Chapter 4 - Common Reproductive Issues

Contraceptive methods: Behavior

-Abstinence -Fertility awayness-based methods (FAM) -withdrawal (coitus interruptus) -Lactational amenorrhea method (LAM)

Contraceptive methods: Hormonal

-OC -injectable contraceptive -transdermal patch -vaginal ring -implantable contraceptive -intrauterine contraceptive -emergency contraceptive

Urogenital changes that occur during menopause

-Vaginal atrophy: occurs because of decline in estrogen. -increase in pH -irritation -loss of lubrication -increase susceptibility to infections -decrease in sexual desire

Contraceptive methods: Barrier

-condom (male & female) -diaphragm -cervical cup -sponge

Management for menopause

-consider weight bearing exercises -calcium & vitamin D -smoking cessation -avoidance of alcohol to treat or prevent osteoporosis -annual breast exams and mammograms are essential -local estrogen creams can be used for vaginal atrophy

Disadvantages of oral contraceptives

-offer no protection against STI -pose slightly increased risk of breast cancer -modest risk for venous thrombosis and pulmonary embolism -increased risk for migraine headaches -increased risk for myocardial infarction, stroke, hypertension for women who smoke -may increase risk of depression -high cost for some women -user must remember to take pill daily

Amenorrhea: physical exam

-pelvic examination -height, weight, BMI, vitals -hypothermia, bradycardia, hypotension, and reduced subcutaneous fat (observed in anorexia nervosa) -facial hair and acne may be evidence of androgen excess secondary to tumor -presence of absence or public hair indicate adrenal and ovarian hypo secretion or delayed puberty

Advantages of oral contraceptives

-regulate and shorten menstrual cycle -decrease severe cramping and bleeding -reduce anemia -reduce ovarian and colorectal cancer -decrease benign breast disease -reduce risk of endometrial cancer, colorectal cancer, and ovarian cancer -improves acne and reduces incidence of menstrual headaches -minimize perimenopausal symptoms -decrease incidence of rheumatoid arthritis -improve PMS symptoms -protects against loss of bone density and reduce risk of osteoporosis

Contraceptive methods: Permanent methods

-tubal ligation or Essure for women -Vasectomy for men

What are the drugs used to terminate a pregnancy during the 1st trimester?

1. Methotrexate (antineoplastic agent) followed by misoprostol (prostaglandin agent) given as a vaginal suppository or in oral form. Methotrexate induces abortion due to its toxicity to trophoblastic tissue (the growing embryo) Misoprostol causes uterine contractions which helps expel the products of conception. 2. Mifepristone (progesterone antagonist) follow 48 hrs later by misoprostol (widely used method) 95% effective when used within 49 days after the last menstrual cycle

Nurses need to consider the causes of amenorrhea as occurring in one of the four anatomical areas:

1. outflow area of the uterus and vagina 2. the ovaries 3. the pituitary glands 4. the central nervous system

Reproduction requires the interaction of the female and male reproductive tracts, which involve:

1. the release of normal preovulatory oocyte 2. the production of adequate spermatoza 3. the normal transport of the gametes to the ampullarf portion of the fallopian tube (where fertilization takes place) 4. the subsequent transport of the cleaving embryo into the endometrial cavity for implantation and development

Surgical abortion

1. vacuum aspiration or dilation 2. evacuation (D&C) The cervix is dilated prior to surgery and then the products of conception are removed by suction evacuation. procedure takes about 10 minutes. Major risk & complications: infection, retained tissue or hemorrhage, uterine perforation, retained products of conception, or cervical care. For women whose blood is Rh (-), RhoGAM is indicated prior

Contraceptive failure problem: 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.

Contraceptive failure problem: inconsistent use of contraceptive

Client education needed:Contraceptives must be used regularly to achieve maximum effectiveness. All it takes is one unprotected act of sexual intercourse to become pregnant. Two to 5% of condoms will break or tear during use.

Contraceptive failure problem: not following instructions for use of contraceptive correctly

Client education needed: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 IUD for placement monthly.

