Chapters 3&4: Assessment and Health Promotion/Reproductive System Concerns
Part 1-Menstruation, Menopause and Menstrual Disorders
Introduction
Before we dive into this content, please take a few moments to review female anatomy.
The first few pages of chapter 3 will get you started. The importance of understanding
the anatomy will become clear later as we cover GYN disorders. It will allow you to
better understand exactly where the disorder is taking place as well as the symptoms
related to the disorders.
Menstruation
Menarche-First menstruation
Precocious puberty-when a child begins changing into that of an adult(puberty) too
soon. Puberty that begins before age 8 in girls and before age 9 in boys is considered
precocious puberty.
Let's start our journey as a young girl. Starting a menses for the first time can be both
exciting and scary! The more educated a young girl is about what to expect the less
traumatic it can be. But just imagine if you didn't understand the upcoming changes and
all of a sudden you began to bleed!! Super scary, embarrassing, etc!
The average age for menarche in the US is 13. When a young girl begins her menses
for the first time(menarche), they are often initially irregular, painless, and anovulatory.
In clinic settings, we often get many calls from scared moms during these first few
months. Moms are often concerned about the irregularity. It is our job to reassure these
moms that menses are often irregular during the few months of menses, up to the first
year. After this initial phase, menses will then often become more regular once ovulation
has started.
Pregnancy risk is always a topic we should explore in adolescents. Although these first
menses are often anovulatory, we cannot predict when ovulation will first occur, thus
pregnancy and prevention methods should always be explored with our adolescent
patients and their families. STI protection should be at the top of our list of education as
well. Adolescents need us to be honest with them and explain the menstrual cycle,
pregnancy risk, and STI protection. Often myths regarding these topics circulate among
their friend groups and can lead to detrimental effects. Being real with these patients
can save heartache later in life.
As a women ages, the menstrual cycle will change and become a vital part of her life.
Being educated about the normal changes as well as potential problems will help guide
her through the changes.
As I said above, the menses will become more regular once ovulation has initiated.
Usually occurring once per month. The average cycle length among women is 28 days.
Now... remember women are not machines, many factors can effect the menstrual
cycle. Things such as stress, medication, weight changes, etc. can vastly affect the
menstrual cycle.
• How many of you are stressed in nursing school? Of course!
• Have you gained weight? Lost weight lately?
• Any changes in medication?
These are just some of the questions you might discuss with your patient. Finding out
that a missed menses is simply due to stress is much less traumatic than not knowing
why.
Day one of a menses is the first day blood is seen. Women are encouraged to keep a
calendar and chart cycle length, and symptoms. This can be helpful when issues or
questions arise regarding the menstrual cycle.
Perimenopause and Menopause
Perimenopause is the transitional phase during which ovarian function and hormone
production decline. During this phase, menses often become irregular once again
(remember from the beginning- with ovulation-menses are often regular but as the
ovaries begin to decline ovulation is unpredictable and thus menses become irregular
again). Women will begin to feel the effects of the decline in hormones during this time
and may begin to seek treatment.
Some women fly through this time with ease and happiness. Some women crash and
burn!!
Once a women has not had a menses for 12 months= we can say she has transitioned
into Menopause. Some women like I said transition well and are happy to see the "old
menstrual cycle" go but others morn this loss and the loss of childbearing abilities.
Menopause is a normal part of life and is NOT a disease process and does not always
have to be treated.
Due to the decline of estrogen production, women may begin to have physical changes.
These changes can include things such as thinning of the labia, vaginal dryness,
increase in lipids, hot flashes, insomnia, etc. I'll repeat-Menopause is a normal part of
life and is NOT a disease process and does not always have to be treated. However, if
symptoms become disruptive, treatment is available.
Treatments include such things as hormone replacement therapy, herbs, vitamins,
exercise, etc. Let's talk about some of these treatments as you will be the one to
educate your patients on the normal changes of menopause as well as the treatment
options as the provider recommends.
Hormone Replacement Therapy(HRT)
The goal of hormone replacement therapy and any other treatment is to help alleviate
the symptoms. However, before treatment can begin, we must weigh risk versus
benefit. Alleviating hot flashes but causing a heart attack is not good treatment.
Providers will look at the patient's history to determine if they are eligible for such
treatments. Many studies have taken place on the safety of hormone replacement
therapy and some risk is involved. Risk of CHD, stroke, venous thromboembolism, and
breast cancer are among the risks. Women with high risk factors for these conditions
may not be eligible for this form of treatment.
One more note about HRT:
HRT should ALWAYS be used at the lowest effective dose for the shortest possible
time.
Also if a women still has a uterus at the time of treatment, she will need estrogen and
progesterone, NOT estrogen alone. Taking estrogen alone places the women with a
uterus at risk for endometrial hyperplasia and cancer.
HRT Zoom Clarification- Click Here opens in new window
Non pharmacological treatments:
Some women will opt for non-pharmacological treatment as first line. Others may chose
this option because they are not candidates for HRT.
Treatment include things such as:
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Relaxation techniques
Phytoestrogens-plants with estrogen properties (flaxseed, soybeans, yams, and
chickpeas)
Isoflavone supplements (soy or red clover, black cohosh, or vitamin E)
Vitamin and Calcium supplements
High fiber, low fat diet
Exercise
Sleep in a cool room, dress in layers( hot flashes)
Have a regular bedtime(insomnia)
Menstrual Disorders
Menstrual Disorders account for many clinic visits from women across the world. As I
said earlier, women are not machines that work perfectly every month for a lifetime.
Inevitably, women will have problems from time to time with their menstrual cycle.
Amenorrhea
1. Primary amenorrhea- is defined as the failure of initiation of menses by age 13
in the absence of secondary sexual characteristics or the absence of menarche
by age 15 regardless of the presence of normal growth and development of
secondary sexual characteristics.
Primary amenorrhea should be evaluated if there is the absence of both menarche and
sexual characteristics by age 13; the absence of menses by age 15 regardless of
normal G&D; or the absence of menstruation within 5 years of breast development.
Many different factors could be the underlying cause of amenorrhea. Some include
anatomical malformations, endocrine disorders, chronic disease, eating disorders, and
medication. Patients should be referred to a provider so underlying causes can be
evaluated.
2. Secondary amenorrhea- is defined as a 6 month or more cessation of menses after
a period of menstruation.
The most common cause for secondary amenorrhea is pregnancy. Pregnancy should
be ruled out first. However, secondary amenorrhea can be a sign of a variety of other
disorders.
As we discussed earlier things like stress, sudden or severe weight loss and medication
can cause amenorrhea. Other common causes include eating disorders, strenuous
exercise, mental illness and being >20% underweight.
Amenorrhea is one of the classic signs of anorexia.
The combination of disordered eating, amenorrhea, and premature osteoporosis is
