PMS, Contraception, and Infertility
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Transcript PMS, Contraception, and Infertility
TODAY’S TOPICS
Contraception
Infertility
Menstrual Disorders
Phases of the Menstrual Cycle
Proliferative Phase (Follicular) 6-14d
High
Ovulation
Secretory Phase (Luteal) 15-26d
High
Estrogen and FSHdevelop follicle
Progesterone, Decreasing Estrogen
Ischemic Phase 27-28d
Menstrual Phase 1-6d
The Menstrual Cycle
Olds, S. London, M., Ladewig,
P., Davidson, M. (2004).
Maternal-newborn nursing &
women’s health care.(7th ed.).
Upper Saddle River, NJ.:
Prentice Hall. (p. 211).
Contraception begins with Fertility
Awareness
Ovulation
Ovum can be fertilized w/in 48 hrs
Sperm viable for 72 hrs
Problem pinpointing ovulation
Basal Body Temperature (BBT)[chart]
Progesterone increases = BBT increases
Take temp when awakened
Temp drops .2-.3 F; 24-36 before ovulation
Rises .7-.8 after ovulation--sample
Contraception begins with Fertility
Awareness
Cervical Mucous (Spinbarkeit)
More
abundant, thin clear,
stretchy mucous at ovulation
Thickens and less amount until menses
Other Symptoms
Mittelschmertz
Increased
libido
Bearing Down Pain
Physiological Methods
Calendar
Keep
records for 6-8 months
18 days from end of SHORTEST cycle
11 days from end of LONGEST cycle
Abstain during “fertile” times
BBT—website with calendar
Billings Method
Barrier Methods
Male Condom
Hold onto ring when withdrawing
Female Condom
Diaphragm
Refit after each childbirth
Use with Contraceptive Jelly
Leave in for 6 hours AFTER intercourse
If repeat intercourse, use more spermicide
Cervical Cap
Leave in for 8-48 hours
Chemical Methods
IUD—Prevents fertilization
Mirena-5
years, SKYLA-3 yrs
Paragard -10 years
Risk of PID, Heavier periods (paragard),
perforation, dysmenorrhea
Teach to string after each menses
Spermicides
May
have to wait to dissolve
Reapply with repeat intercourse
Use with diaphragm/condom
Non-oxinol 9—Kills HIV and other
STD’s
Chemical Methods—BCP’s
Types
Combination P & E
Progesterone ONLY “minipill”
Phasic
Side effects (table 4-2, pg 63; 10th ed)
Estrogen effects: N/V, weight gain, headaches, breast
tenderness, etc.
Progesterone effects: acne, breast tenderness, ↓ libido,
depression, fatigue, hirsuitism, weight gain, etc.
Contraindications
Thrombophlebitis, CHD, Breast CA, SMOKER
Some antibiotics DECREASE effectiveness
Long-Acting Chemical Methods
Implanon
Lasts
up to 3 years
Flexible plastic rod the size of a matchstick that is
put under skin in the upper arm
Chief side effect: irregular bleeding
Depo-Provera
Injection
4 x / yr
Prolonged amennorhea or uterine bleeding
Newer Chemical Methods
Contraceptive Patch
ORTHO
EVRA
Contraceptive Ring
NuvaRing
A helpful website
http://www.ultimatebirthcontrol.com/
Emergency Contraception
Take 2 BCP’s at once and 2 more 12 hours later
Use within 72 hours after unprotected intercourse
Prevents implantation
Operative Sterilization
Male Vasectomy
Outpatient
81-91%
reversal
Ice for pain, swelling
NOT immediate
sterility—up to 36
ejaculations to rid
ducts of all sperm
Sperm count to verify
Female Tubal Ligation
Can
be done with C/sec
General Anesthesia or
epidural if done after
vaginal delivery
20 minutes
Less successful reversals
Outpatient Sterilization
Essure-small metallic
implant that is placed
into the fallopian
tubes under
hysteroscopic
guidance
Induces
scar tissue to
form over the implant,
blocking the fallopian
tube and preventing
fertilization of the egg
by the sperm
99.8% effective
Oral contraceptives
are often prescribed
at least one month
prior to insertion to
induce endometrial
atrophy and to
prevent an
undiagnosed
pregnancy
Paracervical blocks are given to
anesthetize the perineum
NSAIDs and Diazapam can be
given during the procedure to
minimize discomfort
Educate patients to use alternate
contraceptive methods until a
hysterosalpingogram is
performed 3 months after
placement to confirm complete
blockage of fallopian tubes
99.8% effective
Abortion
ElectivePerformed
at woman’s request
Therapeutic
performed for reasons
of maternal or fetal
health
1st trimester
Roe
v. Wade
2nd trimester
States
decide
RU-486
Combination of 2 drugs
Mifepristone is an anti-Progesterone drug that stops
the early pregnancy from growing.
