Amenorrhea is most commonly a result of pregnancy, although it may occur from any defect or interruption in the hypothalamic-pituitary-ovarian-uterine axis (see Chapter 2). It may also result from anatomic abnormalities; other endocrine disorders, such as hypothyroidism or hyperthyroidism; chronic diseases, such as type 1 diabetes; medications, such as phenytoin (Dilantin); eating disorders; strenuous exercise; emotional stress; and oral contraceptive use.

Hypogonadotropic amenorrhea reflects a problem in the central hypothalamic-pituitary axis. In rare instances a pituitary lesion or genetic inability to produce FSH and LH is at fault. More commonly, it results from hypothalamic suppression as a result of two principal influences: stress (in the home, school, or workplace) or a body fat-to-lean ratio that is inappropriate for an individual woman, especially during a normal growth period (Lobo, 2007d). Research has demonstrated a biologic basis for the relationship of stress to physiologic processes. Exercise-associated amenorrhea can occur in women undergoing vigorous physical and athletic training and is associated with many factors, including body composition (height, weight, and percentage of body fat); type, intensity, and frequency of exercise; nutritional status; and the presence of emotional or physical stressors (Lobo). Amenorrhea is one of the classic signs of anorexia nervosa, and the interrelatedness of disordered eating, amenorrhea, and altered bone mineral density has been described as the female athlete triad (Lebrun, 2007). Calcium loss from bone, comparable to that seen in postmenopausal women, may occur with this type of amenorrhea.

Assessment of amenorrhea begins with a thorough history and physical examination. An important initial step is to confirm that the woman is not pregnant. Specific components of the assessment process depend on a woman’s age—adolescent, young adult, or perimenopausal—and whether she has previously menstruated.

Management

When amenorrhea is caused by hypothalamic disturbances, the nurse is an ideal health professional to assist women because many of the causes are potentially reversible (e.g., stress, weight loss for nonorganic reasons). When a stressor known to predispose a woman to hypothalamic amenorrhea is identified, initial management involves addressing the stressor. Together the woman and nurse plan how to decrease or discontinue medications known to affect menstruation, correct weight loss, deal more effectively with psychologic stress, and eliminate substance abuse. Deep-breathing exercises and relaxation techniques are simple yet effective stress-reduction measures. Referral for biofeedback or massage therapy also may be useful. In some instances, referral for psychotherapy is indicated.

If a woman’s exercise program is contributing to her amenorrhea, several options exist for management. She may decide to decrease the intensity or duration of her training, if possible, or to gain some weight, if appropriate. Accepting this alternative is often difficult for women who are committed to a strenuous exercise regimen. Some young women athletes do not understand the consequences of low bone density or osteoporosis; nurses can point out the connection between low bone density and stress fractures. If the woman continues to have low estrogen levels, instituting estrogen therapy, as well as calcium supplementation for osteoporosis prevention, is sometimes necessary (Lobo, 2007d).

Cyclic Perimenstrual Pain and Discomfort

Cyclic perimenstrual pain and discomfort (CPPD) is a concept developed by a nurse science team for a research project for the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) (AWHONN, 2003; Collins Sharp, Taylor, Thomas, Killeen, & Dawood, 2002). This concept includes dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder, as well as symptom clusters that occur before and after the menstrual flow starts. CPPD is a health problem that can have a significant impact on the quality of life for a woman. The following discussion focuses on the three main conditions of CPPD.

Dysmenorrhea, 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. Approximately 75% of women report some level of discomfort associated with menses, and approximately 15% report severe dysmenorrhea (Lentz, 2007b); however, the amount of disruption in women’s lives is difficult to determine. Researchers have 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 relatively more common in women who smoke and who are obese. Severe dysmenorrhea is also associated with early menarche, nulliparity, and stress (Lentz). Traditionally dysmenorrhea is differentiated as primary or secondary. 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.

Critical Thinking/Clinical Decision Making

Management of Dysmenorrhea

Cheri, 16, has come to the Adolescent Health Clinic for a check up. She reports that she has “really bad cramps” for the first 2 days of her period. She has been taking Midol Menstrual Complete but says it does not help “a lot.” She wants to know if anything else can be done to relieve her pain. How should the nurse respond?

1. Evidence—Is evidence sufficient to draw conclusions about what advice the nurse should give?

2. Assumptions—Describe underlying assumptions about the following issues:

a. Causes and symptoms of primary dysmenorrhea

b. Cyclic perimenstrual pain and discomfort

c. Self-help strategies (e.g., comfort measures, medications)

3. What implications and priorities for nursing care can be drawn at this time?

4. Does the evidence objectively support your conclusion?

5. Do alternative perspectives to your conclusion exist?

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. For some women, pain radiates to the lower back or upper thighs.

Primary dysmenorrhea

Primary dysmenorrhea is a condition associated with ovulatory cycles. Research has shown that primary dysmenorrhea has a biochemical basis and arises from the release of prostaglandins with menses. During the luteal phase and subsequent menstrual flow, prostaglandin F₂-alpha (PGF_2a) is secreted. Excessive release of PGF_2a increases the amplitude and frequency of uterine contractions and causes vasospasm of the uterine arterioles, resulting in ischemia and cyclic lower abdominal cramps. Systemic responses to PGF_2a include backache, weakness, sweats, gastrointestinal symptoms (anorexia, nausea, vomiting, and diarrhea), and central nervous system symptoms (dizziness, syncope, headache, and poor concentration). Pain usually begins at the onset of menstruation and lasts 8 to 48 hours (Lentz, 2007b).

Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established. Anovulatory bleeding, common in the few months or years after menarche, is painless. Because both estrogen and progesterone are necessary for primary dysmenorrhea to occur, it is experienced only with ovulatory cycles. This problem is more common among women in their late teens and early twenties than in women in older age groups; the incidence declines with age. Psychogenic factors may influence symptoms, but symptoms are definitely related to ovulation and do not occur when ovulation is suppressed.

Management.

Management of primary dysmenorrhea depends on the severity of the problem and the individual woman’s response to various treatments. Important components of nursing care are information and support. Because menstruation is so closely linked to reproduction and sexuality, menstrual problems such as dysmenorrhea can have a negative influence on sexuality and self-worth. Nurses can correct myths and misinformation about menstruation and dysmenorrhea by providing facts about what is normal. Nurses must support their patients’ feelings of positive sexuality and self-worth.

Often, you can offer more than one alternative for alleviating menstrual discomfort and dysmenorrhea, which gives women options to try and decide which works best for them. Heat (heating pad or hot bath) minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia. Massaging the lower back can reduce pain by relaxing paravertebral muscles and increasing the pelvic blood supply. Soft, rhythmic rubbing of the abdomen (effleurage) is useful because it provides a distraction and an alternative focal point. Biofeedback, transcutaneous electrical nerve stimulation (TENS), progressive relaxation, Hatha yoga, acupuncture, and meditation are also used to decrease menstrual discomfort, although evidence is insufficient to determine their effectiveness (Lentz, 2007b).

Exercise helps relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia. Exercise also releases endogenous opiates (specifically beta-endorphins), suppresses prostaglandins, and shunts blood flow away from the viscera, resulting in reduced pelvic congestion. One specific exercise that nurses can suggest is pelvic rocking.

In addition to maintaining good nutrition at all times, specific dietary changes are helpful in decreasing some of the systemic symptoms associated with dysmenorrhea. Decreased salt and refined sugar intake 7 to 10 days before expected menses may reduce fluid retention. Natural diuretics such as asparagus, cranberry juice, peaches, parsley, or watermelon may help reduce edema and related discomforts. Decreasing red meat intake may also help minimize dysmenorrheal symptoms.

Medications used to treat primary dysmenorrhea include prostaglandin synthesis inhibitors, primarily nonsteroidal antiinflammatory drugs (NSAIDs) (Lentz, 2007b) (Table 3-1). NSAIDs are most effective if started several days before menses or at least by the onset of bleeding. All NSAIDs have potential gastrointestinal side effects, including nausea, vomiting, and indigestion. Warn all women taking NSAIDs to report dark-colored stool because this may be an indication of gastrointestinal bleeding.

TABLE 3-1

Nonsteroidal Antiinflammatory Agents Used to Treat Dysmenorrhea

DRUG	BRAND NAME AND STATUS	RECOMMENDED DOSAGE (ORAL)	COMMON SIDE EFFECTS	COMMENTS	CONTRAINDICATIONS
Diclofenac	Cataflam Rx	50 mg tid or 100 mg initially, then 50 mg tid up to 150 mg/day	Nausea, diarrhea, constipation, abdominal distress, dyspepsia, heartburn, flatulence, dizziness, tinnitus, itching, rash	Enteric coated: immediate release	For all NSAIDs: Do not give if patient has hemophilia or bleeding ulcers, do not give if patient has had an allergic or anaphylactic reaction to aspirin or another NSAID, do not give if patient is taking anticoagulant medication.
Ibuprofen	Motrin Rx	400 mg q 6-8 hrs	See diclofenac	If GI upset occurs, take with food, milk, or antacids; avoid alcoholic beverages; do not take with aspirin; stop taking and call care provider if rash occurs
Ibuprofen	Advil OTC, Nuprin OTC, Motrin IB OTC	200 mg q 4-6 hrs up to 1200 mg/day	See diclofenac
Ketoprofen	Orudis Rx	25-50 mg q 6-8 hrs up to 300 mg/day	See diclofenac	See ibuprofen
Ketoprofen	Orudis KT OTC, Actron OTC	12.5 mg q 6-8 hrs up to 75 mg/day	See diclofenac	See ibuprofen
Meclofenamate	Meclofenamate	100 mg tid up to 300 mg	See diclofenac	See ibuprofen
Mefenamic acid	Ponstel Rx	500 mg initially, then 250 mg q 6 hr	See diclofenac	Very potent and effective prostaglandin-synthesis inhibitor; antagonizes already formed prostaglandins; increased incidence of adverse GI side effects
Naproxen	Naprosyn Rx	500 mg initially, then 250 mg q 6-8 hr up to 1250 mg/day	See diclofenac	See ibuprofen
Naproxen sodium	Anaprox Rx	550 mg initially, then 275 mg q 6-8 hr or 550 mg q12 hr up to 1375 mg/day	See diclofenac	See ibuprofen
	Aleve OTC	440 mg initially, then 220 mg q 6-8 hr up to 660 mg/day
Celecoxib	Celebrex	400 mg initially, then 200 mg bid	See diclofenac	See ibuprofen

GI, Gastrointestinal; NSAID, nonsteroidal antiinflammatory drug; OTC, over the counter.

