Reproductive system concerns (Chapter 6): Clinical Scenario

What symptom described by a woman is characteristic of premenstrual syndrome (PMS)? A. "I feel irritable and moody a week before my period is supposed to start." B. "I have lower abdominal pain beginning the third day of my menstrual period." C. "I have nausea and headaches after my period starts, and they last 2 to 3 days." D. "I have abdominal bloating and breast pain after a couple days of my period."

PMS is a cluster of physical, psychological, and behavioral symptoms, including nausea and headaches, that begin in the luteal phase of the menstrual cycle and resolve within a couple of days of the onset of menses. Abdominal bloating and breast pain are likely to occur a few days prior to menses, not after it has begun as described in statement D. (A)

The nurse is teaching a group of high school students about different strategies to manage primary dysmenorrhea. The nurse tells them to place a heating pad over the abdomen when pain is severe. How would this strategy help in reducing dysmenorrheal pain? A. Blocking pain perception B. Releasing endogenous opiates C. Relaxing the paravertebral muscles D. Increasing blood supply to the uterus

Placing a heating pad over the abdomen increases blood supply to the uterine musculature. Nonsteroidal antiinflammatory drugs and other analgesic drugs block pain perception and reduce pain. This would relax the uterine muscles and reduce ischemia. Exercise helps in reducing dysmenorrheal pain by releasing endogenous opiates. Back massage helps in relaxing the paravertebral muscles, thereby reducing dysmenorrheal pain. (D)

A client reports mood disturbances, emotional breakdowns, and irritation just before the beginning of menses for the last three cycles. After assessment, the nurse finds that the client follows a good diet and exercise regimen. Based on the symptoms, what does the nurse conclude that the client has? A. Amenorrhea. B. Hormonal abnormalities. C. A psychologic illness. D. Premenstrual dysphoric disorder.

Premenstrual dysphoric disorder is a severe variant of premenstrual syndrome that is manifested as emotional lability, irritation, and disturbed mood. The symptoms exhibited by the client are caused by premenstrual dysphoric disorder. Amenorrhea is the absence of menstruation. The client having symptoms for three cycles during the luteal phase does not indicate amenorrhea. The symptoms of premenstrual dysphoric disorder are caused by the normal hormonal changes occurring in the luteal phase of the menstrual cycle. These behavioral symptoms do not indicate that the client has hormonal abnormalities or a psychologic illness. (D)

Which dietary changes will help reduce systemic symptoms associated with dysmenorrhea? Select all that apply. A. Consumption of a low-fat vegetarian diet B. Increased calcium intake during menses C. Consumption of asparagus and cranberry juice D. Decreased salt intake 7 to 10 days before menses E. Increased sugar intake 7 to 10 days before menses

A low-fat vegetarian diet will help minimize dysmenorrheal symptoms such as weakness and dizziness. Asparagus and cranberry juice are natural diuretics and will help reduce edema. Decreasing salt intake 7 to 10 days before menses helps reduce fluid retention. Calcium is helpful to improve bone density. A decrease in refined sugar intake 7 to 10 days before menses will reduce fluid retention. (A, C, D)

A client is prescribed oral contraceptive pills (OCPs) for 6 months for dysfunctional uterine bleeding. After 6 months, the client's condition improves, and she wishes to discontinue the oral contraceptive pills. However, nine weeks later, the client is instructed to start a progestin regimen. Which assessment finding is the reason for this prescription? A. The client is pregnant. B. The bleeding is scanty. C. Menstruation did not resume. D. The disorder reoccurred.

A progestin regimen will help start menstruation and prevent persistent anovulation with chronic unopposed endogenous estrogen hyperstimulation of the endometrium. The client is prescribed progestin only if pregnancy is ruled out. If there is scanty bleeding, there is no need to discontinue OCPs or change the prescription. If the disorder reoccurs, the client will be prescribed laser treatment to ablate the endometrium. (C)

The nurse is reviewing the ultrasound report of a client with endometriosis. The report confirms the presence of adhesions around the uterine tubes that block the fimbriated ends. What does the nurse interpret from this finding? A. The client may not have menstruation. B. The client may not be able to conceive. C. The client may have pain during intercourse. D. The client may have excess bleeding during menses.

Adhesions causing complete blockage of the uterine tubes would prevent the ovum from reaching the uterus. Thus, the client would not be able to conceive. Menstruation is the process regulated by the hormones produced by the ovaries. Therefore, blockage of uterine tubes would not cause amenorrhea. Dyspareunia, or pain during intercourse, is a characteristic of any type of endometriosis irrespective of the site. Menorrhagia, or excess bleeding during menses, is not a symptom associated with endometriosis. (B)

With regard to the diagnosis and management of amenorrhea, nurses should be aware that: A. It probably is the result of a hormone deficiency that can be treated with medication. B. It may be caused by stress or excessive exercise or both. C. It likely will require the client to eat less and exercise more. D. It often goes away on its own.

Amenorrhea may be the result of a decrease in follicle-stimulating hormone (FSH) and luteinizing hormone (LH). It is caused usually by stress or low ratio of body fat to lean mass (possibly as a result of excessive exercise), and, in rare occurrences, by a pituitary tumor. Management of stress and eating disorders is usually necessary, including counseling and education about the causes and possible lifestyle changes. In most cases a client needs to decrease her exercise and increase her body weight to resume menstruation. Amenorrhea cannot be treated by medication. (B)

With regard to the diagnosis and management of amenorrhea, nurses should be aware that: A. It probably is the result of a hormone deficiency that can be treated with medication. B. It may be caused by stress or excessive exercise or both. C. It likely will require the client to eat less and exercise more. D. It often goes away on its own.

Amenorrhea usually is the result of stress and/or an inappropriate ratio of body fat to lean tissue, possibly because of excessive exercise. Management includes counseling and education about the causes and possible lifestyle changes. Amenorrhea may be the result of a decrease in follicle-stimulating hormone (FSH) and luteinizing hormone (LH). It cannot be treated by medication. In most cases a client will need to decrease her amount of exercise and increase her body weight in order to resume menstruation. Management of stress and eating disorders is usually necessary in order to manage this condition. (B)

With regard to dysfunctional uterine bleeding (DUB), the nurse should be aware of what? A. It is most commonly caused by anovulation. B. It most often occurs in middle age. C. The diagnosis of DUB should be the first considered for abnormal menstrual bleeding. D. The most effective medical treatment involves steroids.

