Ch. 6 Women's Health
Ch. 6 Women's Health
Common Menstrual Disorders
Absence of menstrual flow
Often a result of pregnancy
Problem in central hypothalamic-pituitary axis
Results from hypothalamic suppression
Counseling and education
Cyclic perimenstrual pain and discomfort (CPPD
the absence of menstrual flow, is a clinical symptom of a variety of disorders. Although these criteria for a clinical problem of amenorrhea are not universal, these circumstances should generally be evaluated: (1) the absence of both menarche and secondary sexual characteristics by age 14 years; (2) absence of menses by age 16 years, regardless of presence of normal growth and development (primary amenorrhea); or (3) a 3- to 6-month absence of menses after a period of menstruation (secondary amenorrhea) (Harlow, 2000; Speroff & Fritz, 2005).
Although amenorrhea is not a disease,
it is often the sign of one. Still, most commonly and most benignly, amenorrhea is a result of pregnancy.
. It also may result from anatomic abnormalities such as outflow tract obstruction, anterior pituitary disorders, other endocrine disorders such as polycystic ovarian syndrome, hypothyroidism or hyperthyroidism, chronic diseases such as type 1 diabetes, medications such as phenytoin (Dilantin), illicit drug abuse (alcohol, tranquilizers, opiates, marijuana, cocaine), or oral contraceptive use.
In addition, it may occur from any defect or interruption in the hypothalamic-pituitary-ovarian-uterine axis. In rare instances, a pituitary lesion or genetic inability to produce FSH and LH is at fault.
often results from hypothalamic suppression as a result of stress (in the home, school, or workplace) or a sudden and severe weight loss, eating disorders, strenuous exercise, or mental illness
Pain during or shortly before menstruation
Abnormally increased uterine activity
Acquired menstrual pain
Diagnosis and treatment
pain during or shortly before menstruation, is one of the most common gynecologic problems in women of all ages. Many adolescents have dysmenorrhea in the first 3 years after menarche. Young adult women ages 17 to 24 years are most likely to report painful menses. Dysmenorrhea decreases in most women after a full-term pregnancy
Between 30% and 40% of women report
some level of discomfort associated with menses, and 7% to 15% report severe dysmenorrhea (Parent-Stevens & Burns, 2000); however, the amount of disruption in women's lives is difficult to determine. It has been estimated that up to 10% of women with dysmenorrhea have severe enough pain to interfere with their functioning for 1 to 3 days a month. Menstrual problems, including dysmenorrhea, are more common in women who smoke and those who are obese.
Symptoms usually begin with menstruation, although some women have discomfort several hours before onset of flow. The range and severity of symptoms are different from woman to woman and from cycle to cycle in the same woman. Symptoms of dysmenorrhea may last several hours or several days.
Pain is usually located in the suprapubic area or lower abdomen. Women describe the pain as sharp, cramping, or gripping or as a steady dull ache; pain may radiate to the lower back or upper thighs.
Posterior tilt uterus have more problems.
a condition associated with abnormally increased uterine activity, is due to myometrial contractions induced by prostaglandins in the second half of the menstrual cycle
Primary dysmenorrhea pathology
is not caused by underlying pathology; rather it is the occurrence of a physiologic alteration in some women. Primary dysmenorrhea usually appears within 6 to 12 months after menarche when ovulation is established.
TX primary dysmenorrhea
TXheating pads, effluerage, exercise, decrease salt & sugar (7-10 day prior to menstruation, increase H20, increase natural diurectics- peaches, watermelon,asparagus, parsley, decrease red Meat, Aleve or NSAIDs take 2-3 days prior to menstruation
No single OCP has been shown to be
superior to another for the relief of primary dysmenorrhea. ibuprofen, naproxen sodium) as prescription preparations; however, the labeled recommended dose may be subtherapeutic. Preparations containing acetaminophen are even less effective because acetaminophen does not have the antiprostaglandin properties of NSAIDs.
have long been used for management of menstrual problems including dysmenorrhea (Table 7-2). Herbal medicines may be valuable in treating dysmenorrhea; however, it is essential that women understand that these therapies are not without potential toxicity and may cause drug interactions. It is important that women use herbal preparations from well-established companies.
Nurses must routinely ask women about use of herbal and other alternative therapies and document their use.
is acquired menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25 years. This condition is associated with pelvic pathology, such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids). Women with secondary dysmenorrhea often have other symptoms that may suggest an underlying cause. For example, heavy menstrual flow with dysmenorrhea suggests a diagnosis of leiomyomata, adenomyosis, or endometrial polyps.
