Nursing Management: Female Reproductive Problems



Nursing Management


Female Reproductive Problems


Nancy MacMullen and Laura Dulski




Learning Outcomes



1. Summarize the etiologies of infertility and the strategies for diagnosis and treatment of the infertile woman.


2. Describe the etiology, clinical manifestations, and nursing and collaborative management of menstrual problems and abnormal vaginal bleeding.


3. Identify the risk factors, clinical manifestations, and collaborative care of ectopic pregnancy.


4. Describe the changes related to menopause and the nursing and collaborative management of the patient with menopausal symptoms.


5. Differentiate among the common problems that affect the vulva, vagina, and cervix and the related nursing and collaborative management.


6. Describe the assessment, collaborative care, and nursing management of women with pelvic inflammatory disease and endometriosis.


7. Explain the clinical manifestations, diagnostic studies, collaborative care, and surgical therapy for cervical, endometrial, ovarian, and vulvar cancers.


8. Summarize the preoperative and postoperative nursing management for the patient requiring surgery of the female reproductive system.


9. Differentiate among the common problems that occur with cystoceles, rectoceles, and fistulas and the related nursing and collaborative management.


10. Summarize the clinical manifestations of sexual assault and the appropriate nursing and collaborative management of the patient who has been sexually assaulted.



Key Terms


















Reviewed by Brenda Pavill, RN, PhD, FNP, Associate Professor–Nursing, Misericordia University, Dallas, Pennsylvania; and Beth Perry Black, RN, PhD, Professor of Nursing, UNC at Chapel Hill School of Nursing, UNC School of Nursing, Chapel Hill, North Carolina.




Infertility


Infertility is the inability to conceive after at least 1 year of regular unprotected intercourse.1 Approximately 15% of couples in North America are infertile. Understandably, infertility can be both a physical and an emotional crisis.





image eNursing Care Plan 54-1   Patient Having Abdominal Hysterectomy*




Patient Goals







*Postoperative care of the patient with an abdominal hysterectomy includes nursing diagnoses and collaborative problems for the postoperative patient found in eNCP 20-1: Postoperative Patient, available on the website for that chapter.


**Nursing diagnoses listed in order of priority.



Diagnostic Studies


A detailed history and a general physical examination of the woman and her partner provide the basis for selecting diagnostic studies (Table 54-1). The possibility of medical, genetic, or gynecologic diseases is explored before tests are performed to determine problems affecting general health and fertility. These tests include hormone levels, ovulatory studies, tubal patency studies, and postcoital studies. Other screening tests for infertility include semen analysis and pelvic ultrasound.







Nursing and Collaborative Management Infertility


The management of infertility problems depends on the cause. If infertility is secondary to an alteration in ovarian function, supplemental hormone therapy to restore and maintain ovulation may be used. Drug therapy to treat infertility is presented in Table 54-2. Chronic cervicitis and inadequate estrogenic stimulation are cervical factors causing infertility. Antibiotic therapy is indicated for cervicitis. Inadequate estrogenic stimulation is treated using estrogen.



When a couple has not succeeded in conceiving while under infertility management, an option is intrauterine insemination with sperm from the partner or a donor. If this technique does not succeed, assisted reproductive technologies (ARTs) may be used. ARTs include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), donor gametes, and embryo cryopreservation. IVF is the removal of mature oocytes from the woman’s ovarian follicle via laparoscopy, followed by in vitro fertilization of the ova with the partner’s sperm. When fertilization and cleavage have occurred, the resulting embryos are transferred into the woman’s uterus. The procedure requires 2 to 3 days to complete and is used in cases of fallopian tube obstruction, diminished sperm count, and unexplained infertility. Frequently, multiple attempts are needed for successful implantation. IVF is financially costly and emotionally stressful.3


Assist women experiencing infertility by providing information about the physiology of reproduction and the infertility evaluation, and by addressing the psychologic and social distress that can accompany infertility. Reducing psychologic stress can improve the emotional climate, making it more conducive to achieving a pregnancy.


Teaching and providing emotional support are major responsibilities throughout infertility testing and treatment. Feelings of anger, frustration, grief, and helplessness may heighten as additional diagnostic tests are performed. Infertility can generate great tension in a marriage as the couple exhausts financial and emotional resources. Few insurance carriers cover the high cost of infertility testing and treatment. Encourage couples to participate in a support group for infertile couples, as well as individual therapy.



Abortion


An abortion is the loss or termination of a pregnancy before the fetus has developed to a state of viability (ability to survive outside the uterus). Abortions are classified as spontaneous (those occurring naturally) or induced (those occurring as a result of mechanical or medical intervention). Miscarriage is the common term for the unintended loss of a pregnancy.



Spontaneous Abortion


Spontaneous abortion is the natural loss of pregnancy before 20 weeks of gestation. Fetal chromosomal anomalies may account for many miscarriages before 8 weeks of gestation. Other causes of spontaneous abortions include endocrine abnormalities, maternal infection, acquired anatomic abnormalities (e.g., uterine fibroids, endometriosis), immunologic factors, and environmental factors. About 10% to 15% of all pregnancies end as a result of spontaneous abortion.


