Anatomy and Physiology of the Reproductive Systems, Exams of Nursing

Download Anatomy and Physiology of the Reproductive Systems and more Exams Nursing in PDF only on Docsity! Chapter # 3 guide Anatomy and Physiology of the Reproductive Systems • Female • Reproductive cells: eggs or ovum • Organ for development of the fetus: uterus • Male • Reproductive cells: sperm • Organ for deposit of the sperm: penis External Female Reproductive Organ: • Mons Pubis: is the elevated, prominence made up of fatty tissue that overlays the symphysis pubis. The mons pubis protects the symphysis pubis during sexual intercourse. • Labia: The labia majora contain sweat and sebaceous (oil- secreting) glands; after puberty, they are covered with hair. Their function is to protect the vaginal opening and provide cushioning during sexual activity. The labia minora (small lips) are the delicate hairless inner folds of skin; they can be very small or up to 2 in wide. They lie just inside the labia majora and surround the openings to the vagina and urethra. These lips surround the vaginal opening and extend upward to form protection around both the clitoris and urethra. They are highly vascular and abundant in nerve supply. They lubricate the vulva, swell in response to stimulation, and are highly sensitive. • Clitoris and Prepuce: The clitoris is a small, cylindrical mass of erectile tissue and nerves. It is highly sensitive and is analogous to the head of the male’s penis. Unlike the penis, however, the function of the clitoris is purely erogenous . Most of the components of the clitoris are buried under the skin and connective tissue of the vulva. It is located at the anterior junction of the labia minora. There are folds above and below the clitoris. The joining of the folds above the clitoris forms the prepuce, a hood-like covering over the clitoris; the junction below the clitoris forms the frenulum • Vestibule: • Perineum: The perineum is the most posterior part of the external female reproductive organs. This external region is located between the vulva and the anus. It is made up of skin, muscle, and fascia. The perineum can become lacerated or incised during childbirth and may need to be repaired with sutures. Incising the perineum area to provide more space for the presenting part is called an episiotomy. Before the first pregnancy, it measures approximately 3 in long, 2 in wide, and 1 in thick. After a pregnancy, the uterus remains larger than before the pregnancy. After menopause, it becomes smaller and atrophies The uterine wall is relatively thick and composed of three layers: the endometrium (innermost layer ), the myometrium (muscular middle layer ), and the perimetrium (outer serosal layer that covers the body of the uterus ). The endometrium is the mucosal layer that lines the uterine cavity in nonpregnant women. It varies in thickness from 0.5 to 5 mm and has an abundant supply of glands and blood vessels. The myometrium makes up the major portion of the uterus and is composed of smooth muscle linked by connective tissue with numerous elastic fibers. During pregnancy, the upper myometrium undergoes marked hypertrophy, but there is limited change in the cervical muscle content. Anatomic subdivisions of the uterus include the convex portion above the uterine tubes (the fundus); the central portion (the corpus or body) between the fundus and the cervix; and the cervix, or neck, which opens into the vagina . • Cervix: The cervix, the lower part of the uterus, is sometimes called the neck of the uterus. It opens into the vagina and has a channel that allows sperm to enter the uterus and menstrual discharge to exit. It is composed of fibrous connective tissue. During a pelvic examination, the part of the cervix that protrudes into the upper end of the vagina can be visualized. The cervix has an alkaline environment, which protects the sperm from the acidic environment in the vagina. Also help the sperm to move up at the time of ovulation for the fecundation of the ovum. • Fallopian Tubes: The fallopian tubes, also known as oviducts, are hollow, cylindrical structures that extend 2 to 3 in from the upper edges of the uterus toward the ovaries. This structures permit the pass of the ovum, so fertilization of the ovum can occur in the distal portion of the tube . If the egg is fertilized, it will divide over a period of 4 days while it moves slowly down the fallopian tube and into the uterus, where it implants into the uterine lining. • Ovaries: The ovaries are a set of paired glands that are the organs of gamete production in the female . They are set in the pelvic cavity below and to either side of the umbilicus. They are homologous to the testes. Each mature ovary weighs from 2 to 5 g and is about 4 cm long, 2 cm wide, and 1 cm thick. The ovaries are not attached to the fallopian tubes but are suspended nearby from several ligaments, which help hold them in position. The development and the release of the ovum and the secretion of the female hormones estrogen and progesterone are the two primary functions of the ovary. The ovaries link the reproductive system to the body’s system of endocrine glands, as they produce the ova (eggs) and secrete estrogen and progesterone cyclically. After an ovum matures, it passes into the fallopian tubes. Breasts: • The two mammary glands, or breasts, are accessory organs of the female reproductive system that are specialized to secrete milk following pregnancy. • During pregnancy, placental estrogen and progesterone stimulate the development of the mammary glands. • Because of this hormonal activity, the breasts may double in size during pregnancy. At the same time, glandular tissue replaces the adipose tissue of the breasts. • Following childbirth and the expulsion of the placenta, levels of placental hormones (progesterone and lactogen) fall rapidly, and the action of prolactin (milk-producing hormone) is no longer inhibited. • Prolactin stimulates the production of milk within a few days after childbirth, but in the interim, dark yellow fluid called colostrum is secreted. • Colostrum contains more minerals and protein, but less sugar and fat, than mature breast milk. • Colostrum secretion may continue for approximately a week after childbirth, with gradual conversion to mature milk. • Colostrum is rich in maternal antibodies, especially immunoglobulin A (IgA), which offers protection for the newborn against enteric pathogens. (Lactogen stimulate mammary gland) • Typically, this occurs monthly. Menstruation has many effects on girls and women, including emotional and self- image issues. In the United States, the average age at menarche (the start of menstruation in females) is 12.8 years • Genetics is the most important factor in determining the age at which menarche starts, but geographic location, nutrition, weight, general