New Content for Final Exam
“Women’s Health Across the Lifespan: Reproductive System Concerns”
Amenorrhea:
Absence of menstrual flow – it is a clinical symptom, not a disease
Evaluation warranted if:
o Absence of both menarche & secondary sexual characteristics by age 14
o Absence of menses by age 16, regardless of presence of normal growth and development (primary amenorrhea)
o A 3 to 6-month absence of menses after a period of menstruation (secondary amenorrhea)
Most commonly, amenorrhea is caused by pregnancy.
Other Causes
o Medications – oral contraceptive, phenytoin (Dilantin), drug abuse (alcohol, tranquilizers, cocaine)
o Anatomic abnormalities – outflow tract obstruction (primary), anterior pituitary disorders
o Endocrine disorders – PCOS, hypothyroidism, hyperthyroidism, Type 1 DM
Hypogonadotropic amenorrhea – problem in central hypothalamic-pituitary axis (not enough FSH or LH)
o More commonly results from hypothalamic suppression as a result of: stress, severe weight loss, eating disorders, strenuous exercise,
or mental illness
Amenorrhea is a classic sign of anorexia nervosa
Exercise-associated amenorrhea – Female Athlete Triad:
o Interrelatedness of eating disorder, amenorrhea, & altered bone mineral density
o Height weight, body weight, intensity and frequency of exercise, being under stressors
o Found in sports that emphasize low body weight:
Sports in which performance is subjectively scored (distance running, cycling)
Endurance sports favoring participants with low body weight (distance running, cycling)
Sports in which body contour–revealing clothing is worn (swimming, diving, volleyball)
Sports with weight categories for participation (rowing, martial arts)
Sports in which pre-pubertal body shape favors success (gymnastics, figure skating)
Assessment:
o History and physical assessment
o Labs: β-hCG (pregnancy test) – ensure the woman is not pregnant
o If β-hCG is negative: FSH, TSH, prolactin levels, X-ray, or CT
o Progestin challenge test – the woman will be given Provera 10 mg daily for 7-10 days
“Withdrawal bleeding” within about 1 week after the last pill indicates that there is enough estrogen present and the amenorrhea
was due to not ovulating (anovulation).
If vaginal bleeding doesn’t occur after progesterone withdrawal, then the amenorrhea is likely due to either low serum estradiol,
hypothalamic-pituitary axis dysfunction, a nonreactive endometrium, or a problem with the uterine outflow tract.
Another problem that needs to be investigated
Management
o Counseling, education – determine what the cause is
o Correct weight loss, decrease intensity or duration of exercise training, stress management
o Female athlete triad: Calcium intake 1000-1500 mg, Vitamin D 400-800 IU, Potassium 60-90 mg
Help correct the weight loss and deal with emotional stressors
o Low dose oral contraceptives – treating symptoms, not the cause
Cyclic Peri-menstrual Pain & Discomfort (CPPD):
Symptom clusters that occur before & after the menstrual flow starts
o Dysmenorrhea: pain during or shortly before menstruation (primary or secondary)
o Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD)
Dysmenorrhea: pain during or shortly before menstruation
Primary Dysmenorrhea
o A condition associated with ovulatory cycles – related to release of prostaglandins with menses
Because both estrogen and progesterone are necessary for primary dysmenorrhea to occur, it is experienced only with ovulatory
cycles.
The symptoms are related to ovulation, so they do not occur when ovulation is suppressed.
o Excessive release of prostaglandins during luteal phase causes vasospasm of the uterine arterioles, which leads to Ischemia and cramps
o Systemic physiologic response includes: backache, weakness, sweats, GI and CNS symptoms
o More common in late teens & early 20s – incidence declines with age
o Management:
Educate and support – dispel myths; provide facts about normal
Heat (heating pad or hot bath) – increases vasodilation, minimizes cramping/ischemia
, Massage – relax muscles, increase blood flow to pelvis
Effleurage – soft, rhythmic rubbing of the abdomen provides distraction
Exercise – increases vasodilation, endorphins
o Nutrition
Maintain good nutrition
Natural diuretics – asparagus, cranberry juice, peaches, parsley, and watermelon
Decrease salt & refined sugar intake 7-10 d before menses
o Medications – NSAIDs, OCPs, OTCs
o Imagery, relaxation, yoga, meditation
o Nurses must routinely ask women about use of herbal and other alternative therapies and document their use.
