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1/9/24, 2:48 AM Realizeit for Student Introduction Good health throughout the life cycle begins with the individual. Women today can expect to live well into their 80s and need to be proactive in maintaining their own quality of life. Women need to take steps to reduce their risk of disease and ne...

1/9/24, 2:48 AM Realizeit for Student Introduction Good health throughout the life cycle begins with the individual. Women today can expect to live well into their 80s and need to be proactive in maintaining their own quality of life. Women need to take steps to reduce their risk of disease and need to become active partners with their health care professional to identify problems early, when treatment may be most successful. Nurses can assist women in maintaining their quality of life by helping them to become more attuned to their body and its clues and can use the assessment period as an opportunity for teaching and counseling. Nurses are in a prime position to offer information that provides women with the tools needed to maintain a healthy lifestyle and assist in altering behaviors that may cause harm or illness. Menstrual Disorders Menstrual patterns can be an indicator of overall health and self-perception of well-being. Many women sail through their monthly menstrual cycles with little or no concerns. With few symptoms to worry about, their menses are like clockwork, starting and stopping at nearly the same times every month. For others, the menstrual cycle causes physical and emotional symptoms that initiate visits to their health care providers for consultation. The following menstruation-related conditions will be discussed in this section: amenorrhea, dysmenorrhea, abnormal uterine bleeding (AUB), premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), and endometriosis. To gain an understanding of menstrual disorders, nurses should know the word parts used to describe them (Box 4.1). BOX 4.1 MENSTRUAL DISORDER VOCABULARY meno = menstrual related metro = time oligo = few a = without, none or lack of rhagia = excess or abnormal dys = not or pain rhea = flow Amenorrhea Amenorrhea simply means absence of menses. Amenorrhea is normal in prepubertal, pregnant, postpartum, and postmenopausal females. The uterus, endometrial lining, ovaries, pituitary, and hypothalamus must function properly and in harmony for a menstrual cycle to occur. The two categories of amenorrhea are primary and secondary amenorrhea. Primary amenorrhea is defined as either the: 1. Absence of menses by age 15, with absence of growth and development of secondary sexual characteristics, or 2. Absence of menses by age 16, with normal development of secondary sexual characteristics (Creighton et al., 2018). Of girls living in the United States, 98% menstruate by age 15 (Oyelowo & Johnson, 2018). Recent data suggest that pubertal development, and hence menarche, continues to begin earlier in American girls than it did decades ago (Rebar, 2018). Once menarche has occurred, cycles may take up to 2 years to become regular, ovulatory cycles. Secondary amenorrhea is the absence of regular menses for three cycles or irregular menses for 6 months in women who have previously menstruated regularly. Nurses need to consider the causes of amenorrhea as occurring in one of four anatomical areas: outflow area of the uterus and vagina, the ovaries, the pituitary gland, or the central nervous system. Outflow area problems are obstructive in nature and can be found on physical examination, whereas ovarian, pituitary, and central nervous system problems involve disruptions in the hypothalamic–pituitary–ovarian axis that controls the neuroendocrine processes required for a normal menstrual cycle and are generally found through laboratory analysis (Knaus et al., 2018). Etiology https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 1/7 1/9/24, 2:48 AM Realizeit for Student Primary amenorrhea has multiple causes, including: Extreme weight gain or loss Congenital abnormalities of the reproductive system Stress from a major life event Excessive exercise Eating disorders (anorexia nervosa or bulimia) Cushing disease Polycystic ovary syndrome Hypothyroidism Turner syndrome—defective development of the gonads (ovary or testes) Imperforate hymen Chronic illness—diabetes, thyroid disease, depression Pregnancy Cystic fibrosis Congenital heart disease (cyanotic) Ovarian or adrenal tumors Causes of secondary amenorrhea can include: Pregnancy Breast-feeding Chronic prolonged stress Pituitary, ovarian, or adrenal tumors Depression Hyperthyroid or hypothyroid conditions Malnutrition Hyperprolactinemia Rapid weight gain or loss Chemotherapy or radiation therapy to the pelvic area Vigorous exercise, such as long-distance running Kidney failure Colitis Chemotherapy, irradiation Use of tranquilizers