Anovulation may occur because of hypothalamic dysfunction or polycystic ovary syndrome. DUB most often occurs when the menstrual cycle is being established or when it draws to a close at menopause. A diagnosis of DUB is made only after all other causes of abnormal menstrual bleeding have been ruled out. The most effective medical treatment is oral or intravenous estrogen. (A)

With regard to dysfunctional uterine bleeding (DUB), the nurse should be aware that: A. It is most commonly caused by anovulation. B. It most often occurs in middle age. C. The diagnosis of DUB should be the first considered for abnormal menstrual bleeding. D. The most effective medical treatment involves steroids.

Anovulation may occur because of hypothalamic dysfunction or polycystic ovary syndrome. DUB most often occurs when the menstrual cycle is being established or when it draws to a close at menopause. A diagnosis of DUB is made only after all other causes of abnormal menstrual bleeding have been ruled out. The most effective medical treatment is oral or intravenous estrogen. (A)

The nurse is conducting a follow-up assessment of a client with endometriosis who is taking danazol (Danocrine). The client tells the nurse that she is unwilling to take danazol (Danocrine) in the future. What could be the most likely reason for the client's unwillingness to use this medication? A. The medication caused amenorrhea in the client. B. The medication caused abdominal pain in the client. C. The medication caused masculinizing traits in the client. D. The medication caused temporary infertility in the client.

Danazol (Danocrine) is a mildly androgenic synthetic steroid that suppresses the secretion of follicle-stimulating and luteinizing hormones. It causes masculinizing side effects such as weight gain, edema, decreased breast size, oily skin, and hirsutism. This would affect the client's appearance. Therefore, this is the most likely reason for the client's unwillingness to adhere to this medication regimen. Amenorrhea is a side effect associated with the use of danazol,but it is temporary (only during the course of therapy) and is unlikely to be the source of distress to the client. Danazol is helpful in relieving pain associated with endometriosis. Danazol does not cause infertility. However, it is contraindicated in pregnant women because of its teratogenic effects. (C)

Which conditions can be seen in a female client during the menstruation phase of her menstrual cycle? Select all that apply. A. Amenorrhea B. Osteoporosis C. Dysmenorrhea D. Premenstrual syndrome E. Premenstrual dysphoric disorder

Dysmenorrhea is the pain that a client may experience during or shortly before menstruation. The client experiences pain in the suprapubic area or the lower abdomen. Premenstrual syndrome includes multiple symptoms that the client may experience during the menstruation period. There may be fluid retention, behavioral changes, premenstrual cravings, headache, fatigue, and backache. In premenstrual dysphoric disorder, the client experiences anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed. Amenorrhea is associated with the absence of menstrual flow; it is not a condition seen during actual menstruation. Osteoporosis is seen in clients who have low bone density due to poor nutrition and stress, but it is not associated with the menstrual cycle. (C, D, E)

Which condition has a high possibility of occurrence in a client with endometriosis? A. Weight gain B. Mood disorders C. Impaired fertility D. Gastrointestinal bleeding

Endometriosis is the presence and growth of endometrial glands and stroma outside the uterus. This may cause adhesions that pull the uterus into a fixed, retroverted position, which may result in impaired fertility. Weight gain is a side effect of danazol (Danocrine) therapy in clients with endometriosis. Mood disorders may be a comorbid condition in adolescents, and they are not a result of endometriosis. Gastrointestinal bleeding is a risk for clients who are being treated with nonsteroidal antiinflammatory drugs (NSAIDs) for primary dysmenorrhea. (C)

An adolescent who has been participating in competitive gymnastics from a very young age is experiencing hypogonadotropic amenorrhea. Which interventions does the nurse include in the client's plan of care? Select all that apply. A. Suggest increased aerobic exercise. B. Teach deep-breathing exercises. C. Identify the presence of stressors. D. Increase the client's nutritional intake. E. Include biofeedback or massage therapy.

Hypogonadotropic amenorrhea is common in women who participate in athletic activities that emphasize low body weight. Stress can also be a contributing factor and the nurse should help the client identify and cope with possible stressors in her life. For example, in this case, competition is a likely stressor. The nurse teaches deep-breathing exercises because they help relieve stress. Biofeedback or massage therapy may also be provided to help counter stress. An increase in the client's nutritional intake will help her to gain weight and increase her energy. Increased aerobic exercise will require additional energy, which will add to the causes of amenorrhea. Therefore, the client is asked to reduce her exercise to conserve energy. (B,C,D,E)

A client with abnormal uterine bleeding and a hemoglobin level of less than 8 g/dl is hospitalized. The client is given conjugated estrogens, and the nurse monitors the client for the next 24 hours. Which condition in the client indicates a need for dilation and curettage? A. Risk for coma B. Continuous bleeding C. Excessive abdominal pain D. Unstable vital signs

If bleeding does not stop 12 to 24 hours after administering conjugated estrogens, then the nurse needs to prepare the client for dilation and curettage to control severe bleeding and hemorrhage. The client is not at a risk for coma, but there is excessive bleeding, which may induce shock. Excessive abdominal pain can be controlled by effective pain medications if the bleeding stops. Dilation and curettage is performed to control hemorrhage, not to stabilize the vital signs. (B)

Which of the following are examples of differences between primary and secondary dysmenorrhea? (Select all that apply.) A. The pain associated with primary radiates to the back and thighs. B. With primary, the pain originates at the beginning of menses. C. With secondary, the pain can occur also during ovulation. D. With primary, the patient often complains of abdominal bloating. E. With primary, the patient often presents with systemic symptoms such as dizziness and headache.

