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Amenorrhea (5)

absence of menses

Normal before menarche, during pg, pp, and lactation

Menses begins average 12.5yrs (8-16) about after 2 years of physical changes.
Cycle length 21-35 days
Amount about 25-60ml, 2-8 days

Primary Amenorrhea

No menses by 16 years

Secondary amenorrhea

Menses ceases after it has been established (of at least 3 months)

Potential causes of amenorrhea (4)

Hypothalamic dysfunction- severe stress, long distance runners, dancers, marked weight loss

Pituitary dysfunction- cancer, Sheenhans syndrome, head trauma

Chronic anovulation/ovarian failure- Turner syndrome, polycystic ovarian syndrome, radiation, chemotherapy

Anatomic abnormalities- imperforate hymen, congenital absence of structures

Tx amenorrhea (4)

If secondary- do a pregnancy test first-

If primary- pelvic exam, labs- TSH, prolactin, FSH, 2hr gtt

Tx directed at causative factores

Remember emotional support

Dysmenorrhea (2)

Painful menstration
Usually lasts 48-72hrs, menstrual pain, cramps of lower abd, radiate to back and/or legs

May be caused by excessive prostaglandin production, causes uterine muscle contractions

Tx for dysmenorrhea (3)

Oral contraceptives- decrease in endometrial growth

Prostaglandin inhibitors- NSAIDS, Motrin, Advil, Naprosy, Anaprox

Possibly Vit E and B, heating pad or warm bath

Mittelscherz (8)

"middle pain"
Occurs midway between menstrual periates at the time of ovulation
Day 14 in a 28 day cycle

Due to growth of the dominant follicle within the ovary or rupture of the follicle and spillage of follicular fluid/blood into the peritoneal cavity

Sharp pain felt on the left or right side
Lasts from a few hours to 2 days
Might have slight vaginal bleeding

Tx: Generally none required, just patient teaching

AUB- Abnormal Uterine Bleeding (3)

Common gyn prob

This is a starting point- possibility of many diff medical dx

Possible nursing dx- fear? anxiety?

5 most common causes of AUB

-Pregnancy complications
-Anatomic lesions
-Drug-induced bleeding (birth control)
-Systemic disorders (DM, uterine myomas (fibroids) and hypothyroidism
-Failure to ovulate

Endometriosis (6)

Presence of tissue outside the uterus that resembles the endometrium BOTH IN STRUCTURE AND FUNCTION

Cause is unknown- retrograde menstration, altered immunosurveillance, vascular/lymphatic spread

Estrogen and progesterone stimulates growth of this tissue and sloughs during menstruation

Causes pressure and pain due to closed pelvic cavity

Prostaglandin secreted by endometrial tissue irritates nerve endings and stimulates uterine contractions

Bleeding into the pelvic cavity causes inflammation and scar tissure, and results in chronic pain and infertility

s/s Endometriosis (7) & surgical treatments (3)

Pelvic pain, pain during sex, GI complaints, rectal bleeding, oligo or hypermenorrhea, low back pain, infertility

Do not delay pregancy if desire for children
-Surgical Tx
--Hysterectomy with bilateral salpingo-oophorectomy
--Laparoscopic removal of lestions
--Ablation of lesions

Medical tx for endometriosis (4)

COC- combination oral contraceptives- end result is endometrial atrophy- use long term (75% pts report symptom relief)

Gonadotrophin inhibitors (danazol) end result- endometrial atrophy, regression of lesions (84-92% pts have relief) only take for 6 months

GnRH agonists (lupron, zoladex, synarel nasal spray.) 90% of pts report relief, only use for 6mos

Aromatase inhibitors (armidex, femara) decreases estrogen- only use for 6 mos

PMS prementrual syndrome/PMDD premenstrual dysphoric disorder (5)

Cyclic and recurs in luteal phase (after ovulation day 15-28) of menstrual cycle

Woman is symptom free during follicular phase (before ovulation, day 1-13)

PMS- 20-40% 1 or more emotional or physical symptom in at least 3 consecutive cycles

PMDD- 3-8% 5 or more symptoms during most cycles for the previous year- markedly interferes with work, school and relationships

Cause is unknown

PMS/PMDD physical symptoms (8)

Headache
Bloating
Breast tenderness
Hot flashes
Muscle/Joint pain
Fatigue
Appetite changes (binge eating, cravings)
Sleep changes (excessive or insomnia)

PMS/PMDD behavioral symptoms (9)

Depressed mood
Feelings of helplessness
Marked anxiety
Emotional swings
Irritability/anger
Feelings of being out of control
Reduced interest in activities
Difficulty concentrating
Lethargy

