual activity during treatment and for 7 days after treatment. Abstention from sexual activity is also recommended to continue for 7 days after all sexual partners have been treated. All clients with gonorrhea should be offered confidential counseling and testing for other STIs including chlamydia, syphilis, and HIV infection. Clients who are negative for HIV should be offered HIV PrEP (CDC). Syphilis (including stages) Primary → During the first (primary) stage of syphilis, you may notice a single sore or multiple sores. The sore is the location where syphilis entered your body. Secondary → During the secondary stage, you may have skin rashes and/or sores in your mouth, vagina, or anus. This stage usually starts with a rash on one or more areas of your body. The rash can show up when your primary sore is healing or several weeks after the sore has healed. The rash can be on the palms of your hands and/or the bottoms of your feet and look. Latent → The latent stage of syphilis is a period when there are no visible signs or symptoms. Without treatment, you can continue to have syphilis in your body for years. Tertiary → Most people with untreated syphilis do not develop tertiary syphilis. However, when it does happen, it can affect many different organ systems. These include the heart and blood vessels, and the brain and nervous system. Tertiary syphilis is very serious and would occur 10–30 years after your infection began. In tertiary syphilis, the disease damages your internal organs and can result in death. A healthcare provider can usually diagnose tertiary syphilis with the help of multiple tests. Diagnosis depends on microscopic examination of primary and secondary lesion tissue and serology during latency and late infection. Dark-field examinations and tests to detect T. pallidum directly from lesion exudate or tissue are the definitive methods for diagnosing early syphilis. A test for antibodies may not be reactive in the presence of active infection because it takes time for the immune system to develop antibodies to any antigen. Up to one-third of people with early primary syphilis may have nonreactive serologic tests. Two types of serologic tests are used: nontreponemal and treponemal. Nontreponemal antibody tests, such as the Venereal Disease Research Laboratories (VDRL) or the rapid plasma reagin (RPR) test, are used as screening tests. False-positive results are not unusual, particularly when acute infection, autoimmune disorders, malignancy, pregnancy, and substance use disorder exist and after immunization or vaccination. The treponemal tests—fluorescent treponemal antibody-absorption (FTA-ABS) test and T. pallidum particle agglutination (TP-PA) assay—are used to confirm positive results. Test results in clients with early primary or incubating syphilis can be negative. Seroconversion usually takes place 6 to 8 weeks after exposure, so testing should be repeated in 1 to 2 months when a suggestive genital lesion exists. Tests for coexisting STIs (e.g., chlamydia and gonorrhea) should be done (e.g., NAATs and cultures), and HIV testing should be offered if indicated (CDC, 2021a). Penicillin G is the preferred drug for treating syphilis. It is the only proven therapy that has been widely used to treat neurosyphilis, congenital syphilis, or syphilis during pregnancy. Intramuscular benzathine penicillin G is used to treat primary, secondary, and early latent syphilis. Although doxycycline and tetracycline are alternative treatments for penicillin-allergic clients, both are contraindicated in pregnancy. Therefore pregnant women should, if necessary, receive skin testing and be treated with penicillin or be desensitized (CDC, 2021a). Specific protocols are recommended in the CDC STI treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf). HIV Most people have flu-like symptoms within 2 to 4 weeks after infection. Symptoms may last for a few days or several weeks. HIV infection is usually diagnosed by using HIV-1 and HIV-2 antigen/antibody combination tests. Antibody testing is first done with a sensitive screening test such as the enzyme immunoassay (EIA). Reactive screening tests should be confirmed using RNA testing (CDC, 2021). If a positive antibody test is confirmed by a supplemental test, it means that a woman is infected with HIV and is capable of infecting others. HIV antibodies are detectable in at least 95% of individuals within 3 months after infection. Although a negative antibody test usually indicates that a person is not infected, antibody tests cannot exclude recent infection. The FDA has approved six rapid HIV antibody screening tests for clinical use. These tests use a blood sample obtained by fingerstick or venipuncture, an oral fluid sample, or a urine sample to provide test results within 20 minutes. The tests have sensitivity and specificity rates of greater than 99%. If the results are reactive, further testing is necessary (CDC). Quicker results mean that clients do not have to make extra visits for follow-up standard tests, and the oral test provides an option for clients who do not want to have a blood test. While test results are being provided to an HIV-positive woman, privacy with no interruptions is essential. Adequate time for the counseling session is provided. The nurse makes sure that the woman understands what a positive test means and reviews its reliability. Risk-reduction practices are reemphasized. Referral for appropriate medical evaluation and follow-up is made, and the need or desire for psychosocial or psychiatric referrals is assessed. It is important to stress early medical evaluation so that a baseline assessment can be made and prophylactic medication begun. Highly effective antiretroviral therapy (ART) suppresses HIV replication to undetectable levels, reduces morbidity, provides a near-normal life­span, and prevents sexual transmission of HIV to others. The CDC recommends that women with HIV infection be offered ART as soon as possible and linked to care with a HIV/communicable disease ­specialist (CDC, 2021). HSV I & II characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks. Women generally have a more severe clinical course than men. Women with primary genital herpes have many lesions that progress from macules to papules and then form vesicles, pustules, and ulcers that crust and heal without scarring (Fig. 7.3). These ulcers are extremely tender, and primary infections may be bilateral. Women can also have itching, inguinal tenderness, and lymphadenopathy. Severe vulvar edema may develop, and women may have difficulty sitting. HSV cervicitis is also common with initial HSV-2 infections. The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. A heavy watery-to-purulent vaginal discharge is common. Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root. A viral culture and HSV antigen detection by polymerase chain reaction (PCR) are obtained by swabbing exudate during the vesicular stage of the disease. For clients with a clinical history of HSV but who do not have active lesions or whose lesions have a negative culture or PCR result, type-specific serologic tests detecting HSV-1 and HSV-2 antibodies are available and may be useful in the clinical setting (ACOG, 2020). Counseling and education are critical components of the nursing care of women with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. The nurse explains that each woman is unique in her response to herpes and emphasizes the variability of symptoms. Women are helped to understand when viral shedding and transmission to a partner are most likely. They should be counseled to refrain from sexual contact from the onset of the prodrome until the lesions have completely healed. Suppressive therapy may be an option because it can decrease the risk of transmission to partners. HSV increases the risk of acquiring HIV by approximately twofold to fourfold owing to the open ulcers or breaks in the skin caused by the virus (CDC, 2022d). Some authorities recommend consistent use of condoms for all