or antidepressants https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 2/7 1/9/24, 2:48 AM Realizeit for Student Postpartum pituitary necrosis (Sheehan syndrome) Early menopause (Klein et al., 2019) Therapeutic Management Therapeutic intervention depends on the cause of the amenorrhea. The treatment of primary amenorrhea involves the correction of any underlying disorders and estrogen replacement therapy to stimulate the development of secondary sexual characteristics if they are absent (Welt & Barbieri, 2018). If a pituitary tumor is the cause, it might be treated with drug therapy, surgical resection, or radiation therapy. Surgery might be needed to correct any structural abnormalities of the genital tract. Dopamine agonists are effective in treating hyperprolactinemia. In most cases, this treatment can restore normal ovarian endocrine function and ovulation (Casanueva & Ghigo, 2018). Therapeutic interventions for secondary amenorrhea can include: Cyclic progesterone, when the cause is anovulation, or oral contraceptives (OCs) Bromocriptine to treat hyperprolactinemia Nutritional counseling to address anorexia, bulimia, or obesity Gonadotropin-releasing hormone (GnRH), when the cause is hypothalamic failure Thyroid hormone replacement, when the cause is hypothyroidism (Solnik, 2018). Nursing Assessment Nursing assessment for the young girl or woman experiencing amenorrhea includes a thorough health history, physical examination, and laboratory and diagnostic tests of selected hormone levels to help to identify any underlying causes. The Tanner stages of breast development should be noted also. The Tanner stages include: Stage I—Papilla elevation only (tip of nipple is raised) Stage II—Breast buds palpable and areolae enlarge at approximately 11 years old Stage III—Elevation of breast contour; areolae enlarge at approximately 12 years old Stage IV—Areolae forms secondary mound on the breast at approximately 13 years old Stage V—Adult breast contour; areola recesses to breast contour (Edelman & Kudzma, 2018). Information gained from the history and physical examination clearly can exclude certain diagnostic possibilities, but first impressions also can be deceiving and lead to errors in judgment. A methodical, systematic approach to identify the etiology of amenorrhea is best. LABORATORY AND DIAGNOSTIC TESTS Common laboratory tests that might be ordered to determine the cause of amenorrhea include: Karyotype (might be positive for Turner syndrome) Ultrasound to detect ovarian cysts Quantitative human chorionic gonadotropin (hCG) test to rule out pregnancy Thyroid function studies to determine thyroid disorder Prolactin level (an elevated level might indicate a pituitary tumor) Follicle-stimulating hormone (FSH) level (an elevated level might indicate ovarian failure) Luteinizing hormone (LH) level (an elevated level might indicate gonadal dysfunction) 17-ketosteroids (an elevated level might indicate an adrenal tumor) (Pagana, et al., 2019). Nursing Management Counseling and education are primary interventions and appropriate nursing roles. Address the diverse causes of amenorrhea, the relationship to sexual identity, possible infertility, and the possibility of a tumor or a life-threatening disease. Evidence is mounting that loss of menstrual regularity is a risk factor for later development of osteoporosis and hip fractures, so treatment to restore regular menstrual cycles is essential (Creighton et al., 2018). In addition, inform the woman about the purpose of each diagnostic test, how it is performed, and when the results will be available to discuss with her. Listening sensitively, interviewing, and presenting treatment options are paramount to gain the woman's cooperation and understanding. Dysmenorrhea Dysmenorrhea refers to painful menstruation and is a common problem in adolescence. This condition has also been termed cyclic perimenstrual pain. Usually pain starts along with the start of bleeding and lasts for 48 to 72 hours (Smith, 2018). The term dysmenorrhea is derived from the Greek words dys, meaning “difficult, painful, or abnormal,” and rrhea, meaning “flow.” Based on results of large epidemiological studies, it is estimated that it may affect more than half of menstruating women. It is the leading cause of absenteeism of work and school and has adverse effects on the quality of life of young women (Matthewman et al., 2018). Another recent research study https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 3/7 1/9/24, 2:48 AM Realizeit for Student linked early smoking (<13 years old) to an increased risk for developing chronic dysmenorrhea (Dwivedi, 2018). Uterine contractions occur during all periods, but in some women these cramps can be frequent and very intense. It has a major impact on women's quality of life, work productivity, and health care