In primary dysmenorrhea, the patient typically presents with abdominal pain that is dull in nature and radiates to the back and thighs. The pain begins at the start of menses and lasts approximately 8 to 48 hours. The patient presents with systemic complaints as a result of increased prostaglandins and can have gastrointestinal as well as central nervous system symptoms. The patient often complains of cramping. In secondary dysmenorrhea, pain can also occur during ovulation, whereas in primary dysmenorrhea, the pain is associated only with ovulatory cycles. (A,B,C,E)

A patient has been prescribed Danazol (Danocrine) therapy for treatment of endometriosis. Which side effect should the patient be monitored for as a part of this ongoing therapy? A. Increased breast size and fullness B. Increase in heart-protective cholesterol C. Migraine headaches D. Weight loss

Migraine headaches can occur with administration of this medication. Danazol can have masculinizing effects, leading to a decrease in breast size. A decrease in HDL (heart-protective cholesterol) and an increase in LDL occur with this medication, as do weight gain and fluid retention. (C)

A client has been prescribed Danazol (Danocrine) therapy for treatment of endometriosis. For which side effect should the client be monitored as a part of this ongoing therapy? Increased breast size and fullness. Increase in heart protective cholesterol. Migraine headaches Weight loss

Migraine headaches can occur with administration of this medication. Danazol has masculinizing effects that lead to a decrease in breast size. A decrease in HDL (heart protective cholesterol) and an increase in LDL occur with this medication. Weight gain and fluid retention occur with administration of this medication. (C)

The nurse is speaking to a client with premenstrual dysphoric disorder (PMDD) who has been prescribed a nonsteroidal antiinflammatory drug (NSAID). What should the nurse state as the reason for prescribing this medication to the client? A. Prevents abdominal cramps B. Reduces breast tenderness C. Helps to elevate the client's mood D. Is used to prevent inflammation of the uterus

NSAIDs are usually prescribed for a client with PMDD to decrease physical symptoms such as breast tenderness. NSAIDs are also helpful in reducing pain due to abdominal cramps, but abdominal cramps are not a symptom associated with PMDD. NSAIDs do not interfere with the serotonin levels in the body. Therefore, this drug would not be helpful in elevating the client's mood. NSAIDs have antiinflammatory properties. However, inflammation of uterine walls is not a pathologic event occurring in premenstrual syndrome. (B)

A nurse counseling a client with endometriosis understands that which statement regarding the management of endometriosis is accurate? Select all that apply. A. Bone loss from hypoestrogenism is not reversible. B. Side effects from the steroid danazol include masculinizing traits. C. Surgical intervention often is needed for severe or acute symptoms. D. Women without pain and who do not want to become pregnant need no treatment. E. Complete hysterectomy is the only treatment for mild to severe symptoms.

Such masculinizing traits as hirsutism, a deepening voice, and weight gain occur with danazol but are reversible. Surgical intervention often is needed when symptoms are incapacitating. The type of surgery is influenced by the woman's age and desire to have children. Treatment is not needed for women without pain or without the desire to have children. Bone loss is mostly reversible within 12 to 18 months after the medication is stopped. Mild symptoms can be managed with NSAIDS. (B, C, D)

The nurse is assessing a client who reports no menses for the past 6 months. Which test should the nurse ask the client to take? A. Pregnancy test B. Blood sugar test C. Thyroid function test D. Toxicology blood screening

The client last had menses 6 months ago, which indicates that the client has secondary amenorrhea. The most common cause of secondary amenorrhea is pregnancy. Therefore, the nurse should ask the client to take a pregnancy test. A thyroid function test is used to determine alterations in thyroid hormone levels. A blood sugar test is helpful in finding whether the client has diabetes mellitus. Toxicology screening is a lab investigation to determine whether the client is involved in illicit drug abuse. Alterations in thyroid levels, elevated blood sugar levels, and illicit drug use are causes of primary amenorrhea. These factors interrupt the hypothalamic-pituitary-ovarian-uterine axis and thus cause amenorrhea. (A)

A 29-year-old client reports mild pain in the abdomen and upper thighs during menses for the past 6 months. The client also tells the nurse that the pain starts 3 days before menses. The client reports that the menstrual flow is normal. The nurse refers the client for an ultrasound. Tthe most likely reason for this referral is confirmation of whether the client has: A. Adenomyosis B. Endometriosis C. Leiomyomata D. Endometrial polyps

The client's symptoms suggest secondary dysmenorrhea, which is seen in some women over 23 years of age. As reported by the client, the onset of dysmenorrheal pain is a few days before menses. Therefore, the most likely cause of dysmenorrhea is endometriosis. Secondary dysmenorrhea associated with adenomyosis, leiomyomata, and endometrial polyps is usually accompanied by heavy menstrual bleeding. Moreover, in these conditions, the dysmenorrheal pain occurs along with menstrual bleeding, and not before menstruation. Therefore, it is unlikely that the client has secondary dysmenorrheal due to these conditions. (B)

What condition may be seen in a female client who takes oral contraceptive pills (OCPs)? Salpingitis Dysmenorrhea Endometritis Midcycle bleeding

A client who takes OCPs may sometimes have midcycle bleeding. If the OCPs do not maintain a sufficiently hypoplastic endometrium, the endometrium will begin to shed in small amounts at a time. This phenomenon is called breakthrough bleeding. Salpingitis is an infectious and inflammatory process and not a condition caused by OCP administration. Dysmenorrhea is pain associated with menstruation; it is not a side effect of OCPs. Endometritis is an infectious and inflammatory process and is not a result of OCP administration. (D)

A client experiences a single episode of heavy bleeding with abdominal pain. On assessment, the nurse finds that the period was also delayed. Which other factor does the nurse need to evaluate to determine the possible cause of this episode? A. Evaluate bone density test report. B. Evaluate for gastrointestinal bleeding. C. Evaluate renal function reports. D. Evaluate serum β-hCG pregnancy test results.

A single episode of heavy bleeding and abdominal pain may indicate an early pregnancy loss. Therefore, the nurse needs to evaluate the client's serum β-hCG pregnancy test results. A bone density report is a priority when the client is at risk for fractures. Dark-colored stools, not heavy bleeding, indicate gastrointestinal bleeding. Renal function tests are not a priority at this stage, because they will not shed any light on the cause of the bleeding. (D)

What does the nurse assess to detect the cause of amenorrhea in a client? Select all that apply. A. Obesity B. Pregnancy C. Malnutrition D. Exercise regimen E. Urinary tract infection

Amenorrhea is the absence of menstrual flow. Sometimes, pregnancy can cause amenorrhea. Delay of the onset of menstruation can also be caused by malnutrition or starvation. Girls who exercise strenuously before menarche often experience a delayed onset of menstruation until the age of 18 years. Obese girls usually have early-onset menstruation. Urinary tract infections do not delay menstruation; however, the delay may be caused by anatomic abnormalities, endocrine disorders, or the use of oral contraceptives. (B,C,D)

A 16-year-old client with amenorrhea does not want to undergo estrogen therapy. What other possible approaches to treatment might the nurse recommend to the client? Select all that apply. A. Vitamin D B. Biofeedback C. Acupressure D. Acupuncture E. Massage therapy D. Herbal medications

Biofeedback and massage therapy are alternative treatment options in amenorrhea. These interventions are helpful in relieving stress and regulating menstruation. Vitamin D can be used to lower the risk associated with breast cancer. Acupressure and acupuncture are alternative treatment options helpful in relieving dysmenorrheal pain. Herbal preparations are used for menstrual cramps, premenstrual discomfort, breast pain, and menorrhagia. (B, E)

A nurse counseling a client with endometriosis understands which statement regarding the management of endometriosis is not accurate? A. Bone loss from hypoestrogenism is not reversible. B. Side effects from the steroid danazol include masculinizing traits. C. Surgical intervention is often needed for severe or acute symptoms. D. Women without pain and who do not want to become pregnant need no treatment.