persons with genital herpes. Condoms may not prevent transmission, particularly male-to-female transmission; however, this does not mean that the partners should avoid all intimacy. Women can maintain close contact with their partners who are aware of the need to avoid contact with the woman’s herpetic lesions. The nurse explains that when lesions are active, it is important to avoid sharing intimate articles such as washcloths that touch the lesions. Plain soap and water or hand sanitizer can be used to clean hands that have come into contact with herpetic lesions; isolation is neither necessary nor appropriate. Because neonatal HSV infection has serious effects, prevention is critical. Recommendations include carefully examining and questioning all women about symptoms of HSV infection at the onset of labor. If visible lesions are not present at onset of labor, vaginal birth is acceptable. Cesarean birth is recommended if visible lesions are present (ACOG, 2020). Some authorities also recommend cesarean birth if prodromal symptoms (such as genital tingling) are present, even if there are no visible lesions. Infants who are born through an infected vagina should be carefully observed, and their body fluids should be cultured (see Chapter 35). The emotional effect of contracting an incurable STI such as herpes is considerable. At diagnosis, many emotions may surface—helplessness, anger, denial, guilt, anxiety, shame, or inadequacy. Women need the opportunity to discuss their feelings and need help in learning to live with the disease. Herpes can affect a woman’s sexuality, her sexual practices, and her current and future relationships. Women may need help in raising the issue with their partners or future partners. The partners may also benefit from counseling. Hep. A HAV infection is characterized by flulike symptoms, with malaise, fatigue, anorexia, nausea, pruritus, fever, and right upper quadrant pain. Serologic testing to detect the immunoglobulin M (IgM) antibody is done to confirm acute infections. The IgM antibody is detectable 5 to 10 days after exposure and can remain positive for up to 6 months. Because HAV infection is self-limited and does not result in chronic infection or chronic liver disease, treatment is usually supportive. Women who become dehydrated from nausea and vomiting or who have signs or symptoms of acute liver failure may need to be hospitalized. Medications and other ingested substances that might cause liver damage or are metabolized in the liver (e.g., acetaminophen, ethyl alcohol) should be avoided. No specific diet or activity restrictions are necessary. HAV vaccine and immunoglobulin for intramuscular administration are effective in preventing most HAV infections (CDC). Food-related hepatitis A outbreaks are reportable, and local health departments and the CDC are involved in locating the source of infection and as many infected individuals as possible. Vaccination is the most effective preventive measure in mitigating the transmission of HAV among persons at risk for infections (CDC, 2021). In the United States, two monovalent vaccines are approved by the FDA for individuals >12 months of age; both are administered intramuscularly (IM) in a two-dose series. A combined HAV and hepatitis B virus (HBV) vaccine has been approved and used as a three-dose series for adults >18 years of age and at risk for either HAV or hepatitis B virus (HBV) infection (CDC). Hep. B Symptoms of HBV infection are similar to those of HAV infection: arthralgias, arthritis, lassitude, anorexia, nausea, vomiting, headache, fever, and mild abdominal pain. Later the woman may have clay-colored stools, dark urine, increased abdominal pain, and jaundice. Some individuals with HBV have persistence of HBsAg and become chronic HBV carriers. All women at high risk for contracting HBV should be screened regularly at routine appointments. Clients who are found to be HBV-positive should be tested for HIV, syphilis, gonorrhea, and chlamydia (CDC, 2021). Screening for the presence of HBsAg is recommended for all pregnant women at the first prenatal visit regardless of whether they have been tested previously and again at birth if the woman is at high risk for HBV infection (CDC). If HBsAg persists in the blood, the woman is identified as having chronic HBV infection (CDC, 2021). If the HBsAg test result is positive, further laboratory studies may be ordered: anti-HBe, anti-HBc, serum glutamicoxaloacetic transaminase (SGOT), alkaline phosphatase, and a liver panel. Client education includes explaining the meaning of HBV infection and describing transmission, state of infectivity, and sequelae. The nurse explains the need for monoprophylaxis for household members and sexual contacts. To decrease transmission of the virus, women with acute or chronic hepatitis B should be advised to maintain a high level of personal hygiene (e.g., wash hands after using the toilet; carefully dispose of tampons, pads, and bandages in plastic bags; do not share razor blades, toothbrushes, needles, or manicure implements; have male partner use a condom if unvaccinated and without hepatitis; and wipe up blood spills immediately with soap and water). Women with hepatitis B should inform all health care providers of their carrier state. Postpartum women can be reassured that breastfeeding is not contraindicated if their infants received prophylaxis at birth and are currently on the recommended immunization schedule (see Chapter 24). HPV HPV lesions in women are most commonly seen in the posterior part of the introitus; however, lesions are also found on the buttocks, vulva, vagina, anus, and cervix (Fig. 7.2). Typically the lesions are small—2 to 3 mm in diameter and 10 to 15 mm in height. They appear as soft, papillary swellings occurring singly or in clusters in the genital and anorectal regions. Lesions resulting from infections of long duration may appear as a cauliflower-like mass. In moist areas such as the vaginal introitus, the lesions may appear to have multiple, fine finger-like projections. Vaginal lesions are often multiple. Flat-topped papules, 1 to 4 mm in diameter, are seen most often on the cervix and are often visualized only under magnification. Warts are usually flesh-colored or slightly darker based on skin tones. The lesions are often painless but may be uncomfortable, particularly when they are very large, inflamed, or ulcerated. Chronic vaginal discharge, pruritus, or dyspareunia can occur. Viral screening and typing for HPV is available but not standard practice for women younger than 30 years of age. History, evaluation of signs and symptoms, and physical examination are used in making a diagnosis of anogenital warts caused by HPV. The only definitive diagnostic test for the presence of HPV is histologic evaluation of a biopsy specimen. Primary high-risk human papillomavirus (hrHPV) testing can be used in combination with the Papanicolaou (Pap) test to screen for types of HPV that are associated with cervical cancer in women older than age 30 or in women with abnormal Pap test results (ACOG, 2021). In 2020 the American Cancer Society (ACS) revised its guidelines on screening for cervical cancer with hrHPV testing for women 25 to 65 years of age at average risk. At the current time, two hrHPV tests are approved by the FDA (ACOG). In 2021 ACOG, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the Society for Gynecologic Oncology (SGO) endorsed the USPSTF in their recommendations for routine cervical cancer screening (ACOG). These recommendations expand the options for cervical cancer screening in average-risk women age 30 years and older to include screening every 5 years with primary hrHPV testing. The ACS is strongly advocating for the phasing out of cytology-based options and moving to hrHPV testing as the preferred screening option for average-risk women aged 25 to 65 years (Fontham, Wolf, Church, et al., 2020). Based on several barriers such as limited access in rural and underresourced communities and communities of color, limited