Introduction to Reproduction and Sexuality
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Concept definitions
○ Reproduction: The process by which human beings produce a new individual
(Giddens, 2017).
○ Reproductive health: addresses the reproductive processes, functions and
system at all stages of life. Reproductive health, therefore, implies that people
are able to have a responsible, satisfying and safe sex life and that they have the
capability to reproduce and the freedom to decide if, when and how often to do
so (World Health Organization).
Puberty
○ The time during which the reproductive organs become fully functioning
○ Occurs in an orderly sequence
○ Boys mature about 2 years later than girls
○ GnRH (from hypothalamus) → stimulates anterior pituitary gland → LF + FSH
→ affect ovaries in female + testes in male
■ Females:
● FSH – develop follicles → produce estrogen.
● LH – develops corpus luteum → progesterone
■ Males: LH produces testosterone
● Testes enlargement initially
○ Negative feedback system: inhibits the release of stimulating hormones
(LS/FSH) → no further release – birth control accommodates to this mechanism
Menstruation
○ Menarche: 1st menstrual cycle (average age 12 in the U.S)
■ Initially periods can be irregular, painless, and anovulatory
○ Menses: menstrual flow generally 1x monthly
■ *Begins approximately 14 days after ovulation
■ The length of the period does not matter – 14 days before cycle
■ Egg is released during that first day for 24 hours
○ Cycle length: 21-35 days (average 28 days)
○ Amount of flow: 20-80 mL (average 50 mL)
○ Length of menses: 3-6 days (average 5 days)
Nursing considerations for menstruation
○ Girls should be taught to recognize the subtle signs of impending menstruation,
such as tender breasts, and water retention or bloating.
○ They should also be counseled regarding the use of feminine hygiene products
○ Patient teaching about feminine hygiene and toxic shock prevention are
important
Toxic shock syndrome
○ Causative organism: Staphylococcus aureus entering the bloodstream and
causing shock
○ Prevention:
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Avoid super absorbency tampons, use lowest possible absorbency
necessary
■ Change tampons frequently (q4-8hours), pads while sleeping
■ Hand hygiene!
A word about feminine hygiene
○ Vaginal sprays are unnecessary
○ Douching unnecessary
○ Wear cotton underwear
○ Keep vulva and vagina free of moisture
○ Front-to-back wiping to decrease the risk of infection and reduce odors
Ovulation and fertility
○ Ovulation is when a mature egg is released from the ovary, pushed down the
fallopian tube, and is made available to be fertilized.
○ Sperm lives for 3-5 days in the vagina – leaving more time for ovulation
effectiveness → “preparation”
○ An egg lives 12-24 hours after leaving the ovary.
○ Ovulation typically occurs 14 (13-15) days back from the start of menstruation
Other cyclic changes
○ Basal body temperature increases AFTER ovulation
○ Changes in cervical mucus – sticky/clear mucus during ovulation
○ Pain with ovulation
Menstrual/Ovarian Cycle
○ Graafian follicles secrete estrogen and progesterone during the second phase
of the menstrual cycle
○ Corpus luteum: formed after the egg is released, secretes progesterone → the
beginning of the luteal phase → thickens lining of uterus with rich blood supply →
corpus luteum will NOT die during pregnancy
○ When there’s menses, estrogen and progesterone levels are low
○ Endometrial shedding occurs during menses
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Menopause
○ Lack of menses x 12 consecutive months
○ Physiology of Menopause:
■ Decreasing ovarian function
■ FSH levels increase → to compensate for lack of estrogen
■ Estrogen levels decrease
○ Average age = 51.4 years old
○ Perimenopause usually 2-8 years prior to cessation of menses → missed
period, changes in bleeding
Perimenopausal symptoms
○ Bleeding:
■ Longer cycles that differ in type of bleeding
○ Urogenital symptoms:
■ Vaginal mucosa thins and loses elasticity → dry vagina
■ Decreased vaginal secretions
■ Dyspareunia (painful intercourse)
■ Frequent vaginal irritation and itching
■ Incontinence
■ Urinary frequency/urgency
○ Vasomotor symptoms
■ Hot flashes
■ Night sweats
● Other symptoms
■ Restless legs
■ Tenseness
■ Irritability
■ Forgetfulness
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■ Decreased libido
■ Increased risk of osteoporosis – lack of estrogen
Menopause HRT Risks:
○ Over the past 50 years, healthcare providers have commonly prescribed
hormone replacement therapy (HRT) to treat unpleasant symptoms and prevent
long-term consequences of low estrogen, such as osteoporosis
○ Why should we not take hormones?
