NSG 170 - Test 4 - Sexuality

What drugs are used to treat GH?

Antiviral drugs The drugs decrease the severity, promote healing, and decrease the frequency of recurrent outbreaks but do not cure the infection

Pregnancies that occur after tubal sterilization:

Are more likely to be ectopic

Cervarix may be given to 9- to 25-year-old females and protects only against:

HPV types 16 and 18

After the lesions heal, the virus:

Remains in a dormant state in the sacral nerve ganglia

Complications Caused by Sexually Transmitted Organisms

*KNOW THIS CHART*

STIs are largely preventable through:

Safer sex practices Do not assume that a person is not sexually active because of his or her age, education, marital status, profession, or religion Discuss prevention methods, including safer sex, with all patients who are or may become sexually active

Regional lymph nodes:

- Enlarge - Feel firm - Are not painful

Four consecutive phases were identified to describe human sexual response:

- Excitement - Plateau - Orgasmic - Resolution

Dosage and length of treatment differ for:

- Primary outbreaks (7 to 10 days) - Recurrent outbreaks (1 to 5 days)

The fluids with the highest concentrations of HIV are:

- Semen - Blood - Breast milk - Vaginal secretions

Physiological consequences can include, but are not limited to:

- Unfulfilled sexual desire - Unsatisfactory sexual responses - Pain - STI infection as a result of a sexual encounter - Inability to create a pregnancy - Complications with pregnancies

Hormonal Contraceptives - Method of Contraception

Hormonal contraceptives alter the normal hormone fluctuations of the menstrual cycle Hormones are delivered by implant, injection, patch, or vaginal ring, or can be taken orally

Hormone Replacement Therapy

Hormone replacement therapy (HRT) is often used to treat the symptoms of menopause, most notably hot flashes and vaginal dryness HRT may be given as low-dose estrogen (for women who have had a hysterectomy) or combination therapy (estrogen and progesterone) for women who still have their uterus

Gonorrhea infection can become disseminated, requiring:

Hospitalization and IV or IM ceftriaxone 1 g every 24 hours If symptoms resolve within 24 to 48 hours, the patient may be discharged to home to continue oral antibiotic therapy (cefixime 400 mg twice a day) for at least a week

Gender Identity

How one views one's gender as masculine or feminine, socially derived from experiences with the family, friends, and society

Sexual Orientation

How one views one's self in terms of being emotionally, romantically, sexually, or affectionately attracted to an individual of a particular gender

Coitus Interruptus

Also called withdrawal, coitus interruptus is the removal of the penis from the vagina before ejaculation The method requires great control by the man and may be unsatisfying for both partners Sperm spilled on the vulva can enter the vagina and cause pregnancy

Male-to-Female

An adjective to describe people who were identified as male at birth and are changing (or have changed) to a more feminine body or female

What may be indicated for patients with severe HSV infections, such as disseminated (systemic) disease or encephalitis (brain infection)?

IV acyclovir and hospitalization These are severe complications of genital herpes and may be fatal

Considerations for Older Adults for HIV/AIDS

Infection with HIV can occur at any age Assess the older patient for risk behaviors, including a sexual and drug use history Age-related decline in immunity increases the likelihood that the older adult will develop the infection after an HIV exposure

Antibiotics

Infections of the reproductive tract are usually caused by STIs A wide range of antibacterial, antiviral, and anti-protozoal agents are used in the treatment of STIs depending on the microorganism involved

The incubation period of genital herpes is:

2 to 20 days With the average period being 1 week

The incubation period is usually:

2-3 months

Lesions resolve within:

2-6 weeks

After entering a host cell, HIV must:

Insert its genetic material into the host cell's DNA HIV is a retrovirus, which is able to insert its single-stranded ribonucleic acid (ss-RNA) genetic material into the host's DNA The HIV enzyme reverse transcriptase (RT) converts HIV's RNA into DNA, which makes the viral genetic material the same as human DNA The drug classes known as nucleoside reverse transcriptase inhibitors [NRTIs] and non-nucleoside reverse transcriptase inhibitors [NNRTIs] work here to prevent viral replication by reducing how well reverse transcriptase can convert HIV genetic material into human genetic material HIV then uses its enzyme integrase to get its DNA into the nucleus of the host's CD4+ T-cell and insert it into the host's DNA This action completes the infection of the CD4+ T-cell The drug class known as integrase inhibitors works here to prevent viral DNA from integrating into the host's DNA

Nursing Safety Priority: DRUG ALERT

Instruct patients taking PDE-5 inhibitors to abstain from alcohol before sexual intercourse because it may impair the ability to have an erection Common side effects of these drugs include: - Dyspepsia (heartburn) - Headaches - Facial flushing - Stuffy nose If more than one pill a day is being taken, leg and back cramps, nausea, and vomiting also may occur Teach men who take nitrates to avoid PDE-5 inhibitors because the vasodilation effects can cause a profound hypotension and reduce blood flow to vital organs For patients who cannot take these drugs or do not respond to them, other methods are available to achieve an erection

Ongoing Teaching

Instruct the woman to call if she has any questions or difficulties If she chooses a new method, suggest she visit again in 1 to 2 months to discuss her satisfaction with it Make a note to talk about contraception with her again at the next visit, even if it is for another reason

There is no typical appearance of this rash except for:

Its presence on the palms and soles of the feet and on mucous membranes It can appear as diffuse macules (reddish brown), papules (usually less than 5 mm) or pustules, scaly psoriasis-like lesions, or gray-white wartlike lesions (condylomata lata) All of these lesions are highly contagious and should not be touched without gloves Patchy alopecia on the scalp or facial hair (missing part of the eyebrow, "moth-eaten" appearance) is another symptom The rash subsides without treatment in 4 to 12 weeks

The first symptoms of gonorrhea may appear:

3 to 10 days after sexual contact with an infected person The disease can be present without symptoms and can be transmitted or progress without warning

Sex

One of four primary drives that also include thirst, hunger, and avoidance of pain

Penile implants (prostheses) are used when:

Other modalities fail Devices include: - Semirigid - Flexible - Hydraulic inflatable and multi-component or one-piece instruments The three-piece inflatable device is the most commonly implanted prosthesis A reservoir is placed in the scrotum Tubes carry the fluid into the inflatable pieces that are placed in the penis To inflate the prosthesis, the man squeezes the pump located in the scrotum To deflate the prosthesis, a release button is activated Advantages include the man's ability to control his erections The major disadvantages include device failure and infection The device is implanted as an ambulatory care surgical procedure Teach the patient to observe the surgical site for bleeding and infection

Secondary syphilis develops:

6 weeks to 6 months after the onset of primary syphilis

Stage 2 CDC Case Definition describes a patient with:

A CD4+ T-cell count between 200 and 499 cells/mm3 (0.2 to 0.449 × 109/L) a percentage between 14% and 28% An adult at this stage has no AIDS-defining illnesses

Stage 1 CDC Case Definition describes a patient with:

A CD4+ T-cell count of greater than 500 cells/mm3 (0.5 × 109/L) or a percentage of 29% or greater An adult at this stage has no AIDS-defining illnesses

How does viral load affect HIV transmission?

Viral load, or the amount of virus present in blood and other body fluids, affects transmission The higher the blood level of HIV (*viremia*), the greater the risk for sexual and perinatal transmission Current combination antiretroviral therapy (cART) (formerly known as HAART-highly active antiretroviral therapy) has caused the viral load of some infected patients to drop below detectable levels Although there is less virus in seminal or vaginal fluids of patients receiving cART, the risk for transmission still exists

Suppression reduces recurrences in most patients, but it does not prevent:

Viral shedding, even when symptoms are absent

If a wartlike lesion bleeds easily, appears infected, is atypical, or persists, what is performed?

A biopsy of the lesion is performed to rule out other pathologic problems such as cancer A biopsy of warts that are seen on the cervix should be performed before any treatment to eradicate them

Underlying Medical Conditions and Medications - Individual Risk Factors

A number of underlying medical conditions, particularly chronic health conditions, and/or medications used to treat underlying conditions can place an individual at risk for sexual disorders Some of the most common conditions that increase risk include acute or chronic pain, chronic fatigue, anxiety, depression, cardiovascular disease, diabetes, and chronic respiratory conditions Likewise, many medications can affect sexual health

Within 3 to 7 days, it breaks down into its typical appearance:

A painless, indurated, smooth, weeping lesion

Life certainty, defined as living beyond age 21 years and surviving to at least age 35 years, is correlated with:

A reduction in sexual risk-taking behaviors and highest levels of sexual knowledge

GH is confirmed through:

A viral cell culture or polymerase chain reaction (PCR) assays of the lesions PCR is the more sensitive test and is currently the gold standard; however, it is very expensive and usually not available

Tertiary, or late, syphilis occurs:

After a highly variable period, from 4 to 20 years This stage develops in untreated cases and can mimic other conditions because any organ system can be affected

Drugs that are prescribed for patients with allergies to these drugs include:

- Erythromycin - Ofloxacin - Levofloxacin All for 7 days

The emotional responses to syphilis vary and may include:

- Feelings of fear - Depression - Guilt - Anxiety Patients may experience guilt if they have infected others or anger if a partner has infected them If further psychosocial interventions are needed, encourage the patient to discuss these feelings or refer him or her to other resources such as psychotherapy, self-help support groups, or STI/STD clinics

Some adults develop an acute infection within 4 weeks of first being infected. Symptoms of this acute HIV infection can be:

- Fever - Night sweats - Chills - Headache - Muscle aches Which are similar to those of any viral infection—not just HIV A sore throat and rash also may be present With time these symptoms cease, and the patient feels well again, although a "war is going on" between HIV and the immune system Even in this early phase of the disease, the viral numbers in the bloodstream and genital tract are high, and sexual transmission is possible

Three common attributes of sexual development:

- Gender identity - Sexual response - Capacity for meaningful, intimate relationships Are essential as we move from infancy through adulthood

Assess for other symptoms such as:

- Headaches - Fever - General malaise - Swelling of inguinal lymph nodes Ask if urination is painful External dysuria is a painful symptom when urine passes over the eroded areas Patients with urinary retention may need to be catheterized

What can affect the health status of any patient?

- Health literacy - Motivation - Perceived risk

Nurses in a variety of settings are responsible for:

- Identifying people at risk for STIs - Caring for patients with diagnosed STIs - Preventing further cases through education and case finding

What external factors affect the prevalence of STIs?

- Increasing population - Cultural factors (e.g., earlier first intercourse) - Political and economic policies - Incidences of sexual abuse and human trafficking - International travel and migration

Alterations in sexuality and sexual function can be further categorized as:

- Lifelong versus acquired - Situational versus generalized - Organic versus psychogenic These are not necessarily discrete categories; instead, SD is often multifactorial with an overlap between categories

Although it is a simplistic definition, sexual well-being can be evidenced by:

- The presence of positive attitudes - The absence of negative emotions - An "overall satisfaction with life, fulfillment, and positive functioning

Diagnostic procedures include:

- Tissue biopsy - Aspiration - Ultrasound - X-ray - Laparoscopy - Colposcopy - Colonoscopy

The desired outcomes of treatment for HSV-infected patients are:

- To decrease the impaired comfort from painful ulcerations - Promote healing without secondary infection - Decrease viral shedding - Prevent infection transmission

Sites commonly affected by infection include:

- Urinary meatus, - Labia - Vagina - Cervix - Penis - Scrotum - Anus - Perineal area

Other interventions include:

- Vacuum devices - Intracorporal injections - Intraurethral applications - Prostheses (implants)

Focused areas of discussion include:

- Abstinence - Contraception - Safer sex practices - STIs - Healthy relationships - Community resources

The infection can be:

Asymptomatic in both men and women, but women have asymptomatic, or "silent," infections more often than do men

What may be prescribed?

- Acyclovir (Zovirax, Avirax) - Famciclovir (Famvir) - Valacyclovir (Valtrex) The main differences in these drugs are cost and frequency of use

The most common intervention for ED is:

Drug therapy

Gender Dysphoria

Emotional or psychological distress caused by an incongruence between one's natal (birth) sex and gender identity

Without treatment, the chancre usually disappears within:

6 weeks However, the organism spreads throughout the body, and the patient is still infectious

Sexual Behavior

How one responds to sexual impulses and desires

A number of consequences can occur as a result of sexual disorders and are based on:

Physiological and psychological concerns

The diagnosis of GH is based on:

The patient's history and physical examination

Two serotypes of herpes simplex virus (HSV) affect the genitalia:

Type 1 (HSV-1) and Type 2 (HSV-2)

After the second stage of syphilis, there is a period of:

Latency

In contrast, many women have:

No symptoms

With other drugs, such as tadalafil (Cialis), erection can be stimulated:

Over a longer period of time

Transition

The period of time when transgender people change from the gender role associated with their sex to a different gender role

What do patients in the late latent stage receive?

The same dose every week for 3 weeks

Well-Being

The state of being happy, healthy, or successful (function)

Sexual Identity

Whether one is male or female based on biological sexual characteristics

Can either type produce oral or genital lesions through oral-genital or genital-genital contact with an infected person?

Yes

HIV is transmitted most often in these three ways:

• Sexual: genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions • Parenteral: sharing of needles or equipment contaminated with infected blood or receiving contaminated blood products • Perinatal: from the placenta, from contact with maternal blood and body fluids during birth, or from breast milk from an infected mother to child

Genital Congestion

*Genital congestion* is a reflexive autonomic response facilitated by the parasympathetic and inhibited by the sympathetic nervous system responses This vasocongestion can occur within seconds of a sexual stimulus and results in increased blood flow to the genital area In a female, clitoral swelling and vulvar engorgement will occur, along with an increase in vaginal lubrication In a male, this neurovascular response will result in an erection of the penis Concurrently, flushing of skin throughout the body may occur and can be seen as pinking of the skin in areas of the face, torso, genitals, and even hands and feet

Interrelated Concepts

*Reproduction* (and reproductive health) are highly interrelated to sexuality. By definition, they include topics of puberty, contraception, STIs, safer sex practices, fertility, infertility, and sexuality. Additional considerations for females are breast and cervical cancer screening, menstruation, preconceptual counsel and screening, pregnancy, and menopause One barrier to healthy sexual expression and function is *Pain*. Regardless of the source or type of pain the patient experiences, it can contribute to sexual dysfunction; pain can be chronic or acute, physical, psychological, or spiritual. For those in pain, sometimes the pain itself makes having sex not possible. It is noteworthy that both positive touch and sexual intimacy are known to stimulate the release of endorphins, the body's natural painkillers Medical conditions that lead to alterations in *Gas Exchange* (e.g., chronic obstructive pulmonary disease, cystic fibrosis, interstitial lung disease, and asthma) can lead to shortness of breath, fatigue, depression, and feelings of anxiousness and thus can inhibit the human sexual response and can result in sexual dysfunction. Individuals who rely on supplemental oxygen may experience impaired body image "Being present" is identified as a positive attribute of sexuality; *Anxiety* can preoccupy the mind, body, and spirit. Patients with anxiety often present with concerns related to sexual dysfunction; those who seek care for SD often report feelings of anxiety. Anxiety is often linked to stress. If a patient is undergoing extreme *Stress* from other life issues, this may have a negative impact on sexual function. Anxiety stimulates the sympathetic nervous system—the stress response is that of fight-flight-freeze—and negatively impacts the sexual response cycle

Arousal

*Sexual arousal* is the physiological response to the release of neurotransmitters that stimulate specific areas of the brain involved in cognition, emotion, motivation, and organization of genital congestion An awareness of being sexually aroused is described as sexual excitement *Human sexuality* is a sensual matter; consider the notion that someone can be "turned on" or "turned off" sexually by varying stimuli of sight, smell, sound, taste, and touch The *stimulus-response* can be excitatory or inhibitory in action; dopamine, norepinephrine, and melanocortins are excitatory neurotransmitters, whereas serotonin, prolactin, and GABA are inhibitory neurotransmitters

The treatment of choice for chlamydia infections is:

- Azithromycin (Zithromax) 1 g orally in a single dose, or - Doxycycline (Monodox, Doxy-Caps, Doxycin) 100 mg orally twice daily for 7 days The one-dose course, although more expensive, is preferred because of the ease in completing the treatment

As the CD4+ T-cell level drops, the patient is at risk for:

- Bacterial - Fungal - Viral infections As well as opportunistic cancers

HIV is in:

- Blood - Semen - Vaginal secretions - Breast milk - Amniotic fluid - Urine - Feces - Saliva - Tears - Cerebrospinal fluid - Lymph nodes - Cervical cells - Corneal tissue - Brain tissue

The development of human sexuality can be observed through the socially defined stages of:

- Childhood - Preadolescence - Adolescence - Adulthood

What is reportable to local health authorities in every state?

- Chlamydia infection - Gonorrhea - Syphilis - Chancroid - Human immune deficiency virus (HIV) infection - Acquired immune deficiency syndrome (AIDS) Reports are kept strictly confidential

The primary nonsurgical interventions for transgender patients include:

- Drug (hormone) therapy - Counseling about reproduction and reproductive health - Vocal therapy The type of intervention depends on whether the patient is transitioning from MtF or FtM

Interprofessional collaborative care includes:

- Drug therapy - Health teaching to resolve the infection and prevent infection transmission to others

Since then, other human sexual response models have been formulated to consider psychological and sociological factors as well, most notably the notions of sexual motivation and desire. Although aspects of each model may vary slightly, the general phases are the same and include:

- Motivation - Arousal - Genital congestion - Orgasm - Resolution

Those with symptoms have:

- Mucopurulent vaginal discharge (typically yellow and more opaque) - Urinary frequency - Abdominal discomfort or pain Cervical bleeding, from infected and therefore fragile tissue, may present as spotting or bleeding between menses and frequently after intercourse

For men and women, their history may reveal only risk factors associated with C. trachomatis, such as:

- New or multiple sexual partners - Age younger than 26 years and female - A male having sex with a male (MSM)

Symptomatic care may include:

- Oral analgesics - Topical anesthetics - Sitz baths - Increased oral fluid intake

The CDC drafted guidelines for sexual history taking and incorporates five areas that should be broached with patients; these are known as the "the five P's." These stand for:

- Partners - Practices - Protection from infection - Past history of infection - Prevention of pregnancy

What are essential components of health promotions and disease prevention for optimal sexual well-being?

- Patient education - Counseling - Referral

Nursing interventions focus on:

- Patient education about the infection - Sexual transmission - Potential for recurrent episodes - Correct use and possible side effects of antiviral therapy

In women, ascending spread of the organism can cause:

- Pelvic infection (pelvic inflammatory disease [PID]) - Endometritis (endometrial infection) - Salpingitis (fallopian tube infection) - Pelvic peritonitis

Barriers identified by patients include:

- Personal discomfort - Beliefs that their concerns would be dismissed - Belief that it is the provider's responsibility to initiate the dialogue

Barriers identified by nurses include:

- Personal discomfort - Lack of training - Lack of time

A number of underlying situations can lead to sexual disorders or sexual dysfunction (SD), including:

- Physiological - Psychological - Maturational - Environmental factors Specifically, categories include sexually transmitted infections, SD, and intimate partner violence

The human sexual response cycle, first described by Masters and Johnson in 1966, was based on:

- Physiological measures of heart rate, blood pressure - Changes in genital size - Genital lubrication during stimulation and orgasm

Populations at greatest risk for acquiring STIs and suffering from their complications are:

- Pregnant women - Adolescents - Men who have sex with men (MSM)

Adverse drug effects include:

- Priapism (prolonged erection) - Penile scarring - Fibrosis - Bleeding - Bruising at the injection site - Pain - Infection - Vasovagal responses

Syphilis progresses through four stages:

- Primary - Secondary - Latent - Tertiary

Psychosocial consequences include:

- Problems with relationships (particularly if sexual responses between a couple have changed) - Low self-esteem - Anxiety - Depression

Complications of infection with C. trachomatis include:

- Salpingitis (inflammation of the fallopian tubes) - Pelvic inflammatory disease (PID) - Reproduction problems including ectopic pregnancy and infertility

Diagnostic testing may be performed for:

- Screening of genetic issues (ambiguous genitalia noted at birth) - Cancers (cervical, ovarian, prostate, and anus) - Infections (chlamydia, gonorrhea, syphilis, HPV, and HIV) - Hormonal states (hypogonadism and pregnancy) The type of testing is best determined individually for each patient

Specimen collection from a variety of sources includes:

- Serum - Urine - Genital discharge/secretions - Lesions - Semen

Addressing adolescent sexuality includes considering critical factors that may influence their behavior:

- Socioeconomic status - Family structure - Future perspectives for education - Lived experiences

Periodically the virus may activate, and symptoms recur. These recurrences may be triggered by many factors, including:

- Stress - Fever - Sunburn - Poor nutrition - Menses - Sexual activity Assess the patient for these risk factors to provide anticipatory guidance for prevention of outbreaks

Teach all adults about the transmission routes and ways to reduce their exposure:

- Stress that HIV is not transmitted by casual contact in the home, school, or workplace - Sharing household utensils, towels and linens, and toilet facilities does not transmit HIV - HIV is not spread by mosquitos or other insects

What is considered low risk for transmission unless obvious blood is present?