Secondary Dysmenorrhea
o Acquired menstrual pain that develops later in life than primary (after age 25)
o Pain associate with pelvic pathology cause – endometriosis, PID, endometrial polys, fibroids
o Pain characterized by dull, lower abdominal aching, radiating to back or thighs
o Often women experience bloating or pelvic fullness
o Management: physical exam, ultrasound, dilation & curettage (D&C), endometrial biopsy, laparoscopy
o Treatment – diagnose and remove the underlying pathology
Premenstrual Syndrome:
PMS: cluster of physical, psychologic, and behavioral cyclic symptoms that begin in luteal phase of menstrual cycle followed by symptom-
free period
o S/S occur to such a degree that lifestyle or work is affected, followed by a period of time entirely free of symptoms
Studies vary on how many women are affected
Ovarian function is necessary for the condition to occur because it does not occur before puberty, after menopause, or during pregnancy.
o Not dependent on the presence of monthly menses: women who have had a hysterectomy without bilateral salpingo-oophorectomy
(BSO) still can have cyclic symptoms.
Diagnostic Criteria
o Symptoms occur in the luteal phase; resolve within a few days of menses onset
o Symptom-free period occurs in the follicular phase
o Symptoms are recurrent (at least 3 cycles in a row)
o Symptoms have a negative impact on some aspect of life
o Other diagnoses have been excluded
PMDD:
PMDD is a severe variant of PMS – affects 3% to 8% of women
Severe, disabling symptoms: marked irritability, dysphoria, mood lability, fatigue, appetite changes, and a sense of feeling overwhelmed
(most common = mood disturbances)
Diagnostic Criteria
o 5 or < affective and physical symptoms present in week before menses and are absent in the follicular phase of cycle
o At least 1 of the symptoms is irritability, depressed mood, anxiety, or emotional lability
o Symptoms interfere markedly with work or relationships
o Symptoms not due to an exacerbation of another condition or disorder
PMS/PMDD Combined:
Etiology: unknown etiology/complex
o Ovarian function is necessary
o Not dependent on presence of monthly menses – can occur in women with partial hysterectomy (retain ovaries)
Etiology Theories
o Biologic: prostaglandin imbalance; neuroendocrine – hormone-serotonin hypothesis
o Genetic; Psychosocial & Sociocultural – history of sexual abuse as a child
Physical Symptoms: headache, breast changes, fluid retention, swelling, abdominal bloating, N & V, altered appetite, food cravings,
lethargy/fatigue, exacerbations of preexisting diagnosis (ex: asthma)
Psychological Symptoms: irritability, depression, anxiety, sleep alterations, inability to concentrate, anger, violent behavior, crying,
confusion, changes in libido
Management
o No standard treatment – lifestyle changes can be effective
o Goal: Identify individual symptoms to treat
o Self-help strategies – stop smoking, limit refined sugar, red meat, alcohol, and caffeinated beverages
o Avoid physical or emotional triggers
Dietary Revisions
o Limit: salt intake, refined sugar, red meat, caffeine, alcohol
o Include:
Whole grains, legumes, seeds, nuts, vegetables, fruits, vegetable oils
3 small to moderate sized meals & 3 small snacks rich in complex carbs & fiber
Natural diuretics to help reduce fluid retention
, Nutritional Supplements (took this slide out)
Psycho-behavioral
o Exercise*, support groups, psychological counseling, anger management
o Yoga, acupuncture, hypnosis, light therapy, chiropractic therapy, massage, meditation
If no significant improvement after 1-2 months, consider medications.
o Diuretics, NSAIDs (prostaglandin inhibitors), oral contraceptives
o SSRI’s – Fluoxetine (Sarafem), Paroxetine (Paxil), Sertaline (Zoloft)
Endometriosis:
Benign uterine condition characterized by the presence and growth of endometrial tissue outside of the uterus
o Tissue found most commonly in and near ovaries; can be in stomach, lungs, spleen, and intestines
o Chocolate cysts – endometrial cysts in the ovary, color caused by old blood
Tissue responds to the cyclic hormonal stimulation in the same way that the uterine
endometrium does.