known as the female athlete triad. Loss of calcium is comparable to that of
postmenopausal women. WOW!
What types of sports might be known for low body weight participants?
-Gymnastics, running, cycling, figure skating
What are some treatment options you could discuss with this young women?
-yoga, relaxation therapies, counseling, increase calories, decrease strenuous activity
You will soon find that yoga is the recommended treatment for most everything!
Dysmenorrhea
Dysmenorrhea is pain during or shortly after menstruation. Risk factors include smoking
and obesity.
1. Primary-Primary dysmenorrhea often has a biochemical basis and arises from
the release of prostaglandins.
Remember we said earlier that the first few menses after menarche are anovulatory and
are painless- however once ovulation occurs- dysmenorrhea can occur.
What are some treatment options?
Non-pharmacological
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Heating pad
Warm bath
Massage
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Yoga- told you
Accupuncture
Exercise
Decreased salt
Nutritional changes-natural diuretics- cranberry juice, watermelon, low fat diet,
vegetarian diet
Pharmacological-NSAIDS- they decrease prostaglandin synthesis- remember to warn
of possible GI upset. Dark stool=could indicate GI bleed.
2. Secondary- Secondary dysmenorrhea is acquired later in life and is associated with
pelvic pathology.
A workup is needed! In most cases, a pelvic exam will be performed (more details on
that in our in-class session!!! Can't wait! ) Depending on the pelvic exam findings and
other associated symptoms, an ultrasound may be indicated as well for diagnostic
measures. A dilation and curettage, endometrial biopsy or laparoscopy may also be
done for diagnostic or treatment options. The treatment of course depends on the
underlying cause.
Potential pathological finding might include=
1. Pelvic inflammatory disease (PID)(more info on that later but basically that is where
infection has ascended into the pelvic organs! It can make you really sick!)
2. Uterine fibroids (benign tumors in the uterus-more info later!)
3. Polyps (cervical or uterine)
4. Endometriosis (Presence of endometrial tissue outside of the uterus- more on that
later too!)
Premenstrual Syndrome(PMS)
Premenstrual syndrome is cyclic symptoms that occur in the luteal phase of the
menstrual cycle.
If you haven't experienced it - it is likely you will at some point in your life- either first or
second hand!
PMS is actually poorly understood yet 30-80% of women experience it! It is basically a
cluster of physical, psychological, and behavioral symptoms. Some women experience
very few symptoms if any at all and others feel symptoms that are debilitating.
We must be ready to educate our patients on normal findings versus abnormal
findings as well as treatment options!
Non-pharmacological treatments:
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Natural diuretics(foods)
Calcium
Vitamin B6
Evening primrose oil
Self help treatments:
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Stop smoking
Limit sugar
Limit salt
Limit red meat
Limit alcohol
Limit caffeinated beverages
Regular exercise
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Yoga
Massage
Pharmacological Treatments: Nsaids, Diuretics, Oral contraceptives, Antidepressants
Premenstrual Dysphoric Disorder(PMDD)
PMDD is cyclic symptoms occurring in the last 7-10 days of the menstrual cycle. It is a
severe variant of PMS with emphasis on mood affection.
It affects 3-8% of women. Maybe that doesn't sound like a big deal but if it is YOU it is a
huge deal!
Treatment is similar to PMS with the addition of counseling,
medication(antidepressants, anxiolytics, etc.) and alternative therapies such as
hypnosis and acupuncture.
Women with this severe variant should be monitored for suicidal ideations and referred
for appropriate treatment without delay!
Endometriosis
Endometriosis is the presence of endometrial tissue outside of the uterus.
As you can see in this picture, endometrial tissue can effect many organs in the pelvic
region. Due to the abnormal location of the endometrial tissue, symptoms are often
related to where the endometrial tissue has adhered.
Major symptoms include:
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Dysmenorrhea
Dyspareunia( painful intercourse)
Pelvic Pain
Bowel symptoms are often present if endometrial tissue has adhered to the GI
tract. Abnormal bleeding is often a concern as well as potential pain with
exercise.
Due to the scarring and possible blockages this may cause, infertility can be a
concern.
Treatment depends on a women's desire for future fertility. Treatment can include
something simple like NSAIDs to Oral contraceptives to Medical menopause to total
hysterectomy.
Alterations in Cyclic Bleeding
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Oligomenorrhea-infrequent menstruation
Hypomenorrhea-scanty at normal intervals
Menorrhagia (hypermenorrhea)- excessive
Metrorrhagia- Occurs between menses
Abnormal uterine bleeding- any form of uterine bleeding that is irregular in amount,
duration, or timing and is not related to regular menstrual bleeding.
Dysfunctional uterine bleeding- usually hormonal- diagnosis is made only after ruling
out all other causes of abnormal menstrual bleeding.
What are some possible causes of oligomenorrhagia or hypomenorrhea?---•
Oral contraceptive use, Depo Provera use, IUD
(Don't worry if this if foreign to you! We will cover it in the contraceptive lecture!)
Treatment often includes simple education and reassurance. Often it is a simple cause
such as birth control that has altered the menstrual cycle. We can simply make sure the
patient has understood the method appropriately and remind them of expected results.
What are some possible causes for menorrhagia?•
Early pregnancy loss, hormonal imbalances, inherited bleeding disorders,
medications (anticoagulants), uterine fibroids, endometrial polyps, endometrial
cancer.
Treatment often includes NSAIDS, Oral contraceptives (OCP's), Mirena IUD (we will
get to that in the contraceptive lecture), or surgery for causes such as uterine fibroids,
endometrial polyps, endometrial cancer.
OK! Almost done!
One quick question!
What is a hysterectomy?
A. A surgical operation to remove the uterus
FYI Terms:
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Ooherectomy-surgical removal of one or both ovaries; ovariectomy
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Salpingectomy- surgical removal of one (unilateral) or both (bilateral) fallopian
tubes.
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Total hysterectomy- the removal of the uterus and cervix
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Partial hysterectomy - a type of surgery designed to remove a woman's uterus,
leaving her cervix intact
Part 2- Breast Health
In this section we will review breast facts that you should be aware of, then discuss
Patient Education related to the breast that you should know, then cover some common
breast issues.
Breast Facts:
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Paired mammary glands located between the 2nd and 6th ribs
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2/3 of the breast overlies the pectoralis muscle, between the sternum and the
midaxillary line, with an extension to the tail of Spence ( pay close attention to this
bit of knowledge as Most breast cancers develop in the upper outer quadrant of
the breast, closest to the armpit. This is because this area has a lot of glandular
tissue).
 Approximately equal in size and shape but often not absolutely symmetric
If a women's breasts have always been asymmetrical( one bigger than the other) then
this can be a normal finding, however if a sudden change in size has resulted in
asymmetry- then this needs to be reported.
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Contour should be smooth with no retractions, dimpling, or masses
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Nipple slightly elevated above the breast- contains 4-20 openings from the milk
ducts
Some women have inverted nipples. Again if this has always been the case then no