health, nutrition, cultural and social practices, the girl’s educational level, attitude, family environment, and beliefs are also important • Pubertal events preceding the first menses have an orderly progression: • Thelarche, the development of breast buds • Adrenarche, the appearance of pubic and then axillary hair, followed by a growth spurt • Menarche (occurring about 2 years after the start of breast development) • Normal, regular menstrual cycles vary in frequency and blood loss. • Irregular menses can be associated with irregular ovulation, polycystic ovary syndrome, type 2 diabetes, weather conditions, stress, disease, and hormonal imbalances • Cultural considerations Perimenopause: • Perimenopause or menopausal transition and menopause are biologic markers of the transition from young adulthood to middle age. • During the perimenopausal years (2 to 8 years prior to menopause), women may experience physical changes associated with decreasing estrogen levels, which may include vasomotor symptoms of hot flashes, irregular menstrual cycles, weight gain and bloating, headaches, decreased vaginal lubrication, night sweats, fatigue, vaginal atrophy, and also psychological symptoms: sleep disruptions, forgetfulness, irritability, mood disturbances, and depression. • Vasomotor symptoms (hot flashes and night sweats) are the most common complaints for which women seek treatment. • Several therapies can be considered to help manage these complaints. • Choosing an appropriate treatment approach for the management of these symptoms requires careful assessment of the risk/benefit ratio of each alternative, as well as individual client preference. Menopause: • Universal and irreversible part of the overall aging process involving a woman’s reproductive system, after which she no longer menstruates. • This naturally occurring phase of every woman’s life marks the end of her childbearing capacity. • This period is frequently termed the climacteric or perimenopause, but mostly recently the menopausal transition has been used. • It is usually marked by atrophy of the breasts, uterus, fallopian tubes, and ovaries. • Many women pass through menopause without untoward symptoms. • Other women experience vasomotor symptoms of hot flashes, irregular menstrual cycles, weight gain and bloating, headaches, decreased vaginal lubrication, night sweats, fatigue, vaginal atrophy, and also psychological symptoms: sleep disruptions, forgetfulness, irritability, mood disturbances, and depression. • Hormone therapy was the mainstay of menopause pharmacotherapy. • Nurses can play a major role in assisting menopausal women by educating and counseling them about the multitude of options available for disease prevention and treatments for menopausal symptoms during this time of change in their lives. External Male Reproductive Organs: • Penis: • The penis is the organ for copulation and serves as the outlet for both sperm and urine • The prepuce (foreskin) is a circular fold of skin that extends over the glans unless it is removed by circumcision shortly after birth. The urinary meatus, located at the tip of the penis, serves as the external opening to the urethra • Erection results when nerve impulses from the autonomic nervous system dilate the arteries of the penis, allowing arterial blood to flow into the erectile tissues of the organ. • Scrotum: • The scrotum is the thin-skinned sac that surrounds and protects the testes. • The scrotum also acts as a climate-control system for the testes, because they need to be slightly cooler than body temperature to allow normal sperm development. Internal Male Reproductive Organs: • Testes: • Sperm production • Testosterone synthesis • The Ductal System: • Vas deferens (sperm transport) -Endocrine Disorders-Hypothyroidism/Hyperthyroidism, Cushing disease, -Chronic diseases- Type 1 DM, -Medications like Phenytoin (Dilantin), use of oral contraceptives, -Drug abuse- opiates, marijuana, cocaine, -Eating disorders (anorexia nervosa), extreme exercise, stress, -Cystic fibrosis, tumors, polycystic ovarian syndrome u Most often result of pregnancy -Assessment, including history and examination *Amenorrhea cont.… u Primary or Secondary : u Primary Amenorrhea : The absence of both menarche and secondary sexual characteristics by age 14 years or the absence of menses by age 16, regardless normal grow and development u Secondary Amenorrhea : A 3–6-month cessation of menses after a period of menstruation u Hypogonadotropic amenorrhea: u Problem in central hypothalamic-pituitary axis Primary amenorrhea is defined as either the: u Absence of menses by age 15, with absence of growth and development of secondary sexual characteristics; or u Absence of menses by age 16, with normal development of secondary sexual characteristics Primary amenorrhea has multiple causes: u Extreme weight gain or loss, u Stress from a major life event u Excessive exercise u Eating disorders (anorexia nervosa or bulimia) u Hypothyroidism u Pregnancy Secondary Amenorrhea : A 3–6-month cessation of menses after a period of menstruation Causes of secondary amenorrhea can include: u Pregnancy u Breast-feeding u Emotional stress u Pituitary, ovarian, or adrenal tumors u Depression u Hyperthyroid or hypothyroid conditions u Malnutrition u Hyperprolactinemia u Rapid weight gain or loss u Vigorous exercise, such as long-distance running u Early menopause Management: -Therapeutic intervention depends on the cause of the amenorrhea. The treatment of primary amenorrhea involves the correction of any underlying disorders. Therapeutic interventions for secondary amenorrhea can include: u Cyclic progesterone, when the cause is anovulation, or oral contraceptives (OCs); u Bromocriptine to treat hyperprolactinemia. u Nutritional counseling to address anorexia, bulimia, or obesity. u Gonadotropin-releasing hormone (GnRH) when the cause is hypothalamic failure. u Thyroid hormone replacement when the cause is hypothyroidism Common Laboratory Tests: u Ultrasound to detect ovarian cysts. u Human Chorionic Gonadotropin Hormone (hCG) test to rule out pregnancy. u Thyroid function studies to determine thyroid disorder. u Prolactin level (an elevated level might indicate a pituitary tumor). u Follicle-stimulating hormone (FSH) level (an elevated level might indicate ovarian failure). u Luteinizing hormone (LH) level (an elevated level might indicate gonadal dysfunction u Hypogonadotropic amenorrhea: u Problem in central hypothalamic-pituitary axis u Result from hypothalamic suppression u As a result of stress (at home, school, workplace), sudden and severe weight loss, eating disorders (anorexia nervosa), strenuous exercise (athletic training), or mental illness u Management: -Counseling and education regarding stress, exercise, and weight loss -Daily Calcium intake of 1200 