Uterine cramping coupled with vaginal bleeding often indicates a spontaneous abortion. Serial measurements of serum β-human chorionic gonadotropin (β-hCG) hormone and vaginal ultrasound examination of the pelvis are the most reliable indicators of viability of the pregnancy.


Treatment to prevent a possible spontaneous abortion is limited. Although bed rest and avoidance of vaginal intercourse are often recommended, there is no evidence that these measures improve the outcome. The woman is advised to report any bleeding to her health care provider. Most women proceed to abortion regardless of treatment. If the products of conception do not pass completely or bleeding becomes excessive, a dilation and curettage (D&C) procedure is generally performed.4 The D&C involves dilating the cervix and scraping the endometrium of the uterus to empty the contents of the uterus.


Women who are experiencing bleeding and cramping during pregnancy may be admitted to the hospital. Vital signs and estimated blood loss are monitored. Women are distressed and experience both physical and emotional pain. Arrange for someone to stay with the patient, since emotional support is important. Be aware of the grieving process that results from the loss of a pregnancy.



Induced Abortion


Induced abortion is an intentional or elective termination of a pregnancy. Induced abortion is done for personal reasons (at the request of the woman) and for medical reasons. Several techniques are used to induce abortion, including menstrual extraction, suction curettage, dilation and evacuation (D&E), and drug therapy (Table 54-3). Deciding on which technique to use to terminate a pregnancy depends on the gestational age (length of the pregnancy) and the woman’s condition. Suction curettage may be performed up to 14 weeks of gestation and accounts for more than 90% of abortion procedures.



TABLE 54-3


METHODS FOR INDUCING ABORTION















































Method Length of Pregnancy Description
Early Abortion
Menstrual extraction Usually up to 2 wk after first missed period Catheter is inserted through cervix into uterus, and suction is applied. Endometrium and contents of uterus are aspirated.
Suction aspiration (curettage) Up to 14 wk Cervix is usually dilated, uterine aspirator is introduced, and suction is applied, removing endometrial tissue and implanted pregnancy.
Dilation and evacuation (D&E) 10-16 wk (approximate) Cervix is dilated, and products of conception are removed by vacuum cannula and use of other instruments as needed.
mifepristone (Mifeprex, RU-486) with misoprostol (Cytotec) Up to 7 wk Mifepristone is administered orally. Misoprostol (prostaglandin) is administered orally or intravaginally 2 days later.
methotrexate with misoprostol Up to 7 wk Methotrexate is administered intramuscularly. Misoprostol is given intravaginally 5-7 days later.
Late Abortion
Instillation of Drugs
Hypertonic saline solution After 16 wk About 200 mL of amniotic fluid is withdrawn, with similar amount of 20% normal saline solution injected. Uterus is irritated and begins to contract within 12-36 hr. Contractions may be assisted with IV oxytocin.

 After 16 wk Amniocentesis is done, and prostaglandin is inserted into amniotic sac, resulting in stimulation of smooth muscle of uterus. Expulsion of uterine contents occurs within 24 hr.
Hysterotomy 16-20 wk Miniature cesarean delivery is performed. Incision is made into uterus and contents are removed.


image


Drug therapy is another method to induce abortion (medical abortion) early in pregnancy. These agents must be given within the first 49 days of pregnancy (day 1 being the first day of the last menstrual period).


Once the decision is made to have an abortion, the woman and her significant others need support and acceptance. Prepare the patient for what to expect both emotionally and physically. Grief and sadness are normal emotions after an abortion. The patient needs to understand the procedure, including instructions for preprocedure and postprocedure care. Your caring attitude can be a positive factor in the patient’s experience.


After the procedure, teach the patient the signs and symptoms of possible complications, such as abnormal vaginal bleeding, severe abdominal cramping, fever, and foul-smelling drainage. Also stress to the patient to avoid intercourse and vaginal insertions until reexamination, which needs to be in 2 weeks. Contraception can be started the day of the procedure or during the patient’s return visit in accordance with her needs and desires.



Problems Related to Menstruation


The normal menstrual cycle is discussed in Chapter 51. The hormonal changes related to the menstrual cycle are shown in Fig. 51-7. Menstruation may be irregular during the first few years after menarche and the years preceding menopause. Once established, a woman’s menstrual cycles usually have a predictable pattern. However, considerable normal variation exists among women in cycle length and in duration, amount, and character of the menstrual flow (see Table 51-2).