■ Research supporting risks
● Increased risk of breast cancer
● Increased risk of stroke and blood clots
● Increased risk of MI
■ Birth control can cause these symptoms r/t estrogen rush
Hormone replacement therapy
○ The health risks and benefits must always be identified and discussed with the
woman
○ “Hormone therapy use should be limited to the treatment of menopausal
symptoms at the lowest effective dosage over the shortest duration possible,
and continued use should be reevaluated on a periodic basis” (ACOG, 2008)
Menopause health risks - Osteoporosis
○ Decreased bone density
○ Leaves bones porous, fragile and susceptible to fracture
○ Risk factors include:
■ >60 years old
■ Small boned, thin
■ Family hx
■ Late menarche, early menopause
■ Low vit D and Calcium
■ No exercise
■ Smoking history
■ Alcohol consumption
Nursing care in osteoporosis
○ Prevention:
■ Calcium 1200 mg/day (>50 years old), 1500mg/day (>65 years old)
■ Vitamin D 400-800 units/day for maintenance, 50,000 IU weekly X3-6
weeks for replacement
○ Non-pharmacological options:
■ Hot flashes/night sweats: fan, cold showers, breathable clothing,
hydration
■ Insomnia: sleep hygiene
■ Headaches: stress reduction, low stimulus environment,
■ Vaginal irritation: water-based lubricants, no scented products or
douching, good hygiene
■ Nervousness/irritability: meditation, stress reduction, exercise
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Bone density loss: more weight-bearing exercise, diet high in calcium
and Vit. D
Counsel about lifestyle changes
■ Smoking cessation
■ Reduce alcohol and caffeine intake
■ Dietary calcium for ideal peak mass in adolescents
■ Weight bearing and resistance exercise
■ Fall prevention in older adults
Intro to Sexuality
Concept definition:
○ Sexuality:
■ A central aspect of being human throughout life encompasses sex,
gender identities and roles, sexual orientation, eroticism, pleasure,
intimacy and reproduction. Sexuality is experienced and expressed in
thoughts, fantasies, desires, beliefs, attitudes, values, behaviors,
practices, roles and relationships.
■ While sexuality can include all of these dimensions, not all of them are
always experienced or expressed.
■ Sexuality is influenced by the interaction of biological, psychological,
social, economic, political, cultural, legal, historical, religious and spiritual
factors (World Health Organization)
○ Sexual health:
■ A state of physical, emotional, mental, and social well-being in relation to
sexuality; it is not merely the absence of disease, dysfunction, or
infirmity.
■ Sexual health requires a positive and respectful approach to sexuality and
sexual relationships, as well as the possibility of having pleasurable and
safe sexual experiences, free of coercion, discrimination, and violence.
■ For sexual health to be attained and maintained, the sexual rights of all
individuals must be respected, protected, and fulfilled (WHO, 2013).
Sexual health
○ An individual and constantly changing phenomenon that falls within the wide
range of human sexual thoughts, feelings, needs, and desires
○ A continuum ranging from sexual function and wellness to sexual dysfunction
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Age-related differences
○ Human sexuality can be described as a developmental process starting at birth
and ending at death
○ Sexual health as an aspect of sexual identity is influenced by the dynamic
combination of biological, societal, cultural, and familial factors
Sexuality in adolescence
○ Physical changes associated with puberty become evident
○ Must learn to manage physical and emotional aspects of sexuality in order to
form intimate relations
○ Development of gender and sexual identity usually emerges (though this may
happen earlier)
○ Nursing considerations: safe sex practices, adolescents are risky, build trust
with patient while maintaining information confidential, discuss emotional aspect
of sexuality → encourage deterring from influence and persuasion from
friends/online
Sexuality in young adulthood
○ Many individuals begin to form intimate relationships with long-term implications
○ Often concerned about normal sexual response for both themselves and their
partners.
○ Couples should be taught to communicate their needs early in their
courtship
○ They should be aware that sexual needs and response may change so each
partner should listen and respond to the needs of the other
Sexuality in pregnancy
○ Sex is safe during pregnancy
■ Exceptions: vaginal bleeding, preterm labor, leaking of amniotic
fluid, or placenta previa
○ Normal changes of pregnancy may make sex uncomfortable or the woman may
have low desire
○ Should avoid vaginal sex for 6 weeks after birth
○ Women can get pregnant as early as 4 weeks after birth
Sexuality in middle adulthood
○ Both men and women experience decreased hormone production, causing
climacteric
○ Men: reduction in androgens
○ Women: perimenopause (a period of hormonal changes during which the body
gradually makes the transition to permanent infertility), and culminates in
menopause (cessation of menses) → reduction in estrogen
○ *These events often affect an individual’s sexual self-concept, body image, and
sexual identity
Sexuality in older adulthood
○ Many older adults are enjoying sex well into their eighth decade because many
are living healthier and longer lives
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Other chronic issues can impact sexual function, such as cardiovascular disease
and diabetes
○ Men may need more time to achieve an erection and to ejaculate. In addition,
erectile dysfunction (ED) becomes more common
○ Women may experience an increase in sexual desire after menopause.
However, vaginal lubrication and elasticity decrease.
Components of sexual health
○ Sexuality depends on interrelated psychosocial factors
■ Sexual self-concept
■ Body image
■ Gender identity
■ Gender-role behavior or gender expression
■ Freedoms and responsibilities
○ *Importantly, gender and sexuality are distinct concepts
Terms:
○ Intersex (adj): denoting an individual that has both males and female sex organs
or sexual characteristics
○ Transgender (adj): denoting an individual whose personal gender identity and
/or gender expression differs from the gender assigned to them at birth.