- Tears - Saliva - Sweat

Blood tests are also used to diagnose syphilis. The usual screening and/or diagnostic nontreponemal tests are:

- The Venereal Disease Research Laboratory (VDRL) serum test - The more sensitive rapid plasma reagin (RPR) These tests are based on an antibody-antigen reaction that determines the presence and amount of antibodies produced by the body in response to an infection by T. pallidum They become reactive 2 to 6 weeks after infection VDRL titers are also used to monitor treatment effectiveness The antibodies are not specific to T. pallidum; and false-positive reactions often occur from conditions such as viral infections, hepatitis, and systemic lupus erythematosus (SLE)

The significance of the consequences is also dependent on:

- The patient's age - Interest in sex - Whether the underlying sexual disorder is a temporary or chronic condition

Teach patients to avoid intimate sexual contact until:

External lesions are healed Recommend condoms to help reduce transmission even after warts have been treated

Commonly mistaken for influenza, manifestations include:

Flulike symptoms (malaise, low-grade fever, headache, muscular aches, sore throat) and a generalized rash

Therapy for recurrent outbreaks is most beneficial if it is started within:

1 day of the appearance of lesions or during the period of itching or tingling before lesions appear

Sexuality depends on four interrelated psychosexual factors:

1. Sexual identity 2. Gender identity 3. Sexual orientation 4. Sexual behavior

Best Practice for Patient Safety & Quality Care: Performing Breast Self-Examination

1. Lie on your back and place your right arm behind your head. Lying down spreads the breast tissue evenly over the chest wall, making it easier to feel all the breast tissue 2. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-size circular motions of the finger pads to feel the breast tissue 3. Use three different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast 4. Move around the breast in an up-and-down pattern, starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area, going down until you feel only ribs and up to the neck 5. Repeat the examination on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the examination 6. While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling and look at your nipples and breast skin for redness or scaling. (The pressing down-on-the-hips position contracts the chest wall muscles and enhances any breast changes) 7. Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine

Two major types of ED:

1. Organic 2. Functional

Practitioners often equate positive sexual functioning with Masters and Johnson's sexual response cycle rather than considering the psychological and emotional components of what truly makes an optimal sexual encounter. Recent research has identified six components of optimal sexuality:

1. The most predominant component is that of being present—in the moment and fully attentive, described as "utter immersion and intensely focused attention" in which they are fully embodied in the experience and able to allow thinking to stop and arousal to take over 2. Being present is inextricably linked with a second component of authenticity, described as "feeling free to be themselves with their partner." 3. A third theme is intense emotional connection, described as heightened intimacy during the sexual encounter. Many couples felt that intimacy needed to be present both inside and outside of the bedroom, whereas others noted that "great sex" also occurred in new relationships, with friends or "play partners." 4. Another component of optimal sexuality is sexual and erotic intimacy, described as a deep sense of caring for one another regardless of the length of the relationship 5. Excellent communication is also crucial to the success of any sexual encounter, which includes not only verbal communication but also empathy and making one's needs known through touch 6. The sixth component is transcendence, a combination of heightened mental, emotional, physical, relational, and spiritual states of mind. This picture of "great sex" that is painted by these six attributes is certainly different from that touted by mass media. These findings illustrate that optimal sexuality is not necessarily about technique or skill but, rather, about attitude, positive behaviors, and healthy relationships

Fluid from inside the blister obtained within:

48 hours of the first outbreak will yield the most reliable results because accuracy decreases as the blisters begin to heal

Stage 3 CDC Case Definition describes any patient with:

A CD4+ T-cell count of less than 200 cells/mm3 (0.2 × 109/L) or a percentage of less than 14% An adult who has higher CD4+ T-cell counts or percentages but who also has an AIDS-defining illness meets the Stage 3 CDC Case Definition

The infection is usually transmitted by:

Sexual contact and blood exposure, but transmission can occur through close body contact such as kissing

The physical examination is guided by:

The sexual history The patient's age, gender, and pertinent needs

Speculum Examination - Pelvic Examination

A bivalve speculum of the appropriate size is used to inspect the vagina and cervix If a metal speculum is used, it is usually warmed with tap water or a low-temperature electric warmer (heating pad) to reduce chilling and is gently inserted into the vagina To avoid interference with test accuracy, vaginal lubrication with a water-based lubricant may be delayed until specimens for the Pap test or cultures are obtained The size, shape, and color of the cervix are noted A sample is taken for the Pap test. In addition, a sample of any unusual discharge is obtained for microscopic examination or culture

The World Health Organization provides a working definition of sexuality as:

A central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships While sexuality can include all of these dimensions, not all of them are always experienced or expressed Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors

Women may report:

A change in vaginal discharge (yellow, green, profuse, odorous), urinary frequency, or dysuria The cervix and urethra are the most common sites of infection Anal signs and symptoms may include itching and irritation, rectal bleeding or diarrhea, and painful defecation Assess the mouth for a reddened throat, ulcerated lips, tender gingivae, and lesions in the throat

Syphilis

A complex sexually transmitted infection (STI) that can become systemic and cause serious complications, including death

Ill-Being

A condition of being deficient in health, happiness, or prosperity (dysfunction)

The basic design of a vacuum constriction device (VCD) is:

A cylinder that fits over the penis and sits firmly against the body Using a pump, a vacuum is created to draw blood into the penis to maintain an erection A rubber ring (tension band) is placed around the base of the penis to maintain the erection, and the cylinder is removed

Human sexuality can be described as:

A developmental process, beginning at conception and ending at death

Organic ED

A gradual deterioration of function The man first notices diminishing firmness and a decrease in frequency of erections

Gender Reassignment Surgery (SRS)/Gender-Affirming Surgery/Gender-Confirming Surgery

A group of surgical procedures that change primary and/or secondary sex characteristics to affirm a person's gender identity

Assessment of the patient who has signs and symptoms of syphilis begins with:

A history to gather information about any ulcers or rash Take a sexual history and conduct a risk assessment to include whether previous testing or treatment for syphilis or other STDs has ever been done Ask about allergic reactions to drugs, especially penicillin A woman may report inguinal lymph node enlargement resulting from a chancre in the vagina or cervix that is not easily visible to her She may state a history of sexual contact with a male partner who had an ulcer that she noticed during the encounter Men usually discover the chancre on the penis or scrotum

Hysterectomy

A hysterectomy is the surgical removal of the uterus and may be indicated for a variety of uterine conditions, including: - Menorrhagia - Pelvic pain from endometriosis - Prolapse of the female reproductive organs (uterus, cystocele, and rectocele) - Uterine fibroids - Myomas - Cancer

Coming Out

A lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) person's public disclosure regarding sexual orientation or gender identity

Another common term is *transsexual*, which generally describes:

A person who has modified his or her natal body to match the appropriate gender identity, either through cosmetic, hormonal, or surgical means "Transsexual" can be used as both an adjective and a noun, such that a patient can be described "as transsexual" or "as a transsexual" People who were born with anatomically male parts but identify as and/or live as female are known as "male-to-female" or "MtF" Male-to-female people are also known as "transwomen," with the gender descriptor indicating the current-lived gender identity Conversely, "transmen" are natal females who identify as and/or live as men. They are described as "female-to-male" or "FtM" Transgender people are sometimes described as "transvestites" or "cross-dressers," often in a judgmental or negative manner These terms should not be used unless the patient identifies as such Other terms, such as tranny, he-she, or shemale, are offensive and hurtful These terms and other negative comments should never be used

The scope of sexuality as a concept ranges from:

Sexual well-being to sexual ill-being These can be a measure of sexual function and dysfunction

Gender Identity

A person's inner sense of being a male, a female, or an alternative gender (e.g., genderqueer)

History - Assessment

A sexual history is elicited as an essential part of a routine health history during an initial visit and annual visits thereafter Despite the importance of sexual health and patients' expressed desire to be queried about sexual issues, questions related to sexual health are infrequently raised during routine examinations

Gonorrhea

A sexually transmitted bacterial infection that occurs in both men and women The causative organism is Neisseria gonorrhoeae, a gram-negative intracellular diplococcus It is transmitted by direct sexual contact with mucosal surfaces (vaginal intercourse, orogenital contact, or anogenital contact)

During this highly infectious stage, the chancre begins as:

A small papule

The causative organism is:

A spirochete called Treponema pallidum

Newly Unpartnered - Populations at Risk

A unique population at increased risk for negative sequelae are those adults who have recently separated—unpartnered—from their long-term partners because of death or divorce and are now exposed to an entirely new sexual paradigm These adults may begin dating and suddenly have several new and unknown sexual partners Depending on their age, HIV, AIDS, and other STIs may not have been of concern when these adults were initially partnered Although HIV/AIDS infections in the United States are now considered to be chronic conditions, all parties who have intercourse must be cognizant of their risk for exposure to these and other diseases and receive appropriate health education

The cause of HIV infection is:

A virus - the human immune deficiency virus This virus, just like all other viruses, is an intracellular parasite because it must use the infected cell's resources to reproduce The HIV can infect a cell and take over its functions to force the cell to make more copies of the virus (viral particles) These new viral particles are able to infect more cells, repeating the cycle as long as there are new host cells to infect

Health Promotion and Maintenance of HIV/AIDS

AIDS has a high morbidity and mortality rate when untreated Although there is no current cure for HIV/AIDS, the conscientious and continued use of antiretroviral therapy allows HIV patients to live long and healthy lives The foci for health care worldwide are prevention of HIV infection and antiretroviral treatment for all who are HIV positive

Late latent syphilis is a disease of:

More than 1 year's duration after infection This stage is not infectious except to the fetus of a pregnant woman Patients with latent syphilis may or may not have reactive serologic test (e.g., Venereal Disease Research Laboratory [VDRL]) findings

One of the Healthy People 2020 objectives is to:

Completely eliminate syphilis in the United States

Availability - Considerations When Choosing a Contraceptive Method

Condoms and spermicides are readily available without prescriptions They can be purchased anonymously, at any time Their availability may be important to an adolescent who wants to hide her sexual activity or to women who are embarrassed to discuss contraception with a healthcare provider

Cultural/Spiritual Considerations for HIV/AIDS

Most new HIV infections reported in the United States and Canada occur in racial and ethnic minorities, particularly among blacks/African Americans and Hispanics More culturally sensitive efforts targeted at these groups for prevention and treatment are needed

Sexually transmitted infections (STIs) are caused by:

Infectious organisms that have been passed from one person to another through intimate contact—usually oral, vaginal, or anal intercourse Some organisms that cause these diseases are transmitted only through sexual contact Others are transmitted also by parenteral exposure to infected blood, fecal-oral transmission, intrauterine transmission to the fetus, and perinatal transmission from mother to neonate

The CDC provides regularly updated guidelines for treatment of STIs. These best practice guidelines provide:

Information, treatment standards, and counseling advice to help decrease the spread of these diseases and their complications

Sexually Transmitted Infections - Variations and Context

Among the most common sexuality problems are sexually transmitted infections (STIs) These are infections transmitted through sexual contact and can include protozoa, parasites, and viral and bacterial infections Some STIs are associated with symptoms that cause an individual to seek medical attention, and other STIs can be asymptomatic but lead to longer term problems, such as complications with pregnancies and increased cancer risk Some STIs (e.g., chlamydia) are curable with treatment, and others (e.g., genital herpes) are chronic

Genetic/Genomic Considerations for HIV/AIDS

About 1% of adults with HIV infection are long-term nonprogressors (LTNPs) who have been infected with HIV for at least 10 years and have remained asymptomatic, with CD4+ T-cell counts within the normal range and a viral load that is either undetectable or very low A genetic difference for this group is that their CCR5/CXCR4 co-receptors on the CD4+ T-cells are nonfunctional as a result of gene mutations for these co-receptors The mutation creates defective co-receptors that do not bind to the HIV docking proteins, and these cells successfully resist the entrance of HIV Adults who have only one mutated co-receptor gene allele have fewer normal co-receptors and can be infected with HIV, but progression is slow Remind patients that even with low viral levels, they can still transmit the disease to others

Gender Health Considerations for HIV/AIDS

About 25% of newly diagnosed cases are women In less affluent countries 50% of cases occur in women The largest risk factor is sexual exposure Women with HIV disease have a poorer outcome, with shorter mean survival time than that of men This outcome may be the result of late diagnosis and social or economic factors that reduce access to medical care Encourage all women to monitor their HIV status

Abstinence - Contraceptive Method

Abstinence is avoidance of sexual intercourse and any activity that allows sperm to enter the vagina Although it is the only completely effective method of preventing pregnancy and STDs, abstinence requires perfect use to be effective Depending on the time within the menstrual cycle it occurs, intercourse without the use of a contraceptive has up to an 85% chance of resulting in pregnancy Most women are not abstinent all of their reproductive lives but many practice abstinence at various intervals Some women practice abstinence part of the time but have other methods available to use if they decide to become sexually active Periodic abstinence is also practiced by women using the natural family planning methods Sex education programs in schools often include information on ways to maintain abstinence Abstinence-only education programs have not been successful in reducing teen pregnancy Adolescents who choose abstinence need help to learn practical methods to reach their goal They need to think through just what abstinence entails and should role-play situations they might encounter so they know what to say and do before it becomes necessary Women who choose abstinence should know where to get information and contraception if they later decide to become sexually active

Female Sexual Disorders - Variations and Context

According to the National Institute of Health, as many as 40% of women in America suffer from sexual dysfunction, and it can affect a woman at any age Although SD may involve many physiological factors (diabetes, neuropathy, paralysis, and hormones), the majority of research and clinical trials on SD in women have focused on psychological causes (stress, anxiety, depression, and anger) In keeping with the stages of the human sexual response cycle of motivation, arousal, genital congestion, orgasm, and resolution, various sexual dysfunctions have been described The condition of SD includes the medical diagnoses of hyposexual activity disorder, sexual aversion disorder, sexual arousal disorder, orgasmic disorder, sexual pain disorder, and persistent genital arousal disorder; the general nature of the SD can be presumed simply by its name

Protecting Against Sexually Transmitted Diseases

Address defense against STDs, particularly if the woman is using a method that does not provide protection This is a delicate subject A way to approach it might be to say, "The method you are using is very effective against pregnancy but does not protect you against diseases such as HIV that you might catch from a partner. If there is any chance that you or your partner might have sex with someone other than each other or that your partner might have an infection, you should protect yourself by using condoms with your regular contraceptive."

Encourage women to have a Pap test annually, starting at:

Age 21 After they have had three normal smears, they should have a Pap test every 3 years if no new risk factors are present (e.g., new partner, other STIs) The presence of warts should increase suspicion that the patient may have had exposure to other STDs, which warrants additional testing

DRUG ALERT - Nursing Safety Priority

Allergic reactions to benzathine penicillin G can occur Monitor for allergic manifestations (e.g., rash, edema, shortness of breath, chest tightness, anxiety) Penicillin desensitization is recommended for penicillin-allergic patients Keep all patients at the health care agency for at least 30 minutes after they have received the antibiotic so manifestations of an allergic reaction can be detected and treated The most severe reaction is anaphylaxis Treatment should be available and implemented immediately if symptoms occur

Choosing a Contraceptive Method - Nursing Diagnosis and Planning

Lack of knowledge about family planning is common A nursing diagnosis that addresses this problem is: • Risk for Ineffective Health Maintenance related to lack of understanding about contraceptive methods chosen and available

Natural Family Planning Methods - Contraceptive Method

Also called fertility awareness or periodic abstinence methods, use physiologic cues to predict ovulation and avoid coitus when conditions are favorable for fertilization These methods can also help women who want to become pregnant The methods are based on knowledge that the ovum may be fertilized for approximately 24 hours and that most sperm live only 48 hours in the female genital tract, but some may live up to 80 hours Natural family planning helps women learn about how their bodies change throughout the menstrual cycle This method is acceptable to most religious groups and avoids the use of drugs, chemicals, and devices However, couples must be highly motivated because they must abstain from intercourse during as much as half the menstrual cycle Although the methods are very effective if used perfectly, the overall failure rate for typical use is 24% The methods are very unforgiving, and errors in predicting ovulation can lead to pregnancy from having intercourse during the fertile time Women often combine the various fertility awareness methods to improve effectiveness Some women use the methods to determine when they are fertile and use another contraceptive at that time

Cervical Mucus and Two-Day Method

Also called the "Ovulation" or Billings method, the cervical mucus technique is based on changes in cervical mucus that is assessed by wiping it from the vaginal orifice with tissue each day There is no mucus for the first 3 to 4 days after menses; thick, sticky mucus then begins to appear As estrogen increases, the mucus changes to clear, slippery, and stretchy, like egg white (a quality known as spinnbarkeit) After ovulation, mucus decreases in amount and becomes thick and sticky again To prevent pregnancy, couples must avoid intercourse from the time mucus is first present after menses until 4 days after the end of the slippery mucus Intercourse is allowed only every other day when there is little or no mucus, because semen interferes with mucus assessment The Two-Day method is a simpler form of this method The woman assesses cervical secretions daily If she notices vaginal secretions of any kind today or yesterday, she considers herself fertile If there were no secretions either day, she considers herself infertile

Tubal Sterilization

Also called tubal ligation Is widely used throughout the world It involves cutting or occluding the fallopian tubes to prevent fertilization The surgery is easiest during abdominal surgery such as cesarean birth when a woman is sure that she wants the procedure regardless of the outcome of the birth During the first 48 hours after vaginal birth, the fundus is located near the umbilicus, and the fallopian tubes are directly below the abdominal wall, making this a good time for tubal sterilization Interval tubal sterilization, not associated with childbirth, is often performed as outpatient surgery General anesthesia is most common, but regional or local anesthesia can be used

Erectile Dysfunction

Also known as impotence Is the inability to achieve or maintain an erection for sexual intercourse It affects millions of men throughout the world

What Is the Proper Way to Use Condoms?

Although condoms are easy to use, proper use increases their effectiveness Condoms are available in a variety of colors, textures, and materials, but those made of latex are most effective Others may help protect against pregnancy but not against sexually transmitted diseases Check the expiration dates on packages because condoms can deteriorate after 5 years Open the package carefully and check the condom to see that it is not damaged Lubrication may increase comfort for the woman and reduce the risk of breakage Use a water-soluble lubricant because oil-based products (such as petroleum jelly or baby oil) deteriorate latex condoms Always apply the condom before there is any contact of the penis with the vagina Squeeze the air out of the tip of the condom, and leave 1/2 inch of space at the tip as the condom is unrolled onto the erect penis This space allows a place for sperm to collect, which helps prevent breakage While holding the condom at the base, withdraw the penis from the vagina while it is still erect so the condom does not slip off and spill semen into the vagina Use a new condom each time intercourse is repeated

Psychological Factors

Any stressor that impacts the human psyche has the potential to result in SD Psychological and emotional factors such as fear, anxiety, fatigue, reproductive health concerns, and adverse childhood events can result in SD Alterations in body image and self-image, role confusion, and personal conflicts (religion, culture, and values) can also contribute to SD Furthermore, mental health conditions such as psychosis or alterations in cognition related to dementia will impact sexuality

Therapy for Menopause

Although many women comfortably undergo the age-associated changes of menopause, others seek assistance for their individual discomforts such as hot flashes, interrupted sleep, or vaginal dryness The belief that increasing reproductive hormones would slow the aging process and promote a more youthful appearance increased the use of replacement therapy during the climacteric Additional beneficial effects were once thought to be a reduction in cardiovascular disease, colorectal cancer, breast cancer, and osteoporosis as well as other medical-surgical conditions associated with aging As greater research results emerged, including that of the WHI, additional risk factors, as well as benefits, of hormone therapy became evident Two groups of perimenopausal women were included in the hormone studies of the WHI research: • Estrogen and progesterone were given to women with a uterus. Combining progesterone with estrogen therapy prevented uterine hyperplasia, a precursor to uterine cancer, in this group • Estrogen therapy alone was given to women who had had a hysterectomy, because uterine hyperplasia was not a risk Menopause hormone therapy (MHT) is an umbrella term used to describe several hormone preparations Estrogen alone can only be used in women who no longer have a uterus; estrogen plus progesterone is needed if the woman has a uterus, and thus, an endometrium Another common abbreviation for the combination of estrogen and progesterone replacement is hormone replacement therapy, or HRT, whereas the estrogen-only replacement therapy may be called ERT Although once routinely prescribed to reduce the annoying changes of menopause for many women, the decision regarding hormone therapy is complex because both the associated benefits and risks for each woman must be considered. In addition, complementary therapy often is more useful for women having mild menopausal changes Some women do not qualify for hormone therapy, such as those who have breast cancer or blood coagulation disorders Women who had breast cancer before the climacteric often should not take hormone therapy because their risk of cancer recurrence is higher than that of the general population Smoking, hypertension, diabetes, cardiovascular disease, and renal or liver disease are often contraindications for hormone therapy, whether it includes estrogen and progesterone or estrogen alone

Male Sexual Disorders - Variations and Context

Although men can experience sexual dysfunction related to sexual desire (libido), arousal, and pain, the two widely recognized conditions specific to men are erectile dysfunction and ejaculatory disorders *Erectile dysfunction* is an inability to develop or maintain an erection of the penis during sexual activity *Ejaculatory dysfunction* is characterized by reduced or absent semen volume, which may be the result of a psychological condition, a medical condition, a medication, or a surgery Stress, diabetes, antidepressants, antihypertensive medications, and prostate surgery can affect ejaculatory function Four categories of ejaculatory disorders are: - Premature ejaculation - Delayed ejaculation - Retrograde ejaculation - Anejaculation/anorgasmia (no ejaculation/no orgasm)

High-Risk Behaviors - Individual Risk Factors

Although sexual activity is considered a normative process, some individuals inadvertently place themselves at increased risk for sexual health problems—primarily those who engage in sexual activity with multiple and casual partners and/or refrain from "safe sex" practices According to the most recent surveys, these individuals are composed of young people (particularly lesbian, gay, bisexual, and transgender youth) and men who have sex with men regardless of race Of secondary importance is the influence of nonsexual high-risk behavior, such as the use of alcohol, marijuana, or other illicit substances Prior research has shown that when these substances are ingested close to the time of sexual activity, the rate of sexual risk-taking increases The abuse of alcohol or drugs most often results in impaired judgment and consequently less thoughtfulness related to the sexual act

Intrauterine Devices (IUDs) - Method of Contraception

An IUD is inserted into the uterus to provide continuous pregnancy prevention The Copper T 380A (ParaGard) and the levonorgestrel intrauterine system (LNG-IUS or Mirena) are shaped like the letter T ParaGard is effective for 10 years and Mirena for 5 years Fertility returns when the device is removed Increasing the use of IUDs is recommended by ACOG as a long-term, cost-effective means of lowering unintended pregnancy Many women have misperceptions regarding the safety and effectiveness of IUDs Although there was concern about safety with early models, IUDs are considered very safe at this time More education about IUDs is necessary to increase their use IUDs provide contraception without the need to take pills, have injections, or perform other tasks just before intercourse They can be inserted immediately postpartum or after an abortion, although expulsion is higher in the immediate postpartum period IUDs can be used by some women who cannot use hormonal contraception They are safe for adolescents and women who have never had a baby There is a slight risk of infection during the first 20 days after insertion, but there is no increased risk of pelvic inflammatory disease or infertility in women who use IUDs or when couples are not mutually monogamous if condoms are used Women at high risk for STDs should use another method

Genital Herpes (GH)

An acute, recurring, incurable viral disease It is the most common STI in the United States The prevalence among African Americans is higher than for Euro-Americans, disproportionately affecting African-American women more than men

Transgender

An adjective to describe a person who crosses or transcends culturally defined categories of gender

Female-to-Male

An adjective to describe people who were identified as female at birth and are changing (or have changed) to a more masculine body or male

Physiological Factors

An alteration in physiological function of a body system(s) (i.e., cardiovascular, respiratory, musculoskeletal, neurological, and endocrine) can result in SD An acute illness, infection, surgery, trauma, medications, loss of mobility, decreased activity tolerance, hormonal changes, and alcohol or substance abuse are physiological conditions that can contribute to alterations in sexual function Pregnancy and the process of aging, although not pathological conditions, can also result in SD