Premenstrual Syndrome


Premenstrual syndrome (PMS) is a symptom complex related to the luteal phase of the menstrual cycle. The symptoms can be severe enough to impair interpersonal relationships or interfere with usual activities. Because many symptoms may be associated with PMS, it is difficult to define. However, PMS symptoms always occur cyclically during the luteal phase before the onset of menstruation and are not present at other times of the month. About 40% of all women have been significantly affected by PMS during their lifetime.5





Diagnostic Studies and Collaborative Care


PMS can be diagnosed only when other possible causes for the symptoms have been ruled out. A focused health history and physical examination are done to identify any underlying conditions such as thyroid dysfunction, uterine fibroids, or depression that may account for the symptoms. No definitive diagnostic test is available for PMS. When PMS or PMDD is a possible diagnosis, a woman is given a symptom diary to record her symptoms prospectively for two or three menstrual cycles. Diagnosis is based on an evaluation of the woman’s symptoms.


Nondrug and drug strategies can relieve some PMS symptoms (Table 54-4). However, no single treatment is available. The goal of treatment is to reduce the severity of symptoms and enhance the woman’s sense of control and quality of life.



Several conservative approaches to managing PMS symptoms are considered helpful, including stress management, diet changes, exercise, education, and counseling. Techniques for stress reduction include yoga, meditation, and biofeedback. To decrease autonomic nervous system arousal, women should avoid caffeine, reduce dietary intake of refined carbohydrates, exercise on a regular basis, and practice relaxation techniques. Eating complex carbohydrates with high fiber, foods rich in vitamin B6, and sources of tryptophan (dairy and poultry) are thought to promote serotonin production, which improves the symptoms. Vitamin B6 may be found in such foods as pork, milk, and legumes.


Exercise results in a release of endorphins, leading to mood elevation. Aerobic exercise can also have a relaxing effect. Because fatigue tends to exaggerate the symptoms of PMS, adequate rest in the premenstrual period is a priority.


Explanations about PMS help the woman understand the complexity of the disorder and ways that she can regain a sense of control. Assure the patient that her symptoms are real, PMS exists, and she is not “crazy.” Acknowledgment that she has PMS can itself be therapeutic. Teaching the woman’s partner about the nature of PMS helps the partner better understand PMS and its effects.



Drug Therapy.

Drug therapy is considered when symptoms persist or interfere with daily functioning. Currently no single drug can treat all the symptoms associated with PMS. One therapy may be tried for a time; if no improvement is noted, another approach is tried. Many treatments are symptom specific. For fluid retention, diuretics such as spironolactone (Aldactone) are used. For reducing cramping pain, backache, and migraine headache, prostaglandin inhibitors such as ibuprofen (Motrin, Advil) are used. To improve negative mood, vitamin B6 supplementation (50 mg/day) may be used. Calcium and magnesium supplementation may also be effective in alleviating psychologic and physiologic symptoms. For anxiety, buspirone (BuSpar) taken during the luteal phase has helped some women. Women with PMDD may benefit from antidepressants, including fluoxetine (Prozac, Sarafem) and tricyclic antidepressants (e.g., amitriptyline [Elavil]).


Selective serotonin reuptake inhibitors (SSRIs) (e.g., sertraline [Zoloft]) have provided significant relief to women with severe PMS. Other treatments include oral contraceptives containing estrogen and progesterone. Evening primrose oil may help in reducing menstrual cramping for some women.



Drug Alert


Oral Contraceptives (Both Estrogen and Progesterone)





Dysmenorrhea


Dysmenorrhea is abdominal cramping pain or discomfort associated with menstrual flow. The degree of pain and discomfort varies with the individual. The two types of dysmenorrhea are primary (no pathologic condition exists) and secondary (pelvic disease is the underlying cause).5 Dysmenorrhea is one of the most common gynecologic problems.



Etiology and Pathophysiology


Primary dysmenorrhea is not a disease. It is caused by an excess of prostaglandin F2α (PGF2α) and/or an increased sensitivity to it. Stimulation of the endometrium by estrogen, followed by progesterone, results in a dramatic increase in prostaglandin production by the endometrium. With the onset of menses, degeneration of the endometrium releases prostaglandin. Locally, prostaglandins increase myometrial contractions and constriction of small endometrial blood vessels. This causes tissue ischemia and increased sensitization of the pain receptors, resulting in menstrual pain. Primary dysmenorrhea begins in the first few years after menarche, typically with the onset of regular ovulatory cycles.


Secondary dysmenorrhea is usually acquired after adolescence, occurring most commonly at 30 to 40 years of age. Common pelvic conditions that cause secondary dysmenorrhea include endometriosis, chronic pelvic inflammatory disease, and uterine fibroids. Because secondary dysmenorrhea can be caused by many conditions, symptoms vary. However, painful menses is present in all situations.




Nursing and Collaborative Management Dysmenorrhea


Evaluation begins with distinguishing primary from secondary dysmenorrhea. Obtain a complete health history with special attention to menstrual and gynecologic history. A pelvic examination is performed by the health care provider. The probable diagnosis is primary dysmenorrhea if the history reveals an onset shortly after menarche, symptoms are associated only with menses, and the pelvic examination is normal. If a specific cause of dysmenorrhea is evident, the diagnosis is secondary dysmenorrhea.