Bone loss is mostly reversible within 12 to 18 months after the medication is stopped. Such masculinizing traits as hirsutism, a deepening voice, and weight gain occur with danazol but are reversible. Surgical intervention is often needed when symptoms are incapacitating; the type of surgery is influenced by the woman's age and desire to have children. Treatment is not needed for women without pain or the desire to have children. (A)

A young adolescent has been prescribed continuous combined hormone therapy for endometriosis. What advice should the nurse give to the patient to minimize the drug-related adverse effects? A. "Have renal and liver function tested regularly." B. "Have bone mineral density tested regularly." C. "Stop the use of nonsteroidal antiinflammatory drugs (NSAIDs) for pain relief." D. "Use an absorbent sanitary pad for heavy bleeding during menses."

Combined hormone therapy affects bone mineralization in adults. Therefore, the nurse should advise the patient to have bone mineral density tested regularly. Unlike danazol, combined hormone therapy does not affect liver and renal function. NSAIDs are usually prescribed with combined hormone therapy to treat pain in adolescents with endometriosis. Therefore, the use of NSAIDs need not be discontinued when continuous combined hormone therapy is prescribed. Continuous combined hormone therapy causes temporary amenorrhea. It is not associated with heavy bleeding during menses. (B)

The nurse advises a client to start drinking cranberry and watermelon juice regularly 10 days before the expected onset of menses. Which client complaint is the nurse addressing? A. Back pain due to menses B. Peripheral edema before menses C. Nausea associated with menses D. Abdominal cramps due to menses

Cranberry and watermelon juice are natural diuretics that help to prevent fluid retention. Drinking these juices regularly would help reduce peripheral edema related to menstruation. Back pain during menses can be relieved by back massage and heat therapy. Nausea related to menses is usually not severe and does not require any specific therapy. Abdominal cramps during menses can be relieved by various methods such as exercise, heat therapy, and effleurage to the abdominal muscles. (B)

An effective relief measure for primary dysmenorrhea is to: A. Reduce physical activity level until menstruation ceases. B. Begin taking prostaglandin synthesis inhibitors on the first day of the menstrual flow. C. Decrease intake of salt and refined sugar about 1 week before menstruation is about to occur. D. Use barrier methods rather than the oral contraceptive pill (OCP) for birth control.

Decreasing intake of salt and refined sugar can reduce fluid retention. Staying active is helpful because it facilitates menstrual flow and increases vasodilation to reduce ischemia. Prostaglandin inhibitors should be started a few days before the onset of menstruation. OCPs are beneficial in relieving primary dysmenorrhea due to inhibition of ovulation and prostaglandin synthesis. (C)

A client reports heavy blood flow and painful abdominal cramps during the first 2 days of her menstrual cycle. Laboratory reports revealed elevated levels of prostaglandin F2-alpha (PGF2α). What other symptoms does the nurse suspect in this client? Select all that apply. A. Headache B. Skin rashes C. Lower limb edema D. Inability to concentrate E. Excessive sweating

Elevated levels of PGF2α result in central nervous system symptoms such as headache and inability to concentrate. Excessive sweating is a systemic response to excessive PGF2α activity. PGF2α does not affect the skin. Therefore, skin rashes are not associated with PGF2α activity. PGF2α does not interfere with the osmotic or hydrostatic pressure. Therefore, it does not cause lower limb edema. (A, D, E)

A client tells the nurse, "I tend to start gaining weight 1 week before my menstrual cycle begins, and my legs become swollen. My breasts also become very painful. What bothers me most is that I argue with my family members when depressed and irritated." What does the nurse conclude from the client's history? A. The client has primary dysmenorrhea. B. The client has premenstrual syndrome (PMS). C. The client has secondary dysmenorrhea. D. The client has premenstrual dysphoric disorder (PMDD).

Excess weight gain, edema of the lower limbs, breast tenderness, depressed mood, and irritability that persist for 1 week before the onset of menses indicate PMDD. All these symptoms do not occur together in clients with PMS. Because the client does not report the occurrence of pain during menses, the client is unlikely to have primary or secondary dysmenorrhea. All these symptoms do not occur together in clients with premenstrual syndrome. (D)

During the assessment of a client with dysmenorrhea, the client tells the nurse, "My grandmother makes me drink ginger tea when I have cramps during menses. Do you think that ginger tea is helpful?" What should be the nurse's response to the client? "Ginger helps reduce pain by controlling: A. hormones." B. prolactin levels." C. muscle spasms." D. the inflammatory reaction."

