58
Female Reproductive Problems
Robyn Schafer
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Pain
Hormonal Regulation Reproduction
Infection Sexuality
Inflammation
LEARNING OUTCOMES
1. Outline strategies for the diagnosis and treatment of female 5. Outline the etiology and clinical manifestations of lower
infertility. genital tract infections and pelvic inflammatory disease.
2. Identify risk factors and nursing and interprofessional 6. Identify the pathophysiology and appropriate
management of early pregnancy loss and ectopic pregnancy. interprofessional and nursing care for benign gynecologic
3. Describe the etiology and clinical manifestations of problems.
menstrual problems, abnormal uterine bleeding, and 7. Explain the clinical manifestations, diagnostic studies, and
polycystic ovary syndrome. treatment of gynecologic cancers.
4. Describe physiologic changes related to menopause and 8. Discuss the interprofessional and nursing care for victims of
management of perimenopausal symptoms. sexual assault.
KEY TERMS
abnormal uterine bleeding (AUB) pelvic inflammatory disease (PID)
dilation and curettage (D&C) pelvic organ prolapse
dysmenorrhea perimenopause
early pregnancy loss polycystic ovary syndrome (PCOS)
ectopic pregnancy premenstrual syndrome (PMS)
endometriosis sexual assault
fibroids (leiomyomas) sexual dysfunction
infertility spontaneous abortion
menopause
Sexual functioning and satisfaction are important aspects of well- gendered terms here is not meant to exclude any person who
being across the lifespan. Problems with gynecologic and female has these problems.
sexual health profoundly affect health and well-being. This chap-
ter discusses common female reproductive system problems.
Care often includes screening and prevention, health teaching
INFERTILITY
and promotion, and assessment and treatment of complications. Infertility is defined as the inability to conceive after at least
While these are referred to as female reproductive system 1 year of regular intercourse without contraception.1 Around
problems, the terms “female” and “woman” may not reflect the 15% of heterosexual couples experience infertility. It is more
gender identity of patients with these problems. These prob- common with advancing age. The process of assessing and man-
lems may be relevant in transgender, gender-nonconforming, aging infertility is often stressful and emotionally difficult for
and gender-diverse persons assigned female sex at birth. Use of patients and their partners.
1412
, CHAPTER 58 Female Reproductive Problems 1413
TABLE 58.1 Diagnostic Criteria TABLE 58.3 Drug Therapy
Infertility Infertility
Infertility is diagnosed after a person has not been able to conceive after: Mechanism of
• 12 months of regular (frequent) intercourse without contraception in those Class Drugs Action
less than 35 years of age; OR Aromatase letrozole (Femara) ↓ Estrogen by preventing
• 6 months of regular (frequent) intercourse without contraception in those inhibitor the conversion of
35 years of age and older. androgens to estrogens
in the ovaries
Biguanide glucophage (Metformin) ↓ Hyperinsulinemia. May
lead to enhanced
TABLE 58.2 Interprofessional Care spontaneous ovulation
Infertility with PCOS
Diagnostic Assessment Gonadotropin follicle-stimulating Stimulates follicle growth
• History and physical assessment of both partners hormone (Gonal-f) and maturation by
• Detailed menstrual, sexual, reproductive, and gynecologic history human chorionic gonado- mimicking the body’s
• Height, weight, and body mass index tropin (hCG) natural hormones
• Pelvic examination human menopausal
• Laboratory tests (as indicated) gonadotropin (Men-
• CBC opur)
• Thyroid-stimulating hormone (TSH) Selective estro- clomiphene citrate Stimulates ovulation
• STI screening gen receptor (Clomid) by binding estrogen
• Hormone levels (FSH, LH, antimüllerian hormone, progesterone, prolac- modulator receptors in the hypo-
tin) (SERM) thalamus. Leads to ↑
• Imaging gonadotropin-releasing
• Transvaginal ultrasound hormone (GnRH) produc-
• Hysterosalpingogram tion and ↑ LH and FSH
secretion in the pituitary
Management
• Lifestyle changes
• Drug therapy (Table 58.3) tailored to the underlying cause. A patient-centered approach
• Surgery to care is essential in treating infertility. Patients and, when
• Assisted reproductive technologies (ARTs) appropriate, their partners should be involved in determining
the plan of care and weighing the efficacy, safety, and advantages
and disadvantages of various treatment options. These proce-
Etiology and Pathophysiology dures may be expensive and stressful. Provide an overview of
Infertility affects men and women equally. We describe it as infertility evaluation, treatments, and alternatives to help reduce
being caused by male or female factors. There may also be a stress. Teaching about fertility, ovulation, and intercourse is
combination of factors. In as many as 30% of cases, no specific important. This information often improves conception rates.