availability of FDA-approved tests, and laboratory restrictions with this screening modality, ACOG supports the continued use of cytology-based screening options in the current guidelines. However, ACOG acknowledges that future screening recommendations such as raising the age of screening initiation to 25 years as supported by ACS may be a viable consideration as more data become available (ACOG). Client counseling is essential to reduce the prevalence of HPV and to improve the management of HPV in women who are infected. Women need to know that HPV infection is very common and will clear up spontaneously in most cases. Some infections will progress to genital warts, precancerous lesions, or cancers. Women must understand how the virus is transmitted, that no immunity is conferred with infection, and that reacquisition of the infection is likely with repeated contact. It is important to counsel the woman that when she acquired HPV cannot be definitively determined, as genital warts can develop months or years after acquiring the virus. Because HPV is highly contagious, many partners of women with HPV are infected even if they are asymptomatic. All sexually active women with multiple partners or a history of HPV should be encouraged to use latex condoms consistently and correctly for intercourse to decrease the risk of acquisition or transmission of genital HPV (CDC, 2021d). Instructions for all medications and treatments must be detailed. Women should be told that treatments are for the conditions caused by the virus but not for HPV itself. Women should be informed before treatment of the possibility of posttreatment pain associated with specific therapies. The importance of the thorough treatment of concurrent vaginitis or a coexisting STI should be emphasized. The link between cervical cancer and some HPV infections (such as HPV 16 and 18) and the need for close follow-up should be discussed. Annual health examinations are recommended to assess disease recurrence and screen for cervical cancer at the recommended intervals based on age, test used, and past confirmed diagnosis of a cervical dysplasia or neoplasm. Women 21 years of age and older should be counseled to have regular Pap testing, as recommended for women without genital warts; they do not need Pap tests more frequently than the recommendations (CDC, 2021). Women must be counseled on the importance of stopping tobacco use and of smoking cessation programs because of the contribution of smoking to the progression of precancer and cancer due to oncogenic HPV persistence. They need to understand that the types of HPV that cause genital warts are different from the types that can cause cancer (CDC). Preventive strategies such as those presented in the following section should be discussed. Preventive strategies include abstinence from all sexual activity (most reliable method for preventing genital HPV infection), staying in a long-term monogamous relationship, limiting the number of sexual partners, and prophylactic vaccination (CDC, 2021). Gardasil 9, a nine-valent vaccine, is the only available vaccine in the United States (Meites, Szilagvi, Chesson, et al., 2019). This vaccine was initially recommended for females 9 to 26 years old and then became available to males. In 2019 the FDA added an indication for women and men 27 to 45 years old based on shared clinical decision making with their healthcare provider (Thompson, Garz, Galvin, et al., 2021). The vaccine is safe and effective in protecting against some of the most common types of HPV that can lead to genital warts and cancers. Gardasil 9 protects against HPV types 6, 11, 16, 18, 31, 33, 35, 45, 52, and 58. The vaccine is most effective if given before the first sexual contact (Meites et al., 2019). The vaccine can be given to girls and boys as early as 9 years of age and can be given to females and males 15 to 26 years old if they have not received the vaccine previously. The vaccine is given in a two-dose schedule for girls and boys who initiate the vaccine series at ages 9 to 14 years. The three-dose schedule is for individuals who are immunocompromised or initiate the vaccine series at ages 15 to 26 years and individuals 27 to 45 years old. Trichomoniasis Although trichomoniasis may be asymptomatic, commonly women have a characteristic yellowish to greenish discharge that is frothy, mucopurulent, copious, and malodorous. Inflammation of the vulva, vagina, or both may be present, and the woman may experience irritation and pruritus. Dysuria and dyspareunia are often present. Typically the discharge worsens during and after menstruation. Often the cervix and vaginal walls will demonstrate the characteristic “strawberry spots” or tiny petechiae, and the cervix may bleed on contact. In severe infections, the vaginal walls, the cervix, and occasionally the vulva may be acutely inflamed. The use of highly sensitive and specific tests is recommended for detecting T. vaginalis. NAAT is highly sensitive in women, often detecting three to five times more T. vaginalis infections than wet-mount microscopy, a method with poor sensitivity (44% to 68%). Reliable samples for testing are clinician-collected endocervical swabs, clinician-collected vaginal swabs, urine samples, and liquid Pap specimens collected in PreservCyt Solution. Vaginal swab and urine have up to 100% concordance in women. Clinicians using wet mounts should attempt to evaluate slides immediately because sensitivity declines as evaluation is delayed, decreasing by up to 20% within 1 hour after collection (CDC, 2021). Because trichomoniasis is an STI, once diagnosis has been confirmed, appropriate laboratory studies for other STIs should be carried out. The recommended treatment is metronidazole orally twice per day for 7 days or tinidazole orally in a single dose (CDC, 2021). Although the male partner is usually asymptomatic, it is recommended that he receive treatment also because he often harbors the trichomonads in the urethra or prostate. It is important that nurses discuss the significance of partner treatment with their clients because if the partners are not treated it is likely that the infection will recur. Nurses also counsel women to abstain from sex until they and their partners have been treated (i.e., when therapy has been completed and any symptoms have resolved). Women with trichomoniasis must understand the sexual transmission of this disease. They must know that the organism may be present without any associated symptoms, perhaps for several months, and that it is not possible to determine when they became infected. Women are informed of the necessity for treating all sexual partners and helped with ways of raising this issue with them. Bacterial vaginosis It is a syndrome in which normal hydrogen peroxide (H2O2)–producing lactobacilli are replaced with high concentrations of anaerobic bacteria (Gardnerella and Mobiluncus). With the increased number of anaerobes, the level of vaginal amines is increased, and the normal acidic pH of the vagina is altered. Epithelial cells slough, and numerous bacteria attach to their surfaces (clue cells). The odor may be noticed by the woman or her partner after heterosexual intercourse because semen releases the vaginal amines. When present, the BV discharge usually appears profuse, thin, and white, gray, or milky. Some women may also experience mild irritation or pruritus. Microscopic examination of vaginal secretions is always performed (Table 7.2). Both normal saline and 10% potassium hydroxide (KOH) smears are made. The presence of more than 20% clue cells (vaginal epithelial cells coated with bacteria) on a wet saline smear is highly diagnostic because the phenomenon is specific to BV. Vaginal secretions are tested for pH and amine odor. Nitrazine paper is sensitive enough to detect a pH of 4.5 or greater. The fishy odor of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum (CDC, 2021). Treatment of BV with oral or gel metronidazole (Flagyl) and clindamycin cream is equally effective. The