TODAY’S TOPICS
Contraception
Infertility
Menstrual Disorders
Phases of the Menstrual Cycle

Proliferative Phase (Follicular) 6-14d
 High


Ovulation
Secretory Phase (Luteal) 15-26d
 High


Estrogen and FSHdevelop follicle
Progesterone, Decreasing Estrogen
Ischemic Phase 27-28d
Menstrual Phase 1-6d
The Menstrual Cycle
Olds, S. London, M., Ladewig,
P., Davidson, M. (2004).
Maternal-newborn nursing &
women’s health care.(7th ed.).
Upper Saddle River, NJ.:
Prentice Hall. (p. 211).
Contraception begins with Fertility
Awareness

Ovulation
Ovum can be fertilized w/in 48 hrs
 Sperm viable for 72 hrs
 Problem pinpointing ovulation


Basal Body Temperature (BBT)[chart]
Progesterone increases = BBT increases
 Take temp when awakened
 Temp drops .2-.3 F; 24-36 before ovulation
 Rises .7-.8 after ovulation--sample

Contraception begins with Fertility
Awareness

Cervical Mucous (Spinbarkeit)
 More
abundant, thin clear,
stretchy mucous at ovulation
 Thickens and less amount until menses

Other Symptoms
 Mittelschmertz
 Increased
libido
 Bearing Down Pain
Physiological Methods

Calendar
 Keep
records for 6-8 months
 18 days from end of SHORTEST cycle
 11 days from end of LONGEST cycle
 Abstain during “fertile” times


BBT—website with calendar
Billings Method
Barrier Methods

Male Condom



Hold onto ring when withdrawing
Female Condom
Diaphragm
Refit after each childbirth
 Use with Contraceptive Jelly
 Leave in for 6 hours AFTER intercourse
 If repeat intercourse, use more spermicide


Cervical Cap

Leave in for 8-48 hours
Chemical Methods

IUD—Prevents fertilization
 Mirena-5
years
 Paragard -10 years
Risk of PID, Heavier periods (paragard),
perforation, dysmenorrhea
 Teach to  string after each menses


Spermicides
 May
have to wait to dissolve
 Reapply with repeat intercourse
 Use with diaphragm/condom
 Non-oxinol 9—Kills HIV and other
STD’s
Chemical Methods—BCP’s

Types
Combination P & E
 Progesterone ONLY “minipill”
 Phasic


Side effects (Table 5-2, p. 99 Olds et al)
Estrogen effects: N/V, weight gain, headaches, breast
tenderness, etc.
 Progesterone effects: acne, breast tenderness, ↓ libido,
depression, fatigue, hirsuitism, weight gain, etc.


Contraindications
Thrombophlebitis, CHD, Breast CA, SMOKER
 Some antibiotics DECREASE effectiveness

Long-Acting Chemical Methods

Implanon
 Lasts
up to 3 years
 Flexible plastic rod the size of a matchstick that is
put under skin in the upper arm
 Chief side effect: irregular bleeding

Depo-Provera
 Injection
4 x / yr
 Prolonged amennorhea or uterine bleeding
Newer Chemical Methods

Contraceptive Patch
 ORTHO

EVRA
Contraceptive Ring
 NuvaRing

A helpful website
 http://www.ultimatebirthcontrol.com/
Emergency Contraception



Take 2 BCP’s at once and 2 more 12 hours later
Use within 72 hours after unprotected intercourse
Prevents implantation
Operative Sterilization

Male Vasectomy
 Outpatient
 81-91%
reversal
 Ice for pain, swelling
 NOT immediate
sterility—up to 36
ejaculations to rid
ducts of all sperm
 Sperm count to verify

Female Tubal Ligation
 Can
be done with C/sec
 General Anesthesia or
epidural if done after
vaginal delivery
 20 minutes
 Less successful reversals
Outpatient Sterilization

Essure-small metallic
implant that is placed
into the fallopian
tubes under
hysteroscopic
guidance
 Induces
scar tissue to
form over the implant,
blocking the fallopian
tube and preventing
fertilization of the egg
by the sperm


99.8% effective
Oral contraceptives
are often prescribed
at least one month
prior to insertion to
induce endometrial
atrophy and to
prevent an
undiagnosed
pregnancy




Paracervical blocks are given
to anesthetize the perineum
NSAIDs and Diazapam can
be given during the procedure
to minimize discomfort
Educate patients to use
alternate contraceptive
methods until a
hysterosalpingogram is
performed 3 months after
placement to confirm
complete blockage of
fallopian tubes
99.8% effective
Abortion


ElectivePerformed
at woman’s request
Therapeutic
performed for reasons
of maternal or fetal
health

