OB EXAM I
Ch. 4 Reproductive Issues
- Common menstrual disorders
oAmenorrhea
oDysmenorrhea
oDysfunctional uterine bleeding (DUB)
oPremenstrual syndrome (PMS)
oPremenstrual dysphoric disorder (PMDD)
oEndometriosis
- Amenorrhea
Normal in prepuberty and also during pregnancy
Amenorrhea can also occur in the post-partum period
oAbsence of menses during reproductive years
oTwo types of primary amenorrhea
Absence of menses by age 14 w/ absence of development of secondary sexual characteristics
No menses by age 14 and there is an absence of secondary sexual characteristics like no
pubic hair or breast formation
Absence of menses by age 16 w/ normal development of secondary sexual characteristics
oSecondary amenorrhea: absence of menses in women who previously menstruated that is related to
another condition or disorder
Secondary is an absence of menses in someone who had a menstrual cycle for many years and is
not post-menopause. Like something that can happen to someone in their 20s or 30s
We need to look to see if there is a pathologic cause. We have to look at the cause, what is
causing it?
oFor any amenorrhea we have to look at what is causing it.
Is it that we have an eating disorder? Patients with anorexia or bulimia may not start their
menstrual cycle. Even for patients with secondary amenorrhea, it can be due to extreme dieting.
Chemotherapy can also affect the reproductive system and cause amenorrhea. So, we have to
look at any neoplastic causes of secondary amenorrhea
- Question #1: Is the following statement true or false?
oPrimary amenorrhea occurs in women who have previously menstruated regularly.
False!
Primary – we have not start by 14 years old with absence of secondary characteristics or
we have not start by 16 years old with the development of secondary characteristics
Primary amenorrhea is the absence of menses by age 14 with the absence of secondary
sexual characteristics, or absence of menses by age 16 with normal development of
secondary characteristics. Secondary amenorrhea is the absence of menses for three
cycles or 6 months in women who have previously menstruated
- Etiology and types of dysmenorrhea
Dysmenorrhea is painful bleeding
Common in adolescents
We have to assess our patients; we want to know what their perception of pain is and how long
as it been going on
oPrimary
Increased prostaglandin production (primary)
oSecondary
Can be due to fibroids, endometriosis, or some kind of pelvic infection.
Pelvic or uterine pathology
Endometriosis most common cause of secondary dysmenorrhea
1
,OB EXAM I
oQuestion #2: is the following statement true or false?
Endometriosis is the most common cause of secondary dysmenorrhea
True!
oSecondary amenorrhea is most commonly due to endometriosis. Primary
amenorrhea is related to increased prostaglandin production
oNursing management of dysmenorrhea
Nursing assessment
Past medical hx, sexual hx, menstrual hx; bimanual pelvic examination
oWhen did they start menarche?
oHave they had heavy flow? Do they have normal flow? How frequent is the
cycle?
oBimanual pelvic exam is done by the HCP not the nurse
Manifestations: pain, nausea, vomiting, diarrhea, fatigue, fever, HA, dizziness; bloating, water
retention, weight gain, muscle aches, food cravings, breast tenderness
Client education:
Comfort measures: heat, lifestyle changes, pain relief
oTreatment is to provide pain relief. We want them to be able to do their normal
life activities like go to school, the gym, grocery shopping, etc. The goal is to
provide as much pain relief as we can. We can do OTC NSAIDs, some may use
herbal remedies as long as they do not interact with other medications.
oWe can also give oral contraceptives to help regulate the cycle, it helps reduce
the amount of prostaglandin being produced
- Dysfunctional uterine bleeding
oSimilar to and may overlap with other uterine bleeding disorders
oOccurs most often at beginning and end of menstrual cycle
oEtiology related to hormone disturbance
oTreatment involves treating the underlying cause
oNursing management involves client education
oDysfunctional uterine bleeding is an umbrella term used to describe any abnormalities in bleeding
oIt is common in adolescents who are just starting their menses and also at the end
oPain is usually caused by hormonal disturbances
oWe must investigate and treat the underlying cause
oFibroids can be a cause of abnormal uterine bleeding also any endometrial polyp can cause it too. Some
patients can become anemic by loosing a lot of blood from the menses, so we want to treat the anemia
too.
oBirth control can help regulate the cycle and bleeding
- Premenstrual syndrome
oWide range of recurrent symptoms
oMore severe variant: premenstrual dysphoric disorder (PMDD)
Etiology: unknown
Therapeutic management:
Multidimensional approach
Vitamin supplements, diet changes, exercise, lifestyle medications
oBegins in the luteal phase and ends when bleeding or menstruation starts
oDifferent for each woman
oCategorizing premenstrual syndrome symptoms
Patients have to have at least one affective and one somatic symptom at least 5 days
before menses
2
,OB EXAM I
oAffective symptoms are things like anger, depression, anxiety, mood disorders,
etc.
