Folic acid is preventing neural tube defect.
FAMILY STRUCTURES:
Nuclear family:
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Traditional term used to represent a couple with their children (biologic or adopted)
Live as an independent unit
Share roles, responsibilities, and resources
Although historically this term was used to reflect a married couple, many consider this
to have evolved to be more inclusive of a partnered couple and their children
Extended family:
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Consists of the nuclear family plus other family members including grandparents, aunts,
uncles, or other relatives
Typically, extended family members live in close proximity to each other
Similar to a nuclear family, may provide social, emotional, and financial support to one
another
Extended family often represents an important support network that may be called upon
when important health care decisions are being made
Multigeneration family:
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Often used to refer to three or more generations that live together (e.g., grandparents,
children, grandchildren)
Increasingly common, particularly when caregiving and/or financial support is needed
Single-parent family:
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Composed of one parent who is responsible for his or her child(ren); parent may have
sole or shared custody of the child(ren)
Single-parent family may result from the choice to raise a child as a single parent or a
loss of a partner due to death, divorce, separation, or desertion
Blended family:
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Often used to refer to families that join unrelated family members to create a new
household
For example, a divorced parent remarries, and the new household consists of biologic
parent, stepparent, and child
Female reproductive system: Mammary glands, located in the breast, are also considered part
of the female reproductive system because they produce milk to feed an infant
Internal: vagina, uterus, fallopian tube, ovaries
External: Mons pubis, labia, clitoris, vestibule, and perineum
Vagina:
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To allow discharge of the menstrual flow
To receive the penis as the female organ of coitus (sexual union of man and
woman)
To allow passage of the fetus from the uterus
Uterus:
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thick-walled muscular organ shaped like a flattened, upside-down pear. The
uterine wall is made up of three layers: the endometrium, the myometrium, and
part of the perimetrium.
The endometrium is the inner layer of the uterus. It is responsive to the cyclic
variations of estrogen and progesterone. The two layers of the endometrium are:
o The basal layer, which regenerates the functional layer of the
endometrium after each menstruation and after childbirth.
o The functional layer, which lies above the basal layer and is shed during
menstruation.
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Cervix:
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The cervix is the tubular “neck” of the lower uterus.
The os is the opening in the cervix that runs between the uterus and the
vagina. The upper part of the cervix is marked by the internal os, and the
lower cervix is marked by the external os.
Before vaginal delivery, the external os is round and smooth. The cervix
opens to allow passage of the fetus during birth, and after vaginal delivery,
the external os has an irregular, slit-like shape and may have tags of scar
tissue.
Fallopian tube:
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The fallopian tubes are a pathway for the ovum between the ovary and
the uterus. The ovum travels from the ovary to the uterus through the
fallopian tube. The fallopian tubes are lined with folded epithelium
containing cilia, which are hair like projections that move rhythmically
toward the uterus to propel the ovum through the tube. The fallopian
tubes are not directly connected to the ovary. At ovulation, the ovum is
expelled into the abdominal cavity. Wavelike motions of the fimbriae,
which are very near the ovary, draw the ovum into the fallopian tube.
Ovaries:
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The ovaries have two functions: to produce sex hormones and to develop
an ovum to maturity during each reproductive cycle. The ovaries secrete
estrogen and progesterone in varying amounts during a woman’s
reproductive cycle to prepare the uterine lining for pregnancy.
Ovulation is the release of mature ovum from the ovary at intervals
Bony pelvis:
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protection of the pelvic structures
accommodation of the growing fetus during pregnancy
anchorage of the pelvic support structures.
Breast: Mammary gland composed of a number of lobes, divided into lobules
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Lobules are clusters of acini; acinus is a saclike terminal part of a compound gland
emptying through a narrow lumen or duct
The acini are lined with epithelial cells that secrete colostrum and milk
Once ovulation begins in puberty, progesterone levels increase. The increase in
progesterone causes maturation of mammary gland tissue, specifically the lobules and
acinar structures.