Ginger is an herbal medication often used to reduce pain related to dysmenorrhea through its antiinflammatory actions. Herbs such as black cohosh root are hormone suppressants that are also used for relieving pain during menses. Herbs such as chaste tree fruit relieve pain during menses by controlling the levels of prolactin. Herbs such as black haw and catnip are known to reduce pain by controlling muscle spasms. (D)

A professional gymnast reports amenorrhea. During assessment, the nurse finds that the client has a low body mass index. What instruction does the nurse expect from the health care provider in this case? A. To administer aspirin (Acuprin) with oral contraceptives to the athlete B. To administer 200 mg nafarelin (Synarel) by nasal spray to the athlete C. To administer 1200 mg calcium and 90 mg potassium to the athlete D. To suggest a healthful diet and encourage deep breathing exercises

Gymnasts usually have hypogonadotropic amenorrhea caused by vigorous physical and athletic training. The nurse will primarily recommend a healthful diet and deep breathing exercises to restore the body weight and keep the mind relaxed. Aspirin is recommended along with oral contraceptives in case of primary dysmenorrhea. Nafarelin is administered by nasal route in endometriosis. Calcium plus potassium along with vitamin D is recommended in hypogonadotropic amenorrhea, if the gymnast is not willing to comply with the diet and exercise regimen. (D)

Which medications are likely to be prescribed for a client with endometriosis? Select all that apply. A. Sertraline (Zoloft) B. Nafarelin (Synarel) C. Leuprolide (Lupron) D. Fluoxetine (Prozac) E. Goserelin (Zoladex)

Nafarelin (Synarel) is a nasal spray that is administered twice daily to clients with endometriosis. Leuprolide (Lupron) is an intramuscular injection given once a month and goserelin (Zoladex) is given subcutaneously every 28 days. These three medications help reduce endometrial lesions and pelvic pain in clients with endometriosis. Sertraline (Zoloft) and fluoxetine (Prozac) are used in clients with premenstrual syndrome to decrease emotional premenstrual symptoms. (B,C,E)

The nurse is teaching a client about a dietary plan for managing premenstrual dysphoric disorder (PMDD). Which instructions given by the nurse would be beneficial for the client? Select all that apply. A. "Eat nuts daily." B. "Use good-quality vegetable oils for cooking." C. "Avoid consuming caffeinated beverages." D. "Include red meat in your daily diet." E. "Avoid drinking watermelon and cranberry juices."

Nuts, vegetables, and vegetable oils are known to reduce the symptoms related to premenstrual dysphoric disorder. Therefore, the nurse should include these food items in the diet plan. Caffeinated beverages are likely to aggravate symptoms associated with premenstrual dysphoric disorder. Therefore, the nurse should advise the client to avoid these. Red meat is also known to aggravate the symptoms associated with premenstrual dysphoric disorder. Watermelon and cranberry juices are natural diuretics and reduce water retention in the body. Therefore, the nurse should advise the client to drink these juices regularly. (A, B, C)

A client with dysmenorrhea has been prescribed nonsteroidal antiinflammatory drugs (NSAIDs). The client reports passing dark-colored stools 1 week after the therapy. What can the nurse interpret from this? A. The client has developed hemorrhoids. B. The client is allergic to NSAIDs. C. The client has a gastrointestinal infection. D. The client has gastrointestinal bleeding.

One major adverse effect associated with NSAIDs is gastrointestinal bleeding. This is manifested as dark-colored stools. Hemorrhoids may also cause blood in the stools but are not a complication associated with NSAIDs. Allergic reactions related to NSAIDs are rare. These may manifest as skin rashes and itching. NSAIDs are not associated with gastrointestinal infection. Gastrointestinal infection would be manifested as diarrhea and fever. (D)

A gymnast reports she has not had her menstrual period for the past 2 months. After assessment, the nurse finds that the client is stressed out by excessive training. What advice should the nurse give the client for managing stress? Select all that apply. A. "Reduce your physical workout." B. "Increase your nutrition intake." C. "Lower your caloric intake." D. "Engage in regular physical activity." E. "Meditate or do power yoga."

Physical and mental stress are the most common reasons for irregularity in the menstrual cycle. Because gymnastics is a sport that requires physical strength and flexibility, reducing the workout might help the client lower her stress levels. Increasing nutritional value in the diet may ensure proper body growth and reduce the occurrence of amenorrhea. Meditation or power yoga keeps the mind at peace and decreases stress levels. Lowering the calorie intake would not be appropriate because this may affect the client's general health. Because the client is doing rigorous physical training, the nurse need not ask the client to engage in regular physical activity. Strenuous physical activities can further delay the onset of menstruation. (A, B, E)

An adolescent client who experiences primary dysmenorrhea complains of pain and lower abdominal cramps. What is the nurse's best response? A. "You need to increase sugar and fats in your diet." B. "Call the clinic only if you have dark-colored stools." C. "A hot bath or heating pad may help the problem." D. "The problem will diminish in 2 to 3 months."

Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established and may cause ischemia and cyclic lower abdominal cramps. A hot water bath or heating pad may help to decrease cramping and uterine ischemia and increase vasodilation and muscle relaxation. Salt and refined sugar needs to be decreased in the client's diet to reduce fluid retention. Dark-colored stools are not seen in a client with primary dysmenorrhea, but are found in a client with gastrointestinal bleeding. Primary dysmenorrhea does not diminish in 2 to 3 months, but may be common for a few years after menarche. (C)

What symptoms are seen in a client who experiences secondary dysmenorrhea? Select all that apply. A. Feelings of bloating B. Poor concentration C. Heavy menstrual flow D. Lower abdominal aching E. Gastrointestinal bleeding

Secondary dysmenorrhea is sometimes associated with pelvic pathology. Hence, the client may experience feelings of bloating or pelvic fullness. The client may also have a heavy menstrual flow due to leiomyomata, adenomyosis, or endometrial polyps. The client experiences dull, lower abdominal aching that radiates to her back or thighs. Poor concentration is a symptom seen in a client with primary dysmenorrhea. Gastrointestinal bleeding is a risk for clients who are being treated with nonsteroidal antiinflammatory drugs (NSAIDs) for primary dysmenorrhea. (A, C, D)

Which statement is true about primary dysmenorrhea? A. It is experienced by all women. B. It is unaffected by oral contraceptives. C. It occurs in young, multiparous women. D. It may be caused by excessive endometrial prostaglandin.

Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping. It is not experienced by all women. Oral contraceptives can be a treatment choice. It occurs primarily in young, nulliparous women. (D)

The nurse is preparing a care plan for a client diagnosed with hypogonadotropic amenorrhea. The client does not provide any history of sudden weight loss, eating disorder, or involvement in heavy exercise. What should be the most important goal for this client? A. To identify the stressor B. Rule out the possibility of an infection C. Relief of pain in the client D. Preparation of a diet regimen

The most common cause of hypogonadotropic amenorrhea is stress. Other causes are severe weight loss (malnourishment), an eating disorder such as anorexia, or strenuous exercises. Because the client does not have a history of sudden weight loss, eating disorder, or involvement in heavy exercise, the client is most likely to be suffering from stress. Therefore, the most important goal should be identification of the stressor. Infection of the reproductive system is known to cause abnormal bleeding but is not associated with amenorrhea. Pain is not a symptom associated with hypogonadotropic amenorrhea. Because the client has no history of eating disorders or weight loss, it is unlikely that the client has malnutrition. (A)

The provider recommends surgical intervention to a client with endometriosis. The client is worried that her reproductive capacity will be harmed by the procedure. What is the most appropriate treatment option for this client? A. Laparoscopic surgery B. Uterine artery embolization C. Total abdominal hysterectomy with BSO (TAH with BSO) D. Gonadotropin-releasing hormone (GnRH) agonist therapy

Laparoscopic surgery removes all endometrial tissue and retains ovarian function in clients with endometriosis. Therefore, this surgical process is the best treatment option for clients who want to bear children after the surgery. Uterine artery embolization is performed when the client has uterine leiomyomata or fibroids. Total abdominal hysterectomy with BSO (TAH with BSO) will not help preserve the client's childbearing ability. Gonadotropin-releasing hormone (GnRH) agonist therapy is used to suppress endogenous estrogen levels in clients with endometriosis. However, it is not useful if the disease is severe and needs surgical intervention. (A)

Which statement is true with regard to premenstrual dysphoric disorder (PMDD)? A. It can manifest symptoms similar to those of panic disorders. B. Symptom presentation is acute, is episodic in nature, and varies as the disorder progresses, leading to a chronic phase. C. There are no physical symptoms of PMDD until the disease is well progressed. D. A symptom-free period occurs in the follicular phase of the menstrual cycle.

PMDD is a variant of PMD and includes psychologic presentations as well as physical presentations. It is classified as a psychologic disorder. The patient may experience panic attacks. Symptom presentation becomes chronic, recurrent, and cyclical in nature. Physical symptoms occur with PMDD (physical and mood changes) and are present at the start of the disorder. A symptom-free period in the follicular phase of the menstrual cycle is seen in PMD, not PMDD. (A)

What symptom described by a client is characteristic of premenstrual syndrome (PMS)? A. "I feel irritable and moody a week before my period is supposed to start." B. "I have lower abdominal pain beginning the third day of my menstrual period." C. "I have nausea and headaches after my period starts, and they last 2 to 3 days." D. "I have abdominal bloating and breast pain after a couple days of my period."

PMS is a cluster of physical, psychologic, and behavioral symptoms that begins in the luteal phase of the menstrual cycle and resolves within a couple of days of the onset of menses. It does not start after menses has begun. Complaints of nausea and headaches are associated with PMS. However, stating that the timing of these is after a period has started is inaccurate. Abdominal bloating and breast pain are likely to occur a few days prior to menses, not after it has begun. (A)

The nurse is assessing a female adolescent who is experiencing amenorrhea. Which nursing action is a priority in this case? A. Assess the client's height. B. Assess the client's pregnancy status. C. Assess the client's sensitivity to aspirin. D. Assess the client for gastrointestinal bleeding.

Sometimes, amenorrhea may be caused by pregnancy. Therefore, the nurse needs to rule out pregnancy by assessing the β-human chorionic gonadotropin (β-hCG) pregnancy test report. The client's height is not a concern in this case, because it is not related to amenorrhea. Aspirin sensitivity is a concern for women who have been prescribed nonsteroidal antiinflammatory drugs to prevent interaction. Gastrointestinal bleeding is not a concern in this case, because the client has not reported abdominal pain or dark-colored stools. (B)

The nurse is assessing a postmenopausal client who is being treated for vertebral fracture. The nurse finds that the client has a history of smoking and excessive consumption of alcohol, which may cause osteoporosis. What other finding in the client may be a result of osteoporosis? A. Change in height B. Endometriosis C. Hypothyroidism D. High estrogen levels

The first sign of osteoporosis is often loss of height after a vertebral fracture. One of the causes of osteoporosis in this client is excessive alcohol consumption, which exacerbates osteoporosis because it interferes with calcium absorption and depresses bone formation. Secondary amenorrhea, dyspareunia, abnormal uterine bleeding, and infertility are all common side effects of endometriosis. Hyperthyroidism, not hypothyroidism, is a potential risk factor for osteoporosis, because thyroid hormone medication causes bone loss. Smoking causes bone loss and decreases estrogen production. A postmenopausal client would not be expected to have high estrogen levels. (A)

Which finding is associated with endometriosis? A. Chandelier sign B. Chocolate cyst C. Chadwick sign D. Blood in the cul-de- sac

A chocolate cyst is seen in endometriosis as a result of old blood. The chandelier sign is associated with PID. Chadwick sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is a presumptive sign of pregnancy. With endometriosis, fluid is found in the cul-de-sac, which can be associated with ectopic pregnancy and ovarian disease. (B)

A client has been prescribed nonsteroidal antiinflammatory drugs (NSAIDs) for the treatment of primary dysmenorrhea. Which instruction is important for this client? A. "Increase salt and sugar in your diet." B. "Avoid cranberry or watermelon juice." C. "Report any symptoms of nausea and vomiting." D. "Report dark-colored stools immediately."

A client who is taking NSAIDs for primary dysmenorrhea may have adverse effects like dark-colored stools. In this case, the client needs to report this immediately, because it indicates gastrointestinal bleeding. Decreasing salt and sugar intake 7 to 10 days before menses reduces fluid retention. Cranberry and watermelon juices are natural diuretics that help reduce edema. Nausea and vomiting are side effects of NSAIDs and can be reduced by adjusting meal times or taking antacids. (D)

With regard to the diagnosis and management of amenorrhea, nurses should be aware that it: A. probably is the result of a hormone deficiency that can be treated with medication. B. may be caused by stress or excessive exercise or both. C. likely will require the woman to eat less and exercise more. D. often goes away on its own.

Amenorrhea usually is the result of stress and/or an inappropriate ratio of body fat to lean tissue, possibly as a result of excessive exercise. Management includes counseling and education about the causes and possible lifestyle changes. Amenorrhea may be the result of a decrease in follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In most cases a woman will need to decrease her amount of exercise and increase her body weight in order to resume menstruation. Management of stress and eating disorders is usually necessary to manage this condition. (B)

*Which finding is not associated as a health risk with menopause? A. Osteoporosis B. Coronary heart disease C. Breast cancer D. Obesity

Breast cancer may be associated with the use of hormone replacement therapy for women who have a family history of breast cancer. Osteoporosis is a major health problem in the United States; it is associated with an increase in hip and vertebral fractures in postmenopausal women. A woman's risk for development of and death from cardiovascular disease increases significantly after menopause. Women tend to become more sedentary in midlife. The metabolic rate decreases after menopause, so an adjustment in lifestyle and eating patterns may be required. (C)

What should the nurse stress in teaching a woman to deal with the symptoms of premenstrual syndrome (PMS)? A. Decrease her consumption of caffeine. B. Drink a small glass of wine with her evening meal. C. Decrease her fluid intake to prevent fluid retention. D. Eat three large meals a day to maintain glucose levels.

Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates depression and should be avoided. Fluid intake should not be decreased. Three small to moderate meals and three snacks a day can help relieve symptoms. (A)

A woman states, "I'm sure that I am suffering from premenstrual syndrome (PMS). How can I get my doctor to take this seriously?" What is the nurse's best response? A. "Men usually are not sympathetic to PMS sufferers." B. "You are probably right. You should remind your health care provider of your symptoms every time you visit." C. "Because you feel certain that you are right, you should just treat yourself with over-the-counter medications." D. "You should keep a daily record of the occurrence and severity of your symptoms for six months."

Charting symptoms for several cycles is necessary to make an accurate diagnosis of PMS. Stating that men are not sympathetic to PMS sufferers does not help the woman with the present problem. Listing symptoms for several cycles will help the heath care provider better assess the diagnosis. The woman should not treat herself with over-the-counter medications. (D)

A client with endometriosis is planning to start danazol (Danocrine) therapy. On assessment, the nurse finds that the client is 3 weeks pregnant. What instructions does the nurse expect from the primary health care provider? A. Discontinue the drug prescription. B. Initiate surgical treatment immediately. C. Lower the medication dose by half. D. Recommend terminating the pregnancy.

Danazol (Danocrine) is not administered if the client is pregnant, because the drug can cause pseudohermaphroditism in female fetuses. Therefore, the nurse should promptly inform the primary health care provider about the client's pregnancy so that the prescription can be discontinued. Surgical treatment is necessary if the client is not pregnant and the disease is producing incapacitating symptoms. The medication dose is not lowered but terminated at once. The primary health care provider is not likely to recommend terminating the pregnancy. However, close monitoring may be needed to prevent any adverse pregnancy outcomes. (A)

Which adverse effects can be seen in a client who is taking danazol (Danocrine) for endometriosis? Select all that apply. A. Hot flashes B. Depression C. Deepening of voice D. Pseudohermaphroditism E. Decreased lipoprotein levels

Danazol (Danocrine) therapy may cause many adverse effects in a client with endometriosis. The client may experience hot flashes and depression due tothe decreased secretion of estrogen and progesterone caused by the drug. The drug can also cause masculine traits to develop in the client. These include making the client's voice deeper and decreasing her breast size. Danazol (Danocrine) adversely affects lipids and leads to a decrease in high-density lipoprotein levels and an increase in low-density lipoprotein levels. Pseudohermaphroditism is a condition seen in a female fetus when the mother takes danazol (Danocrine) therapy during pregnancy. (A, B, C, E)

What is an effective relief measure for primary dysmenorrhea? A. Reduce physical activity level until menstruation ceases. B. Begin taking prostaglandin synthesis inhibitors on the first day of the menstrual flow. C. Decrease intake of salt and refined sugar about 1 week before menstruation is about to occur. D. Use barrier methods rather than the oral contraceptive pill (OCP) for birth control.

Decreasing intake of salt and refined sugar can reduce fluid retention. Staying active is helpful because it facilitates menstrual flow and increases vasodilation to reduce ischemia. Prostaglandin inhibitors should be started a few days before the onset of menstruation. OCPs are beneficial in relieving primary dysmenorrhea as a result of inhibition of ovulation and prostaglandin synthesis. (C)

The nurse is assessing a 15-year-old high school student who is worried because she has not yet begun menses. The nurse tells the student that she may attain her menses late. What assessment findings might the nurse have noted in the patient? Select all that apply. A. Morbidly obese B. Thyroid disorder C. Anorexia nervosa D. Type 1 diabetes mellitus E. Strenuous sports

Females who have a low body mass index due to malnutrition (anorexia) often have delayed onset of menstruation. Females who are involved in strenuous exercise at the time of menarche may also have delayed onset of menstruation. Females who are obese may have early-onset menstruation because of their high body mass index. Females with thyroid disorders or type 1 diabetes mellitus are not known to have a delayed onset of menarche. They are at risk of developing amenorrhea caused by interruption in the hypothalamic-pituitary-ovarian-uterine axis. (C, D)

A 13-year-old client who recently began menstruating tells the nurse that she has had irregular bleeding since her cycle began. What does the nurse tell the client? A. "There may be some underlying disease." B. "It's likely being caused by a urinary tract infection." C. "You need to include more calcium in your diet." D. "Bleeding may be irregular for the first 2 years."

In early adolescence irregular menstrual bleeding may be common due to anovulatory cycles. After an average of 20 cycles, ovulation occurs regularly. Hence, in the first 2 years of menarche, there can be irregular bleeding. The presence of a coexisting disease will be indicated by other symptoms and not just irregular bleeding. The client does not experience pain or any other symptoms of infection. Clients with a low bone density, not irregular bleeding, may be required to increase the intake of calcium in their diets. (D)

What are the possible causes of menorrhagia in a client? Select all that apply. A. Obesity B. Fibroids C. Endometritis D. Chemotherapy E. Diabetes mellitus

Menorrhagia is excessive menstrual bleeding, in either amount or duration. In obese clients, anovulation may be caused by an increased peripheral conversion of androstenedione to estrogen, which may develop as menorrhagia. Fibroids are benign tumors of the smooth muscle of the uterus that may cause menorrhagia in a client. Infectious and inflammatory processes such as acute or chronic endometritis may cause heavy menstrual bleeding. Chemotherapy and steroid hormone therapy have also been associated with heavy bleeding. Diabetes mellitus is a potential risk for osteoporosis among other comorbidities, not heavy bleeding. (A, B, C, D)

A female client who experiences metrorrhagia has been taking oral contraceptive pills (OCPs). The client is instructed to take the pills at the same time each day to alleviate breakthrough bleeding. On assessment, after a week, the client is prescribed a different contraceptive pill with an increased progestin component. Which condition does the nurse expect led to the change? A. The breakthrough bleeding continued. B. The client had osteoporosis. C. The client experienced nausea. D. The client experienced gastrointestinal bleeding.