Misoprostol is the second drug and causes the uterus
to contract and an early pregnancy to be expelled.
Procedure
Confirm Pregnancy Blood test or U/S
Take Mefipristone (1 pill)
2-4 days later, Take Misoprostol
Come back to office in 2 weeks—U/S to confirm
NO pregnancy
Side Effects
Abdominal cramping pain, bleeding, nausea,
vomiting, and diarrhea, which may be extreme in
some cases.
Dilatation and Curettage (D&C) may be needed
in rare cases.
Plan B Levonorgestrel
Emergency contraception-not effective if already
pregnant
Reduces
risk of pregnancy when take after unprotected
sex
With
No
in 72 hours after intercourse
prescription required for 17 years and older,
prescription needed 16 yrs and younger
Plan B
Levonorgestrel works by stopping ovulation,
fertilization, or implantation, depending on where a
woman is in her cycle.
Side effects
Nausea,
abdominal pain, fatigue, headache and
changes in menstural cycle
NURSE’S ROLE IN
BIRTH CONTROL COUNSELING
•Assess patient’s knowledge, lifestyle, preferences, any
cultural taboos or implications
•Take a thorough patient history to identify any factors
that put a patient at high risk for complications and rule
out certain contraceptives.
•Provide handouts, demonstration, discuss advantages and disadvantages
of each method,
•Allow time for questions and feedback
INFERTILITY
Inability of a couple to produce a living child as a result of a
failure to conceive or inability to carry the conceived child to a
viable state after 12 months of unrestricted sexual relations
Categories
Primary Infertility
Never
having
conceived a child
Secondary Infertility
Has
conceived by
cannot conceive again
or carry a pregnancy
to viability after 1
year of unrestricted
sexual relations
Causes of Infertility by Couple
Female Factor 50%
Male Factor
35%
Unexplained
10%
Other
5%
Causes of Infertility in Women
Endocrine Sources
Ovulatory
Dysfunction 40%
Anovulation
or oligo-ovulation
Hyperprolactinemia
Hyper- and hypo- thyroidism
Premature ovarian failure
Genetic Defects---Turner’s Syndrome (XO)
Excessive Exercise and Dieting
Polycystic Ovarian Syndrome Altered FSH:LH ratio
Severe Emotional Stress
Causes of Infertility in Women
Non-endocrine Causes
Tubal
& Uterine Factors 40%
Block
tubes (PID, endometriosis)
Uterine Fibroids or malformed uterus
Unexplained 10%
Other
10%
Causes of Infertility in Men
Sperm Factors
Too
few, Too slow, Too many malformed
Injury, mumps, high fever, radiation,
Substance abuse: ETOH, cocaine, marijuana, cigarettes
Meds: cimetidine, chemo, sulfas, erythromycin,
tetracycline
Causes of Infertility in Men
Endocrine Factors
Klinefelter’s
syndrome (XXY)
Low testosterone levels
Excessive Prolactin levels
Non-Endocrine Factors
Obstructed
Varicoceles
vas deferens
Female Fertility Work-Up
BBT
Cervical Mucous
Endometrial Biopsy adequacy
of secretory tissue in LUTEAL phase--effect
of progesterone by corpus luteum
7 days BEFORE onset of menses
Can have cramping afterwards
Female Fertility Work-Up
HystersalpingogramDye instilled in uterus—Watch flow through fallopian tubes
Moderate discomfort
Laparoscopy
General Anesthesia
6-8 months after Hysterosalpingogram
Referred shoulder pain
Evaluate for endometriosis, adhesions, tumors, cysts
Male Fertility Work-Up
Sperm adequacy tests
Count
Motility
Morphology
Abstain
for 2 days—Bring into lab within 1 hour after
collection
Couple Tests
Post-Coital Tests
1-2
days prior to expected ovulation
Couple has intercourse
Go to MD within 4-6 hours
Aspirate cervical mucous from os
Evaluate mucous/sperm
Motility
and Number
Infertility Trx--Medications
Pg 200-203; 10th edition
Clomid-Estrogen Antagonist (po)
Take
on days 5-9
Induces Ovulation
Pergonal, Humegon or Repronex (hMG)
IM
Direct
effect on pituitary,stimulate FSH/LH
Infertility Treatments/Medications
Fertinex, Follistim and Gonal F
purified
FSH given SQ
Start on day 2-4 of menstrual cycle