PMS/PMDD management (9)

Based upon symptoms
Vit B6
Calcium 1200mg/day
Magnesium 200-400mg/day

Carbohydrate rich foods and beverages may improve mood and decrease cravings

Reduce caffiene and Vit E during luteal phase may help with mastalgia (breast pain)

Mild potassium sparing diuretic for fluid retention

NSAIDS and betablockers for migranes (Inderal)

Antidepressants (Zoloft/Prozac)

Pt educations for PMS/PMDD (13)

Decrease caffiene intake to decrease irritability

Avoid simple sugars to control blood glucose

Decrease salty food intake to decrease fluid retention

Drink at least 2 quarts (2000ml) water/day

Eat 6 small meals/day to prevent hypoglycemia

Avoid ETOH bc it increases depression

Yaz- oral contraceptive that FDA has approved for PMMD and acne if over 14yrs old
-Higher risk of VTE expecially in an already high risk pt
--over weight, smokes, over 35

Increase physical exercise to decrease tension/depression
Make plans to avoid stressful situations during PMS
Use relaxation techniques
Adhere to regular sleep schedule
Drink a glass of milk before going to sleep (tryptophan)
Exercise in the AM not PM

Beyaz estrogen/progestin COC w/ a folate (4)

prevents pregnancy

Tx symptoms of PMDD for women who choose to use an oral contraceptive for contraception

Tx moderate acne for woman at least 14yrs old only if the pt desires an oral contraceptive for birth control

Raise folate levels in women who chose to use an oral contraceptive for BC

Toxic shock syndrome (4)

Rare but potentially fatal, caused by toxin producing strain of Staph Aureus

The toxin alters capillary permeability which allows intravascular fluid to leak from the blood vessels=>hypovolemia, hypotention, shock

Vagina may harbor this bacteria
Use of high-absorbency tampons, cervical cap, and diaphragm trap and hold bacteria

s/s toxic shock syndrome (4)

suddenly spiking a fever
Flu like symptoms- HA, sore throat, vomiting, diarrhea
Hypotension
Generalized rash resembling a sunburn

tx for toxic shock syndrome (4)

fluid replacement
vasopressor drugs
antimicrobials
corticosteroids

prevention/pt teaching for toxic shock syndrome (2)

If use a tampon, use good handwashing technique, change tampons at least q4h, do not use super absorbent, use pads rather than tampons especially when sleeping

Diaphragm use: good handwashing, DO NOT use diaphragm during menstrual periods, removed diaphragm within the recommended time frame
-usually keep in place at least 6 hrs after intercourse but less than 24hrs

Menopause (6)

Absence of mentruation for 1 full year
Average age 45-52
Not an illness- just another stage of life
can be exciting: try to persue personal development
some grieve: possibility of childbearing has passed
Women must come to terms with aging

unexpected postmenopausal bleeding (2)

needs to be evaluated

may indicate endometrial cancer

perimenopause & s/s (6)

2-8yrs
changes from normal ovulatory cycles to cessation of menses
--hot flashes
--irregular periods
--sleep problems
--PMS

Physiologic changes due to decrease in estrogen (9)

Labia becomes thin, vaginal mucosa atrophies
Vaginal dryness
Dyspareunia = painful intercourse
Breasts become smaller
Loss of bladder tone
LDL increases= increased risk of cardiac disease
HDL decrease
Hot flashes
Psychological changes: possible depression, mood swings, irritability, agitation, insomnia, fatigue

HRT (hormone replacement therapy & ERT (estrogen replacement therapy) (6)

not for everyone

Treats hot flashes, osteoporosis, atrophic vagina
--use the smallest dose for shortest time frame DOES NOT REDUCE CARDIOVASCULAR RISK AND INCREASES RISK OF BREAST CA

If woman has had a hysterectomy, estrogen alone (ERT = estrogen replacement therapy)

Both estrogen and progesterone if pt has a uterus: to lessen the risk of uterine ca, HRT (hormone replacement therapy)

Dosage/Route:
PO, patch, vaginal creams

Contraindications for HRT/ERT (5)

Hx/current breast or ovarian cancer or other estrogen-dependent tumor
Hx/current thromboembolic disease- either venous or arterial
Undiagnosed AUB
Liver dysfunction

(close family hx of breast ca, uterine ca, stroke, GB or pancreatic disease, DM, conditions that may be aggravated by fluid retention, migraine, epilepsy, cardiac or renal dysfunction, depression)

