Chapter 35: Female Reproductive Disorders: Part A

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Chapter 35 Female Reproductive Disorders Part A

• J. Davis BSN, RN
• 2008-2009

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Overview Disorders of Female Reproductive System

• Can occur _at_ any point in a womans adult life
• May affect
• Fertility
• Sexuality
• Sense of well-being
• Sensitivity confidentiality are key

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Menopause (a.k.a. climacteric)

• Menstruation permanently ceases marking the
  natural biologic end of reproduction
• Perimenopause 4-5 yrs surrounding menopause when
  estrogen production declines menses cease due
  to loss of ovarian function extends for 1 yr
  after final menstrual period
• Postmenopausal one year after last menstrual
  period

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Menopause

• Considered normal physiological process
• In U.S. usually occurs b/w 45-55 yrs of age
• Surgical menopause occurs when the ovaries are
  removed in premenopausal women
• Health risks after menopause include heart
  disease, osteoporosis breast cancer

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Menopause Physiology

• As follicles cease to develop there is a decrease
  in estrogen (androgens continue to be produced)
• Estrogen levels insignificant to maintain
  secondary sexual characteristics, causing
• Loss of breast tissue, body hair subQ fat,
  ovaries uterus shrink, skin less elastic,
  perineal tissues atrophy, vaginal lubrication
  decreases

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Menopause Physiology

• Imbalance b/w estrogen FSH from pituitary
  causes vasomotor instability causing
• Night sweats, hot flashes, palpitations,
  headaches
• Increase in vaginitis dyspareunia
• Cycles become irregular eventually stop
• Other symptoms include irritability, anxiety,
  insomnia, difficulty concentrating depression

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S/Sx of Estrogen Deficiency

• Vasomoter symptoms hot flashes irregular
  menses
• GU atrophic vaginitis, vaginal dryness
  incontinence
• Psychologic mood swings, changes in sleep
  patterns decreased REM sleep
• Skeletal decreased bone density
• CV decreased HDL, increased LDL
• Dermatologic decreased skin elasticity, breast
  tissue changes

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Hormone Replacement Therapy

• Used to relieve unpleasant symptoms of menopause
  reduce risks assoc with estrogen deficiency
• Relieves hot flashes night sweats decreases
  vaginal dryness perineal tissue atrophy
• Reduction in bone loss, lowers risk of
  osteoporosis and colon cancer

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HRT I

• Includes estrogen for women without a uterus or
  estrogen combined w/ progesterone for women with
  a uterus
• HRT may be prescribed oral, transdermal,
  intravaginal, intramuscular may be prescribed
  continuously or in a cyclic pattern
• The determination to use HRT depends on the
  womans individual risk factors needs

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HRT II

• If HRT is prescribed it is best used on a
  short-term basis (lt5 yrs)
• HRT is NOT indicated for prophylaxis of heart
  disease is best not prescribed for women w/ a
  high risk of heart disease

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Contraindications for HRT

• Pregnancy
• Heavy smoking
• Cancer (breast, uterus or undiagnosed vaginal
  bleeding)
• Embolism (active thrombophlebitis, thromboembolic
  disorder, stroke, heart disease or high risk for
  heart disease)
• Liver dysfunction
• Gallbladder disease

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Diagnostic tests done prior to HRT

• PAP smear, mammogram possible uterine biopsy
  (if abnormal bleeding is present) may be done to
  r/o cancer
• FSH (to confirm menopause)
• Hormone levels (to determine if replacement is
  necessary)
• Bone mass measurements (determines osteoporosis)

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Assessment of client on HRT

• Watch for side effects
• Increased BP
• Increased wt gain due to fluid
• Breast lumps/abnormalities
• Vaginal bleeding
• Venous thrombosis
• Symptoms of heart or cerebrovascular disease

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HRT Estrogen Progesterone

• Side effects of estrogen
• Nausea, fluid retention, breast enlargement,
  headache
• Side effects of progesterone
• Increased appetite, weight gain, irritability,
  depression, spotting, breast tenderness

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HRT Client Education

• Instruct on advantages, disadvantages
  administration of drug
• Advise client to immediately quit smoking
• Take pills w/ food if nausea develop
• Schedule physicals, pelvic exams, mammograms
  bone density tests when needed
• If using vaginal creams/suppositories, refrain
  from inserting prior to intercourse (partner may
  absorb medication)