worries but if this is a new finding- it should be investigated. Inverted nipples are NOT a
result of pregnancy. The women would have either had inverted nipples before
pregnancy or not..not a result of pregnancy.
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Nipple surrounded by fibromuscular tissue and covered by wrinkled skin(the
areola) The nipple and surrounding tissues are usually more deeply
pigmented.During what time does the areola darken even more? Pregnancy! Yes!
What are the breast's function?
1. Lactation 2. Organs for sexual arousal
Breast Health Education
1. Breast Self Exams(BSE)
Current guidelines recommend BSE as an option. Since physiologic alterations in breast
size reach minimal level about 5 to 7 days after menstruation stops, breast selfexamination is best carried out during this phase of menstrual cycle.
FYI- not for the test- Some resources are now recommending Breast self awareness
versus the strict monthly self breast exams. Some research is stating that it leads to too
many unnecessary biopsies and other procedures. My personal take is that self breast
exams are free and most masses are found by the patient herself first! Why not!
Anyways, we will see what research says in a few years. Breastcancer.org- still
recommends Monthly self breast exams- so that is what we will teach our patients.(and
what I would know for the test!)
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Physiologic alterations in breast size reach minimal level about 5 to 7 days after
menstruation stops.
 Breast self-examination best carried out during this phase of menstrual cycle
What does a women do if she doesn't have a monthly cycle? (Zoom Video) Click
Here opens in new window to find out
Problems of the Breast
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Fibrocystic changes
 Fibroadenoma
 Mammary duct ectasia
 Intraductal papilloma
 Galactorrhea
 Macromastia
 Micromastia
Fibrocystic Breast Changes
The first thing you need to know is that fibrocystic breast changes are NOT a disorder. It
is simply a common benign breast problem. The cause is uncertain. Some theories
attribute hormonal changes.
Symptoms:
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Lumpiness, with or without tenderness
"Achy, heavy breasts"
Sense of fullness
Dull heavy pain
Symptoms occur about one week prior to menses and usually end 1 week after
menstruation ends.
Non-pharmacological treatment:
• Supportive bra
• Heat or cold therapy
• Eliminate smoking
• Eliminate alcohol
• Decrease sodium
• Decrease caffeine
• Vitamin E
• Flaxseed
• Low fat diet
• Evening Primrose Oil
Pharmacological Treatments:
• NSAIDS
• Oral Contraceptives
Galactorrhea
Galactorrhea is a milky sticky discharge from the nipples/breasts.
The cause can be benign or pathologic.
A workup is usually indicated:
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It may include a prolactin level. As the nurse your job would be to educate on the
necessary preparation for this lab work.
1. It must be drawn between 8-10 am
2. No nipple stimulation for 24-48 hours before the lab is drawn
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Possibly ultrasound, mammography, or MRI for diagnostic images.
Interventions depend on the cause. Potential causes include an Endocrine disorder,
Malignancy, pituitary tumor, or medications( HTN meds, OCP's, Antidepressants to
name a few).
Side note: Milk production and leaking is normal is pregnancy. Colostrum(the first milk)
begins to be produced in the first trimester. Some women will notice leakage in
pregnancy and some will not. Pregnant moms can be reassured leakage in pregnancy
is normal.
Mammary Duct Ectasia
Mammary Duct Ectasia is inflammation of the ducts behind the nipple.
The cause is uncertain.
Occurs most often in perimenopausal women
Symptoms:
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Thick, sticky nipple discharge may be white, brown, green or purple
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Some women experience a burning pain, itching, or a palpable mass behind the
nipple.
The work up may include mammography with aspiration and culture of the fluid.
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Interventions:
• Mild pain relievers
• Warm compress
• Supportive bra
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And depending on mammography and culture results-possible antibiotics
or Possible duct removal if no plans to breastfeed
Intraductal Papilloma
Rare benign condition that develops in the terminal nipple ducts.
Cause unknown.
Usually occurs in women 30-50 years old.
Characteristic sign=pailloma usually too small for palpation, spontaneous, unilateral
nipple discharge that is serous, serosanguineous, or bloody.
After malignancy is ruled out, the affected segments of the ducts and breast are
surgically excised.
Micromastia=Very small breasts
Troublesome symptoms –
• poor self image
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problematic fit of clothing.
Interventions –
• Augmentation (implants)
o Saline implants, silicone.
o Counsel pt that the procedure may not be covered by insurance. Implants
must be replaced q 10-15 years.
Macromastia=Very large breasts
Troublesome symptoms –
o Neck and shoulder pain
o Lordosis
Interventionso Breast reduction
o Counsel pt that the procedures not be covered by insurance. Could affect ability
to breastfeed.
Cancer of the Breast
We are not planning to go into detail on Breast cancer treatment, etc in this class. It will
be covered further in future classes. Our focus in this class is prevention and the
teaching involved in its prevention.
As we discussed earlier, Self Breast exams are an excellent way to detect any changes
in the breast early and thus hopefully either prevent the formation of breast cancer or at
the least early treatment which often equals better outcome.
Lets talk Mammograms for a minute!
When should screening mammograms be done?
Routinely, mammogram screening begins at age 40 and is done annually or biennially
until around age 75. After 75, mammograms are ordered at the discretion of the
healthcare provider.
However
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If the patient has a first degree relative that currently has or has had breast
cancer, begin screening 10 years prior to the age at which the relative was
diagnosed.
Teaching Points:
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Schedule mammogram about 2 weeks prior to menses
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No lotions, powders, deodorants under arms or on upper torso on the day of the
test
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Reduce caffeine 5-7 days pre exam
Ultrasounds may be done for:
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Young women
Dense breasts
Evaluate lumps found on mammogram
Guided biopsy needle
Breast MRI:
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Usually done to investigate concerns found by other methods – assess tumor
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locations, ID cancer not detected by other means,
If high risk for BC, pt. may have mammo + MRI
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Good with augmented breasts
Breast cancer staging - assess the effectiveness of chemotherapy
Part 3- GYN Disorders
In this module, we will cover miscellaneous GYN disorders I think you might run into
either in clinical or testing and need to at least be familiar with the disease process and
treatments. There is no way I could cover every GYN disorder but I have narrowed it
down to a few that may be most prevalent in your clinical settings.
If something new pops up in clinical and we have not covered it- simply smile and
absorb as much as you can from your preceptor! Life is a learning process! I learn
something new almost everyday in clinic! A good friend of mine once told me after I
stated I didn't know something- "There are books filled with things you do not know"!
Boy, was she right! So just keep learning day by day!
Pelvic Organ Prolapse
Take a look at the notes at the bottom of this picture. Pelvic Organ Prolapse is simply
when pelvic organs drop down into the vagina due to relaxation of the tissues that