to 1500 mg to prevent osteoporosis Teaching for this patients: u Balance energy intake to maintain ideal weight range. u Modify your diet to maintain ideal weight to avoid becoming over-weight. u Avoid excessive use of alcohol and sedative drugs. u Avoid cigarette smoking to prevent cardiovascular disease and lung cancer. u Identify areas of emotional stress and seek assistance to resolve them. u Balance work, recreation, and rest to reduce anxiety and stress in life. u Maintain a positive outlook regarding the diagnosis and prognosis. u Participate in ongoing care to monitor any medical conditions. u Maintain bone density through: ▪ Calcium intake (1,200 to 1,600 mg daily) Diagnosis and treatment: • Pelvic examination • Ultrasound examination, dilation and curettage, endometrial biopsy, laparoscopy • Treatment directed to removal of underlying pathology Assessment: • Assess for clinical manifestations of dysmenorrhea. Affected women experience: • Sharp, intermittent spasms of pain, usually in the suprapubic area. • Pain may radiate to the back of the legs or the lower back. • Pain usually develops within hours of the start of menstruation and peaks as the flow becomes heaviest during the first day or two of the cycle. • Systemic symptoms of nausea, vomiting, diarrhea, fatigue, fever, headache, or dizziness. • Explore the history for physical symptoms of bloating, water retention, weight gain, headache, muscle aches, abdominal pain, food cravings, or breast tenderness. The nurse should explain in detail the dosing regimen and the side effects of the medication therapy selected. Commonly prescribed drugs include NSAIDs such as ibuprofen (Motrin, Advil) or naproxen (Naprosyn). These drugs alleviate dysmenorrhea symptoms by decreasing intrauterine pressure and inhibiting prostaglandin synthesis, thus reducing pain (Skidmore-Roth, 2015). The primary goal of NSAID therapy of dysmenorrhea is to preempt the production of prostaglandins; thus, starting the medication prophylactically and using sufficient doses to maximally suppress prostaglandin production are essential. Encourage the woman to apply a heating pad or warm compress to alleviate menstrual cramps. Additional lifestyle changes that the woman can make to restore some sense of control and active participation in her care are listed in Teaching Guidelines 4.3 . Teaching guidelines table 4.3 u Exercise to increase endorphins and suppress prostaglandin release. u Limit salty foods to prevent fluid retention. u Increase water consumption to serve as a natural diuretic. u Increase fiber intake with fruits and vegetables to prevent constipation. u Use heating pads or warm baths to increase comfort. u Take warm showers to promote relaxation. u Sip on warm beverages, such as decaffeinated green tea. u Keep legs elevated while lying down or lie on side with knees bent. u Use stress management techniques to reduce emotional stress. u Practice relaxation techniques to enhance ability to cope with pain. u Stop smoking and decrease alcohol use which causes vasoconstriction. NOTE: Secondary amenorrhea is most commonly due to endometriosis. Primary amenorrhea is related to increased prostaglandin production. u PMS (Premenstrual Syndrome) u Recurrent symptoms that occur during the luteal phase or last half of the menstrual cycle and resolve with the onset of menstruation. The occurrence of symptoms needs to be sufficiently severe to interfere with some aspects of life, and that appear with consistent and predictable relationship to menses” ❖ The exact cause of PMS is not known. u It is thought to be related to the interaction between hormonal events and neurotransmitter function, specifically serotonin. u Not all women respond to serotonin reuptake inhibitors (SSRIs; Prozac, Paxil, Zoloft), however, which implies that other mechanisms may be involved. u PMS (Premenstrual Syndrome) u Cluster of physical, psychologic, and behavioral symptoms. u Physicals- joint & muscle pain, headache, fatigue, breast tenderness, bloating, weight gain. u Psychologic & behavioral- Tension & anxiety, mood swings, depression, crying spells, insomnia, poor concentration, change in libido, social withdrawal u Poorly understood u 85% of women experience symptoms u 5% to 14% of women report disabling symptoms u Treatment includes diet, exercise, and herbal therapies u PMDD (Premenstrual Dysphoric Disorder) u Cyclic symptoms occurring in the last 7 to 10 days of the menstrual cycle u Severe variant of PMS with emphasis on mood affectation u Risk factors identified that predispose to PMS/PMDD are: u Age between 25 and 35 years, u Psychiatric history, u Family history of PMDD, u Unhealthy living habits, Danazol (androgen hormone inhibits estrogen production) The ACOG diagnostic criteria for PMS consist of having at least one of the following affective and somatic symptoms during the 5 days before menses in each of the three previous cycles: Affective symptoms: depression, angry outbursts, irritability, anxiety Somatic symptoms: breast tenderness, abdominal bloating, edema, headache Symptoms relieved from days 4 to 13 of the menstrual cycle (ACOG, 2015c). In PMDD, the main symptoms are mood disorders such as depression, anxiety, tension, and persistent anger or irritability. Physical symptoms such as headache, joint and muscle pain, lack of energy, bloating, and breast tenderness are also present. It is estimated that up to 75% of reproductive-age women experience premenstrual symptoms that meet the ACOG criteria for PMS and up to 5% meet the diagnostic criteria for PMDD. According to the American Psychiatric Association, a woman must have at least five of the typical symptoms to be diagnosed with PMDD. These must occur during the week before and a few days after the onset of menstruation and must include one or more of the first four symptoms: Affective lability: sadness, tearfulness, irritability Anxiety and tension Persistent or marked anger or irritability Depressed mood, feelings of hopelessness Difficulty concentrating Sleep difficulties Increased or decreased appetite Increased or decreased sexual desire Chronic fatigue Headache Constipation or diarrhea Breast swelling and tenderness Nursing Assessment: u Physical and Psychological symptoms are very real u Anxiety: Difficulty sleeping, tenseness, mood swings, and clumsiness u Craving: carvings of sweets, salty foods, chocolate u Depression: feelings of low self-esteem, anger easily upset u Hydration: Weight gain, abdominal bloating, breast tenderness u Other: Hot flashes, cold sweats, nausea, change in bowel habits, aches or pains, dysmenorrhea, acne breakout u MANAGEMENT: u LIFESTYLE CHANGES WILL RELIEVE SYMPTOMS u EXERCISE, REDUCE STRESS u MEDICATIONS Medications used in treating PMDD may include: • Antidepressant. • Antianxiety drugs, • Diuretics, • Anti-inflammatory