The breasts change in size and nodularity in response to cyclic ovarian changes
throughout reproductive life. Increasing levels of both estrogen and progesterone in
the 3 to 4 days before menstruation increase the vascularity of the breasts, induce
enlargement of the ducts and acini, and promote water retention breast swelling,
tenderness, and discomfort
Function: lactation, sexual arousal, Physiologic alterations in breast size reach minimal
level about 5 to 7 days after menstruation stops best time for breast self-exam
MENSTRUATION
Menarche: first menstruation
Menstruation: the periodic uterine bleeding that begins approximately 14 days after ovulation.
Menstrual cycle: hypothalamic-pituitary, ovarian, endometrial
1. Hypothalamic-pituitary cycle: FSH and LH signal the ovary to produce ova and
secretes Estrogen and Progesterone. Towards the end of the menstrual cycle, level
of E and P is low stimulates the Hypothalamus to secrete GnRH GnRH
stimulates the anterior pituitary gland to secrete FSH FSH stimulates the
development of ovarian graafian follicle and their production of estrogen
estrogen now begins to decrease, and GnRH triggers the anterior pituitary gland
to release LH A marked surge of LH and a smaller peak of estrogen (day 12)
LH peaks at about day 13 or 14 of a 28-day cycle If fertilization and
implantation of the ovum has not occurred at this time, regression of corpus
luteum follows E and P now decrease and menstruation occurs.
2. Ovarian cycle:
before ovulation, a monthly process in which an ovum is normally released from
the ovary, from 1 to 30 follicles begin to mature in each ovary under the influence
of FSH and estrogen The oocyte matures, ovulation occurs, and the empty
follicle begins its transformation into the corpus luteum. Almost all variations in
ovarian cycle length are the result of variations in the length of the follicular
phase. After ovulation, estrogen levels drop. For 90% of women, only a small
amount of withdrawal bleeding occurs, and it goes unnoticed. In 10% of women,
there is sufficient bleeding for it to be visible, resulting in what is termed
midcycle bleeding The luteal phase begins immediately after ovulation and
ends with the start of menstruation The corpus luteum reaches its peak of
functional activity 8 days after ovulation, secreting the steroids estrogen and
progesterone Coincident with this time of peak luteal functioning, the fertilized
ovum is implanted in the endometrium. If no implantation occurs, the corpus
luteum regresses and steroid levels drop Two weeks after ovulation, if
fertilization and implantation do not occur, the functional layer of the uterine
endometrium is shed through menstruation.
3. Endometrial cycle:
During the menstrual phase, shedding of the functional two thirds of the
endometrium (the compact and spongy layers) is initiated by periodic
vasoconstriction in the upper layers of the endometrium
The proliferative phase is a period of rapid growth lasting from about the fifth
day to the time of ovulation From this point on, an eightfold to tenfold
thickening occurs, with a leveling off of the thickening of the endometrium at
ovulation The proliferative phase depends on estrogen stimulation derived from
ovarian follicles.
The secretory phase extends from the day of ovulation to about 3 days before the
next menstrual period. After ovulation, large amounts of progesterone are
produced. An edematous, vascular, functional endometrium is now apparent At
the end of the secretory phase, the fully matured secretory endometrium reaches
the thickness of heavy, soft velvet Implantation of the fertilized ovum generally
occurs about 7 to 10 days after ovulation
During the ischemic phase, the blood supply to the functional endometrium is
blocked and necrosis developsThe functional layer separates from the basal
layer, and menstrual bleeding begins, marking day 1 of the next cycle
Other cyclic changes: Before ovulation, the woman’s basal body temperature is
often less than 37°C (98.6°F); after ovulation, with increasing progesterone levels,
her basal body temperature rises.