If pt has a uterus and is on HRT

the pt will have vaginal bleeding in cycles dependent on her HRT regimen

Non-hormonal tx for menopause: vaginal dryness

water soluble lubricant

Non-hormonal tx for menopause: Risk for osteoporosis

Ca intake with Vit D, wt bearing exercise

Non-hormonal tx for menopause: Loss of bladder tone/dyspareunia

= Kegels

Non-hormonal tx for menopause: Psychological distress

- support network, exercise, knowledge of the process, herbs (check with MD), also a time to evaluate life choices and make better dicisions (all crossroads in life offer the opportunity for change)

Non-hormonal tx for menopause: Hot flashes

- multivitamins, calcium, black cohosh, soy supplements, soy foods, antidepressants, meditation, relaxation (dress in layers-fan right away)

Prevention of heart disease for women (6)

Smoke free environment
Healthy weight
Heart healthy nutrition (fruits/vegs, whole grain, high fiber, fish 2x a week, limit alcohol to 1x a day, Na<2.3grams

Exercise daily for 30 minutes
Heart disease kills more women than breast CA

Drink tea! Evidence that tea consumption is associated with a reduced risk of vascular disease

Symptoms of heart attack in women (4)

Unusually heavy pressure on chest, like a ton of weight
----most heart attacks involve chest paint or discomfort in the center or left side of chese. Lasts for more than a few minutes or goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness, or pain. May feel like heartburn or indigestion

Sharp upper body pain in neck, back and jaw
----This symtom can include pain or discomfort in one or both arms, back, neck, shoulders, neck, jaw or upper part of stomach. Pain in back, neck and jaw is more common heart attack symptom for women than in men

Severe SOB
----can come on suddenly. May occur at rest or minimal activity. Struggling to breathe or trying to take deep breaths. SOB may start before or at the same time as chest pain or discomfort. May be your only symptom

Cold sweats and you know its not menopause
----Unexplained or excessive sweating, or breaking out into a cold sweat

Osteoporosis (5)

Decreased bone density- leaves bone fragile, porous, and susceptible to fractures

Most common in the vertebrae, wrists, and hips

24% of those with hip fx die within 1 year
80% women have it in U.S.A.

1/2 women over age 50 will have a fracture r/t osteoporosis

Risk for osteoporosis (11)

Small boned, thin
Fair skinned
White and Asian
Family Hx
Moderate/Heavy alcohol intake
Nulliparous
Lack of weight bearing exercise
Early menopause
Low calcium intake
Smoker
Meds= Lithium, steroids, anticonvulsants

Dx criteria of osteoporosis (3)

"Silent thief" Height decrease, waistline "disappears"
Common fractures in vertebrae, hip, distal forarm

DXA(dual-energy xray absorptiometry)
---Testing of postmenopausal women- not yet a standard of care to screen all women but if a pt has multiple risk factors it may be warranted

Px and management of osteoporosis (4)

EXERCISE
ERT- halts bone loss, decreases incidence of fracture, start therapy within 5yrs of menopause and continue for 10yrs ( the positive effect only lasts while during therapy)

Calcium needs
- Between age 20-50: 1000/day
-Postmenopause: 1200-1500mg/day
Vitamin D is necessary for calcium to be absorbed
-400 IU/day for healthy women
-Elderly: 800-100 IU/day
-Found in milk, corn flakes, eggs, margarine and sunshine

Calcium Dietary sources (9)

Milk
Yogurt
Cottage cheese
Swiss cheese
Sardines with the bone
Tofu
Green leafy vegetables
Broccoli
Tums

Drug Management of osteoporosis (2)

Gold Standard: Biphosphonates-Fosamax (Aldronate) Boniva 1x a month
-inhibits bone reabsorption

Evista (Raloxifene)- selective estrogen receptor modulator- doesn't increase breast or uterine ca risk
- increases bone mass in vertebra

Pt teaching with osteoporosis (4)

Quit smoking
drinking alcohol
avoid excessive caffiene
Prevent falls = rugs, electric cords, take care in the bathtub- dont fall

Pelvic organ prolapse & causes (5)

Downward displacement of 1 or more pelvic organs from their normal anatomical position

Caused:
weak support structures, trauma, neuropathic injury, disruption and stretching

Risk factors for pelvic organ prolapse (8)

Vag birth
Large babies
Multiparous
Aging
Excessive abd weight
constipation
heavy lifting
chronic cough

Vaginal wall Prolapse (5)

Cystocele = ANTERIOR VAGINAL WALL PROLAPSE

Anterior vaginal wall prolapses, bladder protrudes into the vagina

Results in incomplete bladder emptying, cystitis, stress urinary incontinence

Most common causes:
child birth, and tissue atrophy r/t menopause

Teach pt KEGELS

Enterocele (3)