Other Collaborative Interventions

An alternative to PDE-5 in the treatment of ED is the *vacuum construction device* This is an external cylinder-like device that fits over the penis and uses a vacuum effect to draw blood into the penis to gain an erection A tension band is placed at the base of the penis to maintain the erection once the cylinder is removed, allowing the individual to have sex The ring is removed within 1 hour

If fever occurs, this may be a sign of:

An ascending (PID or epididymitis) or systemic infection (disseminated gonococcal infection) Symptoms could include joint or tendon pain, either in a single joint or as migratory arthralgias, especially of the knees, elbows, fingers, or toes, and a rash usually on the palms and soles

Genderqueer

An identity label used by some people whose gender identity does not conform to one of the two categories of male or female

Drug therapy should be offered to anyone with:

An initial outbreak of GH regardless of the severity of the symptoms

Side Effects of Oral Contraceptives

Approximately 33% of women who do not wish to become pregnant discontinue OC use within a year, usually because of side effects Most side effects are minor Using formulations with less estrogen helps relieve nausea and breast tenderness Break-through bleeding occurs most often in the first 3 months and then usually subsides Some women complain of weight gain while taking OCs, but studies have not shown it to be caused by the pills Other side effects include fluid retention, amenorrhea, and melasma (brownish pigmentation of the face)

Chlamydia Trachomatis

An intracellular bacterium and the causative agent of genital chlamydia infections It invades the epithelial tissues in the reproductive tract The incubation period ranges from 1 to 3 weeks, but the pathogen may be present in the genital tract for months without producing symptoms C. trachomatis is reportable to local health departments in all states Diagnosed cases continue to increase yearly, which reflects more sensitive screening tests and increased public health efforts to screen high-risk people Because it is frequently asymptomatic, the estimated incidence is about double that reported African-American women between 15 and 24 years of age are at the highest risk for the disease

Viral particle features include:

An outer envelope with special "docking proteins," known as gp41 and gp120, which assist in finding a host Inside, the virus has genetic material along with the enzymes reverse transcriptase (RT) and integrase

Patient-Centered Care - Considerations for Older Adults

Another factor contributing to STI prevalence is the increasing number of older adults that will continue as baby boomers age People older than 50 years may not realize their risk for STIs or feel comfortable discussing their SEXUALITY with health care providers Health care professionals may also lack awareness of the sexual activity of older adults Be sure to teach older adults who are sexually active about their risk for developing STIs

Culture - Considerations When Choosing a Contraceptive Method

Another potential influence is the woman's culture Some cultures place a high value on large families and especially on sons A woman may have more pregnancies in an effort to have sons Asian and Hispanic women are often very modest and do not talk about sexuality with others They need to feel very comfortable with the nurse before talking about sexual matters Taking time to establish rapport before discussing intimate subjects is important Some cultures restrict a woman's activities during menses Methods that have increased bleeding or break-through bleeding as a side effect may not be acceptable to these couples Some African-American women believe that menses removes dirty or excess blood These women may not want to use contraception that increases or decreases bleeding

Contraception

Approximately 90% of sexually active women who do not use contraception will conceive within 1 year if both partners are fertile Approximately 43 million women in the United States are sexually active and could become pregnant but do not want a pregnancy at this time Of those women, 62% are practicing contraception However, they may not be using contraception consistently Eighteen percent of women use contraception inconsistently or incorrectly, which accounts for 41% of all unintended pregnancies Unintended pregnancies are those that are unwanted or that occur in women who want to become pregnant at some time in the future but not at the time their pregnancy occurs These pregnancies can result in: - Economic hardship - Health problems - Interference with educational or career plans - Other disruptions in the lives of women and their families Pregnancies that are spaced less than 6 months apart result in a higher risk for maternal mortality and morbidity, preterm birth, and low birthweight infants A Healthy People 2020 goal is to increase the number of pregnancies that are intended to 56% from a baseline of 51%

Condylomata Acuminata (Genital Warts)

Are caused by certain types of human papilloma virus (HPV), most of which are types 6 and 11 or low-risk HPV These types rarely result in invasive cancer of the genital tract such as cervical cancer However, HPV types 16, 18, 31, 33, and 35, considered high-risk HPV, can be found on the skin of the genitalia and increase the risk for genital cancers, especially cervical cancer Infection with several HPV types can occur at the same time The presence of one strain increases the risk for acquiring a higher-risk strain Genital warts are the most common viral disease that is sexually transmitted and are often seen with other infections

Assessment for the Transgender Patient

As with any patient, it is best to ask during the nursing history and physical assessment how he or she prefers to be addressed For example, for non-transgender patients, some people may go by a nickname or by their middle name and prefer to be addressed as such For transgender patients, it is not uncommon for driver's licenses, insurance cards, and other forms of identification to retain their birth names (and by extension, birth sex) because it can be difficult to change this information, particularly if a person is in the process of transitioning Therefore nurses may receive patient documentation with misleading patient data For example, a nurse may receive a health care record listing a male name and birth sex yet encounter a patient presenting as female in appearance It can be offensive and embarrassing for the patient who clearly identifies as female to be called "Mister," "sir," or the male birth name Not only does it communicate disrespect, it also signals to the patient that she may receive inadequate care or that the environment is unsafe In addition to preferred names, correct pronoun usage is also important Each patient has his or her own preference For example, an MtF patient may visit a clinic during lunch hour at work Because the patient has not disclosed the transgender identity at work, this patient maintains male dress and demeanor at the office Although the patient may identify as female and live as female at home, the patient may request the nurse to use male pronouns (he, him, his) to match the patient's current presentation and may not disclose the transgender identity to the nurse Conversely, even though the patient presents at the time as male, the patient may ask the nurse to use female pronouns (she, her, hers) because the patient identifies with a female gender identity In general, use pronouns that match the patient's physical presentation and dress unless the patient requests otherwise Even though the biologic sex may not match, patients presenting as female should be addressed as female, and patients presenting as male should be addressed as male With changing styles and trends, it can sometimes be difficult to assess by clothing alone However, with a patient whose birth sex is listed as female yet presents in traditionally male attire, facial hair, and a men's hairstyle, it is most appropriate to address this patient as male Appropriately interacting with a transgender patient can sometimes mean the difference between the patient continuing to seek health care or not In some cases, patients may not identify as male or female and prefer not to use male or female pronouns These patients often feel that the binary gender system in which a person must fit clearly into one category or the other is too limiting Although this is a small subset of the transgender population, it is important to be aware of this subculture in case you encounter a patient who refuses to identify with a specific gender Some patients may request the use of gender-neutral pronouns, or they may use these pronouns in the nurse's presence Some examples of gender neutral pronouns are "they/their/their" and "ze/hir/hir"

History for HIV/AIDS Patient

Ask about age, gender, occupation, and where the patient lives Thoroughly assess the current illness, including when it started, the severity of symptoms, associated problems, and any interventions to date Ask the patient about when the HIV infection was diagnosed and which symptoms led to that diagnosis Ask him or her to give a chronologic history of infections and problems since the diagnosis Assess the patient's health history, including whether he or she received a blood transfusion between 1978 and 1985 in the United States or Canada (before routine blood testing for HIV contamination) Ask the immigrant patient about his or her history of transfusion therapy before coming to North America Ask the patient about sex practices, sexually transmitted infections (STIs), and major infectious diseases, including tuberculosis and hepatitis If the patient has hemophilia, ask about treatment with clotting factors Determine whether the patient has engaged in past or present injection drug usage Assess the patient's cognitive function and knowledge level of the diagnosis, symptom management, diagnostic tests, treatments, community resources, and modes of HIV transmission Also assess his or her understanding and use of safer sex practices and provide the appropriate patient teaching

Focused Assessment: The Patient With a Sexually Transmitted Infection

Assess history of present illness: • Chief concern • Onset • Symptoms by quality and quantity, precipitating and palliative factors • Any treatments taken (self-prescribed or over-the-counter products) Assess past medical history: • Major health problems, including any history of STIs/PID or immunosuppression • Surgeries: obstetric and gynecologic, circumcision Assess current health status: • Menstrual history for irregularities • Sexual history: • Type and frequency of sexual activity • Number of lifetime and past 6 months sexual contacts/partners; monogamous • Sexual orientation • Contraception history • Medications • Allergies • Lifestyle risks: drugs, alcohol, tobacco Assess preventive health care practices: • Papanicolaou (Pap) tests • Regular STI screening • Use of barrier contraceptives to prevent STIs and pregnancy Assess physical examination findings: • Vital signs • Oropharyngeal findings • Abdominal findings • Genital or pelvic findings • Anorectal findings Assess laboratory data: • Urinalysis • Hematology • ESR or CRP if PID is being considered • Cervical, urethral, oral, rectal specimens • Lesion samples for microbiology and virology • Pregnancy testing

Assessing the Woman's Satisfaction

Assess the woman's satisfaction with her contraceptive Women may be unsure about their method in the early months until they gain comfort from repetitive use Side effects also affect satisfaction They can be severe enough to cause the woman to consider another method, or they may be relieved by simple techniques Discussing side effects helps differentiate them from serious complications and leads to a discussion of relief methods

About 70% of chlamydia infections are:

Asymptomatic in women

Premalignant changes are described on a continuum from:

Atypia (suspicious) to cervical intraepithelial neoplasia (CIN) to carcinoma in situ (CIS), which is the most advanced premalignant change It generally takes years for the cervical cells to transform from normal to premalignant to invasive cancer CIN, sometimes called dysplasia, is graded on a scale of 1 to 3, depending on the appearance of the cervical tissue under a microscope Not much tissue appears abnormal in CIN1 (mild dysplasia), which is thought to be the least serious cervical precancer; more tissue appears abnormal in CIN2 (moderate dysplasia) Most tissue looks abnormal in CIN3 (severe dysplasia as well as carcinoma in situ), which is the most serious precancer

If a VDRL result is positive, the primary health care provider requests or the laboratory may:

Automatically perform a more specific treponemal test, such as the fluorescent treponemal antibody absorption (FTA-ABS) test or the microhemagglutination assay for T. pallidum (MHA-TP), to confirm the infection These tests are more sensitive for all stages of syphilis, although false-positive results may still occur Patients who have a reactive test will have this positive result for their entire life, even after sufficient treatment This poses a challenge when receiving a positive result for a patient who denies a history of or does not know that he or she had syphilis

After the physical examination, the health care provider obtains a specimen of the chancre for:

Axamination under a darkfield microscope Diagnosis of primary or secondary syphilis is confirmed if T. pallidum is present

During this stage, syphilis is a systemic disease because:

The spirochetes circulate throughout the bloodstream

Lea's Shield

Lea's Shield is a silicone device that fits over the cervix It has a central valve to allow drainage of cervical secretions and a loop for easy removal It is used with spermicide like the diaphragm or cervical cap The shield is obtained by prescription but does not require fitting by a healthcare provider It should remain in place for 8 hours after last intercourse but not longer than 48 hours It should not be used during menses

Basal Body Temperature Assessment

BBT is the lowest, or resting, temperature of the body It is assessed to detect the slight elevation in temperature that occurs near the time of ovulation Your temperature is lower during the first half of the menstrual cycle than during the second half of the cycle The BBT may drop slightly just before ovulation Not all women experience this fall in temperature Progesterone is secreted during the second half of the cycle, rising just after ovulation Progesterone causes an increase in BBT The BBT rises near ovulation and remains higher during the second half of the cycle However, some women do not have a temperature rise even when they ovulate The BBT remains higher if conception occurs and falls approximately 2 to 4 days before menstruation if conception does not occur An electronic thermometer digitally displays temperature in tenths of a degree You should place the thermometer under your tongue as soon as you awaken each morning and before any activity It should remain in place until the electronic signal sounds Record your BBT on a chart Also note relevant events that may alter your BBT, such as menstrual periods, intercourse, illness, or other occurrences The BBT can be altered by illness, restless or inadequate sleep (fewer than 6 hours), waking later than usual, traveling across time zones (jet lag), alcohol intake the evening before, sleeping under an electric blanket, or performing any activity before taking the temperature As a method to avoid pregnancy, you should not have intercourse from the onset of your menstrual period until the night of the third day of elevated temperature This method has limited value for increasing the chances of conception because the rise in temperature indicates that ovulation has already occurred It is helpful as a screening method to identify whether the woman is likely to be ovulating and if progesterone is secreted to prepare the endometrium for implantation

Diagnostic Tests

Based on the patient's history and needs, a number of laboratory tests and diagnostic procedures may be indicated

A diagnosis of AIDS requires that the adult:

Be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 × 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3[ 0.2 × 109/L]) or an opportunistic infection Once AIDS is diagnosed, even if the patient's T-cell count goes higher than 200 cells/mm3 (0.2 × 109/L), or if the percentage rises above 14%, or the infection is successfully treated, the AIDS diagnosis remains

Intermittent or continuous (daily) suppressive antiviral therapy is offered to patients to:

Lessen the severity and frequency of or to prevent outbreaks, even for those with infrequent recurrent episodes

Physical Assessment of the Transgender Patient

Be sure to review the transgender patient's health record carefully before performing a physical assessment Be culturally sensitive, nonjudgmental, and respectful during the assessment Be aware that transgender patients may be young, middle-age, or older adults To help increase the patient's comfort with examinations and the purpose of the assessment, explain why the information or examination is important to their health care When assessing transgender patients, be aware that they will be in varying stages of transition Some patients present with no obvious physical signs that they are in the process of transitioning Others have had gender reassignment surgery such that their new appearance matches their gender identity Realize that a transgender patient's genitalia may not match his or her physical appearance

Sexual partners should:

Be treated and tested for other STDs

Sexual partners must:

Be treated, not just evaluated, to prevent re-infection Sexual partners also need to receive education about the infection

Patient-Centered Care - Gender Health Considerations

Because of the very vascular and large surface area of the mucous membranes of the vagina, women are more easily infected with STIs and are at greater risk for STI-related health problems than are men Young women who are sexually active with men have the greatest risk for contracting an STI Younger adults have greater rates of sexual activity, including more partners and more unprotected sex than older adults Women are also more vulnerable to infections because of the exposure of cervical basal epithelium cells Lesbian women have a decreased risk for STIs because of fewer partners, although many have or have had sex with men Some young women may also be at high risk because they: • Lack knowledge about the risk for disease • Believe that they are not vulnerable to disease • Mistakenly believe that contraceptives also protect them from STIs • Drink alcohol in binges, which promotes risky sexual behavior Postmenopausal women also may be at risk for STIs because many perceive that pregnancy is no longer likely and thus do not use barrier protection Changing social relationships (e.g., divorce and widowhood in the middle years) have changed risk for exposure to STIs Physiologic changes during menopause such as mucosal tears from vaginal atrophy may also place them at risk Women have more asymptomatic infections that may delay diagnosis and treatment Many infectious organisms reside in the cervical os and cause little change in vaginal discharge or vulvar tissue, so women are not aware that they are infected This delay increases the likelihood of complications, including ascending infections that may cause reproductive organ damage and illness Embarrassment, denial, or fear about STIs may further delay treatment, increasing the potential for serious complications

Operative Procedures

Because surgery requires multiple procedures to create a female anatomy, the patient is on the operating table for many hours The surgery may be performed in a hospital or specialized center for transgender surgeries After general or epidural anesthesia is administered, the patient is placed in a lithotomy position (feet in stirrups) for the procedure Epidural anesthesia is preferred for patients who are asthmatic or obese The patient is transferred to the postanesthesia care unit (PACU) with a perineal dressing and packing, Jackson-Pratt drain, and indwelling urinary catheter

Nursing Safety Priority: DRUG ALERT

Before the first dose of transdermal estrogen, teach the patient to apply the patch to an area that is hairless to ensure good contact with the skin When changing to a new patch, wash any excess drug from the skin where the previous patch was applied

What is the evidence-based treatment for primary, secondary, and early latent syphilis?

Benzathine penicillin G given IM as a single 2.4 million-unit dose

Papanicolaou (Pap) tests sample cells from:

Both areas as a screening test for cervical cancer

Breastfeeding

Breastfeeding inhibits ovulation because suckling and prolactin interfere with secretion of gonadotropin-releasing hormone and LH The frequency, intensity, and duration of suckling are very important in inhibiting ovulation Women who breastfeed completely (day and night with no supplementary feedings) may avoid ovulation and resumption of the menstrual cycle Use of formula or solid foods decreases breastfeeding frequency and can lead to ovulation Ovulation generally occurs before menses, making it difficult to know when the menstrual cycle is resuming Ovulation usually occurs by 6 months, even in women fully breastfeeding Another method of contraception should be used by that time or earlier if menses has resumed or if supplementary feedings are used

Expected Outcomes

By the end of the visit, the woman will: • Correctly describe how to use her contraceptive method, including solving common problems • Describe common side effects, indications of complications, and correct follow-up • Report that she and her partner are satisfied with their contraceptive method or will explore another method

Drug therapy recommended by the CDC is:

Ceftriaxone (Rocephin) 250 mg IM PLUS azithromycin (Zithromax) 1 g orally in a single dose OR doxycycline (Monodox, Doxy-Caps, Doxycin) 100 mg orally twice daily for 1 week to treat a presumed co-infection with Chlamydia (up to 40%), unless a negative Chlamydia result has been obtained These combinations seem to be effective for all mucosal gonorrheal infections; treatment failure is rare A test of cure is not required for treatment with ceftriaxone Advise the patient to return for a follow-up examination if symptoms persist after treatment Re-infection is usually the cause of these symptoms

HPV infection has been established as the primary risk factor for development of:

Cervical cancer

Screening for HPV and dysplasia of the cervix is done by obtaining:

Cervical specimens for Papanicolaou (Pap) and HPV DNA testing

Pap Test Purpose

Changes occur in cells of the cervix before cervical cancer develops Cervical cytology, or the Pap test, is the most useful procedure for detecting precancerous and cancerous cells that are shed by the cervix Because infection with HPV contributes to cervical neoplasms, testing for this virus is usually done during the pelvic examination

The prevalence of STIs is also affected by:

Changing human physiology patterns such as: - Earlier onset of menarche - Comorbidities associated with human immune deficiency virus (HIV) and diabetes - Treatments given for cancer or organ transplantation - Health care disparities Substance use disorder has also been identified as a significant risk factor because of the effects that illicit drugs have on sexual risk-taking behavior

Combination Oral Contraceptives

Combined OCs (COCs) containing estrogen and progestin are the most common OCs COCs suppress estrogen and luteinizing hormone (LH), inhibiting maturation of the follicle and ovulation They cause thickening of the cervical mucus, preventing sperm from entering the fallopian tubes In addition, tubal motility is slowed, and the endometrium becomes less hospitable to implantation Monophasic or multiphasic dosages are available The estrogen and progestin content of monophasic pills remains constant throughout the cycle With multiphasic pills, the estrogen and progestin doses vary at different times of the cycle to help reduce side effects Because of the changes in dose over the course of the menstrual cycle, women must take the pills in the proper order Many COCs are available in packets of 21 or 28 tablets With 21-tablet packets, the woman takes 1 pill daily for 3 weeks and then stops for a week, during which the menses occur Packets of 28 tablets include 21 active tablets and 7 tablets made of an inert substance that the woman takes during the fourth week These extra pills avoid disrupting the everyday routine of taking pills Some formulations contain 24 active tablets with 4 inactive tablets Women using these pills have shorter, lighter withdrawal bleeding Some women prefer extended cycles in which the menses are delayed for a few days for special occasions or for a longer time These women take two or more pill packs without taking the placebo pills for several packs or indefinitely A COC designed to provide 84 days of active pills and seven placebo pills or seven pills with a small amount of estrogen allows women to have menses only four times a year The added estrogen is given to decrease breakthrough bleeding and give a shorter withdrawal bleed Another formulation is taken every day without stopping to suspend menstrual periods indefinitely Breakthrough bleeding and spotting are a common problem with extended or continuous use, but they usually lessen with time A disadvantage is that a woman might not recognize a pregnancy early

Safety Alert: Cautions in Using Oral Contraceptives

Combined oral contraceptives (OCs) should not be used by women with a history of any of the following: • Thrombophlebitis and thromboembolic disorders • Cerebrovascular or cardiovascular diseases • Any estrogen-dependent cancer or breast cancer • Benign or malignant liver tumors • Hypertension • Migraines with aura or women older than 35 years of age having migraines without aura • Diabetes longer than 20 years duration or with vascular or other organ involvement Combined OCs should not be used by women who have any of the following: • Any of the above conditions • Impaired liver function • Suspected or known pregnancy • Undiagnosed vaginal bleeding • Age older than 35 years and any smoking • Major surgery requiring prolonged immobilization

Voice and Communication Therapy for FtM Patients

Communication is an essential aspect of human behavior and gender expression Voice deepening for transgender people who are transitioning from female to male is accomplished by taking masculinizing hormones, such as testosterone However, feminizing hormones have no effect on the adult MtF voice MtF patients may seek assistance from a voice and communication specialist to help them develop certain vocal characteristics, such as pitch and intonation Vocal therapy can assist in management of gender dysphoria and be a positive step in the transition process Specialists include speech-language pathologists and speech-voice clinicians Remind patients to seek a specialist who is licensed, is knowledgeable in transgender health, and has specialized training in assessment and development of communication skills for transgender patients The purpose of vocal therapy is to help patients adapt their voice and communication such that it is authentic and reflects their gender identity The voice therapist should take the patient's communication preferences and style into consideration as part of the assessment process to develop an individualized treatment plan Some patients choose follow-up sessions for vocal therapy following voice feminization surgery, also called feminization laryngoplasty

Male Condom

Condoms, one of the most popular contraceptive methods in the United States, cover the penis to prevent sperm from entering the vagina They are most often made of latex Latex condoms provide the best protection available (other than abstinence) against STDs, including HIV Condoms should be used during any possible exposure to an STD, even if another contraceptive technique is used or if the woman is pregnant People allergic to latex should avoid the use of latex condoms because severe reactions are possible Polyurethane, other synthetic materials, and natural membrane condoms are also available Polyurethane condoms are thinner than latex but can require lubrication to avoid breakage and are more likely to slip off Natural membrane condoms do not prevent passage of organisms that cause STDs Condoms are readily available, inexpensive, and can be carried inconspicuously by a man or a woman The effectiveness can be increased by combining condom use with another contraceptive method Reservoir tips and water-based lubricants help prevent breakage The slippage and breakage rate is approximately 5% to 8% Some couples reject condoms because they interfere with spontaneity or sensation Condoms are affected by some vaginal medications and should not be used concurrently

Condylomata lata (secondary syphilis) can resemble:

Condylomata acuminata (genital warts)

Effect on Spontaneity - Considerations When Choosing a Contraceptive Method

Contraceptive methods related to *coitus* (sexual intercourse), such as spermicides and some barrier methods, must be readily available and used just before sexual intercourse They interrupt love making, increasing the chance that the method will not be used Some couples remedy this problem by making placement of the contraceptive device a part of foreplay Others prefer methods such as OCs or IUDs that do not interrupt sexual activity