side effects of metronidazole are numerous, including an unpleasant metallic taste in the mouth, headache, dizziness, weakness, a swollen or “furry” tongue, and gastrointestinal symptoms. In the past, women were counseled to not consume alcohol while taking metronidazole, but the CDC found no data to support this practice and it was removed from their 2021 STI Treatment Guidelines (CDC, 2021). The treatment of sexual partners is not routinely recommended; however, women should be counseled to abstain from sexual activity or to use condoms correctly and consistently during the treatment timeframe. Douching might increase the risk of a relapse, and there are no data to support the use of douching for treatment or symptom relief (CDC, 2021). Medication Alert Metronidazole is not recommended if the woman is breastfeeding. However, if it is necessary to prescribe it, the woman can suspend breastfeeding (pump and discard to maintain milk supply) during treatment and for 12 to 24 hours after the last dose to reduce the infant’s exposure to metronidazole (CDC, 2021). Monilial vaginitis Abnormal vaginal discharge, Itching and burning, Pain during intercourse, irregular menstrual cycle. Microscopic examination, sample of vaginal discharge is collected and examined under a microscope for presence of yeast cells. Vaginal PH testing. Monilial Vaginitis PH is 4 – 4.5. Culture on specific type of Candida that is causing the infection to find the sensitivity to antifungal medications. PCR Testing of Candida vaginal sample. Treatment with antifungal meds clortirmazole, miconazole or fluconazole. Prevention patients need to practice good hygiene, such as wearing cotton underwear, avoid douching, healthy diet, low in sugar, practice safe sex. Pelvic inflammatory disease Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. In the past, the most common causative agent was thought to be N. gonorrhoeae; however, C. trachomatis is now estimated to cause half of all cases of PID. In addition to N. gonorrhoeae and C. trachomatis, a wide variety of anaerobic and aerobic bacteria are recognized to cause PID. PID encompasses a wide variety of pathologic processes; the infection can be acute, subacute, or chronic and can have a wide range of symptoms. PID is difficult to diagnose because of the accompanying wide variety of symptoms. The CDC recommends treatment for PID in all sexually active young women and others at risk for STIs if the following criteria are present and no other cause or causes of the illness are found: lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness. Other criteria for diagnosing PID include an oral temperature of 38.3°C (100.9 °F) or above, abnormal cervical or vaginal discharge, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis (CDC, 2021d). Perhaps the most important nursing intervention is prevention. Primary prevention includes education about preventing the acquisition of STIs, and secondary prevention involves preventing a lower genital tract infection from ascending to the upper genital tract. Instructing women in self-protective behaviors such as practicing risk-reduction measures and using barrier methods is critical. Also important is the detection of asymptomatic gonorrheal and chlamydial infections through routine screening of women with risky behaviors or specific risk factors such as age. All women who have been diagnosed with PID should be tested for gonorrhea, chlamydia, HIV, and syphilis (CDC, 2021). Although treatment regimens vary with the infecting organism, a broad-spectrum antibiotic is generally used. Treatment for mild to moderately severe PID may be oral medication or may involve a combination of oral and parenteral agents, and such regimens can be administered in inpatient or outpatient settings (CDC, 2021). Comfort measures include analgesics for pain and all other nursing measures applicable to pain control. The woman should have as few pelvic examinations as possible during the acute phase of the disease. During the recovery phase the woman should restrict her activity and make every effort to get adequate rest and eat a nutritionally sound diet. Follow-up laboratory work after treatment should include endocervical cultures for a test of cure. Health education is central to effective management of PID. The nurse explains to the woman the nature of her disease and encourages her to comply with all therapy and prevention recommendations. The necessity of taking all medication even if symptoms disappear is emphasized. The nurse counsels the woman to refrain from sexual intercourse until her treatment is complete and provides contraceptive counseling. A woman with a history of PID can choose an IUD as her contraceptive method, and all contraceptive methods may be continued during treatment (CDC, 2021). The potential or actual loss of reproductive ability can be devastating and can adversely affect a woman’s self-concept. The woman may need help in adjusting her self-concept to fit reality and accept alterations in a way that promotes health. Because PID is so closely tied to sexuality, body image, and self-concept, a woman with a diagnosis of PID will need supportive care and should be encouraged to discuss her feelings. Referral to a support group or for counseling may be appropriate. Complete the following: Case study: Sexually transmitted and other infections. (2023). In Sherpath for Maternal newborn (Lowdermilk version) (12th ed.). Elsevier. H.P. is a 22-year-old female who presents to the gynecologist’s office with painful urination. Subjective Data: Last menstrual cycle: 10 days ago Pain is burning sensation Fever Performs monthly breast self-examinations Sexually active, monogamous relationship 6 months Birth control method: oral contraception Objective Data: Multiple vesicles inner labia, ulcerations with clear discharge T=99.9 What other questions should the nurse ask about the painful urination? When did the painful urination begin? How long has it been occuring? How often do you urinate? Has the frequency changed recently? Are there any other symptoms, chills, or lower abdominal pain. Have you had similar symptoms before? Have you had sexual activity recently? Any new partners? What are your hygiene practices related to genital care? What is your daily fluid intake? Are you currently taking any medications, OTC or herbal? What are some of the causes of painful urination? Gonorrhea, Genital Herpes, Trichomoniasis, Develop a problems list from objective and subjective data. Risk for infection related to unprotected sexual and possible exposure to sexually transmitted infections. Acute pain caused by genital lesions and or inflammation due to infections. Knowledge deficit in safe sex practice and prevention of sexually transmitted infections. Increased anxiety due to the bad reputation of sexually transmitted infections and the long term consequences. Nonadherence with treatment and medication that lead to reoccurring infections and complications Risk of transferring infection to sexual partners due to not updating partner or practicing safe sex. Based on the readings and subjective and objective data, what is the most likely cause of painful urination for this patient? Genital Herpes Simplex Virus Objective Data: Multiple vesicles inner labia, ulcerations with clear discharge Women with primary genital herpes have many lesions that progress from macules to papules and then form vesicles, pustules, and ulcers that crust and heal without scarring (Fig. 7.3). These ulcers are extremely tender, and primary infections may be bilateral. Women can also have itching, inguinal tenderness, and lymphadenopathy. Severe vulvar edema may develop, and women may have difficulty sitting. HSV cervicitis is also common with initial HSV-2 infections. The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. A heavy watery-to-purulent vaginal discharge is common. Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root. Recurrent lesions are unilateral, are less severe, and usually last 5 to 7 days. Lesions begin as vesicles and progress rapidly to ulcers. Few women with recurrent disease have cervicitis. What should be included in the plan of care? Management is directed toward specific treatment during primary and recurrent infections, prevention of recurrences, self-help measures, and psychologic support. Systemic antiviral medications partially control the symptoms and signs of HSV infections when used for primary or recurrent episodes or as daily suppressive therapy. Three antiviral medications provide clinical benefit: acyclovir, valacyclovir, and famciclovir. Cleansing lesions twice a day with saline helps prevent secondary infection. Bacterial infection must be treated with appropriate antibiotics. Measures that may increase comfort for women when lesions are active include warm sitz baths with baking soda; keeping lesions dry by blowing the area dry with a hair dryer set on cool or patting dry with a soft towel; wearing cotton underwear and loose clothing; using drying aids such as hydrogen peroxide, Burow solution or oatmeal baths; applying cool, wet black teabags to lesions; and applying compresses with an infusion of cloves or peppermint oil and clove oil to lesions Oral analgesics such as aspirin, acetaminophen, or ibuprofen may be used to relieve pain and systemic symptoms associated with initial infections. Because the mucous membranes affected by herpes are extremely sensitive, any topical agents should be used with caution. Nonantiviral ointments, especially those containing cortisone, should be avoided. A thin layer of lidocaine ointment or an antiseptic spray may be applied to decrease discomfort, especially if walking is painful. Counseling and education are critical components of the nursing care of women with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. TORCH Infections Summary Complete the following table to summarize the effects on mother, fetus, and newborn (for newborn look at Chapter 35, pgs. 772 – 776) Infection Maternal effects Fetal effects Newborn effects Toxoplasmosis Most infections asymptomatic Acute infection similar to mononucleosis The woman is immune after first episode (except for immunocompromised clients). Congenital infection is most likely to occur when maternal infection develops during the third trimester. The risk of fetal injury, however, is greatest when maternal infection occurs during the first trimester. hydrocephalus, chorioretinitis, and cerebral calcifications. Additional signs at birth include microcephaly, seizures, hearing loss, strabismus, petechial rash, jaundice, generalized lymphadenopathy, hepatosplenomegaly, pneumonia, thrombocytopenia, and anemia. Other infections (Hep B) May be transmitted sexually Approximately 10% of clients become chronic carriers. Some people with chronic hepatitis B eventually develop severe chronic liver disease such as cirrhosis or hepatocellular carcinoma. Infection occurs during birth. Maternal vaccination during pregnancy should present no risk for fetus; however, data are not available. The perinatal transmission of hepatitis B virus (HBV) from an infected mother to her fetus usually occurs during the blood exposure that occurs during labor and birth. The majority of infants who become HBsAg positive are asymptomatic at birth, although some show evidence of acute viral hepatitis. There is no specific treatment for acute HBV infection. Rubella Rash; fever; mild symptoms such as headache, malaise, myalgias, and arthralgias; postauricular lymph nodes may be swollen; mild conjunctivitis Approximately 50%–80% of fetuses exposed to the virus within 12 weeks after conception will show signs of congenital infection. Very few fetuses are affected if infection occurs after 18 weeks of gestation. The most common fetal anomalies associated with congenital rubella syndrome are deafness, eye defects (e.g., cataracts or retinopathy), central nervous system defects, and cardiac defects. Congenital rubella syndrome includes cataracts or glaucoma, hearing loss (the most common sign), and cardiac defects (pulmonary artery stenosis, patent ductus arteriosus, or coarctation of the aorta). Multiple other abnormalities may also be present including low birth weight, microphthalmia, hypotonia, hepatosplenomegaly, thrombocytopenic purpura, dermatoglyphic abnormalities, bony radiolucencies, microcephaly, and brain wave abnormalities. Severe infection can result in fetal death. Communication disorders, hearing deficits, microcephaly, and cognitive or motor impairments have been reported after the newborn period (Schleiss & Marsh, 2018). Cytomegalovirus Most adults are asymptomatic or have only mild flulike symptoms. Presence of CMV antibodies does not totally prevent reinfection. The fetus can be infected transplacentally. Infection is much more likely with a primary maternal infection. The most common indications of congenital infection include hepatosplenomegaly, intracranial calcifications, jaundice, growth restriction, microcephaly, chorioretinitis, hearing loss, thrombocytopenia, hyperbilirubinemia, and hepatitis. Congenital infection can occur at any point during the pregnancy. Severe sequelae occur most often when the mother is infected during her first trimester of pregnancy. CMV can be transmitted during birth or through breast milk while the mother has acute CMV infection; however, in a term infant, it is unlikely to result in clinical illness. Most newborns with congenital CMV infection are asymptomatic at birth. Clinical manifestations at birth can include rash, petechiae, jaundice, hepatosplenomegaly, IUGR, microcephaly, chorioretinitis, and intracerebral calcifications (Fig. 35.7). Herpes Primary infection with painful blisters, tender inguinal lymph nodes, fever, viral meningitis (rare). Recurrent infections are much milder and shorter. Transplacental infection resulting in congenital infection is rare and usually occurs with primary maternal infection. The risk mainly exists with infection late in pregnancy. For pregnant women with a primary varicella infection, the rate of transmission to the fetus is estimated to be approximately 25% (Schleiss & Marsh, 2018). When transmission to the fetus occurs during the first or early second trimester, congenital varicella can result in fetal death, limb hypoplasia, damage to the CNS, and eye abnormalities. When maternal varicella infection occurs between 8 and 20 weeks of gestation, the congenital varicella rate is 2%. Maternal infection that occurs in the third trimester is not associated with congenital varicella infection, but it does increase the risk of the newborn having neonatal varicella (Schleiss & Marsh). Varicella infection is more serious for the newborn if the mother develops varicella between 5 days before and 2 days after birth because the infant’s immune system is immature and there has been insufficient time for transplacental transfer of maternal antibodies. The death rate is high among these infants. Infants born to mothers within this time frame of exposure should receive varicella zoster immune globulin as soon as possible after birth (AAP, 2021). Chapter 8 Contraception What factors should be considered when helping a patient determine best method of contraception for her? In most cases, the woman herself seeks contraception through an appointment at a health care facility, although in some situations, her partner may accompany her. The assessment and evaluation involve inquiring about the partner or partners in terms of sexual practices, risk for STIs, and commitment to using contraception. Evaluation of the couple desiring contraception involves assessing the woman’s reproductive history (menstrual, obstetric, gynecologic, contraceptive), physical examination, and sometimes current laboratory tests. The nurse must determine the couple’s knowledge about reproduction, contraception, and STIs and their commitment to any particular method. Assessment of the client begins with the following appraisals: Determining the woman’s knowledge about contraception and her sexual