TODAY’S TOPICS

Contraception

Infertility

Menstrual Disorders

Phases of the Menstrual Cycle

Proliferative Phase (Follicular) 6-14d High Estrogen and FSHdevelop follicle

Ovulation Secretory Phase (Luteal) 15-26d

High Progesterone, Decreasing Estrogen Ischemic Phase 27-28d Menstrual Phase 1-6d

The Menstrual Cycle

Olds, S. London, M., Ladewig, P., Davidson, M. (2004). Maternal-newborn nursing & women’s health care.(7th ed.). Upper Saddle River, NJ.: Prentice Hall. (p. 211).

Contraception begins with Fertility Awareness

Ovulation Ovum can be fertilized w/in 48 hrs Sperm viable for 72 hrs Problem pinpointing ovulation

Basal Body Temperature (BBT)[chart] Progesterone increases = BBT increases Take temp when awakened Temp drops .2-.3 F; 24-36 before

ovulation Rises .7-.8 after ovulation--sample

Contraception begins with Fertility Awareness

Cervical Mucous (Spinbarkeit)

More abundant, thin clear, stretchy mucous at ovulation

Thickens and less amount until menses

Other Symptoms Mittelschmertz Increased libido Bearing Down Pain

Physiological Methods

Calendar Keep records for 6-8 months 18 days from end of SHORTEST cycle 11 days from end of LONGEST cycle Abstain during “fertile” times

BBT—website with calendar Billings Method

Barrier Methods

Male Condom Hold onto ring when withdrawing

Female Condom Diaphragm

Refit after each childbirth Use with Contraceptive Jelly Leave in for 6 hours AFTER intercourse If repeat intercourse, use more

spermicide Cervical Cap

Leave in for 8-48 hours

Chemical Methods IUD—Prevents fertilization

Mirena-5 years Paragard -10 years Risk of PID, Heavier periods

(paragard), perforation, dysmenorrhea

Teach to string after each menses Spermicides

May have to wait to dissolve Reapply with repeat intercourse Use with diaphragm/condom Non-oxinol 9—Kills HIV and other

STD’s

Chemical Methods—BCP’s Types

Combination P & E Progesterone ONLY “minipill” Phasic

Side effects (Table 5-2, p. 99 Olds et al) Estrogen effects: N/V, weight gain,

headaches, breast tenderness, etc. Progesterone effects: acne, breast

tenderness, ↓ libido, depression, fatigue, hirsuitism, weight gain, etc.

Contraindications Thrombophlebitis, CHD, Breast CA, SMOKER Some antibiotics DECREASE effectiveness

Long-Acting Chemical Methods

Implanon Lasts up to 3 years Flexible plastic rod the size of a

matchstick that is put under skin in the upper arm

Chief side effect: irregular bleeding Depo-Provera

Injection 4 x / yr Prolonged amennorhea or uterine

bleeding

Newer Chemical Methods Contraceptive Patch

ORTHO EVRA Contraceptive Ring

NuvaRing A helpful website

http://www.ultimatebirthcontrol.com/

Emergency Contraception

Take 2 BCP’s at once and 2 more 12 hours later

Use within 72 hours after unprotected intercourse

Prevents implantation

Operative Sterilization

Male Vasectomy Outpatient 81-91% reversal Ice for pain,

swelling NOT immediate

sterility—up to 36 ejaculations to rid ducts of all sperm

Sperm count to verify

Female Tubal Ligation Can be done with

C/sec General Anesthesia

or epidural if done after vaginal delivery

20 minutes Less successful

reversals

Outpatient Sterilization Essure-small

metallic implant that is placed into the fallopian tubes under hysteroscopic guidance Induces scar tissue

to form over the implant, blocking the fallopian tube and preventing fertilization of the egg by the sperm

99.8% effective Oral

contraceptives are often prescribed at least one month prior to insertion to induce endometrial atrophy and to prevent an undiagnosed pregnancy

Paracervical blocks are given to anesthetize the perineum

NSAIDs and Diazapam can be given during the procedure to minimize discomfort

Educate patients to use alternate contraceptive methods until a hysterosalpingogram is performed 3 months after placement to confirm complete blockage of fallopian tubes

99.8% effective

Abortion

ElectivePerformed at woman’s request

Therapeutic performed for reasons of maternal or fetal health

1st trimester Roe v. Wade

2nd trimester States decide

RU-486

Combination of 2 drugs Mifepristone is an anti-Progesterone

drug that stops the early pregnancy from growing.