cause is identified. Factors that cause male infertility are dis- Lifestyle changes include weight loss, smoking cessation, and
cussed in Chapter 59. The most common causes of female infer- reduced alcohol and caffeine intake. Intercourse is timed around
tility are hormone imbalances, anatomic or structural problems ovulation. Medical treatment for female infertility focuses on
of the reproductive tract, and other unexplained causes. stimulating the ovaries (known as ovulation induction). Table
58.3 reviews common drugs used in fertility treatment. Surgery
Diagnostic Studies may address blockages in the ovarian tubes or uterine prob-
Formal evaluation of infertility is usually done after 12 months lems. Finally, assisted reproductive technology (ART) procedures
of regular, unprotected intercourse (Table 58.1). Earlier evalua- include insemination through intracervical insemination (ICI),
tion is appropriate in women over the age of 35 or in the pres- intrauterine insemination (IUI), or in vitro fertilization (IVF).
ence of known medical or physical problems. Evaluation starts The National Infertility Association (RESOLVE) is a useful
with a history and physical assessment (Table 58.2). Based on resource to support patients in exploring treatment options.3
the findings, laboratory tests and diagnostic imaging may be
done. These explore common causes of infertility, including
diminished ovarian reserve, ovulatory dysfunction, and struc-
PREGNANCY LOSS
tural problems of the fallopian tubes and uterus.2 A semen anal- Pregnancy loss is the term used to describe the loss of a nonvi-
ysis of the male partner is often part of the infertility workup. able pregnancy up to 20 weeks gestation. Early pregnancy loss
occurs in the first trimester (the first 13 weeks of pregnancy). It
Interprofessional and Nursing Management is the most common type of pregnancy loss. Abortion is another
There are multiple treatment options for infertility. These include term used to describe the loss of a previable pregnancy or the
lifestyle changes, drug therapy, and surgery. The approach is elective termination of pregnancy at any stage. We classify
, 1414 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
Vagina
TABLE 58.4 Types of Spontaneous Abortion
Type Description
Complete abortion All products of conception (POC) are expelled
Curette
Incomplete abortion Passage of some but not all POC through the
cervix Uterus
Inevitable abortion Pregnancy loss cannot be prevented due to Speculum
opening of the cervix or rupture of amniotic
membranes
Infected (septic) Serious maternal infection occurring with any type
abortion of abortion
Missed abortion Nonviable POC remain in the uterus
Threatened abortion Vaginal bleeding in a pregnancy prior to 20 weeks’
gestation in the absence of cervical dilation Cervix
abortions as spontaneous or induced. Pregnancy loss can lead Fig. 58.1 D&C.
to grief and psychological distress.
Drug therapy involves drugs such as misoprostol (Cytotec)
Spontaneous Abortion and mifepristone (Mifeprex) to open the cervix and induce
Spontaneous abortion is the natural loss of pregnancy before 20 passage of the POC from the uterus. This approach offers more
weeks of gestation. Many refer to this as a “miscarriage.” Types predictable timing of the POC than expectant management. It is
of spontaneous abortions are listed in Table 58.4. Around 20% less invasive than surgery. The ability to prescribe and dispense
of pregnancies result in spontaneous abortion. Most occur in mifepristone is restricted in the United States.5 This limits its
the first trimester. They are often related to embryonic chromo- accessibility in some settings. Teaching about side effects and
somal abnormalities. Other common causes include endocrine anticipatory guidance is essential to safety in this approach.
problems, maternal infection, uterine abnormalities (e.g., uter- Surgery of an abortion involves dilation and curettage
ine fibroids, endometriosis), immune factors, and environment (D&C) (Fig. 58.1). With a D&C, the cervix is dilated and the
factors. Risk factors for spontaneous abortion include age greater uterine contents removed using either manual vacuum aspiration
than 35 years, history of prior pregnancy loss, and chronic med- (MVA) or electric vacuum aspiration (EVA). This approach is the
ical problems such as diabetes, obesity, or thyroid disease. Stress most invasive of spontaneous abortion treatment options. But it
and substance use are also related to an increased risk. is highly effective and offers rapid resolution of pregnancy loss.