Metrorrhagia is an episode of bleeding that occurs at a time other than the normal menses. Metrorrhagia may occur if the client takes OCPs. The problem can be resolved if the client takes the OCPs at the same time each day. However, if the bleeding continues, the client is prescribed a different formulation of the OCP that increases either the estrogen or progestin component of the pill. An increase in calcium intake is usually prescribed for a client who develops osteoporosis. Nausea is a side effect of estrogen use. Nausea occurs if the progestin component in the pills is increased. Gastrointestinal bleeding is a side effect of nonsteroidal antiinflammatory drugs (NSAIDs). (A)

Which finding is associated as a health risk with menopause? A. Osteoporosis B. Coronary heart disease C. Breast cancer D. Obesity E. Stomach cancer

Osteoporosis is a major health problem in the United States. It is associated with an increase in hip and vertebral fractures in postmenopausal women. A woman's risk of developing and dying of cardiovascular disease increases significantly after menopause. Women tend to become more sedentary in midlife, which can increase obesity rates. The metabolic rate decreases after menopause, which may require an adjustment in lifestyle and eating patterns. Breast cancer may be associated with the use of hormone replacement therapy for women who have a family history of breast cancer. Stomach cancer is not associated with menopause. (A, B, D)

Which symptom described by a woman is characteristic of premenstrual syndrome (PMS)? A. "I feel irritable and moody a week before my period is supposed to start." B. "I have lower abdominal pain beginning the third day of my menstrual period." C. "I have nausea and headaches after my period starts, and they last 2 to 3 days." D. "I have abdominal bloating and breast pain after a couple days of my period."

PMS is a cluster of physical, psychologic, and behavioral symptoms that begin in the luteal phase of the menstrual cycle and resolve within a couple of days of the onset of menses. PMS begins in the luteal phase and resolves as menses occurs. It does not start after menses has begun. This complaint is associated with PMS. However, the timing reflected in this statement is inaccurate. PMS begins in the luteal phase and resolves as menses occurs. It does not start after menses has begun. Abdominal bloating and breast pain are likely to occur a few days prior to menses, not after it has begun. (A)

What medications are traditionally used in the treatment of physical symptoms of premenstrual syndrome (PMS)? Select all that apply. Progesterone Estrogen replacement therapy Prostaglandin inhibitors Selective serotonin reuptake inhibitors (SSRIs) Gonadotropin-releasing hormone (GnRH) agonist therapy

Progesterone and prostaglandin inhibitors are used in the treatment of premenstrual syndrome (PMS) to relieve the physical symptoms such as abdominal bloating, pelvic fullness, edema of the lower extremities, breast tenderness, and weight gain. Selective serotonin reuptake inhibitors (SSRIs) are used to relieve emotional premenstrual symptoms, especially depression. Estrogen replacement therapy is used in the treatment of menopause, not PMS. Gonadotropin-releasing hormone (GnRH) agonist therapy is used to suppress endogenous estrogen levels in clients with endometriosis. (A, C, D)

The nurse is preparing to speak to a group of women who are at risk of developing dysmenorrhea. Which patients should be included in the teaching session? Select all that apply. A. Those who smoke B. Those who have a low body mass index C. Those who have more than two children D. Those who have high stress due to work E. Those who are involved in strenuous exercise

Research has proven that women who smoke are more susceptible to dysmenorrhea. Women who are highly stressed are also prone to have dysmenorrhea. Smoking and stress may cause excessive release of prostaglandin F2-alpha (PGF2α) which causes painful uterine contractions. Women who have a low body mass index are not susceptible to dysmenorrhea. Such patients are more likely to have amenorrhea. However, women with a high body mass index are more likely to have primary dysmenorrhea. Multiparous women are not known to have dysmenorrhea. Women who are nulliparous (have no child) are more likely to have dysmenorrhea. Patients who are involved in heavy exercise are not susceptible to dysmenorrhea. They are more likely to have primary amenorrhea. (A, D)

A 15-year-old female client experiences extreme stress due to schoolwork, which has led to an eating disorder and significant weight loss. Which condition is likely to be seen in the client? Dysmenorrhea Hypothyroidism Hypogonadotropic amenorrhea Premenstrual dysphoric disorder

Stress and eating disorders result in hypothalamic suppression, which may further lead to hypogonadotropic amenorrhea. Dysmenorrhea refers to the pain experienced before or during menstruation. Weight gain and constipation, not weight loss, are seen in hypothyroidism. In premenstrual dysphoric disorder, the client feels overwhelmed and often experiences mood disturbances. (C)

A nurse counseling a woman with endometriosis understands which statements regarding the management of endometriosis are accurate? Select all that apply. A. Bone loss from hypoestrogenism is not reversible. B. Side effects from the steroid danazol include masculinizing traits. C. Surgical intervention often is needed for severe or acute symptoms. D. Women without pain and who do not want to become pregnant need no treatment. E. Women with mild pain who may want a future pregnancy may take nonsteroidal antiinflammatory drugs (NSAIDs).

Such masculinizing traits as hirsutism, a deepening voice, and weight gain occur with danazol but are reversible. Surgical intervention often is needed when symptoms are incapacitating. The type of surgery is influenced by the woman's age and desire to have children. Treatment is not needed for women without pain or the desire to have children. Bone loss is mostly reversible within 12 to 18 months after the medication is stopped. In women with mild pain who may desire a future pregnancy, treatment may be limited to use of NSAIDs during menstruation. (B,C,D)

A client who is the mother of two children experiences menorrhagia due to uterine leiomyomata. The client's condition is severe, and therefore surgical removal of fibroids is recommended. After discussing the surgical options, the client decides to undergo uterine artery embolization. Which surgical side effect should the nurse verify that the client understands before her surgery? A. Obesity B. Menopause C. Osteoporosis D. Loss of fertility

Uterine artery embolization has a risk for fertility loss in the client. Obesity is not a side effect of uterine artery embolization. Instead, there is reduced menorrhagia, less dysmenorrhea, and reduced pelvic pressure and urinary symptoms. Excessive smoking, alcoholism, heredity, menopause, or conditions like diabetes mellitus may contribute to osteoporosis, but these are not surgical complications (D)