NURS 7045 Chapter 137 - Women's Health PDF

Women’s Health Chapter 137 Evaluation and Management of GYNECOLOGIC Concerns  Amenorrhea- p. 867 DEFINITION: Absence or abnormal cessation of menstrual bleeding Primary amenorrhea ◦ The absence of both spontaneous uterine bleeding and secondary sexual characteristics (delayed puberty)...

Women’s Health Chapter 137 Evaluation and Management of GYNECOLOGIC Concerns  Amenorrhea- p. 867 DEFINITION: Absence or abnormal cessation of menstrual bleeding Primary amenorrhea ◦ The absence of both spontaneous uterine bleeding and secondary sexual characteristics (delayed puberty) at the age of 14 years ◦ Or, by 2 years after sexual maturation or the absence of menarche at the age of 16 years regardless of the presence of secondary sexual characteristics (breast buds or pubic hair) ◦ Half of the cases of primary amenorrhea result from failure of gonad's to develop ◦ Also caused by structural abnormalities (imperforate hymen, transverse septum, vaginal inversion, PCOS, malnutrition, or any disturbances in the hypothalamic pituitary ovarian axis that also cause secondary amenorrhea Secondary amenorrhea- more common ◦ The absence of menstrual bleeding in a woman with prior menstruation (e.g., pregnancy, endurance sports (running, ballet), anorexia or obesity) ◦ Caused by pregnancy, lactation, early menopause, discontinue OCPs or Depo Provera. Can also be linked to disordered functioning along the hypothalamic pituitary ovarian axis (PCOS) Types of Secondary Amenorrhea Hyperprolactin Amenorrhea- caused by drugs (OCPs, phenothiazines, reserpine, metoclopramide, methyldopa), pituitary tumors that are prolactin screening, systemic illness (acromegaly, hypothyroidism). -Physiologic causes of high prolactin- nipple stimulation, lactation Hyperandrogenic Amenorrhea- seen most commonly in women with PCOS, can also be caused by obesity, Cushing's, hyperprolactinemia, thyroid disease, adrenal disease (adenoma, hyperplasia, carcinoma), androgen secreting ovarian tumors or drug abuse Hypogonadotropic Amenorrhea- congenital or acquired causes. Common in young women from physical or emotional stress (athletic training, depression, nutritional deficiency, weight loss, eating disorders) Clinical Presentation- will present with absent bleeding Obtain a thorough menstrual history- age at menarche, frequency, duration, flow of periods, last period, history of missed periods A complete sexual history- number of partners, date of last intercourse, method of birth control and percentage of use, number of pregnancies, abortions, miscarriages, ectopic pregnancies, surgical history Age at menarche and menopause for family members and any family history of infertility PMHx Medication history- OTC, illicit drug use, prescribed meds Nutritional and exercise history- disordered eating behavior, recent weight loss or gain, athletic training, growth and development ROS + Social history (for substance use, stressful life events) ◦ A review of systems may reveal indications of systemic illness (such as thyroid dysfunction, headaches, visual disturbances, galactorrhea, hyperandrogenism, hypoestrogenism  Physical Exam and Diagnostics General growth and development assessment Thorough P.E. focusing on ◦ Visual acuity (may reflect intercranial mass) ◦ Thyroid assessment (for masses or nodules) ◦ Pelvic exam- assess estrogen status by vaginal epithelium and cervical mucus. May reveal imperforate hymen and a gross exam of the cervix, uterus and ovaries Diagnostics ◦ R/O pregnancy before any other diagnostic evaluation ◦ Initial Labs ◦ Serum human chorionic gonadotropin ◦ FSH, LH- anovulation (if amenorrhea is secondary to anovulation, may be from Cushing’s , ovary tumor, or PCOS) ◦ FSH > 20 indicates ovarian failure and >30 indicates menopause ◦ Elevated LH/FSH ratio > 0.2 indicated PCOS ◦ TSH- hypothyroidism ◦ Prolactin- hyperprolactinemia or early presentation of acromegaly ◦ Imaging: MRI/CT scan if prolactin