CHP 4 MATERNITY

COMPLEMENTARY AND ALTERNATIVE THERAPIES

-No single treatment is universally recognized as effective, and many clients often turn to therapeutic approaches outside of conventional medicine. Many women use dietary supplements and herbal remedies for their menstrual health and bleeding disorders, though there has been little research to demonstrate their efficacy. Alternative treatments for treating PMDD include calcium supplementation, vitex agnus castus (chaste tree berry), Hypericum perforatum (St. John's wort), Angelica sinensis (dong quai), Paeonia lactiflora (Chinese peony), and cognitive, behavioral, and relaxation therapies. Some other alternative therapies include the use of yoga, magnesium, vitamin B6, evening primrose oil, ginkgo biloba, viburnum, dandelion, stinging nettle, burdock, raspberry leaf, and skullcap ---- ASSESSMENT More than 150 symptoms are assigned to PMS, but irritability; food cravings; mood swings; tearfulness; depression; sleep disturbances; edginess; headache; back pain; fatigue; bloating; edema of the face, abdominal area, and extremities; difficulty concentrating; binge eating; breast tenderness; tension; and dysphoria (a profound state of unease and anxiety) are the most prominent and consistently described ( Ask the woman to bring her list of symptoms to the next appointment. Symptoms can be categorized using the following:

CERVICAL MUCUS PRODUCTION

-The cervical mucus ovulation method is used to assess the character of the cervical mucus. Cervical mucus changes in consistency during the menstrual cycle and plays a vital role in fertilization of the egg. In the days preceding ovulation, fertile cervical mucus helps draw sperm up and into the fallopian tubes, where fertilization usually takes place. It also helps maintain the survival of sperm. As ovulation approaches, the mucus becomes more abundant, clear, slippery, and smooth; it can be stretched between two fingers without breaking. Under the influence of estrogen, this mucus looks like egg whites. It is called spinnbarkeit mucus -The cervical position can also be assessed to confirm changes in the cervical mucus at ovulation. Near ovulation, the cervix feels soft and is high and deep in the vagina, the os is slightly open, and the cervical mucus is copious and slippery (Hatcher et al., 2018). This method works because the woman becomes aware of her body changes that accompany ovulation. When she notices them, she abstains from sexual intercourse or uses another method to prevent pregnancy. Each woman is an individual, so each woman's fertile time of the month is unique and thus must be individually assessed and determined.

ASSESSING MALE FACTORS

-The man should abstain from sexual activity for 2 to 5 days before giving the sample. For a semen examination, the man is asked to produce a specimen by ejaculating into a specimen container and delivering it to the laboratory for analysis within 1 hour. When the specimen is brought to the laboratory, it is analyzed for volume, viscosity, number of sperm, sperm viability, motility, and sperm shape. If semen parameters are normal, no further male evaluation is necessary

TRANSDERMAL PATCH

-The transdermal patch is a 2-in square adhesive that contains ethinyl estradiol and norelgestromin. These substances are absorbed through the skin when placed on the lower abdomen, upper outer arm, buttocks, or upper torso (avoiding the breasts). The patch is applied weekly for 3 weeks followed by a patch-free week when withdrawal bleeding occurs. The patch delivers continuous levels of progesterone and estrogen. Transdermal absorption allows the drug to enter the bloodstream directly, avoiding rapid inactivation in the liver known as first-pass metabolism. Because estrogen and progesterone are metabolized by liver enzymes, avoiding first-pass metabolism was thought to reduce adverse effects. However, recent evidence suggests that the risk of venous -thrombosis and embolism is increased with the patch but still lower than the risk of venous thromboembolism during pregnancy (Peachman, 2018). Additional studies are underway to understand the clinical significance of these findings, but in the interim, nurses need to focus on ongoing risk assessment and should be prepared to discuss current research findings with clients. Adherence to the regimen of combination contraceptive patch use has been shown to be significantly greater than adherence with OCs. In addition, research suggests that overweight and obese women exceeding 198 lb should be advised of the potentially decreased effectiveness of the patch and increase incidence of venous thromboembolism and weight gain (Patel & Carey, 2018). The patch provides combination hormone therapy with a side effect profile similar to that of OCs

THERPUTIC

-Therapeutic interventions for PMS and PMDD address the symptoms since the exact causes of this condition are still unknown. Treatments may include vitamin supplements, dietary changes, exercise, lifestyle changes, and medications (Box 4.2). Pharmacotherapies (particularly SSRIs and serotonin-norepinephrine reuptake inhibitors) represent the first-line treatment for the mood and behavioral symptoms of PMDD. Other medications may include other antidepressant and antianxiety drugs, diuretics, antiinflammatory medications, analgesics, synthetic androgen agents, OCs, and GnRH agonists to regulate menses. Unlike the approach to the treatment of depression, antidepressants need not be given daily, but may be effective when used cyclically, only in the luteal phase, or even limited to the duration of the symptoms. TX Treatment Options for PMS and PMDD • Lifestyle changes • Reduce stress • Exercise three to five times a week • Eat a balanced diet and increase water intake • Decrease caffeine intake • Stop smoking and limit the intake of alcohol • Attend a PMS or women's support group • Vitamin and mineral supplements • Multivitamin daily • Vitamin E, 400 units daily • Calcium, 1,200 to 1,600 mg daily • Magnesium, 200 to 400 mg daily • Medications • NSAIDs taken a week prior to menses • OCs (low dose) • Antidepressants (SSRIs) • Anxiolytics (taken during luteal phase) • Diuretics to remove excess fluid • Progestins • GnRH agonists • Danazol (androgen hormone inhibits estrogen production)

UROGENTIAL CHANGE

-Vaginal atrophy occurs during menopause because of declining estrogen levels. These changes include thinning of the vaginal walls, an increase in pH, irritation, increased susceptibility to infection, dyspareunia (difficult or painful sexual intercourse), loss of lubrication with intercourse, vaginal dryness, and a decrease in sexual desire related to these changes. Decreased estrogen levels can also influence a woman's sexual function as well. Delayed clitoral reaction, decreased vaginal lubrication, diminished circulatory response during sexual stimulation, and reduced contractions during orgasm have all been linked to low estrogen levels. Genitourinary tract disorders susceptible to estrogen deficiency are progressive and worsen over time ( -Management of these changes might include the use of estrogen vaginal tablets (Vagifem) or Premarin cream; Estring, an estrogen-releasing vaginal ring that lasts for months; testosterone patches; and over-the-counter moisturizers and lubricants (Astroglide) (Skidmore-Roth, 2020). A positive outlook on sexuality and a supportive partner are also needed to make the sexual experience enjoyable and fulfilling. Nurses can improve the sexual health and quality of life in menopausal women by educating them about their symptoms and offering them choices about managing them. ---------- Preventing and Managing Osteoporosis Menopause predisposes women to osteoporosis due to declining estrogen levels. This results in a decrease in bone mineral density and an increase in fractures. Osteoporosis has been recognized as a significant worldwide public health problem. As the world's population ages, both in the United States and internationally, the prevalence of osteoporosis is expected to increase significantly. Osteoporosis is the state of diminished bone density. This disorder is a syst

STANDARD DAY METHOD

-Women with menstrual cycles between 26 and 32 days long can use the SDM to prevent pregnancy by avoiding unprotected intercourse on days 8 through 19 of their cycles. Most SDM users utilize a visual aid—CycleBeads—to assist their correct use of SDM. SDM identifies the 12-day "fertile window" of a woman's menstrual cycle. These 12 days take into account the lifespan of the women's egg (about 24 hours) and the viability of the sperm (about 5 days) as well as the variation in the actual timing of ovulation from one cycle to another. -With the 2-day method, women observe the presence or absence of cervical secretions by examining toilet paper or underwear or by monitoring their physical sensations. Every day, the woman asks two simple questions: "Did I note any secretions yesterday?" and "Did I note any secretions today?" If the answer to either question is yes, she considers herself fertile and avoids unprotected intercourse. If the answers are no, she is unlikely to become pregnant from unprotected intercourse on that day -To help women keep track of the days on which they should avoid unprotected intercourse, a string of 32 color-coded beads called CycleBeads can be is used, with each bead representing a day of the menstrual cycle. Starting with the red bead, which represents the first day of her menstrual period, the woman moves a small rubber ring one bead each day. The brown beads are the days when pregnancy is unlikely, and the white beads represent fertile days (Rodriguez, 2018). This method has been used in underdeveloped countries for women with limited educational resources

LARGOSCOPY

A laparoscopy is usually performed early in the menstrual cycle. It is not part of the routine infertility evaluation. It is used when abnormalities are found on the ultrasound or the hysterosalpingogram or when endometriosis is suspected. Because of the added risks of surgery, the need for anesthesia, and operative costs, it is only used when clearly indicated. During the procedure, an endoscope is inserted through a small incision in the anterior abdominal wall. Visualization of the peritoneal cavity in an infertile woman may reveal endometriosis, pelvic adhesions, tubal occlusion, fibroids, or polycystic ovaries CONTRACEPTION The terms "contraception," "family planning," and "birth control" are used interchangeably when referring to the intentional prevention of pregnancy through the use of various devices, agents, drugs, sexual practices, and surgical procedures. In the United States, there are over 68 million women in their childbearing years (between the ages of 15 and 44), and throughout those years, a variety of contraceptive methods may be used. Studies have shown that 98% of sexually active women in the United States report having used at least one form of contraception; however, despite the widespread use of contraceptives, almost half of all pregnancies in the United States are unintended, accounting for a higher unintended pregnancy rate than any other Western country -n addition to unwanted pregnancies, some contraceptives also help prevent transmission of STIs and human immunodeficiency virus (HIV). The UN report also shows that over 40,000 people in the United States become infected with HIV every year. -Contraceptive methods can be grouped according to their estimated effectiveness in preventing pregnancy as follows: Most effective methods: male and female sterilization, intrauterine contr