Treatment for primary dysmenorrhea includes heat, exercise, and drug therapy. Heat is applied to the lower abdomen or back. Regular exercise is beneficial because it may reduce endometrial hyperplasia and subsequent prostaglandin production. Primary drug therapy is nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen (Naprosyn), which has antiprostaglandin activity. NSAIDs should be started at the first sign of menses and continued every 4 to 8 hours to maintain a sufficient level of the drug to inhibit prostaglandin synthesis for the usual duration of discomfort.


Oral contraceptives may also be used. They decrease dysmenorrhea by reducing endometrial hyperplasia. Acupuncture and transcutaneous nerve stimulation may be used for women who have inadequate relief from medications or who prefer not to take medications. Patients who are unresponsive to these treatments should be evaluated for chronic pelvic pain (discussed later in this chapter on p. 1289).


Treatment of secondary dysmenorrhea depends on the cause. Some individuals with secondary dysmenorrhea are helped by the approaches used for primary dysmenorrhea.


Instruct women on why dysmenorrhea occurs and how to treat it. This will provide women with a foundation for coping with this common problem and increase feelings of control and self-reliance.


Women often ask what can be done for minor discomforts associated with menstrual cycles. Advise women that during acute pain, relief may be obtained by applying heat to the abdomen or back and taking NSAIDs for analgesia. Also suggest noninvasive pain-relieving practices such as relaxation breathing and guided imagery.


Other health care measures to reduce the discomfort of dysmenorrhea include regular exercise and proper nutritional habits. Avoiding constipation, maintaining good body mechanics, and eliminating stress and fatigue, particularly before menstrual periods, can also decrease discomfort. Staying active and interested in activities may also help.



Abnormal Vaginal Bleeding


Abnormal vaginal or uterine bleeding is a common gynecologic concern. Abnormalities include oligomenorrhea (long intervals between menses, generally greater than 35 days), amenorrhea (absence of menstruation), menorrhagia (excessive or prolonged menstrual bleeding), and metrorrhagia (irregular bleeding or bleeding between menses). The cause of abnormal bleeding may vary from anovulatory menstrual cycles to more serious conditions such as ectopic pregnancy or endometrial cancer.


The woman’s age provides direction for identifying the cause of bleeding. For example, a postmenopausal woman with abnormal bleeding must always be evaluated for endometrial cancer but does not need to be evaluated for possible pregnancy. For a 20-year-old woman with abnormal bleeding, the possibility of pregnancy must always be considered, and endometrial cancer would be unlikely.


Abnormal bleeding may be caused by dysfunction of the hypothalamic-pituitary-ovarian axis such as a pituitary adenoma. Another possible cause is infection. Changes in lifestyle such as marriage, recent moves, a death in the family, financial stress, and other emotional crises can also cause irregular bleeding. Because psychologic factors can influence endocrine function, they should be considered when the patient is evaluated.



Types of Irregular Bleeding



Oligomenorrhea and Amenorrhea.

Anovulation is the most common reason for missing menses once pregnancy has been ruled out. Additional causes of amenorrhea are listed in Table 54-5. Primary amenorrhea refers to the failure of menstrual cycles to begin by age 16 years or by age 14 years if secondary sex characteristics are present. Secondary amenorrhea refers to the cessation of menstrual cycles once they had been established.



Ovulation is often erratic for several years after menarche and before menopause. Thus oligomenorrhea due to anovulation is common for women at the beginning and end of menstruation. In anovulatory cycles the corpus luteum that produces progesterone does not form. This may result in a situation referred to as unopposed estrogen. When unopposed by progesterone, estrogen can cause excessive buildup of the endometrium. Persistent overgrowth of the endometrium increases a woman’s risk for endometrial cancer. To reduce this risk, progesterone or oral contraceptives are prescribed to ensure that the patient’s endometrial lining is shed at least four to six times per year.




Metrorrhagia.

Metrorrhagia, also referred to as spotting or breakthrough bleeding, is bleeding between menstrual periods. For all reproductive-age women, pregnancy complications such as spontaneous abortion or ectopic pregnancy must be considered as a possible cause. Other causes include cervical or endometrial polyps, infection, and cancer. Spotting is common during the first three cycles of oral contraceptives. If spotting continues beyond that, a different pill formulation can be prescribed once other causes of metrorrhagia have been ruled out. Spotting with long-acting progestin therapy (e.g., Mirena intrauterine device [IUD]) or progestin-only pills (medroxyprogesterone [Depo-Provera, Provera]) is also common. For postmenopausal women, endometrial cancer must be considered whenever spotting is experienced. In postmenopausal women, exogenous estrogen administration during hormone therapy is a common cause of metrorrhagia.



Diagnostic Studies and Collaborative Care


Because abnormal vaginal bleeding has multiple causes, the diagnostic and collaborative care varies. A health history and physical examination directed at the most likely causes of vaginal bleeding for the woman’s age-group is the first step. These findings provide the basis for selecting laboratory tests and diagnostic procedures. Treatment depends on the etiology of the problem (e.g., menorrhagia, amenorrhea), degree of threat to the patient’s health, and whether children are desired in the future.