usually support these organs. There are many reasons or causes for this to happen.
Anything from obesity to congenital anomalies to childbirth trauma.
Uterine Prolapse(Protrusion of the uterus into the vaginal vault)
Again this is the result of pelvic relaxation for whatever reason.
Common causes:
o Poor muscle tone(there are many potential causes for this)
o Obesity
o Chronic coughing or straining
Symptoms:
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Pulling sensation
Vaginal pressure
Low back pain
Fatigue
Dyspareunia
o Some women may simply report " I feel like something is falling out". Thankfully
there are treatment options. Women may be eligible for treatment options that
range from simple estrogen therapy to surgical intervention such as a
hysterectomy.
Interventions:
1. Pessary- see below picture. These devices allow for a nonsurgical treatment option.
These are placed high into the vagina and simply hold the pelvic organs up as the
original tissues would have.
Check out this sample patient education sheet for pessary care-Click Here opens in
new window
2. Estrogen therapy- (loss of estrogen with menopause can contribute to pelvic floor
dysfunction)
3. Hysterectomy
Cystocele(Protrusion of the bladder into vaginal wall)
Causes:
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Congenital defects
Trauma (childbirth, etc.)
Obesity
Aging
Symptoms:
o Bearing down sensation
o Urinary frequency or retention
o Incontinence
Interventions:
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Pessary
Weight loss
Kegel exercises
Surgery-Click Here opens in new window for a sample patient education sheet
for a brief overview of surgical interventions if symptoms are not managed with
non-surgical options.
Rectocele(Protrusion of the rectum into vaginal wall)
Causes:
o Weakened posterior vaginal wall
o Chronic constipation(that makes sense huh! Just imagine those effects)
Symptoms:
o Bearing down sensation
Interventions:
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High fiber diet
Increase fluids
Stool softeners
Laxatives
Surgical interventions
Osteoporosis
What is it? Decreased bone density-Reduced bone strength
Risk factors:
o Genetics-Caucasian, Asian descent at most risk, Petite/thin women, heredity
o Age-Greater than 50 years old
o Nutrition-lack of calcium and vitamin D intake essentially, some research notes
that some food sources can be detrimental as well- Click here opens in new
window for a link relating Diet and nutrition to osteoporosis. Take a look at sodas
and caffeine intake! Bad news for some of us!
o Exercise- More specifically lack of proper exercise(weight bearing exercise) To
define weight bearing exercise-think it forces you to work against gravity. What
are some examples of weight bearing exercise? walking, jogging, climbing stairs,
tennis, and dancing, tai chi, yoga
o Examples of non-weight bearing exercise? Swimming, bicycling
o Lifestyle-sedentary versus active
o Menstrual function- the loss of estrogen during perimenopause and menopause
increase the risk of osteoporosis. Other menstrual disorders caused by hormonal
imbalances(decrease in estrogen) may increase the risk as well
o Smoking
o Alcohol use
Note: During pregnancy, the baby growing needs plenty of calcium to develop its
skeleton. This need is especially great during the last 3 months of pregnancy. If the
mother doesn't get enough calcium,? her baby will draw (take) what it needs from the
mother's bones (calcium). Thus depleting mom of her own calcium stores.
Interventions:
Prevention is obviously the best option. Counseling women on risk factors, especially
the modifiable ones and ways in which they can lower their risk and hopefully prevent
the disease is essential.
Patient education should include:
o Encouragement of weight bearing exercise(30 minutes three times a week)
o Increase calcium(1200mg per day in divided doses) and vitamin D(800IU for
most women) consumption
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o What are common Calcium sources?
o What are some common sources of Vitamin D? Sunshine, Dietary sources
fatty fish (such as salmon, tuna, and mackerel), Some dairy, Fortified
foods.
Modest use of alcohol and caffeine
Stop smoking!
Now sometimes despite our own and our patient's best efforts- osteoporosis
diagnosis is inevitable and medical treatment is needed.
Osteoporosis Treatment:
1. Calcium and Vitamin D
2. Bisphosphonates are a class of drugs used to prevent as well as treat osteoporosis.
They include:
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Alendronate (Fosamax), a weekly pill
Risedronate (Actonel), a weekly or monthly pill
Ibandronate (Boniva), a monthly pill or quarterly intravenous (IV) infusion
 Zoledronic acid (Reclast), an annual IV infusion
These drugs work to increase bone mass and decrease reabsorption of bone.
Unfortunately, these drugs can have undesired side effects and thus patients must be
educated on on their use!
Bisphosphonate patient education:
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Avoid use with active upper GI issues
Take in the AM on an empty stomach with 8oz of water
Remain upright for 30 minutes after taking
Calcium can interfere with absorption and should be taken at least one hour
apart
Food also impairs absorption-thus the above instructions to take on an empty
stomach
Be aware that GI upset (heartburn, etc) can occur if the above instructions are
not followed closely. If patients do complain of these side effects, it would be
essential to question how and when they are taking the medication.
Osteoporosis screening methods:
DXA scan –(Dual-energy x-ray absorptiometry (DXA)Data obtained from
both the femur and AP spine scans are considered gold standards for
diagnosing osteoporosis.
Patient Teaching:
What do we need to tell our patients?
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The test causes no discomfort, involves no injections or special preparation, and
usually takes only 5 to 10 minutes.
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The x-ray detector will detect any metal on your clothing (zippers, belt buckles),
so you may be asked to wear a gown for the test.
Begin at age 65 or sooner if there are significant risk factors
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Polycystic Ovarian Syndrome(PCOS)
Polycystic Ovarian Syndrome is a complicated disease that causes multi-system
symptoms. I see this often in the clinic setting and the prevalence seems to grow on a
daily basis.
Understanding the patho behind the disease can be somewhat difficult. I do not expect
you to become experts but I would like for you to be introduced to the disease.
I have provided a link to a brief intro into the disease as well as common symptoms and
treatment regimens.
Take a look! Click Here opens in new window
Leiomyomas(fibroid tumors)
Fibroid tumors are basically benign tumors present in the uterus. Some women have
fibroid tumors and never know it and never develop any ill effects. However, some
women due to size, location, quantity, etc will develop symptoms that are not only
bothersome but dangerous if left untreated.
Take a look at this brief overview! Click Here opens in new window
Pay attention to the information in regard to potential complications!
Some women develop excessive uterine bleeding leading to at times severe anemia,
fatigue, possible syncope, etc. We want our patients to be aware that they should report
these symptoms as interventions can be implemented before things progress to more
serious complications. If reported to you as the nurse, a provider should be notified so
evaluation and treatment can be started!
(I have provided these external sources as the information in our book is either limited
or missing)
Symptoms:
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May be asymptomatic
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Back pain
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Abdominal pressure
Constipation
Dysmenorrhea
Anemia
Urinary incontinence
Menorrhagia
Interventions:
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NSAIDS
Oral contraceptives
Myomectomy
Embolization
Ablation
Hysterectomy
Bartholin cysts: cyst is simply a blocked Bartholin duct.
Symptoms:



May have pain when walking or sitting
Dyspareunia,
Can also be asymptomatic
Interventions:



Sitz baths
May need antibiotics
Surgery for recurrent problems
Part 4- Sexually Transmitted Diseases
Sexually transmitted infections(STIs) include more than 25 infectious
organisms transmitted sexually. 20 million people are affected annually in
the U.S. per the CDC. WOW!!
So what can we do about it?
Patient teaching of course!!
Prevention is obviously key!

Primary- preventing infection.
o condoms
 Example education:
use once, with every act, avoid heat, avoid sharp objects, use
condom with expiration date, use condom only once. You get
the idea! You would be surprised what the general population
do NOT know! Never assume your patients know! Educate!
o
o
o
o
o
abstinence
knowledge of partner
reducing partners
low risk sex
vaccination

Secondary-prompt diagnosis and treatment of current infections
Here is where we come in!
Let's get to talking to our patients!
For you to be able to educate your patient you must understand each
disease(symptoms, risk factors, etc), the treatment, and ways of prevention.
Chlamydia
Chlamydia is the most frequently reported STI!
Unfortunately the infection is often silent, yet highly destructive. More on
the highly destructiveness in a minute.
Many patients report NO symptoms. So is it possible to have chlamydia
and NOT know it! Absolutely!
Due to often limited symptoms, it is difficult to diagnose based solely on
exam. Routine screening of high risk populations is recommendedincluding those that are asymptomatic as well as pregnant women.
High risk populations include: (to name a few)
Women younger than 25
 Persons with new sex partners
 Persons with multiple sex partners
TreatmentAzythromycin 1 gram STAT dose or Doxycycline 100mg BID x 7 days
*Note-Doxycycline cannot be given in pregnancy!*
Now for the highly destructive part! Chlamydia if left untreated can lead to a
serious complication called Pelvic Inflammatory Disease(PID). PID is when
a organism ascends into the pelvic organs and infection spreads causing
destruction. This spread of infection into the pelvic organs can effect the
uterus, fallopian tubes, etc. If left untreated-it can lead to scarring in these
areas.
Here's the worst part- this scarring can lead to increased risk for ectopic
pregnancy as well as tubal factor infertility(scarring in the fallopian tubes).
I am going to go ahead and place a video on PID here(6 mins) as the
information discussed will be helpful throughout this module as well future
modules!