Postcoital emergency contraceptives (ECs)

Description: Combination of levonorgestrel-only pills; combined estrogen and progestin pills; or the copper IUS inserted within 72 hr after unprotected intercourse Pros: provides a last chance to prevent a pregnancy Cons: risk of ectopic pregnancy if EC fails Danger signs: nausea, vomiting, abdominal pain, fatigue, headache Comments: inform woman that ECs do not interrupt an established pregnancy, and the sooner they are taken the more effective they are

Depo-Provera Injection

Description: an injectable progestin that inhibits ovulation Pros: long duration of action (3 months); highly effective; estrogen-free; may be used by smokers; may be used by lactating women Cons: menstrual irregularities; return visit needed every 12 weeks; weight gain, headache, depression, return to fertility delayed up to 12 months Danger signs: if depression is a problem, this method may increase the depression Comments: inform woman that fertility is delayed after stopping the injections Primary side effect is menstrual cycle disturbance

Sponge with spermicide

Description: disk-shaped polyurethane device containing spermicide that is activated by wetting it with water. prevents pregnancy by covering the cervix and releasing spermicide. Pros: offers immediate and continuous protection for 24 hours; OTC Cons: can fall out of vagina with voiding; is not form fitting in the vagina Danger signs: irritation, allergic reactions, toxic shock syndrome can occur if sponge left in too long Comments: caution woman not to leave sponge beyond 24 hours. the woman first wets the sponge with water, 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 6 hours following intercourse. provides protection for up to 12 hours

Withdrawal (coitus interruptus)

Description: man withdraws before ejaculation (pull out) Pros: involves no device and is always available Cons: requires considerable self-control by the man; the first few drops of the true cum contains greatest concentration of sperm, if some pre-cum fluid escapes from the urethra before orgasm, conception may result Comments: places woman in trusting and dependent role

Fertility awareness-based methods

Description: natural, refrain from sex or use barrier methods during fertile period Pros: no side effects; acceptable to most religious groups Cons: high failure rate with incorrect use Comments: requires high level of couple commitment -a single ovum is released from the ovary 14 days before the next menstrual period; it lives 24 hrs -women using this method must have regular menstrual cycles for it to be effective -sperm can live up to 5 days after intercourse. the "unsafe period" during the menstrual cycle is 6 days: 3 days before and 3 days after ovulation. -the exact time of ovulation cannot be determined, so 2-3 days are added to the beginning and end to avoid pregnancy

Oral contraceptive (progesterone only mini pills)

Description: pill containing only progestin that thickens cervical mucus to prevent sperm from penetrating Pros: no estrogen-related side effects; may be used by lactating women; may be used by women with history of thrombophlebitis Cons: must be taken meticulous accuracy; may cause irregular bleeding; less effective than combo pills Danger signs: irregular bleeding, weight gain, increased incidence of ectopic pregnancy Comments: women should be screened for history of functional ovarian cysts previous ectopic pregnancy, and hyperlipemia prior Prescribed for women who cannot take estrogen at all.

Oral contraceptives (combination)

Description: pill that suppresses ovulation by combined action of estrogen & progesterone Pros: easy to use; high rate of effectiveness; protection against ovarian and endometrial cancer Cons: must remember to take pill daily; possible undesirable side effects Danger signs: dizziness, nausea, mood changes, high BP, blood clots, heart attack, strokes Comments: woman must be assessed to make sure she is not a smoker and does not have history of thromboembolic disease

Female condom

Description: polyurethane sheath inserted vaginally to block sperm Pros: use controlled by woman; eliminates postcoital drainage of semen Cons: expensive for frequent use; cumbersome; noisy during sex; single use only STI: provides protection Danger signs: allergy to polyurethane Comments: couples must be instructed on proper use of condom

Abstinence

Description: refrain from sexual activity Pros: cost nothing, reduces risk of contracting HIV/AIDS, other STI's Cons: difficult to maintain Comments: must be a joint couple decision Reasons some people choose this: -wait until they are older -wait for a long-term relationship -avoid pregnancy or STI -relieve feelings of depression or anxiety -follow religious or cultural expectations

Diaphragm with spermicide

Description: soft latex 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. Should be replaced every 1-2 years. User-controlled, non hormonal method, that are needed only at the time of intercourse. Pros: does not use hormones; considered medically safe; provides some protection against cervical cancer Cons: requires accurate fitting by health care professional; increase in UTI's Danger signs: allergy to latex, rubber, polyurethane, spermicide. Report symptoms: toxic shock syndrome. May become dislodged in the female superior position Comments: woman must be taught to insert and remove diaphragm correctly

Implant (nexplanon)

Description: time-release implant of levonorgestrel for 3 years Pros: long duration of action; low dose of hormones; reversible; estrogen-free Cons: Irregular bleeding, weight gain, breast tenderness, headaches, difficulty in removal Danger signs: if bleeding is heavy, anemia may occur Comments: before insertion, assess woman to make sure she is aware that this method will produce about 3 years of infertility Side effects: irregular bleeding, headaches, weight gain, breast tenderness, depression.