medications, • Analgesics, • OCs, • GnRH agonists to regulate menses, Ex. Lupron-S/E mood swings, headaches, and hot flashes. • Synthetic androgen agents, • Unlike the approach to the treatment of depression, antidepressants need not be given daily but can be effective when used cyclically, only in the luteal phase, or even limited to the duration of the monthly symptoms. Treatment Options: u Lifestyle changes u Reduce stress u Exercise three to five times each week u Eat a balanced diet and increase water intake u Decrease caffeine intake u Stop smoking and limit the intake of alcohol u Support groups u Vit- E 400 units daily u Calcium 1,200 mg daily u Magnesium 200-400 MG daily u NSAIDS u Oral contraceptives u Antidepressants & anxiolytics- SSRI Menstrual Disorders Endometriosis: HEALTH HISTORY Obtain a health history and elicit a description of signs and symptoms to determine risk factors. Endometriosis is often asymptomatic, but it can be a severe and debilitating condition. It typically is chronic and progressive. Ask specifically about menarche, history of menstrual problems, details of pregnancies, and difficulties with conception. Assess the client for clinical manifestations, which include: Infertility Back pain Pain before and during menstrual periods Pain during or after sexual intercourse Painful urination Depression Fatigue Painful bowel movements Chronic pelvic pain Hypermenorrhea (heavy menses) Pelvic adhesions Irregular and more frequent menses Premenstrual vaginal spotting PHYSICAL EXAMINATION AND LABORATORY AND DIAGNOSTIC TESTS The pelvic examination typically correlates with the extent of the endometriosis. The usual finding is nonspecific pelvic tenderness. The hallmark finding is the presence of tender nodular masses on the uterosacral ligaments, the posterior uterus, or the posterior cul-de-sac. The only definitive diagnosis is the one made during surgery. Assessment: Endometriosis is often asymptomatic, but it can be a severe and debilitating condition. It typically is chronic and progressive. Ask specifically about menarche, history of menstrual problems, details of pregnancies, and difficulties with conception. Assess the client for clinical manifestations, which include: u Major symptoms u Dysmenorrhea, pelvic pain, Cyclic pelvic pain u Deep pelvic dyspareunia (painful intercourse) u Bleeding- experience several “mini-periods” throughout her abdomen, wherever this endometrial tissue exists u Tenderness posterior fornix u Bowel and bladder symptoms u Infertility. u PHYSICAL EXAMINATION AND LABORATORY AND DIAGNOSTIC TESTS u The usual finding is nonspecific pelvic tenderness. u The hallmark finding is the presence of tender nodular masses on the uterosacral ligaments, the posterior uterus, or the posterior cul-de-sac. The only definitive diagnosis is the one made during surgery. Treatment: Treatment can include surgical removal of ectopic endometrial tissue or medications. Also, alternative therapies may be used, including acupuncture and supplements of vitamins, minerals, and fish oil. These interventions may control symptoms initially, but many have significant adverse effects and limits on duration of therapy u Treatment-Drug therapy : u NSAIDs u GnRH agonist therapy: Lupron- 3.75 mg IM injection given monthly-suppress pituitary gonadotropin secretion of FSH and LH stimulation, then the ovary function declines (medically induced menopause- PSEUDOMENOPAUSE) resulting in anovulation and amenorrhea. The result is the shrinkage of the endometrial tissue. Nafarelin 200 mg nasal spray twice a day. u Treatment is limited to 6 months u Surgical intervention- SUCH AS HYSTERECTOMY OR CAUTERY u Menstrual Disorders u Alterations in cyclic bleeding: u Oligomenorrhea: infrequent menstrual periods, intervals of 40 to 45 days or longer u Hypomenorrhea: scanty bleeding at normal intervals *Causes: Abnormalities of hypothalamic, pituitary, or ovarian function *Treatment: Hormone therapy using progestin with or without estrogens u Metrorrhagia: Intermenstrual bleeding (BLEEDING BETWEEN CYCLES) It is frequent in women taking contraceptive pills, or using progestin contraceptive injection, IUD u Menorrhagia (hypermenorrhea): Excessive menstrual bleeding in duration or amount. Causes: Hormonal disturbances, systemic disease, benign or malign neoplasm, infection, and contraception (IUD). Important check Hb and Hto. Use of Aspirin is contraindicated Polycystic ovary syndrome Morbid obesity Steroid therapy Hypothyroidism Blood dyscrasias/clotting disorder Malignancy and hyperplasia Uterine polyps Treatment options for AUB include combined OCs, progestogens, NSAIDS, tranexamic acid (antifibrinolytic), GnRH analogs, Danazol, and Levonorgestrel = releasing intrauterine system (LNG IUS). Management of AUB might include: • medical care with pharmacotherapy • or insertion of a hormone-secreting intrauterine system. • OCs are used for cycle regulation as well as for contraception. They help prevent the risks associated with prolonged, unopposed estrogen stimulation of the endometrium. • NSAIDS and progestin therapy (progesterone-releasing IUS [Mirena] or Depo-Provera) decrease menstrual blood loss significantly. The drug categories used in the treatment of AUB are the following: Estrogens: cause vasospasm of the uterine arteries to decrease bleeding Progestins: used to stabilize an estrogen-primed endometrium OCs: regulate the cycle and suppress the endometrium NSAIDs: inhibit prostaglandins in ovulatory menstrual cycles Progesterone-releasing IUSs: suppress endometrial growth Androgens: create a high-androgen/low-estrogen environment that inhibits endometrial growth Antifibrinolytic drugs: (tranexamic acid) prevent fibrin degradation to reduce bleeding Iron replacement therapy: replenish iron stores lost during heavy bleeding If the client does not respond to medical therapy, surgical intervention might include. Educate the client about normal menstrual cycles and the possible reasons for her abnormal pattern. Inform the woman about treatment options. Do not simply encourage the woman to “live with it.” Instruct the client about any prescribed medications and potential side effects. For example, if high-dose estrogens are prescribed, the woman may experience nausea. Management of AUB might include: • Medical care with pharmacotherapy • Insertion of a hormone-secreting intrauterine system. • OCs are used for cycle regulation as well as for contraception. They help prevent the risks associated with prolonged, unopposed estrogen stimulation of the endometrium. • NSAIDS and progestin therapy (progesterone-releasing IUS [Mirena] or Depo-Provera) decrease menstrual blood loss significantly. The drug categories used in the treatment of AUB are the following: u Estrogens: Cause vasospasm of the uterine arteries to decrease bleeding u Progestins: Used to