utilization. Dysmenorrhea is a symptom, not a full diagnosis. It is classified as primary (spasmodic) or secondary (congestive) (Oyelowo & Johnson, 2018). Etiology Primary dysmenorrhea refers to painful menstrual bleedings in the absence of any detectable underlying pathology. It is caused by increased prostaglandin production by the endometrium in an ovulatory cycle. This hormone causes contraction of the uterus, and levels tend to be higher in women with severe menstrual pain than women who experience mild or no menstrual pain. Dysmenorrhea is caused by an excess of prostaglandin production. These levels are highest during the first two days of menses, when symptoms peak (Fulghesu, 2018). This results in increased rhythmic uterine contractions from vasoconstriction of the small vessels of the uterine wall. This condition usually begins within a few years of the onset of ovulatory cycles at menarche. Secondary dysmenorrhea is painful menstruation due to pelvic or uterine pathology. It may be caused by endometriosis, adenomyosis, fibroids, pelvic infection, an intrauterine system (IUS), cervical stenosis, or congenital uterine or vaginal abnormalities. Adenomyosis involves the ingrowth of the endometrium into the uterine musculature. Endometriosis involves ectopic implantation of endometrial tissue in other parts of the pelvis. It occurs most commonly in the third or fourth decades of life and affects 10% of women of reproductive age. The pain tends to get worse, rather than better, over time (American College of Obstetricians & Gynecologists [ACOG], 2018b). Endometriosis is the most common cause of secondary dysmenorrhea and is associated with pain beyond menstruation, dyspareunia, low back pain, heavy or irregular bleeding, bloating, nausea, and vomiting, and infertility (ACOG, 2018b). The most effective treatment involves removing the underlying pathology, but there is no cure. Izzy, a 27-year-old, presents to her health care provider complaining of progressive severe pelvic pain associated with her monthly periods up” with pills to endure the pain. In addition, she has been trying to conceive for over a year without any luck. Is her pelvic pain complaint Therapeutic Management The goal of treatment is to provide adequate pain relief to allow the woman to perform her usual activities. Current treatment mainly includes surgery and ovarian suppressive agents (OCs, progestins, GnRh antagonist, levonorgestrel-releasing intrauterine system [LNGIUS], and androgenic agents). Hormonal treatments are often associated with unwanted side effects and recurrence of symptoms when stopped. Severe dysmenorrhea can be distressing, adversely affecting social and occupational activities. Treatments vary from over-thecounter remedies to hormonal control. Nursing Assessment As with any gynecologic complaint, a thorough focused history and physical examination are needed to make the diagnosis of primary or secondary dysmenorrhea. In primary dysmenorrhea, the history usually reveals the typical cramping pain with menstruation, and the physical examination is completely normal. With secondary dysmenorrhea, the history discloses cramping pain starting after 25 years old with a pelvic abnormality, a history of infertility, heavy menstrual flow, irregular cycles, and little response to nonsteroidal anti-inflammatory drugs (NSAIDs), OCs, or both (Smith, 2018). HEALTH HISTORY AND CLINICAL MANIFESTATIONS Note the past medical history, including any chronic illnesses and family history of gynecologic concerns. Determine medication and substance use, such as prescription medications, contraceptives, anabolic steroids, tobacco, and marijuana, cocaine, or other illegal drugs. A detailed sexual history is essential to assess for inflammation and scarring (adhesions) secondary to pelvic inflammatory disease (PID). Women with a previous history of PID, sexually transmitted infections (STIs), low consumption of fruits and vegetables, depression, high stress level, multiple sexual partners, or unprotected sex are at increased risk (Magowan et al., 2019). PHYSICAL EXAMINATION The physical examination performed by the health care provider centers on the bimanual pelvic examination. This examination is done during the nonmenstrual phase of the cycle. Explain to the woman how it is to be performed, especially if it is her first pelvic examination. Prepare the woman in the examining room by offering her a cover gown to put on and covering her lap with a privacy sheet on the examination table. Remain in the examining room throughout the examination to assist the health care provider with any procedures or specimens and to offer the woman reassurance. LABORATORY AND DIAGNOSTIC TESTS Common diagnostic tests that may be ordered to determine the cause of dysmenorrhea can include: https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 