It is so important for our teaching to include prevention methods as well as
the importance of prompt screening and treatment!
Gonorrhea
Meet Gonorrhea! Gonorrhea is a friend of Chlamydia! They often travel together!
It is the oldest communicable disease.
Unfortunately, just like with chlamydia women with gonorrhea are often asymptomatic.
Because co infection with chlamydia is common (remember they are friends!) any
women with gonorrhea should have a culture for chlamydia and be treated for both.
*Note- If any women is positive for one STI- she should be offered testing for other STI's
as well! ( that makes sense right!). Chamydia and Gonorrhea have tag alongs
sometimes!*
Treatment:
•
•
Ceftriaxone(Rocephin) 250mg Im in a single dose
Azithromycin 1 gram in a singe dose
*Note-Drug resistance has been a problem in the past- thus it is imperative that patients
are treated appropriately and monitored for drug resistance*
Syphilis
Syphilis is another ugly disease that if left untreated can cause lasting/potentially deadly
effects!
You may have seen Syphilis in headlines lately! It's prevalence is on the rise and
causing alarm!
Syphilis is different from some other STI's in that it has stages of disease progression.

Primary
 Secondary
 Latent
 Tertiary
Syphilis gains entry in subcutaneous tissue through microscopic abrasions.
Symptoms:
Each stage presents with different potential symptoms.

Primary-painless papule (in medical terms called a chancre). Wow! So this
simply presents with a "sore down there" that doesn't hurt! How many of you
have had a sore " down there" that didn't hurt at some point in life? How many
people would simply dismiss this and move on? ( you get the point!) This stage
usually presents 5-90 days from time of inoculation.
 Secondary-Often more widespread, systemic symptoms=Fever, headache,
malaise, generalized lymphadenopathy, ( up to this point it sounds like a million
other diseases! COVID-19?, maculopapular rash on the palms of hands and
soles of feet (now that ones more distinctive huh!). This stage usually presents
6 weeks to 6 months from time of inoculation.
 Latent-asymptomatic
 Tertiary-This is where it can get serious! Neurological, cardiovascular,
musculoskeletal, or multi-organ involvement. Not everyone(most people won'tbut who wants to take a chance?) will progress to this point if left untreated but
potentially could! This stage is very serious and often presents 10-30 years
after initiation of infection. This stage can end in death.
Some more serious stuff......
Syphilis can be very dangerous in pregnancy.
Transplacental transmission can occur at any time during pregnancy! Bad news huh!
All pregnant women should be screened at their first prenatal visit and if positive treated
ASAP!
Here is link to a CDC patient fact sheet on Congential Syphilis. Pay attention to the first
statement=Syphilis is making a comeback and we should be on high alert! Click
Here opens in new window
Diagnosis:
Diagnosis can be made through simple lab work! Most often labs include an initial VDRL
or RPR (name of tests).Followed by a treponemal confirmatory test if the VDRL or RPR
is positive.
False negative tests can occur in early primary stages or in the incubating stage. It may
take 6-8 weeks after inoculation for tests to be positive.
False positive results can occur in autoimmune disorders, malignancy, and pregnancy
to name a few. This is why the treponemal confirmatory test is performed if the VDRL or
RPR is positive. This test will either rule out or rule in a true syphilis infection.
Treatment:
For primary, secondary, or early latent stage less than 1 year.

Benzathine Penicillin G 2.4 million units IM in a single dose
o Pregnant women who have primary, secondary, or early latent syphilis
a second dose of benzathine penicillin 2.4 million units IM can be
administered 1 week after the initial dose.
For latent greater than 1 year, latent of unknown duration.

Benzathine Penicillin G 2.4 million units IM in 3 doses each at 1 week intervals
*If questions on appropriate treatment occur- the state health department can often
assist with the decision making process. Some STI's(not just syphilis) are required to be
reported to the state! (Don't worry about HIPPA- these disclosures are covered by law.
A simple disclosure note is made in the patients chart). The state keeps up with the
infections, tracks contacts, assists with treatment as well as policy and procedures for
eradication of the disease. Because of this tracking, the state will have record of -if and
when-a patient has been diagnosed in the past and thus help with the treatment plan. In
Texas there are assigned STI nurses to each region and are easily contacted.)
With all STI treatment- Don't forget to remind your patient to:
1. Be abstinent during treatment.
2. Both the patient and partner need to be treated.
3. Best case scenario is for both to receive treatment at the same time. (If unable to do
this, remain abstinent until both are treated.
Ever thought of being an STI nurse?
PID
I think we covered the basics earlier!
What about treatment of PID?
Treatment of course would include medications that would treat any potential organismChlamydia, Gonorrhea, Bacterial vaginosis (we will learn about that in a bit-Not an STI
but often is present when an STI is present).

Ceftiaxone(treats Gonorrhea)
 Doxycycline or Azithromycin( treat chlamydia)
 Metronidazole( treat Bacterial vaginosis)
Oral/IM medication regimens can be administered as long the patient tolerates the
meds, is responding appropriately, and is not severely ill. If the patient develops severe
symptoms (high fever, N/V, abcess, etc) they may need hospitalization and IV
medication treatment. The severely ill patients may also need bedrest until symptoms
begin to improve.
Education post treatment in regard to STI prevention is essential!
Human Papillomavirus(HPV)
HPV is prevalent in ambulatory setting so you may just get the chance to experience
this in clinical.
It is the most common STI in the USA. (remember chlamydia was most reported but
HPV is not a reportable STI)
There are more than 40 types.
They are divided into a "low risk group"( wart-causing) and a "high risk group"( cancer
causing).

Good news...the wart causing types don't often cause cancer! Although I've
never met a person happy to have them.