Prostaglandins (PGs) are oxygenated fatty acids classified as hormones. PGs
affect smooth muscle contractility and modulation of hormonal activity. Indirect
evidence indicates that PGs have an effect on ovulation, fertility, changes in the
cervix and cervical mucus that affect receptivity to sperm, tubal and uterine
motility, sloughing of endometrium (menstruation), onset of miscarriage and
induced abortion, and onset of labor (term and preterm). PGs may play a key role
in ovulation. If PG levels do not rise along with the surge of LH, the ovum
remains trapped within the graafian follicle. After ovulation, PGs may
influence production of estrogen and progesterone by the corpus luteum. PGs
produced by the woman cause regression of the corpus luteum and regression and
sloughing of the endometrium, resulting in menstruation. PGs increase
myometrial response to oxytocic stimulation, enhance uterine contractions, and
cause cervical dilation.
Social determinants of health: Social determinants of health are conditions in the environments
in which people are born, live, learn, work, play, worship, and age that affect a wide range of
health functioning, and quality-of-life outcomes and risks. Poverty, education, nutrition, exercise,
smoking, drinking, and drug use are potent social determinants of a woman’s health.
Risk Factors:
Health disparities and social, cultural, and genetic disorders
MENSTRUAL DISORDER
Dysmenorrhea: pain during or shortly before menstruation
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Primary: associated with ovulatory cycle, biochemical basis and arises from the
release of prostaglandin; excessive prostaglandin (PGF2alpha) increases the
amplitude and frequency of uterine contraction and causes vasospasm of the
uterine arterioles ischemia and cyclic lower abdominal pain. Primary
dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is
established. Anovulatory bleeding, common in the first few months or years after
menarche, is painless. Because both estrogen and progesterone are necessary for
primary dysmenorrhea to occur, it is experienced only with ovulatory cycles.
o Nurse management: heat minimizes cramping by increasing vasodilation
and muscle relaxation and minimizing uterine ischemia; aerobic exercise,
Relaxation training, biofeedback, transcutaneous electrical nerve
stimulation (TENS), Lamaze, hypnotherapy, imagery, and desensitization
o Exercise (like pelvic rocking) minimizes pain by causing vasodilation and
decrease ischemia release endogenous opiatesblocking prostaglandin
o Good nutrition: less sugar and salt, natural diuretics: asparagus, cranberry
juice, peach, parsley, watermelonrelease discomfort and edema; low fat
vegetarian diet
o Oral contraceptive pills (OCPs)
Secondary dysmenorrhea: happens later; associated with pelvic pathology such as
adenomyosis, endometriosis, pelvic inflammatory disease (PID), endometrial
polyps, or submucous or interstitial myomas (fibroids)
o In contrast to primary dysmenorrhea, the pain of secondary dysmenorrhea
is often characterized by dull lower-abdominal aching that radiates to
the back or thighs: bloating or pelvic fullness
o Diagnostic test: ultrasound examination, dilation and curettage
(D&C), endometrial biopsy, or laparoscopy
Premenstrual syndrome (PMS): complex, poorly understood condition that includes one or
more of a large number (more than 150) of physical and psychologic symptoms beginning in the
luteal phase of the menstrual cycle, occurring to such a degree that lifestyle or work is affected,
and followed by a symptom-free period
o Symptoms include fluid retention (abdominal bloating, pelvic fullness, edema of the
lower extremities, breast tenderness, and weight gain), behavioral or emotional changes
(depression, crying spells, irritability, panic attacks, and impaired ability to concentrate),
premenstrual cravings (sweets, salt, increased appetite, and food binges), headache,
fatigue, and backache.
o Diagnosis: is made when a specific group of symptoms consistent with PMS occur in the
luteal phase and resolve within a few days of menses onset. Common physical
symptoms include breast tenderness, bloating, and headache. Irritability, anxiety, and
depression are common behavioral symptoms
PMDD: PMDD is a more severe variant of PMS in which women have marked irritability,
dysphoria, mood lability, anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed
Diagnosis: Five or more affective and physical symptoms are present in the week before menses
and begin to improve in the follicular phase of the menstrual cycle.
• At least one of the symptoms is marked affective lability, marked irritability or anger,
depressed mood or feelings of hopelessness or self-deprecating thoughts, or anxiety.
