RNSG 1251OB Exam 1 Notes CH 4 REPRODUCTIVE SYSTEM CONCERNS

MENSTRUAL DISORDERS ENDOMETRIOSIS Definition/Etiology/Pathophysiology:  Characterized by the presence & growth of the endometrial tissue outside of the uterus.  Endometrial tissue contains uterine glands & stroma (connective tissue) & responds to cyclic hormone stimulation in the same way that the uterine endometrium does but often out of phase w/ it.  The tissue grows during the proliferative & secretory phases of the cycle. During or immediately after menstruation the tissue bleeds, resulting in an inflammatory response w/ subsequent fibrosis & adhesions to adjacent organs.  Etiology & pathology of this condition is poorly understood. One of the most widely accepted theories is transplantation or retrograde menstruation. – Endometrial tissue is refluxed through the uterine tubes/fallopian tubes during menstruation into the peritoneal cavity, where it implants on the ovaries & other organs. – Recent theory: there is an interaction between the amount of retrograde menstruation & an individual woman's immunologic response, which may be influenced by ethnic & genetic variability Signs & Symptoms:  Wide variation of Sx; extent of pain is not correlated w/ severity of endometriosis  Pelvic pain  Dysmenorrhea  Dyspareunia (painful intercourse)  Chronic noncyclic pelvic pain  Pelvic heaviness  Pain radiating into thighs  Bowel symptoms: diarrhea, pain w/ defecation, & constipation  Abnormal bleeding (hypermenorrhea, menorrhagia, premenstrual staining)  Pain during exercise because of adhesions Complications  Impaired fertility may result from adhesions around the uterus that pull the uterus into a fixed, retroverted position.  Adhesions around the uterine tubes may block the fimbriated ends or prevent the spontaneous movement that carries the ovum to the uterus. Risk Factors  5% to 15% in reproductive-age women  30% to 45% in infertile women  33% in women w/ chronic pelvic pain  5% of postmenopausal women receiving menopausal hormone therapy  50% of teens w/ pelvic pain are found to have endometriosis  Recurs in approximately 40% of women  Usually develops in the 3rd or 4th decade of life; has been found in adolescents w/ disabling pelvic pain or abnormal vaginal bleeding.  Endometriosis may worsen w/ repeated cycles, or it may remain asymptomatic & undiagnosed, eventually disappearing after menopause. Therapeutic Management  Women without pain who do not want to become pregnant need no treatment.  Women w/ mild pain who may desire a future pregnancy, treatment may be limited to use of NSAIDs during menstruation.  Suppression of endogenous estrogen production is cornerstone of management: GnRH agonists & androgen derivatives – GnRH agonist therapy (leuprolide [Lupron], nafarelin acetate [Synarel], goserelin acetate [Zoladex]) acts by suppressing pituitary gonadotropin secretion. – FSH & LH stimulation of the ovary declines markedly, & ovarian function decreases significantly. – Hypoestrogenism results in hot flashes in almost all women – Trabecular bone loss is common, although most loss is reversible within 12-24 months after medication is stopped.  Leuprolide (3.75 mg IM INJ given once a month), Nafarelin (200 mg BID daily nasal spray, goserelin (3.6 mg every 28 days SUBQ implant)  Danazol, a mildly androgenic synthetic steroid, suppresses FSH & LH secretion  produces anovulation & hypogonadotropism. This results in decreased secretion of estrogen & progesterone & regression of endometrial tissue. – Masculinizing S/E: weight gain, edema, decreased breast size, oily skin, hirsutism, deepening of voice), all of which will disappear when treatment is discontinued. – Other S/E: amenorrhea, hot flashes, vaginal dryness, insomnia, decreased libido, migraine HA, dizziness, fatigue, depression – Adversely affect lipids: decrease HDL & increased LDL – Contraindicated in pregnancy, liver disease, & used w/ caution w/ cardiac & renal disease  Early symptomatic disease & who can postpone pregnancy may be treated with OCPs that have a low estrogen-progestin ratio to shrink endometrial tissue. – Taken continuously for 6-12 months without any withdrawal time of the OCP (leads to more complete suppression  decreasing endometriosis; breakthrough bleeding)  Adolescents < 16 y/o combined hormone therapy (OCPs, estrogen/progestin patch, estrogen/progestin vaginal ring) for menstrual suppression & administration of NSAIDs – GnRH agonist therapy for severe symptoms may have possible adverse effects on bone mineralization in adolescents, & bone mineral density should be carefully monitored.  Severe, acute, or incapacitating Sx  surgical intervention. Nursing Considerations:  Regardless of the type of treatment (short of TAH with BSO), endometriosis recurs in approximately 40% of women.  Counseling & education are critical components of nursing care.  Women need an honest discussion of treatment options, with review of the potential risks & benefits of each option.  Because pelvic pain is a subjective, personal experience that can be frightening, support is important.  Sexual dysfunction resulting from dyspareunia is common & may necessitate referral for