Combined oral contraceptives may be prescribed for a woman with amenorrhea to ensure regular shedding of the endometrium if she also wants contraception. Tranexamic acid (Lysteda) may be used to treat heavy menstrual bleeding. This drug stabilizes a protein that helps blood to clot. Side effects may include headache, back pain, abdominal pain, muscle and joint pain, anemia, and fatigue. Women using hormonal contraception should take tranexamic acid only if they have a strong medical need, since there is an increased risk of blood clots and stroke. Estradiol valerate/dienogest (Natazia) may be given to women with heavy menstrual bleeding who desire an oral contraceptive to prevent pregnancy.


The treatment goal for women with menorrhagia is to minimize further blood loss. If menorrhagia is the result of anovulatory cycles, the endometrium must be stabilized by a combination of oral estrogen and progesterone.


Balloon thermotherapy is a technique for menorrhagia that involves the introduction of a soft, flexible balloon into the uterus. The balloon is then inflated with sterile fluid (Fig. 54-1). The fluid in the balloon is heated and maintained for 8 minutes, thus causing ablation (removal) of the uterine lining. When the treatment is completed, the fluid is withdrawn from the balloon and the catheter is removed from the uterus. The uterine lining sloughs off in the next 7 to 10 days. Uterine balloon thermotherapy is contraindicated for women who desire to maintain their fertility and for women with any suspected uterine abnormalities such as fibroids, suspected endometrial cancer, prior cesarean delivery, or myomectomy. With severe bleeding, hospitalization is indicated. All patients with menorrhagia should be evaluated for anemia and treated as indicated.


image
FIG. 54-1 Balloon thermotherapy for treatment of menorrhagia. A, Balloon-tipped catheter is inserted into the uterus through the vagina and the cervix. B, The balloon is inflated with a sterile fluid that expands to fit the size and shape of the uterus. The fluid is heated to 188° F (87° C) and maintained for 8 minutes while the uterine lining is treated. C, Fluid is withdrawn from the balloon and the catheter is removed. (Courtesy Ethicon, Inc, Cornelia, Ga.)


Surgical Therapy.

Surgery may be indicated depending on the underlying cause of the abnormal vaginal bleeding. D&C is used only in cases of acute excess bleeding or for older women when endometrial biopsy and ultrasonography have not provided the necessary diagnostic information. Endometrial ablation for menorrhagia may be done by laser, thermal balloon, cryotherapy, or microwave energy for patients who do not want to have children.


If menorrhagia is caused by uterine fibroids, a hysterectomy (surgical removal of the uterus) may be performed. A myomectomy (removal of fibroids without removal of the uterus) may be performed if the patient wants to preserve her uterus. The myomectomy is done via laparotomy, laparoscopy, or hysteroscopy. Hormonal regimens and embolization of the blood vessels supplying the fibroid tumor are other treatment options.



Nursing Management Abnormal Vaginal Bleeding


Teaching women about the characteristics of the menstrual cycle will enable them to identify normal variations. Table 51-2 includes characteristics of the menstrual cycle and related patient teaching. This knowledge can decrease apprehension and dispel misconceptions about the menstrual cycle. If the patient’s menstrual cycle pattern does not fall within the normal range, urge her to discuss this with her health care provider.


The selection of internal or external sanitary protection is a matter of personal preference. Tampons are convenient and make menstrual hygiene easier, whereas pads may provide better protection. Using a combination of tampons and pads and avoiding prolonged use of superabsorbent tampons may decrease the risk of toxic shock syndrome (TSS). TSS is an acute life-threatening condition caused by a toxin from Staphylococcus aureus. TSS causes high fever, vomiting, diarrhea, weakness, myalgia, and a sunburn-like rash.7


Whenever excessive, the amount of the vaginal bleeding should be assessed as accurately as possible. The patient should record and report the number and size of pads or tampons used and the degree of saturation. The patient’s fatigue level, along with variations in blood pressure and pulse, should be monitored because anemia and hypovolemia may be present. For the patient requiring a surgical procedure, provide the appropriate preoperative and postoperative care.



Ectopic Pregnancy


An ectopic pregnancy is the implantation of the fertilized ovum anywhere outside the uterine cavity. Approximately 3% of all pregnancies are ectopic, and approximately 98% of these occur in the fallopian tube8 (Fig. 54-2). The remaining 2% to 3% may be ovarian, abdominal, or cervical. Ectopic pregnancy is a life-threatening condition. Earlier identification has contributed to decreased mortality rates.


image
FIG. 54-2 Ectopic pregnancy occurring in the fallopian tube.