• One or more of the following additional symptoms are present, reaching a total of five
symptoms when combined with the above symptoms: decreased interest in usual activities,
subjective difficulty concentrating, lethargy, marked change in appetite (overeating, food
cravings), hypersomnia or insomnia, feeling overwhelmed, physical symptoms of breast
tenderness, muscle pain, bloating, weight gain.
• Symptoms interfere markedly with work or interpersonal relationships.
• Symptoms are not caused by an exacerbation of another condition or disorder.
• The woman and the HCP must confirm that symptoms are occurring, evidenced through daily
ratings
• Symptoms are not caused by physiologic effects of a substance or a specific medical treatment.
Nursing management:
Diet and exercise: aerobic exercise increases beta-endorphin levels to offset symptoms of
depression and elevate mood; less salt and sugar, less caffeine; Calcium, B6, vit D; Herbal
therapy
Medication: diuretics, NSAID, progesterone, OCPs, SSRIs
Endometriosis: presence and growth of endometrial tissue outside of the uterus. A cystic
lesion of endometriosis found in the ovary is sometimes described as a chocolate cyst because of
the dark coloring of the contents of the cyst caused by the presence of old blood.
o The major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia
(painful intercourse). Many women report bowel symptoms such as diarrhea, pain with
defecation, and constipation caused by avoiding defecation because of the pain. Other
symptoms include abnormal bleeding (hypermenorrhea, menorrhagia, or premenstrual
staining) and pain during exercise as a result of adhesions (Advincula).
o Nursing management:
 Women without pain who do not want to become pregnant need no treatment
 In women with mild pain who may desire a future pregnancy, treatment may be
limited to use of NSAIDs during menstruation
 Suppression of endogenous estrogen production, and subsequent endometrial
lesion growth, is the cornerstone of management of the disease: GnRH agonists
and androgen derivatives.
 GnRH agonist therapy (leuprolide [Lupron], nafarelin acetate [Synarel],
goserelin acetate [Zoladex]) acts by suppressing pituitary gonadotropin
secretionFSH and LH stimulation of the ovary declines markedly, and ovarian
function decreases significantly. A medically induced menopause develops,
resulting in anovulation and amenorrhea.
 Danazol, a mildly androgenic synthetic steroid, suppresses FSH and LH
secretion, thus producing anovulation and hypogonadotropism decreased
secretion of estrogen and progesterone and regression of endometrial tissue.
 Surgical intervention: For women who do not want to preserve their ability to
have children, the only definite cure is total abdominal hysterectomy (TAH); In
women who want children and in whom the disease does not prevent bearing
children, reproductive capacity should be retained through careful removal by
laparoscopic surgery or laser therapy
Oligomenorrhea is often used to describe decreased menstruation, either in amount, duration, or
both. This refers to infrequent menstrual periods characterized by intervals of 40 to 45 days or
longer
Hypomenorrhea is to scanty bleeding at normal intervals
Metrorrhagia, or intermenstrual bleeding, refers to any episode of bleeding—whether spotting,
menses, or hemorrhage—that occurs at a time other than the normal menses
Menorrhagia (hypermenorrhea) is defined as excessive menstrual bleeding, in either duration
or amount. The causes of heavy menstrual bleeding are many, including hormonal disturbances,
systemic disease, benign and malignant neoplasms, infection, and contraception (IUDs)
Abnormal uterine bleeding (AUB) is any form of uterine bleeding that is irregular in amount,
duration, or timing and is not related to regular menstrual bleeding. AUB can be anovulatory or
ovulatory but is commonly caused by anovulation. AUB also occurs with any condition that
gives rise to chronic anovulation associated with continuous estrogen production. Such
conditions include obesity, hyperthyroidism and hypothyroidism, polycystic ovarian syndrome,
and any of the endocrine conditions discussed in the sections on amenorrhea and infrequent
menstruation.