Data from Facts and Comparisons. (2012). Nonsteroidal antiinflammatory drugs. www.factsandcomparisons.com; Lentz, G.M. (2012). Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder: etiology, diagnosis, and management. In Lentz, G.M., Lobo, R.A., Gershenson, D.M., et al. (Eds.). Comprehensive gynecology (6th ed.). Philadelphia: Mosby; U.S. Department of Health and Human Services, U.S. Food and Drug Administration. (2008). Medication guide for nonsteroidal antiinflammatory drugs (NSAIDs). www.fda.gov/CDER/drug/infopage/COX2/NSAIDmedguide.htm.

Nursing Alert

If one NSAID is ineffective, a different one may often be effective. If the second drug is unsuccessful after a 6-month trial, combined oral contraceptive pills (OCPs) may be used. Women with a history of aspirin sensitivity or allergy should avoid all NSAIDs.

OCPs prevent ovulation and can decrease the amount of menstrual flow, which can decrease the amount of prostaglandin, thus decreasing dysmenorrhea. There is evidence that combined OCPs can effectively treat dysmenorrhea (Lentz, 2007b). OCPs may be used in place of NSAIDs if the woman wants oral contraception and has primary dysmenorrhea. OCPs have side effects, and women who do not need or want them for contraception may not wish to use them for dysmenorrhea. OCPs also may be contraindicated for some women.

Over-the-counter (OTC) preparations that are formulated for primary dysmenorrhea include the same active ingredients (e.g., ibuprofen, naproxen sodium) as prescription preparations. However, the labeled recommended dose is often subtherapeutic. Preparations containing acetaminophen are even less effective because acetaminophen does not have the antiprostaglandin properties of NSAIDs.

Alternative and complementary therapies are increasingly popular and used in developed countries. Therapies such as acupuncture, acupressure, biofeedback, desensitization, hypnosis, massage, reiki, relaxation exercises, and therapeutic touch have been used to treat pelvic pain (Dehlin & Schuiling, 2006). Herbal preparations have long been used for the management of menstrual problems, including dysmenorrhea (Table 3-2). Herbal medicines can be valuable in treating dysmenorrhea; however, women must understand that these therapies are not without potential toxicity and may cause drug interactions. Women should use herbal preparations from well-established companies. It is also important to know that research is limited about the effectiveness of use (Dehlin & Schuiling, 2006).

TABLE 3-2

Herbal Therapies for Menstrual Disorders

SYMPTOMS OR INDICATIONS	HERBAL THERAPY	ACTION
Menstrual cramping	Black haw	Uterine antispasmodic
	Ginger	Antiinflammatory
	Valerian	Uterine antispasmodic
Premenstrual discomfort	Black cohosh root	Estrogen-like LH suppressant; binds to estrogen receptors
Premenstrual discomfort	Chaste tree fruit	Decreases prolactin levels
Tension, breast pain	Bugleweed	Antigonadotropic; decreases prolactin levels
Dysmenorrhea	Potentilla	Uterotonic
Dysmenorrhea	Dong quai	Antiinflammatory; possibly analgesic activity
Menorrhea, metrorrhagia	Shepherd’s purse	Uterotonic

LH, Luteinizing hormone.

Sources: Bascom, A. (2002). Incorporating herbal medicine into clinical practice. Philadelphia: FA Davis; Fugh-Berman, A., & Awang, D. (2001). Black cohosh. Alternative Therapies in Women’s Health, 39(11), 81-85; Dog, L. (2001). Conventional and alternative treatments for endometriosis. Alternative Therapies, 7(6), 50-56; Stevinson, C., & Ernst, E. (2001). Complementary/alternative therapies for premenstrual syndrome: A systemic review of randomized controlled trials. American Journal of Obstetrics and Gynecology, 185(1), 227-235.

Secondary dysmenorrhea

Secondary dysmenorrhea is menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25. It is associated with pelvic abnormalities such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, submucous or interstitial myomas (uterine fibroids), or use of an intrauterine device (IUD). Pain often begins a few days before menses, but it 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. Women often experience feelings of bloating or pelvic fullness. Treatment is directed toward removal of the underlying pathology. Many of the measures described for pain relief of primary dysmenorrhea are also helpful for women with secondary dysmenorrhea.

Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Nursing Care Plan: Premenstrual Syndrome

Approximately 30% to 80% of women experience mood or somatic symptoms (or both) that occur with their menstrual cycles (Lentz, 2007b). Establishing a universal definition of premenstrual syndrome (PMS) is difficult, given that so many symptoms have been associated with the condition, and at least two different syndromes have been recognized: PMS and premenstrual dysphoric disorder (PMDD).

PMS is a complex, poorly understood condition that includes one or more of a large number (more than 100) of physical and psychologic symptoms beginning in the luteal phase of the menstrual cycle, occurring to such a degree that lifestyle or work is affected, and followed by a symptom-free period. Symptoms include fluid retention (abdominal bloating, pelvic fullness, edema of the lower extremities, breast tenderness, and weight gain); behavioral or emotional changes (depression, crying spells, irritability, panic attacks, and impaired ability to concentrate); premenstrual cravings (sweets, salt, increased appetite, and food binges); and headache, fatigue, and backache.