Etiology and Pathophysiology


Any blockage of the fallopian tube or reduction of tubal peristalsis that impedes or delays the zygote passing to the uterine cavity can result in tubal implantation. After implantation, the growth of the gestational sac expands the tubal wall. Eventually the tube ruptures, causing acute peritoneal symptoms. Less acute symptoms usually begin within 6 to 8 weeks after the last normal menstrual period and weeks before rupture would occur.


Risk factors for ectopic pregnancy include a history of pelvic inflammatory disease, prior ectopic pregnancy, current progestin-releasing IUD, progestin-only birth control failure, and prior pelvic or tubal surgery. Additional risk factors for ectopic pregnancy include procedures used in infertility treatment, including IVF, embryo transfer, and ovulation induction.



Clinical Manifestations


The classic manifestations of ectopic pregnancy are abdominal or pelvic pain, missed menses, and irregular vaginal bleeding. Other manifestations include morning sickness, breast tenderness, gastrointestinal disturbance, malaise, and syncope. Pain is almost always present and is caused by distention of the fallopian tube. It may start unilaterally and then spread to become bilateral. The character of the pain varies among women and can be colicky or vague. If tubal rupture occurs, the pain is intense and may be referred to the shoulder as a result of irritation of the diaphragm by blood released into the abdominal cavity. Symptom severity does not necessarily correlate with the extent of external bleeding present. With rupture, the risk of hemorrhage and hypovolemic shock is present. Suspected rupture is treated as an emergency.


The vaginal bleeding that may accompany ectopic pregnancy is usually described as spotting. However, bleeding may be heavier and can be confused with menses.



Diagnostic Studies


Ectopic pregnancy can be a diagnostic challenge because of its similarity to other pelvic and abdominal disorders, such as salpingitis, spontaneous abortion, ruptured ovarian cyst, appendicitis, and peritonitis. A serum (radioimmunoassay) pregnancy test should be performed. If the test is negative, an ectopic pregnancy is not likely. If ectopic pregnancy cannot be excluded by the pregnancy test, further evaluation is warranted. If the patient is in stable condition, a combination of serial measurements of serum β-hCG and vaginal ultrasonography is used.9 Absence of a normal intrauterine pregnancy means that the diagnosis is probably a spontaneous abortion or an ectopic pregnancy. With a spontaneous abortion, serial serum β-hCG levels will decrease over time. A complete blood count is obtained when there is any concern regarding the amount of blood loss or if surgery is contemplated.



Nursing and Collaborative Management Ectopic Pregnancy


Surgery remains the primary approach for treating ectopic pregnancies and should be performed immediately. However, medical management with methotrexate (Folex) is being used with increasing success in patients who are hemodynamically stable and have a mass less than 3 cm in size.10 A conservative surgical approach limits damage to the reproductive system as much as possible. Removal of the fetus from the tube is preferred to removing the tube. Laparoscopy is preferable to laparotomy because it decreases blood loss and the length of the hospital stay (Fig. 54-3). If the tube ruptures, conservative surgical approaches may not be possible. The patient may need a blood transfusion and supplemental IV fluid therapy to relieve shock and restore a satisfactory blood volume for safe anesthesia and surgery. The use of laparoscopy has resulted in fewer repeated ectopic pregnancies and a higher rate of future successful pregnancies.


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FIG. 54-3 Laparoscopic treatment of ectopic pregnancy in the right fallopian tube.

Nursing care depends on the patient’s condition. Before the diagnosis has been confirmed, be alert to patient signs of increasing pain and vaginal bleeding, which may indicate that the tube has ruptured. Monitor vital signs closely and observe for signs of shock. Give explanations and prepare the patient for diagnostic procedures when appropriate. Preparation of the patient for abdominal surgery may follow rapidly. Provide reassurance and support for the surgery to the patient and her family. Postoperatively, the patient may express a fear of future ectopic pregnancies and have many questions about the impact of this experience on her fertility.



Perimenopause and Postmenopause


Perimenopause is a normal life transition that begins with the first signs of change in menstrual cycles and ends after cessation of menses.11 Menopause is the physiologic cessation of menses associated with declining ovarian function. It is usually considered complete after 1 year of amenorrhea (absence of menstruation). Menopause starts gradually and is usually associated with changes in menstruation, including menstrual flows that are increased, decreased, or irregular. Eventually complete cessation of menses occurs. Postmenopause is a term that refers to the time in a woman’s life after menopause.


The age at which menopause occurs ranges from 44 to 55 years, with an average age of 51 years. Menopause may occur earlier due to illness, surgical removal of the uterus or both ovaries, side effects of radiation therapy or chemotherapy, or drugs. The age at which menopause occurs is not affected by age at menarche, physical characteristics, number of pregnancies, date of last pregnancy, or oral contraceptive use. However, genetic factors, autoimmune conditions, cigarette smoking, and racial or ethnic factors are related to an earlier age at menopause.