Breast conditions
Atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH) are the two most
common, with a risk factor 4 to 5 times greater for developing breast cancer
****BENIGN BREAST CONDITIONS****
Fibrocystic changes: most common (THEORY may be due to excess estrogen and deficient
progesterone in luteal phase)
Diagnosis: Steps in the workup of a breast lump may begin with ultrasonography to determine
whether it is fluid filled or solid. Fluid-filled cysts are aspirated, and the woman is monitored on
a routine basis for the development of other cysts. If the lump is solid, a mammogram is
obtained. A fine-needle aspiration (FNA) is performed, regardless of the woman’s age, to
determine the nature of the lump.
A low-fat, nutrient-dense diet with decreased saturated fat is advised, and sometimes, despite
lack of clear evidence, eliminating methylxanthines (colas, coffee, tea, chocolate) is also advised;
taking mild diuretics, and decreasing alcohol intake.
Fibroadenoma: Occasionally the woman with a fibroadenoma experiences tenderness in the
tumor during the menstrual cycle; Fibroadenomas do not increase in size in response to the
menstrual cycle as cysts do; They increase in size during pregnancy and decrease in size as the
woman ages
Diagnosis: past history and physical exam; Mammography, ultrasound, or magnetic resonance
imaging (MRI) helps determine the type of lesion; FNA (Fine needle aspiration) may be used to
determine underlying pathologic conditions;
Surgical excision for the severe symptoms cases.
Mammary duct ectasia: dilated ducts and nipple inversion (acquired, not congenital), most
commonly presents during the perimenopausal period, but not common post menopause.
Smoking and diabetes are risk factors
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Pathologically, the ducts are dilated with thick walls. Ducts fill with epithelial secretions
and common skin bacteria may enter the duct, causing mastitis. There is fibrotic stroma,
rupture, and leakage of secretion into surrounding tissue that results in inflammation and
fat necrosis.
s/s: pain, redness of the skin, nipple inversion, and greenish, thick and sticky nipple
discharge. The breast tissue is thickened and inflamed, suggestive of mastitisPain
meds and antibiotics, wear supportive bra, applying the heat, and sleep on the unaffected
side
A surgical incision and drainage are usually performed for an abscess.
Intraductal papilloma (30-50 y.o) is a rare benign condition that develops within the terminal
nipple ducts
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The papilloma is usually too small to be palpated, and the characteristic sign is
spontaneous unilateral nipple discharge that is serous, serosanguineous, or bloody
After eliminating the possibility of malignancy, the affected segments of the ducts and
breasts are surgically excised
Cellulitis (with or without abscess formation):
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Risk factors: obesity, large breasts, previous surgeries, radiation, sebaceous cysts
of the chest and axillae, smoking, and diabetes, nipple piercing
Common pathogens: S. aureus, MRSA.
S/S: painful, red inflamed skin that is usually thickened. It feels warm or hot to
touch
Diagnosis: Ultrasound images show a mixed fluid collection. If abscess is
present, it can be managed by percutaneous ultrasound aspiration or, if large
enough, incision and drainage
Tx: antibiotics
****MALIGNANT BREAST CONDITIONS****
Because of a higher rate of BRCA mutations, Ashkenazi Jewish women are at higher risk of
breast cancer. It is more common in Black women as compared with White women; and Black
women have a higher mortality rate due to breast cancer than Asian, Hispanic, and Native
American women.
Etiology of breast cancer and risk factors
Age, history, family history, genetic mutation in BRCA1 and BRCA2
Pathophysiology: Although breast cancer presents within the breast, it is, in fact, considered to
be a systemic disease because as it is growing in the breast, invasive tumors have the capability
of traveling elsewhere in the body. Tumors are classified by location in the breast and
histological type. Breast cancer is generally either ductal or lobular. By far the most frequently
occurring cancer of the breast is invasive ductal carcinoma
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Ductal carcinoma originates in the lactiferous ducts and invades surrounding breast
structures. The tumor is usually unilateral, not well delineated, solid, nonmobile, and
nontender.
Lobular carcinoma originates in the lobules of the breasts. This type of breast cancer
can be nonpalpable and appear smaller on imaging studies than its actual size.