levels are high to identify microadenomas or macroadenomas ◦ MRI has been shown to be effective and accurate tool to evaluate the cause of primary amenorrhea ◦ Additional testing: CMP, serum electrolytes, urinary free cortisol, thyroid antibodies, ESR, HbA1C to differentiate autoimmune amenorrhea like Addison's, diabetes, thyroiditis, and hypoparathyroidism Differential Diagnosis Turner’s syndrome (45, X) mosaicism Abnormal X chromosomes Chromosomal deletions Structural abnormalities Malnutrition Systemic illness Tumors Early menopause Pregnancy Primary ovarian insufficiency PCOS Medication-related amenorrhea  Management Psychiatric counseling (when indicated) Medication ◦ Progesterone Challenge Test if MRI/CT are normal—medroxyprogesterone 10 mg daily for 5-7 days to further evaluate estrogen status, prevent endometrial hyperplasia, and treat amenorrhea ◦ Positive result- vaginal bleeding within 2-7 days after progesterone cessation indicates both adequate estrogen stores and patency of the outflow tract ◦ Negative result- no vaginal bleeding within 2-7 days after progesterone cessation indicates wither inadequate estrogen stores or outflow tract obstruction ◦ Menses returns within 6-14 months of last injection of medroxyprogesterone and 6 months after stopping OCPs Restoration of the hypothalamic-pituitary-adrenal and the hypothalamic-pituitary-thyroidal axes (Kallmann syndrome, pituitary lesions, head injuries, infections Anorexia-related disorder ◦ Increased nutritional intake, return to the weight, and reduced exercise to bring back menses ◦ Amenorrhea is one of the cardinal features of anorexia Therapies—pulsatile GnRH, recombinant human leptin Hospitalization May be necessary for women with anorexia nervosa who have lost more than 30% of their desired body weight and fail to gain weight, as well as for those with suicidal ideation  Dysmenorrhea- p. 864 Pain and cramping associated with menstruation Most common gynecological symptom reported by women 1. Primary: ◦ A. Absence of any pelvic pathology; most commonly seen in adolescents ◦ B. The etiology of primary dysmenorrhea is believed to be hormonal and endocrine- related. ◦ C. Most cases of primary dysmenorrhea begin 6-12 months after menarche, with symptoms gradually increasing until patients are in their mid 20s. ◦ Physical exam findings are normal 2. Secondary dysmenorrhea results at around 30-40 years old and from underlying pathologic cause such as pregnancy, pelvic inflammatory disease (PID), and endometriosis. ◦ Physical exam findings- pelvic mass, abnormal pelvic/vaginal tenderness Signs and Symptoms Signs and Symptoms: 1.Cramping and painful menses for 1-3 days 2.Lower abdominal pain associated with menstruation (usually worse in the first few days of bleeding 3.Associated back pain 4. May have nausea, vomiting, fatigue, headache and diarrhea 5. Red flags include unilateral dysmenorrhea, signs suggestive of acute abdomen or STDs. Ectopic pregnancy should always be ruled out Laboratory/Diagnostics 1. Primary dysmenorrhea: ◦ N0 testing is necessary, the diagnosis is made clinically 2. Testing for secondary dysmenorrhea: ◦ According to suspected underlying cause  Management 1. Education about menstruation, proper diet (decrease arachidonic acid with low fat diet rich in fish, beans, seeds, whole grains, fruits and vegetables) 2. Support measures ◦ A. Heat application (hot water bottle, baths) ◦ B. Psychological support (relaxation training, biofeedback, mind body awareness, acupuncture, TENS) ◦ C. Over the counter analgesics, preferably ibuprofen: 400 mg every 4-6 hours, beginning at the onset of menstrual cycle and continuing 24-72 hours 3. Stronger NSAIDS for moderate to severe dysmenorrhea. The best initial therapy for dysmenorrhea. - Supplements- Vit B1 (thiamine), vit B3 (niacin), vit B6 (pyridoxine), zinc, calcium, magnesium and omega 3 4. Oral contraceptives- skip placebo week which will not allow for a period week 5. Referral as needed