Transdermal Patch (ortho evra)

Description: transdermal patch that releases estrogen and progestin into circulation. avoids hepatic first-pass metabolism allowing a lower total hormone dose when compared to oral products metabolized in the liver (reduces side effects) Pros: easy system to remember; very effective Cons: may cause skin irritation where it is placed; may fall off and not be noticed thus providing no protection Danger signs: less effective in women weighing more than 200 lbs Comments: instruct woman to apply patch every week for 3 weeks and then not to wear one during week 4

Lactational amenorrhea method (LAM)

Description: uses lactational infertility for protection from pregnancy; used by breast-feeding mothers. continuous breast feeding can postpone ovulation and prevent pregnancy. breast-feeding stimulates prolactin, while inhibiting gonadotropin (necessary for ovulation) Pros: no cost Cons: temporary method; effective for only 6 months after giving birth Comments: mother must breastfeed infant on demand without supplementation for 6 months Can be effective for 6 months after giving birth only if:• a woman has not had a period since she gave birth; • infant is younger than 6 months of age; • the woman breast-feeds her baby at least six times daily on both breasts; • she breast-feeds her baby "on demand" at least every 4 hours; • a woman does not substitute other foods for a breast-milk meal; • nighttime feedings are provided at least every 6 hours.

Ring (NuvaRing)

Description: vaginal contraceptive ring about 2 inches in diameter that is inserted into the vagina; releases estrogen and progestin. inserted by the user for a 3 wk period of continuous use followed by a ring-free week to allow withdrawal bleeding. Pros: easy system to remember; very effective Cons: may cause vaginal discharge, can be expelled without noticing and offer no protection Danger signs: similar to oral contraceptives Comments: instruct woman to use a backup method if ring is expelled and remains out for more than 3 hours Reported problems associated: erosion of vaginal wall, ring expulsion, interference with coitus, unpleasant ring odor, premature discontinuation due to vaginal discomfort

Perimenopause

Ovaries bein to fail, producing irregular and missed periods and an occasional hot flash. when menopause finally appears, viable ova are gone. The major hormone produced during reproductive years is estradiol; the estrogen found in postmenopausal women is estrone.

Warnings for IUD users of potential complications

P= period late, pregnancy, abnormal spotting or bleeding A= abdominal pain, pain with intercourse I= infection exposure, abnormal vaginal d/c N= not feeling well, fever, chills S= string length shorter or longer or missing

Laparoscopy

Performed early in the menstrual cycle. Used when abnormalities are found on the ultrasound or hysterosalpingogram. 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

Amenorrhea: therapeutic management

Primary: involves the correction of any underlying disorders and estrogen replacement therapy to stimulate the development of secondary sexual characteristics Secondary: 1) cyclic progesterone, when the cause is anovulation, or oral contraceptives (OCs); 2) bromocriptine to treat hyperprolactinemia; 3) nutritional counseling to address anorexia, bulimia, or obesity; 4) gonadotropin-releasing hormone (GnRH), when the cause is hypothalamic failure; 5) thyroid hormone replacement, when the cause is hypothyroidism

Semen analysis

Semen analysis is the most important indicator of male fertility. The man should abstain from sexual activity for 24 to 48 hours 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 to 2 hours. 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

Clomiphene citrate challenge test

Used to assess a woman's ovarian reserve (ability of her eggs to become fertilized) If FSH level is >15, the result is considered abnormal and likelihood of conception with her own eggs is very low

Cervical mucus ovulation method

Used to assess the character of the cervical mucus. 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 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.

Permanent sterilization: Male

Vasectomy* Description: sealing, typing, or cutting the vas deferens Pros: one-time decision provides permanent sterility; short recovery time; low long-term risks Cons: procedures are difficult to reverse; initial cost may be high; chances of regret; some pain/discomfort after procedures Danger signs: postoperative complications: pain, bleeding, infection Comments: counsel both as to permanence of procedure and urge them to think it through prior to signing consent

The Standard Days Method (SDM) and Two-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 takes into account the life span 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. For the Two-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

Female condom insertion / removal technique and counseling:

• Practice wearing and inserting prior to first use with sexual intercourse. • Condom can be inserted up to 8 hours before intercourse. • Condom is intended for one-time use. • It can be purchased over the counter—one size fits all. • Avoid wearing rings to prevent tears; long fingernails can also cause tears. • Spermicidal lubricant can be used if desired. • Insert the inner ring high in the vagina, against the cervix. • Place the outer ring on the outside of the vagina. • Make sure the erect penis is placed inside the female condom. • Remove the condom after intercourse. Avoid spilling the ejaculate.