partner’s commitment to any particular method Collecting data about the frequency of coitus, the number of sexual partners, the level of contraceptive involvement, and her or her partner’s objections to any methods Assessing the woman’s level of comfort and willingness to touch her genitals and cervical mucus Identifying any misconceptions as well as religious and cultural factors and paying close attention to the woman’s verbal and nonverbal responses to hearing about the various available methods Considering the woman’s reproductive life plan Completing a history (including menstrual, contraceptive, and obstetric), physical examination (including pelvic examination), and laboratory tests (as needed for identifying the presence of STIs) Use the table below to summarize the types of contraception available in the United States. Method How does it work? What are the advantages? What are the disadvantages? Patient teaching Fertility Awareness Fertility awareness-based (FAB) methods of contraception, also known as periodic abstinence or NFP, depend on identifying the beginning and end of the fertile period of the menstrual cycle. These methods provide contraception by relying on avoidance of intercourse during fertile periods. NFP methods are the only contraceptive practices acceptable to the Roman Catholic Church. When women who want to use FABs are educated about the menstrual cycle, three phases are identified: 1. Infertile phase: before ovulation 2. Fertile phase: approximately 5 to 7 days around the middle of the cycle, including several days before and during ovulation and the day afterward 3. Infertile phase: after ovulation Advantages of these methods include low to no cost, heightened awareness and understanding of personal fertility, increased self-reliance, absence of chemicals, instant availability, increased involvement and intimacy with partner, and the ability of the couple to follow religious/cultural traditions. Disadvantages of FABs include difficulty with adherence to strict recordkeeping, requirement of male partner support, lower typical effectiveness than other methods, decreased effectiveness in women with irregular cycles (particularly adolescents in whom regular ovulatory patterns have not been established), decreased spontaneity of coitus, and no protection from STIs, including HIV infection. The typical failure rate for most FAB methods is 15% during the first year of use (Loder & Villavicencio, 2020). FAB methods involve several techniques to identify fertile days. The following discussion includes the most common techniques and some promising techniques for the future. Various smartphone applications (apps) have been developed to assist with following FAB methods; these apps are currently being studied to understand their effectiveness (Jennings & Polis, 2018; Karasneh, Al-Azzam, Alzoubi, et al., 2020). Spermicides Spermicides such as nonoxynol-9 (N-9) work by reducing sperm mobility. The chemicals attack the sperm flagella and body, thereby preventing the sperm from reaching the cervical os. N-9, the most commonly used spermicidal chemical in the United States, is a surfactant that destroys the sperm cell membrane. Effective, Easy to use, Non hormonal, Immediate action, accessibility, Minimal Side Effects. Data suggest that frequent use (more than two times a day) of N-9 or the use of N-9 as a lubricant during anal intercourse may increase the transmission of HIV and can cause lesions. Insert according to instructions. Wait few minutes after insertion before intercourse. Do not douche immediately after. Male Condoms Sheath is applied over the erect penis before insertion or loss of preejaculatory drops of semen. Used correctly, condoms prevent sperm from entering the cervix. Spermicide-coated condoms cause ejaculated sperm to be immobilized rapidly, thus increasing contraceptive effectiveness.  Safe  No side effects  Readily available  Premalignant changes in cervix can be prevented or reduced in women whose partners use condoms.  Method of male nonsurgical contraception.  Must interrupt sexual activity to apply sheath  Sensation may be altered.  If used improperly, spillage of sperm can result in pregnancy.  Condoms occasionally may tear during intercourse. Teaching should include the following instructions:  Use a new condom (check expiration date) for each act of sexual intercourse or other acts between partners that involve contact with the penis.  Place condom after penis is erect and before intimate contact.  Place condom on head of penis (Fig. A) and unroll it all the way to the base.  Leave an empty space at the tip (see Fig. A); remove any air remaining in the tip by gently pressing air out toward the base of the penis.  If a lubricant is desired, use water-based products. Do not use petroleum-based products because they can cause the condom to break.  After ejaculation, carefully withdraw the still-erect penis from the vagina, holding on to condom rim; remove and discard the condom.  Store unused condoms in cool, dry place.  Do not use condoms that are sticky, brittle, or obviously damaged. Female Condoms The female condom, which can be inserted 8 hours prior to intercourse, is a vaginal sheath made of nitrile, a nonlatex synthetic rubber, with flexible rings at both ends (Fig. 8.6A). Female condoms may protect against HIV, CMV, and other STIs, but they must be used properly and consistently. The closed end of the pouch is inserted into the vagina and anchored around the cervix; the open ring covers the labia. Women whose partner will not wear a male condom can use this device as a protective mechanical barrier. The female condom is available in one size, is intended for single use only, and is sold over the counter. Female condoms are more expensive than other contraceptives. Not as widely available. Difficult to insert. Noise during intercourse. Allergic reaction to materials used in female condom. Female condoms should not be reused. Easily accessible over the counter, Can be used with any type of lubricant. Diaphragms Non hormonal option, Reversible Contraception, protection Against STIs, Increased Control, No Systemic Side Effects, Immediate Effectiveness, Cost effective, Compatible with breast feeding. Disadvantages of diaphragm use include the reluctance of some women to insert and remove it. A diaphragm can be inserted up to 6 hours before intercourse; if insertion of the diaphragm occurs immediately before intercourse, a cold diaphragm and a cold gel temporarily reduce vaginal response to sexual stimulation. Some women or couples object to the messiness of the spermicide. These annoyances of diaphragm use, along with failure to insert the device once foreplay has begun, are the most common reasons for failures of this method. Side effects may include irritation of tissues related to contact with spermicides. The male could also have a reaction to the spermicide. The diaphragm is not a good option for women with poor vaginal muscle tone or recurrent urinary tract infections. Toxic shock syndrome (TSS), although reported in very small numbers, can occur in association with the use of the contraceptive ­diaphragm. The nurse should instruct the woman about ways to reduce her risk for TSS. These measures include prompt removal 6 to 24 hours after intercourse, not using the diaphragm during menses, and learning and watching for danger signs of TSS (Bartz, 2022). Use spermicide to the inside and around the rim before inserting the diaphragm. Pinch sides to insert, to remove hook one finger under the rim and pull out. Use every time for intercourse. Leave in place for at least 6 hours after intercourse to allow time for spermacide to work. Cervical Caps It comes in three sizes and is made of silicone rubber. The cap fits snugly around the base of the cervix, close to the junction of the cervix and vaginal fornices. It is recommended that the cap remain in place no less than 6 hours and not more than 48 hours at a time. It is left in place at least 6 hours after the last act of intercourse. The