Patients experiencing a spontaneous abortion often present Teach patients to call the HCP for heavy vaginal bleeding,
with vaginal bleeding and cramping. Following a history and fever, foul-smelling vaginal discharge, or severe pain. Discuss
physical assessment, transvaginal ultrasound imaging is rec- the use of pain medications, such as ibuprofen. Give resources
ommended for diagnosis. Bloodwork is done to assess serum or referrals for psychologic support and grief counseling to
human chorionic gonadotropin levels (hCG, also called β-hCG reduce mental health complications such as depression and anx-
or “beta”). We have few interventions to prevent pregnancy loss. iety. Review contraceptive options or planning for a subsequent
We used to place patients with threatened abortions on bed rest. pregnancy. Ovulation can resume within days or weeks after a
Research shows this practice has more potential to be harmful pregnancy loss. Historically, we told patients to abstain from
than helpful. So, we no longer recommend bed rest. vaginal intercourse and wait several weeks or months before
There are 3 approaches to treatment of spontaneous abortion: trying to become pregnant again. However, these practices do
(1) expectant management, (2) drug therapy, and (3) surgery.4 A not reduce complications like infection or recurrent pregnancy
patient-centered approach should be used to determine the plan loss and are no longer recommended.
of care based on the patient’s preferences and values. Provide
patients with information about treatment options. Discuss the Induced Abortion
risks and benefits of each. Involving patients in decision mak- Induced abortion is the elective termination of a pregnancy.
ing leads to the best mental health outcomes. Any patients with There are several ways to induce an abortion. In the United
signs of acute complications such as hemorrhage or infection States, the most common ways are medical abortion and aspi-
need emergency care. ration (sometimes called surgical) abortion (Table 58.5). The
Expectant management involves waiting for the pregnancy approach used depends on the gestational length of the preg-
tissue (also called products of conception [POC]) to pass on nancy, patient preference, and availability of care. State laws and
its own. When appropriate criteria are met, this approach is agency regulations affect abortion care. Cost can be a signifi-
about 75% effective in the 1st trimester. This option is the least cant factor since most patients pay out-of-pocket for abortion
invasive. However, it is not as predictable or effective as other services. Engage patients in decision making about the risks,
approaches. Patient teaching about warning signs is needed. benefits, and alternatives to help them make the most appro-
We need to monitor for complications and have a clear plan for priate decision. Provide patients information about all available
follow-up. options and referral to a setting that provides safe abortion care.6
Female Reproductive Problems
Robyn Schafer
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Pain
Hormonal Regulation Reproduction
Infection Sexuality
Inflammation
LEARNING OUTCOMES
1. Outline strategies for the diagnosis and treatment of female 5. Outline the etiology and clinical manifestations of lower
infertility. genital tract infections and pelvic inflammatory disease.
2. Identify risk factors and nursing and interprofessional 6. Identify the pathophysiology and appropriate
management of early pregnancy loss and ectopic pregnancy. interprofessional and nursing care for benign gynecologic
3. Describe the etiology and clinical manifestations of problems.
menstrual problems, abnormal uterine bleeding, and 7. Explain the clinical manifestations, diagnostic studies, and
polycystic ovary syndrome. treatment of gynecologic cancers.
4. Describe physiologic changes related to menopause and 8. Discuss the interprofessional and nursing care for victims of
management of perimenopausal symptoms. sexual assault.
KEY TERMS
abnormal uterine bleeding (AUB) pelvic inflammatory disease (PID)
dilation and curettage (D&C) pelvic organ prolapse
dysmenorrhea perimenopause
early pregnancy loss polycystic ovary syndrome (PCOS)
ectopic pregnancy premenstrual syndrome (PMS)
endometriosis sexual assault
fibroids (leiomyomas) sexual dysfunction
infertility spontaneous abortion
menopause
Sexual functioning and satisfaction are important aspects of well- gendered terms here is not meant to exclude any person who
being across the lifespan. Problems with gynecologic and female has these problems.
sexual health profoundly affect health and well-being. This chap-
ter discusses common female reproductive system problems.
Care often includes screening and prevention, health teaching
INFERTILITY
and promotion, and assessment and treatment of complications. Infertility is defined as the inability to conceive after at least
While these are referred to as female reproductive system 1 year of regular intercourse without contraception.1 Around
problems, the terms “female” and “woman” may not reflect the 15% of heterosexual couples experience infertility. It is more
gender identity of patients with these problems. These prob- common with advancing age. The process of assessing and man-
lems may be relevant in transgender, gender-nonconforming, aging infertility is often stressful and emotionally difficult for
and gender-diverse persons assigned female sex at birth. Use of patients and their partners.