Misoprostol is the second drug and causes the uterus to contract and an early pregnancy to be expelled.

Procedure

Confirm Pregnancy Blood test or U/S Take Mefipristone (1 pill) 2-4 days later, Take Misoprostol Come back to office in 2 weeks—U/S to

confirm NO pregnancy

Side Effects

Abdominal cramping pain, bleeding, nausea, vomiting, and diarrhea, which may be extreme in some cases.

Dilatation and Curettage (D&C) may be needed in rare cases.

Plan B Levonorgestrel

Emergency contraception-not effective if already pregnant Reduces risk of pregnancy when take after

unprotected sex With in 72 hours after intercourse

No prescription required for 17 years and older, prescription needed 16 yrs and younger

Plan B

Levonorgestrel works by stopping ovulation, fertilization, or implantation, depending on where a woman is in her cycle.

Side effects Nausea, abdominal pain, fatigue, headache

and changes in menstural cycle

NURSE’S ROLE IN BIRTH CONTROL COUNSELING

•Provide handouts, demonstration, discuss advantages and disadvantages of each method,

•Allow time for questions and feedback

•Assess patient’s knowledge, lifestyle, preferences, any cultural taboos or implications•Take a thorough patient history to identify any factors that put a patient at high risk for complications and rule out certain contraceptives.

INFERTILITYInability of a couple to produce a living child as a result of a failure to conceive or inability to carry the conceived child to a viable state after 12 months of unrestricted sexual relations

Categories

Primary Infertility Never having

conceived a child

Secondary Infertility Has conceived by

cannot conceive again or carry a pregnancy to viability after 1 year of unrestricted sexual relations

Causes of Infertility by Couple

Female Factor 50% Male Factor 35% Unexplained 10% Other 5%

Causes of Infertility in Women Endocrine Sources

Ovulatory Dysfunction 40% Anovulation or oligo-ovulation

Hyperprolactinemia Hyper- and hypo- thyroidism Premature ovarian failure Genetic Defects---Turner’s Syndrome (XO) Excessive Exercise and Dieting Polycystic Ovarian Syndrome Altered FSH:LH

ratio Severe Emotional Stress

Causes of Infertility in Women Non-endocrine Causes

Tubal & Uterine Factors 40% Block tubes (PID, endometriosis) Uterine Fibroids or malformed uterus

Unexplained 10% Other 10%

Causes of Infertility in Men

Sperm Factors Too few, Too slow, Too many malformed Injury, mumps, high fever, radiation, Substance abuse: ETOH, cocaine,

marijuana, cigarettes Meds: cimetidine, chemo, sulfas,

erythromycin, tetracycline

Causes of Infertility in Men

Endocrine Factors Klinefelter’s syndrome (XXY) Low testosterone levels Excessive Prolactin levels

Non-Endocrine Factors Obstructed vas deferens Varicoceles

Female Fertility Work-Up

BBT Cervical Mucous Endometrial Biopsy-

adequacy of secretory tissue in LUTEAL phase--effect of progesterone by corpus luteum

7 days BEFORE onset of menses Can have cramping afterwards

Female Fertility Work-Up

Hystersalpingogram- Dye instilled in uterus—Watch flow through

fallopian tubes Moderate discomfort

Laparoscopy General Anesthesia 6-8 months after Hysterosalpingogram Referred shoulder pain Evaluate for endometriosis, adhesions, tumors,

cysts

Male Fertility Work-Up

Sperm adequacy tests Count Motility Morphology Abstain for 2 days—Bring into lab within 1

hour after collection

Couple Tests

Post-Coital Tests 1-2 days prior to expected ovulation Couple has intercourse Go to MD within 4-6 hours Aspirate cervical mucous from os Evaluate mucous/sperm

Motility and Number

Infertility Trx--Medications

Olds et al, 9th ed. Pp. 252-255 Clomid-Estrogen Antagonist (po)

Take on days 5-9 Induces Ovulation

Pergonal, Humegon or Repronex (hMG) IM Direct effect on pituitary,stimulate FSH/LH

Infertility Treatments/Medications Fertinex, Follistim and Gonal F

purified FSH given SQ Start on day 2-4 of menstrual cycle Watch growth of follicles via U/S and

serum estradiol levels Give hCG IM when follicles/levels OK Have intercourse within 2 days