seal provides a physical barrier to sperm; spermicide inside the cap adds a chemical barrier. The extended period of wear may be an added convenience for women. Instructions for the actual insertion and use of the cervical cap closely resemble those for a contraceptive diaphragm. Some of the differences are that the cervical cap can be inserted hours before sexual intercourse, the cervical cap requires less spermicide than the diaphragm when initially inserted, and no additional spermicide is required for repeated acts of intercourse. The FemCap is less effective than the diaphragm (Bartz, 2022). The angle of the uterus, the vaginal muscle tone, and the shape of the cervix may interfere with ease of fitting and use of the cervical cap. The woman must check the position of the cap before and after each act of intercourse. Use of the cervical cap during menstruation is not advised. The cap should be refitted after any gynecologic surgery or birth and after major weight losses or gains. Otherwise, the size should be checked at least once a year. Some women are not good candidates for wearing the cervical cap. These include women with abnormal Papanicolaou (Pap) test results, women who cannot be fitted properly with the existing cap sizes, women who find insertion and removal of the device too difficult, women who have a history of TSS, women who have vaginal or cervical infections, and women who experience allergic reactions to the latex cap or spermicide. Failure rates vary according to parity: 13% to 16% for nulliparous women and 23% to 32% for multiparous woman (Bartz, 2022). Correct fitting does not require a trained clinician, but it is recommended to ensure proper fit and education on insertion and removal (Bartz, 2022). Combined Oral Contraceptives Because taking the pill does not relate directly to the sexual act, the acceptability of the pill may be increased. Improvement in sexual response may occur once the possibility of pregnancy is not an issue. For some women it is convenient to know when to expect the next menstrual flow. The noncontraceptive health benefits of COCs include reduction of menorrhagia and regulation of irregular cycles, treatment of endometriosis, and reduced incidence of dysmenorrhea and premenstrual syndrome (PMS). Oral contraceptives also offer protection against endometrial cancer and ovarian cancer, decrease hirsutism and acne, protect against the development of functional ovarian cysts, and increase bone mass (Roe, Bartz, & Douglas, 2021). Oral contraceptives are considered a safe option for nonsmoking women until menopause. Perimenopausal women can benefit from regular bleeding cycles, a regular hormonal pattern, and the noncontraceptive health benefits of oral contraceptives. A pelvic examination and Pap test are not necessary before initiating COCs. If STI screening is indicated in an asymptomatic woman, a urine-based or vaginal swab test can be used to screen for some infections (e.g., chlamydia, gonorrhea) (American College of Obstetricians and Gynecologists [ACOG], 2018/2020). Most health care providers assess the woman 3 months after beginning COCs to detect any complications. Use of oral hormonal contraception can be initiated at any time during the menstrual cycle without any restrictions, as long as the woman is not pregnant. This is known as the Quick Start method and offers faster, more reliable pregnancy protection, increased continuation rates, and virtually no difference in breakthrough bleeding patterns compared with conventional start methods (wherein the pill must be started at the first day of the menstrual period). Taken exactly as directed, oral contraceptives prevent ovulation, and pregnancy cannot occur; the overall effectiveness rate is almost 100%. Almost all failures (i.e., pregnancy occurs) are caused by omission of one or more pills during the cycle. The typical failure rate of COCs due to omission is 7% (CDC, 2022). Women must be screened for conditions that present absolute or relative contraindications to oral contraceptive use. Contraindications to Combined Oral Contraceptive Use  History of thromboembolic disorders  Smoking ≥15 cigarettes/day at age ≥35  Cerebrovascular or cardiovascular disease  Breast cancer (current and past with no evidence of disease within 5 years)  Positive antiphospholipid antibodies  Migraine with aura  Multiple sclerosis with prolonged immobility  Irritable bowel syndrome  Malabsorptive bariatric procedures  Medically treated and current gallbladder disease  Acute or flare-up of viral hepatitis (initiation only)  Pregnancy  History of COC-related cholestasis  Severe cirrhosis  Hepatocellular tumor  Malignant hepatoma  Complicated solid organ transplantation  Use of fosamprenavir, rifampin, or rifabutin  Use of certain anticonvulsant medications and lamotrigine  Lactation and nonlactation less than 6 weeks postpartum  Hypertension (≥140/90 mm Hg, controlled or uncontrolled)  Diabetes mellitus of >20 years’ duration or with vascular disease, nephropathy, neuropathy, or retinopathy. Certain side effects of COCs are attributable to estrogen, progestin, or both. Serious adverse effects documented with high doses of estrogen and progesterone include stroke, myocardial infarction, thromboembolism, hypertension, gallbladder disease, and liver tumors. Common side effects of estrogen excess include nausea, breast tenderness, fluid retention, and chloasma. Side effects of estrogen deficiency include early spotting (days 1 to 14), hypomenorrhea, nervousness, and atrophic vaginitis leading to painful intercourse (dyspareunia). Side effects of progestin excess include increased appetite, tiredness, depression, breast tenderness, vaginal yeast infection, oily skin and scalp, hirsutism, and postpill amenorrhea. Side effects of progestin deficiency include late spotting and breakthrough bleeding (days 15 to 21), heavy flow with clots, and decreased breast size. One of the most common side effects of combined COCs is bleeding irregularities (Roe et al., 2021). If a woman experiences unpleasant or unsafe side effects when taking a particular COC, the health care provider may prescribe an alternative COC that has a different mix of estrogen and progestin. The ideal COC for a woman contains the lowest dose of hormones that prevents ovulation and that has the fewest and least harmful side effects. There is no way to predict the right dosage for any particular woman. Issues to consider in prescribing oral contraceptives include history of oral contraceptive use, side effects during past use, menstrual history, and drug interactions. There is no evidence of a relationship between use of oral contraceptives and the development of diabetes or glucose intolerance. The risks and benefits should be assessed before prescribing oral contraceptives for women who have diabetes with vascular problems. No strong pharmacokinetic evidence exists that shows a relationship between broad-spectrum antibiotic use and altered hormonal levels among oral contraceptive users (Allen, 2022). After discontinuing oral contraception, return to fertility ­usually happens within several months (Roe et al., 2021). Many women ­ovulate the next month after stopping oral contraceptives; it may take ­longer for ovulation to resume in others. Women who discontinue oral contraception for a planned pregnancy commonly ask whether they should wait before attempting to conceive. There is a lack of evidence to support delaying attempts to achieve pregnancy after discontinuing oral contraceptive use. Little evidence suggests that oral contraceptives cause post-pill amenorrhea. SIGNS OF POTENTIAL COMPLICATIONS Oral Contraceptives When oral contraceptives are initially prescribed and at follow-up visits throughout hormone therapy, alert the woman to stop taking the pill and to report any of the following symptoms to the health care provider immediately. The mnemonic, ACHES, is useful to help clients remember this information: A—Abdominal pain may indicate a problem with the liver or gallbladder