PMDD is a more severe variant of PMS in which 3% to 8% of women have marked irritability, dysphoria, mood lability, anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed (Lentz, 2007b).

A diagnosis of PMS is made when the following criteria are met (American College of Obstetrics and Gynecology [ACOG], 2000; AWHONN, 2003):

• Symptoms consistent with PMS occur in the luteal phase and resolve within a few days of menses onset.

• Symptom-free period occurs in the follicular phase.

• Symptoms are recurrent.

• Symptoms have a negative impact on some aspect of a woman’s life.

• Other diagnoses that better explain the symptoms have been excluded.

For a diagnosis of PMDD, the following criteria must be met (American Psychiatric Association [APA], 2000):

• Five or more affective and physical symptoms are present in the week before menses and are absent in the follicular phase of the menstrual cycle.

• At least one of the symptoms is irritability, depressed mood, anxiety, or emotional lability.

• Symptoms interfere markedly with work or interpersonal relationships.

• Symptoms are not caused by an exacerbation of another condition or disorder.

• These criteria must be confirmed by prospective daily ratings for at least two menstrual cycles (APA, 2000).

The causes of PMS and PMDD are unknown. Researchers have theorized that PMS has a significant psychologic component or may result from cultural beliefs that lead to the menstrual cycle being associated with a variety of negative reactions. In reality, PMS is most likely not a single disorder but is rather a collection of different problems (Lentz, 2007b). Much controversy exists regarding PMS. The existence, diagnosis, and causes of PMS are controversial. Explore current feminist, medical, and social science literature for more information on these topics.

Management

Little agreement exists on management. A careful, detailed history and daily log of symptoms and mood fluctuations spanning several cycles may give direction to a plan of management. Any changes that assist a woman with PMS to exert control over her life have a positive impact. For this reason, lifestyle changes are often effective in the treatment of PMS.

Education is an important component of the management of PMS. Nurses can advise women that self-help modalities often result in significant symptom improvement. Women have found a significant number of complementary and alternative therapies to be useful in managing the symptoms of PMS. Diet and exercise changes are a useful way to begin and provide symptom relief for some women. Suggest that women refrain from smoking and limit their consumption of refined sugar (less than 5 tbsp/day), salt (less than 3 g/day), red meat (up to 3 oz/day), alcohol (less than 1 oz/day), and caffeinated beverages. Also, encourage them to include whole grains, legumes, seeds, nuts, vegetables, fruits, and vegetable oils in their diet. Three small-to-moderate-sized meals and three small snacks a day that are rich in complex carbohydrates and fiber help reduce symptoms (Lentz, 2007b). Use of natural diuretics (see section on dysmenorrhea management) also helps reduce fluid retention as well. Nutritional supplements may assist in symptom relief. Calcium (1000-1200 mg daily), magnesium (300-400 mg daily), and vitamin B₆ (100-150 mg daily) have been reported to be moderately effective in relieving symptoms, have few side effects, and are safe. Daily supplements of evening primrose oil are also useful in relieving breast symptoms with minimal side effects. Other herbal therapies have long been used to treat PMS; Table 3-2 lists specific suggestions.

Regular exercise (aerobic exercise three to four times a week), especially in the luteal phase, is widely recommended for relief of PMS symptoms (Lentz, 2007b). A monthly program that varies in intensity and type of exercise according to PMS symptoms is best. Women who exercise regularly seem to have less premenstrual anxiety than do nonathletic women. Researchers believe aerobic exercise increases beta-endorphin levels to offset symptoms of depression and elevate mood. Yoga, acupuncture, hypnosis, chiropractic therapy, and massage therapy have all been reported to have a beneficial effect on PMS. Further research is needed for all of these suggested therapies.

Nurses can explain the relationship between cyclic estrogen fluctuation and changes in serotonin levels, that serotonin is one of the brain chemicals that assist in coping with normal life stresses, and how the different management strategies recommended help maintain serotonin levels. Counseling, in the form of support groups or individual or couple counseling, is helpful. Stress-reduction techniques also may assist with symptom management (Lentz, 2007b).

Nursing Care Plan: Endometriosis

If these strategies do not provide significant symptom relief in 1 to 2 months, medication is often begun. Many medications have been used in treatment of PMS, but no single medication alleviates all PMS symptoms. Medications often used in the treatment of PMS include diuretics, prostaglandin inhibitors (NSAIDs), progesterone, and OCPs. Selective serotonin reuptake inhibitors such as Fluoxetine (Sarafem or Prozac) are U.S. Food and Drug Administration (FDA)-approved agents for PMS. Use of these medications results in a decrease in emotional symptoms, especially depression (Lentz, 2007b).

Endometriosis

Endometriosis is the presence and growth of endometrial tissue outside of the uterus. The tissue may be implanted on the ovaries, cul-de-sac, uterine ligaments, rectovaginal septum, sigmoid colon, pelvic peritoneum, cervix, or inguinal area (Fig. 3-1). Endometrial lesions have been found in the vagina and in surgical scars; on the vulva, perineum, and bladder; and in sites far from the pelvic area, such as the thoracic cavity, gallbladder, and heart. A chocolate cyst is a cystic area of endometriosis in the ovary. Old blood causes the dark coloring of the cyst’s contents.