1st trimester
 Roe

v. Wade
2nd trimester
 States
decide
RU-486



Combination of 2 drugs
Mifepristone is an anti-Progesterone drug that stops
the early pregnancy from growing.
Misoprostol is the second drug and causes the uterus
to contract and an early pregnancy to be expelled.
Procedure




Confirm Pregnancy Blood test or U/S
Take Mefipristone (1 pill)
2-4 days later, Take Misoprostol
Come back to office in 2 weeks—U/S to confirm
NO pregnancy
Side Effects


Abdominal cramping pain, bleeding, nausea,
vomiting, and diarrhea, which may be extreme in
some cases.
Dilatation and Curettage (D&C) may be needed
in rare cases.
Plan B Levonorgestrel

Emergency contraception-not effective if already
pregnant
 Reduces
risk of pregnancy when take after unprotected
sex
 With
 No
in 72 hours after intercourse
prescription required for 17 years and older,
prescription needed 16 yrs and younger
Plan B


Levonorgestrel works by stopping ovulation,
fertilization, or implantation, depending on where a
woman is in her cycle.
Side effects
 Nausea,
abdominal pain, fatigue, headache and
changes in menstural cycle
NURSE’S ROLE IN
BIRTH CONTROL COUNSELING
•Assess patient’s knowledge, lifestyle, preferences, any
cultural taboos or implications
•Take a thorough patient history to identify any factors
that put a patient at high risk for complications and rule
out certain contraceptives.
•Provide handouts, demonstration, discuss advantages and disadvantages
of each method,
•Allow time for questions and feedback
INFERTILITY
Inability of a couple to produce a living child as a result of a
failure to conceive or inability to carry the conceived child to a
viable state after 12 months of unrestricted sexual relations
Categories

Primary Infertility
 Never
having
conceived a child

Secondary Infertility
 Has
conceived by
cannot conceive again
or carry a pregnancy
to viability after 1
year of unrestricted
sexual relations
Causes of Infertility by Couple




Female Factor 50%
Male Factor
35%
Unexplained
10%
Other
5%
Causes of Infertility in Women

Endocrine Sources
 Ovulatory
Dysfunction 40%
 Anovulation







or oligo-ovulation
Hyperprolactinemia
Hyper- and hypo- thyroidism
Premature ovarian failure
Genetic Defects---Turner’s Syndrome (XO)
Excessive Exercise and Dieting
Polycystic Ovarian Syndrome Altered FSH:LH ratio
Severe Emotional Stress
Causes of Infertility in Women

Non-endocrine Causes
 Tubal
& Uterine Factors 40%
 Block
tubes (PID, endometriosis)
 Uterine Fibroids or malformed uterus


Unexplained 10%
Other
10%
Causes of Infertility in Men

Sperm Factors
 Too
few, Too slow, Too many malformed
 Injury, mumps, high fever, radiation,
 Substance abuse: ETOH, cocaine, marijuana, cigarettes
 Meds: cimetidine, chemo, sulfas, erythromycin,
tetracycline
Causes of Infertility in Men

Endocrine Factors
 Klinefelter’s
syndrome (XXY)
 Low testosterone levels
 Excessive Prolactin levels

Non-Endocrine Factors
 Obstructed
 Varicoceles
vas deferens
Female Fertility Work-Up



BBT
Cervical Mucous
Endometrial Biopsy adequacy
of secretory tissue in LUTEAL phase--effect
of progesterone by corpus luteum
 7 days BEFORE onset of menses
 Can have cramping afterwards
Female Fertility Work-Up

HystersalpingogramDye instilled in uterus—Watch flow through fallopian tubes
 Moderate discomfort


Laparoscopy
General Anesthesia
 6-8 months after Hysterosalpingogram
 Referred shoulder pain
 Evaluate for endometriosis, adhesions, tumors, cysts

Male Fertility Work-Up

Sperm adequacy tests
 Count
 Motility
 Morphology
 Abstain
for 2 days—Bring into lab within 1 hour after
collection
Couple Tests

Post-Coital Tests
 1-2
days prior to expected ovulation
 Couple has intercourse
 Go to MD within 4-6 hours
 Aspirate cervical mucous from os
 Evaluate mucous/sperm
 Motility
and Number
Infertility Trx--Medications


Olds et al, 9th ed. Pp. 252-255
Clomid-Estrogen Antagonist (po)
 Take
on days 5-9
 Induces Ovulation

Pergonal, Humegon or Repronex (hMG)
 IM
 Direct
effect on pituitary,stimulate FSH/LH
Infertility Treatments/Medications

Fertinex, Follistim and Gonal F
 purified




FSH given SQ
Start on day 2-4 of menstrual cycle
Watch growth of follicles via U/S and serum
estradiol levels
Give hCG IM when follicles/levels OK
Have intercourse within 2 days
Egg Retrieval
Infertility Trx