ABORTION

Abortion is defined as the expulsion of an embryo or fetus before it is viable (Webster et al., 2018). The practice of abortion is legal in the United States. Abortion can be a medical or surgical procedure. The purpose of abortion is to terminate a pregnancy. One in four women will end a pregnancy by abortion at some time in their reproductive lives. SURGICAL ABORTION Surgical Abortion Two types of surgical abortion are available: vacuum aspiration or dilation and evacuation (D&C). Method selection is based on gestational age. It is an ambulatory procedure done under local anesthesia. The cervix is dilated prior to surgery and then the products of conception are removed by suction evacuation. The uterus may gently be scraped by curettage to make sure that it is empty. The entire procedure lasts about 10 minutes. The overall risk of complications is less than 1% for surgical termination (Magowan et al., 2019). The major risks and complications in the first trimester are infection, retained tissue or hemorrhage, uterine perforation, retained products of conception, or cervical tear (Webster et al., 2018). For women whose blood is Rh-negative, RhoGAM is indicated prior to the start of either medical or surgical termination. MEDICAL ABORTION Medical Abortion Medical abortions are achieved through administration of medication either vaginally or orally. The administration of medication occurs in the clinic or doctor's office, may require more than one office visit, and costs between $500 and $800 (Planned Parenthood, 2020b). The most common regimen in the United States involves the use of two different medications, mifepristone and misoprostol. Mifepristone blocks progesterone, which is essential to the development of pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and

AMNEROHEA

Amenorrhea simply means absence of menses. It is a symptom, not a diagnosis. Amenorrhea is normal in prepubertal, pregnant, postpartum, and postmenopausal females. It usually indicates a defect somewhere in the hypothalamic-pituitary-ovarian-uterine axis to induce cyclic changes in the endometrium that normally result in menses. All of these parts of the body must function properly and in harmony for a menstrual cycle to occur. Amenorrhea is categorized as either primary or secondary. Primary amenorrhea is defined as either the: absence of menses by age 15, with absence of growth and development of secondary sexual characteristics; or absence of menses by age 16, with normal development of secondary sexual characteristics Nurses need to consider the causes of amenorrhea as due to one of four factors: ovarian failure; congenital absence of the uterus and vagina; GnRH deficiency; or constitutional delay of puberty. Outflow area problems are obstructive in nature and can be found on physical exam, while ovarian, pituitary, and central nervous system problems involve disruptions in the hypothalamic-pituitary-ovarian-uterine axis that controls the neuroendocrine processes required for a normal menstrual cycle and are generally found through laboratory analysi

ASSESSMENT N MANGEMENT

Assess for clinical manifestations of AUB, which commonly include vaginal bleeding between periods, irregular menstrual cycles (usually less than 28 days between cycles), infertility, mood swings, hot flashes, vaginal tenderness, variable menstrual flow ranging from scanty to profuse, obesity, acne, stress, anorexia, thyroid disease, and diabetes. Signs of polycystic ovary syndrome might be present, because it is associated with unopposed estrogen stimulation, elevated androgen levels, and insulin resistance, and it is a common cause of anovulation (Azziz, 2018). Measure orthostatic blood pressure and orthostatic pulse; a drop in pressure or pulse rate may occur with anemia. With the nurse assisting, the health care provider performs a pelvic examination to identify any structural abnormalities. Nursing Management Educate the client about normal menstrual cycles and the possible reasons for her abnormal pattern. Inform the woman about treatment options. Do not simply encourage the woman to "live with it." Instruct the client about any prescribed medications and potential side effects. For example, if high-dose estrogens are prescribed, the woman may experience nausea. Teach her to take antiemetics as prescribed and encourage her to eat small, frequent meals to alleviate nausea. Adequate follow-up and evaluation are essential for women who do not respond to medical management

S/S

A—Angina (chest pain) B—Breathlessness C—Chronic fatigue D—Dizziness E—Edema of hands and feet F—Fluttering of the heart G—Gastric upset H—Heavy pain in back and shoulders ---------------------------- Lifestyle and medical history factors such as the following play a major role: Smoking Obesity High-fat diet Sedentary lifestyle High cholesterol levels Family history of CVD Hypertension Apple-shaped body Diabetes -Two of the major risk factors for coronary heart disease are hypertension and dyslipidemia. Both are modifiable and can be prevented by lifestyle changes and if needed, controlled by medication. This is why prevention is essential. In addition, women who experience early menopause lose the protection afforded by endogenous estrogen to the cardiac system and are at greater risk for more extensive atherosclerosis. Major preventive strategies include a healthy diet, increased activity, exercise, smoking cessation, decreased alcohol intake, and weight reduction.

S/S

A—anxiety: difficulty sleeping, tenseness, mood swings, and clumsiness C—craving: cravings for sweets, salty foods, chocolate D—depression: feelings of low self-esteem, anger, dysphoria H—hydration: weight gain, abdominal bloating, breast tenderness, ankle swelling O—other: hot flashes or cold sweats, nausea, change in bowel habits, aches or pains, dysmenorrhea, acne breakout The ACOG diagnostic criteria for PMS include at least one of the following affective and somatic symptoms during the 5 days before menses in each of the three previous cycles: Affective symptoms: depression, angry outbursts, irritability, anxiety Somatic symptoms: breast tenderness, abdominal bloating, edema, headache Symptoms relieved from days four to 13 of the menstrual cycle In PMDD, the main symptoms are mood disruption such as depression, sadness, anxiety, tension, and persistent anger or irritability. Physical symptoms such as headache, joint and muscle pain, lack of energy, bloating, and breast tenderness are also present (Appleton, 2018). It is estimated that up to 75% of reproductive-age women experience premenstrual symptoms that meet the ACOG criteria for PMS and up to 8% meet the diagnostic criteria for PMDD Affective lability: sadness, tearfulness, irritability Anxiety and tension Persistent or marked anger or irritability Depressed mood, feelings of hopelessness Difficulty concentrating Sleep difficulties Increased or decreased appetite Increased or decreased sexual desire Chronic fatigue Headache Constipation or diarrhea Breast swelling and tenderness (

Tips for Maintaining a Healthy Lifestyle

Balance energy expenditure with energy intake to maintain ideal weight range. • Modify your diet to maintain ideal weight to avoid becoming overweight. • Avoid excessive use of alcohol and mood-altering or sedative drugs. • Avoid cigarette smoking to prevent cardiovascular disease and lung cancer. • Identify areas of emotional stress and seek assistance to resolve them. • Consume adequate fiber to promote regularity • Balance work, recreation, and rest to reduce anxiety and stress in life. • Maintain a positive outlook regarding any diagnoses and prognoses. • Protect yourself from too much sun exposure. • Participate in ongoing care and screenings to monitor any medical conditions. • Maintain bone density through: • Calcium intake (1,200 to 1,600 mg daily) • Vitamin D (600 to 1,000 IU/daily) • Weight-bearing exercise (30 minutes or more daily) • Hormone therapy (HT) for low-risk wom

BARRIER METHODS

Barrier contraceptives are physical or chemical devices that prevent pregnancy by preventing the sperm from reaching the ovum. Mechanical barriers include condoms, diaphragms, cervical caps, and sponges. These devices are placed over the penis or cervix to physically obstruct the passage of sperm through the cervix. Chemical barriers called spermicides may be used along with mechanical barrier devices. They come in creams, jellies, foam, suppositories, and vaginal films. They chemically destroy the sperm in the vagina. These contraceptives are called barrier methods because they not only provide a physical barrier for sperm but also protect against STIs. Since the HIV/AIDS epidemic started in the early 1980s, these methods have become extremely popular. Progress has been made in society's reaction to condom use as a disease prevention device now and not just as a contraceptive (

BODY SYSTEMS

Brain and central nervous system: hot flashes, disturbed sleep, mood, and memory problems Cardiovascular: lower levels of high-density lipoprotein (HDL) and increased risk of CVD Skeletal: rapid loss of bone density that increases the risk of osteoporosis Breasts: replacement of duct and glandular tissues by fat Genitourinary: vaginal dryness, stress incontinence, cystitis Gastrointestinal: less absorption of calcium from food, increasing the risk for fractures Integumentary: dry, thin skin and decreased collagen levels Body shape: more abdominal fat; waist size that swells relative to hips -Many women consider nonhormonal therapies such as bisphosphonates and selective estrogen receptor modulators (SERMs). Consider weight-bearing exercises, calcium, vitamin D, smoking cessation, and avoidance of alcohol to treat or prevent osteoporosis. Regular breast examinations and mammograms are essential. Local estrogen creams can be used for vaginal atrophy. Many women consider herbal therapies for symptoms, though none have been validated by rigorous research studies -ACOG has reaffirmed guidelines on treating menopausal symptoms. Their recommendations include: systemic HT with estrogen or estrogen plus progestin as the most effective approach for treating vasomotor symptoms; the lowest effective dose for the shortest duration is the best regimen; thromboembolic disease and breast cancer are risks for combined systemic HT; and local estrogen therapy is advised for isolated atrophic vaginal symptoms

Common diagnostic tests that may be ordered to determine the cause of dysmenorrhea can include:

Complete blood count to rule out anemia Urinalysis to rule out a bladder infection Pregnancy test (hCG level) to rule out pregnancy Cervical culture to exclude STI Erythrocyte sedimentation rate to detect an inflammatory process Stool guaiac test to exclude gastrointestinal bleeding or disorders Pelvic and/or vaginal ultrasound to detect pelvic masses or cysts Diagnostic laparoscopy and/or laparotomy to visualize pathology that may account for the symptoms NURSING MANGEMENT Educating the client about the normal events of the menstrual cycle and the etiology of her pain is paramount in achieving a successful outcome. Although dysmenorrhea itself is not life threatening, it can have a profound negative impact on a woman's day-to-day life. The nurse should keep this in mind and not minimize this condition. Explaining the normal menstrual cycle will teach the woman the correct terms to use so she can communicate her symptoms more accurately; this will also help dispel myths. Provide the woman with monthly graphs, charts, or apps to record menses, the onset of pain, the timing of medication, relief afforded, and coping strategies used. This involves the woman in her care and provides objective information so therapy can be modified if necessary. Educate women about the associated risk factors for dysmenorrhea which include attempts to lose weight, depression or anxiety, disruption of social networks, heavy menses, nulliparity, and smoking -The nurse should explain in detail the dosing regimen and the side effects of the medication therapy selected. Commonly prescribed drugs include NSAIDs such as ibuprofen (Motrin, Advil) or naproxen (Naprosyn). These drugs alleviate dysmenorrhea symptoms by decreasing intrauterine pressure and inhibiting prostaglandin synthesis, thus reducing pain (Ritter et al., 2020). The primary goal

Education and Counseling of Women Using Injectable Contraceptives

Consume a diet high in calcium and vitamin D to prevent bone mineral loss. • Know the conditions that need to be reported to the health care provider: • Significant headaches • Abnormal uterine bleeding • Depression • Severe abdominal pain • Any infection present at injection site

ABNROMAL UTERINE BLEEDING

Disturbances of menstrual bleeding manifest in a wide range of presentations. Abnormal uterine bleeding (AUB) is the umbrella term used to describe any deviation from normal menstruation or from a normal menstrual cycle pattern. It can occur in women of any age with a prevalence of 10% to 30% among women of reproductive age (Wouk & Helton, 2019). The key characteristics are that regularity, frequency, volume or heaviness of flow, and duration of flow are abnormal, but each of these may exhibit considerable variability. THese may exhibit considerable variability. AUB is a disorder that occurs most frequently in women at the beginning and end of their reproductive years. It is common and somewhat debilitating in women of reproductive age. AUB is defined as painless endometrial bleeding that is prolonged, excessive, and irregular, and not attributed to any identified underlying structural or systemic disease. The International Federation of Gynecology and Obstetrics (FIGO) recommends the use of the term "AUB" to describe any aberration of menstrual volume, regulation, duration, and/or frequency in a women who isn't pregnant. FIGO also recommends to discard such terminology as "menorrhagia," "metrorrhagia," and "dysfunctional uterine bleeding," as they are controversial, confusing, and poorly defined -AUB is frequently associated with anovulatory cycles, which are common for the first year after menarche and associated with immaturity of the hypothalamic-pituitary-ovarian axis. It also occurs later in life as women approach menopause and experience irregular menstrual cycles. The pathophysiology of AUB is related to a hormone disturbance. With anovulation, estrogen levels rise as usual in the early phase of the menstrual cycle. In the absence of ovulation, a corpus luteum never forms and progesterone

DYSMONORHEA

Dysmenorrhea Dysmenorrhea refers to painful menstruation and is a highly prevalent problem among menstruating women. This condition has also been termed cyclic perimenstrual pain. Usually pain starts along with the start of bleeding and lasts for 48 to 72 hours (Smith, 2018). The term dysmenorrhea is derived from the Greek words dys, meaning "difficult, painful, or abnormal," and rrhea, meaning "flow." Etiology Primary dysmenorrhea refers to painful menstrual bleeding in the absence of any identified underlying pelvic pathology. It is caused by increased prostaglandin production by the endometrium in an ovulatory cycle. This hormone causes contraction of the uterus, and levels tend to be higher in women with severe menstrual pain than in women who experience mild or no menstrual pain. Dysmenorrhea is caused by the activation of the prostaglandin and leukotriene cascade in the uterine wall. These levels are highest during the first 2 days of menses, when symptoms peak (Fulghesu, 2018). This results in increased rhythmic uterine contractions from vasoconstriction of the small vessels of the uterine wall. This condition usually begins within a few years of the onset of ovulatory cycles at menarche. Secondary dysmenorrhea is painful menstruation due to pelvic or uterine pathology. It may be caused by endometriosis, pelvic adhesions, adenomyosis, fibroids, pelvic inflammatory disease (PID), an intrauterine system, cervical stenosis, or congenital uterine or vaginal abnormalities. Adenomyosis involves the ingrowth of tissue similar to that of the endometrium into the uterine musculature. Endometriosis involves ectopic implantation of tissue similar to that of the endometrium in other parts of the pelvis and throughout the body. Endometriosis is the most common cause of secondary dysmenorrhea and is associated with pa

MANGEMENT

Encourage women to eat a balanced diet that includes nutrient-rich foods to avoid hypoglycemia and associated mood swings. Encourage all women to participate in aerobic exercise three times a week to promote a sense of well-being, decrease fatigue, and reduce stress. Administer calcium (1,200 to 1,600 mg/day), magnesium (400 to 800 mg/day), and vitamin B6 (50 to 100 mg/day) as prescribed. In some studies, these nutrients have been shown to decrease the intensity of PMS symptoms. NSAIDs may be useful for painful physical symptoms, and spironolactone (Aldactone) may help with bloating and water retention. Herbs such as vitex agnus castus (chaste tree berry), evening primrose, and SAM-e (a dietary supplement used to enhance mood) may be recommended; though not harmful unless the woman has a contraindication, not all herbs have enough clinical or research evidence to document their efficacy. Nutritional treatments include a diet low in salt, alcohol, caffeine, and sugar -------------- Explain to the client the relationship between cyclic estrogen fluctuation and changes in levels of serotonin levels and how the different management strategies help maintains serotonin levels, thus improving mood symptoms. It is important to rule out other conditions that might cause erratic or dysphoric behavior. If the initial treatment regimen does not work, explain to the woman that she should return for further testing. Behavioral counseling and stress management might help women regain control during these stressful periods. Reassuring the woman that support and help are available through many community resources and support groups can be instrumental in her acceptance of this monthly disorder. Nurses can be a calming force for many women experiencing PMS or PMDD. A holistic approach, including lifestyle modifications, pharmacotherapy,

ENDOMETRIOSIS

Endometriosis is a complex syndrome characterized by an estrogen-dominant chronic inflammatory process that affects primarily pelvic tissues, including the ovaries. It is caused when tissue similar to that of the endometrium implants outside of the uterus, most commonly throughout the abdominal cavity -Endometriosis tissue is commonly found attached to the ovaries, fallopian tubes, the outer surface of the uterus, the bowels, the area between the vagina and the rectum (rectovaginal septum), and the pelvic side wall (Fig. 4.1) though lesions have been found in locations as far from the uterus as the brain. The places where the tissue attaches are called implants, or lesions. These lesions create their own blood supply and respond to hormones released during the menstrual cycle in the same way as the endometrial lining within the uterus. -At the beginning of the menstrual cycle, when the lining of the uterus is shed and menstrual bleeding begins, endometriosis implants swell and bleed as well. In short, the woman with endometriosis experiences several "mini-periods" throughout her abdomen, wherever this endometriosis tissue exists. In addition to cyclic bleeding outside the uterus, pelvic pain that can be debilitating, scarring, and adhesion formation occur throughout the pelvis. Symptoms begin as early as adolescence and may settle after menopause.

MEDICATIONS

Estrogens: cause vasospasm of the uterine arteries to decrease bleeding. Progestins: used to stabilize an estrogen-primed endometrium. OCs: regulate the cycle and suppress the endometrium. NSAIDs: inhibit prostaglandins in ovulatory menstrual cycles. Progesterone-releasing IUSs: suppress endometrial growth. Androgens: create a high-androgen/low-estrogen environment that inhibits endometrial growth. Antifibrinolytic drugs: (tranexamic acid) prevent fibrin degradation to reduce bleeding. Iron replacement therapy: replenish iron stores lost during heavy bleeding. -If the client does not respond to medical therapy, surgical intervention might include dilation and curettage (D&C), endometrial ablation, uterine artery embolization, or hysterectomy. Surgery should be considered for women for whom medical treatment has failed, cannot be tolerated, or is contraindicated (Oyelowo & Johnson, 2018). Endometrial ablation is an alternative to hysterectomy, but both would only be for the woman who no longer desires fertility as both procedures can cause infertility

RISK FACTORS

Etiology and Risk Factors It is not currently known why endometriosis tissue implants and grows in other parts of the body. Several theories exist, but to date none has been scientifically proven. However, several factors tend to be correlated with a diagnosis of endometriosis: The aging process Lean body size Smoking or exposure to second-hand smoke Family history of endometriosis in a first-degree relative Short menstrual cycle (less than 28 days) Long menstrual flow (more than 1 week) High dietary fat consumption Infertility Young age of menarche (younger than 12) Few (one or two) or no pregnancies

MANGMENT OF MENOPOAUSE

Evidence-based interventions include lifestyle modifications, risk management therapies, and preventive drug interventions, such as: Participate actively in maintaining health. Stay current on health screenings and vaccinations. Exercise regularly to prevent CVD and osteoporosis. Take supplemental calcium and eat appropriately to prevent osteoporosis. Stop smoking to prevent lung and heart disease. Reduce caffeine and alcohol intake to prevent osteoporosis. Monitor blood pressure, lipids, and diabetes (drug therapy management). Use low-dose aspirin to prevent blood clots. Reduce dietary intake of fat, cholesterol, and sodium to prevent CVD. Maintain a healthy weight for body frame. Perform breast self-examinations for breast awareness. Control stress to prevent depression

Risk factors for infertility in men include:

Exposure to toxic substances (lead, mercury, x-rays, chemotherapy) Cigarette or marijuana smoke Diabetes Heavy alcohol consumption Use of prescription drugs for ulcers or psoriasis Exposure of the genitals to high temperatures (hot tubs or saunas) Hernia repair Cardiovascular disease Obesity associated with decreased sperm quality Cushing syndrome Frequent long-distance cycling or running STIs Undescended testicles (cryptorchidism) Mumps after puberty (

TX FOR UNFERTILITY

Fertility Drugs Clomiphene citrate (Clomid) A nonsteroidal synthetic antiestrogen used to induce ovulation. Clomid is typically discontinued after three cycles of use. Nurse can advise the couple to have intercourse every other day for 1 wk starting after day 5 of medication. Human menopausal gonadotropin (HMG) (Pergonal) Induces ovulation by direct stimulation of ovarian follicle Same as above Artificial insemination The insertion of a prepared semen sample into the cervical os or intrauterine cavity Enables sperm to be deposited closer to improve chances of conception Husband or donor sperm can be used. Nurse needs to advise couple that the procedure might need to be repeated if not successful the first time. In vitro fertilization (IVF) Oocytes are fertilized in the lab and transferred to the uterus. Usually indicated for tubal obstruction, endometriosis, pelvic adhesions, and low sperm counts Nurse advises woman to take medication to stimulate ovulation so the mature ovum can be retrieved by needle aspiration. Gamete intrafallopian transfer (GIFT) Oocytes and sperm are combined and immediately placed in the fallopian tube so fertilization can occur naturally. Requires laparoscopy and general anesthesia, which increases risk Nurse needs to inform couple of risks and have consent signed. Intracytoplasmic sperm injection (ICSI) One sperm is injected into the cytoplasm of the oocyte to fertilize it. Indicated for male factor infertility Nurse needs to inform the male that sperm will be aspirated by a needle through the skin into the epididymis. Donor oocytes or sperm Eggs or sperm are retrieved from a donor, and the eggs are inseminated; resulting embryos are transferred via IVF. Recommended for women older than 40 yrs and those with poor-quality eggs. Nurse needs to support couple in their ethical/religious discussion

Fertility Awareness-Based Methods

Fertility awareness methods are based on identifying fertile days in a woman's cycle and avoiding sexual intercourse during that time. FAMs use physical signs and symptoms that change with hormone fluctuations throughout a woman's menstrual cycle to predict a woman's fertility. Ovulation occurs on one day during each menstrual cycle, and the several days preceding ovulation are when intercourse is most likely to result in pregnancy. Collectively, the potentially fertile days up to and including the -The unifying theme of FAMs is that a woman can reduce her chance of pregnancy by abstaining from coitus or using barrier methods during times of fertility. These methods require couples to take an active role in preventing pregnancy through their sexual behaviors, and women need to have regular menstrual cycles for it to be effective. Couples agree to practice certain techniques, use calculations, and be observant of the fertile and the nonfertile periods in a monthly menstrual cycle. Using these methods for birth control requires a strong commitment from both partners. The normal physiologic changes caused by hormonal fluctuations during the menstrual cycle can be observed and charted. This information can then be used to avoid or promote pregnancy --A single ovum is released from the ovary 14 days before the next menstrual period. It lives approximately 24 hours. Women using this method must have regular menstrual cycles for it to be effective. Sperm can live up to 5 days after intercourse. The fertile period during the menstrual cycle is thus approximately 6 days—3 days before and 3 days after ovulation. Because body changes start to occur before ovulation, the woman can become aware of them and not have intercourse on these days or use another method to prevent pregnancy. The exact time of ovulation cannot be d

HOME OVULATION KIT

Home ovulation predictor kits contain monoclonal antibodies specific for LH and use an enzyme-linked immunosorbent assay (ELISA) test to determine the amount of LH present in the urine. A significant color change from baseline indicates the LH surge and presumably the most fertile day of the month for the woman. CLOMIPHENE CITRATE CHALLENGE TEST The clomiphene citrate challenge test is used to assess a woman's ovarian reserve (ability of her eggs to become fertilized). FSH levels are drawn on cycle day 3 and on cycle day 10 after the woman has taken 100 mg clomiphene citrate on cycle days 5 through 9. If the FSH level is greater than 15, the result is considered abnormal and the likelihood of conception with her own eggs is low HYSTEROSALPINGOGRAPHY Hysterosalpingography (HSG) is the gold standard in assessing patency (being open and unobstructed) of the fallopian tubes. Fallopian tube obstruction is among the most common causes of female factor infertility. Ultrasonography and magnetic resonance imaging (MRI) are used in this assessment. In hysterosalpingography, 3 to 10 mL of an opaque oil-based contrast medium is slowly injected through a catheter into the endocervical canal so that the uterus and tubes can be visualized during fluoroscopy and radiography. If the fallopian tubes are patent, the dye will ascend upward to distend the uterus and the tubes and will spill out into the peritoneal cavit

Common Symptoms of Menopause

Hot flashes or flushes of the head and neck • Dryness in the eyes and vagina • Personality changes • Anxiety and/or depression • Loss of libido • Decreased lubrication • Weight gain and water retention • Night sweats • Atrophic changes—loss of elasticity of vaginal tissues • Fatigue • Irritability • Poor self-esteem • Insomnia • Stress incontinence • Heart palpitations

INJECTABLE CONTRACEPTIVE

INJECTABLE CONTRACERPTIVE Depo-Provera is the trade name for a 3-month intramuscular injectable of a progesterone-only contraceptive that works at the hypothalamic/pituitary level to stop the hormonal cycle. Depo-Provera works by suppressing ovulation and the production of FSH and LH by the pituitary gland, increasing the viscosity of cervical mucus and causing endometrial atrophy. A single injection of 150 mg into the buttocks acts like other progestin-only products to prevent pregnancy for 3 months at a time (Fig. 4.13). The primary side effects of Depo-Provera are menstrual cycle disturbances, depression, acne, weight gain, and loss of bone mineral density. It should also be noted that cycles may not be restored fully for up to 9 months following the last Depo-Provera injection. -Recent clinical studies have raised concerns about Depo-Provera's impact on bone mineral density. This evidence has prompted the manufacturer and the FDA to issue a warning about the long-term use (over 2 years) of Depo-Provera and bone loss (Webster et al., 2018). It is not entirely clear if this loss is reversible because there have not been any long-term prospective studies in current and past users.

WITHDRAWL

In coitus interruptus, also known as withdrawal, a man controls his ejaculation during sexual intercourse and ejaculates outside the vagina. It is better known colloquially as "pulling out." It is one of the oldest and most widely used means of preventing pregnancy in the world and also one of the least effective methods for preventing pregnancy (Hatcher et al., 2018). The problem with this method is that the first few drops of the true ejaculate contain the greatest concentration of sperm, and if some pre-ejaculatory fluid escapes from the urethra before orgasm, conception may result. The typical failure rate is estimated at 18% to 22% (Jordan et al., 2019). This method requires that the woman rely solely on the cooperation and judgment of the man. --------- Lactational Amenorrhea Method The lactational amenorrhea method (LAM) is an effective temporary method of contraception used by breastfeeding mothers. It relies on physiologic changes associated with breastfeeding for contraception. Continuous breastfeeding can usually postpone ovulation and thus prevent pregnancy. Breastfeeding stimulates the hormone prolactin, which is necessary for milk production, and it also inhibits the release of another hormone, gonadotropin, which is necessary for ovulation. Breastfeeding as a contraceptive method can be fairly effective for up to 6 months after giving birth if: the woman has not had a menses since she gave birth. the infant is younger than 6 months of age. the woman breastfeeds her baby at least six times daily on both breasts. the woman breastfeeds her baby "on demand" at least every 4 hours. the woman does not substitute other foods for a breast-milk meal. nighttime feedings are provided at least every 6 hours. -Also, pumping or manual expression of milk may reduce effectiveness. Women should not rely on this m

RISK FACTORS FOR OSTEPORISS

Increasing age Postmenopausal status without hormone replacement Small, thin-boned frame Weight less than 127 lb Low bone mineral density White or Asian with small bone frame Impaired eyesight that would increase risk of falling Rheumatoid arthritis Family history of osteoporosis Sedentary lifestyle Celiac disease Depression History of treatment with: Antacids with aluminum Heparin Long-term use of steroids (longer than 3 months) Thyroid replacement drugs Smoking and consuming alcohol Low calcium and vitamin D intake Excessive amounts of caffeine Personal history of nontraumatic fracture Anorexia nervosa or bulimia The best management for this painful, crippling, and potentially fatal disease is prevention. ---- TX FOR RISK FACTORS Women can modify many risk factors by doing the following: Engage in daily weight-bearing exercise, such as walking, to increase osteoblast activity. Increase calcium and vitamin D intake. Remove indoor and outdoor falling hazards. Avoid smoking and excessive alcohol (more than two drinks per day). Discuss bone health with a health care provider. When appropriate, have a bone density test and take medication if needed Medications that can help prevent and manage osteoporosis include: HT (Premarin) SERMs (raloxifene [Evista]) Calcium and vitamin D supplements (Tums) Estrogen agonist/antagonist (SERM) (Evista) Bisphosphonates (Actonel, Fosamax, Boniva, or Reclast) Parathyroid hormone (Forteo) Calcitonin (Miacalcin) (