oSomatic symptoms are things like N/V/D, bloating, HA, edema
Treated using NSAIDs and vitamins
Nursing assessment: irritability, tension, dysphoria (most prominent and consistent symptoms)
A: anxiety
C: craving
D: depression
H: hydration
O: other
oThis is going to come from the client, what is affecting them specifically. What
symptoms are they dealing with?
oIt is something that is not in the textbook
oSo, listen to the clients and take into consideration what they are dealing with
ACOG criteria
Mood disorders: main symptoms of PMDD
PMDD patients can have severe depression and/or anxiety. It can be so severe, that they
may need antidepressants if the effective disorder and dysphoria is bad. We want to
make sure that the condition is not negatively impacting their daily life.
oQuestion #3: When assessing a woman for premenstrual syndrome, which of the following would the
nurse be least likely to find?
Irritability
Tension
Dysphoria
Weight loss
The woman with PMS reports weight gain, not weight loss, irritability, tension, and
dysphoria
- Endometriosis
A very common gynecological issue
Endometriosis is when the endometrial tissue is located on the outside of the uterus. It can be
retro-vaginal, in the pelvis, or pelvic cavity. Because it is still endometrial tissue, it still responds
to hormones and is a cause for break through dysmenorrhea (painful menses)
It is treated with medications, oral contraceptives, NSAIDs. Some progesterone to help destroy
endometrial cells. If medications do not work, then surgery is the last line of defense. We can
surgically remove the lesions and in severe cases, we may have to do a hysterectomy (this is the
very last option!)
The only way to diagnosis endometriosis is surgically or laparoscopically but a lot of times, the
OB/GYN may do a pelvic or ultrasound to make sure the structures are sound and intact
oEtiology: risk factors; exact cause is unknown
oTherapeutic management
Surgery
Medication therapy
oNursing assessment: infertility and pain; non-specific pelvic tenderness; tender nodular masses on
uterosacral ligaments, posterior uterus, or posterior cul-de-sac
oEndometriosis management
Education
Educate the patient on how we will manage the pain. If we give medication, we want to
make sure they adhere to the medication regimen
Healthy lifestyle habits
3
, OB EXAM I
Support groups
Support groups are important especially for patients having surgery and those with
infertility issues r/t the condition. We want to make sure we give them the community
support they need
- Infertility
Infertility is the inability to get pregnant after having unprotected intercourse for one year
oPrimary or secondary
Primary is when they tried to get pregnant after w/ one year of unprotected intercourse
Secondary is if the woman has had a pregnancy but is unable to get pregnant after that
So, she had one baby but now she cannot get pregnant again
oCultural expectations for reproduction
oImpact of culture, ethnicity, or religion on perceptions and management of infertility
oMultiple known and unknown factors affecting fertility
oMale and female risk factors
Risk factors for males become infertile include heavy smokers, marijuana smokers, heavy
drinkers, obesity, a male with undescended testicles, any male that has gone through chemo is
at risk for being infertile
Risk factors for females include STIs, nutrition such as being obese or underweight. When a
patient is over or under nutritious that will disrupt the hormones and prevent implantation.
Additionally, increased age and any abnormalities like endometriosis are also risk factors. The
older the female gets, the more failure of the ovaries they have. Sometimes we have a genetic
component as well
oTherapeutic management: drugs or surgery
oFertility assessment
Male factor assessment: semen analysis (non-invasive, looks at the sperm count), sexual
characteristics, external and internal reproductive organ examination, digital prostate
examination
Female factor assessment: ovarian function, pelvic organs
Laboratory and diagnostic testing: home ovulation predictor kits, clomiphene citrate challenge
test, hysterosalpingogram, laparoscopy
Educate females on how to use home ovulation tests
Clomiphene can be given to stimulate the ovaries
Hysterosalpingogram – they inject a dye to make sure that no blockages are present in
the uterus
oNursing management of infertility
Respect for couple
Education, anticipatory guidance, stress management, counseling
Assistance in decision making; advocacy
Assistance with financial strategies
- Contraception: behavioral methods
There are various ways to prevent contraception
4 categories: behavioral, hormonal, surgical/permanent, and barrier methods
oAbstinence
Abstinence is 100% protective against pregnancy and STIs
It is a lifestyle choice
oFertility awareness
Refrain from sex during fertile period
4
Ch. 4 Reproductive Issues
- Common menstrual disorders
oAmenorrhea
oDysmenorrhea
oDysfunctional uterine bleeding (DUB)
oPremenstrual syndrome (PMS)
oPremenstrual dysphoric disorder (PMDD)
oEndometriosis
- Amenorrhea
Normal in prepuberty and also during pregnancy
Amenorrhea can also occur in the post-partum period
oAbsence of menses during reproductive years
oTwo types of primary amenorrhea
Absence of menses by age 14 w/ absence of development of secondary sexual characteristics
No menses by age 14 and there is an absence of secondary sexual characteristics like no
pubic hair or breast formation
Absence of menses by age 16 w/ normal development of secondary sexual characteristics
oSecondary amenorrhea: absence of menses in women who previously menstruated that is related to
another condition or disorder
Secondary is an absence of menses in someone who had a menstrual cycle for many years and is
not post-menopause. Like something that can happen to someone in their 20s or 30s
We need to look to see if there is a pathologic cause. We have to look at the cause, what is
causing it?