Laboratory test to determine the cause of amenorrhea

• 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)

CycleBeads

A string of 32-color-coded beads with each bead representing a day of the menstrual cycle. Help women keep track of the days on which they should avoid unprotected intercourse The brown beads are the days when pregnancy is unlikely, white beads represent fertile days

Early signs of complications for users of oral contraceptives

A= abdominal pain may indicate liver or gallbladder problems C= chest pain or SOB may indicate pulmonary embolism H= headaches may indicate hypertension or impending stroke E= eye problems may indicate hypertension or an attack S= severe leg pain may indicate thromboembolic event

Amenorrhea

Absence of menses Primary amenorrhea is defined as: 1) absence of menses by age 14, with absence of growth and development of secondary sexual characteristics, or 2) absence of menses by age 16, with normal development of secondary sexual characteristics Secondary amenorrhea: absence of regular menses for 3 cycles or irregular menses for 6 months in women who have previously menstruated regularly

Medical Abortion

Administration of medication either vaginally or orally; may require two or four office visits, and cost between $300-$800.

Factors that trigger vasomotor symptoms (hot flashes):

Caffeine & alcohol consumption Intake of hot drinks & spicy foods Hot environment Depression Stress Anxiety

Education & 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 • Menorrhagia • Depression • Severe abdominal pain • Awareness of any infection present at injection site.

Home ovulation predictor kits

Contain antibodies specific for LH and use the ELISA test to determine amount of LH present in urine.

Abortion

Defined as the expulsion of an embryo or fetus before it is viable. Can be medical or surgical procedure. the purpose is to terminate a pregnancy. Roe v. Wade legalized abortion

Infertility

Defined as the inability to conceive a child after 1 year of regular sexual intercourse unprotected by contraception

Intrauterine contraceptives (IUC/IUD)

Description:A T-shaped device inserted into the uterus that releases copper or progesterone or levonorgestrel. 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. Pros:It is immediately and highly effective; allows for sexual spontaneity; can be used during lactation; return to fertility not impaired; requires no motivation by the user after insertion Cons:Insertion requires a skilled professional; menstrual irregularities; prolonged amenorrhea; can be unknowingly expelled; may increase the risk of pelvic infection; user must regularly check string for placement; no protection against STIs; delay of fertility after discontinuing for possibly 6-12 mo Danger signs: cramps, bleeding, pelvic inflammatory disease, infertility, perforation of the uterus Comments: instruct woman how to locate string to check for monthly placement Makes periods lighter, shorter, less painful, making this a useful method for women with heavy & painful periods.

Screening evaluation/assessment for women for infertility

Diagnostic tests to determine female infertility may include: - Assessment of ovarian function - Ovulation predictor kits used midcycle - Urinary LH level - Clomiphene citrate challenge test - Assessment of pelvic organs - Papanicolaou (Pap) smear to rule out cervical cancer or inflammation - Cervical culture to rule out any STIs - Ultrasound to assess pelvic structures - Hysterosalpingography to visualize structural defects - Laparoscopy to visualize pelvic structures and diagnose endometriosis

Dyspareunia

Difficult or painful sexual intercourse

Screening evaluation/assessment for men for infertility

From male perspective: the number of sperm must be adequate, the sperm must be healthy and mature, the perm must be able to penetrate and fertilize the egg in order for conception to take place -Reproductive history -Semen analysis -assessment for male sexual characteristics, such as body hair, adam's apple, muscle development -examination of the penis, scrotum, testicles, epididymysis, vas deferens -assessment for normal development of external genitalia (small testicles) -performance of a digital internal examination of the prostate to check for tenderness or swelling

Hysterosalpingography

Gold standard in assessing patency of the fallopian tubes Fallopian tube obstruction is most common cause of female infertility Ultrasounds and MRI are used in this assessment. 3-10 mL of opaque contract medium is injected through a catheter into the endocervical canal so the uterus and tubes can be visualized. 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 cavity

Amenorrhea: health history

Include questions about: -women's menstrual history -past illnesses -hospitalization and surgeries -obstetric history -use of prescription and over the counter drugs -recent or past lifestyle changes -history of present illness -assessment of body changes

Basal Body Temperature method

Lowest temperature reached on awakening. The woman takes her temp orally before rising and records it on a chart. 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 their body temperature and give a false reading

Contraception

Method that prevents conception or childbirth, including OC's, sterilization of the female, the male condom. In addition to unwanted pregnancies, contraceptives help prevent transmission of STI's and HIV.