Women who do not plan to become pregnant may have gaps in:

Contraceptive use when there are changes in their relationships or when they are planning to change contraceptive methods Approximately 40% of unintended pregnancies occur in women who used their contraceptive method incorrectly or inconsistently Such errors might occur less often if women had adequate ongoing education about their chosen method

Convenience - Considerations When Choosing a Contraceptive Method

Convenience is another important factor in choosing a contraceptive method If the woman perceives her contraceptive as difficult to use, time-consuming, or too much "bother," she is less likely to use it consistently Methods that can be used monthly or weekly instead of daily or with each intercourse are more convenient and likely to lead to better compliance Spotting or bleeding between periods, common with some methods, can be viewed as very inconvenient The desire to avoid monthly menstruation should also be considered Some women prefer extended cycles with several months between menses, and others want to avoid menstrual periods altogether Extended or continuous use of OCs, the patch, and the ring can be used *Hormone implants* or injections and intrauterine devices (IUDs) can also lead to amenorrhea in some women

Most cervical cancers arise from:

The squamous cells on the outside of the cervix The other cancers arise from the mucus-secreting glandular cells (adenocarcinoma) in the endocervical canal

Stage Unknown CDC Case Definition is used to:

Describe any patient with a confirmed HIV infection but no information regarding CD4+ T-cell counts, CD4+ T-cell percentages, and AIDS-defining illnesses is available

Gender/Gender Identity

Describes a person's inner sense of maleness or femaleness Is not related to reproduction anatomy Gender identity describes one's social role as a man or a woman

Determining the Woman's Understanding

Determine the woman's understanding of her contraceptive technique For example, ask where she places her patch or if it is hard for her to remember to take her OC each day The woman should know how to use her technique effectively and what to do in special circumstances, such as missing an OC pill Explore any misinformation, concerns, or problems that she may have in regard to effectiveness, technique, or common side effects of the method

Two nonsurgical methods of sterilization are available:

Essure involves the insertion of a small coil through the vagina and uterus into each fallopian tube The Adiana system uses radiofrequency energy to remove a thin layer of tissue and a silicone implant is inserted into each tube The procedures can be performed in the physician's office The tubes become permanently blocked over the next 3 months as tissue grows in and around the inserts During this time, another contraceptive method is necessary A hysterosalpingogram is performed at the end of 3 months The American College of Obstetricians and Gynecologists (ACOG) emphasizes the importance of the hysterosalpingogram at 3 months to ensure the tubes are completely blocked

There is growing evidence that HPV infection through oral and anal sex, especially in men who have sex with men (MSM), may be a risk factor for:

Developing oral and anal cancers

Stage 0 CDC Case Definition describes a patient who:

Develops a first positive HIV test result within 6 months after a negative HIV test result Changing the patient's status to stage 1, 2, or 3 does not occur until 6 months have elapsed since the stage 0 designation, even when CD4+ T-cell counts decrease or an AIDS-defining condition is present

Effects of HIV infection are related to the new genetic instructions that now:

Direct CD4+ T-cells to change their role in immune system defenses The new role is to be an "HIV factory," making up to 10 billion new viral particles daily The immune system is made weaker by removing some CD4+ T-cells from circulation In early HIV infection before HIV disease is evident, the immune system can still attack and destroy most of the newly created virus particles However, with time the number of HIV particles overwhelms the immune system Gradually CD4+ T-cell counts fall, viral numbers (viral load) rise, and without treatment, the patient eventually dies of opportunistic infection or cancer

The disease spreads by:

Direct extension to the vaginal mucosa, lower uterine segment, parametrium, pelvic wall, bladder, and bowel Metastasis is usually confined to the pelvis, but distant spread can occur through lymphatic spread and the circulation to the liver, lungs, or bones

Virus-host interactions are needed after infection for:

Disease development When an adult is infected with HIV, the virus randomly "bumps" into many cells The docking proteins on the outside of the virus must find special receptors on a host cell to which the virus can bind and then enter the cell The CD4+ T-cell has surface receptors known as CD4, CCR5, and CXCR4 The gp120 and gp41 proteins on the HIV particle surface recognize these receptors on the CD4+ T-cell For the virus to enter this cell, both the gp120 and the gp41 must bind to the receptors The gp120 first binds to the primary CD4 receptor, which changes its shape and allows the gp120 to bind to either the CCR5 co-receptor or the CXCR4 co-receptor Once co-receptor binding occurs, gp41 inserts a fusion peptide into the T-cell membrane, boring a hole to allow insertion of viral genetic material and enzymes into the host cell This attachment allows the virus to then enter the CD4+ T-cell

For primary and secondary syphilis, what is provided at the first visit, which may suggest to the patient that no further visits are indicated or important?

Drug therapy Remind the patient that follow-up for partners and assessment that symptoms have resolved are imperative and part of continuing care Recommend sexual abstinence until the treatment of both the patient and partner(s) is completed

Drug Therapy for the Transgender Patient

Drug therapy may be started after a psychosocial assessment by a qualified mental health care professional and informed consent has been obtained According to WPATH's most recent standards of care, the criteria for hormone therapy include: • Continuing and well-documented gender dysphoria • Patient ability to make a fully informed decision and give consent to treatment • Patient older than 18 years • Well-controlled existing medical or mental health problems, if any

Adolescence (13-19 Years)

During adolescence, the physical changes associated with puberty become evident Although these physical changes associated with sexual maturation signal the possibility of adult-like sexual activity, psychosocial factors can facilitate or inhibit such sexual expression During adolescence, two developmental tasks present: learning to manage physical and emotional aspects of sexuality in order to form intimate relations and resolving the conflict between identity and role confusion Further development of gender identity, just as sexual identity, emerges as well *Sexual identity*, a sense of being attractive and being attracted to others, is described in terms of being heterosexual, homosexual (lesbian and gay), bisexual, and transgendered

Preadolescence (8-12 Years)

During this stage, there is often a general social division of boys and girls into separate groups and, thus, sexual curiosity and learning occurs between children of the same sex Research indicates that many children engage in masturbation during this stage, with as many as 40% of females and 38% of males in a sample of college students reporting this activity prior to starting puberty

If symptoms are present, men usually notice:

Dysuria and a penile discharge that can be either profuse, yellowish-green fluid, or scant, clear fluid The urethra is most commonly affected, but infection can extend to the prostate, the seminal vesicles, and the epididymis Men seek curative treatment sooner, usually because they have symptoms, and thereby avoid some of the serious complications

Erectile Dysfunction

ED is estimated to affect 18-30 million men in the United States; it is believed to be an underreported disease process as a result of embarrassment, shame, and lack of understanding of the condition ED affects men of all ages and can be chronic or transient in nature ED is positively correlated with age, cardiovascular conditions, risk factors, physical inactivity, alcohol use, smoking, and obesity; these conditions impact vascular perfusion, which is necessary for penile erection For some men, there is an associated alteration in body image, self- concept, and self- esteem, all of which can be negatively impacted by a perceived loss of manhood

One of the primary tools for prevention of sexually transmitted diseases (STIs), including syphilis, is:

Education All people, regardless of age, gender, ethnicity, socioeconomic status, education level, gender identity, or sexual orientation, are susceptible to these diseases

Viral binding to the CD4 receptor and to either of the co-receptors is needed to:

Enter the cell The drug class known as entry inhibitors works here to prevent the interaction needed for entry of HIV into the CD4+ T-cell

Emergency Contraception

Emergency contraception (EC; also called the "morning-after pill") prevents pregnancy after unprotected intercourse This method can be used after contraceptive failure, such as condom breaking during intercourse, after rape, or after contraceptives were used incorrectly or not at all Two types of EC (Plan B One-Step and Next Choice) contain the progestin levonorgestrel Both are available at pharmacies without a prescription for women who are 17 years of age and older with picture identification for proof of age Those under 17 need a prescription Another type of EC is ulipristal acetate (Ella), which requires a prescription for all ages The progestin ECs delay or inhibit ovulation and interfere with corpus luteum function They are effective if ovulation has not already occurred The treatment is ineffective if implantation has already occurred It does not harm a developing fetus Ulipristal acetate (Ella) acts to delay or block the luteinizing surge and ovulation It also inhibits implantation Pregnancy should be excluded before Ella is taken because it can interfere with an existing pregnancy EC involves taking one or two tablets (taken together) that contain a high dose of progestin Treatment reduces the risk of pregnancy by approximately 85% Combined OCs in larger-than-usual doses can also be used for this purpose The dose varies with the brand and may require taking a large number of tablets EC is most effective if used as soon as possible within 72 hours of intercourse but can be used with lessened effectiveness within 120 hours Ulipristal acetate (Ella) can be taken within 5 days of unprotected intercourse EC will not prevent pregnancy if unprotected intercourse occurs after EC is used Insertion of the copper IUD within 5 days of intercourse is up to 99% effective in preventing pregnancy Mifepristone is also used for EC The drug inhibits ovulation and prevents endometrial development However, mifepristone will disrupt an existing pregnancy Because it is also used for medically induced abortion, some women will prefer to use another method Many women are unaware of the availability of EC One survey found that although most female college students had heard of EC, many had inaccurate knowledge about the action, side effects, and how to obtain it Information about its use and how to obtain it should be included any time education about contraception is offered Women who need EC should receive counseling about their regular contraceptive method They may not understand how to use their method correctly or may want information about other, more effective options Because of the short time during which EC is effective, some health providers give women prescriptions to use at a later date, if needed Women who use EC are not more likely to have risky sex, future unplanned pregnancies, or STDs

Injecting the penis with vasodilating drugs can make the penis erect by:

Engorging it with blood The most common agents used for this purpose include: • Alprostadil (Caverject), a synthetic vasodilator identical to prostaglandin E1 produced in the body • Paverine, also a vasodilator • Phentolamine (Regitine), an alpha-1, alpha-2 selective adrenergic receptor antagonist • A combination of any or all of these drugs

The diagnosis of condylomata acuminata is made by:

Examination of the lesions They are initially small, white or flesh-colored papillary growths that may grow into large cauliflower-like masses Multiple warts usually occur in the same area Bleeding may occur if the wart is disturbed Warts may disappear or resolve on their own without treatment They may occur once or recur at the original site Warts can occur on the external or internal surfaces of the genitalia, including the mucosal surfaces of the vagina and urethra

Feminizing Drug Therapy for MtF Patients: Expected Changes and Monitoring

Expected Physical Changes • Enlargement of breast tissue (gynecomastia) • Decreased testicular size • Decreased erectile function • Decreased libido (sex drive) • Decreased body hair growth • Decreased male pattern baldness • Increased fat compared with muscle • Softening of skin Laboratory/Imaging Studies • Chemistry panel (including glucose and electrolytes) • Liver function tests • Lipid profile • Complete blood count • Prostate-specific antigen (PSA) if recommended for age-group • Mammogram (when breast tissue develops) • Papanicolaou (Pap) smear (if vagina present)

Increasing Understanding of the Chosen Method

Fill in gaps in the woman's knowledge about how her contraceptive method works, its effectiveness, advantages and disadvantages, common side effects and complications, and when to seek help Use demonstrations (such as applying a patch or inserting a vaginal ring) and return demonstrations for using the method Give suggestions for managing side effects and common problems Understanding common side effects and the ability to manage them helps women continue to use a method

To infect, HIV must:

First enter the host's bloodstream and then "hijack" certain cells, especially the CD4+ T-cell, also known as the CD4+ cell, helper/inducer T-cell, or T4-cell This cell directs immunity and regulates the activity of all immune system cells When HIV enters a CD4+ T-cell, it can then create more virus particles

How to Use a Diaphragm:

Follow instructions carefully when using your diaphragm Skill at insertion and removal increases with practice Plan to insert the diaphragm up to 6 hours before intercourse Empty your bladder before insertion Spread about a tablespoon of spermicidal cream or gel inside the dome and around the rim Insert it into the vagina with the spermicide toward the cervix A squatting position or placing one foot on the tub or toilet seat makes insertion and removal easier Be sure that the front rim fits behind your pubic bone and that you can feel the cervix through the center of the diaphragm If more than 6 hours elapse between insertion and intercourse or if you have intercourse again, insert more spermicide into the vagina without removing the diaphragm Leave the diaphragm in place for at least 6 hours after the last intercourse To reduce risk of infection, remove it by 24 hours after insertion Douching with the diaphragm in place is unnecessary and will lessen its effectiveness To remove the diaphragm, assume a squatting position and bear down Hook a finger around the front rim to break the suction, and pull down Wash the diaphragm with mild soap and dry well after each use Inspect it for holes by holding it up to a light or filling it with water If you find a hole, use another contraceptive method and go to your healthcare provider for a new diaphragm

After treatment, the CDC recommends:

Follow-up evaluation, including blood tests at 6, 12, and 24 months Repeat treatment may be needed if the patient does not respond to the initial antibiotic

Patient-Centered Care - Gender Health Considerations

For men, ask about dysuria, frequent urination, and a mucoid discharge that is more watery and less copious than a gonorrheal discharge These signs and symptoms indicate urethritis, the main symptom of chlamydia infection in men Some men have the discharge only in the morning on arising Complications include: - Epididymitis - Prostatitis - Infertility - Reiter's syndrome, a type of connective tissue disease

Cognitive-Behavioral Therapy - Collaborative Interventions

For some individuals, cognitive-behavioral therapy (CBT) and sexual counseling have proven effective in the treatment of sexual problems with psychological origins, including some cases of ED Many psychological and emotional factors, such as fear, anxiety, fatigue, and reproductive health concerns, can impair sexual performance Individuals with sex addictions may also benefit from CBT

Maturational

For some, SD can be a result of a knowledge deficit with regard to sexuality, birth control, safer sex practices, and changes associated with aging Lack of general social skills can interfere with establishing intimate and social relationships necessary in the growth and development of one's own sexuality

What is an essential component of the nurse's intervention?

Frank discussion about sexual activity, including whether the patient has new or multiple partners

What is used to provide immunity for HPV types 6 and 11 (predominantly types causing warts, low risk for cervical cancer) and 16 and 18 (high risk for cervical cancer)?

Gardasil Initially approved for females, the vaccine is also recommended for males ages 9 to 26 years

How does gender affect HIV transmission?

Gender affects HIV transmission, and the infection is more easily transmitted from infected male to uninfected female than vice versa This is because HIV is most easily transmitted when infected body fluids come into contact with mucous membranes or nonintact skin The vagina has more mucous membrane (surface area) than does the urethra of the penis Teach women the importance of always either using a vaginal or dental dam or female condom or having their male partners use a condom

The term transgender is often used as an umbrella description for all people whose:

Gender identity and presentation do not conform to social expectations In this text, transgender describes patients who self-identify as the opposite gender or a gender that does not match their natal sex For proper usage, transgender should be used only in adjective form For example, a patient "is transgender," "identifies as transgender," or "is a transgender patient" Note that "transgender" never ends in "-ed" The term transgender should not be used as a noun, and a patient should never be described as "a transgender"

Orgasm

Generally a pleasurable sensation, orgasm produces rapid contractions of the muscles in the genital and anal area and, for some humans, throughout the body; it is the mechanism by which pelvic congestion is relieved slowly The physical process of orgasm is similar for both sexes In females, contractions occur in the lower part of the vagina, in the uterus, anus, and pelvic floor Approximately 10% of women also ejaculate a clear fluid from the urethra at orgasm; the fluid originates from the Skene's glands in the wall of the urethra and is much like the prostate fluid found in male ejaculate In males, the pelvic floor muscle contractions result in a pulsatile ejaculation of seminal fluid Ejaculation with orgasm is much more common in men than in women Most of the time, a man will have an orgasm at the same time he ejaculates, but occasionally men have an orgasm without ejaculating or ejaculate without having an orgasm

Historically HSV-2 caused most of the:

Genital lesions However, this distinction is academic because the transmission, symptoms, diagnosis, and treatment are nearly identical for the two types

In men, gonorrhea can be diagnosed by:

Gram staining smears of urethral discharge that has been swabbed onto a glass slide, dried, and stained The presence of gram-negative diplococci is diagnostic for gonococcal urethritis in men If the man has symptoms, Gram stains are very sensitive and specific for gonorrhea and allow for immediate diagnosis and treatment in the clinical setting Without symptoms, Gram stains are less reliable Smears do not confirm the diagnosis in women because the female genital tract normally harbors other Neisseria organisms that resemble N. gonorrhoeae

Physical Assessment/Signs and Symptoms for HIV/AIDS Patients

HIV disease and AIDS progress on a continuum The patient with HIV disease may either have few symptoms and problems or may have problems that are acute rather than chronic However, as the disease progresses, more severe health problems occur Assess for clusters of symptoms that may indicate disease progression

Everyone who has AIDS has:

HIV infection However, not everyone who has HIV infection has AIDS The distinction is the number of CD4+ T-cells and whether any opportunistic infections have occurred A healthy adult usually has at least 800 to 1000 CD4+ T-cells per cubic millimeter (mm3) of blood This number is reduced in HIV disease

Many adolescents are at risk for:

HIV, STIs, unintended pregnancy, and sexual violence According to the 2013 U.S. Youth Risk Behavior Surveillance System, 7.3% of students reported having been physically forced to have sexual intercourse when they did not want to, and the prevalence of physical dating violence was reported as 9.4% Although unintended pregnancy remains a risk factor, the pregnancy rate is at its lowest point in 30 years at 67.8 per 1000, and the birth rate at its lowest point in 70 years at 39.1 births per 1000 adolescent females

Human papilloma virus (HPV) can be prevented by:

HPV vaccination There are currently three U.S. Food and Drug Administration-approved HPV vaccines available; each is a three-dose series Vaccination is routinely given at 11 or 12 years of age to both girls and boys HPV vaccination is considered to be safe and effective, and it offers protection from genital warts and cancers caused by HPV, including that of the female cervix

Most nongenital lesions such as cold sores are caused by:

HSV-1, transmitted via oral-oral contact

Which type recurs and sheds asymptomatically more often?

HSV-2

Patient-Centered Care - Cultural/Spiritual Considerations

Health care disparities exist between racial and ethnic groups in the incidence of primary and secondary syphilis In the most recent report from the CDC, the rates increased among Hispanics, American Indians/Alaska Natives, Euro-Americans, and most dramatically among Asian/Pacific Islanders; rates have decreased among African Americans Nevertheless, African Americans have a seven times greater rate of acquiring syphilis than whites Compared with Euro-Americans, the 2014 rate for Hispanics was two times higher (CDC, 2017c) The reason for these differences is unclear, but status of health literacy and lack of access to health care may be factors

The stigma of STIs in the United States has been associated with:

Higher rates of these infections compared with rates in other developed countries

In contrast, in the menopausal woman, the squamo-columnar junction may be:

Higher up in the endocervical canal, making it difficult to sample for a Pap test

Action of IUDs

IUDs cause a sterile inflammatory response that results in a spermicidal intrauterine environment They do not cause abortion Progestin is continuously released from the LNG-IUS, Mirena The progestin causes decreased sperm and ova viability, thickening of the cervical mucus (barring sperm penetration), inhibits sperm motility, prevents ovulation some of the time, and makes the endometrium hostile to implantation

Psychosocial Assessment of the Transgender Patient

If gender and sexuality are relevant to the patient's presenting health problem, ask specific questions to determine how these factors may impact care Again, it is helpful to share with patients why this information is relevant to their treatment Reassure patients that their responses are confidential and will not be shared with any family, friends, or significant others without the patient's permission However, evidence of abuse must be reported as mandated by law Appropriate screening questions about psychosocial functioning related to gender and sexuality include: • Are you experiencing any challenges, concerns, or anxiety related to your sexuality? • Related to your gender, how do you identify? • Are you experiencing any sadness, depression, or thoughts of hurting yourself? • Have you experienced any violence or discrimination in your personal or work life? • Are you currently being seen by a counselor or psychologist related to your sexuality and gender identity? If so, why? If the responses to these questions indicate that the patient has potential or actual mental health problems, consult with the health care provider for further evaluation by a qualified mental health care professional, such as a licensed counselor or clinical psychologist

Functional ED

If the patient has episodes of ED, it usually has a functional (psychological) cause Men with functional ED usually have normal nocturnal (nighttime) and morning erections Onset is usually sudden and follows a period of high stress

Assessing Appropriate Choices

If the woman is considering a change in contraceptive method, assess factors to help determine the best method for her Include a history of medical conditions, childbearing history, cultural and religious beliefs, and intensity of her desire to prevent pregnancy The woman's ability to understand and follow complicated directions is important as well The relationship of the couple is important If intercourse is frequent, the woman may wish to have a method that is always in place, such as an IUD or hormone implant In a mutually monogamous relationship, there is no risk of STDs if neither partner is infected If either of the couple has more than one partner, condom use to protect against STDs is essential, even if the woman uses another contraceptive method

Postoperative Care

Immediately after surgery, apply an ice pack to the perineum to decrease pain and bruising Monitor the patient's pain level carefully and offer analgesia as needed Genital surgery is painful because there is a high concentration of nerve endings in the perineum Although not a common postoperative complication, monitor the patient for bleeding Observe the surgical dressing and surrounding area for oozing or bright red blood Report and document any indication of bleeding immediately to the surgeon and keep the patient in bed Encourage the patient to drink liquids after surgery; discontinue the patient's IV line once oral fluids are tolerated Evaluate the patient's intake and output every 8 to 12 hours All patients stay in the hospital for at least one night after surgery, but some patients may stay longer, depending on the number and complexity of the surgical procedures Some agencies transfer the patient the day after surgery to a local hotel for continued follow-up and monitoring by a health care professional (usually a nurse) Collaborate with the case manager for discharge planning and follow-up care The Jackson Pratt drain is removed typically 3 to 5 days after surgery when drainage is less than 15 to 20 mL in a 24-hour period About a week after surgery, the surgical pressure dressing, packing, and external sutures are removed At this time, patients are taught how to douche and insert vaginal stents to dilate the vagina Sexual intercourse also helps keep the vagina dilated Remind patients that routine douching and douching after intercourse are needed to prevent infection in the new vagina A solution of vinegar and water or a commercial product such as Massengill can be used Vaginal stents (also called dilators) must be inserted several times a day for months after surgery The stent should remain in the vagina for 30 to 45 minutes or as instructed by the surgeon Teach patients the importance of using the stents with water-based lubrication The urinary catheter is removed between postoperative day 7 and 12 Early removal can cause urinary retention, but prolonged placement can lead to catheter-associated urinary tract infection (CAUTI) Patients should continue follow-up visits with their primary health care provider for signs and symptoms of complications One of the worst complications is a vaginal-rectal fistula, which is caused by rectal perforation during surgery Teach patients to report any leakage of stool into the vagina immediately to their surgeon The treatment for this complication is a temporary colostomy and fistula wound management for many months In addition to physical complications after surgery, some MtF patients are not satisfied with the quality of the results For example, the neovagina may not be functional for sexual intercourse Some patients request another surgery to achieve more satisfying results