1412
, CHAPTER 58 Female Reproductive Problems 1413
TABLE 58.1 Diagnostic Criteria TABLE 58.3 Drug Therapy
Infertility Infertility
Infertility is diagnosed after a person has not been able to conceive after: Mechanism of
• 12 months of regular (frequent) intercourse without contraception in those Class Drugs Action
less than 35 years of age; OR Aromatase letrozole (Femara) ↓ Estrogen by preventing
• 6 months of regular (frequent) intercourse without contraception in those inhibitor the conversion of
35 years of age and older. androgens to estrogens
in the ovaries
Biguanide glucophage (Metformin) ↓ Hyperinsulinemia. May
lead to enhanced
TABLE 58.2 Interprofessional Care spontaneous ovulation
Infertility with PCOS
Diagnostic Assessment Gonadotropin follicle-stimulating Stimulates follicle growth
• History and physical assessment of both partners hormone (Gonal-f) and maturation by
• Detailed menstrual, sexual, reproductive, and gynecologic history human chorionic gonado- mimicking the body’s
• Height, weight, and body mass index tropin (hCG) natural hormones
• Pelvic examination human menopausal
• Laboratory tests (as indicated) gonadotropin (Men-
• CBC opur)
• Thyroid-stimulating hormone (TSH) Selective estro- clomiphene citrate Stimulates ovulation
• STI screening gen receptor (Clomid) by binding estrogen
• Hormone levels (FSH, LH, antimüllerian hormone, progesterone, prolac- modulator receptors in the hypo-
tin) (SERM) thalamus. Leads to ↑
• Imaging gonadotropin-releasing
• Transvaginal ultrasound hormone (GnRH) produc-
• Hysterosalpingogram tion and ↑ LH and FSH
secretion in the pituitary
Management
• Lifestyle changes
• Drug therapy (Table 58.3) tailored to the underlying cause. A patient-centered approach
• Surgery to care is essential in treating infertility. Patients and, when
• Assisted reproductive technologies (ARTs) appropriate, their partners should be involved in determining
the plan of care and weighing the efficacy, safety, and advantages
and disadvantages of various treatment options. These proce-
Etiology and Pathophysiology dures may be expensive and stressful. Provide an overview of
Infertility affects men and women equally. We describe it as infertility evaluation, treatments, and alternatives to help reduce
being caused by male or female factors. There may also be a stress. Teaching about fertility, ovulation, and intercourse is
combination of factors. In as many as 30% of cases, no specific important. This information often improves conception rates.
cause is identified. Factors that cause male infertility are dis- Lifestyle changes include weight loss, smoking cessation, and
cussed in Chapter 59. The most common causes of female infer- reduced alcohol and caffeine intake. Intercourse is timed around
tility are hormone imbalances, anatomic or structural problems ovulation. Medical treatment for female infertility focuses on
of the reproductive tract, and other unexplained causes. stimulating the ovaries (known as ovulation induction). Table
58.3 reviews common drugs used in fertility treatment. Surgery
Diagnostic Studies may address blockages in the ovarian tubes or uterine prob-
Formal evaluation of infertility is usually done after 12 months lems. Finally, assisted reproductive technology (ART) procedures
of regular, unprotected intercourse (Table 58.1). Earlier evalua- include insemination through intracervical insemination (ICI),
tion is appropriate in women over the age of 35 or in the pres- intrauterine insemination (IUI), or in vitro fertilization (IVF).
ence of known medical or physical problems. Evaluation starts The National Infertility Association (RESOLVE) is a useful
with a history and physical assessment (Table 58.2). Based on resource to support patients in exploring treatment options.3
the findings, laboratory tests and diagnostic imaging may be
done. These explore common causes of infertility, including
diminished ovarian reserve, ovulatory dysfunction, and struc-
PREGNANCY LOSS
tural problems of the fallopian tubes and uterus.2 A semen anal- Pregnancy loss is the term used to describe the loss of a nonvi-
ysis of the male partner is often part of the infertility workup. able pregnancy up to 20 weeks gestation. Early pregnancy loss
occurs in the first trimester (the first 13 weeks of pregnancy). It
Interprofessional and Nursing Management is the most common type of pregnancy loss. Abortion is another
There are multiple treatment options for infertility. These include term used to describe the loss of a previable pregnancy or the
lifestyle changes, drug therapy, and surgery. The approach is elective termination of pregnancy at any stage. We classify
, 1414 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
Vagina
TABLE 58.4 Types of Spontaneous Abortion
Type Description
Complete abortion All products of conception (POC) are expelled
Curette
Incomplete abortion Passage of some but not all POC through the
cervix Uterus
Inevitable abortion Pregnancy loss cannot be prevented due to Speculum
opening of the cervix or rupture of amniotic
membranes
Infected (septic) Serious maternal infection occurring with any type
abortion of abortion
Missed abortion Nonviable POC remain in the uterus
Threatened abortion Vaginal bleeding in a pregnancy prior to 20 weeks’
gestation in the absence of cervical dilation Cervix
abortions as spontaneous or induced. Pregnancy loss can lead Fig. 58.1 D&C.
to grief and psychological distress.