Prolapse of the UPPER POSTERIOR vaginal wall between vagina and rectum. PROLAPSE OF SMALL BOWEL

Pouch of Douglas (a fold of peritoneum that dips down between the rectum and uterus)

May include a loop of bowel

Rectocele (4)

POSTERIOR wall of vagina weakens, during defecation, feces in the rectum protrudes into the vagina

May have difficulty having a BM
Digital pressure may be required

Pt teaching: Avoid Constipation

Uterine prolapse degrees & symptoms (7)

1st to 4th degree

Symptoms:
Feeling of pelvic fullness
Pelvic pressure
Low backache
Feeling that everything is falling out
Urinary frequency, urgency, incontinence
Constipation, flatulence, difficulty defecating
Symptoms worsen when standing

Uterine prolapse management (5)

Surgery=
Anterior and Posterior Colporrhaphy (A&P repair)
Sutures supporting fascia to lift bladder, perineum, or rectum
Vaginal hysterectomy
Pessary= device to support pelvic structures (inserted into vagina)
HRT- helps decrease genital atrophy and pelvic relaxation
KEGELS

Cultural lessons from Mali (4)

Marry early
Many children are a blessing
Nurse midwives are primary caregivers

Can obtain any meds except narcotics by going to a pharmacy

Uterine Leiomyomas (Fibroids) (5)

30% of women have clinically detectable fibroids- they are not CA
Unknown cause
Can occur anywhere in the uterus- at any layer of the uterus

Dx with PE, palpation with bimanual exam,f urther evaluated with US or MRI possibly a hysterosonography (saline infusion of the uterus trans vaginal ultrasound

Most patients do NOT have symptoms

s/s uterine leiomyomas (7) & when do they diminish

May be none or pelvic pressure
Excessive menses
Anemia
Weakness
Bloating
Urinary frequency
PAIN

Fibroids diminish in menopause

During pg fibroids may enlarge d/t

estrogen dependent

During pg fibroids may increase the risk of

miscarriage and preterm birth

Tx for uterine fibroids (7)

Factors to consider- size, location, preservation of fertility and SYMPTOMS

Myomectomy: surgical removal of fibroid
Hysterectomy
*uterine artery EMBOLIZATION (focuses on reducing the fibroid size by introducing obstruction in the arteries that supply the fibroid)
MRI guided US ablation
Combined Oral Contraceptives
GnRH antagonists reduce size of myomas and lessen symptoms before surgical removal

Candidiasis, Moniliasis, Yeast

Most common form of vaginitis NOT AN STD

risk factors for Yeast (3)

Pregnancy, Diabetes, ANTIBX therapy changes normal flora

s/s yeast (4)

Itching
vulvular and vaginal tissues inflamed
burning on urination
vag discharge is white with a cottage cheese appearance

dx of yeast

PE w/ wet mount possible culture of Candida Albicans

OTC tx for yeast (2) & 1 Rx drug

Miconazole (monistat)
Clotrimazole (gyne-Lotrimin)

Fluconazole (Diflucan)
Recommend to seek medical dx with the 1st occurrence. Need a Rx for oral dose Diflucan

Bacterial vaginosis, s/s, Dx, & drugs (6)

Most prevalent vaginitis & only 50% have symptoms

Caused by Bacillus Gardnerella Vaginalis and other microorganisms

Inhabits vagina of healthy women in a small number. If growth overpowers normal flora balance then infection occurs --> pH of vagina then >4.5

S/S thin, grayish white vaginal discharge, fishy odor
Dx: saline wet mount and whiff test, clue cells
Tx: Metronidazole, Clindamycin cream

Trichomoniasis- STD (6)

Caused by Trichomonas Vaginalis
anaerobic protozoan

Purulent vaginal discharge, thin, frothy, malodorous, yellow green color, vaginal itching, edema, redness

Cervix- strawberry spots, multiple, small petechiae

Dx Trichomoniasis

Dx- wet mount slide- see them moving

Tx Trich (4)

nonpregnant: Metroniadazole (Flagyl) NO ETOH intake during use (antabuse like reaction)

No sexual intercourse until cure is established to prevent reinfection

MUST check pt for other STDs

Associated with many perinatal complications and
THE INCREASED TRANSMISSION OF HIV TO FETUS

Chlamydia

Most common STD in western countries especially in teens

s/s chlamydia & dx (3)

incubation 7-21 days may be asymptomatic

May have yellowish vaginal discharge and painful urination
MAY CAUSE INFERTILITY IF NOT TREATED! PID!