Artificial Insemination
 1-2
days BEFORE ovulation
 Fresh semen placed at cervical os

In-Vitro Fertilization (IVF)
 Stimulate
ovum production—Harvest eggs
 Sperm and Egg meet in Test tube
 Fertilized ovum transferred into uterus
Infertility Trx

Gamete Intrafallopian Transfer (GIFT)
 Sperm
and egg transferred separately into fallopian
tube where fertilization can occur
 Go past cervical mucous

Zygote Introfallopian Transfer (ZIFT)
 Fertilized
zygote transferred into fallopian tube and
then travels back into uterus to implant
Other Alternatives
Adoption
 Surrogate

Nurse’s Role in Infertility Trx




Highly Sensitive Issue
Self-Esteem/Body Image
Marital Relations
Expensive
Menstrual Cycle & Disorders

Menarche
 Age
at which menses begins
 Usually about 13 y/o, range 10-16

Menopause
 Time
when periods stop; 50-51 y/o
 Initially periods are irregular, painless and
anovulatory—BUT can get pregnant
 Peri-menopausal period
PreMenstrual Syndrome (PMS)


Affects 30-40% of all women
Three criteria need to be met
 Symptoms
occur in the luteal phase (after ovulation and
4-10 days before menses starts)
 About 1 week w/o symptoms in follicular phase
 Symptoms sever enough to interfere with life
Characteristic Symptoms






Fluid Retention/
Bloating
Anxiety/Irritability
Agitation/
Arguementative
Depression/Crying
Lethargy
Panic Attacks



Accident Prone
Decreased
concentration
Food Cravings
 Salt
& Sweets

Breast tenderness

Headaches/dizziness
Causes of PMS





Unknown
Interaction between Estrogen and Progesterone-Progesterone Deficiency
Prolactin & Prostaglandin Excess
? Role of Endorphins
Nutritional Deficiency—Mg ++
Treatments



Track symptoms
BCP’s, Progesterone
Prostaglandin Inhibitors
 Efamol
 Mefenamic

Acid 250mg/day in luteal phase
Danazol & Xanax less effective
Toxic Shock Syndrome



Pyrogenic exotoxins from Staph. Aureus
15-24 y/o, using tampons
Three Principal Clinical Manifestations
 Sudden
onset high Fever > 102
 HYPOtension, systolic < 90mm Hg
 Rash—diffuse, macular, desquamation of palms and
soles

Other S/S
Treatment





Early dx is critical
IV fluid—trx dehydration
Antibiotics
Platelets
Meds for skin rash and hypotension
NURSING EDUCATION
Olds et al, 9th ed. p.135
“Client Self-Care—Prevention of TSS”
Amenorrhea

Primary

 Absence
or Cessation
of periods

6
month cessation after
women has started
periods
Causes
 Congenital
Obstructions
 Hormone Imbalance
Secondary

Causes
 Pregnancy/Lactation
 Poor
Nutrition
Dysmenorrhea—Painful Periods

Primary
 Pain
w/o pelvic
pathology
 Incapacitate 2-3 days


 Organic/pathological
 Endometriosis,
PID,
ovarian cysts, myomas,
IUD
Cause
 Prostaglandins
 Vasopressin


Dx
 U/S,
D&C, biopsy
Laparoscopy
Treatment
 BCP’s
Secondary
& NSAID’s

Trx depends on cause
Endometriosis


Endometrial tissue outside the uterus  ovary,
tubes, vaginal vault, abdomen
Tissue responds to hormonal changes of menstrual
cycle
 Bleed,

inflammation, scarring, adhesions
3-10% of all women, 25-25% of infertile women,
28% of women with chronic pelvic pain
Cause of Endometriosis


Again—UNKNOWN
? Reflux of fallopian tube, retrograde
menstruation endometrial tissue cells go out into
abdominal cavity
Symptoms

Vary Greatly
Little disease  Lots of Pain
 Lots of disease  Little Pain






Dysmennorhea
Chronic, non-cyclic pelvic pain
Dysparueunia
Diarrhea/Constipation
Infertility
Treatments

Medication
 Lupron
& Synarel GnRH agonists
 Danazol
 Oral Contraceptives

Surgical
 Laparoscopy
or Laparotomy
 Total Abdominal Hysterectomy with Bilateral SalpingoOophorectome (TAH w/ BSO)
Nursing Assessment & Care



Gynecological History
Symptoms
Nursing Diagnoses
 Anxiety;
Body Image, disturbances of Self-Image;
Knowledge Deficit, Pain

Encourage woman to avoid delaying pregnancy
if desired d/t increased risk of infertility.