Preoperative Care

In addition to the required criteria to qualify for a vaginoplasty (also called transvaginal surgery), the transgender patient is medically evaluated like any other presurgical patient Patients who have poorly controlled diabetes with vascular complications, coronary artery disease, or other systemic disease that limits functional ability are not candidates for gender reassignment surgery The surgeon explains the options for selected procedures, postoperative care expectations, and potential for complications after surgery Postoperative recovery for transvaginal surgery takes a long time and has a high complication rate Overweight patients have a higher incidence of wound infection and may have problems with adequate ventilation (breathing) and ambulation after surgery Refer these patients for nutritional counseling as needed Written and verbal preoperative instructions are provided by the surgeon, including optional methods of body hair removal A bowel preparation may be started 24 hours before surgery and includes a clear liquid diet, laxatives, and Fleet's enemas Increased fluids are recommended until the patient goes to bed the night before surgery because the bowel "prep" can be very dehydrating Antimicrobials such as neomycin sulfate and metronidazole (Flagyl) are typically given on the day of surgery to minimize the risk for infection Some surgeons require that the patient take supplements to prevent bruising and promote tissue healing, such as vitamin C Patients who are very thin are encouraged to eat a high-protein diet A powdered protein supplement with arginine (an amino acid) may also be prescribed to promote wound healing Patients have a number of laboratory tests to ensure that they are healthy before surgery Adequate hemoglobin and hematocrit (H&H) levels are especially important because some blood is lost during surgery For patients who have low H&H levels, an erythropoietin such as epoetin alfa (Procrit) or IM testosterone with iron is given Most patients choose testosterone because it is a lower-cost drug

Sexual Orientation: Lesbian, Gay, Bisexual, Transgender - Populations at Risk

In comparison to their heterosexual counterparts, gay, lesbian, and bisexual youths have been found to engage in more high-risk sexual practices Young women who primarily have sex with women also report that they are likely to engage in sexual activity with men who are homosexual, bisexual, or injection drug users Adolescent boys who participate in sexual activity with bisexual men are at significantly increased risk for possible transmission of HIV and AIDS New cases of HIV diagnosis are increasing among men who have sex with men (particularly those of racial minorities) perhaps because of the "glamorization" of anal intercourse, misperceptions that partners are at low risk, and the belief that medical advances in the treatment of AIDS have eliminated the need for appropriate protection during sexual activity

Introducing the Subject

In the postpartum setting, introduce the subject by asking the woman if she plans to have more children Most women indicate a desire to wait a period of time before the next pregnancy Ask the woman what contraceptive method she is planning to use or how she liked methods she has used before Introduce the subject during well-woman checks by asking about the woman's current contraceptive and how satisfied she is with it These questions will help identify problems and questions that the woman may have about contraception

The Five P's: Partners

Includes the number and gender of the patient's sexual partners Practices refers to safe sex practices If the patient reports more than one partner in the past 12 months or if the patient has had sex with a partner who has other sex partners, the nurse should inquire about condom use

History of a Transgender Patient

Interventions for transgender people who experience gender dysphoria (discomfort with one's natal sex) include one or more of these options: • Changes in gender expression that may involve living part time or full time in another gender role • Psychotherapy to explore gender identity and expression, improve body image, or strengthen coping mechanisms • Hormone therapy to feminize or masculinize the body • Surgery to change primary and/or secondary sex characteristics (e.g., the breasts/chest, facial features, internal and/or external genitalia) During the health history, inquire about which interventions the patient has had, if any, or if there are plans to have them in the future Ask about current use of drug therapy, including hormones, and other feminizing or masculinizing agents, including silicone injections These medications are usually prescribed by endocrinologists or other specialists in transgender health care, but some patients may obtain them from nonmedical sources, including the Internet Exogenous hormone therapy can cause adverse health problems and requires careful patient monitoring, including laboratory testing For example, estrogen therapy can cause increased health risks such as increased blood clotting causing venous thromboembolism (VTE), elevated blood glucose, hypertension, estrogen-dependent cancers, and fluid retention Smoking and obesity increase these risks. The risks also increase with higher doses of the medication. Ask the patient about a history of these problems Inquire about the patient's surgical history For the MtF patient, ask about breast surgery and any surgical changes to the genitalia, such as a penectomy (removal of the penis) and vaginoplasty (creation of a vagina) The MtF patient still has a prostate gland For older patients, ask about any problems with prostate health problems, such as urinary dribbling and retention For the FtM patient, ask whether a hysterectomy, bilateral salpingo-oophorectomy (BSO), mastectomy, phalloplasty (creation of a penis), and/or scrotoplasty (creation of a scrotum) was performed Keep in mind that health insurance usually does not cover the cost of the transition process and patients may seek alternative care For example, hormones may be obtained illegally or from countries that do not have quality controls for medication MtF patients may seek silicone for creating breasts from nonmedical people, causing a high risk for hepatitis C and silicone complications Ask patients about the use of these alternatives as a part of their transition process

Including the Woman's Partner

Invite the woman to include her partner in discussions, if possible If the partner understands the proper method of use, he may be more cooperative and willing to help ensure contraceptive success

Sexuality

Is the result of biological, psychological, social, and experiential factors that mold an individual's sexual development, self-concept, body image, and behavior

Blood Hormone Levels with Oral Contraceptives

Maintaining a constant blood hormone level is important for effectiveness, especially with POPs The woman must take the pills close to the same time each day Many women take the pills as a part of their morning or bedtime routine The pills can be taken with a meal to avoid nausea Illness can affect the blood hormone levels A woman who experiences vomiting or diarrhea should use a back-up method of contraception for 7 days because the hormones may not have been properly absorbed

Mammography

Mammography is used either to screen for cancer or assist in the diagnosis of a palpable mass in the breast Mammography is the primary screening tool that can detect breast lumps long before they are large enough to be palpated This procedure, often accompanied by ultrasound studies, allows early diagnosis and treatment, thus increasing the chance of long-term survival ACS recommends yearly mammography to screen for breast cancer in women starting at the age of 40 years Women at higher risk for breast cancer or with a suspicious growth in the breast may need mammography and other diagnostic studies at a younger age Despite the value of screening mammography, many women have never had a mammogram (study of breast tissue using very-low-dose-radiography) Reasons include expense, fear that x-ray exposure will cause cancer, fear of pain, and reluctance to hear "bad news" Nurses provide information and reassurance to help the woman overcome her objections to the use of this valuable screening tool Although mammography is relatively expensive, the cost is often covered by health insurance, Medicaid, and Medicare, and screening mammograms are frequently offered by the community at low cost It is important to acknowledge that some discomfort occurs when the breast is compressed between two plates while the radiograph is taken One measure that reduces discomfort is scheduling the mammography after a menstrual period, when the breasts are less tender Knowledge that the risk of mammography is minimal to nonexistent because of the very-low-dose x-rays used may help women overcome some of their fear Digital mammography, although more expensive, can provide clearer images Ultrasound images or magnetic resonance imaging (MRI) can also be used if needed No screening test is 100% accurate Therefore, nurses must emphasize that the mammogram should be performed in conjunction with a monthly BSE and the recommended frequency of CBEs

Menopause

Menopause is associated with the cessation of ovulation The age of onset is variable, with the average age at 51 years Common symptoms include: - Hot flashes - Night sweats - Impaired sleep - Headaches - Changes in memory - Loss of sexual desire - Urinary concerns - Mood alterations - Dryness of skin and vaginal tissues In addition to managing symptoms, issues to be addressed include: - Nutrition - Bone health - Heart disease prevention - Weight management - Hormonal balance - Cancer screening - Psychosocial concerns of relationships, retirement, and available community support systems Nurses have the ability to provide accurate information to patients regarding the physiology of menopause and its effect on sexuality

Postoperative Complications of Vaginoplasty Surgery

Most Serious Complications • Vaginal-rectal fistula • Rectal perforation • Bleeding Other Complications • Surgical wound infection • Urinary leakage/incontinence • Chronic urinary tract infections • Urinary meatus stenosis • Vaginal stenosis • Vaginal collapse • Labial hematoma • Inadequate vaginal length or width • Lack of sensation • Lack of sexual pleasure

Side Effects - Considerations When Choosing a Contraceptive Method

Many methods of contraception have bothersome side effects that should be explained When women know what to expect, they are often more willing to tolerate side effects, especially if they know they do not indicate a health risk

Surgical Management for Transgender Patients

Many transgender people are satisfied with their gender identity, role, and self-expression without surgery Surgery, particularly procedures that affect the external or internal genitalia, is usually the last and most carefully considered option for transitioning from one's natal sex to one's inner gender identity These procedures are often referred to as *gender or sex reassignment surgery (SRS)* but are also known as gender-affirming surgery or gender-confirming surgery The patient has a number of surgical options to achieve either feminizing or masculinizing effects Regardless of the procedure performed, the nurse collaborates with the patient, family, and health care team to promote positive outcomes for the transition process Gender reassignment surgeries are procedures that alter anatomically healthy structures Not all surgeons feel comfortable in performing procedures that could "harm" transgender patients However, these procedures help treat gender dysphoria Some patients elect to undergo the full range of surgeries, whereas others choose to have only some or none of them, typically because of the profound medical expense Genital surgeries "below the waist" are the most invasive procedures The criteria for genital surgery depend on the type of surgery being requested For example, most surgeons (usually urologists or plastic surgeons) require 12 months of hormone therapy plus one or two referrals from qualified psychotherapists for MtF patients who desire an orchiectomy (removal of testes) The same requirements are needed for FtM patients who desire a hysterectomy (uterus removal) and bilateral salpingo-oophorectomy (BSO), or removal of both fallopian tubes and ovaries The psychotherapist assesses the patient's readiness for genital surgery and hormone therapy, including a discussion of risks and out-of-pocket costs The patient's support system is assessed to ensure that the patient makes the best possible decision and achieves the desired outcomes For MtF patients requesting a vaginoplasty (creation of a vagina) or FtM patients desiring a phalloplasty (creation of a penis), the required criteria include 12 continuous months of living in a gender role that is congruent with the patient's gender identity It is also recommended that these patients have regular visits with a mental health care professional

Teaching About Oral Contraceptives

Many unintended pregnancies result from failure to take OCs correctly However, education about proper use greatly increases effectiveness Because the instructions can be complicated, the woman should receive written as well as verbal instructions in her own language if she can read Teaching about when to start taking OCs is especially important The woman will be told to start taking her pills either on the day they are prescribed (if it is reasonably sure she is not pregnant [Quick Start method]), on the first day of the next menstrual period, or on the first Sunday after her next menses begins The Quick Start method provides immediate protection A Sunday start prevents the woman from having periods on weekends Unless she begins her pills on the first day of her menses, the woman is usually told to use a back-up contraceptive for the first week One study showed that women who did not fully understand the advantages of OCs and had low confidence in their ability to use them were less likely to continue use at 6 months The nurse should listen carefully to women's concerns about side effects and help them find methods of relief Teaching about temporary side effects may help the women endure them until they are no longer present When women discontinue OCs because they are unhappy with the side effects, they might not use another contraceptive or use one that is less effective, becoming pregnant as a result Women should be instructed to keep a back-up contraceptive method readily available should they decide to stop taking their OCs

Masculinizing Surgeries for FtM Patients

Masculinizing surgeries are performed for FtM patients to create a functional and/or aesthetic male anatomy, including: • Breast/chest surgeries, usually a bilateral mastectomy (removal of both breasts) and chest reconstruction • Genital surgeries, such as a hysterectomy and bilateral BSO, vaginectomy (removal of the vagina), phalloplasty (creation of an average-size male penis) with ureteroplasty (creation of a urethra) or metoidioplasty (creation of a small penis using hormone-enhanced clitoral tissue), and scrotoplasty (creation of a scrotum) with insertion of testicular prostheses • Other surgeries, such as liposuction, pectoral muscle implants, and other body-contouring procedures If the patient has not had previous abdominal surgery, a laparoscopic procedure is preferred for the hysterectomy and BSO surgery Procedures to create a male anatomy are not performed as often as MtF surgeries Phalloplasties are the most difficult reconstructive genital surgeries to perform and usually require several stages Skin flaps from the radial forearm, anterior lateral thigh, or back are used to create the penis Fat grafts may be needed to increase penile girth, and buccal mucosal tissue may be used to create the urethra A penile prosthesis or implant is not inserted until months after surgery when the initial surgical healing has occurred Complications from phalloplasty include: - Urinary tract stenosis - Donor graft site scarring - Occasionally necrosis of the neopenis (new penis) In addition to these physical problems, the patient may not be satisfied with the results of the surgery, such as an inadequate length of the penis For these reasons, most FtM patients do not have this procedure and prefer to have only a laparoscopic hysterectomy and BSO

If possible, the health care provider determines the cause of the ED through a variety of diagnostic testing, including:

Measuring serum hormone levels and using Doppler ultrasonography to determine blood flow to the penis

Mechanical Barriers

Mechanical barriers are devices placed over the penis or cervix to prevent sperm from entering the uterus They include the condom, sponge, diaphragm, and cervical cap

Hormone Injections

Medroxyprogesterone acetate, or DMPA (Depo-Provera), is an injectable progestin that is available for intramuscular (IM) and subcutaneous (Sub Q) administration It is convenient, has no estrogen, and prevents ovulation for 14 weeks, although injections should be scheduled every 12 weeks Action and side effects are similar to those of other progestin contraceptives Women who should not use other hormone contraceptives should avoid Depo-Provera as well The IM form of Depo-Provera is given by deep intramuscular injection The Sub Q form is given in the anterior thigh or abdomen The site should not be massaged after injection because massage accelerates absorption and decreases the period of effectiveness A back-up method of contraception should be used for the first 7 days unless the injection is given within 5 days after a menstrual period starts Back-up contraception is also recommended if the woman is more than 2 weeks late in returning for subsequent injections, and a pregnancy test may be performed Menstrual irregularity is the major reason for discontinuation Although spotting and break-through bleeding are common, amenorrhea occurs in 80% of women using the IM form at 5 years and in 55% of women using the Sub Q form at 1 year Other side effects include breast tenderness, weight gain, headaches, depression, and decreased bone density Because of the loss of bone density that occurs with prolonged use, the prescribing information states that Depo-Provera should not be used for more than 2 years unless no other contraceptive is suitable Although bone density losses reverse after the drug is discontinued, it is not known if the bone loss is fully reversible Bone loss could be a bigger problem for women who begin Depo-Provera during adolescence or in the perimenopausal period Women who use Depo-Provera should get adequate amounts of calcium and vitamin D and should increase weight-bearing exercises Depo-Provera can be started in the immediate postpartum period It increases the quantity of milk in lactating women, and its effectiveness is not affected by a woman's weight After the drug is discontinued, there is a delay in return to fertility Approximately 59% of women resume menses in 6 months, and 25% do not resume menses for a year or more

What is currently the most widely used standard and preferred over cultures or microscopic examinations?

Molecular testing for N. gonorrhoeae These nucleic acid amplification tests (NAATs) are highly sensitive and specific During examination, providers can swab the male urethra or female cervix to obtain specimens These specimens can be placed in medium for molecular testing, cultured on chocolate agar (gold standard), or viewed microscopically after Gram staining (male urethral specimens only) Patient-collected urine or vaginal swabs can also be used to diagnose both gonorrhea and chlamydia infections, allowing for testing without a full examination

The time from the beginning of HIV infection to development of AIDS ranges from:

Months to years The range depends on how HIV was acquired, which additional health problems the patient has, personal factors, and interventions For example, for adults who have been transfused with HIV-contaminated blood, AIDS often develops quickly For those who become HIV positive as a result of a single sexual encounter, progression to AIDS takes much longer Other personal factors that influence progression to AIDS include frequency of re-exposure to HIV, presence of other sexually transmitted infections (STIs), nutrition status, and stress

Because the best treatment for gonorrhea is injected Rocephin (ceftriaxone), is expedited partner therapy (EPT) ideal?

No If there is concern that the partner may not come to a health care facility for treatment, providing oral cefixime as an alternative has been recommended by the CDC Because of the potential for resistance of gonorrhea to cefixime, a test of cure is recommended after treatment is completed

Protection From Sexually Transmitted Diseases - Considerations When Choosing a Contraceptive Method

No contraceptive (other than total abstinence) is 100% effective in preventing sexually transmitted diseases (STDs) The risk of exposure to STDs should be discussed when counseling women about contraceptive choices The male condom is inexpensive and offers the best protection available It should be used whenever there is a risk that one partner has an STD, even when another form of contraception is practiced or the woman is pregnant

Other Medications on Oral Contraceptives

OCs can interact with other medications Drugs that stimulate metabolism in the liver, such as St. John's wort and some anticonvulsants, can alter the effectiveness of OCs Most broad-spectrum antibiotics and antifungals do not decrease OC effectiveness The woman should always tell her healthcare providers and her pharmacist about other drugs she is taking

Sexual Acts

Occur when behaviors include genitalia and erogenous zones

Several surgical methods are used for tubal sterilization:

One uses a minilaparotomy incision near the umbilicus during the postpartum period or just above the symphysis pubis at other times Another is performed through a laparoscope inserted through a small incision In each method, the surgeon blocks the tubes with clips, bands, or rings, removes a piece of the tubes, and either ties the ends or uses electrocoagulation to destroy a portion of the tubes

Both vaccines are recommended before:

Onset of sexual activity (and before age 26 years) and possible exposure to HPV Because exposure to HPV is likely for most sexually active young adults, vaccination protects them against the strains to which they have not yet been exposed Vaccination is also especially encouraged for MSM and immunocompromised young adults up to the age of 26 years

Drug Therapy Interventions for Condylomata Acuminata (Genital Warts)

Patients may apply podofilox (Condylox) 0.5% cream or gel twice daily for 3 days with no treatment for the next 4 days This regimen should be repeated for four cycles Other options are imiquimod (Aldara) 5% cream applied topically at bedtime three times a week and sinecatechins 15% ointment (made from green tea extract) applied three times a day, both until the warts disappear or for up to 16 weeks Imiquimod boosts the immune system rather than simply destroying the warts These self-treatments are less expensive than those performed in the health care provider's office, but they take longer for healing Teach patients that over-the-counter (OTC) wart treatments should not be used on genital tissue Cryotherapy, trichloroacetic acid (TCA) or bichloroacetic acid (BCA), and podophyllin (Pododerm) are provider-applied treatments *Cryotherapy* (freezing), usually with liquid nitrogen, can be used every 1 to 2 weeks until lesions are resolved TCA/BCA (80% to 90%) can be applied weekly Podophyllin resin can be applied weekly but needs to be washed off 1 to 4 hours after application Extensive warts have been treated with the carbon dioxide laser, intra-lesion interferon injections, and surgical removal

Minor Procedures

Other surgical procedures include removal of genital lesions (e.g., warts or polyps) or incision and drainage for cysts or abscess

Discuss with the patient with syphilis the importance of:

Partner notification and treatment, including the risk for re-infection if the partner goes untreated All sexual partners must be prophylactically treated as soon as possible, preferably within 90 days of the syphilis diagnosis

The priority nursing intervention is:

Patient and sexual partner education about the mode of transmission, incubation period, treatment, and complications, especially the association with cervical cancer Reinforce instructions about local care of the lesions or patient-applied treatment for self-management Inform patients that recurrence is likely, especially in the first 3 months, and that repeated treatments may be needed Urge all patients to have complete STI testing, since exposure to one STI may increase risk for contracting another Sexual partners should also be evaluated and offered treatment if warts are present

Nursing Safety Priority: ACTION ALERT

Patients are in a lithotomy position for an extended period during surgery Therefore, after surgery, monitor lower-extremity neurovascular status and encourage the patient to move the legs often during the first 24 hours after surgery Report and document any unexpected findings, such as continued numbness or inability to move the lower legs or feet Patients who had epidural anesthesia are not able to move their legs for several hours after surgery until the effect of the drug diminishes

Drugs for MtF Patients

Patients transitioning from male to female (MtF) typically take a combination of estrogen therapy and androgen-reducing medications to achieve feminizing effects Expected physical changes from estrogen therapy are breast enlargement, thinning hair, decreased testicular size, decreased erectile function, and increased body fat compared with muscle mass Because oral estrogen (ethinyl estradiol) can increase the risk for venous thromboembolism, transdermal estrogen (Climara) or injectable estradiol is preferred for use in transgender patients The typical dosing is two 0.1-mg patches changed twice weekly. Injectable estradiol is usually prescribed in a dose between 5 and 20 mg IM every 2 weeks Progesterone may also be prescribed for 10 days each month Teach patients taking any form of estrogen about side effects such as headache, breast tenderness, nausea/vomiting, and weight gain (often due to fluid retention) or loss Tell them to report increased feelings of anxiety or depression to their primary health care provider Estrogens can also cause estrogen-dependent cancers, hypertension (due to fluid retention), venous thromboembolism (VTE) such as deep vein thrombosis (DVT), and gallbladder disease Teach patients to follow up with their primary health care provider to monitor for these potential adverse drug effects In addition to estrogen therapy, androgen-reducing agents (anti-androgens) are often given to block the effects of testosterone, including: • Spironolactone (Aldactone), a low-cost diuretic that also inhibits testosterone secretion and androgen binding to androgen receptors • 5-alpha reductase inhibitors (e.g., finasteride [Proscar]), drugs typically used to treat benign prostatic hyperplasia (BPH) (These drugs block the conversion of testosterone to a more active ingredient to decrease the hair loss associated with estrogen therapy and shrink prostate tissue) • GnRH agonists (e.g., goserelin [Zoladex]), neurohormones that block the gonadotropin-releasing hormone receptor, thus inhibiting the release of the follicle-stimulating hormone (FSH), and luteinizing hormone (LH) (These drugs are more expensive and are available only as implants and parenteral preparations) Common side effects of finasteride and other 5-alpha reductase inhibitors include dizziness, cold sweats, and chills These symptoms typically decrease over time If patients continue to have them, instruct them to contact their primary health care provider Teach patients receiving GnRH agonists how to self-administer subcutaneous injections Major side effects of these drugs are tachycardia and other cardiac dysrhythmias Remind patients to follow up with their health care provider to monitor heart rate and rhythm Teach them to call 911 if they experience chest pain

Penile Implant Surgery

Penile implant surgery is the insertion of an inflatable device in the penis with a reservoir placed in the scrotum The device is inflated by squeezing the reservoir This procedure has become much less common since the introduction of pharmacotherapy for ED