o Grows during the proliferative/secretory phases, causes bleeding during menses
(adhesions to organs)
o The condition disappears with menopause
Incidence
o Occurs in all ethnic groups, although Asians appear to be at increased risk
o Most commonly women in 30s & 40s, women with family history
o Early menarche & short menstrual cycles
o Approximately 5.5 million women, i.e., 6% to 10% of women of reproductive age
Pathophysiology – Many Theories
o Retrograde menstruation/reverse flow – endometrial tissue is refluxed through the
uterine tubes during menstruation into the peritoneal cavity, where it implants on the
ovaries and other organs
o Other potential contributing factors – immunologic, hormonal abnormalities, heredity,
environmental toxins
o Tissue responds to hormones during menstrual cycle
o Each month estrogen causes ALL endometrial tissue, regardless of location, to become inflamed, and cause pain
Clinical Presentation
o Varying degrees of symptoms; some women are asymptomatic
Bowel symptoms – diarrhea, pain with defecation, and constipation
Urinary problems, abnormal menstrual bleeding, pain during exercise (adhesions)
o Pelvic pain (71% - 87%)
Secondary dysmenorrhea, dyspareunia (painful intercourse), worse during menses
Sacral backache during menses
o Infertility – a leading cause of infertility
30-45% of women with infertility have endometriosis
Common sites – ovary, rectum, uterus, bladder, endometrial lining, fallopian tubes, lining of pelvic cavity
Assessment
o Detailed history of pelvic pain, family history of endometriosis
o Complete gynecologic hx – obtain sexual history, history of abuse
o Physical exam: bimanual exam
o Diagnostic laparoscopy with biopsy to inspect and identify the disorder
Management
o No treatment needed if asymptomatic (no pain) and have no desire to become pregnant
o Goals of management: relieve & reduce pain, shrink, slow endometrial growths, restore fertility, prevent/delay recurrence
o NSAIDS
o Suppression of endogenous estrogen – suppresses subsequent endometrial lesion growth
This suppression places the woman in a medically induced menopause
o Nursing care plan – education; Mental health referrals
o Surgical treatment – severe, acute, or incapacitating symptoms
Laparoscopic – laser ablation of endometriosis
Tell these women that within first 6 months, they are the highest chance of becoming pregnant
Hysterectomy for most severe cases unresponsive to other therapies
Total hysterectomy with bilateral Causes of Intermenstrual Bleeding
salpingectomy and oophorectomy Reproductive Pregnancy Problem Infections
Anything less and the patient will have 40% Disorder
recurrence rate Functional Pregnancy implantation Endometritis
ovarian cysts Miscarriage Sexually
Alterations in Cyclic Bleeding: Cervical erosion, Ectopic pregnancy transmitted
Oligomenorrhea – infrequent menstrual periods (intervals of Leiomyoma, Molar pregnancy infections
40+ days) polyps, uterine or Retained placenta, miscarriage,
endocervical, or induced abortion
trauma, foreign Retained placenta, birth
body, malignancy
of reproductive
tract
“Women’s Health Across the Lifespan: Reproductive System Concerns”
Amenorrhea:
Absence of menstrual flow – it is a clinical symptom, not a disease
Evaluation warranted if:
o Absence of both menarche & secondary sexual characteristics by age 14
o Absence of menses by age 16, regardless of presence of normal growth and development (primary amenorrhea)
o A 3 to 6-month absence of menses after a period of menstruation (secondary amenorrhea)
Most commonly, amenorrhea is caused by pregnancy.
Other Causes
o Medications – oral contraceptive, phenytoin (Dilantin), drug abuse (alcohol, tranquilizers, cocaine)
o Anatomic abnormalities – outflow tract obstruction (primary), anterior pituitary disorders
o Endocrine disorders – PCOS, hypothyroidism, hyperthyroidism, Type 1 DM
Hypogonadotropic amenorrhea – problem in central hypothalamic-pituitary axis (not enough FSH or LH)
o More commonly results from hypothalamic suppression as a result of: stress, severe weight loss, eating disorders, strenuous exercise,
or mental illness
Amenorrhea is a classic sign of anorexia nervosa
Exercise-associated amenorrhea – Female Athlete Triad:
o Interrelatedness of eating disorder, amenorrhea, & altered bone mineral density
o Height weight, body weight, intensity and frequency of exercise, being under stressors
o Found in sports that emphasize low body weight:
Sports in which performance is subjectively scored (distance running, cycling)
Endurance sports favoring participants with low body weight (distance running, cycling)
Sports in which body contour–revealing clothing is worn (swimming, diving, volleyball)
Sports with weight categories for participation (rowing, martial arts)
Sports in which pre-pubertal body shape favors success (gymnastics, figure skating)
Assessment:
o History and physical assessment
o Labs: β-hCG (pregnancy test) – ensure the woman is not pregnant
o If β-hCG is negative: FSH, TSH, prolactin levels, X-ray, or CT
o Progestin challenge test – the woman will be given Provera 10 mg daily for 7-10 days
“Withdrawal bleeding” within about 1 week after the last pill indicates that there is enough estrogen present and the amenorrhea
was due to not ovulating (anovulation).
If vaginal bleeding doesn’t occur after progesterone withdrawal, then the amenorrhea is likely due to either low serum estradiol,
hypothalamic-pituitary axis dysfunction, a nonreactive endometrium, or a problem with the uterine outflow tract.
