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Today’s Topics

Today’s Topics. Contraception Infertility Menstrual Disorders. Phases of the Menstrual Cycle. Proliferative Phase (Follicular) 6-14d High Estrogen and FSH develop follicle Ovulation Secretory Phase (Luteal) 15-26d High Progesterone, Decreasing Estrogen Ischemic Phase 27-28d

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Today’s Topics

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  1. Today’s Topics Contraception Infertility Menstrual Disorders

  2. Phases of the Menstrual Cycle • Proliferative Phase (Follicular) 6-14d • High Estrogen and FSHdevelop follicle • Ovulation • Secretory Phase (Luteal) 15-26d • High Progesterone, Decreasing Estrogen • Ischemic Phase 27-28d • Menstrual Phase 1-6d

  3. The Menstrual Cycle Olds, S. London, M., Ladewig, P., Davidson, M. (2004). Maternal-newborn nursing & women’s health care.(7th ed.). Upper Saddle River, NJ.: Prentice Hall. (p. 211).

  4. Contraception begins with Fertility Awareness • Ovulation • Ovum can be fertilized w/in 48 hrs • Sperm viable for 72 hrs • Problem pinpointing ovulation • Basal Body Temperature (BBT)[chart] • Progesterone increases = BBT increases • Take temp when awakened • Temp drops .2-.3 F; 24-36 before ovulation • Rises .7-.8 after ovulation--sample

  5. Contraception begins with Fertility Awareness • Cervical Mucous (Spinbarkeit) • More abundant, thin clear, stretchy mucous at ovulation • Thickens and less amount until menses • Other Symptoms • Mittelschmertz • Increased libido • Bearing Down Pain

  6. Physiological Methods • Calendar • Keep records for 6-8 months • 18 days from end of SHORTEST cycle • 11 days from end of LONGEST cycle • Abstain during “fertile” times • BBT—website with calendar • Billings Method

  7. Barrier Methods • Male Condom • Hold onto ring when withdrawing • Female Condom • Diaphragm • Refit after each childbirth • Use with Contraceptive Jelly • Leave in for 6 hours AFTER intercourse • If repeat intercourse, use more spermicide • Cervical Cap • Leave in for 8-48 hours

  8. Chemical Methods • IUD—Prevents fertilization • Mirena-5 years, SKYLA-3 yrs • Paragard -10 years • Risk of PID, Heavier periods (paragard), perforation, dysmenorrhea • Teach to  string after each menses • Spermicides • May have to wait to dissolve • Reapply with repeat intercourse • Use with diaphragm/condom • Non-oxinol 9—Kills HIV and other STD’s

  9. Chemical Methods—BCP’s • Types • Combination P & E • Progesterone ONLY “minipill” • Phasic • Side effects (table 4-2, pg 63; 10th ed) • Estrogen effects: N/V, weight gain, headaches, breast tenderness, etc. • Progesterone effects: acne, breast tenderness, ↓ libido, depression, fatigue, hirsuitism, weight gain, etc. • Contraindications • Thrombophlebitis, CHD, Breast CA, SMOKER • Some antibiotics DECREASE effectiveness

  10. Long-Acting Chemical Methods • Implanon • Lasts up to 3 years • Flexible plastic rod the size of a matchstick that is put under skin in the upper arm • Chief side effect: irregular bleeding • Depo-Provera • Injection 4 x / yr • Prolonged amennorhea or uterine bleeding

  11. Newer Chemical Methods • Contraceptive Patch • ORTHO EVRA • Contraceptive Ring • NuvaRing • A helpful website • http://www.ultimatebirthcontrol.com/

  12. Emergency Contraception • Take 2 BCP’s at once and 2 more 12 hours later • Use within 72 hours after unprotected intercourse • Prevents implantation

  13. Operative Sterilization • Male Vasectomy • Outpatient • 81-91% reversal • Ice for pain, swelling • NOT immediate sterility—up to 36 ejaculations to rid ducts of all sperm • Sperm count to verify • Female Tubal Ligation • Can be done with C/sec • General Anesthesia or epidural if done after vaginal delivery • 20 minutes • Less successful reversals

