NURS 3450 Module 2 CH 6 PDF

NURS 3450 Maternity and Women’s Health Nursing Chapter 6 Reproductive System Concerns 1. 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...

NURS 3450 Maternity and Women’s Health Nursing Chapter 6 Reproductive System Concerns 1. 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. 2. Cyclic perimenstrual pain and discomfort (CPPD) includes what disorders? What are their definitions? a. 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 b. 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). c. 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. NURS 3450 Maternity and Women’s Health Nursing d. 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). e. 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. f. 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. 3. 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 NURS 3450 Maternity and Women’s Health Nursing 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 (FerriesRowe 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 NURS 3450 Maternity and Women’s Health Nursing (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. 4. 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 5. 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. 6. 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. NURS 3450 Maternity and Women’s Health Nursing 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 NURS 3450 Maternity and Women’s Health Nursing 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) 7. Describe the physical changes a woman experiences during menopause and explain the cause for that change. Change Bleeding Cause 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 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. Vasomotor Instability 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. NURS 3450 Maternity and Women’s Health Nursing 8. What education does a woman experiencing menopause need about these topics? Topic Sexual Health Brief Summary of Teaching 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) NURS 3450 Maternity and Women’s Health Nursing Topic Brief Summary of Teaching 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.). 9. 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). 10. 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. NURS 3450 Maternity and Women’s Health Nursing 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. 11. Complete the following: a. 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. a. 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. b. 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. c. 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. NURS 3450 Maternity and Women’s Health Nursing 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 1. 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)?