Endometrial tissue contains glands and stoma and responds to cyclic hormonal stimulation in the same way that the uterine endometrium does but is often out of phase with it. During the proliferative and secretory phases of the cycle the endometrial tissue grows. During or immediately after menstruation the tissue bleeds, resulting in an inflammatory response with subsequent fibrosis and adhesions to adjacent organs.

Endometriosis is a common gynecologic problem, affecting from 6% to 10% of women of reproductive age (Lobo, 2007b). Although the condition usually develops in the third or fourth decade of life, endometriosis occurs in approximately 10% of adolescents with disabling pelvic pain or abnormal vaginal bleeding (ACOG, 2005). The condition is found equally in Caucasian and African-American women, is slightly more prevalent in Asian women, and may have a familial tendency for development (Lobo, 2007b). Endometriosis may worsen with repeated cycles, or it may remain asymptomatic and undiagnosed, eventually disappearing after menopause.

Several theories have been offered to account for the cause of endometriosis, yet the causes and pathologic features of this condition are poorly understood. One of the most widely accepted, long-debated theories is transtubal migration or retrograde menstruation. According to this theory, endometrial tissue is regurgitated or mechanically transported from the uterus during menstruation to the uterine tubes and into the peritoneal cavity, where it implants on the ovaries and other organs.

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 dysmenorrhea, infertility, and deep pelvic dyspareunia (painful intercourse). Women also 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 secondary to 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 (Lobo, 2007b).

Management

Treatment is based on the severity of symptoms and the goals of the woman or couple. Women without pain who do not want to become pregnant need no treatment. Women with mild pain who may desire a future pregnancy may use NSAIDs for pain relief. Women who have severe pain and can postpone pregnancy may be treated with continuous OCPs that have a low estrogen-to-progestin ratio to shrink endometrial tissue. However, when this therapy stops, women often experience high rates of recurrence of pain and other symptoms.

Hormonal antagonists that suppress ovulation and reduce endogenous estrogen production and subsequent endometrial lesion growth are currently used to treat mild to severe endometriosis in women who wish to become pregnant at a future time. Gonadotropin-releasing hormone (GnRH) agonist therapy (leuprolide, nafarelin [Synarel], goserelin acetate [Zoladex]) acts by suppressing pituitary gonadotropin secretion. FSH and LH stimulation to the ovary declines noticeably, and ovarian function decreases significantly. The hypoestrogenism results in hot flashes in almost all women. In addition, minor bone loss sometimes occurs, most of which is reversible within 12 to 18 months after the medication is stopped. Leuprolide (3.75 mg intramuscular injection given once a month) or nafarelin (200 mcg administered twice daily by nasal spray) are both effective and well tolerated. Both medications reduce endometrial lesions and pelvic pain associated with endometriosis and have posttreatment pregnancy rates similar to that of danazol therapy (Lobo, 2007b). Common side effects of these drugs are similar to those of natural menopause—hot flashes and vaginal dryness. Some women report headaches and muscle aches. These medications are not given to adolescents as the hypoestogenic state that occurs can affect bone mineralization (ACOG, 2005).

Danazol (Danocrine), a mildly androgenic synthetic steroid, suppresses FSH and LH secretion, thus producing anovulation with resulting decreased secretion of estrogen and progesterone and regression of endometrial tissue. Bothersome side effects include masculinizing traits in the woman—weight gain, edema, decreased breast size, oily skin, hirsutism, and deepening of the voice—all of which often disappear when treatment is discontinued. Other side effects are amenorrhea, hot flashes, vaginal dryness, insomnia, and decreased libido. Some women report migraine headaches, dizziness, fatigue, and depression. In addition, some women experience decreases in bone density that are only partially reversible. Danazol should never be prescribed when pregnancy is suspected, and contraception should be used with it because ovulation may not be suppressed. Danazol can produce pseudohermaphroditism in female fetuses. The drug is contraindicated in women with liver disease and should be used with caution in women with cardiac and renal disease (Lobo, 2007b).

Surgical intervention is often needed for severe, acute, or incapacitating symptoms. A woman’s age, desire for children, and location of the disease influence decisions regarding the extent and type of surgery. For women who do not want to preserve their ability to have children, the only definite cure is hysterectomy and bilateral salpingo-oophorectomy (BSO) (total abdominal hysterectomy [TAH] with BSO). In women who are in their childbearing years and who want children if the disease does not prevent pregnancy, surgery or laser therapy is used to carefully remove as much endometrial tissue as possible to maintain reproductive function (Lobo, 2007b).

Short of TAH with BSO, endometriosis recurs in approximately 40% to 50% of women, regardless of the form of treatment. Therefore, for many women, endometriosis is a chronic disease with conditions such as chronic pain or infertility. Counseling and education are critical components of nursing care of women with endometriosis. Women need an honest discussion of treatment options with potential risks and benefits of each option reviewed. Because pelvic pain is a subjective, personal experience that can be frightening, support is important. Sexual dysfunction resulting from dyspareunia may be present and may necessitate referral for counseling. Some locations have support groups for women with endometriosis. The nursing care measures discussed in the section on dysmenorrhea are appropriate for managing chronic pelvic pain associated with endometriosis (see Nursing Care Plan).