oFor any amenorrhea we have to look at what is causing it.
Is it that we have an eating disorder? Patients with anorexia or bulimia may not start their
menstrual cycle. Even for patients with secondary amenorrhea, it can be due to extreme dieting.
Chemotherapy can also affect the reproductive system and cause amenorrhea. So, we have to
look at any neoplastic causes of secondary amenorrhea
- Question #1: Is the following statement true or false?
oPrimary amenorrhea occurs in women who have previously menstruated regularly.
False!
Primary – we have not start by 14 years old with absence of secondary characteristics or
we have not start by 16 years old with the development of secondary characteristics
Primary amenorrhea is the absence of menses by age 14 with the absence of secondary
sexual characteristics, or absence of menses by age 16 with normal development of
secondary characteristics. Secondary amenorrhea is the absence of menses for three
cycles or 6 months in women who have previously menstruated
- Etiology and types of dysmenorrhea
Dysmenorrhea is painful bleeding
Common in adolescents
We have to assess our patients; we want to know what their perception of pain is and how long
as it been going on
oPrimary
Increased prostaglandin production (primary)
oSecondary
Can be due to fibroids, endometriosis, or some kind of pelvic infection.
Pelvic or uterine pathology
Endometriosis most common cause of secondary dysmenorrhea
1
,OB EXAM I
oQuestion #2: is the following statement true or false?
Endometriosis is the most common cause of secondary dysmenorrhea
True!
oSecondary amenorrhea is most commonly due to endometriosis. Primary
amenorrhea is related to increased prostaglandin production
oNursing management of dysmenorrhea
Nursing assessment
Past medical hx, sexual hx, menstrual hx; bimanual pelvic examination
oWhen did they start menarche?
oHave they had heavy flow? Do they have normal flow? How frequent is the
cycle?
oBimanual pelvic exam is done by the HCP not the nurse
Manifestations: pain, nausea, vomiting, diarrhea, fatigue, fever, HA, dizziness; bloating, water
retention, weight gain, muscle aches, food cravings, breast tenderness
Client education:
Comfort measures: heat, lifestyle changes, pain relief
oTreatment is to provide pain relief. We want them to be able to do their normal
life activities like go to school, the gym, grocery shopping, etc. The goal is to
provide as much pain relief as we can. We can do OTC NSAIDs, some may use
herbal remedies as long as they do not interact with other medications.
oWe can also give oral contraceptives to help regulate the cycle, it helps reduce
the amount of prostaglandin being produced
- Dysfunctional uterine bleeding
oSimilar to and may overlap with other uterine bleeding disorders
oOccurs most often at beginning and end of menstrual cycle
oEtiology related to hormone disturbance
oTreatment involves treating the underlying cause
oNursing management involves client education
oDysfunctional uterine bleeding is an umbrella term used to describe any abnormalities in bleeding
oIt is common in adolescents who are just starting their menses and also at the end
oPain is usually caused by hormonal disturbances
oWe must investigate and treat the underlying cause
oFibroids can be a cause of abnormal uterine bleeding also any endometrial polyp can cause it too. Some
patients can become anemic by loosing a lot of blood from the menses, so we want to treat the anemia
too.
oBirth control can help regulate the cycle and bleeding
- Premenstrual syndrome
oWide range of recurrent symptoms
oMore severe variant: premenstrual dysphoric disorder (PMDD)
Etiology: unknown
Therapeutic management:
Multidimensional approach
Vitamin supplements, diet changes, exercise, lifestyle medications
oBegins in the luteal phase and ends when bleeding or menstruation starts
oDifferent for each woman
oCategorizing premenstrual syndrome symptoms
Patients have to have at least one affective and one somatic symptom at least 5 days
before menses
2
,OB EXAM I
oAffective symptoms are things like anger, depression, anxiety, mood disorders,
etc.