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HRT Client education

• Instruct client on s/sx of myocardial infarction
  (abdominal pain, vague chest symptoms, arm pain,
  leg swelling, SOB)
• Instruct on how to prevent DVT
• Avoid wearing constricting socks or knee-high
  stockings
• Avoid sitting for long periods of time take
  short walks perform ankle pumps stretch legs
• Report leg pain, edema, redness, warmth or
  tenderness

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HRT Complications

• Teratogenesis (malformation of fetus/embryo)
  confirm menopause, discontinue immediately if
  pregnancy is suspected
• Embolic Complications MI, Stroke, Venous
  thrombosis, blood clots (risk increases w/
  smoking)
• Cancer
• Long-term use increases risk for breast cancer
• Long-term use of estrogen-only HRT increases risk
  of ovarian endometrial cancer (risk is
  decreased w/ 12 or more days of progesterone per
  month)

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HRT Gerontologic Considerations

• HRT can be helpful in preventing some age-related
  problems
• Osteoporosis
• Atrophic vaginitis (vaginal burning, bleeding,
  pruritus painful intercourse)
• Older clients can decrease the risk of
  osteoporosis by performing regular wt-bearing
  exercises, increasing intake of high-protein
  high-calcium foods avoiding alcohol, caffeine,
  tobacco taking calcium w/ Vit D supplements

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Selective estrogen receptor modulators

• An alternative for women who cannot take HRT
• Examples Evista, tamoxifen, Fareston
• Works on receptor sites inside of the cells that
  are sensitive to estrogen act like estrogen
• Reduces risk of breast cancer osteoporosis but
  does NOT prevent the symptoms of menopause

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Complementary Therapies

• Some alternative therapies are thought to be
  beneficial for the woman undergoing menopause
• Aromatherapy geranium, rose or fennel
• Herbal therapy vitex, ginseng dong quai
• Meditation
• Vitamin supplements Vit D, E soy protein

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Additional Pharmacological Implications

• Drugs Prempro, Premphase, Combipatch
• Action Replace lost estrogen minimize effects
  risks of menopause progesterone ? risk of
  endometrial CA
• Nsg Imp Notify Dr if pregnant, breast CA,
  abnormal vaginal bleeding, hx of stroke or
  thrombophlebitis complete current cycle prior to
  changing products
• Pt Teaching Dont use if may be pregnant, may
  have spotting, get yearly Pap mammogram, report
  adverse effects advise to stop smoking
  consider limiting HRT therapy to less than 5 yrs

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Care Plan Client undergoing menopause

• Deficient Knowledge
• Discuss symptoms, give info on risks benefits
  of HRT encourage aerobics wt-bearing exercise
• Sexual Dysfunction
• Express feelings concerns suggest spending
  more time w/ foreplay
• Risk for Situational Low Self-Esteem
• Encourage expression of fears, activity healthy
  lifestyle

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Menopause Client Teaching

• Lubricant during intercourse eat yogurt avoid
  douches
• Avoid hot flash triggers such as alcohol,
  caffeine, sugar, hot/spicy foods very large
  meals
• Use relaxation techniques dress in layers, lower
  thermostat use cool cloths
• Stay involved in work or volunteer activities
  maintain balance between work activity

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Premenstrual Syndrome (PMS) Premenstrual
Dysphoric Disorder (PMDD)

• Symptom complex irritability, depression, edema
  breast tenderness prior to menses
• Risk factors major life stressors, gt 30 yrs,
  depression
• PMDD is simply PMS that has gotten to the point
  to which it interferes with daily living
  activities

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PMS Pathophysiology

• Not clearly understood thought to be from
  hormonal fluctuations increase in aldosterone
• Aldosterone contributes to bloating edema

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PMS Symptoms

• Symptoms occur 7-10 days prior are relieved
  when menstrual flow begins
• H/A, inability to concentrate, depression,
  irritability, anxiety, mood swings, anger,
  aggressive behavior, acne, herpes recurrence,
  backache, edema, food cravings, wt. gain,
  increase susceptibility to infection, N/V/C
  (diarrhea when flow actually starts)

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PMS Diagnosis/Treatment

• Must keep diary/calendar of symptoms for several
  months to make accurate diagnosis
• Management focuses on diet, exercise, relaxation
  stress management
• Diet high in complex CHO, Ca, Mg Vit B
• Diet low in sugar, alcohol, caffeine salt
• Exercise rest are both important
• Relaxation techniques breathing, meditation,
  relaxation guided imagery

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PMS Pharmacology Alternative Therapies