Changes within the ovary start the cascade of events that finally result in menopause. The regression of the follicles within each ovary begins at puberty and accelerates after age 35. With age, fewer follicles remain that are responsive to follicle-stimulating hormone (FSH). FSH normally stimulates the dominant follicle to secrete estrogen. When the follicles can no longer respond to FSH, the production of estrogen and progesterone from the ovary declines. However, perimenopausal women can get pregnant until menopause has occurred, since many women have long anovulatory cycles interspersed with shorter, ovulatory cycles.


With decreased ovarian function, decreased levels of estrogen cause a gradual increase in FSH and luteinizing hormone (LH) as a result of the negative feedback process. By the time menopause occurs, there is a 10- to 20-fold increase in FSH. The elevated FSH level may take several years to return to the premenopausal level. The reduced estrogen level also causes a decrease in the frequency of ovulation and results in changes in the reproductive organs and tissues (e.g., atrophy of vaginal tissue).



Clinical Manifestations


Clinical manifestations of perimenopause and postmenopause are presented in Table 54-6. Perimenopause is a time of erratic hormonal fluctuation. Irregular vaginal bleeding is common. With decreasing estrogen, hot flashes and other symptoms begin. The signs and symptoms of diminished estrogen are listed in Table 54-7. The loss of estrogen plays a significant role in the cause of age-related alterations. Changes most critical to a woman’s well-being are the increased risks for coronary artery disease (CAD) and osteoporosis (secondary to bone density loss). Other changes include a redistribution of fat, a tendency to gain weight more easily, muscle and joint pain, loss of skin elasticity, changes in hair amount and distribution, and atrophy of external genitalia and breast tissue.




Hallmarks of perimenopause include vasomotor instability (hot flashes) and irregular menses. A hot flash (occurs in up to 80% of all women) is described as a sudden sensation of intense heat along with perspiration and flushing.12 These sensations may last from several seconds to 5 minutes and occur most often at night, thereby disturbing sleep. The cause of hot flashes, or vasomotor instability, is not clearly understood. It has been theorized that temperature regulators in the brain are in proximity to the area where gonadotropin-releasing hormone (GnRH) is released. The lowered estrogen levels are correlated with dilation of cutaneous blood vessels, resulting in hot flashes and increased sweating. The more sudden the withdrawal of estrogen (e.g., surgical removal of the ovaries), the more likely the symptoms will be severe if no hormone replacement is provided. Symptoms usually subside over time and typically last from 5 to 10 years with or without treatment.13 Hot flashes can be triggered by stress and situations that affect body temperature, such as eating a hot meal, hot weather, or warm clothing. Women who smoke are at higher risk for hot flashes because smoking affects estrogen metabolism. African American women report the highest incidence of hot flashes, whereas Asian American women report the lowest number.13


Atrophic vaginal changes secondary to decreased estrogen include thinning of the vaginal mucosa and disappearance of rugae. Vaginal secretions also decrease and become more alkaline. As a result of these changes, the vagina is easily traumatized and more susceptible to infection, including a higher risk for human immunodeficiency virus (HIV) infection if exposed. Dyspareunia (painful intercourse) may also occur. This can lead to unnecessary and premature cessation of sexual activity. Dryness is a problem that can be corrected with water-soluble lubricants or, if needed, with hormonal creams or systemic hormone therapy.


Atrophic changes in the lower urinary tract also occur with a decrease in estrogen. Bladder capacity decreases, and the bladder and urethral tissue lose tone. These changes can cause symptoms that mimic a bladder infection (e.g., dysuria, urgency, frequency) when no infection is present.


Whether decreasing estrogen causes the psychologic changes associated with perimenopause is unclear. Depression, irritability, and cognitive problems, which are often attributed to menopause, could result from life stressors or sleep deprivation from hot flashes. Depressive symptoms appear to improve when hormone levels stabilize.



Collaborative Care


The diagnosis of perimenopause should be made only after careful consideration of other possible causes for the woman’s symptoms. Depression, thyroid dysfunction, anemia, or anxiety can cause the same symptoms. Review a woman’s history of menstrual patterns as part of establishing the diagnosis. Because of the hormonal fluctuations that occur before menopause, routine testing of the serum FSH level to establish a diagnosis is not indicated.



Drug Therapy.

Hormone therapy (HT) was once standard therapy in the United States for treating menopausal symptoms. HT includes estrogen for women without a uterus or estrogen and progesterone for women with a uterus. Findings from the Women’s Health Initiative (WHI) clinical trials changed this practice.14 The data showed that women who had taken estrogen plus progestin (Prempro) had an increased risk of breast cancer, stroke, heart disease, and emboli. However, these women had fewer hip fractures and a lower risk of developing colorectal cancer. Women who took only estrogen (Premarin) had an increased risk of stroke and emboli. However, these women had decreased risk for fractures with no increased risk for heart disease or breast or colorectal cancer. A recent systematic review has updated and validated the results of the WHI trials.15


If women wish to consider taking HT for the short-term treatment (4 to 5 years) of menopausal symptoms, the risks and benefits of therapy (e.g., minimizes bone loss, hot flashes, vaginal atrophic changes) should be considered carefully. The woman and her health care provider should thoroughly discuss the decision to take HT, and which ones to take. If a woman chooses to use HT, the lowest effective dose should be used. The age that a woman starts HT may determine her risk of heart disease. The risk appears to increase the further a woman moves away from menopause.