Egg Retrieval

Infertility Trx

Artificial Insemination 1-2 days BEFORE ovulation Fresh semen placed at cervical os

In-Vitro Fertilization (IVF) Stimulate ovum production—Harvest eggs Sperm and Egg meet in Test tube Fertilized ovum transferred into uterus

Infertility Trx

Gamete Intrafallopian Transfer (GIFT) Sperm and egg transferred separately into

fallopian tube where fertilization can occur Go past cervical mucous

Zygote Introfallopian Transfer (ZIFT) Fertilized zygote transferred into fallopian

tube and then travels back into uterus to implant

Other Alternatives

AdoptionSurrogate

Nurse’s Role in Infertility Trx

Highly Sensitive Issue Self-Esteem/Body Image Marital Relations Expensive

Menstrual Cycle & Disorders

Menarche Age at which menses begins Usually about 13 y/o, range 10-16

Menopause Time when periods stop; 50-51 y/o Initially periods are irregular, painless and

anovulatory—BUT can get pregnant Peri-menopausal period

PreMenstrual Syndrome (PMS)

Affects 30-40% of all women Three criteria need to be met

Symptoms occur in the luteal phase (after ovulation and 4-10 days before menses starts)

About 1 week w/o symptoms in follicular phase

Symptoms sever enough to interfere with life

Characteristic Symptoms

Fluid Retention/ Bloating

Anxiety/Irritability Agitation/

Arguementative Depression/Crying Lethargy Panic Attacks

Accident Prone Decreased

concentration Food Cravings

Salt & Sweets Breast tenderness

Headaches/

dizziness

Causes of PMS

Unknown Interaction between Estrogen and

Progesterone--Progesterone Deficiency Prolactin & Prostaglandin Excess ? Role of Endorphins Nutritional Deficiency—Mg ++

Treatments

Track symptoms BCP’s, Progesterone Prostaglandin Inhibitors

Efamol Mefenamic Acid 250mg/day in luteal phase

Danazol & Xanax less effective

Toxic Shock Syndrome

Pyrogenic exotoxins from Staph. Aureus

15-24 y/o, using tampons Three Principal Clinical Manifestations

Sudden onset high Fever > 102 HYPOtension, systolic < 90mm Hg Rash—diffuse, macular, desquamation of

palms and soles Other S/S

Treatment

Early dx is critical IV fluid—trx dehydration Antibiotics Platelets Meds for skin rash and hypotension

NURSING EDUCATION

Olds et al, 9th ed. p.135

“Client Self-Care—Prevention of TSS”

Amenorrhea

Primary Absence or

Cessation of periods

Causes Congenital

Obstructions Hormone

Imbalance

Secondary 6 month cessation

after women has started periods

Causes Pregnancy/

Lactation Poor Nutrition

Dysmenorrhea—Painful Periods

Primary Pain w/o pelvic

pathology Incapacitate 2-3

days Cause

Prostaglandins Vasopressin

Treatment BCP’s & NSAID’s

Secondary Organic/

pathological Endometriosis, PID,

ovarian cysts, myomas, IUD

Dx U/S, D&C, biopsy

Laparoscopy Trx depends on

cause

Endometriosis

Endometrial tissue outside the uterus ovary, tubes, vaginal vault, abdomen

Tissue responds to hormonal changes of menstrual cycle Bleed, inflammation, scarring, adhesions

3-10% of all women, 25-25% of infertile women, 28% of women with chronic pelvic pain

Cause of Endometriosis

Again—UNKNOWN ? Reflux of fallopian tube, retrograde

menstruation endometrial tissue cells go out into abdominal cavity

Symptoms

Vary Greatly Little disease Lots of Pain Lots of disease Little Pain

Dysmennorhea Chronic, non-cyclic pelvic pain Dysparueunia Diarrhea/Constipation Infertility

Treatments

Medication Lupron & Synarel GnRH agonists Danazol Oral Contraceptives

Surgical Laparoscopy or Laparotomy Total Abdominal Hysterectomy with

Bilateral Salpingo-Oophorectome (TAH w/ BSO)

Nursing Assessment & Care

Gynecological History Symptoms Nursing Diagnoses

Anxiety; Body Image, disturbances of Self-Image; Knowledge Deficit, Pain

Encourage woman to avoid delaying pregnancy if desired d/t increased risk of infertility.