Nursing Care Plan

Endometriosis

Nursing Diagnosis Acute pain related to menstruation secondary to endometriosis

Expected outcome Woman will verbalize a decrease in intensity and frequency of pain during each menstrual cycle.

Nursing Interventions/Rationales

• Assess location, type, and duration of pain and history of discomfort to determine the severity of dysmenorrhea.

• Administer analgesics to assist with pain relief.

• Administer hormone-altering medications if ordered to suppress ovulation.

• Provide nonpharmacologic methods such as heat to increase blood flow to the pelvic region.

Nursing Diagnosis Deficient knowledge related to unfamiliarity with treatment, as evidenced by patient statements

Expected outcome Woman will verbalize correct understanding of the use of self-management methods and prescribed therapies.

Nursing Interventions/Rationales

• Assess the woman’s current understanding of the disorder and related therapies to validate the accuracy of the knowledge base.

• Give information to the woman regarding the disorder and treatment regimen to empower the woman to become a partner in her own care.

Nursing Diagnosis Situational low self-esteem related to infertility as evidenced by the patient’s statements of decreased self-worth

Expected outcome Woman will verbalize positive feelings of self-worth.

Nursing Interventions/Rationales

• Provide therapeutic communication to validate feelings and provide support.

• Refer the woman to a support group to enhance feelings of self-worth through group communication.

Nursing Diagnosis Anxiety related to possible invasive surgical procedure as evidenced by the patient’s verbal report

Expected outcome Woman will report a decreased number of anxious feelings.

Nursing Interventions/Rationales

• Provide the opportunity to discuss feelings to identify source of anxiety.

• Reinforce information provided to keep expectations realistic and dispel myths or inaccuracies.

• Provide emotional support to encourage verbalization of feelings.

Nursing Diagnosis Risk for injury related to disease progression

Expected outcome Woman will report any changes in health status to the health care provider.

Nursing Interventions/Rationales

• Teach the woman to report any changes in health status to initiate prompt treatment.

• Review side effects of medications to recognize possible rationales for changes in health status.

• Encourage ongoing communication with the health care provider to promote trust and comfort.

Alterations in Cyclic Bleeding

Women often experience changes in amount, duration, interval, or regularity of menstrual cycle bleeding. Commonly, women worry about menstruation that is infrequent or scanty (oligomenorrhea), is excessive (menorrhagia), or occurs between periods (metrorrhagia).

Treatment depends on the cause and may include education and reassurance. For example, tell women that OCPs can cause scanty menstrual flow and midcycle spotting. Progestin intramuscular injections and implants can also cause midcycle bleeding. A single episode of heavy bleeding may signal an early pregnancy loss such as a miscarriage or ectopic pregnancy. This type of bleeding is often thought to be a period that is heavier than usual, perhaps delayed, and is associated with abdominal pain or pelvic discomfort. When early pregnancy loss is suspected, hematocrit and pregnancy tests are indicated.

Uterine leiomyomas (fibroids or myomas) are a common cause of menorrhagia. Fibroids are benign tumors of the smooth muscle of the uterus with an unknown cause. Fibroids occur in approximately one fourth of women of reproductive age; the incidence of fibroids is higher in African-American women than in Caucasian, Asian, or in Hispanic women (Katz, 2007). Other uterine growths ranging from endometrial polyps to adenocarcinoma and endometrial cancer are common causes of heavy menstrual bleeding, as well as intermenstrual bleeding.

Treatment for menorrhagia depends on the cause of the bleeding. If the bleeding is related to contraceptive method (e.g., an IUD), provide factual information and reassurance and discuss other contraceptive options. If bleeding is related to the 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. Most fibroids can be monitored by frequent examinations to judge growth, if any, and correction of anemia, if present. Warn women with metrorrhagia to avoid using aspirin because of its tendency to increase bleeding. Medical treatment is directed toward temporarily reducing symptoms, shrinking the myoma, and reducing its blood supply (Katz, 2007). This reduction is often accomplished with the use of a GnRH agonist. If the woman wishes to retain childbearing potential, a myomectomy may be performed. Myomectomy, or removal of the tumors only, is particularly difficult if multiple myomas must be removed. If the woman does not want to preserve her childbearing function, or if she has severe symptoms (severe anemia, severe pain, considerable disruption of lifestyle), uterine artery embolization (procedure that blocks blood supply to fibroid), endometrial ablation (laser surgery or electrocoagulation), or hysterectomy (removal of uterus) may be performed.

Dysfunctional uterine bleeding

Abnormal uterine bleeding (AUB) is any form of uterine bleeding that is irregular in amount, duration, or timing and is not related to regular menstrual bleeding. Box 3-1 lists possible causes of AUB. Although often used interchangeably, the terms AUB and dysfunctional uterine bleeding (DUB) are not synonymous. DUB is a subset of AUB defined as “excessive uterine bleeding with no demonstrable organic cause (genital or extragenital)” (Lobo, 2007a, p. 915). DUB is most commonly caused by anovulation. When no surge of LH occurs, or if insufficient progesterone is produced by the corpus luteum to support the endometrium, it will begin to involute and shed. This process most often occurs at the extremes of a woman’s reproductive years—when the menstrual cycle is just becoming established at menarche or when it draws to a close at menopause. DUB also occurs with any condition that gives rise to chronic anovulation associated with continuous estrogen production. Such conditions include obesity, hyperthyroidism and hypothyroidism, polycystic ovarian syndrome, and any of the endocrine conditions discussed in the sections on amenorrhea and oligomenorrhea. A diagnosis of DUB is made only after ruling out all other causes of abnormal menstrual bleeding (Lentz, 2007a).

