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TODAY’S TOPICS Contraception Infertility Menstrual Disorders Phases of the Menstrual Cycle Proliferative Phase (Follicular) 6-14d High Ovulation Secretory Phase (Luteal) 15-26d High Estrogen and FSHdevelop follicle 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 No in 72 hours after intercourse 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 •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. •Provide handouts, demonstration, discuss advantages and disadvantages of each method, •Allow time for questions and feedback INFERTILITY Inability 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 Varicoceles vas deferens 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 HystersalpingogramDye 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 Adoption Surrogate 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 6 month cessation after women has started periods Causes Congenital Obstructions Hormone Imbalance Secondary Causes Pregnancy/Lactation Poor Nutrition Dysmenorrhea—Painful Periods Primary Pain w/o pelvic pathology Incapacitate 2-3 days Organic/pathological Endometriosis, PID, ovarian cysts, myomas, IUD Cause Prostaglandins Vasopressin Dx U/S, D&C, biopsy Laparoscopy Treatment BCP’s Secondary & NSAID’s 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 SalpingoOophorectome (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.