INTRAUTERINE

Intrauterine contraceptives are classified as either hormonal or nonhormonal. Both types prevent pregnancy via inhibition of sperm mobility and sperm viability and change the speed of transport of the ovum in the fallopian tube. An intrauterine contraceptive (IUC) is a small T-shaped object that is placed inside the uterus to provide contraception (Fig. 4.16). It prevents pregnancy by making the endometrium of the uterus hostile to implantation of a fertilized ovum by causing a nonspecific inflammatory reaction and inhibiting sperm and ovum from meeting (Webster et al., 2018). The hormonal IUC will make monthly periods lighter, shorter, and less painful, making this a useful method for women with heavy, painful periods. The implants contain either copper or progesterone to enhance their effectiveness. One or two attached strings protrude into the vagina so that the user can check its placement. -The ParaGard-TCu-380A is approved for 10 years of use and is nonhormonal. Its mechanism of action is based on the release of copper ions, which alone are spermicidal. Additionally, the device causes an inflammatory action leading to a hostile uterine environment. The TCu-380A is also approved for use as emergency contraception. Mirena provides intrauterine conception for 5 years, but has been shown to be effective for as long as 7 years. Jaydess has been approved for 3 years of pregnancy prevention, and Kyleena is effective for 5 years. These three devices release a low dose of progestin causing thinning of the endometrium and thickening of cervical mucus, which inhibits sperm entry into the upper genital tract. Their use results in a major reduction in menstrual flow and dysmenorrhea, suggesting that they are a viable alternative to hysterectomy and endometrial ablation in women with AUB (Smith, 2018). An advantage of these ho

MISCONCEPTION

It is also important to clear up common misconceptions about contraception and pregnancy. Resolving misconceptions will permit new learning to take hold and a better client response to whichever methods are explored and ultimately selected. Some common misconceptions include: Breastfeeding protects against pregnancy. Pregnancy can be avoided if the male partner "pulls out" before he ejaculates. Pregnancy cannot occur during menses. Douching after sex will prevent pregnancy. Pregnancy will not happen during the first sexual experience. Taking birth control pills protects against STIs. The woman is too old to get pregnant. If female orgasm is not reached, conception is not likely. Irregular menstruation prevents pregnancy.

TX FOR HOT FLASHES

Lower room temperature; use fans. Wear clothing in layers for easy removal. Limit caffeine and alcohol intake. Drink eight to 10 glasses of water daily. Increase fruit and vegetable intake daily. Consume seafood and skinless chicken. Stop smoking. Avoid hot drinks and spicy food. Avoid high cholesterol and fast foods. Take calcium (1,200 to 1,600 mg) and vitamin D (400 to 600 IU). Perform daily aerobic exercise. Maintain a healthy weight. Identify stressors and ways to manage them. Keep a diary to identify triggers of hot flashes. Use chamomile as a mild sedative to alleviate insomnia. Try relaxation techniques, deep breathing, and meditation. Get acupuncture to reduce the frequency of hot flashes. Take vitamin E (100 mg daily)

NURSING ASSESSMENT

Medical history: smoking status, cancer of reproductive tract, diabetes mellitus, migraines, hypertension, thromboembolic disorder, allergies, risk factors for cardiovascular disease (CVD) Family history: cancer, CVD, hypertension, stroke, diabetes OB/GYN history: menstrual disorders, current contraceptive, previous STIs, PID, vaginitis, sexual activity Personal history: use of tampons and female hygiene products, plans for childbearing, comfort with touching herself, number of sexual partners and their involvement in the decision Physical examination: height, weight, blood pressure, breast examination, thyroid palpation, pelvic examination Diagnostic testing: urinalysis, complete blood count, Pap smear, wet mount to check for STIs, HIV/AIDS tests, lipid profile, glucose level -After collecting the assessment data, consider the medical factors to help decide if the woman is a candidate for all methods or whether some should be eliminated. For example, if she reports she has multiple sex partners and a history of pelvic infections, she would not be a good candidate for an IUC. Barrier methods (male or female condoms) of contraception might be recommended to this client instead to offer protection against STIs. ----- INTERVENTIONS Encourage the client or couple to participate in choosing a method. Provide client education. The client or couple must become informed users before the method is chosen. Education should be targeted to the client's level so it is understood. Provide step-by-step teaching and an opportunity for practice for certain methods (cervical caps, diaphragms, vaginal rings, and condoms). See Teaching Guidelines 4.5 and Figure 4.21. Obtain written informed consents, which are needed for IUCs, implants, abortion, or sterilization. Informed consent implies that the client is making a knowledgeable, vol

CONTRACEPTIVE PROBLEMS

Not following instructions for use of contraceptive correctly Take pill the same time every day. Use condoms properly and check condition before using. Make sure diaphragm or cervical cap covers cervix completely. Check IUS for placement monthly. Inconsistent use of contraceptive Contraceptives must be used regularly to achieve maximum effectiveness. All it takes is one unprotected act of sexual intercourse to become pregnant. During use, 2-5% of condoms will break or tear. Condom broke during sex Check expiration date. Store condoms properly. Use only a water-based lubricant. Watch for tears caused by long fingernails. Use spermicides to decrease possibility of pregnancy. Seek emergency postcoital conception. Use of antibiotics or other herbs taken with OCs Use alternative methods during the antibiotic therapy, plus seven additional days. Implement on day 1 of taking antibiotics. Belief that you can't get pregnant during menses or that it is safe "just this one time" It may be possible to become pregnant on almost any day of the menstrual cycle.

Primary amenorrhea

PRIMARY AMMNEROHEA Extreme weight gain or loss Congenital abnormalities of the reproductive system Stress from a major life event Excessive exercise Eating disorders (anorexia nervosa or bulimia) Cushing disease Polycystic ovary syndrome Hypothyroidism Turner syndrome—defective development of the gonads (ovary or testes) Imperforate hymen Chronic illness—diabetes, thyroid disease, depression Pregnancy Cystic fibrosis Congenital heart disease (cyanotic) Ovarian or adrenal tumors SECONDARY AM Pregnancy Breastfeeding Chronic prolonged stress Pituitary, ovarian, or adrenal tumors Depression Hyperthyroid or hypothyroid conditions Malnutrition Hyperprolactinemia Rapid weight gain or loss Chemotherapy or radiation therapy to the pelvic area Vigorous exercise, such as long-distance running Kidney failure Colitis Chemotherapy, irradiation Use of tranquilizers or antidepressants Postpartum pituitary necrosis (Sheehan syndrome) Early menopause

PREMESNSTRAL SYNDOMRE

Premenstrual syndrome (PMS) describes a constellation of recurrent physical, emotional, and behavioral symptoms that occur during the luteal phase or last half of the menstrual cycle and resolve with the onset of menstruation. A majority of women in their reproductive years experience a variety of premenstrual symptoms that can alter their behavior and well-being. Women have between 400 and 500 menstrual cycles over their reproductive years, and since premenstrual distress symptoms peak during 4 to 7 days prior to menses, consistently symptomatic women may spend up to 10 years of their lives in a state of compromised physical functioning and/or psychological well-being; thus, it constitutes a major health problem for women. Therapeutic Management Treatment of PMS is often frustrating for both clients and health care providers. Clinical outcomes can be expected to improve as a result of recent consensus on the diagnostic criteria for PMS and PMDD, data from clinical trials, and the availability of evidence-based clinical guidelines. The management of PMS or PMDD requires a multidimensional approach because these conditions are not likely to have a single cause, and they appear to affect multiple systems within a woman's body; therefore, they are not likely to be amenable to treatment with a single therapy (Reid & Soares, 2018). To reduce the negative impact of premenstrual disorders on a woman's life, education along with reassurance and anticipatory guidance are needed for women to feel they have some control over this condition.

Advantages Disadvantages

Regulate and shorten menstrual cycle Offer no protection against STIs Decrease severe cramping and bleeding Pose slightly increased risk of breast cancer Reduce anemia Modest risk for venous thrombosis and pulmonary emboli Reduce ovarian, endometrial, and colorectal cancer risk Increased risk for migraine headaches Decrease benign breast disease Increased risk for myocardial infarction, stroke, and hypertension for women who smoke Improve acne and reduce incidence of menstrual headaches May increase risk of depression Minimize perimenopausal symptoms User must remember to take pill daily Decrease incidence of rheumatoid arthritis High cost for some women Improve PMS symptoms Protect against loss of bone density and reduce risk of osteoporosis --------------- Early Signs of Complications for Users of Oral Contraceptives • A = Abdominal pain may indicate liver or gallbladder problems. • C = Chest pain or shortness of breath may indicate a pulmonary embolus. • H = Headaches may indicate hypertension or impending stroke. • E = Eye problems may indicate hypertension or an attack. • S = Severe leg pain may indicate a thromboembolic event.

elect Religious Choices for Family Planning and Abortion

Roman Catholic—Abstinence and natural family planning; no abortion • Judaism (Orthodox)—Family planning and abortion accepted in first trimester; conservative and Reform Judaism accept both family planning and abortion • Islam—Family planning accepted; abortion only for serious reasons • Protestant Christianity—Firmly in favor of family planning; mixed on abortion • Buddhism—Long experience with family planning and abortion • Hinduism—Accept both family planning and abortion • Native American religions—Accept both family planning and abortion • Chinese religions—Taoism and Confucianism accept both family planning and abortion

sexual abstinence

Sexual abstinence (not having intercourse) is one of the least expensive forms of contraception and has been used for thousands of years. Pregnancy cannot occur if sperm is kept out of the vagina. It also reduces the risk of contracting HIV/AIDS and other STIs, unless body fluids are exchanged through oral sex; however, some infections, like herpes and human papilloma virus (HPV), can still be passed by skin-to-skin contact. Dental dams can be used to prevent transmission, however. There are many pleasurable options for sex play without intercourse ("outercourse"), such as kissing, masturbation, erotic massage, sexual fantasy, sex toys such as vibrators, and oral sex. Behavioral • Abstinence • Fertility awareness-based methods (FAMs) • Withdrawal (coitus interruptus) • Lactational amenorrhea method (LAM) • Barrier • Condom (male and female) • Diaphragm • Cervical cap • Sponge • Hormonal • OC • Injectable contraceptive • Transdermal patch • Vaginal ring • Implantable contraceptive • Intrauterine contraceptive • Emergency contraceptive Permanent Methods • Tubal ligation or Essure for women • Vasectomy for men Some people choose sexual abstinence because they want to: wait to have sex until they are older. wait to have sex for a long-term relationship. avoid pregnancy or STIs. relieve feelings of depression or anxiety. follow religious or cultural expectations.