Watch growth of follicles via U/S and serum
estradiol levels
Give hCG IM when follicles/levels OK
Have intercourse within 2 days
Egg Retrieval
Infertility Trx
Artificial Insemination
1-2
days BEFORE ovulation
Fresh semen placed at cervical os
In-Vitro Fertilization (IVF)
Stimulate
ovum production—Harvest eggs
Sperm and Egg meet in Test tube
Fertilized ovum transferred into uterus
Infertility Trx
Gamete Intrafallopian Transfer (GIFT)
Sperm
and egg transferred separately into fallopian
tube where fertilization can occur
Go past cervical mucous
Zygote Introfallopian Transfer (ZIFT)
Fertilized
zygote transferred into fallopian tube and
then travels back into uterus to implant
Other Alternatives
Adoption
Surrogate
Nurse’s Role in Infertility Trx
Highly Sensitive Issue
Self-Esteem/Body Image
Marital Relations
Expensive
Menstrual Cycle & Disorders
Menarche
Age
at which menses begins
Usually about 13 y/o, range 10-16
Menopause
Time
when periods stop; 50-51 y/o
Initially periods are irregular, painless and
anovulatory—BUT can get pregnant
Peri-menopausal period
PreMenstrual Syndrome (PMS)
Affects 30-40% of all women
Three criteria need to be met
Symptoms
occur in the luteal phase (after ovulation and
4-10 days before menses starts)
About 1 week w/o symptoms in follicular phase
Symptoms sever enough to interfere with life
Characteristic Symptoms
Fluid Retention/
Bloating
Anxiety/Irritability
Agitation/
Arguementative
Depression/Crying
Lethargy
Panic Attacks
Accident Prone
Decreased
concentration
Food Cravings
Salt
& Sweets
Breast tenderness
Headaches/dizziness
Causes of PMS
Unknown
Interaction between Estrogen and Progesterone-Progesterone Deficiency
Prolactin & Prostaglandin Excess
? Role of Endorphins
Nutritional Deficiency—Mg ++
Treatments
Track symptoms
BCP’s, Progesterone
Prostaglandin Inhibitors
Efamol
Mefenamic
Acid 250mg/day in luteal phase
Danazol & Xanax less effective
Toxic Shock Syndrome
Pyrogenic exotoxins from Staph. Aureus
15-24 y/o, using tampons
Three Principal Clinical Manifestations
Sudden
onset high Fever > 102
HYPOtension, systolic < 90mm Hg
Rash—diffuse, macular, desquamation of palms and
soles
Other S/S
Treatment
Early dx is critical
IV fluid—trx dehydration
Antibiotics
Platelets
Meds for skin rash and hypotension
NURSING EDUCATION
Pg 104; 10th edition
“Client Self-Care—Prevention of TSS”
Amenorrhea
Primary
Absence
or Cessation
of periods
6
month cessation after
women has started
periods
Causes
Congenital
Obstructions
Hormone Imbalance
Secondary
Causes
Pregnancy/Lactation
Poor
Nutrition
Dysmenorrhea—Painful Periods
Primary
Pain
w/o pelvic
pathology
Incapacitate 2-3 days
Organic/pathological
Endometriosis,
PID,
ovarian cysts, myomas,
IUD
Cause
Prostaglandins
Vasopressin
Dx
U/S,
D&C, biopsy
Laparoscopy
Treatment
BCP’s
Secondary
& NSAID’s
Trx depends on cause
Endometriosis
Endometrial tissue outside the uterus ovary,
tubes, vaginal vault, abdomen
Tissue responds to hormonal changes of menstrual
cycle
Bleed,
inflammation, scarring, adhesions
3-10% of all women, 25-25% of infertile women,
28% of women with chronic pelvic pain
Cause of Endometriosis
Again—UNKNOWN
? Reflux of fallopian tube, retrograde
menstruation endometrial tissue cells go out into
abdominal cavity
Symptoms
Vary Greatly
Little disease Lots of Pain
Lots of disease Little Pain
Dysmennorhea
Chronic, non-cyclic pelvic pain
Dysparueunia
Diarrhea/Constipation
Infertility
Treatments
Medication
Lupron
& Synarel GnRH agonists
Danazol
Oral Contraceptives
Surgical
Laparoscopy
or Laparotomy
Total Abdominal Hysterectomy with Bilateral SalpingoOophorectome (TAH w/ BSO)
Nursing Assessment & Care
Gynecological History
Symptoms
Nursing Diagnoses
Anxiety;
Body Image, disturbances of Self-Image;
Knowledge Deficit, Pain
Encourage woman to avoid delaying pregnancy
if desired d/t increased risk of infertility.