BOX 3-1

Possible Causes of Abnormal Uterine Bleeding

Anovulation

• Hypothalamic dysfunction

• Polycystic ovary syndrome

Pregnancy-Related Conditions

• Threatened or spontaneous miscarriage

• Retained products of conception after elective abortion

• Ectopic pregnancy

Lower Reproductive Tract Infections

• Chlamydial cervicitis

• Pelvic inflammatory disease

Neoplasms

• Endometrial hyperplasia

• Cancer of cervix and endometrium

• Endometrial polyps

• Hormonally active tumors (rare)

• Leiomyomata

• Vaginal tumors (rare)

Trauma

• Genital injury (accidental, coital trauma, sexual abuse)

• Foreign body

• Primary coagulation disorders

Systemic Diseases

• Diabetes mellitus

• Thyroid dysfunction (hypothyroidism, hyperthyroidism)

• Severe organ disease (renal or liver failure)

Iatrogenic Causes

• Exogenous hormone use (oral contraceptives, menopausal hormone therapy)

• Medications with estrogenic activity

• Herbal preparation (ginseng)

Sources: American College of Nurse-Midwives (ACNM). (2002). Abnormal and dysfunctional uterine bleeding. ACNM Clinical Bulletin No. 6. Journal of Midwifery and Women’s Health, 47(3), 207-213; Katz, V. (2007). Benign gynecologic lesions: Vulva, vagina, cervix, uterus, oviducts and ovary. In V. Katz, G. Lentz, R. Lobo, & D. Gershenson (Eds.). Comprehensive gynecology (5th ed.). Philadelphia: Mosby.

The most effective medical treatment of acute bleeding episodes of DUB is administration of oral or intravenous estrogen. Dilation and curettage may be done if the bleeding has not stopped in 12 to 24 hours. An oral conjugated estrogen and progestin regimen is usually given for at least 3 months. If the woman wants contraception, she should continue to take OCPs. If she has no need for contraception, the treatment may be stopped to assess the woman’s bleeding pattern. If her menses does not resume, a progestin regimen (e.g., medroxyprogesterone, 10 mg each day for 10 days before the expected date of her menstrual period) may be prescribed after ruling out pregnancy. This is done to prevent persistent anovulation with chronic unopposed endogenous estrogen hyperstimulation of the endometrium, which can result in eventual atypical tissue changes (Lobo, 2007a).

Evidence-Based Practice

Heavy Menstrual Bleeding: Treatments to Improve Quality of Life

Pat Gingrich

Ask the Question

What treatments are available for women experiencing heavy menstrual bleeding? Is surgery or medicine the better treatment?

Search for Evidence

Search Strategies:

Professional organization guidelines, metaanalyses, systematic reviews, randomized controlled trials, nonrandomized prospective studies, retrospective studies, and systematic reviews of qualitative research since 2006

Search Databases:

Cumulative Index to Nursing and Allied Health Literature, Cochrane, Medline, National Guideline Clearinghouse, Turning Research Into Practice (TRIP) Database, and National Institute for Clinical Excellence (NICE)

Critically Analyze the Data

Heavy menstrual bleeding (HMB) is usually defined as anything more than 80 ml lost. A systematic review of qualitative research reported that women experiencing HMB find it to be physically, socially, and emotionally challenging to their quality of life (Garside, Britten, & Stein, 2008). The authors reported that uncertainty, embarrassment, feeling that concerns were minimized, difficulty with menstrual etiquette, and fears of anemia and cancer can cause women to experience stress and anxiety.

The range of treatments for HMB includes medication and surgical interventions. Danazol, a modified testosterone, has anti-estrogen and anti-progesterone properties. A metaanalysis of randomized controlled trials revealed that danazol was more effective than progesterone, nonsteroidal antiinflammatory drugs (NSAIDs), oral contraceptives (Beaumont et al., 2007), or tranexamic acid (Lethaby, Irvine, & Cameron, 2008). However, danazol may produce intolerable side effects of masculinization, menopause-like symptoms, weight gain, or acne. The recommendation statement of the National Institute for Health and Clinical Excellence (2007) lists the first-line drug as the levonorgestrel-releasing intrauterine system (an intrauterine device [IUD] that releases progesterone, preventing endometrial proliferation). Their second-line treatments include tranexamic acid, NSAIDs, and combined oral contraceptives. Third line includes oral and injected progesterones.

Surgically, HMB can be treated according to the severity of the symptoms and the woman’s desire to preserve fertility. Hysterectomy is successful at stopping the bleeding, but it carries the most surgical risk. Endometrial ablation can use several mechanical and thermal techniques to destroy the uterine lining. This more conservative surgery can be performed on an outpatient basis and has reduced risk of postoperative complications. Both hysterectomy and endometrial ablation eliminate future pregnancies. If the bleeding is caused by a fibroid and the woman desires future pregnancies, the blood supply to the fibroid can be blocked using uterine artery embolization, or the tumor can be removed using a myomectomy. The NICE recommendation guidelines (2007) state that dilation and curettage for HMB is not recommended.