  14. Outpatient Sterilization • Essure-small metallic implant that is placed into the fallopian tubes under hysteroscopic guidance • Induces scar tissue to form over the implant, blocking the fallopian tube and preventing fertilization of the egg by the sperm

  15. 99.8% effective • Oral contraceptives are often prescribed at least one month prior to insertion to induce endometrial atrophy and to prevent an undiagnosed pregnancy • Paracervical blocks are given to anesthetize the perineum • NSAIDs and Diazapam can be given during the procedure to minimize discomfort • Educate patients to use alternate contraceptive methods until a hysterosalpingogram is performed 3 months after placement to confirm complete blockage of fallopian tubes • 99.8% effective

  16. Abortion • ElectivePerformed at woman’s request • Therapeutic performed for reasons of maternal or fetal health • 1st trimester • Roe v. Wade • 2nd trimester • States decide

  17. RU-486 • Combination of 2 drugs • Mifepristone is an anti-Progesterone drug that stops the early pregnancy from growing. • Misoprostol is the second drug and causes the uterus to contract and an early pregnancy to be expelled.

  18. Procedure • Confirm Pregnancy Blood test or U/S • Take Mefipristone (1 pill) • 2-4 days later, Take Misoprostol • Come back to office in 2 weeks—U/S to confirm NO pregnancy

  19. Side Effects • Abdominal cramping pain, bleeding, nausea, vomiting, and diarrhea, which may be extreme in some cases. • Dilatation and Curettage (D&C) may be needed in rare cases.

  20. Plan B Levonorgestrel • Emergency contraception-not effective if already pregnant • Reduces risk of pregnancy when take after unprotected sex • With in 72 hours after intercourse • No prescription required for 17 years and older, prescription needed 16 yrs and younger

  21. Plan B • Levonorgestrel works by stopping ovulation, fertilization, or implantation, depending on where a woman is in her cycle. • Side effects • Nausea, abdominal pain, fatigue, headache and changes in menstural cycle

  22. Assess patient’s knowledge, lifestyle, preferences, any cultural taboos or implications • Take a thorough patient history to identify any factors that put a patient at high risk for complications and rule out certain contraceptives. Nurse’s Role in Birth Control Counseling • Provide handouts, demonstration, discuss advantages and disadvantages of each method, • Allow time for questions and feedback

  23. Infertility Inability of a couple to produce a living child as a result of a failure to conceive or inability to carry the conceived child to a viable state after 12 months of unrestricted sexual relations

  24. Categories • Primary Infertility • Never having conceived a child • Secondary Infertility • Has conceived by cannot conceive again or carry a pregnancy to viability after 1 year of unrestricted sexual relations

  25. Causes of Infertility by Couple • Female Factor 50% • Male Factor 35% • Unexplained 10% • Other 5%

  26. Causes of Infertility in Women • Endocrine Sources • Ovulatory Dysfunction 40% • Anovulation or oligo-ovulation • Hyperprolactinemia • Hyper- and hypo- thyroidism • Premature ovarian failure • Genetic Defects---Turner’s Syndrome (XO) • Excessive Exercise and Dieting • Polycystic Ovarian Syndrome Altered FSH:LH ratio • Severe Emotional Stress

  27. Causes of Infertility in Women • Non-endocrine Causes • Tubal & Uterine Factors 40% • Block tubes (PID, endometriosis) • Uterine Fibroids or malformed uterus • Unexplained 10% • Other 10%

  28. Causes of Infertility in Men • Sperm Factors • Too few, Too slow, Too many malformed • Injury, mumps, high fever, radiation, • Substance abuse: ETOH, cocaine, marijuana, cigarettes • Meds: cimetidine, chemo, sulfas, erythromycin, tetracycline

  29. Causes of Infertility in Men • Endocrine Factors • Klinefelter’s syndrome (XXY) • Low testosterone levels • Excessive Prolactin levels • Non-Endocrine Factors • Obstructed vas deferens • Varicoceles

  30. Female Fertility Work-Up • BBT • Cervical Mucous • Endometrial Biopsy- • adequacy of secretory tissue in LUTEAL phase--effect of progesterone by corpus luteum • 7 days BEFORE onset of menses • Can have cramping afterwards