Another problem that needs to be investigated
Management
o Counseling, education – determine what the cause is
o Correct weight loss, decrease intensity or duration of exercise training, stress management
o Female athlete triad: Calcium intake 1000-1500 mg, Vitamin D 400-800 IU, Potassium 60-90 mg
Help correct the weight loss and deal with emotional stressors
o Low dose oral contraceptives – treating symptoms, not the cause
Cyclic Peri-menstrual Pain & Discomfort (CPPD):
Symptom clusters that occur before & after the menstrual flow starts
o Dysmenorrhea: pain during or shortly before menstruation (primary or secondary)
o Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD)
Dysmenorrhea: pain during or shortly before menstruation
Primary Dysmenorrhea
o A condition associated with ovulatory cycles – related to release of prostaglandins with menses
Because both estrogen and progesterone are necessary for primary dysmenorrhea to occur, it is experienced only with ovulatory
cycles.
The symptoms are related to ovulation, so they do not occur when ovulation is suppressed.
o Excessive release of prostaglandins during luteal phase causes vasospasm of the uterine arterioles, which leads to Ischemia and cramps
o Systemic physiologic response includes: backache, weakness, sweats, GI and CNS symptoms
o More common in late teens & early 20s – incidence declines with age
o Management:
Educate and support – dispel myths; provide facts about normal
Heat (heating pad or hot bath) – increases vasodilation, minimizes cramping/ischemia
, Massage – relax muscles, increase blood flow to pelvis
Effleurage – soft, rhythmic rubbing of the abdomen provides distraction
Exercise – increases vasodilation, endorphins
o Nutrition
Maintain good nutrition
Natural diuretics – asparagus, cranberry juice, peaches, parsley, and watermelon
Decrease salt & refined sugar intake 7-10 d before menses
o Medications – NSAIDs, OCPs, OTCs
o Imagery, relaxation, yoga, meditation
o Nurses must routinely ask women about use of herbal and other alternative therapies and document their use.
Secondary Dysmenorrhea
o Acquired menstrual pain that develops later in life than primary (after age 25)
o Pain associate with pelvic pathology cause – endometriosis, PID, endometrial polys, fibroids
o Pain characterized by dull, lower abdominal aching, radiating to back or thighs
o Often women experience bloating or pelvic fullness
o Management: physical exam, ultrasound, dilation & curettage (D&C), endometrial biopsy, laparoscopy
o Treatment – diagnose and remove the underlying pathology
Premenstrual Syndrome:
PMS: cluster of physical, psychologic, and behavioral cyclic symptoms that begin in luteal phase of menstrual cycle followed by symptom-
free period
o S/S occur to such a degree that lifestyle or work is affected, followed by a period of time entirely free of symptoms
Studies vary on how many women are affected
Ovarian function is necessary for the condition to occur because it does not occur before puberty, after menopause, or during pregnancy.
o Not dependent on the presence of monthly menses: women who have had a hysterectomy without bilateral salpingo-oophorectomy
(BSO) still can have cyclic symptoms.
Diagnostic Criteria
o Symptoms occur in the luteal phase; resolve within a few days of menses onset
o Symptom-free period occurs in the follicular phase
o Symptoms are recurrent (at least 3 cycles in a row)
o Symptoms have a negative impact on some aspect of life
o Other diagnoses have been excluded
PMDD:
PMDD is a severe variant of PMS – affects 3% to 8% of women
Severe, disabling symptoms: marked irritability, dysphoria, mood lability, fatigue, appetite changes, and a sense of feeling overwhelmed
(most common = mood disturbances)
Diagnostic Criteria
o 5 or < affective and physical symptoms present in week before menses and are absent in the follicular phase of cycle
o At least 1 of the symptoms is irritability, depressed mood, anxiety, or emotional lability
o Symptoms interfere markedly with work or relationships
o Symptoms not due to an exacerbation of another condition or disorder
PMS/PMDD Combined:
Etiology: unknown etiology/complex
o Ovarian function is necessary
o Not dependent on presence of monthly menses – can occur in women with partial hysterectomy (retain ovaries)
Etiology Theories
o Biologic: prostaglandin imbalance; neuroendocrine – hormone-serotonin hypothesis
o Genetic; Psychosocial & Sociocultural – history of sexual abuse as a child
Physical Symptoms: headache, breast changes, fluid retention, swelling, abdominal bloating, N & V, altered appetite, food cravings,
lethargy/fatigue, exacerbations of preexisting diagnosis (ex: asthma)
Psychological Symptoms: irritability, depression, anxiety, sleep alterations, inability to concentrate, anger, violent behavior, crying,
confusion, changes in libido
Management
o No standard treatment – lifestyle changes can be effective
o Goal: Identify individual symptoms to treat
o Self-help strategies – stop smoking, limit refined sugar, red meat, alcohol, and caffeinated beverages
o Avoid physical or emotional triggers
Dietary Revisions
o Limit: salt intake, refined sugar, red meat, caffeine, alcohol
o Include:
Whole grains, legumes, seeds, nuts, vegetables, fruits, vegetable oils
3 small to moderate sized meals & 3 small snacks rich in complex carbs & fiber
Natural diuretics to help reduce fluid retention
, Nutritional Supplements (took this slide out)
Psycho-behavioral
o Exercise*, support groups, psychological counseling, anger management
o Yoga, acupuncture, hypnosis, light therapy, chiropractic therapy, massage, meditation
If no significant improvement after 1-2 months, consider medications.