• Prozac, Zoloft, Paxil, Danocrine may be
  prescribed (Danocrine has severe side effects
  such as masculinization the others havent been
  shown to be effective)
• Acupuncture, reflexology, homeopathy or
  aromatherapy may be beneficial
• Herbal therapies vitex, evening primrose oil

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Dysmenorrhea Painful menstruation

• Primary dysmenorrhea
• No disease process identified
• Prostaglandins stimulate cramping (ischemia
  pain)
• From onset of menses up to 24-48 hrs may radiate
  to lower back thighs
• H/A, nausea, vomiting diarrhea, fatigue or breast
  tenderness may be present anxiety tension

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Dysmenorrhea Painful menstruation

• Secondary dysmenorrhea
• Related to an underlying disorder that causes
  scarring or injury of reproductive organs
• Endometriosis, ovarian cancer, PID, fibroid
  tumors may cause painful menses

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Dysmenorrhea Treatment

• Identify cause manage pain
• Analgesics NSAIDS
• Oral contraceptives
• Diet changes decrease salt, sugar, caffeine
  alcohol (fluid consumption) increase protein,
  Ca, Mg Vit B
• Balance rest exercise
• Alternative therapies as in PMS tx
• Usually decreases in severity w/ age after
  childbirth

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Dysfunctional Uterine Bleeding (Abnormal
Uterine Bleeding)

• Hormonal deficiency (especially progesterone
  deficiency) may lead to uterine lining sloughing
  or bleeding
• Anovulation may also occur (absence of ovulation)
• Causes hormonal deficiencies or changes caused
  by stress, emotional upsets pelvic tumors

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Dysfunctional Uterine BleedingAmenorrhea

• Absence of menstruation
• Need to determine if it is primary (has NEVER
  menstruated) or secondary (has had previous
  menses)
• Usually caused by hormone imbalance
• May be triggered by anorexia or excessive
  athletic activity
• Is normal in pregnancy, breastfeeding, menopause
  removal of uterus or ovaries

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Dysfunctional Uterine Bleeding Oligomenorrhea
Menorrhagia

• Oligomenorrhea
• Scant menses usually related to hormonal
  imbalances may be seen in women on BCP
  adolescent girls during first year or two of
  menses
• May also be caused by poor nutrition
• Menorrhagia
• Excessive or prolonged menstruation resulting
  from endocrine or reproductive system disorders
  (gt7 days)
• Clotting disorders anticoagulant medications
  can may be the cause
• May lead to excessive blood loss, anemia,
  fatigue, hemorrhage sexual dysfunction
• BCP may help by producing a pill period

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Dysfunctional Uterine Bleeding Metrorrhagia

• Unexpected bleeding between menstrual periods
• May be sign of cervical or uterine cancer or may
  be pituitary or ovarian stimulation
• Post-menopausal bleeding may be caused by polyps
  or uterine cancer
• Intermenstrual or postcoital bleeding
• Should be evaluated promptly
• Mittleschmerz is mid-cycle spotting associated
  with ovulation occurs in many women is not
  considered metrorrhagia

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DUB Diagnostic Tests

• CBC
• Thyroid function tests
• Serum estradiol
• Serum HCH LH
• Pelvic ultrasound
• Laparoscopy
• Endometrial biopsy
• Pap smear

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DUB Treatments

• BCP or progesterone iron supplements
• DC dilation curretage uterine wall is
  scraped (removal of lining) contraindicated if
  taking anticoagulants
• Endometrial ablation permanently destroys
  endometrial layer of uterus using laser or
  electrosurgical resection (ends menstruation
  reproduction)
• Uterine balloon heat therapy balloon in uterus
  is inflated heated outpatient

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DC Nursing Care

• Pre-op Routine pre-op teaching insertion of a
  laminaria tent
• Post-op Routine post-op care, monitor
  circulation in legs avoid tampons next
  menstrual period may be delayed avoid
  intercourse until after follow-up visit vaginal
  d/c ceases avoid lifting, report bright red or
  excessive bleeding

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Hysterectomy

• Removal of uterus
• In premenopausal women, the ovaries are usually
  left in place
• In postmenopausal women, a panhysterectomy (or
  total hysterectomy) may be done removal of the
  uterus, fallopian tubes ovaries
• Abdominal, vaginal, or laparoscopy-assisted
  vaginal

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Hysterectomy Pre-op

• Reinforce teaching provide support
• Instruct cleansing of abdomen perineal areas as
  ordered
• Routine preop care
• Foley cath is usually inserted intraoperatively
  is kept in place for at least 24 hr
• Tell client that temporary depression/sadness may
  occur after procedure (especially in younger
  females) if this persists seek counseling