○ Transsexual (adj): denoting an individual who has changed or seeks to change
their sexual anatomy through medical intervention, including, but not limited to
hormones and/or surgery (older term)
○ *importantly sexual orientation may be heterosexual, homosexual, or bisexual
(gender and sexual orientation are distinct too)
○ *Also, gender and external genitalia do not always correlate
Gender dysphoria
○ Condition involving individuals having strong and persistent feelings of
discomfort with their assigned genders
○ Introduced in the 5th edition of DSM-5
○ Some advocacy groups reject any formal diagnosis related to gender expression
because they see transgender identity as one of many normal variations on a
spectrum of human sexual identity (GLAAD, 2015)
Preconception Care
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Preconception care
○ Ideally creating optimal health in ALL women in their reproductive years whether
or not they are planning a pregnancy.
○ Healthy pregnancies and healthy babies closely related to women's health before
conception
○ A goal is to identify reversible risks to a woman’s health or pregnancy outcome
are a concern for mother and baby in the event of pregnancy
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The initiation of activities that promote healthy mothers and babies must occur
before the period of critical fetal organ development, which is 17-56 days after
conception
■ By the time someone has missed their period, the brain of the infant is
already forming
○ Preconception health care should occur well in advance of an actual pregnancy
and may be the most important part of prenatal care
Sensitive periods of development
Public health perspective
○ Pre-conceptual counseling for women of childbearing age has the potential to
favorably impact rates of:
■ Infant mortality and morbidity
■ Maternal mortality and morbidity
■ Mom and babies that survive and do well.
Strategies
○ Risk identification, reduction, and elimination
○ Appropriate intervention, treatment and referral
○ Ongoing education, counseling and support
○ Prevention of unplanned pregnancy
Conditions addressed by preconception care
○ Those that need time to correct prior to conception
■ Optimal weight/nutritional health
■ Dental health
■ Immunization status
■ Choice and use of medications
■ Substance use and abuse
Common conditions amenable to preconception care
○ Diabetes
○ Hypertension
○ Cardiac conditions
○ Seizure disorder
○ Thyroid disorder
○ Thrombo-embolic disease
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○ STIs
○ Depression
○ Eating disorders
○ Substance abuse
○ Domestic violence
○ Poor nutrition
○ History of repeated miscarriages
Conditions addressed by preconception care
○ Factors that could change the timing or choice to conceive a pregnancy
■ Domestic violence
■ Mental health/stress
■ Preparedness for parenting
■ Birth spacing
■ Genetic disease
■ Diseases with poor prognosis (HIV)
■ Diseases that are dangerous in pregnancy (CHF)
● Do not vaccinate for rubella/varicella during pregnancy because
they are live
Roles of nurses in preconception care
○ Review medical history and immunizations
○ Review family history for genetic disorders (Tay-sachs, Thalessemia, CF, Sickle
cell disease)
○ Risk assessment for infectious diseases and environmental hazards
○ Lifestyle assessment
○ Recommend folic acid and good nutritional practices
○ Review contraceptive measures
○ Provide community resources
○ EDUCATION!!!
49% of all pregnancies in the US are not planned
Baby spacing
○ A short pregnancy interval (usually considered less than 18 months) may be
associated with:
■ Birth of a Small for Gestational Age baby (SGA) in the subsequent
pregnancy
■ Preterm birth in the subsequent pregnancy
Preconception and Genetic counseling and screening
○ Family history of genetic diseases
○ Discussion of age-related risks
○ Discussion of disease-related risks
○ Carrier screening
○ Potential options for donor egg and sperm or early genetic testing
○ Discussion of exposure to teratogens
Weight management
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Underweight: increased risk for low birth weight, fetal death and mental
retardation
○ Overweight and obese: increased risk for diabetes, hypertension,
thromboembolic disease, birth trauma, abnormal labor, cesarean delivery
Nutritional Risks in pregnancy Vitamins and Minerals
○ Folic acid-modifies the risk of neural tube defects
○ Iron-anemia causes increased risk of preterm delivery, low birth weight
○ Over supplementation of Vitamin A&D-increases risk of congenital defects
○ Pica-a result of iron deficiency, and can result in lead poisoning
Vitamins and minerals
○ Calcium (1000mg/day)
■ 3 or more servings of dairy a day
○ Iron (30 mg of elemental iron)
■ Meat, poultry, fish, shellfish, broccoli, kale, turnip greens, and collards,
yeast-leavened whole wheat breads, iron-enriched bread, cereal
○ Folic acid
■ Recommended 0.4 mg/day supplementation for all women of
childbearing age
● Increase to .8 mg a day when a person is pregnant → 10x more (4
mg) when child or mother has had neural tube defects
■ Leafy greens, orange juice, bananas, broccoli, asparagus, berries, nuts,
beans, citrus fruits, and fortified cereals, pastas, and breads
■ Should be started at least 1 month prior to conception, most important in
the first 28 days after conception
○ Omega-3 fatty acids (3g/day)
■ Certain fish like bluefish, anchovies, sardines, tuna, fish oil, walnuts, flax
and flaxseed oil, canola oil, olive oil, and soybean oil
○ Zinc (8mg/day)
■ Meat, poultry, grains
Prevention of neural tube defects
○ Supplementation for all women of childbearing potential with folic acid
○ No history of NTD: 0.4 mg. qday
○ Prior infant with NTD: 4.0 mg. qday
○ Woman with NTD: 4.0 mg. qday
○ Nutritional sources often inadequate
○ Approximately 4000 affected pregnancies in the US each year
○ Neural tube forms in the first 28 days of pregnancy
Exercise
○ Effective in prevention of cardiovascular disease
○ Effective in management of chronic illnesses—hypertension, arthritis, diabetes,
respiratory disorders, and osteoporosis
○ Contributes to stress reduction
○ Improves body image and self-esteem
○ Acts as a mood enhancer
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Dental health
○ Research suggests that the bacteria that cause inflammation in the gums can
actually get into the bloodstream and target the fetus, potentially leading to
premature labor and low birth weight babies.