oSomatic symptoms are things like N/V/D, bloating, HA, edema
Treated using NSAIDs and vitamins
Nursing assessment: irritability, tension, dysphoria (most prominent and consistent symptoms)
A: anxiety
C: craving
D: depression
H: hydration
O: other
oThis is going to come from the client, what is affecting them specifically. What
symptoms are they dealing with?
oIt is something that is not in the textbook
oSo, listen to the clients and take into consideration what they are dealing with
ACOG criteria
Mood disorders: main symptoms of PMDD
PMDD patients can have severe depression and/or anxiety. It can be so severe, that they
may need antidepressants if the effective disorder and dysphoria is bad. We want to
make sure that the condition is not negatively impacting their daily life.
oQuestion #3: When assessing a woman for premenstrual syndrome, which of the following would the
nurse be least likely to find?
Irritability
Tension
Dysphoria
Weight loss
The woman with PMS reports weight gain, not weight loss, irritability, tension, and
dysphoria
- Endometriosis
A very common gynecological issue
Endometriosis is when the endometrial tissue is located on the outside of the uterus. It can be
retro-vaginal, in the pelvis, or pelvic cavity. Because it is still endometrial tissue, it still responds
to hormones and is a cause for break through dysmenorrhea (painful menses)
It is treated with medications, oral contraceptives, NSAIDs. Some progesterone to help destroy
endometrial cells. If medications do not work, then surgery is the last line of defense. We can
surgically remove the lesions and in severe cases, we may have to do a hysterectomy (this is the
very last option!)
The only way to diagnosis endometriosis is surgically or laparoscopically but a lot of times, the
OB/GYN may do a pelvic or ultrasound to make sure the structures are sound and intact
oEtiology: risk factors; exact cause is unknown
oTherapeutic management
Surgery
Medication therapy
oNursing assessment: infertility and pain; non-specific pelvic tenderness; tender nodular masses on
uterosacral ligaments, posterior uterus, or posterior cul-de-sac
oEndometriosis management
Education
Educate the patient on how we will manage the pain. If we give medication, we want to
make sure they adhere to the medication regimen
Healthy lifestyle habits
3
, OB EXAM I
Support groups
Support groups are important especially for patients having surgery and those with
infertility issues r/t the condition. We want to make sure we give them the community
support they need
- Infertility
Infertility is the inability to get pregnant after having unprotected intercourse for one year
oPrimary or secondary
Primary is when they tried to get pregnant after w/ one year of unprotected intercourse
Secondary is if the woman has had a pregnancy but is unable to get pregnant after that
So, she had one baby but now she cannot get pregnant again
oCultural expectations for reproduction
oImpact of culture, ethnicity, or religion on perceptions and management of infertility
oMultiple known and unknown factors affecting fertility
oMale and female risk factors
Risk factors for males become infertile include heavy smokers, marijuana smokers, heavy
drinkers, obesity, a male with undescended testicles, any male that has gone through chemo is
at risk for being infertile
Risk factors for females include STIs, nutrition such as being obese or underweight. When a
patient is over or under nutritious that will disrupt the hormones and prevent implantation.
Additionally, increased age and any abnormalities like endometriosis are also risk factors. The
older the female gets, the more failure of the ovaries they have. Sometimes we have a genetic
component as well
oTherapeutic management: drugs or surgery
oFertility assessment
Male factor assessment: semen analysis (non-invasive, looks at the sperm count), sexual
characteristics, external and internal reproductive organ examination, digital prostate
examination
Female factor assessment: ovarian function, pelvic organs
Laboratory and diagnostic testing: home ovulation predictor kits, clomiphene citrate challenge
test, hysterosalpingogram, laparoscopy
Educate females on how to use home ovulation tests
Clomiphene can be given to stimulate the ovaries
Hysterosalpingogram – they inject a dye to make sure that no blockages are present in
the uterus
oNursing management of infertility
Respect for couple
Education, anticipatory guidance, stress management, counseling
Assistance in decision making; advocacy
Assistance with financial strategies
- Contraception: behavioral methods
There are various ways to prevent contraception
4 categories: behavioral, hormonal, surgical/permanent, and barrier methods
oAbstinence
Abstinence is 100% protective against pregnancy and STIs
It is a lifestyle choice
oFertility awareness
Refrain from sex during fertile period
4