Choosing a Contraceptive Method - Assessment

Perform the assessment in a quiet area where interruptions are unlikely Assure the woman that her confidentiality will be maintained Keep voices low to increase the woman's comfort

Progestin Only Oral Contraceptives

Progestin-only pills (POPs) are less effective at inhibiting ovulation but avoid the use of estrogen, which cannot be used by some women POPs cause thickening of the cervical mucus to prevent penetration by sperm, and they make the endometrial lining unfavorable for implantation The woman should start POPs during the first 5 days of her menstrual cycle and take one pill at the same time of day continuously She can start the pills on another day if she is sure she is not pregnant If she misses any pills or does not take them at the same time each day, the chance of pregnancy increases The woman should use a back-up method of contraception for 2 days when the pills are first started, if she is more than 3 hours late in taking a pill, or has vomiting or diarrhea within 4 hours of taking a pill (Raymond, 2011) Break-through bleeding and greater chances of error have made these OCs less popular than the combination OCs

First-line oral drugs used to manage ED, phosphodiesterase-5 (PDE-5) inhibitors, work by:

Relaxing the smooth muscles in the corpora cavernosa so blood flow to the penis is increased The veins exiting the corpora are compressed, limiting outward blood flow and resulting in penile tumescence (swelling) Teach patients to take the pill 1 hour before sexual intercourse

Opportunistic Infections of AIDS

Protozoal infections: • Toxoplasmosis • Cryptosporidiosis • Isosporiasis • Microsporidiosis • Strongyloidiasis • Giardiasis Fungal infections: • Candidiasis • Pneumocystis jiroveci pneumonia • Cryptococcosis • Histoplasmosis • Coccidioidomycosis Bacterial infections: • Mycobacterium avium complex infection • Tuberculosis • Nocardiosis Viral infections: • Cytomegalovirus infection • Herpes simplex virus infection • Varicella-zoster virus infection

Teaching About Other Methods

Provide information about other forms of contraceptives, if the woman wishes Discuss characteristics of other methods that are most important to the woman and her lifestyle Compare various methods to the one she is currently using Include benefits, disadvantages, and risks so she can make an informed choice If a prescription or fitting is needed, discuss what will happen during the visit Provide written information she can take home to discuss with her partner, if she wishes, before making a final decision

Nurses can increase the likelihood of a woman using contraception by:

Providing contraceptive counseling that is directed to the woman's specific needs Therefore, the nurse must provide individualized family planning information to women in every situation for which it is appropriate

Nurses in primary care community settings and acute care settings have a responsibility to:

Recognize patients who are at risk for or who have STIs, possibly while being treated for another unrelated health problem

Patients receiving continuous therapy should periodically (possibly once a year) be reassessed for:

Recurrences, usually by stopping the antiviral drug temporarily

Safer sex practices are those that:

Reduce the risk for nonintact skin or mucous membranes coming in contact with infected body fluids and blood

Secondary Prevention (Screening)

Referred to as screening with a goal of reducing morbidity and mortality and preserving quality of life

Sex/Biological Sex/Natal Sex

Refers to a person's genital anatomy present at birth

The Five P's: Protection

Refers to questions assessing measures that the patient takes to protect himself or herself from STIs This may include exploring about abstinence, monogamy, and the patient's perception of his or her own risk or his or her partner's risk These questions are helpful in assessing patient risk for STIs

Religious and Personal Beliefs - Considerations When Choosing a Contraceptive Method

Religious or other personal beliefs also affect the choice of contraceptives Ninety-nine percent of Protestants and Catholics have used contraception at some time in their lives Two percent of Catholics rely on natural family planning

Whether the patient is symptomatic or not, the virus:

Remains dormant and recurs periodically Therefore, recurrences are not caused by re-infection *However, there is viral shedding, and the patient is infectious*

ACTION ALERT - Nursing Safety Priority

Remind patients to abstain from sexual activity while GH lesions are present Sexual activity can be painful, and likelihood of viral transmission is higher Urge condom use during all sexual exposures because of the increased risk for HSV transmission from viral shedding, which can occur even when lesions are not present Teach the patient about how to use condoms

Resolution

Resolution is described as a sense of well-being, muscular relaxation throughout the body, or fatigue that generally follows orgasm; sexual arousal need not result in orgasm for resolution to occur Resolution is believed to be directly related to the neurotransmitters prolactin, ADH, and oxytocin that are released during orgasm In a female, relief of pelvic congestion will occur slowly, and the sense of pelvic and genital fullness will abate In a male, the penis will decrease in size and return to its flaccid state as pelvic congestion is relieved

Sexual Transmission of HIV/AIDS

Safer sex methods of A, abstinence; B, be faithful (monogamous); and C, condom use can reduce HIV transmission Abstinence and mutually monogamous sex with a noninfected partner are the only absolutely safe methods of preventing HIV infection from sexual contact Many forms of sexual expression can spread HIV infection if one partner is infected The risk for becoming infected from a partner who is HIV positive is always present, although some sexual practices are more risky than others Because the virus concentrates in blood and seminal fluid and is also present in vaginal secretions, risk differs by gender, sexual act, and the viral load of the infected partner

Diagnosis is made by:

Sampling cells from the endocervix, urethra, or both, easily obtained with a swab Because chlamydiae can reproduce only inside cells, cervical (or host) cells that harbor the organism (or parts of it) are required in the sample Tissue culture (the gold standard) obtained from the cervical os during the female pelvic examination or from male urethral examination obtained by swabbing has been replaced by genetic tests As with gonorrhea, the nucleic acid amplification tests (NAATs) and gene amplification tests (ligand chain reaction [LCR], and polymerase chain reaction [PCR] transcription-mediated amplification) are the newest methods of detecting Chlamydia in endocervical samples, urethral swabs, and urine They are more sensitive than the tissue culture Samples can be obtained by swab by the examining clinician or by a patient-collected urine specimen This urine self-collection method has been found to be more acceptable and highly sensitive and specific The acceptability of urine testing has resulted in increased identification of asymptomatic people

STIs cause complications that can contribute to:

Severe physical and emotional suffering, including: - Infertility - Ectopic pregnancy - Cancer - Death

How do sexual acts affect HIV transmission?

Sexual acts or practices that permit infected seminal fluid to come into contact with mucous membranes or nonintact skin are the most risky for sexual transmission of HIV The practice with the highest risk is anal intercourse with the penis and seminal fluid of an infected adult coming into contact with the mucous membranes of the uninfected partner's rectum Anal intercourse in which the semen depositor (inserting or active partner [top]) is infected is a very risky sexual practice, regardless of whether the semen receiver (receiving partner [bottom]) is male or female Anal intercourse allows seminal fluid to make contact with the rectal mucous membranes and also tears the mucous membranes, making infection more likely Teach patients who engage in anal intercourse that the semen depositor needs to wear a condom during this act

Disabilities: Cognitive, Developmental, and Physical - Populations at Risk

Sexuality and its expression has long been overlooked as an essential aspect and an inherent right of people with disabilities; there exists an underlying assumption that these individuals are asexual and have no need of sexual fulfillment All people, including those with disabilities, are entitled to move toward both sexual and social maturity in the same manner For some with disabilities, ignorance will place them at further risk because sexual behavior is a result of poor decision making, loneliness, manipulation, or even force instead of being a healthy expression of their sexuality

What term is used if the STI continues to recur and become chronic?

Sexually transmitted disease (STD) STD continues to be the most acceptable term used by the Centers for Disease Control and Prevention (CDC)

The adolescent has more columnar cells exposed on the outer cervix, which may be one reason that:

She is more vulnerable to sexually transmitted infections (STIs) and human immune deficiency virus (HIV)

Side Effects of IUDs

Side effects include cramping and bleeding with insertion *Menorrhagia* (increased bleeding during menstruation) and dysmenorrhea (painful menstruation) are common reasons for removal of the copper device Ibuprofen may relieve cramping and reduce bleeding Irregular bleeding or spotting may occur during the early months with the LNG-IUS, but bleeding is less than with the copper IUD and may be followed by amenorrhea The LNG-IUS can be used by women who had amenorrhea before using an IUD Complications include expulsion of the IUD and perforation of the uterus Although pregnancy with an IUD is rare, ectopic pregnancy or spontaneous abortion is more likely if pregnancy does occur Infection can occur in the first few weeks after insertion because of contamination at the time of insertion Women with recent or recurrent pelvic infections, a history of ectopic pregnancy, bleeding disorders, or abnormalities of the uterus should choose another contraceptive method

Patient-Centered Care - Cultural/Spiritual Considerations

Significant health care disparities exist between age and racial groups Young (ages 15 to 24 years) African-American women have the highest gonorrhea rate, followed by young African-American men The reasons for these differences are not known, although lack of access to health care may be a factor

Conduct a physical examination, including inspection and palpation, to identify:

Signs and symptoms of syphilis Wear gloves while palpating any lesions because of the highly contagious treponemes that are present Observe for and document rashes of any type because of the variable presentation of secondary syphilis

Expedited partner therapy, or patient-delivered partner therapy, shows:

Signs of reducing chlamydia infection rates

Sildenafil (Viagra)

Sildenafil (Viagra) is approved for the treatment of erectile dysfunction Other erectile dysfunction drugs with longer durations of action include: - Vardenafil - Tadalafil - Avanafil Sildenafil potentiates the physiologic sexual response, causing penile erection after sexual arousal by relaxing smooth muscle and increasing blood flow into the penis Sildenafil use is contraindicated in patients with a known hypersensitivity to it Sildenafil can potentiate the hypotensive effects of nitrates, and its administration to patients who are using organic nitrates in any form, either regularly or intermittently, is therefore contraindicated Recommended dosages are given in the table on the previous page

Benefits - Considerations When Choosing a Contraceptive Method

Some methods have special benefits that should be discussed with women OCs have many beneficial side effects such as improvement of acne, decreased bleeding with periods, or prolonged amenorrhea Natural family planning methods offer freedom from exposure to hormones Condoms provide better protection against human immunodeficiency virus (HIV)

All patients with gonorrhea should be tested for:

Syphilis, chlamydia, hepatitis B and hepatitis C, and HIV infection and, if possible, examined for HSV and HPV because they may have been exposed to these STIs as well Sexual partners who have been exposed in the past 30 days should be examined, and specimens should be obtained

A complete history includes reviewing the genitourinary systems, including:

Taking a sexual history that includes sexual orientation and sites of sexual exposure or intercourse Assess for allergies to antibiotics

Education Needed - Considerations When Choosing a Contraceptive Method

Some women fail to use contraception because they do not understand their risk for pregnancy They may be unfamiliar with the variety of methods available or the risks and benefits of the different types Some methods, such as condoms, involve very little education, whereas others are more complicated Women using natural family planning methods need extensive education to practice these methods successfully Women knowledgeable about a contraceptive technique are less likely to feel that the contraceptive is difficult to use

The uterine cervix is covered with:

Squamous cells on the outer cervix and columnar (glandular) cells that line the endocervical canal

Sterilization - Method of Contraception

Sterilization (male and female combined) is one of the most widely used methods of contraception in the United States Approximately one in three married couples uses this method Although it is expensive at the time of surgery, sterilization ends all further contraceptive costs It should always be considered a permanent end to fertility because reversal surgery is difficult, expensive, not always successful, and often not covered by insurance

Nursing Safety Priority: DRUG ALERT

Teach patients taking *spironolactone* to monitor their blood pressure and have periodic laboratory tests to assess for hyperkalemia if the health care provider determines them to be at risk for these drug effects Remind them that increased serum potassium can cause cardiac dysrhythmias and skeletal muscle spasticity

Self-Management Education Interventions for Gonorrhea

Teach the patient about transmission and treatment of gonorrhea The use of medication to treat chlamydia infection at the same time as treating gonorrhea should be explained to the patient since the likelihood of co-infection is high Discuss the possibility of re-infection, including the risk for pelvic inflammatory disease (PID) Instruct patients to cease sexual activity until the antibiotic therapy is completed and they no longer have symptoms; but, if abstinence is not possible, urge men and women to use condoms Explain that gonorrhea is a reportable disease When a diagnosis of gonorrhea is made, patients may have feelings of fear or guilt They may be concerned that they have contracted other STIs or consider the disease a punishment for promiscuity or "unnatural" sex acts They may believe that acquiring gonorrhea (or any STI) is a risk that they must take to pursue their desired lifestyle Such feelings can impair relationships with sexual partners Encourage patients to express their feelings and offer other information and professional resources to help them have a correct understanding of their diagnosis and treatment Ensuring privacy during your discussion with them and maintaining confidentiality of personal health information are essential in meeting psychosocial needs

Teaching for IUDs

Teaching the woman about side effects and to check for the presence of the plastic strings, or "tail," extending from the IUD into the vagina is important The woman should feel for the strings once a week during the first 4 weeks, then monthly after menses, and if she has signs of expulsion (cramping or unexpected bleeding) If the strings are longer or shorter than they were previously, she should see her physician, nurse-midwife, or nurse practitioner The healthcare provider should be informed about signs of infection, such as unusual vaginal discharge, pain or itching, low pelvic pain, and fever Any signs of pregnancy should be reported to rule out ectopic pregnancy and remove the device if pregnancy has occurred

Transsexual

Term often used by health care professionals to describe people who want to change or have changed their primary and/or secondary sex characteristics

Drugs for FtM Patients

Testosterone is the major drug used for achieving masculinizing effects in transgender people transitioning from female to male; however, much of the available drug converts to estrogen in the body This drug can be taken orally, transdermally, or parenterally (IM) Buccal and implantable forms of testosterone are also available Oral testosterone (Andriol) is the least effective form of the drug Depo-Testosterone, the most common IM preparation, is usually started in a low dose and increased to 100 to 200 mg every 1 to 2 weeks Teach patients the importance of not sharing needles to prevent bloodborne diseases such as hepatitis C AndroGel and Androderm are topical forms that are more expensive than other testosterone preparations but may provide more consistent (although slower) results A newer topical form of the drug, Axiron, can be applied to the armpits to increase serum testosterone levels For all topical testosterone preparations, be sure that the patient washes his hands between applications and covers the area with clothing Expected effects of testosterone therapy include deepening of the voice, increased libido (sex drive), increased body hair growth, breast and ovarian atrophy, clitoral enlargement, and cessation of menses Teach the patient taking testosterone that some of these changes take up to a year to appear If menses does not stop in the first few months of drug therapy, the patient is placed on Depo-Provera (progesterone) every 3 months until the testosterone becomes effective Common side effects of testosterone therapy include: - Edema - Acne - Seborrhea (oily skin) - Headaches - Weight gain - Possible psychotic symptoms Before taking this medication, the patient is screened for a history of liver and heart disease Testosterone therapy can cause: - Increased liver enzymes - Increased low-density lipoproteins (LDLs, or "bad" cholesterol) - Decreased high-density lipoproteins (HDLs, or "good" cholesterol) Increased blood glucose and decreased clotting factors can also occur when taking the drug Teach patients that these changes can lead to diabetes, heart disease, and stroke Therefore remind patients that they need to follow up with their primary health care providers for careful monitoring for these complications, including having extensive diagnostic and laboratory testing

The nurse's role in family planning is:

That of counselor and educator To fulfill this role, nurses need current, correct information about contraceptive methods and need to share this information with the women they see in their practice

Couples considering sterilization need counseling to ensure:

That they understand all aspects of the procedure When surgery is planned for immediately after childbirth, the decision should be made well before labor begins Future marriage, divorce, or death of a child can cause couples to regret their decision Although pregnancy is rare after sterilization, the risk of failure should be discussed

Serology testing, which is glycoprotein G antibody based, can identify:

The HSV type, either 1 or 2 Serologic tests are used to identify infection in high-risk groups such as HIV-positive patients, patients who have partners with HSV, or men who have sex with men (MSM)

What may also follow antibiotic therapy for syphilis?

The Jarisch-Herxheimer reaction This reaction is caused by the rapid release of products from the disruption of the cells of the organism Symptoms include: - Generalized aches - Pain at the injection site - Vasodilation - Hypotension - Fever They are usually benign and begin within 2 hours after therapy with a peak at 4 to 8 hours This reaction may be treated symptomatically with analgesics and antipyretics

Screening for Intimate Partner Violence

The USPSTF recommends that all women of childbearing age (14-46 years) be screened for intimate partner violence (IPV), whereas others advocate for universal screening of patients across the lifespan Available screening instruments, including the Hurt, Insult, Threaten, Scream (HITS) screening tool, have been determined to be valid and reliable in the detection of current, past, and risk for abuse in clinical settings Adequate evidence supports that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age

Veterans' Health Considerations for HIV/AIDS

The Veteran's Health Administration (VHA) is a major health care provider in the United States and has found that a significant number of veterans have undiagnosed HIV disease As a result, in 2009 the VHA eliminated the need for written consent for including HIV screening as part of routine testing Despite the directive, only about 9% of veterans treated annually at VHA facilities have ever been tested When asked, most veterans believed that they were HIV negative because they thought the test had already been done as part of routine testing and that the VHA would have notified them of positive results This false sense of security has major implications because of the high prevalence of risky behaviors such as substance abuse and unsafe sexual practices among the VHA patient population When interacting with veterans and discussing the issue of being aware of their HIV status as part of disease prevention, be sure to inform them that HIV screening is available to them through the VHA

Calendar or Rhythm Method

The calendar or rhythm method is based on the timing of ovulation, approximately 14 days before the onset of menses The couple must abstain or use another method during the days calculated to be fertile This method is unreliable because many factors, such as illness or stress, can affect the time of ovulation

Assessment of HIV/AIDS Patients

The adult who has HIV disease is monitored on a regular basis for changes in immunity or health status that indicate disease progression and the need for intervention The frequency of monitoring varies from every 2 to 6 months based on disease progression and responses to treatment Continuing assessment is crucial to ensure that the drugs continue to work optimally because the patient may have medication issues or problems related to disease in many organ systems Assess for subtle changes so any problems can be found early and treated

Rectal Examination

The anus is inspected for hemorrhoids, inflammation, and lesions The lubricated index finger is gently inserted, and sphincter tone is noted A slide may be prepared to test for the presence of occult blood in stool Fecal occult blood testing (FOBT) is a useful screening measure for colorectal cancer Special instructions are necessary to prevent false test results when materials for FOBT are sent home with the woman. She should be instructed to: • Avoid aspirin and nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen or naproxen, for at least 7 days before collecting the specimen • Avoid red meat, raw fruits and vegetables, horseradish, and vitamin C for 72 hours before testing • Collect a specimen from three consecutive stools • Return slides as directed within 4 to 6 days after the specimens are collected

Chancre

The appearance of an ulcer called a *chancre* is the first sign of primary syphilis It develops at the site of entry (inoculation) of the organism from 10 to 90 days after exposure (3 weeks is average) Chancres may be found on any area of the skin or mucous membranes but occur most often on the genitalia, lips, nipples, and hands and in the mouth, anus, and rectum

Ask the patient if he or she felt itching or a tingling sensation in the skin 1 to 2 days before the outbreak, known as the prodrome. These sensations are usually followed by:

The appearance of vesicles (blisters) in a typical cluster on the penis, scrotum, vulva, vagina, cervix, or perianal region at the site of inoculation The blisters rupture spontaneously in a day or two and leave painful ulcerations that can become extensive

Barrier Methods - Method of Contraceptive

The barrier methods of contraception involve chemicals or devices that prevent sperm from entering the cervix All of the barrier methods are coitus-related and may interfere with spontaneity They avoid the use of systemic hormones and provide some protection from STDs

Bimanual Examination - Pelvic Examination

The bimanual examination provides information about the uterus, fallopian tubes, and ovaries The labia are separated, and the gloved, lubricated index finger and middle finger of the examiner's hand are inserted into the vaginal introitus The cervix is palpated for consistency, size, and tenderness to motion The uterus is evaluated by placing the other hand on the abdomen with the fingers pressing gently just above the symphysis pubis so that the uterus can be felt between the examining fingers of both hands The size, configuration, consistency, and motility of the uterus are evaluated The ovaries are palpated between the fingers of both hands Because ovaries atrophy after menopause (permanent cessation of menstruation), it is often impossible to palpate the ovaries of a postmenopausal woman

Cervical Cap

The cervical cap is similar to the diaphragm but smaller It is fitted by a healthcare provider The flexible silicone cap fits over the cervix and remains in place by suction The cap causes no pressure on the bladder and can stay in place for 48 hours Spermicide is placed on both sides of the cap before insertion; if intercourse is repeated, more spermicide is inserted into the vagina without removing the cap The nurse should teach the woman to feel her cervix to check placement before and after intercourse, because the cap can be dislodged The cap should not be removed for 6 hours after the last intercourse It should not be used during menses or in women with a history of toxic shock syndrome

Chemical Barriers

The chemicals that kill sperm, called spermicides, come in many forms Creams and gels are generally used with mechanical barriers such as the diaphragm or cervical cap Foams, foaming tablets, suppositories, and vaginal film are used alone or with another contraceptive They are inserted deep into the vagina approximately 30 minutes before sexual intercourse Spermicides are effective for less than an hour to as long as 8 hours, depending on the type used and should be reapplied before repeated intercourse Women should not douche for at least 6 hours after intercourse Spermicides are readily available without a prescription, are inexpensive per use, and are easy to use They can be used with condoms to enhance lubrication, decreasing the risk of condom breakage They may be helpful during lactation or in the menopausal woman when vaginal secretions are diminished Spermicides do not protect against STDs Frequent use or sensitivity to the products can cause genital irritation, which increases susceptibility to infection Some women and their partners think that spermicides are messy and interfere with sensation during intercourse Effectiveness is increased when spermicides are used with a mechanical barrier method

Motivation

The desire to engage in sexual activity is also known as libido or sex drive *Libido* is biological, psychological, sociological, and spiritual in nature It can be impacted by medical conditions, medications, personality, temperament, personality, lifestyle, relationships, and environmental stressors

Sponge

The contraceptive sponge is made of soft polyurethane that traps and absorbs semen It contains the spermicide nonoxynol-9 It does not require a prescription, contains no hormones, is easy to use, and can be inserted just before intercourse or hours ahead of time. It provides contraception for 24 hours To use the sponge, the woman should wash her hands and wet the sponge with approximately 2 tablespoons of water, squeezing it until it becomes sudsy She folds the sponge with the concave ("dimple") area inside and the loop on the outside of the fold and inserts it into the vagina When the sponge is released, the "dimple" covers the cervix Repeated intercourse does not require added spermicide or a new sponge It should remain in place for at least 6 hours after the last intercourse, but should not remain in the vagina longer than 30 hours total It is removed by inserting a finger into the loop and pulling slowly Use during menstruation increases the risk of toxic shock syndrome The sponge should not be used by women with a history of toxic shock syndrome and does not protect against STDs It can cause irritation or be difficult to remove for some women