4/7 1/9/24, 2:48 AM Realizeit for Student Complete blood count to rule out anemia Urinalysis to rule out a bladder infection Pregnancy test (hCG level) to rule out pregnancy Cervical culture to exclude STI Erythrocyte sedimentation rate to detect an inflammatory process Stool guaiac test to exclude gastrointestinal bleeding or disorders Pelvic and/or vaginal ultrasound to detect pelvic masses or cysts Diagnostic laparoscopy and/or laparotomy to visualize pathology that may account for the symptoms (Pagana et al., 2019). What diagnostic tests might be ordered to diagnose Izzy’s pelvic pain? Nursing Management Educating the client about the normal events of the menstrual cycle and the etiology of her pain is paramount in achieving a successful outcome. Explaining the normal menstrual cycle will teach the woman the correct terms to use so she can communicate her symptoms more accurately and will help dispel myths. Provide the woman with monthly graphs or charts to record menses, the onset of pain, the timing of medication, relief afforded, and coping strategies used. This involves the woman in her care and provides objective information so that therapy can be modified if necessary. Educate women about the associated risk factors for dysmenorrhea which include attempts to lose weight, depression or anxiety, disruption of social networks, heavy menses, nulliparity, and smoking (Dwivedi, 2018).The nurse should explain in detail the dosing regimen and the side effects of the medication therapy selected. Commonly prescribed drugs include NSAIDs such as ibuprofen (Motrin, Advil) or naproxen (Naprosyn). Abnormal Uterine Bleeding Disturbances of menstrual bleeding manifest in a wide range of presentations. Abnormal uterine bleeding (AUB) is the umbrella term used to describe any deviation from normal menstruation or from a normal menstrual cycle pattern. It can occur in women of any age with a prevalence of 10% to 30% among women of reproductive age (Wouk & Helton, 2019). The key characteristics are that regularity, frequency, volume or heaviness of flow, and duration of flow are abnormal, but each of these may exhibit considerable variability. AUB is a disorder that occurs most frequently in women at the beginning and end of their reproductive years. It is common and somewhat debilitating in women of reproductive age. AUB is defined as painless endometrial bleeding that is prolonged, excessive, and irregular, and not attributed to any identified underlying structural or systemic disease. The International Federation of Gynecology and Obstetrics (FIGO) recommends the use of the term “AUB” to describe any aberration of menstrual volume, regulation, duration, and/or frequency in a women who isn’t pregnant. FIGO also recommends to discard such terminology as “menorrhagia,” “metrorrhagia,” and “dysfunctional uterine bleeding,” as they are controversial, confusing, and poorly defined (FIGO, 2018). AUB is frequently associated with anovulatory cycles, which are common for the first year after menarche and associated with immaturity of the hypothalamic–pituitary–ovarian axis. It also occurs later in life as women approach menopause and experience irregular menstrual cycles. The pathophysiology of AUB is related to a hormone disturbance. Therapeutic Management Treatment of AUB depends on the cause of the bleeding, the age of the client, and whether or not she desires future fertility. When known, the underlying cause of the disorder is treated. Otherwise, the goal of treatment is to normalize the bleeding, correct anemia, prevent or diagnose early cancer, and restore quality of life. Once malignancy and pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option (Knaus et al., 2018). Treatment options for AUB include combined OCs, which help to regulate the timing and intensity of each cycle; Depo-Provera, a progestinonly birth control injection that reduces the thickness of the endometrial lining; NSAIDs, which can reduce bleeding and modulate pain; tranexamic acid (antifibrinolytic); GnRH analogs; danazol; and levonorgestrel-releasing intrauterine system (LNG IUS) (Ghlichloo & Gerriets, 2019; Singh et al., 2018). Management of AUB might include medical care with pharmacotherapy or insertion of a hormone-secreting intrauterine system. OCs are used for cycle regulation as well as for contraception. They help prevent the risks associated with prolonged, unopposed estrogen stimulation of the endometrium. NSAIDs and progestin therapy (progesterone-releasing IUS [Mirena] or Depo-Provera) decrease menstrual blood loss significantly (Skidmore-Roth, 2020). Drug categories used in the treatment of AUB include: Estrogens: cause vasospasm of the uterine arteries to decrease bleeding. Progestins: used to stabilize an estrogen-primed endometrium. OCs: regulate the cycle and suppress the endometrium. NSAIDs: inhibit prostaglandins in ovulatory menstrual cycles. Progesterone-releasing IUSs: suppress endometrial growth. Androgens: create a high-androgen/low-estrogen environment that inhibits endometrial growth. Antifibrinolytic drugs: (tranexamic acid) prevent fibrin degradation to reduce bleeding. Iron replacement therapy: replenish iron stores lost during heavy bleeding. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 5/7 1/9/24, 2:48 AM Realizeit for Student If the client does not respond to medical therapy, surgical intervention might include dilation and curettage (D&C), endometrial ablation, uterine artery embolization, or hysterectomy. Premenstrual Syndrome Premenstrual syndrome (PMS) describes a constellation of recurrent symptoms that occur during the luteal phase or last half of the menstrual cycle and resolve with the onset of menstruation. A majority of women in their reproductive years experience a variety of premenstrual symptoms that can alter their behavior and well-being. Therapeutic Management Treatment of PMS is often frustrating for both clients and health care providers. Clinical outcomes can be expected to improve as a result of recent consensus on the diagnostic criteria for PMS and premenstrual dysphoric disorder (PMDD), data from clinical trials, and the availability of evidence-based clinical guidelines. The management of PMS or PMDD requires a multidimensional approach because these conditions are not likely to have a single cause, and they appear to affect multiple systems within a woman's body; therefore, they are not likely to be amenable to treatment with a single therapy (Reid & Soares, 2018). To reduce the negative impact of premenstrual disorders on a woman's life education, along with reassurance and anticipatory guidance, is needed for women to feel they have some control over this condition. Symptoms can be categorized using the following: A—anxiety: difficulty sleeping, tenseness, mood swings, and clumsiness C—craving: cravings for sweets, salty foods, chocolate D—depression: feelings of low self-esteem, anger, dysphoria H—hydration: weight gain, abdominal bloating, breast tenderness, ankle swelling O—other: hot flashes or cold sweats, nausea, change in bowel habits, aches or pains, dysmenorrhea, acne breakout (Oyelowo & Johnson, 2018). Endometriosis Endometriosis is a complex syndrome characterized by an estrogen-dominant chronic inflammatory process that affects primarily pelvic tissues, including the ovaries. It is caused when tissue similar to that of the endometrium implants outside of the uterus, most commonly throughout the abdominal cavity (Bulun et al., 2019). It is one of the most common gynecologic diseases, affecting more than 6 million women in the United States, about 11% of the adult women population (Patel et al., 2018). Endometriosis tissue is commonly found attached to the ovaries, fallopian tubes, the outer surface of the uterus, the bowels, the area between the vagina and the rectum (rectovaginal septum), and the pelvic side wall (Fig. 4.1) though lesions have been found in locations as far from the uterus as the brain. The places where the tissue attaches are called implants, or lesions. These lesions create their own blood supply and respond to hormones released during the menstrual cycle in the same way as the endometrial lining within the uterus. FIGURE 4.1. Common sites of endometriosis formation. (Asset provided by Anatomical Chart Co.) https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 6/7 1/9/24, 2:48 AM Realizeit for Student At the beginning of the menstrual cycle, when the lining of the uterus is shed and menstrual bleeding begins, endometriosis implants swell and bleed as well. In short, the woman with endometriosis experiences several “mini-periods” throughout her abdomen, wherever this endometriosis tissue exists. In addition to cyclic bleeding outside the uterus, pelvic pain that can be debilitating, scarring, and adhesion formation occur throughout the pelvis. Symptoms begin as early as adolescence and may settle after menopause. Therapeutic Management Therapeutic management of the client with endometriosis falls into three categories: pain relief, hormonal suppression, and surgery. The plan must take into consideration the following factors: severity of symptoms, desire for fertility, degree of the disease, and the client’s therapy goals. Currently, a definitive diagnosis of endometriosis is only possible via laparoscopy and visualization of the lesions; to date, no imaging modality can prove the presence of lesions. Treatment of endometriosis involves surgery to remove the lesions. Ovarian suppressive agents (OCs, progestins, long-acting GnRH analogs, and androgenic agents like danazol) can manage symptoms. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zUraqIasLrohurDGqXpGq6QB9gdqiPJLc88OmWKG9Kloy4LbjaH… 7/7