The side effects of estrogen include nausea, fluid retention, headache, and breast enlargement. Side effects of progesterone include increased appetite, weight gain, irritability, depression, spotting, and breast tenderness. A commonly used estrogen preparation is 0.625 mg of conjugated estrogen (Premarin) daily. For symptom relief, a higher dose may be needed. To receive the protective benefit of progesterone, 5 to 10 mg of medroxyprogesterone is indicated for 12 days of each month on a cyclic regimen, or 2.5 mg on a continuous regimen. If the estrogen is increased for symptom relief, the progesterone should also be increased. Other forms of progesterone include norethindrone (Aygestin) and micronized progesterone creams, dermal patches, gels, and lotions; rings placed around the cervix; and subcutaneous pellets. Vaginal creams are especially useful for urogenital symptoms (e.g., dryness). Transdermal estrogen (skin patch or spray [EvaMist]) has the advantage of bypassing the liver, but the disadvantage of causing skin irritation.



Drug Alert


Medroxyprogesterone (Depo-Provera, Provera)




SSRI antidepressants, including paroxetine (Paxil), fluoxetine, and venlafaxine (Effexor), are an effective alternative to HT in reducing hot flashes. This effect is noted even if the user is not depressed. The mechanism of action is unknown. Clonidine (Catapres), an antihypertensive drug, and gabapentin (Neurontin), an antiseizure drug, have also been shown to relieve hot flashes.


Selective estrogen receptor modulators (SERMs), such as raloxifene (Evista), are also used to treat menopausal problems. These drugs have some of the positive benefits of estrogen, such as preventing bone loss, without the negative effects such as endometrial hyperplasia. Raloxifene competes with estrogen for estrogen receptor sites.16 It decreases bone loss and serum cholesterol with minimal effects on breast and uterine tissue.


Bisphosphonates, including alendronate (Fosamax) and risedronate (Actonel), are also used to decrease the risk for osteoporosis in postmenopausal women. These drugs enhance bone mineral density by suppressing resorption. SERMs and bisphosphonates are discussed further in Chapter 64 with respect to their role in the management of osteoporosis.



Nonhormonal Therapy.

Because of the risks associated with HT, many women try other therapies to relieve menopausal symptoms. Paroxetine (Brisdelle) is a newer nonhormonal treatment that may be used for moderate to severe hot flashes associated with menopause. This drug is a selective serotonin reuptake inhibitor.


Hot flash frequency and severity can be reduced through measures that lead to a decrease in heat production and an increase in heat loss. Keeping a cool environment and limiting caffeine and alcohol intake lower heat production. Relaxation techniques (e.g., relaxation breathing, imagery) may also help. To promote heat loss at night when hot flashes can disrupt sleep, increase air circulation in the room and avoid bedding that traps the heat (e.g., heavy quilts). Loose-fitting clothes do not retain body heat, whereas clothes with tight necks and wrists do. Cool cloths applied to flushed areas also aid in heat loss.


Daily intake of vitamin E in doses up to 800 IU may also help reduce hot flashes in some women. Changing sleep patterns may be helped by avoiding alcohol and controlling hot flashes. Relaxation techniques can promote a better night’s sleep by decreasing anxiety. A regular moderate program (three to four times per week) of aerobic and weight-bearing exercises can slow the process of bone loss and a tendency toward weight gain.



Nutritional Therapy.

Good nutrition can decrease the risk of cardiovascular disease and osteoporosis in addition to assisting with vasomotor symptoms. A daily intake of about 30 cal/kg of body weight is recommended. A decrease in metabolic rate and careless eating habits can cause the weight gain and fatigue often attributed to menopause. An adequate intake of calcium and vitamin D helps maintain healthy bones and counteracts loss of bone density. Postmenopausal women not receiving supplemental estrogen should have a daily calcium intake of at least 1500 mg, whereas those taking estrogen replacement need at least 1000 mg/day. Calcium supplements are best absorbed when taken with meals. Either dietary calcium or calcium supplements may be used (see Tables 64-14 and 64-15).


The diet should be high in complex carbohydrates and vitamin B complex, especially B6. Phytoestrogens (soy, tofu, chickpeas, sunflower seeds) have been used to reduce menopausal symptoms. Herbal remedies, such as black cohosh, have become popular in treating menopausal symptoms (see Complementary & Alternative Therapies box above). Consultation with an experienced herbal practitioner is recommended before initiating therapy.



image Complementary & Alternative Therapies


Herbs and Supplements for Menopause














Herb Scientific Evidence Nursing Implications
Black cohosh Mixed evidence for use in the treatment of menopausal symptoms*

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Nov 17, 2016 | Posted by in NURSING | Comments Off on Nursing Management: Female Reproductive Problems

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