Pain associated with endometriosis
often begins a few days before menses, but can be present at ovulation and continue through the first days of menses or start after menstrual flow has begun. In contrast to primary dysmenorrhea, the pain of secondary dysmenorrhea is often characterized by dull, lower abdominal aching radiating to the back or thighs. Often women experience feelings of bloating or pelvic fullness. In addition to a physical examination with a careful pelvic examination, diagnosis may be assisted by ultrasound examination, dilation and curettage, endometrial biopsy, or laparoscopy. Treatment is directed toward removal of the underlying pathology. Many of the measures described for pain relief of primary dysmenorrhea also are helpful for women with secondary dysmenorrhea.
Premenstrual syndrome (PMS)
Cystic symptoms occurring in luteal phase of menstrual cycle
PMS: cluster of physical, psychologic, and behavioral symptoms
Premenstrual dysphoric disorder (PDD)
Severe variant of PMS
Diet and exercise
Premenstrual syndrome (PMS) is a complex, poorly understood condition that includes a number of cyclic symptoms occurring in the luteal phase of the menstrual cycle. About 85% of women experience mood and/or somatic symptoms that coincide with their menstrual cycles
Between 5% to 14% of women report
symptoms severe enough to be disabling (Angst, Sellaro, Merikangas, & Endicott, 2001). All age-groups are affected, with women in their twenties and thirties most frequently reporting symptoms. Ovarian function is necessary for the condition to occur, since it does not occur before puberty, after menopause, or during pregnancy. The condition is not dependent on the presence of monthly menses: women who have had a hysterectomy without bilateral salpingo-oophorectomy still can have cyclic symptoms.
Mood major symptom of PMS
However, Speroff and Fritz (2005) suggest that the simplest definition is a commonsense one: "The cyclic appearance of one or more of a large constellation of symptoms just prior to menses, occurring to such a degree that lifestyle or work is affected, followed by a period of time entirely free of symptoms." PMS symptoms include distressing physical, mood, and behavioral experiences.
PMS dietary helps
wheat bread, dry beans, seeds, unsalted nuts, plain vegetables, fruits, 3 small meals and 3 smalls snacks hi in carbs and fiber.
keep a mood journal
se: HA, WT gain, sleep disturb, dry mouth, dizziness, decrease libido
also are herbal tx but make sure MD knows.
Presence and growth of endometrial tissue outside of the uterus
Deep pelvic dyspareunia (painful intercourse)
is characterized by the presence and growth of endometrial glands and stroma outside of the uterus. The tissue may be implanted on the ovaries, the anterior and posterior cul-de-sac, the broad, uterosacral, and round ligaments, the uterine tubes, the rectovaginal septum, the sigmoid colon, the appendix, the pelvic peritoneum, the cervix, and the inguinal area (Fig. 7-1). Endometrial lesions have been found in the vagina and surgical scars, as well as on the vulva, the perineum, and the bladder, and sites far from the pelvic area such as the thoracic cavity, the gallbladder, and the heart. A cystic lesion of endometriosis found in the ovary is sometimes described as a chocolate cyst because of the dark coloring of the contents of the cyst caused by the presence of old blood.
Endometriosis may worsen
womenThere appears to be a familial tendency to develop endometriosis; with repeated cycles, or it may remain asymptomatic and undiagnosed, eventually disappearing after menopause. Endometriosis can occur in women who have been pregnant and may be a cause of secondary infertility (Speroff & Fritz).
Ask mother if she has all the children she wishes to have? (possible hysterectomy)
danazol- steriod type med
weak partial agonist, inhibits P450 enzymes needed for gonadal steroid synthesis, tx of endometriosis, adverse: weight gain, hirsutism, edema and acne
Symptoms vary among women, from nonexistent to incapacitating. Severity of symptoms can change over time and may be disconnected from the extent of the disease. The major symptoms of endometriosis are pelvic pain, dysmenorrhea, dyspareunia (painful intercourse), abnormal menstrual bleeding, and infertility. Women also may experience chronic noncyclic pelvic pain, pelvic heaviness, or pain radiating into the thighs. Many women report bowel symptoms such as diarrhea, pain with defecation, and constipation caused by avoiding defecation because of the pain. Less common symptoms include abnormal bleeding (hypermenorrhea, menorrhagia, or premenstrual staining) and pain during exercise as a result of adhesions (Lemaire, 2004). Women who have endometriosis may also have other conditions such as chronic fatigue syndrome, fibromyalgia, endocrine disorders, and autoimmune disorders (Conversations with Colleagues, 2002-2003).