stabilize an estrogen-primed endometrium u OCs: Regulate the cycle and suppress the endometrium u NSAIDs: Inhibit prostaglandins in ovulatory menstrual cycles u Progesterone-releasing IUSs: Suppress endometrial growth u Androgens: Create a high-androgen/low-estrogen environment that inhibits endometrial growth u Antifibrinolytic Drugs: (tranexamic acid) Prevent fibrin degradation to reduce bleeding u Iron replacement therapy: Replenish iron stores lost during heavy bleeding u If the client does not respond to medical therapy, surgical intervention might include. Infertility, Contraception, and Abortion Infertility: u Is defined as the inability to conceive a child after 1 year of regular sexual intercourse unprotected by contraception u Incidence u Affects about 10% to 15% of reproductive-age population u Subfertility: prolonged time to conceive u Sterility: inability to conceive u Increases with age of woman, particularly in women 40 years and older u Diagnosis and treatment of infertility require physical, emotional, and financial investment NOTES: Infertility is defined as the inability to conceive a child after 1 year of regular sexual intercourse unprotected by contraception. Secondary infertility is the inability to conceive after a previous pregnancy. Subfertility: prolonged time to conceive Sterility: inability to conceive Increases with age of woman, particularly in women 40 years and older Diagnosis and treatment of infertility require physical, emotional, and financial investment. information about anovulation, amenorrhea, and premature ovarian failure. • GYNECOLOGIC HISTORY : Abnormal uterine contours or any history of disorders that can contribute to the formation of scar tissue that can cause blockage of ovum or sperm. • SEXUAL HISTORY : Intercourse frequency, number of partners across the lifespan, and any history of STIs. Male Assessment: u MEDICAL HISTORY : Mumps, especially after adolescence; endocrine disorders; genetic disorders; and anomalies in the reproductive system. u SEXUAL HISTORY : Intercourse frequency, and history of sexually transmitted infections. u SUBSTANCE USE: Alcohol, tobacco, heroin, methadone. u OCCUPATIONAL/ENVIRONMENTAL EXPOSURE RISK u ASSESSMENT: Exposure to hazardous teratogenic materials in home or work environment, exposure of scrotum to high temperatures. Nursing Care Management: u Assessment of female: u Diagnostic tests u Evaluation of the anatomy u Detection of ovulation u Hormone analysis u Ultrasonography u Endometrial biopsy u Hysterosalpingography u Laparoscopy NOTES: If all the Test Results became negative/Normal conception may still not occurs. Unexplained infertility accounts for 20% of cases. DIAGNOSTIC PROCEDURES Female u PELVIC EXAMINATION: Assesses for uterine or vaginal anomalies. u HORMONE ANALYSIS: Evaluates hypothalamic- pituitaryovarian axis to include blood prolactin, FSH, LH, estradiol, progesterone, and thyroid hormone levels. u POSTCOITAL TEST: Evaluates coital technique and mucus secretions. u ULTRASONOGRAPHY: A transvaginal or abdominal ultrasound procedure performed to visualize reproductive organs. u HYSTEROSALPINGOGRAPHY: Outpatient radiological procedure in which dye is used to assess the patency of the fallopian tubes. Assess for history of allergies to iodine and seafood prior to beginning the procedure. uHYSTEROSCOPY: A radiographic procedure in which the uterus is examined for defect, distortion, or scar tissue that can impair successful impregnation. u LAPAROSCOPY: A procedure in which gas insufflation under general anesthesia is used to observe internal organs. Male u SEMEN ANALYSIS: In 40% of couples who are infertile, inability to conceive is due to male infertility. This test is the first in an infertility workup because it is less expensive and less invasive than female infertility testing. It can need to be repeated. u ULTRASONOGRAPHY: An ultrasound procedure is performed to visualize testes and abnormalities in the scrotum. A transrectal ultrasound is performed to assess the ejaculatory ducts, seminal vesicles, and vas deferens. Nursing Care Management: u Assessment of male u Semen analysis: “IT IS THE 1ST MALE TEST PERFORMED”. Number of sperms must be adequate, healthy and mature. Normally have 20 million sperm per ml volume, number of sperm with greater than 50% motility even is analyzed for viscosity, sperm viability and shape. Sexual abstinence for 24 to 48 hours before sample collection. Specimen is produced by ejaculating into a specimen container and delivering it to the laboratory for analysis within 1 to 2 hours u Hormone analysis: Testosterone levels, FSH (follicle- stimulant hormone), LH (Luteinizing hormone) u Scrotal ultrasound (Look for varicoceles) u Assessment of couple u Postcoital test: The test is performed several Hrs after sexual intercourse. The specimen of cervical mucus is obtained and is examined under microscope. The quality of the mucus and the number of sperm moving forward are evaluated Therapy for Infertility: u Donor embryo (embryo adoption): Donated embryo is placed in the recipient’s uterus, which is hormonally prepared. u Gestational carrier (embryo host): A couple completes the process of IVF with the embryo placed in another person, who will carry the pregnancy. This is a contract agreement with the carrier having no genetic investment with the embryo. u Surrogate mother: A person is inseminated with semen and carries the fetus until birth. u Therapeutic donor insemination : Donor sperm is used to inseminate a person. * Pre-implantation genetic diagnosis: Genetic testing that eliminate embryos with genetic disease before implantation NOTES: GENETIC COUNSELING ● Genetic counseling may be recommended by the provider if there is a family history of birth defects. ● Identify clients who are in need of genetic counseling, such as a client who has a sickle cell trait or sickle cell anemia, or a client older than 35. Make referrals to genetic specialists as necessary. ● Prenatal assessment of genetic disorders (amniocentesis) can pose potential risks to the fetus. ● Provide and clarify information pertaining to the risk of or the occurrence of genetic disorders within a family preceding, during, and following a genetic counseling session. NURSING ACTIONS ● Assist in the construction of family medical histories of several generations. ● Provide emotional support. Client responses vary and include denial, anger, grief, guilt, and self-blame. ● Make referrals to support groups and provide follow-up. COMPLICATIONS Ectopic pregnancy ● Ovum implants in the fallopian tubes or abdominal cavity due to the presence of endometrial tissue. ● As ovum increases in size, fallopian tube can rupture, and extensive bleeding occurs, resulting in surgical removal of the damaged tube. ● If ectopic pregnancy is identified prior to rupture of the