C—Chest pain or shortness of breath may indicate possible clot problem within the lungs or heart H—Headaches (sudden or persistent) may be caused by cardiovascular accident or hypertension E—Eye problems may indicate vascular accident or hypertension S—Severe leg pain may indicate a thromboembolic process Many different preparations of oral hormonal contraceptives are available. The nurse reviews prescribing information with the woman, individualizing this education and prescribing instructions based on the specific oral contraceptive that is prescribed for her. Because of the wide variations, each woman must be clear about the unique dosage regimen for the preparation prescribed for her. Directions for care after missing one or two pills also vary. It is important that the woman speak with her health care provider about the best way to manage missing any pills. Withdrawal bleeding tends to be short and scanty when some combination pills are taken. A woman may see no fresh blood at all. A drop of blood or a brown smudge on a tampon or the underwear counts as a menstrual period. All women choosing to use oral contraceptives should be provided with a second method of birth control and be instructed in and comfortable with this backup method. Most women stop taking oral contraceptives for nonmedical reasons. The nurse also reviews the signs of potential complications associated with the use of oral contraceptives (see Signs of Potential Complications). Oral contraceptives do not protect a woman against STIs or HIV. A barrier method such as condoms and spermicide must be used to provide this protection. 91-day Oral Contraceptive Some women prefer to take COCs in 3-month cycles and have fewer menstrual periods. A 91-day regimen may be prescribed for women who prefer to take COCs in 3-month cycles so that they have fewer menstrual periods. The FDA has approved a COC Seasonale (Seasonique) that combines levonorgestrel (progestin) and ethinyl estradiol (estrogen). It is taken in 3-month cycles of 12 weeks of active pills (pills that contain hormones) followed by 1 week of inactive pills (pills that do not contain hormones). Menstrual periods occur during the 13th week of the cycle. There is no protection from STIs, and risks are similar to COCs. Other monophasic COCs may be prescribed for extended cycle use and must be taken on a daily schedule, regardless of the frequency of intercourse (Kaunitz, 2022c). Transdermal Hormonal Available by prescription only, contraceptive transdermal patches deliver continuous levels of either ethinyl estradiol and norelgestromin (EE/N; Xulane, Zafemy) or ethinyl estradiol and levonorgestrel (EE/LNG; Twirla). The patch can be applied to intact skin of the upper outer arm, upper torso (front and back, excluding the breasts), lower abdomen, or buttocks. Application is on the same day once a week for 3 weeks, followed by a week without the patch. Withdrawal bleeding occurs during the no-patch week. Mechanism of action, efficacy, contraindications, skin reactions, and side effects are similar to those of COCs. The typical failure rate during the first year of use of the EE/N patch is 1.07%, consistent with oral contraception. For the EE/LNG patch, typical failure rate is 3.5%, 5.7%, and 8.6% in normal weight, overweight, and obese women; thus obesity is a contraindication for this device (Burkman, 2021). Vaginal Contraceptive Ring Available only with a prescription, the vaginal contraceptive ring is a flexible ring (made of ethylene vinyl acetate copolymer) worn in the vagina to deliver continuous levels of either etonogestrel and ethinyl estradiol (ENG/EE; NuvaRing and EluRyng) or segesterone and ethinyl estradiol (SA/EE; Annovera). One vaginal ring remains in the vagina for 3 weeks, followed by a week without the ring. The ENG/EE ring is discarded, and a new ring is inserted to start the cycle over. The SA/EE ring is reusable for 1 year (13 cycles). Care involves washing with soap and water, drying, and storage in its case until the next cycle. The ring is inserted by the woman and does not have to be fitted. Some wearers may experience vaginitis, leukorrhea, and vaginal discomfort. Withdrawal bleeding occurs during the no-ring week. If the woman or partner notices discomfort during coitus, the ring can be removed from the vagina, but only up to 2 hours for the SA/EE ring and 3 hours for the ENG/EE ring to still be effective when reinserted. Mechanism of action, efficacy, contraindications, and side effects are similar to those of COCs. The typical failure rate of the ENG/EE ring is 9% and the SA/EE ring is 3% during the first year of use (Kerns & Darney, 2022). Progestin-only Oral Contraceptives Progestin-only methods impair fertility by inhibiting ovulation, thickening and decreasing the amount of cervical mucus, thinning the endometrium, lowering midcycle peaks of FSH and LH, and altering cilia in the uterine tubes (Kaunitz, 2022d). The mechanism of action in progestin-only pills can vary among women and can also vary in one woman from cycle to cycle (Raymond & Grossman, 2018). Effectiveness is increased if minipills are taken correctly. Because the dose of progesterone is low, the minipill must be taken at the same time every day (Kaunitz, 2022d). Users often report irregular vaginal bleeding. Injectable Progestins Injectable progesterone can be administered as a long-acting reversible contraceptive (LARC). There are two formulations of injectable progestins, referred to as depot medroxyprogesterone acetate (DMPA [Depo-Provera]). There is a an intramuscular injection given in the deltoid or gluteus maximus muscle and a subcutaneous injection. DMPA can be given any time in the cycle Advantages of DMPA include a contraceptive effectiveness comparable to that of perfect use of COCs, long-lasting effects, requirement of injections only four times a year, and the improbability of lactation being impaired. Side effects at the end of a year include possible decreased bone mineral density, weight gain, headaches, mood changes, and irregular vaginal spotting. Other disadvantages include no protection against STIs (including HIV). However, to avoid the need for backup or emergency contraception, it should be initiated during the first 7 days of the menstrual cycle and then administered every 11 to 13 weeks (Kaunitz, 2022b). Return to fertility may be delayed as long as up to 10 months after discontinuing DMPA. The typical failure rate is 6% in the first year of use (Kaunitz, 2022a). Implantable Progestins Contraceptive implants consist of one or more nonbiodegradable flexible tubes or rods that are inserted under the skin of a woman’s arm. These implants contain a progestin hormone and are effective for contraception for at least 3 years. They must be removed at the end of the recommended time. The only FDA-approved implant in the United States is a single-rod etonogestrel implant (Nexplanon). Its predecessor, Implanon, was discontinued at the advent of Nexplanon use. Nexplanon is radiopaque, a feature that Implanon lacked. Three other devices used worldwide are unavailable in the United States. One of these is Norplant, which was used frequently in the United States, but due to difficulties in insertion and removal (because it contains six rods) is no longer used. The newer implantable progestin, Nexplanon, is made of a single rod that releases etonogestrel. Research studies have indicated that not only is this an effective long-acting contraceptive, but it also helps to decrease dysmenorrhea (Mendiratta & Lentz, 2022). Insertion and removal of the single-rod etonogestrel capsule are minor, in-office surgical procedures that include a local anesthetic, a small incision, and no sutures. The capsule is injected subdermally in the inner aspect of the nondominant upper arm. Implants will prevent some, but not all, ovulatory cycles and will thicken cervical mucus. Other advantages include reversibility and long-term continuous contraception that is not related to frequency of coitus. Nexplanon can be inserted imm