Bad news...the cancer-causing types may go unnoticed! Thus the importance of
yearly annual exams and paps if appropriate.
 More good news...In young otherwise healthy people, HPV can often be present
and never known and then the immune system fight it off naturally. Good news
right! NOT smoking, proper nutrition helps that out too!
Symptoms:
•
•
Irritating vaginal discharge with itching
Dyspareunia
•
•
Postcoital bleeding (bleeding after sex)
Genital warts -they look like small flesh colored bumps or if grouped together like
a cauliflower. If small, can be easily unnoticed.
Screening and Diagnosis:
As I said earlier, this is where annual exams/pap smears come in, a pap test is used to
test for cervical cancer but can also screen for HPV (at least the high risk groups that
cause cancer) or a separate collection sample can be made for the HPV screening. This
can be all done at the same time.
Women should be strongly encouraged to have annual exams!
If HPV is detected, the frequency of pap smears may be increased!
Management:
I used the word management here versus treatment as there is no treatment for the
HPV infection itself, however there are prevention interventions as well as some
medications for symptoms(genital warts, etc)
First, let's talk about prevention!
Safer sex talks should always be included( condom use, etc.)
Thankfully, there is a vaccine for HPV.
I am inserting a link here from the mayo clinic. It covers who needs the vaccine as well
as how it works. Print it out! Pay attention to who needs it and when it is recommended
for them to get it( the schedule). You very well may see this info again(if not soonerlater). Click Here opens in new window
The HPV vaccine is ideally given BEFORE a person is sexually active. Remember this
is prevention NOT treatment!
If a person, is already infected and bothered by either genital warts or other symptoms,
medications can be used to help.
Genital warts do not have to be treated. But if symptoms are bothersome there are
available treatments. Keep in mind that genital warts often return after treatmentremember there is no cure for the virus itself.
Medications: (no need to memorize all of these, I just want you to be aware of the
names)

Imiquimod (Aldara, Zyclara)
 Podophyllin and podofilox (Condylox)
 Trichloroacetic acid
 Sinecatechins (Veregen)
Some of these can be used at home, but it will be your job to make sure the patient
understands instructions for use. See this link for detailed patient education Click
Here opens in new window. Remember, no need to memorize every detail, just quickly
review to get the general idea. These medication are meant to be used on the genital
warts only, being very careful to avoid the surrounding healthy tissue- it will cause
irritation the healthy tissue if exposed.
In pregnancy, genital warts often grow in size/quantity and may not always respond to
treatment(Pregnancy is an immune compromised state). Just a fun note to warn your
pregnant mommy's about
. Good news...HPV in and of itself, in most cases, will
cause no harm to the fetus in utero and will not change the plan of care( no pregnancy
complications to anticipate). In other words, a c-section would not be indicated as with
other infections( more info on those later). Occasionally, genital warts get really large
and multiply to the point that they cause an obstruction in the vagina- these may need to
be removed prior to childbirth. In very rare cases, a newborn could develop warts in the
throat.
Herpes Simplex Virus(HSV)
Herpes simplex virus 1 (HSV-1) Transmitted nonsexually
Herpes simplex virus 2 (HSV-2)  Transmitted sexually
*Note- HSV 1 is generally oral lesions and HSV 2 is generally genital lesions- however,
with oral sex infection could be transmitted and present in atypical places. (HSV 1 in
genital area, HSV 2 in oral area)*
Symptoms:
•
•
•
•
•
•
•
Could be asymptomatic
Painful lesions-blisters or ulcers
Fever
Chills
Malaise
Dysuria
Tingling or shooting pain in the legs, hips, and buttocks before lesions
appear
Symptoms of initial infections are often more severe, then getting less
severe the more outbreaks that occur.
Here is a quick little zoom! ( 2 min 30 sec) From my experience with
HSV as a provider
( yall got scared didn't you!) Sorry for bad lighting
and all the hesitations! I definitely do NOT need to EVER consider
Hollywood!
Click Here opens in new window
Diagnosis:

Gold Standard=culture of suspicious lesion

Serum labs can be drawn to detect antibodies of a past infection
Management:
Again NO CURE!
Prevention is critical!
Symptoms can often be managed by Antiviral medication.

Example-Acyclovir (Zovirax), Valacyclovir (Valtrex)
Medication may be given only when symptoms occur or a daily dose. This would be up
to the provider. There is some research showing an advantage of taking a daily dose for
those that are HSV+ with a HSV- partner- to help possibly prevent transmission.
It is important to note that HSV viral shedding can occur even if a patient is
asymptomatic- so please warn patients that transmission can occur even if
an active outbreak is NOT present.
Pregnancy considerations:
Maternal infection can have adverse effects on both the mother and fetus. Some
research shows an increased rate of miscarriage if contracted in the first trimester.
There is a higher risk of transmission to the baby if a primary(first "outbreak") occurs
versus recurrent infection(outbreaks) in pregnancy.
Antiviral medications are used in pregnancy safely.
Suppressive therapy is started (on any women reporting a history of HSV) at 36 weeks.
A daily dose of antiviral medication is taken until delivery. This is done to hopefully
prevent an outbreak at the time of delivery. A c-section is indicated if active genital
lesions are noted at the time of delivery. (Do not get HSV confused with HPV!)

HSV is not a contraindication for breastfeeding.
Viral Hepatitis
I am gonna be short and sweet here!
I am sure this not the first time you have had
a overview of these disease. So quickly review!
1. Hep A




Acquired primarily through fecal-oral route
Ingestion of contaminated food
Person to person contact
Vaccination is most effective means of preventing HAV transmission
2. Hep B





Most threatening to fetus and neonate
Disease of liver potential; often a silent infection
Transmitted parenterally, perinatally, orally (rarely), and through intimate contact
OK to breastfeed!
If pregnant mom is +:
o Newborn nursery must be notified
o Transmission can be prevented if Hep B immunoglobulin and Hep B
vaccine is given within 12 hours of birth

Vaccination series important-you got this!
3. Hep C


Most common blood-borne infection in United States
High risk groups are screened in pregnancy as can be harmful! Hgh risk
groups=( hx IV drug use, etc)
 Maternal transmission is rare but increased risk of mother also HIV+
 Currently there is no vaccine but treatment are emerging
HIV
Again this is not the first time you have heard an HIV lecture so Short and Sweetit is!
Reminders:
• Seroconversion usually within 6-12 weeks after exposure. Could take up to 6
months.
• Consent is needed prior to testing.
• Positive results are reported to the state!
• Positive results are given face to face. No phone calls!
•
Patient will need post test counseling and may need referral to social services,
TDH , etc.
• All partners need to be notified.
• Of course! Safer sex counseling is highly recommended!! Condom use , etc.
• Persons who are HIV positive need to be offered TB testing, Hep B vaccine, and
flu vaccine.
In pregnancy:

Women are tested at 1st prenatal visit and in the third trimester by law.