  31. Female Fertility Work-Up • Hystersalpingogram- • Dye instilled in uterus—Watch flow through fallopian tubes • Moderate discomfort • Laparoscopy • General Anesthesia • 6-8 months after Hysterosalpingogram • Referred shoulder pain • Evaluate for endometriosis, adhesions, tumors, cysts

  32. Male Fertility Work-Up • Sperm adequacy tests • Count • Motility • Morphology • Abstain for 2 days—Bring into lab within 1 hour after collection

  33. Couple Tests • Post-Coital Tests • 1-2 days prior to expected ovulation • Couple has intercourse • Go to MD within 4-6 hours • Aspirate cervical mucous from os • Evaluate mucous/sperm • Motility and Number

  34. Infertility Trx--Medications • Pg 200-203; 10th edition • Clomid-Estrogen Antagonist (po) • Take on days 5-9 • Induces Ovulation • Pergonal, Humegon or Repronex (hMG) • IM • Direct effect on pituitary,stimulate FSH/LH

  35. Infertility Treatments/Medications • Fertinex, Follistim and Gonal F • purified FSH given SQ • Start on day 2-4 of menstrual cycle • Watch growth of follicles via U/S and serum estradiol levels • Give hCG IM when follicles/levels OK • Have intercourse within 2 days

  36. Egg Retrieval

  37. Infertility Trx • Artificial Insemination • 1-2 days BEFORE ovulation • Fresh semen placed at cervical os • In-Vitro Fertilization (IVF) • Stimulate ovum production—Harvest eggs • Sperm and Egg meet in Test tube • Fertilized ovum transferred into uterus

  38. Infertility Trx • Gamete Intrafallopian Transfer (GIFT) • Sperm and egg transferred separately into fallopian tube where fertilization can occur • Go past cervical mucous • Zygote Introfallopian Transfer (ZIFT) • Fertilized zygote transferred into fallopian tube and then travels back into uterus to implant

  39. Other Alternatives • Adoption • Surrogate

  40. Nurse’s Role in Infertility Trx • Highly Sensitive Issue • Self-Esteem/Body Image • Marital Relations • Expensive

  41. Menstrual Cycle & Disorders • Menarche • Age at which menses begins • Usually about 13 y/o, range 10-16 • Menopause • Time when periods stop; 50-51 y/o • Initially periods are irregular, painless and anovulatory—BUT can get pregnant • Peri-menopausal period

  42. PreMenstrual Syndrome (PMS) • Affects 30-40% of all women • Three criteria need to be met • Symptoms occur in the luteal phase (after ovulation and 4-10 days before menses starts) • About 1 week w/o symptoms in follicular phase • Symptoms sever enough to interfere with life

  43. Characteristic Symptoms • Fluid Retention/ Bloating • Anxiety/Irritability • Agitation/ Arguementative • Depression/Crying • Lethargy • Panic Attacks • Accident Prone • Decreased concentration • Food Cravings • Salt & Sweets • Breast tenderness • Headaches/dizziness

  44. Causes of PMS • Unknown • Interaction between Estrogen and Progesterone--Progesterone Deficiency • Prolactin & Prostaglandin Excess • ? Role of Endorphins • Nutritional Deficiency—Mg ++

  45. Treatments • Track symptoms • BCP’s, Progesterone • Prostaglandin Inhibitors • Efamol • Mefenamic Acid 250mg/day in luteal phase • Danazol & Xanax less effective

  46. Toxic Shock Syndrome • Pyrogenic exotoxins from Staph. Aureus • 15-24 y/o, using tampons • Three Principal Clinical Manifestations • Sudden onset high Fever > 102 • HYPOtension, systolic < 90mm Hg • Rash—diffuse, macular, desquamation of palms and soles • Other S/S

  47. Treatment • Early dx is critical • IV fluid—trx dehydration • Antibiotics • Platelets • Meds for skin rash and hypotension

  48. Nursing Education Pg 104; 10th edition “Client Self-Care—Prevention of TSS”

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