tube, surgical removal of the products of conception may be performed, or methotrexate is prescribed to dissolve the pregnancy. ● Client faces increased risk of recurrence of an ectopic pregnancy and infertility. Multiple gestation Assisted reproductive technology is associated with an increased incidence of multiple gestations. This poses a risk for the mother and babies. NURSING INTERVENTIONS u Encourage couples to express and discuss their feelings and recognize infertility as a major life stressor. Assist the couple to consider options and provide education to assist in decision- making. u Explain role of genetic counselor, reproductive specialist, geneticist, and pharmacist in providing psychosocial and medical care. u Monitor for adverse effects associated with medications to treat infertility. u Advise that the use of medications to treat female infertility can increase the risk of multiple births by more than 25%. u Provide information regarding assisted reproductive therapies (in vitro fertilization, embryo transfer, intrafallopian gamete transfer, surrogate parenting, and reproductive alternatives such as adoption). u Make referrals to grief and infertility support groups. Nursing Care Management u Reproductive alternatives u Adoption u Surrogate motherhood u Nurses Role: Supportive role as they make decisions. Reinforce all are normal feelings. Help couple identify ways to communicate with each other and discuss available options. Try and increase the couple’s sense of control. Reinforce plus coping skills. Relaxation techniques, support groups Contraception u Intentional prevention of pregnancy with the use of any method u Birth control is the device or practice to decrease the risk of conceiving u Family planning is the conscious decision on when to conceive or avoid pregnancy u May still be at risk for pregnancy NOTES: Contraception refers to strategies or devices used to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy. The human ovum can be fertilized 24 hr after ovulation. Motile sperm’s ability to fertilize the ovum lasts an average of 48 to 72 hr. A nurse should assess clients’ need, desire, and preference for contraception. A thorough discussion of benefits, risks, and alternatives Calendar rhythm method: Involves determining fertile days by tracking the menstrual cycle to estimate the time of ovulation, which occurs about 14 days before the onset of the next menstrual cycle. u CLIENT EDUCATION u Maintain a diary. Accurately record the number of days in each menstrual cycle, counting from the first day of menses for a period of at least six menstrual cycles. u The start of the fertile period is figured by subtracting 18 days from the number of days in the shortest menstrual cycle. u The end of the fertile period is established by subtracting 11 days from the number of days of the longest cycle. For example: u Shortest cycle, 26 - 18 = 8th day u Longest cycle, 30 - 11 = 19th day u Fertile period is days 8 through 19. Refrain from intercourse during these days to avoid conception. ADVANTAGES: Most useful when combined with basal body temperature or cervical mucus method u Inexpensive DISADVANTAGES u Not a very reliable technique u Does not protect against STIs u Requires accurate record-keeping u Requires adherence regarding abstinence during fertile periods RISKS u Various factors can affect and change the time of ovulation and cause unpredictable menstrual cycles. u Possible pregnancy due to miscalculating fertile period or not abstaining from intercourse during fertile days Standard Days Method (Cycle Bead) u The cycle beads are color-coded and located on a stringed necklace. CLIENT EDUCATION u Start the first day of the menstrual cycle. Use the rubber ring to advance one bead per day. u Red bead: the first bead and marks the first day of the menstrual cycle. u Brown beads: non-fertile days. u White beads: fertile days. ADVANTAGES u Increased adherence by using a visual aid u Mobile app available u Easy to understand DISADVANTAGES u Unreliable for menstrual cycles longer than 32 days or shorter than 26 days u Can lose track of the days RISKS/POSSIBLE COMPLICATIONS u Do not use if menstrual cycles are short or long u Possible pregnancy u Less effective with hormonal contraceptives, IUD, breastfeeding. Basal body temperature (BBT) u BBT is the temperature of the body at rest. Prior to ovulation, the temperature drops slightly and rises during ovulation. Identifying the time of ovulation is a symptom-based method that can be used to facilitate or avoid conception. CLIENT EDUCATION u Take temperature immediately after waking up and before getting out of bed. If working at night, take temperature after awakening from the longest sleep cycle. Use a thermometer that records temperature to the tenths. Record the temperatures on a specialized graph. u The first day the temperature drops or elevates is considered the first fertile day. Fertility extends through 3 consecutive days of temperature elevations. u Use this method with the calendar method to increase effectiveness. AVANTAGES: Inexpensive, convenient, and no adverse effects DISADVANTAGES u Reliability can be influenced by many variables that can cause inaccurate interpretation of temperature changes (stress, fatigue, illness, alcohol, warmth of sleeping environment). u Does not protect against STIs. RISKS: Possible pregnancy. Cervical Mucus Ovulation Detection Method u Fertility awareness method (also known as Billings method) is a symptom-based method in which the client analyzes cervical mucous to determine ovulation. u Following ovulation, the cervical mucus becomes thin and flexible under the influence of estrogen and progesterone to allow for sperm viability and motility. u The ability for the mucus to stretch between the fingers is greatest during ovulation. This is the spinnbarkeit sign. u The fertile period begins when the cervical mucus is thin, slippery, and lasts until 4 days after the last day of cervical mucus having this appearance. RISK: Possible pregnancy. Lactation amenorrhea method: When the infant suckles at the mother breast Prolactin Hormone is release which inhibits estrogen and gonadotropin production causing suppress ovulation and the return of menses BARRIER METHODS u Barrier methods: u Condoms, male (STI protection) u Female Condom u Spermicides u Diaphragm: Left in place for 6 Hrs after intercourse and must instill spermicide in vagina (not removing Diaphragm) for repeated intercourse u Cervical cap u Contraceptive sponge: contains N-9 spermicide, protect for 24 Hrs, and need to be left in place for 6 Hrs after intercourse NOTES: Nurses should question about latex allergy before recommending latex condom to any Pt. RISKS/POSSIBLE COMPLICATIONS/CONTRAINDICATIONS: Not for clients who have abnormal Pap test results or those who have a history