Can cross the placenta and into breastmilk
 Breastfeeding is contraindicated in the USA

In US, transmission now less than 2% for pregnant women if:
o receive antiretroviral medication
o C-section at 38 wks before Rupture of Membranes(before the "water
breaks")
o Avoid breastfeeding
 Risk factors associated with perinatal transmission:
o advanced diagnosis in mom
o Ruptures membranes greater than 4 hours
o Certain OB procedures
 Amniocentesis

Scalp electrode( a device used to monitor fetal well being in
labor) - you can look that up if interested.
 A c-section is indicated if viral load is greater than 1000 or unknown
 Baby is given AZT for a minimum of 6 weeks after birth
 Baby is tested at intervals of 14-21 days, 1-2 months, and 3-6 months.
Trichomoniasis
Trichomoniasis is the most common curable STI.
It is more common in women than men.
It is more common in older women.
Symptoms:
•
•
Greenish- Yellow vaginal discharge that is often frothy in appearance.
Strong fishy vaginal odor
•
•
•
•
Painful urination
Vaginal irritation and itching
Dyspareunia
Strawberry cervix-the inflammation that is caused by the infection will cause the
cervix to have a strawberry look
Spotting between menses or with intercourse-due to the friability(look that word
up- you might hear it in clinic) of the cervix.
•
Treatment:
•
Metronidazole(Flagyl) 2 grams orally in a single dose
Let's talk Metronidazole(Flagyl) for a second! There is some important
patient teaching that you should know:

Avoid alcohol with metronidazole use
o It can cause unwelcome side effects:
 Headaches
 Abdominal pain
 Tremors
 Flushing
 N/V
Vaginal Infections
These three infections are NOT considered sexually transmitted diseases. Now this is
not to say that it wouldn't be theoretically possible to transmit sexually but it is not
usually.
Bacterial Vaginosis(BV)
FYI-BV is often present if an STI is present. Also is associated with multiple
sex partners.
Medical explanation: Bacterial vaginosis syndrome occurs when normal
hydrogen peroxide-producing lactobacilli are replaced with high
concentrations of anaerobic bacteria.
Talavera explanation: In the vagina, bacteria and yeast live happily ever
after until one tries to take over. If bacteria, takes over you have a bacterial
infection. If yeast takes over, you have a yeast infection. An imbalance in
vaginal flora.
Symptoms:
•
Fishy vaginal odor
•
Thin, milky white discharge
Extra info: On microscopic exam of vaginal discharge, clue cells can be
seen.
Treatment:
Metronidazole(Flagyl) vaginal gel or oral dosage.

Oral-500mg BID x 7 days
Candidiasis
You know most of this stuff already! Just a review!
Medical name-Vulvovaginal candidiasis
Common name- Yeast infection
Predisposition:
•
•
•
•
•
•
•
Antibiotic therapy
Diabetes
Pregnancy
Obesity
Diets high in refined sugars
Use of corticosteroids
Immunosuppressed states
Symptoms:
•
•
•
•
Thick white clumpy discharge- cottage cheese appearance
Dyspareuina
Extreme itching
Vaginal irritation and/or redness
Treatment:
•
•
Antifungal cream
Fluconazole(Diflucan)
Patient teaching:




No douching. Douching destroys the normal vaginal flora and thus may cause a
disruption of healthy flora.
No strong soaps in vaginal area. No need to over scrub. Just water works! The
vagina is made to clean itself out. It doesn't need our help.
Yogurt with active cultures/Probiotics could help restore normal flora
Yeast likes to grow in warm, moist environments- the vagina happens to be a
happy place for yeast! So:

Wear cotton panties- allows for air circulation

Sleep with no panties/pants- allow things to get some air
 Avoid tight fitting clothing and underwear
Group B Streptococci
Group B strep is a bacteria that can live in the vagina and not cause any harm and the
women will likely be asymptomatic. However, it becomes a problem in pregnancy. If the
fetus is exposed to group B strep at delivery- it can make them very sick and lead to
death if not treated quickly.
Screening:

Pregnant women are screened at 36 weeks for group B strep. If positive, mom
will be given IV antibiotics in labor (If vaginal birth is anticipated) in order to
prevent transmission to baby at birth.
 Group B strep infection is NOT an indication for a c-section.
 If a c-section is planned, treatment of group B strep is NOT needed as the
infection lives in the vagina and transmission occurs with contact with
vagina(during a vaginal birth).
So you may ask then why do we test mothers that are planning a c-section? Well,
deliveries are not always 100% controllable- what if a mom planning a c-section has a
fast labor and delivers vaginally by "accident".
Treatment:
IV antibiotics in labor
Treatment is indication with:




Previous infant with invasive Group B strep infection
Group B strep in the urine at any time in pregnancy
Positive Group B strep culture
Unknown Group B strep

Delivery before 37 weeks
 Rupture of membranes greater than 18 hours
 Intrapartum temperature greater than 100.4F
One last thing!
TORCH infections in pregnancy
Infections such as Varicella, Rubella, Fifths disease, Herpes, Toxoplasmosis,
Cytomegalovirus are infections that can occur at any time in life and are not always
super dangerous but in pregnancy can be deadly.
TORCH titers is a blood test that tests for these certain diseases. They would be
indicated any time in pregnancy that one of the diseases might be suspected or there is
some poor outcome with no known cause and investigation is warranted( fetal demise,
fetal anomaly, etc).