○ Encourage routine dental health care
STI screening
○ A risk assessment should be done for every sexually active woman
○ Per CDC, ALL women 25 years and younger should be tested yearly for
Chlamydia
○ Other STIs should be tested for based on risk factors
○ Any woman with risk factors should also be counseled about the need to be
tested for HIV infection
■ Assess what kind of sex they’ve been having and how many sexual
partners they’ve had
Immunization status
○ Women of childbearing age in the US should be immune to measles, mumps,
rubella, varicella, tetanus, diptheria, and polio through childhood immunizations
○ If immunity is determined to be lacking, proper immunizations should be provided
before getting pregnant
○ Need for immunizations according to age group of women and occupational or
lifestyle risks
Rubella vaccination
○ Determine rubella immunity prior to conception
○ Vaccinate all susceptible non-pregnant women 3-6 months before stopping birth
control
○ Cannot attempt to conceive until 3 months after vaccination
○ Congenital rubella syndrome may result from infection in pregnancy especially
during the first trimester (microcephaly, blindness, deafness, fetal growth
restriction, cardiac malformations, mental retardation, etc)
○ DO NOT VACCINATE FOR MMR OR VARICELLA DURING PREGNANCY
■ NO FLU MIST
○ Need a flu shot and TDAP vaccine during third trimester to pass immunity to the
child
Toxin/teratogen avoidance
○ Alcohol
○ Excessive caffeine
○ Drugs
○ Smoking
○ Pathogens
○ Medications (unless approved)
■ Alcohol
● **** NO THRESHOLD HAS BEEN IDENTIFIED FOR “SAFE” USE
IN PREGNANCY
○ Effects are related to the dose
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○ Effects in all stages of pregnancy
● There is no study of safe thresholds of alcohol during pregnancy
Tobacco
● ***** CAUSES VASOCONSTRICTION WHICH RESTRICTS
BLOOD FLOW TO THE FETUS AND REDUCES THE % OF
OXYGEN AND NUTRIENTS CARRIED TO THE FETUS IN THE
BLOOD
Caffeine
● Questionable research available
○ Possible increases in rates of miscarriage, neural tube
defects, & cleft palate
○ Moderation is best rule of thumb that is less than 16 oz.
per day
Street drugs
● Marijuana, Cocaine, Methamphetamines, Ecstasy, Heroin (or any
opioid)
○ Increased incidence in preterm births, low birth weight
○ Increased incidence in placental abruption
○ Neurological problems in the newborn
○ Neonatal abstinence syndrome
○ Malnourishment & ability to resist infection
○ Increased risk of pregnancy induced hypertension
TORCH infections
○ Toxoplasmosis: no changing cat litter boxes during
pregnancy
○ Chlamydia & Gonorrhea = can cause blindness if it gets
in the babies eyes during delivery
■ Test again after 3 weeks to see if infection is gone
○ Syphillis
○ Hepatitis B
○ Varicella-Zoster
○ Rubella
○ Cytomegalovirus: #1 infectious cause of mental
retardation in a baby
○ Herpes
○ Common cause of birth defects
○ Can cause stillbirth
○ Infection causes few symptoms in pregnant woman
○ In infants-serious birth defects result in infections
contracted during pregnancy/delivery
○ 1st trimester-more serious birth defects for most, at
delivery for some.
○ Current pregnancy: check titers, vaccines available but
most not in pregnancy
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Medications
● Not all medications are safe while trying to conceive (or having
unprotected sex) and during pregnancy
● Must consider all types of meds:
● OTC
● Prescription
● Herbals
● vitamins
● Pregnancy risk categories for medications
● All medications should be reviewed before getting pregnant
Drug categories in pregnancy
● Category A: no associated fetal risks
○ -Ex: prenatal vitamins, folic acid
● Category B:
○ Animal studies show no adverse effects and no good
human studies exist or animal studies show risk but human
studies fail to show a risk
○ Ex: penicillins, acetaminophen
● Category C:
○ No adequate studies or animal studies show risk but
human studies not available
○ Ex: SSRIs, corticosteroids (most prescription medications)
■ Benefits may outweigh the risk – mom must be
healthy for the baby to be healthy
● Category D: fetal harm possible - weigh risks and benefits
○ Ex: alcohol, tetracycline
● Category X: clear fetal risks
○ Ex: Accutane, warfarin
New FDA labeling
● In 2015 the FDA replaced the former pregnancy risk letter
categories on prescription and biological drug labeling to both
patients and healthcare providers.