Dx: Tissue culture of cervical cells: get with pap

tx chlamydia/4 drugs (6)

erythromycin while pg

doxycylcine (Vibramycin)
clindamycin (Cleocin)
azythromycin\

Must tx sex partner to px reexposure
retest after 3-4months

Gonorrhea (6) (includes 5 drugs)

Caused by gonococcus neissseria gonorrhea- incubation 3-5 days
May be asymptomatic and will progress to PID w/o tx

May have purulent discharge, dysuria, dyspareunia, pharyngitis, urinary frequency, vaginal bleeding btw periods

Dx: GC Culture
Tx: Ceftriaxone (Rocephin), PCN, Tetracycline, Doxycycline, Axithromycin DUAL THERAPY

Pt must be tested for other stds

PID pelvic inflammatory disease (8)

Acute salpingitis (fallopian tubes)- most freq acute infection in reproductive age non pregnant women (ages 15-19)

25% have 1 or more long term issues

Most common infections- Chlamydia, Gonorrhea

S/S fever >100.4, abd/pelvic pain, mucopurulent vag discharge.
Exam: Cervical motion tenderness CMT

Tx: Antibx (possible IVPB)

A single episode can cause infertility in 12-18% of women

Risks: under age 25, multiple partners, douching- not needed for hygiene, it actually puts pt at risk for infections because changing the vaginal pH

Syphilis (2)

Caused by spirochete Treponema Pallidum

Transmitted by direct contact with infectious, moist lesion
10-90 days chancre

Primary syphilis (3)

painless chancre on genitals, anus, lips, oral cavity
heals in 6wks
MOST INFECTIOUS

Secondary syphilis (5)

2wks to 6mos later
Generalized rash
Spirochete lives in blood
Enlargement of spleen, liver, lymphadema occurs
HA, anorexia, check palms and soles of feet for rash

Latent or Tertiary Syphilis (5)

May occur 4-20 yrs later
Damages heart valves/vessels
CNS effected
Generalized paralysis
psychosis- death

Dx syphilis (4)

Culture of chancre or blood test

VRDL: Venereal Disease Research Lab
RPR: Rapid Plasma Reagin
FTA-ABS- Fluorescent Treponema Antibody Absorption

Cure for syphilis

Benzathine penicillin G 2.4 million units IM

Just one dose!

genital Herpes (HSV) (10)

1 oral - pharyngeal
2 genital

Vesicles in clusters on vulva, perineum, perianal area,

Incubation 2-7 days, transmission by contact with secretions or mucosal surfaces with HSV

Primary infection: lesions are painful, flu like symptoms, fever, malaise, enlarged lymph nodes
(Severe effect on infant if primary infection occurs during 1st 20wks gestation)

Virus remains dormant in basal ganglia, periodically reactivates, especially with stress, fever, and menses

Recurrent episodes are less extensive or painful

Dx: Culture of fluid from vesicle, or blood test IgM + HSV

Tx: No cure, Acyclovir helps reduce symptoms, possible suppression therapy

HPV/Condylomata Acuminata/Venereal warts (4)

HPV- human papilloma virus- incubation 3months or longer

Dry, wartlike growths, small or resemble cauliflower

Common sites vagina, labia, cervix

99.7% of cervical cancer is caused by HPV

HPV tx (5)

Remove the warts, Trichloroacetic acid (topical)
Cryotherapy, electrocautery, laser

One study 91% patients with HPV test negative after 24months
If persisent infection- Cervical CA

Many serotypes >100

Oncogenic:
16>/50%
18. 10-15%

HPV vaccine & contraindications (5)

Recombinant L1 protein self assembles into virus like particles (antigen)

Stimulates immune system to produce antibodies

Gardasil (16,18,6,11) MEN also get HPV associated cancers
In males includes certain anal, penile, and oropharyngeal and oral cavity cancers primarily by HPV 16

Cevarix (16,18) ONLY WOMEN. 2 serotypes that cause the most cervical cancers in North America

Contraindications: yeast allergy, moderate or severe acute illness, PREGNANCY

Vaccine administration (5)

Series of 3 injections
1st dose, and then 2nd dose is 1-2 months later, then 3rd dose is 6months after the 1st dose

Costs $120 per dose, check with insurance for coverage

Almost 100% efficacy for prevention if given before sexual activity

Advisory Comittee on Immunization Practices recommend routine HPV4 vaccination of females and males aged 11-12yrs and catch-up on vaccination for males and females ages 13-18yrs

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