o Diuretics, NSAIDs (prostaglandin inhibitors), oral contraceptives
o SSRI’s – Fluoxetine (Sarafem), Paroxetine (Paxil), Sertaline (Zoloft)
Endometriosis:
Benign uterine condition characterized by the presence and growth of endometrial tissue outside of the uterus
o Tissue found most commonly in and near ovaries; can be in stomach, lungs, spleen, and intestines
o Chocolate cysts – endometrial cysts in the ovary, color caused by old blood
Tissue responds to the cyclic hormonal stimulation in the same way that the uterine
endometrium does.
o Grows during the proliferative/secretory phases, causes bleeding during menses
(adhesions to organs)
o The condition disappears with menopause
Incidence
o Occurs in all ethnic groups, although Asians appear to be at increased risk
o Most commonly women in 30s & 40s, women with family history
o Early menarche & short menstrual cycles
o Approximately 5.5 million women, i.e., 6% to 10% of women of reproductive age
Pathophysiology – Many Theories
o Retrograde menstruation/reverse flow – endometrial tissue is refluxed through the
uterine tubes during menstruation into the peritoneal cavity, where it implants on the
ovaries and other organs
o Other potential contributing factors – immunologic, hormonal abnormalities, heredity,
environmental toxins
o Tissue responds to hormones during menstrual cycle
o Each month estrogen causes ALL endometrial tissue, regardless of location, to become inflamed, and cause pain
Clinical Presentation
o Varying degrees of symptoms; some women are asymptomatic
Bowel symptoms – diarrhea, pain with defecation, and constipation
Urinary problems, abnormal menstrual bleeding, pain during exercise (adhesions)
o Pelvic pain (71% - 87%)
Secondary dysmenorrhea, dyspareunia (painful intercourse), worse during menses
Sacral backache during menses
o Infertility – a leading cause of infertility
30-45% of women with infertility have endometriosis
Common sites – ovary, rectum, uterus, bladder, endometrial lining, fallopian tubes, lining of pelvic cavity
Assessment
o Detailed history of pelvic pain, family history of endometriosis
o Complete gynecologic hx – obtain sexual history, history of abuse
o Physical exam: bimanual exam
o Diagnostic laparoscopy with biopsy to inspect and identify the disorder
Management
o No treatment needed if asymptomatic (no pain) and have no desire to become pregnant
o Goals of management: relieve & reduce pain, shrink, slow endometrial growths, restore fertility, prevent/delay recurrence
o NSAIDS
o Suppression of endogenous estrogen – suppresses subsequent endometrial lesion growth
This suppression places the woman in a medically induced menopause
o Nursing care plan – education; Mental health referrals
o Surgical treatment – severe, acute, or incapacitating symptoms
Laparoscopic – laser ablation of endometriosis
Tell these women that within first 6 months, they are the highest chance of becoming pregnant
Hysterectomy for most severe cases unresponsive to other therapies
Total hysterectomy with bilateral Causes of Intermenstrual Bleeding
salpingectomy and oophorectomy Reproductive Pregnancy Problem Infections
Anything less and the patient will have 40% Disorder
recurrence rate Functional Pregnancy implantation Endometritis
ovarian cysts Miscarriage Sexually
Alterations in Cyclic Bleeding: Cervical erosion, Ectopic pregnancy transmitted
Oligomenorrhea – infrequent menstrual periods (intervals of Leiomyoma, Molar pregnancy infections
40+ days) polyps, uterine or Retained placenta, miscarriage,
endocervical, or induced abortion
trauma, foreign Retained placenta, birth
body, malignancy
of reproductive
tract