of TSS Contraceptive sponge Small, round, concave-shaped, polyurethane sponge containing spermicide. It fits over the cervix and acts as a physical/chemical barrier against sperm from entering the vagina. CLIENT EDUCATION ● One size fit all. ● Moisten with water prior to insertion in the vagina. ● Should be left in place for 6 hr after the last act of intercourse and provides protection for up to 24 hr. ADVANTAGES ● Can have repeated acts of intercourse ● Easy to insert DISADVANTAGES: Does not protect against STIs RISKS/COMPLICATIONS: Risk of TSS if left in the vagina greater than 24 hr. Condoms, male (STI Protection) A thin sheath used to cover the penis during sexual intercourse as a contraceptive or as protection against infection. Male condoms can be made of latex rubber, polyurethane, or natural membrane. ADVANTAGES u Protects against most STIs u Involves males in the birth control method u No adverse effects u Readily accessible DISADVANTAGES u Can reduce spontaneity of intercourse. u Decreased sensation. u The penis must be erect to apply a condom u Withdrawing the penis while still erect can interfere with sexual intercourse. u Does not protect against STIs that are transmitted from lesions on the skin or mucus membranes (HPV, HSV, syphilis). u Condoms have a one-time usage, which creates a replacement cost Female Condom: Vaginal sheath made of nitrile, a nonlatex synthetic rubber with flexible rings on both ends that is pre‐lubricated with a spermicide CLIENT EDUCATION u The closed end of the condom pouch is inserted into the vagina by the client prior to intercourse and anchored around the cervix. u The open ring of the condom covers the labia. The condom is removed and thrown away after each act of intercourse. u Do not use in conjunction with a male condom. ADVANTAGES u Offers protection against pregnancy and STIs u Offers some protection against STI transmitted by skin to-skin contact (HPV, HSV, syphilis) DISADVANTAGES u Complicated to use u Bulky u Noisy during intercourse u More expensive than male condoms Spermicides: Chemical barrier that is available in a variety of forms and destroys sperm before they can enter the cervix. It causes the vaginal flora to be more acidic, which is not favorable for sperm survival. CLIENT EDUCATION u Plan to insert spermicide 15 min before intercourse. Spermicide is only effective for 1 hr after insertion but should not be removed until 6 hr after intercourse. u Fold films prior to use and insert in the vagina, where it will dissolve. u Risk of allergic reaction and UTIs. Left in place for 6 Hrs after intercourse and must instill spermicide in vagina (not removing Diaphragm) for repeated intercourse u Avoid oil-based lubricants (destroys the latex) u Toxic shock syndrome: if using tampons , must remove every four hours Cervical cap Silicone rubber cap that fits tightly around the base of the cervix. This serves as a physical barrier against sperm entering the cervix. Use with a spermicide increases its effectiveness. Cervical caps come in three sizes. CLIENT EDUCATION u Insert up to 6 hrs before intercourse and leave in place at least 6 hrs after intercourse but for no more than 48 hr at a time. u Replace every 2 years and refit after any gynecological surgery, birth, or any major weight fluctuation. ADVANTAGES u Extended period of use u No additional application of spermicide needed DISADVANTAGES u Possible risk of acquiring TSS u Risk of allergic reaction u Does not protect against STIs RISKS/POSSIBLE COMPLICATIONS/CONTRAINDICATIONS: Not for clients who have abnormal Pap test results or those who have a history Contraceptive Sponge u Small, round, concave-shaped, polyurethane sponge containing spermicide. It fits over the cervix and acts as a physical/chemical barrier against sperm from entering the vagina. CLIENT EDUCATION u One size fit all. u Moisten with water prior to insertion in the vagina. u Should be lef t in place for 6 hrs after the last act of intercourse and provides protection for up to 24 hr. ADVANTAGES u Can have repeated acts of intercourse u Easy to insert DISADVANTAGES: Does not protect against STIs RISKS/COMPLICATIONS: Risk of TSS if left in the vagina greater than 24 hr. Barrier Methods Diaphragm Cervical Cap Contraceptive Sponge • Inserted up to 6 hrs. before intercourse and must stay in place 6 hrs. after intercourse but for no more than 24 hrs. • Be properly fitted by a provider. • Replace every 2 years and refit for a 20% weight • Insert up to 6 hrs. before intercourse and leave in place at least 6 hrs. after intercourse but for no more than 48 hrs. at a time. • Replace every 2 years and refit after any gynecological • Should be left in place for 6 hrs. after the last act of intercourse and provides protection for up to 24 hr. • One size fit all. fluctuation, after surgery, birth, or any abdominal or pelvic major weight surgery, and after fluctuation. every pregnancy Hormonal Methods u Combined estrogen-progestin contraceptives (COCs): suppress the action of the Hypothalamus and Anterior Pituitary gland, Leading to insufficient secretion of FSH and LH. Therefore, follicles do not mature, and ovulation is inhibited. u The effectiveness of the pill decreases when some medications are taking simultaneously: Anticonvulsants- Phenytoin, oxycarbazepine, phenobarbital. Antifungal- Griseofulvin. Antituberculosis- Rifampicin. Anti-HIV- Nelfinavir and amprenavir u Transdermal contraceptive system: deliver continuous level of progesterone and ethynyl estradiol. Could be applied weekly for 3 weeks and rest 1 week for menstrual period u Vaginal ring: Deliver continuous level of progesterone and ethynyl estradiol. I ring can be worn for 3 weeks, then rest for 1 week NOTES: Combined oral contraceptives (COCs) Hormonal contraception containing estrogen and progestin, which acts by suppressing ovulation, thickening the cervical mucus to block semen, altering the uterine decidua to prevent implantation CLIENT EDUCATION ● Medication requires a prescription and follow-up appointments with the provider. ● Routine Pap smears and breast examination might be needed. u In the event of missing a dose, if one pill is missed, take one as soon as possible; if two or three pills are missed, follow the manufacturer’s instructions. Instruct the client on the use of alternative forms of contraception or abstinence to prevent pregnancy until regular dosing is resumed. u If nausea occurs, take at bedtime. ADVANTAGES u Highly effective if taken correctly and consistently, preferably at the same time each day. u Hormonal contraception containing low-dose estrogen (less than 35 mcg) has other therapeutic effects, including decreased menstrual blood loss, decreased iron deficiency anemia, regulation of menorrhagia and irregular cycles, and reduced incidence of dysmenorrhea and premenstrual findings. u