NURS 3358 - Final Exam Study Guide.
“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
,NURS 3358 - Final Exam Study Guide.
▪ 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
, NURS 3358 - Final Exam Study Guide.
• 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 salpingectomy and Causes of Intermenstrual Bleeding
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 Leiomyoma, Molar pregnancy infections
of 40+ days) polyps, uterine or Retained placenta, miscarriage,
endocervical, or induced abortion
trauma, foreign Retained placenta, birth
body, malignancy
“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
,NURS 3358 - Final Exam Study Guide.
▪ 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
, NURS 3358 - Final Exam Study Guide.
• 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 salpingectomy and Causes of Intermenstrual Bleeding
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 Leiomyoma, Molar pregnancy infections
of 40+ days) polyps, uterine or Retained placenta, miscarriage,
endocervical, or induced abortion
trauma, foreign Retained placenta, birth
body, malignancy