BREAST STAGE

Stage I—Papilla elevation only (tip of nipple is raised) Stage II—Breast buds palpable and areolae enlarge at approximately 11 years old Stage III—Elevation of breast contour; areolae enlarge at approximately 12 years old Stage IV—Areolae forms secondary mound on the breast at approximately 13 years old Stage V—Adult breast contour; areola recesses to breast contour LABORATORY AND DIAGNOSTIC TESTS Common laboratory tests that might be ordered to determine the cause of amenorrhea include: Karyotype (might be positive for Turner syndrome) Ultrasound to detect ovarian cysts Quantitative human chorionic gonadotropin (hCG) test to rule out pregnancy Thyroid function studies to determine thyroid disorder Prolactin level (an elevated level might indicate a pituitary tumor) Follicle-stimulating hormone (FSH) level (an elevated level might indicate ovarian failure) Luteinizing hormone (LH) level (an elevated level might indicate gonadal dysfunction) 17-ketosteroids (an elevated level might indicate an adrenal tumor)

TUBAL LIGATION

TUBAL LIGATION Tubal ligation, the sterilization procedure for women, can be performed postpartum, after an abortion, or as an interval procedure unrelated to pregnancy. Mini-laparotomies and laparoscopies are the two most common techniques. In the laparoscopy procedure, the abdomen is filled with carbon dioxide gas so that the abdominal wall balloons away from the tubes to provide a view of the fallopian tubes. They are grasped and sealed with a cauterizing instrument or with rings, bands, or clips, or cut and tied ---- ESSURE Essure is a nonsurgical, nonhormonal, permanent birth control method that is 99% effective. This method is for women who desire no more children as it is a permanent method of birth control. It offers several advantages over a conventional tubal ligation; general anesthesia and incisions are not needed, thereby increasing safety, lowering costs, and improving access to sterilization. A tiny coil (Essure) is introduced and released into the fallopian tubes through the cervix. The coil promotes tissue growth in the fallopian tubes, and over a period of 3 months, this growth blocks the tubes. The buildup of tissue creates a barrier that keeps sperm from reaching the ovum, thus preventing conception. This less invasive technique uses a hysteroscopy under local anesthesia in an office -setting. Sterilization does not occur immediately after this procedure, so women must be educated to use additional contraception for 3 months until permanent tubal occlusion is verified. Women need to know that this form of sterilization is completely irreversible ----- VASECGOMY Male sterilization is accomplished with a minor surgical procedure known as a vasectomy. More than 500,000 men have a vasectomy performed in the United States each year (Ostrowski et al., 2018). It is usually performed under local anesthesia

BASAL BODY TEMP

The basal body temperature (BBT) refers to the lowest temperature reached on awakening. The woman takes her temperature orally before rising and records it on a chart. Preovulation temperatures are suppressed by estrogen, while postovulation temperatures are increased under the influence of heat-inducing progesterone. Temperatures typically rise within a day or two after ovulation and remain elevated for approximately 2 weeks (at which point bleeding usually begins). If using this method by itself, the woman should avoid unprotected intercourse until the BBT has been elevated for 3 days. Nurses should instruct women using the BBT method that it is important to keep in mind that illness and any drugs, including alcohol, can raise body temperature and give a false reading -SYMPTOTHERMAL METHOD The symptothermal method relies on a combination of techniques to recognize ovulation, including BBT, cervical mucus changes, alterations in the position and firmness of the cervix, and other symptoms of ovulation, such as increased libido, mittelschmerz (midcycle, lower abdominal pain at ovulation), pelvic fullness or tenderness, and breast tenderness (Clark et al., 2018). Combining all these predictors increases the awareness of when ovulation occurs and increases the effectiveness of this method. A home predictor test for ovulation is also available in most pharmacies. It measures LH levels to pinpoint the day before or the day of ovulation. These tests are widely used for fertility and infertility regimens.

CONTRACEPTIVE SPONGE

The contraceptive sponge is a nonhormonal, nonprescription device that includes both a barrier and a spermicide. It is a soft concave device that prevents pregnancy by covering the cervix and releasing spermicide. The sponge, made of polyurethane saturated with 1 g of nonoxynol-9, releases 125 mg of the spermicide over 24 hours of use. Unlike the diaphragm, the sponge can be used for more than one coital act within 24 hours without the insertion of additional spermicide, and it does not require fitting or a prescription from a health care provider (Kwansa & Stewart-Moore, 2019). While it is less effective than several other methods and does not offer protection against STIs, the sponge achieved a wide following among women who appreciated the spontaneity with which it could be used and its easy availability. -To use the sponge, the woman first wets it with water, squeezes it until it is thoroughly wet and foamy, and then inserts it into the vagina with a finger, using a cord loop attachment. It can be inserted up to 24 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours, but should not be left in for more than 30 hours after insertion to avoid the risk of TSS ---- As early as 1937, scientists recognized that the injection of progesterone inhibited ovulation in rabbits and provided contraception. The first hormonal pill, called Enovid, was approved by the Food and Drug Administration (FDA) in May 1960. It contained high levels of estrogen to prevent ovulation. Since that time, it has evolved through gradual lowering of estrogen and is now combined with many different progestins. Breakthrough bleeding was reported in early clinical trials in women, and the role of estrogen in cycle control was launched. This established the rat

VAGINAL DIAPHRAGM

The diaphragm is a soft latex or silicone dome surrounded by a metal spring. Used in conjunction with a spermicidal jelly or cream, it is inserted into the vagina to cover the cervix (Fig. 4.9). The diaphragm may be inserted up to 2 hours before intercourse and must be left in place for at least 6 hours afterward. Diaphragms are available in a range of sizes and styles. The diaphragm is available only by prescription and must be professionally fitted by a health care provider. Women may need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 lb or more. As a general rule, diaphragms should be replaced every 1 to 2 years. Recently, a single-size diaphragm used with contraceptive jelly was introduced and studied for its effectiveness. -Diaphragms are user-controlled, nonhormonal methods that are needed only at the time of intercourse, but they are not effective unless used correctly. Women need to receive thorough instruction about diaphragm use and should practice putting one in and taking it out before they leave the health care office --- CERVICAL CAP CERVICAL CAP cervical cap is smaller than the diaphragm and covers only the cervix; it is held in place by suction. It is shaped like a sailor's hat and prevents sperm from entering the cervix. Caps are made from silicone and are used with spermicide (Fig. 4.11). The FemCap is the only cervical cap device currently available in the United States and comes in three sizes (Planned Parenthood, 2020a). The cap may be inserted up to 36 hours before intercourse and provides protection for 48 hours. The cap must be kept in the vagina for 6 hours after the final act of intercourse and should be replaced every year of use. A refitting may also be necessary when a woman experiences pregnancy, abortion, or w

THERPAIES FOR HOT FLASHES

The following are traditional therapies for the management of hot flashes: Pharmacologic options HT unless contraindicated Androgen therapy (potentiates estrogen) Estrogen and androgen combinations Progestin therapy (Depo-Provera injection every 3 months) Clonidine (central alpha-adrenergic agonist) weekly patch Neurontin (antiseizure) decreased hot flashes Propranolol (beta-adrenergic blocker) Brisdelle: FDA-approved nonhormonal medication Short-term sleep aids: Ambien, Dalmane Gabapentin (Neurontin): antiseizure drug SSRIs: venlafaxine (Effexor) and paroxetine (Paxil) have shown promise Many women are choosing alternative treatments for managing menopausal symptoms. Bioidentical hormones have the ability to bind to receptors in the human body and function in the same way as a woman's natural hormones. They simulate three estrogens (estradiol, estriol, and estrone), as well as progesterone, testosterone, dehydroepiandrosterone (DHEA), thyroxine, and cortisol. Bioidentical hormones are not, however, natural hormones. The estrogens are derived via a chemical process from soybeans (Glycine max) and progesterone from Mexican yam (dioscorea villosa). As with conventional hormones, however, bioidentical hormones are available only with a physician's -prescription and through a pharmacy. Because of their natural origin, women sometimes believe alternative treatments are safer. The interest in phytoestrogens came about because of the low prevalence of hot flashes in Asian women, which was attributed to their diet being rich in phytoestrogens. Recent studies have found that black cohosh, wild yam, licorice, multibotanical herbs, and increased soy intake do not reduce the frequency or severity of menopausal hot flashes or night sweats.