Male condom

Pros: widely available; low cost Cons: decreased sensation for men; interferes with sexual spontaneity; breakage risk STI: provides protection Danger signs: latex allergy Comments: couple must be instructed on proper use of condom

Menopausal transition

Refers to the transition from a woman's reproductive phase of her life to her final menstrual period. It is the end of the childbearing capacity and her menstruation. The absolute number of ova in the ovary is a major determinant of fertility. The hypothalamic-pituitary-ovarian axis breaks down before any sign of menopause. Usually 2-8 years before cessation of menstruation is called perimenopause.

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 A home predictor test for ovulation may be used; measures LH levels to pinpoint the day before or the day of ovulation

How does OC work?

work primarily by suppressing ovulation by adding estrogen and progesterone to a woman's body, thus mimicking pregnancy. This hormonal level stifles GnRH, which in turn suppresses FSH and LH and thus inhibits ovulation. Cervical mucus also thickens, which hinders sperm transport into the uterus. Implantation is inhibited by suppression of the maturation of the endometrium and alterations of uterine secretions

Cervical cap

Smaller than the diaphragm and covers only the cervix; it is held in place by suction. caps are made from silicone or latex and are used with spermicide. The cap may be inserted up to 26 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. Contraindications include cervical cancer, recent UTI, latex allergy, pelvic-organ prolapse, and history of toxic shock syndrome. using the cap before menstruation increases the risk for toxic shock syndrome

Tanner stages of breast development:

Stage 1: Papilla evaluation only Stage 2: breast bugs palpable and areolae enlarge (11 yr old) Stage 3: evaluation of breast contour; areolae enlarge (12 yr old) Stage 4: areolae forms secondary mound on the breast (13 yr old) Stage 5: adult breast contour; areola recesses to breast contour

Permanent sterilization: Female

Tubal ligation* Fallopian tubes are blocked to prevent conception

Secondary infertility

The inability to conceive after a previous pregnancy

Nursing management of the woman choosing a contraceptive method:

The nurse can educate clients about which methods are available and their advantages and disadvantages, efficacy, cost, and safety. Knowledge of contraceptive effectiveness is crucial to making an informed choice. The couple has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness. Counseling can help the woman choose a contraceptive method that is efficacious and fits her preferences and lifestyle.

Internality: nursing management

The nurse's focus must encompass the whole person, not just the results of the various infertility studies. Throughout the entire process, the nurse's role is to provide information, anticipatory guidance, stress management, and counseling. The couple's emotional distress is usually very high, and the nurse must be able to recognize that anxiety and provide emotional support. The nurse may need to refer couples to a reproductive endocrinologist or surgeon, depending on the problem identified

Essure

nonsurgical, non hormonal, permanent birth control method that is 99% effective. used for women who desire no more children as it is a permanent method. 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. sterilization does not occur immediately, instruct women to use additional contraception for 3 months until permanent tubal occlusion is verified.

Managing hot flashes & night sweats

these are classic signs of estrogen deficiency and the predominant complaint of perimenopausal women. hot flashes are caused by vasomotor instability; this instability causes inappropriate peripheral vasodilation of superficial blood vessels which give the sensation of heat. hot flashes can be mild or extreme and can last from 2-30 mins.

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 vagina.

Male Condom Insertion / Removal Technique and counseling:

• Always keep the condom in its original package until ready to use. • Store in a cool, dry place. • Spermicidal condoms should be used if available. • Check expiration date before using. • Use a new condom for each sexual act. • Condom is placed over the erect penis prior to insertion. • Place condom on the head of the penis and unroll it down the shaft. • Leave a half-inch of empty space at the end to collect ejaculate. • Avoid use of oil-based products, because they may cause breakage. • After intercourse, remove the condom while the penis is still erect. • Discard condom after use.

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.

