Gynaecological Disorder Lecture 7

Introduction 1- Menstruation stops during the duration of pregnancy. Some women continue to have irregular bleeding during the first trimester. This bleeding may indicate a threatened miscarriage and requires immediate attention by the physician. 2- When women breastfeed they are unlikely to ovulate. After that time, menstruation usually resumes and they are fertile again. 3- Peri-menopause starts when the intervals between periods begin to lengthen, and it ends with menopause itself (the complete cessation of menstruation).

Menstrual Disorders There are a number of different menstrual disorders. Problems can range from heavy, painful periods to no period at all.

1. Dysmenorrhea (Painful Cramps) Painful menstrual cramps. Painful menses without evidence of a physical abnormality. Believed to be normal body response to uterine contractions

Dysmenorrhea (Painful Cramps) Other symptoms : Nausea, vomiting, gastrointestinal disturbances. Prostaglandins cause forceful, frequent uterine contractions called cramps. Pain occurs in the lower abdomen but can spread to the lower back and thighs. Dysmenorrhea is usually referred to as primary or secondary.

a. Primary dysmenorrhea Cramps occur from contractions in the uterus. These contractions are a normal part of the menstrual process. With primary dysmenorrhea, cramping pain is directly related to and caused by menstruation. About half of menstruating women experience primary dysmenorrhea. It usually begins two to three years after a women begins to menstruate. pain typically develops when the bleeding starts and continues for up to 48 hours, Cramps are generally most severe during heavy bleeding.

b. Secondary dysmenorrhea Secondary dysmenorrhea is menstrually related pain that accompanies another medical or physical condition, such as endometriosis or uterine fibroids.

Dysmenorrhea: Treatment Identify cause & manage pain Analgesics & NSAIDS Oral contraceptives Diet changes: decrease salt, sugar, caffeine (fluid consumption); increase protein, Ca, Mg & Vit B complex Balance rest & exercise

2. Menorrhagia (Heavy Bleeding) During normal menstruation the average woman loses about (20 – 80 ml). Menorrhagia is the medical term for significantly heavier bleeding. Menorrhagia occurs in 9 - 14% of all women and can be caused by a number of factors.

women should consult their doctor if any of the following occurs 1- Soaking through at least one pad or tampon every hour for several hours. 2- Heavy periods that regularly last 10 or more days. 3- Bleeding between periods or during pregnancy.

3. Premenstrual Syndrome (PMS) Symptoms Symptoms occur 7-10 days prior & are relieved when menstrual flow begins S and S: inability to concentrate, depression, irritability, anxiety, mood swings, anger, aggressive behavior, acne, herpes recurrence, backache, edema, food cravings, wt. gain, increase susceptibility to infection. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle.

Premenstrual Syndrome (PMS): Pathophysiology Not clearly understood; thought to be from hormonal fluctuations & increase in aldosterone Diagnosis: Must keep diary/calendar of symptoms for several months to make accurate diagnosis

Premenstrual Syndrome (PMS) Treatment Management focuses on diet, exercise, relaxation & stress management Diet high in complex CHO, Ca, Mg & Vit B Diet low in sugar, caffeine & salt Exercise & rest are both important Relaxation techniques: breathing, meditation, relaxation.

4. Uterine Prolapse Uterine prolapse is a condition in which a woman’s uterus slips out of its normal position . The uterus may slip enough that it drops part way into the vagina (birth canal) creating a lump or bulge . This is called incomplete prolapse. 14

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GRADING UTERINE PROLAPSE GRADE 0: No prolapse GRADE 1: Descent towards vaginal introitus (>1cm above hymen) GRADE 2: Descent to vaginal introitus (1cm from hymen) GRADE 3: Descent through introitus (> 1cm below hymen) GRADE 4: Prolapse totally outside introitus 16