Expense - Considerations When Choosing a Contraceptive Method

The cost of family planning methods is important Less expensive contraceptives are chosen by some couples to save money Less expensive methods are often less effective, and thus, more likely to result in pregnancy, which costs more than the yearly expense of any contraceptive The "per use" cost of a contraceptive can be compared with long-term expense The price of condoms and spermicides is relatively low, but frequent use makes them expensive over a period of years Methods that depend on periodic visits to a healthcare provider are more costly than over-the-counter methods However, these visits provide an opportunity for teaching about correct use that improves the contraceptive effectiveness The visits also provide the woman an opportunity to discuss other health concerns Long-term contraceptives such as IUDs are very cost-effective over a 5- or 10-year period because they prevent pregnancy so well Publicly funded clinics may provide free or low-cost contraceptives However, many require a long wait, and the woman is likely to see a different healthcare provider at each visit Twenty-eight states have laws in place that insurance companies must cover prescription medications, including contraceptive drugs and devices These laws are is important, as millions of women rely on insurance coverage to help them afford contraception

Assess the patient's and partner's emotional responses to:

The diagnosis of genital herpes Many people are initially shocked and need reassurance that they can manage the disease Infected patients may have feelings of disbelief, uncleanness, isolation, and loneliness They may also be angry at their partner(s) for transmitting the infection or fear rejection because they have it Help patients cope with the diagnosis by being sensitive and supportive during assessments and interventions Encourage social support and refer patients to support groups and therapists

Diaphragm

The diaphragm is a latex dome surrounded by a spring or coil The woman places spermicidal cream or gel into the dome and around the rim and then inserts it over the cervix The diaphragm prevents passage of sperm into the cervix while holding spermicide for additional protection It must be fitted by a healthcare provider Weight changes or vaginal delivery can affect the fit of the diaphragm The woman should be checked for size changes after a gain or loss of 10 lb or more and after a pregnancy Pressure on the urethra can cause irritation and urinary tract infections Voiding after intercourse helps to prevent infections An allergy to latex or a history of toxic shock syndrome precludes use The diaphragm can be damaged by oil-based lubricants and some medications used for vaginal infections

Our early awareness of sexual self as an aspect of self-identity begins in infancy and is influenced by:

The dynamic combination of biological, societal, cultural, and familial factors

Acceptability - Considerations When Choosing a Contraceptive Method

The effectiveness of a method must be balanced against its acceptability to the couple For example, a spermicide may be considered unacceptable because it seems "messy" to the woman Teenagers who are not comfortable with their bodies are unlikely to accept methods that require insertion of a device into the vagina Although sterilization is very effective, it is not chosen by those who want to have more children Side effects cause some women to choose less effective methods The woman or her partner may be concerned about certain contraceptives because of potential effects such as weight gain

Transdermal Contraceptive Patch

The ethinyl estradiol and norelgestromin transdermal contraceptive patch (Ortho Evra) releases small amounts of estrogen and progestin that are absorbed through the skin to suppress ovulation and make cervical mucus thick It also regulates menstrual cycles A nonhormonal contraceptive should also be used during the first week of use unless the patch is started on the first day of the menstrual period The patch is applied to clean, dry, nonirritated skin of the abdomen, buttock, upper torso (excluding the breasts), or upper outer arm It should not be placed over areas where lotions or oils have been used or where the patch would be rubbed by clothing A new patch is applied to a different site on the same day of the week each week for 3 weeks and worn continuously for 7 days No patch is worn during the fourth week During the patch-free week, the woman has a period After 7 patch-free days, she applies a new patch and begins the cycle again Women can have extended cycles without menses by using patches for several cycles or continuously Patches should not be cut or altered, and no more than one patch should be worn at a time The patch usually adheres to the skin even in the shower or when exercising or swimming However, approximately 5% of patches detach A patch should be replaced with a new patch if it cannot be reattached Extra patches are available by prescription The day the patch is changed does not change even if a replacement for a detached patch is necessary If a patch is detached for more than 24 hours or there is a delay of more than 2 days within the cycle, a new patch is applied to start a new cycle The patch change day will be the day of the week the new patch is applied Back-up contraception is necessary for 1 week of the first cycle Side effects include spotting, especially during the first two cycles, breast tenderness, and skin reactions Other side effects and risks are similar to combination OCs The patch may be less effective in women who weigh more than 90 kg (198 lb) The risk of venous thromboembolism may be higher with patch use than with OC use because the estrogen exposure is 60% higher over time when patches are used However, studies report conflicting results Women with risk factors for thromboembolic conditions should discuss the risks and benefits of patch use with their healthcare provider

Female Condom

The female condom (also called a vaginal pouch) is a polyurethane or nitrile sheath inserted into the vagina A flexible ring inside the closed end of the condom fits over the cervix like a diaphragm Another ring extends outside the vagina to partially cover the perineum The female condom is the first contraceptive device that allows a woman some protection from STDs without relying on the male condom Male and female condoms should not be used together because they may adhere to each other

Female Physical Examination

The first genital exam should occur at birth with the infant girl in a supine position; it is a relatively easy and noninvasive assessment A general assessment of the vulva will include inspection of the labia majora, labia minora, clitoris, urethral opening, introitus, hymen, perineum, and anus The initial assessment should confirm the sex of the infant and the patency of the urethra and anus; this is baseline data Nurses observe for the passage of urine and meconium to confirm patency of the urethra and anus Throughout childhood, the sexual history will guide the appropriate physical examination The gynecologic examination, generally associated with puberty and beyond, includes inspection and palpation of the external genitalia, internal inspection of the vagina per speculum, collection of specimens as indicated (swabs for cervical smears and STI screening), and bimanual palpation (pelvic exam) if indicated; a rectal exam may be performed if indicated Physical findings might include the following: - Healed scars from childbirth or trauma - Hymenal tags - Bulges (cystoceles or rectoceles) - Thinning of the vaginal wall - Fistulas - Masses - Lesions - Inflammation An annual gynecological exam typically includes a clinical breast exam as well

Inform the patient that the disease will be reported to:

The local health authority and that all information will be held in strict confidence Encourage him or her to provide accurate information for this follow-up to ensure that all at-risk partners are treated appropriately Provide a setting that offers privacy and encourages open discussion Urge the patient to keep follow-up appointments

Male Physical Examination

The first genital exam should occur at birth with the infant male in a supine position A general assessment will include inspection of the penis, testes, scrotum, perineum, and anus The initial assessment will confirm the sex of the infant, patency of the anus, and the location of the urinary meatus with any deviation (epispadias and hypospadias) documented; this is baseline data Throughout childhood, the sexual history will guide the appropriate physical examination A general assessment of the male examination includes inspection and palpation of the penis, scrotum, testicles, perineum, and perianal area; a digital rectal examination (DRE) for assessment of the prostate may be indicated The nurse should begin by examining the penis, scrotum, and testicles The penis is inspected for discharge and lesions; the scrotum is inspected for lesions and contour The testicles within the scrotal sac are palpated for size, texture, and tenderness, which may reveal such findings as hydrocele, masses, nodules, tenderness, or inflammation

Although a great diversity of opinion exists regarding how to address sexuality issues in the United States, two common themes have been identified that support a communication framework for sexual health:

The first theme is about protecting health through making good choices with regard to sexual behavior The second theme supports broadening sexual health programs to go beyond disease control prevention to include wellness-related approaches to promote sexual health

Early latent syphilis occurs during:

The first year after infection, and infectious lesions can recur

Least Reliable Methods of Contraception

The following methods of contraception are not considered reliable but they are used by women who lack information about their risks, lack other options, or do not want to use other methods for medical or personal reasons The nurse needs to be familiar with these methods to help women understand the risks involved Include: - Breast feeding - Coitus interruptus

Sex (also called natal sex)

The gender assigned at one's birth

When babies are born, the gender of the child is determined by:

The genitalia present, but there is no way of knowing the child's true sense of gender The sense of gender and feelings toward maleness or femaleness can develop in children as early as age 2 years and is usually present in most children during the early elementary years

Pelvic Examination

The gynecologic assessment includes a pelvic examination The woman is advised to schedule the examination approximately 2 weeks after her menstrual period and not to douche or have sexual intercourse for at least 48 hours before the examination She is advised to avoid vaginal medications, douches, sprays, or deodorants that can interfere with a Pap test or other specimens obtained during the examination Before the examination, the procedure is carefully explained, and the woman empties her bladder She is placed in the lithotomy position, with a pillow under her head If she wishes, she may assume a semi-sitting position and use a hand mirror so that she can observe the external genitalia and the examination She is draped so that only the parts being examined are exposed Equipment needed for the pelvic examination includes gloves, a speculum of appropriate size, plus equipment to obtain test specimens needed, including a Pap test (also called a Pap smear) Additional equipment for collecting tissue specimens for the Pap test may include slides, cotton swabs, a fixative agent, and a cytobrush and spatula Newer equipment for the Pap test transfers cervical cells to a liquid preservative A stool specimen may be obtained by the examiner during the rectal examination, and a slide for this specimen should also be available Equipment to obtain specimens for suspected infection should also be available

Effectiveness - Considerations When Choosing a Contraceptive Method

The importance of avoiding pregnancy must be considered when choosing a contraceptive method Effectiveness is determined by how often the method prevents pregnancy Effectiveness rates reflect two different types of contraceptive failure: 1. That of the method itself 2. That related to the user The ideal, perfect, or theoretical effectiveness rate refers to perfect use of the method with every act of intercourse The typical, actual, or user effectiveness rate is most useful because it refers to the actual occurrence of pregnancy in people using the method Effectiveness drops greatly when the user does not understand how to use the method The failure rate commonly decreases after the first year of use because experience with a method leads to more accurate use Combining two less reliable methods, such as a condom and a spermicide, increases effectiveness

Vasectomy

The male sterilization procedure Involves making a small incision or puncture in the scrotum to cut, tie, cauterize, or remove a section of the vas deferens, which carries sperm from the testes to the penis After vasectomy, sperm no longer pass into the semen Vasectomy is safer, easier, less expensive, and has a lower failure rate than tubal sterilization It can be performed in a physician's office under local anesthesia and is less expensive After surgery, the man rests and wears a scrotal support for 2 days He applies ice to the area for 4 hours and takes a mild analgesic if needed Strenuous activity should be avoided for 1 week Sperm may be present in the ductal system, distal to the ligation of the vas deferens when the surgery is performed The couple should understand that the man may be able to impregnate a woman until sperm are no longer present in the semen, which may be 3 months or more He should submit semen specimens for analysis until two specimens show no sperm present

Human Papilloma Virus Infection (HPV)

The most common type of sexually transmitted infection (STI) in the United States Almost all women will have HPV sometime in their life, but not all types lead to cancer Most cases of cervical cancer are caused by certain types of HPV The high-risk HPV types, especially strains 16 and 18, impair the tumor-suppressor gene and cause most of the cervical cancers The unrestricted tissue growth can spread, becoming invasive and metastatic The number of cases of cervical cancer (and deaths from cervical cancer) has decreased significantly over the past 40 years because more women regularly get Pap tests and HPV vaccines are routinely given

Counseling must be focused on:

The needs, feelings, and preferences of the woman and her partner For example, nurses working in maternity settings should discuss family planning with postpartum women to provide an opportunity to clarify misinformation and answer questions Then the woman will be ready to discuss contraception further with her primary caregiver, if necessary

Safety - Considerations When Choosing a Contraceptive Method

The safety of the method is a primary consideration Medical conditions make some methods unsafe for certain women For example, women who have had thrombophlebitis or stroke should not use OCs because the hormones increase the risk for these conditions to recur

People who have tested serology positive to HSV-1 or HSV-2 but have never had GH symptoms should be counseled with:

The same information as those who have symptoms

Follow Up on Oral Contraceptives

The only essential follow-up for women who take OCs is yearly blood pressure measurement Yearly pelvic examinations, Pap tests, and breast examinations are not necessary to receive prescriptions for OCs Women should follow the same recommendations for these examinations as women who do not take OCs The woman's ability to remember to take a pill every day should be evaluated, and other methods should be discussed if this requirement is a problem Return of fertility usually occurs within 3 months after the pills are discontinued in women who were ovulating before pill use Any signs of adverse reaction should be reported immediately Use of the word ACHES may help the woman remember the signs that indicate complications

Interventions for Condylomata Acuminata (Genital Warts)

The outcome of treatment is to remove the warts No current therapy eliminates the HPV infection, and recurrences after treatment are likely It is not known whether removal of visible warts decreases the risk for disease transmission

External Organs - Pelvic Exam

The pelvic examination is conducted systematically and gently The external organs are scrutinized for the degree of development or atrophy of the labia, the distribution of hair, and the character of the hymen Any cysts, tumors, or inflammation of Bartholin's glands are noted The urinary meatus and Skene's glands are inspected for purulent discharge Perineal scarring caused by childbirth is noted

Childhood (Birth - 7 Years)

The physiological capacity for sexual response is first observed in infancy: Baby boys get erections and baby girls exhibit increased vaginal lubrication, a result of genital congestion Infants of both sexes have been observed fondling their own genitals, a natural form of sexual expression and arousal Attitudes and behaviors conveyed by a child's family during childhood are key in shaping sexuality as each child begins to form a gender identity—the sense of maleness and femaleness Sexual interest and activity are observed as young children begin to model adult behaviors while they "play house" or "play doctor" as part of their natural curiosity Facilitated by positive physical contact, the quality of relationships during early childhood is instrumental in shaping sexual and emotional relationships later in life

Expedited Partner Therapy (EPT)

The practice of treating sexual partners of patients diagnosed with chlamydia infection or gonorrhea by providing prescriptions or medication to the patient, which they can take to their partner(s), without the primary health care provider examining the partner(s) When patients have been given the drug to give to their partner, rates of infection have decreased, and more partners have reported receiving treatment

Many people do not have symptoms during:

The primary outbreak

Adulthood (20 Years +)

The process of sexual maturation continues throughout a lifetime Two major developmental tasks for adults are learning to effectively communicate in intimate relationships and making informed decisions about sexual health, such as issues of family planning and prevention of sexually transmitted infections Attitudes and behaviors related to sexuality are further defined as adults experience varying lifestyles and social influences Sexual lifestyle options include celibacy, long-term monogamy, serial monogamy, and polyamory Although many factors contribute to changes in sexual function, sexual interest and desire may continue well into late adulthood

Hormone Implants

The progestin implant, Implanon (or Nexplanon), a single rod implant, is inserted subcutaneously into the upper inner arm Implanon is 2 mm thick and 4 cm (1.6 in) long and releases progestin continuously to provide 3 years of contraception Like other progestin-only contraceptives, it inhibits ovulation, thickens cervical mucus to prevent sperm penetrability, and makes the endometrium unfavorable for implantation Increasing the use of hormone implants is recommended by ACOG as a means of offering effective long acting reversible contraception Side effects include irregular menstrual bleeding The woman should be taught that bleeding is expected and not a sign of abnormality Amenorrhea can occur with longer use Implanon is safe during lactation; body weight does not affect its effectiveness, and fertility returns within a few weeks after the implant is removed If it is inserted within 7 days of the start of menses, no back-up method is needed If it is inserted later, a back-up contraceptive should be used for at least 3 days

Long-term complications of GH include:

The risk for neonatal transmission and an increased risk for acquiring HIV infection

In the United States, one of the greatest factors associated with STI prevalence is:

The secrecy that surrounds sexuality, sexual behavior, and intimacy in the American culture

Identifying high-risk strains of HPV and correlating with abnormal Pap smear findings are:

The standard of care High-risk HPV may coexist with low-risk HPV, the likely cause of the warts The diagnosis should include consideration of condyloma lata or secondary syphilis since STIs frequently coexist A VDRL test, HIV test, and cultures for chlamydia and gonorrhea infections are done

Symptothermal Method

The symptothermal method combines assessment of basal body temperature (BBT; body temperature at rest) and cervical mucus daily In addition, symptoms that occur near ovulation, such as weight gain, abdominal bloating, mittelschmerz (pain on ovulation), or increased libido (sexual desire), are noted Some women also use an electronic hormonal fertility monitor The monitor is designed for women trying to become pregnant but can also be used to avoid pregnancy by identifying fertile times in the cycle

The squamo-columnar junction is:

The transformation zone where most cell abnormalities occur

Classification of Cervical Cytology - Pap Test

The widely used Bethesda system describes standard terminology for results of both the conventional Pap test and the liquid preparation The most recent Bethesda system reports three elements: (1) A statement of specimen adequacy (2) A general descriptive category (normal or abnormal) (3) A descriptive diagnosis for abnormal cytology, whether results suggest malignancy or another disorder Categories for epithelial cell abnormalities include: • Squamous cells: 1. Atypical squamous cells of undetermined significance (ASCUS) 2. Squamous intraepithelial lesion (SIL), which is subdivided into (a) low-grade, or LSIL (including cellular changes of HPV); and (b) high-grade, or HSIL (previously categorized as carcinoma in situ). HSIL is more likely to become cancerous without definitive treatment 3. Squamous cell cancer that is likely to be invasive • Glandular cells: 4. Atypical glandular cells of uncertain significance (AGCUS) 5. Adenocarcinoma The woman's follow-up depends on the nature of the abnormality and whether it is persistent Pap tests that have persistent abnormal findings after a 3- to 6-month interval usually are evaluated by a colposcopy (examination of vaginal and cervical tissue with a colposcope for cell magnification), and biopsy is conducted on suspicious lesions DNA testing is now available for the types of HPV most likely to cause cervical cancer The sample of cervical cells is collected in the same way as the Pap test HPV cell types most strongly associated with cancers are HPV 16, HPV 18, HPV 31, HPV 33, and HPV 45 Approximately two-thirds of cervical cancers are caused by HPV 16 and 18

Missed Doses on Oral Contraceptives

The woman should follow instructions from her provider if she misses one or more doses of her OC Instructions vary according to the type of OC she uses, the number of doses missed, and the time in the cycle when the OC is missed Instructions for missed OCs commonly include: • One missed dose: Take the pill as soon as remembered. Take the next dose at the usual time. No back-up contraception is necessary • Two missed doses in the first 2 weeks: Take two pills for 2 days, and then take one tablet each day. Use back-up contraception for the next 7 days • Two missed doses in the third week or more than two active pills missed at any time: If using the Sunday start schedule, take one active pill each day until Sunday. On Sunday, start a new package. If on a different schedule, start a new package immediately. Use another form of contraception for 7 days • Missing inactive tablets will not increase the risk of pregnancy. Discard the tablets missed If a woman misses a period and thinks she may be pregnant because she missed one or more doses, she should stop taking the pills and get a sensitive pregnancy test immediately It is essential that she use another contraceptive method during this time Although an association with significant fetal anomalies has not been established, continued use of OCs during pregnancy is not advisable

Preference - Considerations When Choosing a Contraceptive Method

The woman usually makes the final decision about her contraceptive method Consistent use of any method depends on whether it meets the needs of the woman and her partner If the woman feels pressured to choose a certain method or if a chosen method fails to live up to her expectations, use is more likely to be inconsistent The opinion of the woman's partner and her friends can also influence what method she chooses

Nurses must be comfortable discussing contraception and be sensitive to:

The woman's concerns and feelings It is important that nurses do not introduce their own biases for or against specific methods The nurse's personal experiences and choices regarding contraception are not pertinent

Environmental

There is increasing evidence that environmental pollutants and chemicals can depress sexual function Situational factors that influence the patient's environment include social isolation and the absence or lack of a partner, disallowing persons to experience the wholeness of their sexuality Lack of privacy or an appropriate environment in which to be sexual can contribute to SD

Screening for Sexually Transmitted Infection

There is limited consistency in the literature regarding screening recommendations The U.S. Preventive Services Task Force (USPSTF) recommends screening based on level of risk Level of risk is based on sexual behavior and includes: - Unprotected intercourse - Having sex with multiple partners - Adolescent-onset intercourse - Sharing of intravenous needles - History of STIs Individuals in a mutually monogamous relationship are considered low risk For individuals who are at increased risk, periodic screening for chlamydia, gonorrhea, syphilis, and HIV is recommended; specific screening intervals vary, but it is common for screenings to occur as part of an annual pelvic examination

Most people with GH have not been diagnosed because:

They have mild symptoms and shed virus intermittently

Standard Days Method

This method uses a string of color-coded beads to help keep track of the fertile and infertile days of each cycle It can be used by women with cycles that range from 26 to 32 days in length but is ineffective for other women Days 8 through 19 are considered fertile days

Typical health history questions for males include:

Those about contraception, penile discharge or lesions, scrotal pain or swelling, and alterations in urine elimination and andropause

Typical health history questions for females include:

Those about menarche, menstruation, pregnancy, contraception, and menopause

Opportunistic Infections

Those caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity The profound reduced immunity in the adult with AIDS allows these usually harmless organisms to overgrow and cause infection

Clinical symptoms of gonorrhea can resemble:

Those of chlamydia infection and need to be differentiated

Questions about practices for both sexes include:

Those regarding safer sex knowledge and practice, frequency of intercourse, number of partners/lifetime partners, sexual behaviors, preferences, sexual response, and personal safety

What type of therapy is NOT recommended?