Alterations in cyclic bleeding
The term oligomenorrhea often is used to describe decreased menstruation, either in amount, time, or both. refers to infrequent menstrual periods characterized by intervals of 40 to 45 days or longer, and hypomenorrhea to scanty bleeding at normal intervals. Causes: oligomenorrhea are often abnormalities of hypothalamic, pituitary, or ovarian function. Oligomenorrhea also can be physiologic, or part of a woman's normal pattern for the first few years after menarche or for several years before menopause.
TX aimed at reversing the underlying cause, if possible. HRT using progestins, with or without estrogens
Women with menstruation s/s- prolonged intervals between cycles need education and counseling. woman keeping careful records of her vaginal bleeding.
One of the most common causes of scanty menstrual flow is OCPs. If a woman is considering OCPs for contraception, it is important that the nurse explain in advance that the use of OCPs can decrease menstrual flow by as much as two thirds.
Metrorrhagia, or intermenstrual bleeding, refers to any episode of bleeding, whether spotting, menses, or hemorrhage, that occurs at a time other than the normal menses. Mittlestaining, a small amount of bleeding or spotting that occurs at the time of ovulation (14 days before onset of the next menses), is considered normal. The cause of mittlestaining is not known; however, its common occurrence can be documented by its repetition in the menstrual cycle.
Women taking OCPs may have midcycle bleeding or spotting.
Breakthrough bleeding is most common in the first three cycles of OCPs. The reduced potency of OCPs (resulting in increased safety) has decreased the amount of available hormones, making it more important that blood levels be kept constant. Taking the pill at exactly the same time each day may alleviate the woman's problem. If the spotting continues, a different formulation of the OCP that increases either the estrogen or progestin component of the pill can be tried.
The causes of intermenstrual bleeding
are varied (Table 7-3). It is important that the nurse always consider the possibility that any woman who has not undergone menopause and who seeks care for intermenstrual bleeding is or recently has been pregnant.
Menorrhagia (hypermenorrhea) is defined as excessive menstrual bleeding, in either duration or amount. The causes of heavy menstrual bleeding are many, including hormonal disturbances, systemic disease, benign and malignant neoplasms, infection, and contraception (IUDs). A single episode of heavy bleeding may occur, or a woman may have regular flooding as a pattern in which she changes tampons or pads every few hours for several days.
uterine leiomyoma (fibroids)
Uterine leiomyoma (fibroids or myomas) are a common cause of menorrhagia. Fibroids are benign tumors of the smooth muscle of the uterus, the etiology of which is unknown. Fibroids are estrogen sensitive and commonly develop during the reproductive years and shrink after menopause. Other uterine growths ranging from endometrial polyps to adenocarcinoma and endometrial cancer are other common causes of heavy menstrual bleeding, as well as of intermenstrual bleeding.
TX- shrink them, Gonatropic Hormone(
can be removed- Myomectomy
Treatment for menorrhagia depends
on the cause of the bleeding. If the bleeding is related to contraceptive method, the nurse provides factual information and reassurance and discusses other contraceptive options. If bleeding is related to presence of fibroids, the degree of disability and discomfort associated with the fibroids and the woman's plans for childbearing will influence treatment decisions. Treatment options include medical and surgical management.
Uterine Artery Embolization
to cut off blood flow to fibroid. Does increase risk of infertility., Minimally invasive procedure used to treat fibroids of the uterus by blocking arteries that supply blood to the fibroids. First, an arteriogram is used to identify the vessels. Once identified, tiny gelatin beads, about the size of grains of sand, are inserted into the vessels to create a blockage. The blockage stops the blood supply to the fibroids causing them to shrink.
exfoliative biopsy or a scraping of the cervix to diagnose conditions of the cervix and surrounding tissues
how do we prepare women- don't douche, explain procedure, 1st- provide relaxation
if it is first time- they may want to be by themself.
always allow woman to talk while having the physical- always listen
hot flashes and night sweats
triggered by eating a hot meal, hot weather, drinking alcohol, stress
Complete cessation of menses
Anovulation occurs more frequently
Menstrual cycles increase in length
Ovarian follicles become less sensitive to hormonal stimulation from FSH and LH
Ovulation occurs with less frequency
Progesterone not produced by corpus luteum
NEED ASTROGLIDE & CALCIUM
The average age for the onset of the perimenopausal transition is 46 years; 95% of women experience the onset between ages 39 and 51. The average duration of the perimenopause is 5 years, with a range of 2 to 8 years for 95% of women (Speroff & Fritz). Cigarette smoking and a history of short intermenstrual intervals seem to decrease the age at onset of menopause. However, the popular belief that an early menarche predisposes to a late menopause is not substantiated. Unlike menarche, the average age of menopause has remained about the same since the Middle Ages.