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Hysterectomy Key Factors

• May be performed for uterine cancer
• Noncancerous conditions fibroids,
  endometriosis, genital prolapse
• S/Sx of these disorders painful intercourse,
  hypermenorrhea, pelvic pressure, urinary
  urgency/frequency, constipation

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Hysterectomy Post-op

• Report excess bleeding, especially following a
  vaginal hyst. (gtone saturated pad in 4 hr)
• Monitor for complications infections, ileus,
  venous thrombosis pulmonary embolus
• Assess vaginal drainage teach perineal care
• Restrict physical activity for 4-6 weeks avoid
  heavy lifting, stair climbing, douching, tampons,
  sexual intercourse
• Instruct to shower avoid tub baths, until
  bleeding as stopped

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Hysterectomy Post-op (cont)

• Watch for fever, HTN
• Monitor breath sounds (atelectasis)
• Monitor bowel sounds (ileus)
• Monitor for decrease in UOP
• Monitor for blood loss
• Monitor for infection

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Hysterectomy Post-op Teaching (cont)

• Instruct to report the following temp greater
  than 100 F, vaginal bleeding more than a typical
  menstrual period or that is bright red, urinary
  incontinence, urgency, burning or frequency,
  severe pain
• Encourage expression of feelings
• Provide information on HRT
• Discuss importance of gynecologic exams even
  after hysterectomy
• Encourage leg exercises, ambulation
• Women should NOT smoke
• Report leg or calf pain, swelling of leg, CP or
  SOB

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Endometriosis

• Condition in which endometrial tissue is found
  outside of the uterus
• Common sites are the ovaries other pelvic
  organs or tissues rarely in other organs such as
  the lungs
• Risk factors
• Family history early menarche short, regular
  menstrual cycles w/ heavy flow

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Endometriosis Pathophysiology

• Cause unknown may be from backflow of menstrual
  blood that carries endometrial cells
• Endometrial tissue responds to hormone
  fluctuations may bleed during menses
• Bleeding may cause cysts, scarring, inflammation
  adhesions
• Scarring can lead to infertility other problems
  such as bowel obstruction

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Endometriosis Assessment Findings Management

• Assessment severe dysmenorrhea chocolate cysts
  (in ovary), copious menstrual bleeding
  pain/tenderness painful defacation confirmed by
  US /or exploratory laparoscopy
• Med-Surg Tx removal of cysts adhesions
  panhysterectomy medical menopause
  Estrogen-Progestin contraceptives or Danocrine to
  keep client in non-bleeding phase of cycle
  symptoms regress during pregnancy

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Endometriosis Nursing Care Plan

• Pain
• Evaluate severity timing of pain discuss using
  drugs nonpharmacologic measures for pain (heat,
  yoga, meditation, exercise)
• Anxiety
• Encourage discussions regarding concern for
  fertility discuss advantages of having children
  soon in rapid succession BCP

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Ovarian Cysts

• Ovarian cysts are benign are filled w/ fluid
• Follicular (mature follicle doesnt rupture)
• Corpus luteum (remains enlarged p ovulation)
• Chocolate cysts (secondary to endometriosis)
• S/Sx pressure in lower abd menstrual
  irregularities pain sometimes confused w/
  appendicitis
• Tx often require no tx BCP may help surgery if
  complications occur

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Polycystic Ovarian Syndrome

• Multiple fluid-filled cysts affects women b/w 20
  40
• Endocrine abnormalities are present (abnormal
  levels of various hormones)
• May have overproduction but INEFFECTIVE use of
  insulin may also have high testosterone levels
  from adrenal cortex
• May cause hirsutism, acne, obesity, irregular
  periods infertility
• May increase risk for endometrial cancer, HTN,
  abnormal cholesterol levels

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Polycystic Ovarian Syndrome

• Diagnostic Tests
• LH, FSH, testosterone, glucose tolerance tests,
  laparoscopy
• Medications
• BCP Clomid (to promote ovulation if client
  wishes to become pregnant) progesterone or
  corticosteroids
• Surgery
• Laser surgery, resection of ovary oophorectomy
  may be done as last resort

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References

• Burke, K. LeMone, P. Mohn-Brown, E. (2007).
  Medical-surgical nursing care (2nd Ed). Upper
  Saddle River, New Jersey Pearson Prentice Hall