Implications for Practice

Women experiencing HMB may delay in getting medical care because of embarrassment or uncertainty. Nurses should regularly ask their female patients about their menstrual cycle amount and duration, including clots. Evaluate for anemia. Concerns about bleeding should trigger a detailed focused menstrual history and pregnancy history, including the desire for future pregnancies. The nurse can explain normal parameters for duration and flow. Clots are usually an indicator of heavy flow. Once identified, nurses should ask women experiencing HMB about their concerns and fears. As the health care provider identifies the various options, the woman and her partner may need a sounding board and resource for answers to questions. In the event of loss of fertility, counseling and referral to a group such as Resolve (www.resolve.org) may provide support.

References:

Beaumont, H., Augood, C., Duckitt, K., Lethaby, A., Danazol for heavy menstrual bleeding Issue 3. The Cochrane Database of Systematic Reviews 2007, 2007.

Garside, R., Britten, N., Stein, K. The experience of heavy menstrual bleeding: A systematic review and meta-ethnography of qualitative studies. Journal of Advanced Nursing. 2008; 63(6):550–562.

Lethaby, A., Irvine, G., Cameron, I., Cyclical progesterones for heavy menstrual bleeding Issue 1. The Cochrane Database of Systematic Reviews 2008, 2008.

National Institute for Health and Clinical Excellence (NICE). Heavy menstrual bleeding [NICE Clinical Guideline 44]. Internet document available at www.nice.org.uk/Guidance/CG44, 2007. [(accessed May 2, 2009)].

If hormonal therapy does not control the recurrent, heavy bleeding, ablation of the endometrium through laser treatment may be performed (Lobo, 2007a). Nursing roles include informing women of their options, counseling and providing education as indicated, and referring to the appropriate specialists and health care services.

Care Management

Medical and nursing management have been discussed with each menstrual problem. Specific aspects of the nursing process are listed in the Nursing Process box.

Nursing Process

Menstrual Disorders

Assessment

• Take a thorough menstrual, obstetric, sexual, and contraceptive history.

• Explore the woman’s perceptions of her condition, cultural or ethnic influences, lifestyle, and patterns of coping.

• Evaluate the amount of pain or bleeding experienced and its effect on daily activities.

• Note any home remedies and prescriptions to relieve discomfort. A symptom diary, in which the woman records emotions, behaviors, physical symptoms, diet, and exercise and rest patterns, is a useful diagnostic tool.

Nursing Diagnoses

Nursing diagnoses include:

• Risk for ineffective individual coping related to:

• Insufficient knowledge of the cause of the disorder

• Emotional and physiologic effects of the disorder

• Deficient knowledge related to:

• Self-management

• Available therapy for the disorder

• Risk for disturbed body image related to:

• Menstrual disorder

• Sexual dysfunction

• Risk for situational low self-esteem related to:

• Others’ perception of her discomfort

• Inability to conceive

• Acute or chronic pain related to:

• Menstrual disorder

Expected Outcomes of Care

Expected outcomes for the woman are that she will do the following:

• Verbalize her understanding of reproductive anatomy, cause of her disorder, medication regimen, and diary use.

• Verbalize her understanding and accept her emotional and physical responses to her menstrual cycle.

• Develop personal goals that benefit her emotionally and physically.

• Choose appropriate therapeutic measures for her menstrual problems.

• Adapt successfully to the condition, if cure is not possible.

Plan of Care and Interventions

• Accept the woman’s symptoms as valid.

• Correlate data from the daily diary of emotional status, subjective feelings, and physical state with physiologic changes.

• Encourage the woman to express her feelings about her symptoms.

• Provide information about therapeutic options (pharmacologic and nonpharmacologic) so that the woman (couple) makes choices considered best for her (them).

• Provide information about local support groups.

Evaluation

Care has been effective when the woman reports improvement in the quality of her life, skill in self-management, and a positive self-concept and body image.

Infections

Infections of the reproductive tract can occur throughout a woman’s life and are often the cause of significant reproductive morbidity, including ectopic pregnancy and tubal factor infertility (Centers for Disease Control and Prevention [CDC], 2007a). The direct economic costs of these infections can be substantial, and the indirect cost is equally overwhelming. Some consequences of maternal infection, such as infertility, last a lifetime. The emotional costs may include damaged relationships and lowered self-esteem.

Sexually Transmitted Infections

Nursing Care Plan: Sexually Transmitted Infections

Sexually transmitted infections are infections or infectious disease syndromes transmitted primarily by sexual contact (Box 3-2). The term sexually transmitted infection includes more than 25 infectious organisms that are transmitted through sexual activity and the dozens of clinical syndromes that they cause. STIs are among the most common health problems in the United States today, with an estimated 19 million people in the United States being infected with STIs every year (CDC, 2007c). Later, this chapter discusses the most common STIs in women. Chapter 21 discusses effects on pregnancy and the fetus. Chapter 24 discusses neonatal effects.

BOX 3-2 Sexually Transmitted Infections

Bacteria