● Prescription drugs submitted for FDA approval after June 30, 2015
will use the new format immediately
● The A, B, C, D and X risk categories, in use since 1979, are now
replaced with narrative sections and subsections to include:
○ Pregnancy (includes Labor and Delivery):
■ Pregnancy Exposure Registry
■ Risk Summary
■ Clinical Considerations
■ Data
○ Lactation (includes Nursing Mothers)
■ Risk Summary
■ Clinical Considerations
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○ Females and Males of Reproductive Potential
○ Pregnancy Testing
○ Contraception
○ Infertility
○ Data
General medication warnings when trying to get pregnant or already
pregnant
● You should never start or stop taking medication while
pregnant or trying to get pregnant without first consulting your
healthcare provider. Here are some steps to help make sure you
and/0r your developing baby are properly cared for.
● Always consult your doctor: This is your first and most
important step.
● Read the Label: Look for warnings or pregnancy indications. You
should also look for potential allergic reactions as well as
expiration dates.
● Be aware of side effects: Consult your healthcare provider or the
pharmacist about potential side effects. Some medications cause
side effects like sleepiness, headaches, or vomiting, which may be
enhanced because of pregnancy hormones.
● Organize your medications: Be careful to not mix up your
medications to avoid overdosing.
● Do not skip medications: Take as prescribed by your healthcare
provider
● Do not share medications!
● Ask Questions: It is appropriate to ask questions about
medication safety for you and your developing baby. Ask about the
medication name, generic alternatives, benefits and risks, and
problems to watch for.
● Keep Records: It is always beneficial to keep a record of
medications taken whether pregnant or not. This becomes even
more important if you are expecting.
● Check Pregnancy Medication Registries: The FDA has a new
pregnancy medication registry that you may find helpful.
Substance use and preconception care
● Patient education as to the effects of substances on the fetus
○ Diet, smoking, OTC medications may not cross the
mother’s mind that they are harmful
● Screening for use/abuse
● Family Dysfunction
● Financial stress
● Potential for law enforcement involvement
● Referral for pregnancy-specific treatment programs
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● Pregnancy may be a strong motivator for change
■ Environmental hazards
● Chemical: lead (ask when home was built bc lead paint), mercury
(fish), herbicides, and pesticides
● Physical: hyperthermia → hot tubs, saunas, fever
● Radiation: x-rays
● Infectious: Live vaccines [avoid varicella, MMR], STIs, Listeria
[found in unpasteurized milk/cheeses, aged meats],
● TORCH
● Exposures at home, workplace, or environment
● Cultural considerations
Psychosocial concerns
■ Preparedness for parenting
● Psychological
● Financial
● Social concerns
● Age
● Life plans (education, career)
■ Adolescents and Preconception counseling
● Sex education/review safe sex practices
● Family planning counseling
● Empower to make healthy decisions
● Develop trust
● Nutrition, self-care, stress reduction
● Implications of pregnancy
● Teens more likely to have labor, delivery, and low birth weight
problems
● Almost half of all pregnant teens do not receive prenatal care
in the first trimester
■ Older women and preconception counseling
● May experience a delay in becoming pregnant
● Increased risk of complications associated with pregnancy →
comorbid dx → HTN, diabetes
● Increased risk of miscarriage and stillbirths
● Increased risk of fetal chromosomal abnormalities
● Identifying risk factors prior to pregnancy
● Genetic counseling/genetic testing in pregnancy
■ Preconception care for men
● Review family and medical and genetic history
● Alcohol, drug, tobacco use
○ May be associated with physical and emotional abuse
○ May decrease fertility
● Occupational exposure
● Sexually transmitted infections → testing
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○ Syphilis, herpes, HIV
Should play an active role in preconception planning
Cellular Regulation
Concept definitions for cellular regulation
○ Cellular regulation: all functions carried out within a cell to maintain
homeostasis, including its responses to extracellular signals and the way each
cell produces an intracellular response.
○ Included within these functions is cellular replication and growth (proliferation and
differentiation)
○ Neoplasia: abnormal and progressive multiplication of cells, leading to formation
of a tumor, either benign or malignant
Cellular replication
○ Cells should replicate to create new cells at the same rate that older cells die
○ The determination and timing of cellular division is tightly controlled process with
molecular signals of “go” and “stop”
○ In a pathological process, these signals can function abnormally with faulty “go”
signals or ignoring “stop” signals
○ There is redundancy in error-correcting mechanisms in cellular regulation and it
generally takes multiple errors compounded over time for healthy cells to
turn malignant
Scope of cellular regulation
○ Normal cell growth is at one end of the spectrum and malignant neoplasm is at
the opposite
○ Benign neoplasms tend to retain normal morphology (shape) and function but are
capable of overgrowth
○ Malignant neoplasms tend to have abnormal morphology, function, growth, and
can spread to distant sites
Types of Alterations in cellular regulation
○ Hyperplasia
○ Metaplasia: cells transform to different cell types → r/t chemical/infectious
irritants
○ Dysplasia: abnormal shapes/sizes in cells → based on a continuum: normal
cell growth → malignant neoplasia
○ Anaplasia: production of immature, non-differentiated cells
○ Any of these alterations has the potential to become cancerous or cause
disorders that can compromise a patient’s health.