THERAPTUCI MANGEMENT

The goal of treatment is to provide adequate pain relief to allow the woman to perform her usual activities. Current treatment mainly includes surgery and ovarian suppressive agents (OCs, progestins, GnRH antagonists, levonorgestrel-releasing intrauterine systems, and androgenic agents). Hormonal treatment is often associated with unwanted side effects and recurrence of symptoms when stopped. Severe dysmenorrhea can be distressing, adversely affecting social and occupational activities. Treatments vary from over-the-counter remedies to hormonal control. However, for some women, satisfactory pain relief is difficult to achieve, and they increasingly seek alternative options. Complementary therapies such as massage therapy, acupuncture (needles used to stimulate certain points of the body to balance the flow of energy within the body), and acupressure (the use of fingers nd hands to stimulate acupoints to maintain the balance of energy) are gaining popularity as different ways to cope with the cyclic discomfort. - Therapeutic intervention is directed toward pain relief and building coping strategies that will promote a productive lifestyle. General measures for management include client education and reassurance. Treatment is supportive and should be guided by individual needs. Treatment measures usually include treating infections if present; suppressing hormones if endometriosis is suspected and cannot be treated with surgery by administering low-dose OCs; administering prostaglandin inhibitors to reduce the pain; administering Depo-Provera to suppress ovulation, which thins the endometrial lining of the uterus with subsequent reduction of fluid contents of the uterus during menses; and initiating lifestyle changes A detailed sexual history is essential to assess for inflammation and scarring (adhesions) secondary to

MANGEMTN

The gold standard for endometriosis treatment is laparoscopic excision surgery while pain-relieving drugs and hormone suppressants can address symptoms. Alternative therapies may be used, including acupuncture and supplementation with vitamins, minerals, and fish oil (Nothnick et al., 2018). Because endometriosis has no cure and surgery with an endometriosis specialist is not widely accessible, surgery with a general gynecologist may only control symptoms temporarily. Women with endometriosis frequently experience only short-term relief. Endometriosis-associated pelvic pain can be managed by suppression of ovulatory menses and estrogen production, cyclooxygenase inhibitors, and surgical removal of pelvic lesions. Many pain relief and hormonal suppression therapies have significant adverse effects and limits on the duration of therapy TX FOR ENDO Conservative surgery Removal of implants/lesions using laser, cautery, or small surgical instruments for excision. This intervention may reduce pain and allow pregnancy to occur in the future but may need to be repeated. Definitive surgery Abdominal hysterectomy with or without bilateral salpingo-oophorectomy. Will eliminate bleeding but will leave a woman unable to become pregnant in the future. Pain may not resolve if extrauterine lesions are not completely removed. Medication Therapy NSAIDs First-line treatment to reduce pain; taken early when premenstrual symptoms are first felt Oral contraceptives Suppresses cyclic hormonal response of the endometriosis tissue Progestogens Decreases the activity of estrogen receptors, suppressing the effects of estrogen Antiestrogens Suppresses a woman's production of estrogen, thus stopping the menstrual cycle and reducing symptoms Gonadotropin-releasing hormone analogs (GnRH-a) Suppresses endometriosis symptoms by creating a temporary

PHYSICAL EXAM AND LAB DIAGNOSTIC

The hallmark finding is the presence of tender nodular masses on the uterosacral ligaments, the posterior uterus, or the posterior cul-de-sac. A skilled endometriosis specialist may be able to identify suspected adhesions with a pelvic exam, but the only definitive diagnosis is the one made during surgery and with biopsy ( INFERTILITY Infertility is defined as the inability to conceive a child after 1 year of regular sexual intercourse unprotected by contraception (RESOLVE, 2019). Secondary infertility is the inability to conceive after a previous pregnancy Etiology and Risk Factors Reproduction requires the interaction of the female and the male reproductive tracts, which involves (1) the release of a normal preovulatory oocyte; (2) the production of adequate spermatozoa; (3) the normal transport of the gametes to the ampullary portion of the fallopian tube (where fertilization takes place); and (4) the subsequent transport of the cleaving embryo into the endometrial cavity for implantation and development RISK FACTORS Risk factors for infertility in women include: Overweight or underweight (can disrupt hormone function) Scarred fallopian tubes from infections Uterine fibroids Tubal blockages Anovulation Cervical stenosis Reduced oocyte quality Chromosomal abnormalities Congenital anomalies of the uterus Immune system disorders Chronic illnesses such as diabetes, thyroid disease, asthma Sexually transmitted infections (STIs) Ectopic pregnancy Increased age Endometriosis Turner syndrome Eating disorders History of PID Smoking and alcohol consumption Multiple miscarriages Environmental pollutants Menstrual abnormalities Exposure to chemotherapeutic agents Psychological stress

ETIOLOGY

The most common causes of AUB can be classified using the PALM-COEIN acronym: PALM (structural) Polyp Adenomyosis Leiomyosis Malignancy COEIN (other) Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified Therapeutic Management Treatment of AUB depends on the cause of the bleeding, the age of the client, and whether or not she desires future fertility. When known, the underlying cause of the disorder is treated. Otherwise, the goal of treatment is to normalize the bleeding, correct anemia, prevent or diagnose early cancer, and restore quality of life. Once malignancy and pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option -Management of AUB might include medical care with pharmacotherapy or insertion of a hormone-secreting intrauterine system. OCs are used for cycle regulation as well as for contraception. They help prevent the risks associated with prolonged, unopposed estrogen stimulation of the endometrium. NSAIDs and progestin therapy (progesterone-releasing IUS [Mirena] or Depo-Provera) decrease menstrual blood loss significantly Drug categories used in the treatment of AUB include:

MENPAUSAL SYMTOMS

The term menopausal transition refers to the transition from a woman's reproductive phase of her life to her final menstrual period. This period is also referred to as perimenopause. The average age of natural menopause, defined as 1 year without a menstrual period, is 51.4 years old. The average age of natural menopause has remained constant for the last several hundred years despite improvements in nutrition and health care (Woods & Utian, 2018). With current female life expectancy at 84 years, this event comes in roughly the middle of a woman's adult life. Many women go through the menopausal transition with few or no symptoms, while some have significant or even disabling symptoms. -Menopause signals the end of an era for many women. It concludes their ability to reproduce, and some women find advancing age, altered roles, and these physiologic changes to be overwhelming events that can precipitate depression and anxiety (Webster et al., 2018). Menopause does not happen in isolation. Midlife is often experienced as a time of change and reflection. Change happens in many arenas; children are leaving or returning home, employment pressures intensify as career moves or decisions are required, older adult parents require more care or the death of a parent may have a major impact, and partners are retrenching or undergoing their own midlife changes. Women must negotiate all these changes in addition to menopause. Managing this stress can be challenging for many women as they make this transition. - Maturing ova are surrounded by follicles that produce two major hormones: estrogen, in the form of estradiol, and progesterone. The cyclic maturation of the ovum is directed by the hypothalamus. The hypothalamus triggers a cascade of neurohormones, which act through the pituitary and the ovaries as a pulse generator for

MANGEMTN

Therapeutic interventions for secondary amenorrhea can include: Cyclic progesterone, when the cause is anovulation, or oral contraceptives (OCs) Bromocriptine to treat hyperprolactinemia Nutritional counseling to address anorexia, bulimia, or obesity GnRH, when the cause is hypothalamic failure Thyroid hormone replacement, when the cause is hypothyroidism --- PHYISCLA EXAMINATION The physical examination should begin with an overall assessment of the woman's nutritional status and general health. A sensitive and gentle approach to the pelvic examination is critical in young women. Height, weight, and body mass index (BMI) should be taken, along with vital signs. Hypothermia, bradycardia, hypotension, and reduced subcutaneous fat may be observed in women with anorexia nervosa. Facial hair and acne might be evidence of androgen excess secondary to a tumor. The presence or absence of axillary and pubic hair may indicate adrenal and ovarian hyposecretion or delayed puberty. A general physical examination may uncover unexpected findings that are indirectly related to amenorrhea. For example, hepatosplenomegaly, which may suggest a chronic systemic disease or an enlarged thyroid gland, might point to a thyroid disorder as well as a reason for amenorrhe

SLLERGY TO LATEX

Tips for Individuals Allergic to Latex • Symptoms of latex allergy include: • Skin rash, itching, hives • Itching or burning eyes • Swollen mucous membranes in the genitals • Shortness of breath, difficulty breathing, wheezing • Anaphylactic shock • Use of or contact with latex condoms, cervical caps, and diaphragms is contraindicated for men and women with a latex allergy. • If the female partner is allergic to latex, have the male partner apply a natural condom over the latex one. • If the male partner experiences penile irritation after condom use, try different brands or place the latex condom over a natural condom. • Use polyurethane condoms rather than latex ones. • Use female condoms; they are made of polyurethane. • Switch to another birth control method that doesn't involve latex, such as OCs, IUSs, Depo-Provera, fertility awareness, and other nonbarrier methods. However, be aware these methods do not protect against STIs. CONDOMS Condoms are barrier methods of contraceptives made for both males and females. The male condom is made from latex or polyurethane or natural membrane and may be coated with spermicide. Male condoms are available in many colors, textures, sizes, shapes, and thicknesses. When used correctly, the male condom is put on over an erect penis before it enters the vagina and is worn throughout sexual intercourse (Fig. 4.8). It serves as a barrier to pregnancy by trapping seminal fluid and sperm after orgasm and offers protection against STIs. Condoms are not perfect barriers, however, because breakage and slippage can occur. Emergency postcoital contraception may need to be sought to prevent a pregnancy. Additionally, nonlatex condoms have a higher risk of pregnancy and STIs than do latex condoms -The female or internal condom is a polyurethane or nitrile pouch inser

EMERGENCY CONTRACEPTION

Unplanned pregnancy is a major health, economic, and social issue. Approximately one third of all unplanned pregnancies end in abortion. The unintended pregnancy rate is significantly higher in the United States than in other developed countries (Guttmacher Institute, 2019c). Using an emergency contraceptive provides a woman a second chance to prevent an unintended pregnancy. Emergency contraception (EC) reduces the risk of pregnancy after unprotected intercourse or contraceptive failure such as condom breakage -It is used within 72 to 120 hours of unprotected intercourse to prevent pregnancy. The sooner ECs are taken, the more effective they are. They reduce the risk of pregnancy for a single act of unprotected sex by almost 90% (WHO, 2018b). The methods currently available in the United States are (1) ulipristal acetate (UPA), an oral progesterone receptor agonist-antagonist (Ella); (2) levonorgestrel (LNG), an oral progestin (Plan B One-Step); (3) the copper intrauterine device (Cu-IUD); and (4) off-label use of combined oral contraceptives (Yuzpe method) -Warnings for Potential Complications for Intrauterine System Users --- P = Period late, pregnancy, abnormal spotting or bleeding • A = Abdominal pain, pain with intercourse • I = Infection exposure, abnormal vaginal discharge • N = Not feeling well, fever, chills • S = String length shorter or longer or missing -Prime points to stress concerning ECs are: ECs do not offer any protection against STIs or future pregnancies. ECs should not be used in place of a regular birth control method because they are less effective. ECs may delay the next menses, so evaluation for pregnancy is needed if menses does not occur within 3 weeks after EC use. Report any severe abdominal pain to the health care provider immediately. ECs can be regular birth control pills giv