Offers protection against endometrial, ovarian, and colon cancer, reduces the incidence of benign breast disease, improves acne, and protects against the development of functional ovarian cysts. DISADVANTAGES u Does not protect against STIs. u Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, and liver tumor. u Exacerbates conditions affected by fluid retention (migraine, epilepsy, asthma, kidney or heart disease). u Adverse effects include headache, nausea, breast tenderness, and breakthrough bleeding. (Estrogen can cause nausea, breast tenderness, fluid retention. Progestin can cause increased appetite, fatigue, depression, breast tenderness, oily skin and scalp, and hirsutism.) RISKS/POSSIBLE COMPLICATIONS/CONTRAINDICATIONS ➢ Clients who have a history of thromboembolic disorders, stroke, heart attack, coronary artery disease, ➢ Gallbladder disease, ➢ Cirrhosis or liver tumor, ➢ Headache with focal neurologic findings, ➢ Uncontrolled hypertension, ➢ Diabetes mellitus with vascular involvement, ➢ Breast or estrogen related cancers, pregnancy, ➢ Lactating, less than 6 weeks postpartum, ➢ Smoking (if over 35 years of age) are advised not to take oral contraceptive medications. u Oral contraceptive effectiveness decreases when taking medications that affect liver enzymes (anticonvulsants, antifungals, some antibiotics). Anticonvulsants- Phenytoin, oxycarbazepine, phenobarbital. Antifungal- Griseofulvin. Antituberculosis- Rifampicin. Anti-HIV- Nelfinavir and amprenavir Oral contraceptives and side effects: u A = Abdominal pain may indicate liver or gallbladder problems u C = Chest pain or shortness of breath may indicate a pulmonary embolus u H = Headaches may indicate hypertension or impending stroke u E = Eye problems may indicate hypertension or an attack u S = Severe leg pain may indicate a thromboembolic event Progestin-only pills (minipill) Oral progestins that provide the same action as combined oral contraceptives, which decreases the chance of fertilization and implantation CLIENT EDUCATION u Take the pill at the same time daily to ensure effectiveness secondary to a low dose of progestin. u Do not miss a pill. u Might need another form of birth control during the first month of use to prevent pregnancy. ADVANTAGES u Fewer adverse effects when compared with a combined oral contraceptive u Considered safe to take while breastfeeding DISADVANTAGES u Less effective in suppressing ovulation than combined oral contraceptives. u Increased occurrence of ovarian cysts. u No protection against STIs. u Adverse effects include breakthrough, irregular, vaginal bleeding (frequently reported/most common); headache; nausea; and breast tenderness. RISKS/POSSIBLE COMPLICATIONS/CONTRAINDICATIONS u Oral contraceptive effectiveness decreases when taking medications that affect liver enzymes (anticonvulsants, some antibiotics). u Contraindications include bariatric surgery, lupus, severe cirrhosis, liver tumors, and current or past breast cancer Emergency oral contraceptive Morning-after pill that prevents fertilization from taking place by inhibiting ovulation and the transport of sperm CLIENT EDUCATION u The pill is taken within 72 hrs after unprotected coitus. Medroxyprogesterone is an intramuscular or subcutaneous injection given to a female client every 11 to 13 weeks. It inhibits ovulation and thickens cervical mucus. CLIENT EDUCATION u ● Start of injections should be during the first 5 days of the menstrual cycle and every 11 to 13 weeks thereafter. Injections in postpartum non-breastfeeding clients should begin within 5 days following delivery. For breastfeeding clients, injections should start in the sixth week postpartum. u Keep follow-up appointments. u Maintain an adequate intake of calcium and engage in weight- bearing exercise to decrease the risk of osteoporosis. u Do not massage after IM injections because it decreases the absorption and effectiveness of the medication. ADVANTAGES u Very effective and requires only four injections per year u Does not impair lactation u Possible absence of periods and decrease in bleeding u Decreased risk of uterine cancer if used long-term DISADVANTAGES Adverse effects include: • Decreased bone mineral density. • Weight gain. • Increased depression. • Amenorrhea, headache. • Irregular vaginal spotting or bleeding. u Does not protect against STIs. u Return to fertility can be delayed as long as up to 18 months after discontinuation. u Should only be used as a long-term method of birth control (more than 2 years) if other birth control methods are inadequate. RISKS/POSSIBLE COMPLICATIONS/CONTRAINDICATIONS u Avoid massaging injection site following administration to avoid accelerating medication absorption, which will shorten the duration of its effectiveness. u Contraindications include breast cancer, evidence of current cardiovascular disease, abnormal liver function, liver tumors, and unexplained vaginal bleeding. u This method can impair glucose tolerance for clients who have diabetes mellitus and increase diabetes risk for clients who do not have diabetes mellitus. Contraception u Hormonal methods: cont. u Progestin-only contraceptives: Are less effective than combined u Oral progestins (minipill) u Injectable progestins (Depo-provera) u Implantable progestins (Norplant Implantable progestins (Norplant) Small, thin rods consisting of progestin that are implanted by the provider under the skin of the inner upper aspect of the arm ● Prevents pregnancy by suppressing the ovulatory cycle and thickening cervical mucus CLIENT EDUCATION ● Avoid trauma to the area of implantation. ● Wear condoms for protection against STIs. ADVANTAGES ● Effective continuous contraception for 3 years ● Can be inserted immediately after spontaneous or elective abortion, childbirth, while breastfeeding ● Reversible DISADVANTAGES u Does not protect against STIs. u Adverse effects include irregular and unpredictable menstruation (most common), mood changes, headache, acne, depression, decreased bone density, and weight gain. u Scarring at insertion site can warrant the need for removal. RISKS/POSSIBLE COMPLICATIONS/CONTRAINDICATIONS u Method has increased risk of ectopic pregnancy if pregnancy occurs. u Contraindications include unexplained vaginal bleeding. u Infection can occur at site. Contraception u Intra Uterine Devices- IUD u Cooper intrauterine device (IUD): insertion within 120 Hrs/5 days after intercourse. Must be inserted within 5 to 6 days of menstrual period u Small, T-shaped device inserted into the uterine cavity, can remain in the uterus for 10 years. IUD offers no protection against STIs or HIV u Medicated IUDs loaded with either copper or pregestational agent u Para Gard: can remain in the uterus up to 10 years u Mirena: Levonorgestrel releasing intrauterine system, can remain in the uterus up to 5 years