Unmodifiable Risk Factors
○ Age
○ Biological gender
○ Ethnicity
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○ Genetic risk factors
○ Family history
○ Personal history
Genetic considerations and risk factors for cancer
○ Genetic basis for some cancers
■ Skin, ovarian, breast, prostate, colon
○ Genes
■ Tumor suppressor genes – BRCA1 and BRCA2
■ Tumor-associated growth factor – HER2
○ Socioeconomic factors have a major impact
■ Low socioeconomic status (SES), lack of healthcare coverage increase
risk
○ Age
■ Risk greatly increases across the lifespan with aging
■ 78% of new cancer diagnoses are in people than 55
Modifiable risk factors for cancer
○ Poor diet
■ Excessive consumption of sugar and fatty foods
■ Processed meats or other processed foods
■ Excessive consumption of alcohol
○ Lack of physical activity
○ Smoking, tobacco, second-hand smoke
○ Exposure to UV radiation and ionizing radiation
○ Infections → HPV, H.pylori, Hep B or C, HIV
○ Chemicals → insecticides, herbicides, metals
○ Living in areas with high levels of air pollution
○ Hormone replacement therapy → estrogen
○ Exposure to radon
Prevention
○ Familial history
■ Encourage families to learn about disorder
■ Have children receive regular surveillance as they enter young adulthood
○ Screenings
■ Papanicolaou test
■ Mammograms
■ Colorectal screening
■ Testicular examination
Cancer screening Guidelines
○ Colorectal Cancer (men and women)
■ starting at 45 years of age and should continue to 75 if in good health
■ Fecal occult blood test annually
■ Stool DNA tests every 3 years
■ Colonoscopy every 10 years or sigmoidoscopy q5 years
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Breast Cancer (women)
■ No clear benefits of physical breast exams performed by healthcare
professionals or women themself
■ The ACS no longer recommends a clinical/self breast exam (CBE) as
a screening method for women in the U.S.
■ Women should also know how their breasts normally look and feel and
report any breast changes to a health care provider right away
● Breast cancer screening
○ Choice to start mammograms annually at 40
○ Mammograms recommended annually at by 45
○ Can change to every 2 years at age 55 and older (with life
expectancy of 10 years or more)
○ May need MRIs if at high risk
Well Woman Care And Cervical Cancer Screening (USING GUIDELINE)
○ Physical exam
■ Head-to-toe exam
● Breast exam
■ Pelvic exam
● External exam → visualization
● Internal exam → using speculum
○ Collection of specimens
○ Vaginal exam
■ Bimanual exam → screening for displacement of uterus
■ Rectal exam
○ Assisting with pelvic exam
■ Wash hands and assemble equipment needed
■ Assist in relaxation techniques for women
■ Encourage women's involvement in exam
■ Assess for and treat signs of problems
■ Warm speculum
■ Instruct woman to bear down when speculum inserted
■ Apply gloves and assist the examiner in collection of specimens
■ Lubricate examiners fingers for bimanual
■ Assist the woman after exam and allow for privacy
○ Well-woman gynecologic care
■ Not just for pap smears
■ If planning to become sexually active (not just intercourse) to discuss safe
sex practices and family planning
■ Annual pelvic exams starting at age 21, unless signs of a menstrual
disorder, unusual vaginal discharge, or pelvic pain
■ Start pap smears at age 21 and follow current guidelines
○ GYN Screening Procedures
■ Pap smear (USPSTF and ACS/ASCCP/ASCP, 2012):
● No screening before 21 years old
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21-29 – every 3 years is recommended
30-65 years old – every 5 years with combined HPV testing
preferred
● > 65 – no screening if three consecutive negative cytology results
or two consecutive negative co-tests within the 10 years
Adolescent needs
■ Care for contraception needs and STI screening/treatment
■ No pap test
■ No speculum exam for asymptomatic women
■ STI testing can be done using urine
Pap Smear
■ Based on the idea that changes occur in the cells of the cervix before
cancer develops
■ Sampling of cells from endocervix and ectocervix at the squamocolumnar
junction
■ Thinprep liquid based
■ Preparation for the best quality Pap:
● Avoid douching or using vaginal creams/spermicides for 24 hours
prior to exam
● Avoid intercourse for 24-48 hours prior
● Best time to have a pap smear is mid-cycle
Human Papillomavirus (HPV)
■ HPV is the Human Papilloma Virus, which is acquired through sexual
contact, causes virtually all cases of cervical cancer
■ USE OF CONDOMS REDUCE RISK
■ Over 100 types of this virus
● HPV 6 & 11 – associated with genital warts
● HPV 16 & 18 – cause 70% of all cervical cancers
■ Majority of women with detectable HPV infection will spontaneously clear
the infection within 24 months
● Not tested for every year anymore because it will clear and most
women will never get dysplasia
■ In the US 20 million people are thought to be infected with HPV
Bethesda System for Pap Smears
■ Categories of epithelial abnormalities:
● ASCUS – atypical squamous cells of undetermined significance
○ Most mild form
● LGSIL – low grade squamous intraepithelial lesion (CIN1)
● HGSIL – high grade squamous intraepithelial lesions (CIN2 or
CIN3)
● Squamous cell carcinoma
What to do with abnormals…
■ ASCCP guidelines (algorithms): http://www.asccp.org/
■ Diagnosis
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Colposcopy with or without biopsy → visualize cervix with
colposcope
Treatment:
● Cryotherapy or laser ablation
● LEEP (loop electrosurgical excision procedure)
● Hysterectomy
What leads to cervical cancer?