The rate of breast cancer growth depends on the effects of estrogen and progesterone and
other prognostic factors such as its grade, Ki67 score (a proliferative marker), human
epidermal growth factor receptor 2 (HER2)/neu receptor status, and other variables
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To determine the likelihood of recurrence and metastasis, two genetic profile tests may be
performed (Oncotype DX and MammaPrint)
Clinical manifestations and diagnosis
When breast cancer is detected either as a palpable lump or ill-defined thickening in the
breast, it is usually painless. One might see nipple retraction, skin dimpling or skin changes
to the nipple, or redness with edema and pitting of the skin, which is suggestive of a locally
advanced and aggressive form of breast cancer
Screening:
Mammography remains the gold standard for breast cancer screening and early
detection
Ultrasound has become a valuable screening adjunct to mammography, especially for
women with significant breast density. It is cost-effective, noninvasive, and widely
available.
Ultrasound has been helpful in distinguishing between fluid-filled masses (cysts) and solid
masses (benign and malignant). It uses high-frequency sound waves to assess the breast
tissue and axillae
MRI: It may be useful in women with difficult-to-find masses, sometimes referred to as
occult breast cancers. MRI is indicated for women who have silicone implants, those at high
risk for breast cancer, and those with a history of breast cancer. One concern with MRI is that
although it helps find small, difficult-to-detect abnormalities, it has been found to lead to
more unnecessary mastectomies instead of lumpectomies with radiation.
Positron emission tomography (PET) scans, which are based on glucose uptake
metabolism, can help determine if breast cancer has spread to other parts of the body,
identifying metastatic disease.
Diagnosis: biopsy. When a suspicious finding on a mammogram is noted or a lump is
detected, diagnosis is confirmed by core needle biopsy (stereotactically or ultrasound-guided
core) or by needle localization biopsy
Surgery: include breast-conserving surgery (BCS such as lumpectomy) and mastectomy.
o BCS is used for the primary treatment of women with early-stage (I or II) breast
cancer. The criteria for recommending BCS are as follows: a tumor that is relatively
small compared to breast volume and will result in acceptable cosmetic outcome; no
previous breast radiation; no previous mantle field radiation (area includes neck,
chest, and underarm lymph nodes) as a youth; and/or no evidence of multicentric
disease
o Mastectomy is the removal of the breast, including the nipple and areola. Women
who are advised to have mastectomy instead of BCS are women who have:
• Had radiation to the breast • Multiple tumors in the breast occupying several
quadrants of the breast • Invasive or extensive DCIS that occupies a large area of the
breast tissue • A large tumor compared to breast volume
Since breast cancer cells can migrate through the lymphatic tissue, axillary node biopsies are part
of the surgical procedures. There are two types of node biopsies: axillary lymph node dissection
(ALND) and sentinel lymph node biopsy (SLNB).
Hormonal therapy: SERMs and aromatase inhibitors (AIs)
Tamoxifen, the oldest and longest used, is an oral antiestrogen medication that mimics
progesterone and estrogen. Tamoxifen attaches to the hormone receptors on cancer cells and
prevents natural hormones from attaching to the receptorsWhen tamoxifen fits into the
receptors, the cell is unable to growAdjuvant hormonal therapy with tamoxifen for 5 years is
recommended for most premenopausal women with breast cancer whose tumors are hormone
receptor positive
Chemotherapy: Treatment with chemotherapy or hormonal therapy, or a combination of the
two, often causes changes in reproductive function. Women receiving chemotherapy and their
partners must understand that chemotherapy can be teratogenic, that is, chemotherapy agents
can cause congenital birth defects women in childbearing age must use birth control (but oral
contraceptive is not recommended)
INFERTILITY
Spinnbarkeit: ability to stretch
Laparoscopic examination verifies normal development of internal genitals and absence of
adhesions, infections, endometriosis, and other lesions.
ESTROGEN:
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Estrogen stimulates growth of the breasts by inducing fat deposition in the breasts,
development of stromal tissue (i.e., increase in its amount and elasticity), and growth of
the extensive ductile system. Estrogen also increases the vascularity of breast tissue.