TX AND ASSMENT

clomiphene to promote ovulation; hormone injections to promote ovulation; intrauterine insemination; and IVF. Various ovulation-enhancement drugs and timed intercourse might be used for the woman with ovulation problems. The woman should understand a drug's benefits and side effects before consenting to take it. Depending on the type of drug used and the dosage, some women may experience multiple pregnancies. If the woman's reproductive organs are damaged, surgery can be done to repair them. Still, other couples might opt for the hi-tech approaches of artificial insemination Nursing Assessment Infertile couples may be under tremendous pressure and often keep the problem a secret, considering it to be personal. Couples and women are often beset by feelings of inadequacy and guilt, and many are subject to pressures from both family and friends. As the problem becomes more chronic, they may begin to blame one another, with consequent marital discord. Seeking help is often a difficult step, and it may take a lot of courage to discuss something about which they feel embarrassed or upset. The nurse working in this specialty setting must be aware of the conflict and problems couples experience and must be sensitive to their needs. A full medical history should be taken from both partners, along with a physical examination. The data needed for the infertility evaluation are sensitive and of a personal nature, so the nurse must use professional interviewing skills. -Infertility has numerous causes and contributing factors, so it is important to use the process of elimination, determining what problems do not exist to better comprehend the problems that may exist. At the first visit, a plan of investigation is outlined and a complete health history is taken. This first visit forces many couples to confront the reality that

MENOPAUSAL WOMEN

menopausal transition affects not only the reproductive organs, but also other body systems: Brain and central nervous system: hot flashes, disturbed sleep, mood, and memory problems Cardiovascular: lower levels of high-density lipoprotein (HDL) and increased risk of CVD Skeletal: rapid loss of bone density that increases the risk of osteoporosis Breasts: replacement of duct and glandular tissues by fat Genitourinary: vaginal dryness, stress incontinence, cystitis Gastrointestinal: less absorption of calcium from food, increasing the risk for fractures Integumentary: dry, thin skin and decreased collagen levels Body shape: more abdominal fat; waist size that swells relative to hips -n perimenopause, the ovaries begin to fail, producing irregular and missed periods and an occasional hot flash. When menopause finally appears, viable ova are gone. Estrogen levels plummet by 90%, and estrone, produced in fat cells, replaces estradiol as the body's main form of estrogen. The major hormone produced by the ovaries during the reproductive years is estradiol; the estrogen found in postmenopausal women is estrone. Estradiol is much more biologically active than estrone (Oyelowo & Johnson, 2018). In addition, testosterone levels decrease with menopause. With its dramatic decline in estrogen, menopausal transition affects not only the reproductive organs, but also other body systems:

MANGEING HOT FLAHES

ot flashes during menopause are distressing and result in poor quality of life. The emergence of hot flashes and night sweats (also known as vasomotor symptoms) coincides with a period in life that is also marked by dynamic changes in hormone and reproductive function that interconnect with the aging process, changes in metabolism, lifestyle behaviors, and overall health (Oyelowo & Johnson, 2018). Hot flashes and night sweats are classic signs of estrogen deficiency and the predominant complaint of perimenopausal women -A hot flash is a transient and sudden sensation of warmth that spreads over the body, particularly the neck, face, and chest. Hot flashes are caused by vasomotor instability. This instability causes inappropriate peripheral vasodilation of superficial blood vessels, which gives the sensation of heat. -Hot flashes are an early and acute sign of estrogen deficiency. These flashes can be mild or extreme and can last from 2 to 30 minutes and may occur as frequently as every hour to several times per week. On average, women experience hot flashes for a period of 6 months to 2 years, but the symptoms may last up to 10 years or more. Severe vasomotor symptoms can have a significant and detrimental effect on quality of life. Factors that trigger vasomotor symptoms include caffeine and alcohol consumption, intake of hot drinks and spicy foods, hot environment, depression, stress, and anxiety -Many options are available for treating hot flashes. Treatment must be based on symptom severity, the client's medical history, and the client's values and concerns. Although the gold standard in the treatment of hot flashes is estrogen, this is not recommended for all women who have high-risk factors in their history.

VAGINAL RING

vaginal ring contains both estrogen and progesterone. The contraceptive vaginal ring, NuvaRing, is a flexible, soft, transparent ring that is inserted by the user for a 3-week period of continuous use followed by a ring-free week to allow withdrawal bleeding (Fig. 4.15). Ethinyl estradiol and etonogestrel are rapidly absorbed through the vaginal epithelium and result in a steady serum concentration. Because the hormones are released directly into the vagina, a lower daily dose of hormones is required in comparison with OC doses. Studies have demonstrated that the efficacy and safety of the ring are equivalent to those of OCs. Clients report being highly satisfied with the vaginal ring and report fewer systemic side effects than do OC users. The ring provides effective cycle control as well as symptom relief for women with AUB and polycystic ovary syndrome. Reported problems associated with the use of vaginal rings include erosion of the vaginal wall, ring expulsion, increased vaginal discharge, --- interference with coitus, unpleasant ring odor, and premature discontinuation due to vaginal discomfort (Kwansa & Stewart-Moore, 2019). The ring can be inserted by the woman and does not have to be fitted. The woman compresses the ring and inserts it into the vagina, behind the pubic bone, as far back as possible, but precise placement is not critical. The hormones are absorbed through the vaginal mucosa. It is left in place for 3 weeks and then removed and discarded. Effectiveness and adverse events are similar to those of combination OCs. Clients need to be counseled regarding timely insertion of the ring and what to do in case of accidental expulsion. ----- The implant is a subdermal time-release method that delivers synthetic progestin that inhibits ovulation. Once in place, it delivers 3 years of continuous, highly effe

Diaphragm Insertion/Removal Technique

• Always empty the bladder prior to inserting the diaphragm. • Inspect diaphragm for holes or tears by holding it up to a light source, or fill it with water and check for a leak. • Place approximately a tablespoon of spermicidal jelly or cream in the dome and around the rim of the diaphragm. • The diaphragm can be inserted up to 6 hours prior to intercourse. • Select the position that is most comfortable for insertion: • Squatting • Leg up, raising the nondominant leg up on a low stool • Reclining position, lying on back in bed • Sitting forward on the edge of a chair • Hold the diaphragm between the thumb and fingers and compress it to form a "figure eight" shape. • Insert the diaphragm into the vagina, directing it downward as far as it will go. • Tuck the front rim of the diaphragm behind the pubic bone so that the rubber hugs the front wall of the vagina. Feel for the cervix through the diaphragm to make sure it is properly placed. • To remove the diaphragm, insert the finger up and over the top side and move slightly to the side, breaking the suction. • Pull the diaphragm down and out of the vagin Client Teaching and Counseling Regarding the Diaphragm • Avoid the use of oil-based products, such as baby oil, because they may weaken the rubber. • Wash the diaphragm with soap and water after use and dry thoroughly. • Place the diaphragm back into the storage case. • The diaphragm may need to be refitted after weight loss or gain or childbirth. • Diaphragms should not be used by women with latex allergies. Vaginal Ring Insertion/Removal Technique and Counseling • Each ring is used for one menstrual cycle, which consists of 3 weeks of continuous use followed by a ring-free week to allow for menses. • No fitting is necessary; one size fits all. • The ring is compressed

TIPS FOR DMONORRHEA

• Exercise to increase endorphins and suppress prostaglandin release. • Limit salty foods to prevent fluid retention. • Increase water consumption to serve as a natural diuretic. • Increase fiber intake with fruits and vegetables to prevent constipation. • Use heating pads or warm baths to increase comfort. • Take warm showers to promote relaxation. • Sip on warm beverages, such as decaffeinated green tea. • Keep legs elevated while lying down or lie on your side with knees bent. • Use stress management techniques to reduce emotional stress. • Practice relaxation techniques to enhance ability to cope with pain. • Stop smoking and decrease alcohol use which causes vasoconstriction.

Cervical Cap Insertion/Removal Technique

• It is important to be involved in the fitting process. • To insert the cap, pinch the sides together, compress the cap dome, insert into the vagina, and place over the cervix. • Use one finger to feel around the entire circumference to make sure there are no gaps between the cap rim and the cervix. • After a minute or two, pinch the dome and tug gently to check for evidence of suction. The cap should resist the tug and not slide off easily. • To remove the cap, press the index finger against the rim and tip the cap slightly to break the suction. Gently pull out the cap. • The woman should practice inserting and removing the cervical cap three times to validate her proficiency with this device. Client Teaching and Counseling Regarding the Cervical Cap • Fill the dome of the cap up about one third full with spermicide cream or jelly. Do not apply spermicide to the rim since it may interfere with the seal. • Wait approximately 30 minutes after insertion before engaging in sexual intercourse to be sure that a seal has formed between the rim and the cervix. • Leave the cervical cap in place for a minimum of 6 hours after sexual intercourse. It can be left in place for up to 48 hours without additional spermicide being added. • Do not use during menses due to the potential for toxic shock syndrome. Use an alternative method such as condoms during this time. • Replace the cervical cap after each year of use. • Inspect the cervical cap prior to insertion for cracks, holes, or tears. • After using the cervical cap, wash it with soap and water, dry thoroughly, and store in its container.