■ Being rarely or never screened is the major contributing factor to most
cervical cancer deaths today
Gardasil Vaccine
■ Although deaths are prevalent in HPV, a vaccine is available
■ The FDA approved a vaccine in 2006
■ Series of three injections over 6 months: first shot, one 2 months later,
and one six months after the first. Lasts at least 8 years.
■ GARDASIL is approved for girls and women ages 9-26 to help protect
against:
● HPV 16 + 18 that causes about 70% of cervical cancer
● HPV 6 + 11 that causes 90% of genital warts cases
■ In boys and young men ages 9 to 26 → helps protect against 90% of
genital warts cases
■ Does not take the place of pap smear screening
Improved vaccination for HPV
■ Gardasil 9
● 5 additional types of high-risk HPV
● FDA approved in 2014
● Recently extended approval for ages 27-45 in males and females
○ For people ages 9-14, only need to get 2 shots
○ For people ages 15-45, 3 separate shots are required.
The second shot is given 2 months after the first, and the
third shot is given 4 months after the second shot
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Reproduction: Conception and Fetal Development
Concept characteristics
○ Reproduction: process by which human beings produce a new individual
○ Sexual intercourse between a man and a woman may result in the conception of
a child
○ The sex glands or gonads (ovaries in the female; testes in the male) produce the
germ cells (oocytes + spermatozoa) that unite and grow into a new individual
○ During sexual intercourse interaction between the male and female reproductive
systems may result in fertilization of the woman's ovum by the man's sperm
○ Fertilization of the ovum may also be achieved outside the uterus without sexual
intercourse using a process known as assisted reproductive technology, such as
in vitro fertilization
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Pelvis
○ False – widest portion of the pelvis provided support for the weight of the
enlarging uterus and directs the presenting part into the pelvis
○ True – space below the linea terminalis that the narrow portion of the birth canal
○ Pelvic inlet – hole area in the middle of the pelvis
○ Pelvic outlet – space between ischial spine – narrowest portion the baby passes
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Basic Pelvic Types
○ Gynecoid (female) – 40-50%
■ Best for childbirth
○ Android (male) – 20%
■ Not usually adequate for childbirth
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Anthropoid – very narrow from side to side
Platypelloid – flat from front to back and not suitable for vaginal delivery
generally
Male External Reproductive Organs
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Penis
■ Elimination
■ Passage of sperm
○ Scrotum
■ Suspend testes to protect from high body temperatures
■ Contains testes, epididymis, and spermatic cords
■ Protect against traumatic injury
Male Internal Reproductive Organs
○ Testes
■ House sperm during development
■ Site for spermatogenesis
○ Epididymis
■ Reservoir for sperm
■ Area of maturation
■ Travels to vas deferens
○ Vas deferens
■ Storehouse for immotile sperm
■ Allows sperm to travel from epididymis to duct
○ Ejaculatory duct
■ Passageway for seminal fluids
○ Accessory glands
■ Secretes components of the seminal fluids
What Are Gametes?
○ Gametes: ova and sperm
○ Each gamete contains the haploid number (23) to add together with another
gamete to form a zygote with the diploid number (46)
○ Gametogenesis
○ Oogenesis – the process of egg (ovum) formation, beginning during fetal life in
the ovaries
○ Spermatogenesis – the process by which spermatozoa are formed, beginning at
puberty
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The Ovum: Oogenesis
○ Ovaries develop early in fetal life
○ By the 6th month all ova any female will ever produce have been formed and are
ready to undergo mitosis during the reproductive stage of life.