Drug therapy involves drugs such as misoprostol (Cytotec)
Spontaneous Abortion and mifepristone (Mifeprex) to open the cervix and induce
Spontaneous abortion is the natural loss of pregnancy before 20 passage of the POC from the uterus. This approach offers more
weeks of gestation. Many refer to this as a “miscarriage.” Types predictable timing of the POC than expectant management. It is
of spontaneous abortions are listed in Table 58.4. Around 20% less invasive than surgery. The ability to prescribe and dispense
of pregnancies result in spontaneous abortion. Most occur in mifepristone is restricted in the United States.5 This limits its
the first trimester. They are often related to embryonic chromo- accessibility in some settings. Teaching about side effects and
somal abnormalities. Other common causes include endocrine anticipatory guidance is essential to safety in this approach.
problems, maternal infection, uterine abnormalities (e.g., uter- Surgery of an abortion involves dilation and curettage
ine fibroids, endometriosis), immune factors, and environment (D&C) (Fig. 58.1). With a D&C, the cervix is dilated and the
factors. Risk factors for spontaneous abortion include age greater uterine contents removed using either manual vacuum aspiration
than 35 years, history of prior pregnancy loss, and chronic med- (MVA) or electric vacuum aspiration (EVA). This approach is the
ical problems such as diabetes, obesity, or thyroid disease. Stress most invasive of spontaneous abortion treatment options. But it
and substance use are also related to an increased risk. is highly effective and offers rapid resolution of pregnancy loss.
Patients experiencing a spontaneous abortion often present Teach patients to call the HCP for heavy vaginal bleeding,
with vaginal bleeding and cramping. Following a history and fever, foul-smelling vaginal discharge, or severe pain. Discuss
physical assessment, transvaginal ultrasound imaging is rec- the use of pain medications, such as ibuprofen. Give resources
ommended for diagnosis. Bloodwork is done to assess serum or referrals for psychologic support and grief counseling to
human chorionic gonadotropin levels (hCG, also called β-hCG reduce mental health complications such as depression and anx-
or “beta”). We have few interventions to prevent pregnancy loss. iety. Review contraceptive options or planning for a subsequent
We used to place patients with threatened abortions on bed rest. pregnancy. Ovulation can resume within days or weeks after a
Research shows this practice has more potential to be harmful pregnancy loss. Historically, we told patients to abstain from
than helpful. So, we no longer recommend bed rest. vaginal intercourse and wait several weeks or months before
There are 3 approaches to treatment of spontaneous abortion: trying to become pregnant again. However, these practices do
(1) expectant management, (2) drug therapy, and (3) surgery.4 A not reduce complications like infection or recurrent pregnancy
patient-centered approach should be used to determine the plan loss and are no longer recommended.
of care based on the patient’s preferences and values. Provide
patients with information about treatment options. Discuss the Induced Abortion
risks and benefits of each. Involving patients in decision mak- Induced abortion is the elective termination of a pregnancy.
ing leads to the best mental health outcomes. Any patients with There are several ways to induce an abortion. In the United
signs of acute complications such as hemorrhage or infection States, the most common ways are medical abortion and aspi-
need emergency care. ration (sometimes called surgical) abortion (Table 58.5). The
Expectant management involves waiting for the pregnancy approach used depends on the gestational length of the preg-
tissue (also called products of conception [POC]) to pass on nancy, patient preference, and availability of care. State laws and
its own. When appropriate criteria are met, this approach is agency regulations affect abortion care. Cost can be a signifi-
about 75% effective in the 1st trimester. This option is the least cant factor since most patients pay out-of-pocket for abortion
invasive. However, it is not as predictable or effective as other services. Engage patients in decision making about the risks,
approaches. Patient teaching about warning signs is needed. benefits, and alternatives to help them make the most appro-
We need to monitor for complications and have a clear plan for priate decision. Provide patients information about all available
follow-up. options and referral to a setting that provides safe abortion care.6