Topical

Care Coordination and Transition Management

Transgender patients often take hormone therapy for many years Teach them that ongoing follow-up with a qualified health care professional is needed to maintain health and detect any complications, such as diabetes or cardiovascular problems, as early as possible Long-term follow-up with the surgeon after gender reassignment is essential to detect and treat the frequent complications that occur Assess the patient's support systems and coping strategies, including financial status and health insurance benefits Collaborate with the case manager to ensure a smooth transition into the community, including the possible need for any ongoing mental health counseling or therapy Urogenital care is also needed for patients who have gender reassignment surgery FtM patients usually do not have a vaginectomy and therefore may experience vaginal atrophy causing itching and burning Recommend that they seek gynecologic care to treat this problem, although the examination can be physically and emotionally painful MtF patients need counseling about sexuality, genital hygiene, and prevention of sexually transmitted diseases They are also at a high risk for frequent urinary tract infections as a result of a shortened urethra and urinary incontinence as a result of genital surgery Teach patients the importance of having follow-up care for these problems Preventive health care screenings for transgender patients are also important For example, the MtF patient requires prostate health care screenings that natal males need Mammograms are also recommended to monitor for early signs of breast cancer

Considerations for Older Adults - The Transgender Patient

Transgender patients who are older than 65 years lived in an era when most of them concealed their sexual orientation and true gender identity because of social stigma These people have not been well studied as a group, but research indicates that those who lived with a partner have fewer mental health problems and better self-esteem than those who lived alone

Transgender Health Issues

Transgender people (also referred to as trans-people) encounter frequent discrimination and are faced with numerous stressful situations related to their identity Sources of stress such as job discrimination and bias-related harassment can have an impact on patients' physical and psychological health In the most recent large-scale national survey on discrimination, the majority of transgender people had experienced mistreatment in the workplace Also, almost half of transgender respondents reported loss of job or denial of promotion because of their transgender identity As a result, they may be homeless, use alcohol or illicit drugs as coping mechanisms, and ignore their health needs In some cases, they may turn to sex work (prostitution) as a mechanism for survival Only a small subset of primarily MtF transgender people engage in sex work, which can expose them to human immune deficiency virus (HIV) and sexually transmitted infection (STI) Transgender people are also vulnerable to bias-related violence and verbal harassment, including threats and intimidation MtF people are more than two times more likely to experience physical violence and discrimination than non-transwomen; the likelihood of harassment is even greater for transwomen of color Transgender people are also vulnerable to bias-related violence and verbal harassment, including threats and intimidation MtF people are more than two times more likely to experience physical violence and discrimination than non-transwomen; the likelihood of harassment is even greater for transwomen of color Factors that increase this risk for violence include poverty, homelessness, and sex work Having an identity that puts a person at risk for violence and mistreatment can lead to emotional distress, particularly if the person has been victimized directly Transgender people who have experienced traumatic situations may demonstrate symptoms of posttraumatic stress disorder (PTSD) and/or depression They may turn to a variety of coping strategies to deal with distress, some of which can negatively impact physical health Rates of smoking in the transgender community are higher than the rates in the LGB community and general population of U.S. adults Most important, major life stressors, emotional distress, and lack of resources can lead to suicidal ideation or suicide attempt when all other methods of coping have failed In a sample of over 7000 transgender adults, 41% reported at least one suicide attempt in their lifetime

Gender Dysphoria

Transgender people feel a mismatch between their gender identity and natal sex, often extending back into early childhood When this incongruence occurs, they can experience gender dysphoria, or discomfort with one's natal sex Some people who have gender dysphoria may seek interventions to transition to the identified gender

Stress and Transgender Health

Transgender people have additional sources of stress when attempting to access health care, such as lack of health insurance due to unemployment and lack of health care-professional knowledge This barrier to health care causes them to postpone both acute and preventive medical care For people who are insured, coverage for health care related to gender transition, such as hormone use and surgery, is usually denied When transgender people gain access to health care, they are often fearful and anxious about the providers and setting In particular, they may be hesitant to disclose their transgender status because of fear of discrimination or ridicule They may also fear that this information will be documented in health records and shared with family members This reluctance is increased if they have had previous negative experiences with primary health care providers One national survey found that 19% of transgender adults were refused health care services due to their gender identity, and 28% reported receiving verbal harassment in a health care setting Male-to-female transgender people were more likely to encounter discrimination and avoid health care because of these experiences Even with providers who seem tolerant and caring with transgender patients, there is still a risk for patients overhearing jokes in the hallway and defamatory comments Another source of stress faced by many transgender people is lack of health care-professional knowledge regarding health care needs When this situation occurs, transgender patients are put in a position of acting as health care experts, which can limit the quality of their care Although most transgender patients generally expect their providers to have some level of knowledge or know where to seek answers, at least half of them find that they have to teach their providers When they encounter primary health care providers who are unfamiliar with the specific health care needs of their population, patient confidence is likely to diminish drastically and affect desire for future health care Although it is important to be generally knowledgeable about a patient's gender status and understand how it may affect health care needs, this factor is not always relevant for every health problem For example, transgender patients with fractures or influenza do not need to be questioned extensively about their gender identity

Phosphodiesterase-5 Inhibitors

Two phosphodiesterase-5 (PDE-5) drugs (sildenafil and vardenafil) represent the first-line treatment for erectile dysfunction (ED) These drugs act by relaxing smooth muscles in the corpora cavernosa of the penis to increase blood flow and compressing the veins in the corpora to reduce outward blood flow These combined actions result in penile erection with sexual stimulation

Interventions for Gonorrhea

Uncomplicated gonorrhea is treated with antibiotics Chlamydia infection, which is four times more common, is frequently found in patients with gonorrhea Because of this, patients treated for gonorrhea should also be managed with drugs that treat chlamydia infection

Patient-Centered Care - Gender Health Considerations

Unique needs regarding sexual health and prevention and treatment of STIs for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) patients should be identified and addressed by the nurse Because of discrimination, health care disparities, and health care provider lack of understanding, the overall health status of people in these populations may be poor LGBTQ people may have difficulty finding health care that identifies and addresses their particular risks and concerns Taking a health history that provides opportunity for the patient to identify his or her sexual orientation, gender identity, and sexual activity is crucial Especially among transgender people, opportunities for physical examination are avoided or missed by both the patient and care provider because of fears of being misunderstood or inadequately prepared to give or receive appropriate care The CDC does not currently collect or report the incidence or prevalence of STIs among transgender people Men who have sex with men (MSM) are at greatest risk for contracting primary and secondary syphilis and made up 75% of cases of these diseases in 2012 These men are 17 times more likely to have anal cancer than heterosexual men, and those infected with HIV are at even greater risk Infection with high-risk human papilloma virus (HPV) has been associated with greater risk for anal cancers among this population Assuming that lesbian women or gay men have sex only with same-gender partners or similarly assuming that heterosexual patients never have sexual encounters with partners of their same sex may limit the accuracy of the nurse's risk assessment Nurses must be aware that patients may not reveal that they are bisexual Establish a trusting relationship and be culturally sensitive and nonjudgmental when working with LGBTQ patients

How long could it take for antibodies to develop?

Up to 12 weeks So false-negative results can occur if tested too soon after the initial infection

Reproductive Health Options for FtM Patients

Using feminizing or masculinizing hormone therapy affects reproductive health, especially fertility Therefore be sure that patients know their options for reproduction, if desired, before transition begins MtF patients may want to consider sperm banking before drug therapy or gender reassignment surgery if they desire to have a biologic child FtM patients may want to consider oocyte (egg) or embryo freezing These frozen gametes or embryo could be implanted in a surrogate woman to become pregnant and carry to birth Inform patients that these options are expensive, but be sure that all patients are informed Be sure to include the patient's sexual partner, if any, in discussions related to reproductive options

Vulvar Self-Examination

Vulvar self-examination should be performed monthly by all women older than 18 years and by those younger than 18 years who are sexually active Chronic HPV is a risk factor for vulvar cancer and can spread to other parts of the body Vulvar self-examination involves visual inspection and palpation of the female external genitalia to detect signs of precancerous conditions or infections The woman should sit in a well-lighted area and use a hand-held mirror to see her external genitalia She is taught to examine the vulva in a systematic manner, starting at the mons pubis and progressing to the clitoris, labia minora, labia majora, perineum, and anus Palpation of the vulvar area should accompany visual inspection The woman should report new moles, warts or growths of any kind, ulcers, sores, changes in skin color, or areas of inflammation or itching to her healthcare provider as soon as possible

Contraceptive Vaginal Ring

Women using the ethinyl estradiol contraceptive ring (NuvaRing) insert a soft, flexible ring into the vagina and leave it in place for 3 weeks The ring releases small amounts of progestin and estrogen continuously to prevent ovulation The woman removes the ring at the end of the third week, and bleeding occurs A new ring is inserted to begin the next cycle a week after the old ring was removed Although a prescription is required, no fitting or particular placement in the vagina is necessary Unless the ring is inserted on the first day of menses, a back-up contraceptive should be used during the first 7 days of the first cycle Side effects such as break-through bleeding are less common than with OCs Some women experience expulsion, vaginal discharge, or discomfort because they feel the ring in the vagina Although some couples can feel the ring during intercourse, it is not generally a problem The ring can be removed for short periods However, if more than 3 hours elapse, a back-up method of contraception is needed until the ring has been used continuously for the next 7 days If the woman desires extended cycles, she can insert a new ring at the end of the third week and avoid withdrawal bleeding

Benefits, Risks, and Cautions with Oral Contraceptives

When choosing OCs, the balance between the benefits and risks must be weighed for each individual Women often believe the risks of OCs are higher than they actually are, yet taking OCs is safer for most women than pregnancy In addition to safe, reliable contraception, OCs result in regular menses and decreases in flow, premenstrual syndrome, and dysmenorrhea, reduced acne, and improved bone density OCs should not be used by women who have certain medical complications Smoking significantly increases complications for women of all ages Women older than age 35 who smoke should not use OCs Women who have previously smoked must abstain from all sources of nicotine for at least 6 to 12 months to be considered a nonsmoker Obese women have a higher risk of thromboembolic problems, but this is not considered a contraindication to OC use Evidence is inconsistent regarding the effect of body weight on OC effectiveness OCs provide no protection against STDs and may increase susceptibility to chlamydia A woman should be advised to use a condom and spermicide if her partner could be infected or the relationship is not monogamous

The adult with HIV infection can transmit the virus to others at all stages of disease, but the recently infected adult:

With a high viral load and those at end-stage without drug therapy can be particularly infectious

Procedure of a Pap Test

With the speculum blades open and the cervix in view, samples of the superficial layers of the cervix and endocervix are obtained Samples are best obtained with a spatula and a cytobrush or with a broom-type sampling device A sample is taken where most lesions develop, at the squamocolumnar junction (the border where developing squamous tissue meets the immature columnar epithelium) Cervical tissue is placed on slides that are then sprayed with or immersed in a fixative solution before being sent to the laboratory for analysis (if the older Pap test technique is used) Specimens obtained with the broom-type device as used in the liquid-based Thin-Prep or AutoCyte tests, are rotated in a liquid that preserves the cells for analysis The liquid-based tests use image processing to select the slides that need additional reading by a technician for best analysis

For some drugs, such as sildenafil (Viagra) and vardenafil (Levitra), sexual stimulation is needed:

Within 1/2 to 1 hour to promote the erection

Other - Considerations When Choosing a Contraceptive Method

Women also consider other factors when choosing a contraceptive The length of time before another pregnancy is desired will determine if a long-acting contraceptive is appropriate Breastfeeding women must choose a method that will not harm the baby or reduce milk production A woman at risk for acquiring or transmitting an STD should use condoms either alone or with another, more effective, method of preventing pregnancy Obese women using combined OCs have a higher risk of thromboembolic disorders than nonobese women However, the risk is less than that of pregnancy Evidence is inconsistent as to whether the effectiveness of OCs is less for obese women

Postpartum and Lactation on Oral Contraceptives

Women have an increased risk of thrombosis after giving birth. They are usually advised to wait 3 to 4 weeks to begin COCs COCs reduce milk production in lactating women, and small amounts are transferred to the milk POPs are a better choice because they do not decrease milk production; in fact, they can increase it. POPs can be started immediately after delivery

CDC Recommendations for Annual HIV Testing and One-Time Screening

You should be tested annually for HIV if you: • Have a sexually transmitted infection • Use injection drugs • Consider yourself at risk • Are a woman of childbearing age with identifiable risks, including: - Used injection drugs - Engaged in sex work - Had sexual partners who were infected or at risk - Had sexual contact with men from countries with high HIV prevalence • Received a transfusion between 1978 and 1985 • Plan to get married • Are undergoing medical evaluation or treatment for symptoms that may be HIV related • Are in correctional institutions such as jails and prisons • Are a sex worker or have had sex with a sex worker In the absence of any of the above conditions, you should be tested (screened) once: • If you are between the ages of 18 and 65 years • As part of routine prenatal screening when you are pregnant

Cervical Mucus Assessment

Your cervical mucus normally changes throughout your menstrual cycle If you check the mucus each day, you can estimate when ovulation occurs Before and after ovulation, the mucus is scant, thick, sticky, and whitish It stretches less than 6 cm (2.3 inches) Just before and for 2 to 3 days after ovulation, the cervical mucus is thin, slippery, and clear—similar to raw egg white It stretches 6 cm (2.3 inches) or more When this mucus is present, you have probably ovulated and could become pregnant Use a tissue to obtain a small sample of mucus each day from just inside your vagina Note the following: • The general sensation of wetness (around ovulation) or dryness (not near ovulation) on your labia • The appearance and consistency of the mucus: thick, sticky, and whitish; or thin, slippery, and clear or watery • The distance the mucus will stretch between your fingers Your cervical mucus may be thicker if you take antihistamines Vaginal infections, contraceptive foams or jellies, sexual arousal, and semen can make the mucus thinner even if ovulation has not occurred Keep a daily record of the type of mucus present and anything that might affect it To use cervical mucus assessment as a method of contraception, avoid intercourse from the time secretions first occur until 4 days after the slippery mucus ends Intercourse is allowed only every other day when there is no mucus because semen interferes with mucus assessment As a method to enhance conception, you should have intercourse on each of the 2 days during the period of ovulatory mucus Ovulation predictors available over the counter provide added information that is helpful if you are trying to conceive

Safer sex practices are those that reduce the risk for nonintact skin or mucous membranes coming in contact with infected body fluids and blood. Teach all adults the importance of consistently using these safer sex practices:

• A latex or polyurethane condom for genital and anal intercourse • An appropriate water-based lubricant with a latex condom • A condom or latex barrier (dental dam) over the genitals or anus during oral-genital or oral-anal sexual contact • Latex gloves for finger or hand contact with the vagina or rectum

Best Practice for Patient Safety & Quality Care: Care of or Self-Management for the Patient With Genital Herpes

• Administer oral analgesics as prescribed • Apply local anesthetic sprays or ointments as prescribed • Apply ice packs or warm compresses to the patient's lesions • Administer sitz baths three or four times a day • Urge an increase in fluid intake to replace fluid lost through open lesions • Encourage frequent urination • Pour water over the patient's genitalia while voiding or encourage voiding while the patient is sitting in a tub of water or standing in a shower • Catheterize the patient as necessary • Encourage genital hygiene, and encourage keeping the skin clean and dry • Wash hands thoroughly after contact with lesions and launder towels that have had direct contact with lesions • Wear gloves when applying ointments or making any direct contact with lesions • Advise the patient to avoid sexual activity when lesions are present • Advise the patient to use latex or polyurethane condoms during all sexual exposures • Instruct the patient in the use, side effects, and risks versus benefits of antiviral agents • Advise the patient to discuss the diagnosis of genital herpes (GH) with current and new partners

Common Medications That Reduce Sexual Desire or Response

• Antihypertensives (ACE inhibitors, β blockers, β agonists, diuretics) • Antiulcer medications (cimetidine, omeprazole) • Antidepressants • Antipsychotics • Anticonvulsants • Diuretics • Narcotics

Core Principles for Health Care Professionals Who Care for Transgender Patients

• Become knowledgeable about the health care needs of transgender and other gender-nonconforming people • Become knowledgeable about the treatment options for transgender patients and required follow-up care • Do not assume that all transgender patients are the same; treat each one as an individual and develop an individualized plan of care • Demonstrate respect for patients with nonconforming gender identities • Provide culturally sensitive care and use appropriate terminology that affirms the patient's gender identity • Facilitate patient access to appropriate and knowledgeable health care providers • Seek informed consent before providing treatment • Offer continuity of care or refer patients for ongoing quality health care • Advocate for patients within their families and communities

Signs and symptoms of late syphilis include:

• Benign lesions of the skin, mucous membranes, and bones • Cardiovascular syphilis, usually in the form of aortic valvular disease and aortic aneurysms • Neurosyphilis, causing central nervous system symptoms (e.g., meningitis, hearing loss, generalized paresis [weakness])

Choosing a Contraceptive Method - Evaluation

• Can the woman explain the proper use of her contraceptive technique? • Can she describe side effects, complications, and how to solve common problems? • Do she and her partner report satisfaction with their chosen method? • Has she discussed other methods and chosen one if she is unhappy with her present contraceptive?

Central Nervous System Signs and Symptoms of AIDS

• Confusion • Dementia • Headache • Fever • Visual changes • Memory loss • Personality changes • Pain • Seizures

Respiratory Signs and Symptoms of AIDS

• Cough • Shortness of breath

GI Signs and Symptoms of AIDS

• Diarrhea • Weight loss • Nausea and vomiting

Integumentary Signs and Symptoms of AIDS

• Dry skin • Poor wound healing • Skin lesions • Night sweats

Safer sex practices include:

• Using a latex or polyurethane condom for genital and anal intercourse • Using a condom or latex barrier (dental dam) over the genitals or anus during oral-genital or oral-anal sexual contact • Wearing gloves for finger or hand contact with the vagina or rectum • Abstinence • Mutual monogamy • Decreasing the number of sexual partners

Patient and Family Education: Preparing for Self-Management - Testicular Self-Examination

• Examine your testicles monthly immediately after a bath or a shower, when your scrotal skin is relaxed • Examine each testicle by gently rolling it between your thumbs and fingers. Testicular tumors tend to appear deep in the center of the testicle • Look and feel for any lumps; smooth, rounded masses; or any change in the size, shape, or consistency of the testes • Report any lump or swelling to your primary health care provider as soon as possible

Causes of organic ED include:

• Inflammation of the prostate, urethra, or seminal vesicles • Surgical procedures such as prostatectomy • Pelvic fractures • Lumbosacral injuries • Vascular disease, including hypertension • Chronic neurologic conditions, such as Parkinson disease or multiple sclerosis • Endocrine disorders, such as diabetes mellitus (a major cause) or thyroid disorders • Smoking and alcohol consumption • Drugs, such as antihypertensives • Poor overall health that prevents sexual intercours

Malignancies of AIDS

• Kaposi's sarcoma • Non-Hodgkin's lymphoma • Hodgkin's lymphoma • Invasive cervical carcinoma

Immunologic Signs and Symptoms of AIDS

• Low white blood cell counts: - CD4+/CD8+ ratio <2 - CD4+ count <200/mm3 (0.2 × 109/L) • Hypergammaglobulinemia • Opportunistic infections • Lymphadenopathy • Fatigue

As time passes, more CD4+ T-cells are infected and taken out of immune system service. The count decreases, and those that remain function poorly. Poor CD4+ T-cell function leads to these immunity abnormalities:

• Lymphocytopenia (decreased numbers of lymphocytes) • Increased production of incomplete and nonfunctional antibodies • Abnormally functioning macrophages

The Joint Commission Recommendations for Creating a Safe, Welcoming Environment for LGBTQ Patients

• Post the Patients' Bill of Rights and nondiscrimination policies in a visible place • Make waiting rooms inclusive for LGBTQ patients and families, such as posting Safe Zone, rainbow, or pink triangle signs • Designate unisex or single-stall restrooms • Ensure that visitation policies are equitable for families of LGBTQ patients • Avoid assumptions about any patient's sexual orientation and gender identity • Include gender-neutral language on all medical forms and documents (e.g., "partnered" in addition to married, single, or divorced categories) • Do not limit gender options on medical forms to "male" and "female" • Reflect the patient's choice of terminology in communication and documentation • Provide information on special health concerns for LGBTQ patients • Become knowledgeable about LGBTQ health needs and care • Refer LGBTQ patients to qualified health care professionals as needed • Provide community resources for LGBTQ information and support as needed

Obtain a complete history, including a genitourinary system review, psychosocial history, and sexual history. In particular, ask about:

• Presence of symptoms, including vaginal or urethral discharge, dysuria (painful urination), pelvic pain, irregular bleeding • Any history of sexually transmitted diseases (STIs) • Whether sexual partners have had symptoms or a history of STIs • Whether patient has had a new or multiple sexual partner(s) • Whether patient or partner has had unprotected intercourse

Meeting Healthy People 2020 Objectives and Targets for Improvement: Sexually Transmitted Infections/Diseases

• Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections (by 10%) • Reduce the proportion of females ages 15 to 44 years who have ever required treatment for pelvic inflammatory disease (by 10%) • Reduce gonorrhea rates (by 10%) • Reduce sustained domestic transmission of primary and secondary syphilis (by 10%) • Reduce the proportion of females with human papilloma virus (HPV) infection (no specific target) • Reduce the proportion of young adults with genital herpes due to herpes simplex type 2 (by 10%)

Patient and partner education is a crucial nursing intervention. Explain:

• The sexual mode of transmission • The incubation period • The high possibility of asymptomatic infections and the usual symptoms if present • Treatment of infection with antibiotics and need for completion of course of treatment • The need for abstinence from sexual intercourse until the patient and partner(s) have all completed treatment (7 days from the start of treatment, including a single-dose regimen) • That women should be re-screened for re-infection 3 to 12 months after treatment because of the high risk for PID; also, that there is less evidence of the need for re-screening of treated men, but it should be considered • The need to return for evaluation if symptoms recur or new symptoms develop (most recurrences are re-infections from a new or untreated partner) • Complications of untreated or inadequately treated infection, which may include PID, ectopic pregnancy, or infertility

Patient and Family Education: Preparing for Self-Management: Use of Condoms

• Use latex or polyurethane condoms rather than natural membrane condoms • Use a condom with every sexual encounter (including oral, vaginal, and anal) • Female condoms (Reality)—polyurethane or nitrile sheaths in the vagina—are effective in preventing transmission of viruses, including HIV • Condoms infrequently (2 per 100) break during sexual intercourse • Keep condoms (especially latex) in a cool, dry place, out of direct sunlight • Do not use condoms that are in damaged packages or are brittle or discolored • Always handle a condom with care to avoid damaging it with fingernails, teeth, or other sharp objects • Put condoms on before any genital contact. Hold the condom by the tip and unroll it on the penis. Leave a space at the tip to collect semen • If you use a lubricant with condoms, make sure that the lubricant is water based and washes away with water. Oil-based products damage latex condoms • Use of spermicide (nonoxynol-9) with condoms, either lubricated condoms or vaginal application, has not been proven to be more or less effective against STIs than use without spermicide. Spermicide-coated condoms have been associated with Escherichia coli urinary tract infections in women. Nonoxynol-9 may increase risk for transmission of HIV during vaginal and anal intercourse. Its use is discouraged • If a condom breaks, replace it immediately • After ejaculation, withdraw the erect penis carefully, holding the condom at the base of the penis to prevent the condom from slipping off • Never use a condom more than once

Recommendations for Preventing HIV Transmission by Health Care Workers

• Workers should adhere to Standard Precautions • Workers with exudative lesions or weeping dermatitis should not perform direct patient care or handle patient care equipment and devices used in invasive procedures • Workers must follow guidelines for disinfection and sterilization of reusable equipment used in invasive procedures • Workers infected with HIV are not restricted from practice of non-exposure-prone procedures, as long as they comply with Standard Precautions and sterilization and disinfection recommendations • Workers should identify exposure-prone procedures by institutions where they are performed • Workers who perform exposure-prone procedures should know their HIV antibody status • Workers who are infected with HIV should seek advice from an expert review panel before performing exposure-prone procedures to determine under which circumstances they may continue to practice these procedures. These circumstances would include notification of prospective patients of HIV positivity