Tips for maintaining a healthy life style

• Balance energy expenditure with energy intake to maintain ideal weight range. • Modify your diet to maintain ideal weight to avoid becoming over weight. • 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. • Balance work, recreation, and rest to reduce anxiety and stress in life. • Maintain a positive outlook regarding the diagnosis and prognosis. • Participat2e in ongoing care to monitor any medical conditions. • Maintain bone density through: •Calcium intake (1,200 to 1,600 mg daily) •Vitamin D (600 to 1,000 International Units/daily) •Weight-bearing exercise (30 min or more daily) •Hormone therapy (HT) for low risk women

How does menopausal transition affect the body systems?

• Brain: 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

Common misconceptions about contraception and pregnancy:

• Breast-feeding 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.

Nursing assessment when assessing which contraceptive method might meet the client's needs:

• Do your religious beliefs interfere with any methods? • Will this method interfere with your sexual pleasure? • Are you aware of the various methods currently available? • Is cost a major consideration, or does your insurance cover it? • Does your partner influence which method you choose? • Are you in a stable, monogamous relationship? • Have you heard anything troubling about any of the methods? • How comfortable are you touching your own body? • What are your future plans for having children?

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 and inserted into the vagina, behind the pubic bone, as far back as possible. • Precision placement is not essential. • Backup contraception is needed for 7 days if the ring is expelled for more than 3 hours during the 3-week period of continuous use. • The vaginal ring is left in place for 3 weeks, then removed and discarded. • The vaginal ring is not recommended for women with uterine prolapse or lack of vaginal muscle tone

The following guidelines are helpful in counseling and educating the client or couple about contraceptives:

• Encourage the client/couple to participate in choosing a method. • Provide client education. The client/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 • Obtain written informed consents, which are needed for intrauterine contraceptives, implants, abortion, or sterilization. Informed consent implies that the client is making a knowledgeable, voluntary choice; has received complete information about the method, including the risks; and is free to change her mind before using the method or having the procedure. • Discuss contraindications for all selected contraceptives. • Consider the client's cultural and religious beliefs when providing care. • Address myths and misperceptions about the methods under consideration in your initial discussion of contraceptives.

Risk factors for internality in men include:

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

Cause of primary amenorrhea:

• 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 • Causes of secondary amenorrhea can include: • Pregnancy • Breast-feeding • Emotional 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

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.

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

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.

Lifestyle changes & CAM therapies for the treatment of hot flashes:

• Lifestyle changes • Lower room temperature; use fans • Wear clothing in layers for easy removal • Limit caffeine and alcohol intake • Drink 8 to 10 glasses of water daily • Stop smoking or cut back • Avoid hot drinks and spicy food • Take calcium (1,200 to 1,600 mg) and vitamin D (400 to 600 International Units) • Exercise daily, but not just before bedtime • Maintain a healthy weight • Identify stressors and learn to manage them • Keep a diary to identify triggers of hot flashes • Phytoestrogens: isoflavones, ligands, coumetrols • Black cohosh • Chamomile: mild sedative to alleviate insomnia • Unopposed transdermal progesterone • Compounded bioidentical hormones • Try relaxation techniques, deep breathing, and meditation • Acupuncture may reduce the frequency of hot flashes • Vitamin E: 100 mg daily Dehydroepiandrosterone (DHEA) • Chaste tree berry (vitex): balances progesterone and estrogen • Dong quai: acts as a form of phytoestrogen • Ginseng: purported to improve memory • St. John's wort: reduces depression and fatigue • Wild yam: treats menopausal symptoms • Valerian root: induces sleep and relaxation

Areas of focus during the nursing assessment when assessing which contraceptive method meets the clients needs:

• 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

Several considerations influence a person's choice of contraceptives, such as:

• Motivation • Cost • Cultural and religious beliefs • Convenience • Effectiveness • Side effects • Desire for children in the future • Safety of the method • Comfort level with sexuality • Protection from STIs • Interference with spontaneity

Risk factors for internality in women include:

• Overweight or underweight (can disrupt hormone function) • Hormonal imbalances leading to irregular ovulation • Uterine fibroids • Tubal blockages • Cervical stenosis • Reduced oocyte quality • Chromosomal abnormalities • Congenital anomalies of the uterus • Immune system disorders • Chronic illnesses such as diabetes, thyroid disease, asthma • STIs • Ectopic pregnancy • Age older than 27 • Endometriosis • Turner syndrome • Eating disorders • History of PID • Smoking and alcohol consumption • Multiple miscarriages • Menstrual abnormalities • Exposure to chemotherapeutic agents • Psychological stress

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)