○ Oogenesis halts in fetal life before first division is completed
○ Resumes division process at puberty with ovulation
Each month – Oogenesis
○ Shortly before ovulation usually one primary oocyte matures and completes the
first meiotic division
○ Division of cytoplasm is unequal with secondary oocyte receiving most, first polar
body almost none. Each contains 22 autosomes and one X chromosome (23X)
○ Secondary oocyte begins second meiotic division at ovulation and arrests
○ Division is only completed if fertilization of ova occurs
Ova trivia
○ Newborn: 2 million immature ova (primary oocytes): most degenerate
spontaneously
○ Puberty: 40,000 immature ova
○ About 400-500 will mature to become secondary oocytes at ovulation during
a woman reproductive years
The Sperm: Spermatogenesis
○ Occurs in the seminiferous tubules of the testes once a male reaches puberty
○ Takes about 70 days to complete
○ Spermatogonium matures to Primary Spermatocyte (46XY)
○ Primary spermatocyte undergoes reduction division and forms:
■ 2 secondary spermatocytes
● contains 22 autosomes and one X chromosome (23X)
● contains 22 autosomes and one Y chromosome (23Y)
The Sperm: Spermatogenesis
○ Every secondary spermatocyte divides to form 2 spermatids (4 total) which
mature and lose their cytoplasm
○ The nucleus becomes compacted to form the head, which contains the
chromosomal material
○ Sperm penetrates using their head section: acrosome and then it falls off,
releasing enzymes
Sperm Trivia
○ 200 - 500 million/ejaculation
○ only 1000 will reach ampulla-most are lost in the cervical mucus, or in the
endometrium or enter the tube without an ovum
○ Sperm can live 2-3 day (rarely up to 5) after ejaculation
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Ovum activity
○ The ovum has no inherent power of movement → fallopian tubes contract
the ovum forward
○ High estrogen levels during ovulation increase the contractility of the tubes to
propel the ovum into the fallopian tube and toward the uterus.
○ Each month, one ovum matures and is released from the ruptured ovarian follicle
and is fertile for about 12-24 hours after release
Sperm activity
○ Sperm are able to propel themselves up the female genital tract.
○ Use fructose in semen as the energy source
○ Prostaglandins in seminal fluid facilitate transport by increasing the peristalsis of
the fallopian tubes
○ Transport through fallopian tubes can be as fast as 5 minutes after
ejaculation, but the average is 4-6 hours.
Fertilization
○ Fertilization: the fusion of an ovum from a female and a sperm of a male
■ Occurs in the outer curve of the fallopian tube called the ampulla
Sperm Preparation for Fertilization
○ Capacitation
■ Occurs as travels through the female genital tract
■ Removal the plasma membrane over the acrosome
■ Process of removal of acrosome allows:
● Enhanced sperm motility
● Allows binding to the zona pellucida
○ Acrosomal reaction
■ Occurs once capacitated sperm bound to the zona pellucida, enzymes
are released that allow sperm to penetrate
■ Surface membrane fuses with underlying membrane of oocyte
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Fertilization
○ Ovum Reacts To Contact with Sperm In 2 Ways:
■ Ovum’s plasma membrane change to prevent entry of other sperm (zona
reaction) → REJECTION
■ Secondary oocyte completes 2nd meiotic division and yields a
mature ovum:
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Stages of Development
○ Zygotic (preembryonic) – first 14 days after conception (or until completed
implantation
■ Cellular Multiplication
● Zygote moves through the tubes for 3-4 days
● Zygote begins rapid mitotic divisions called cleavage: dividing
into 2 cells, 4 cells, 8 cells → called blastomeres, held in zona
pellucida
● Blastomeres become smaller and form a solid ball called morula
● Morula inside of ZP enters uterus → fluid enters morula →
becomes blastocyst → implants on uterus
● Blastocysts secrete HcG to signal pregnancy
■ Cellular Differentiation
○ *Embryonic – 2-8 weeks
■ Differentiation of tissues into essential organ systems
■ Time most susceptible to teratogens
○ Fetal – 9 weeks to completed gestation
■ Refining structures
■ Perfecting function
Zygotic stage-Cellular multiplication
○ First 14 days after fertilization
○ Begins as zygote moving through the tubes for 3-4 days
○ Zygote begins rapid mitotic divisions called Cleavage
○ Zygote DIVIDES INTO :
2 cells, 4 cells, 8 cells……
○ These cells are called blastomeres, which are held in by the zona pellucida
○ Blastomeres become smaller because zona pellucida stays the same size,
eventually forming a solid ball called the morula
○ The morula, still inside the ZP enters into the uterus
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○ Fluid enters into the morula forming a central cavity
○ This creates the blastocyst:
○ An inner cell mass (embryoblast)
○ An outer layer of cells (trophoblast)
Blastocyst
○ The zona pellucida disappears to permit rapid expansion as floats in uterine
cavity
○ The trophoblast is the outside layer of cells that replaces the zona pellucida
○ Trophoblast later develops into one of the 2 embryonic membranes, known as
the chorion
○ The inner cell mass yields the embryo and the other embryonic membrane,
known as the amnion.
Implantation
○ Blastocyst is nourished by uterine glands while floating
○ Secretes HcG to signal woman’s body that pregnancy
○ Trophoblast attaches to the endometrial lining
○ Blastocyst burrows into the lining (7-10 days after conception).
■ displacing endometrial cells at the implantation site
■ penetrating toward the maternal capillaries until completely covered
■ Site is important—usually on upper uterus, more often posterior wall
■ Implantation bleeding
Implantation
○ Endometrial lining below blastocyst thickens due to progesterone
○ After implantation the endometrial lining is known as the decidua
■ Decidua capsularis
■ Decidua basilis
■ Decidua vera
○ Trophoblast grow into the decidua forming the chorionic villi
○ Chorionic villi touching the decidua basalis eventually will form the fetal side of
the placenta
○ Decidua basalis will eventually form the maternal side of the placenta
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