Figure 1: Prolapse staging – 0,1,2,3,4 (uterine – by the position of the leading edge of the cervix). Symphysis Bladder (Empty) 1 2 4 3 Rectum 1cm Hymen BH / JL 2007 Position: Section 2D (ii/iii) 17

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Reproductive Pathophysiology GRADE 1 GRADE 2 Figure 23-09.   Degrees of uterine prolapse. A, Normal uterus. B, First-degree prolapse: descent within the vagina. C, Second-degree prolapse: the cervix protrudes through the introitus. D, Third-degree prolapse: the vagina is completely everted. 19 GRADE 3 GRADE 4 Reproductive Pathophysiology NURSING 621 W. Rose 19 AHMAD AL-ISSA

Signs and Symptoms Pelvic heaviness or pressure Urinary frequency Pelvic pain Sexual dysfunction decreased libido Lower back pain Constipation Difficulty walking Difficulty urinating Urinary frequency Urinary urgency Urinary incontinence Nausea 20

causes uterine prolapse There are several factors that may contribute to the weakening of the pelvic muscles, including : Loss of muscle tone as the result of aging Injury during childbirth, especially if the woman has had many babies or large babies (more than 9 pounds) Other factors (obesity, chronic coughing or straining and chronic constipation all place added tension on the pelvic muscles, and may contribute to the development of uterine prolapse) 21

Risk Factors of Uterine Prolapse? One or more pregnancies and vaginal births Giving birth to a large baby Increasing age Frequent heavy lifting Chronic coughing Frequent straining during bowel movements 22

Prevention Not to prolong the time of birth pay more than necessary. Non pressure on the uterus after childbirth. Sport after giving birth. Treat constipation. 23

Diagnoses The doctor will perform a pelvic examination to determine if the uterus has lowered from its normal position. During a pelvic exam, the doctor inserts a speculum (an instrument that lets the clinician see inside the vagina ) and examines the vagina and uterus. The doctor will feel for any bulges caused by the uterus protruding into the vaginal canal . 24

Treatment There are surgical and non-surgical options for treating uterine prolapse. The treatment chosen well as the woman’s general health, age and desire to have children. Treatment generally is effective for most women. Treatment options include the following: 25

Treatment A- Non surgical options 1.Exercise special exercise, called kegel exercise, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. To do kegel exercise, tighten your pelvic muscles as if you are trying to hold back urine. Hold the muscle tight for a few seconds and then release. Repeat 10 times. You may do these exercise anywhere and any time (up to 4 times a day ) 26

Treatment A- Non surgical options 2-Vaginal pessary A pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus and hold it in place. A health care provider will fit and insert the pessary , which must be cleaned frequently and removed before sex. 28

Treatment A- Non surgical options 3. Estrogen replacement therapy (ERT) However, there are some drawbacks to taking estrogen, such as an increased risk of blood clots, gallbladder disease and breast cancer. 30

Treatment B- Surgical options 1. Hysterectomy uterine prolapse may be treated by removing the uterus in a surgical procedure called hysterectomy. 2. Uterine suspenstion This procedure involves putting the uterus back into its normal position. 31

Complications If left untreated, uterine prolapse can interfere with bowel, bladder and sexual functions. Infection A prolapsed bladder bulges into the front part of vagina, causing a cystocele that can lead to difficulty in urinating and increased risk of urinary tract infection . A prolapsed rectum causes a rectocele, which often leads to uncomfortable constipation and possibly hemorrhoids . 32

Nursing management preventive measures: 1. Early visits to HC provider = early detection 2. Teach Kegel’s exercises during postpartum period preoperative nursing care: 1. Thorough explanation of procedure, expectation and effect on future sexual function 2. Laxative at home a day prior procedure 3. Perineal shave prescribed also Lithotomy position for surgery 33

Nursing management postoperative nursing care: Pt. is to void few hours after surgery; catheter if unable (after 6 hrs) Pain 1. Administer analgesic as prescribed. 2. Provide comfort measures such as backrub. 34

5. Infertility Pregnancy has not occurred after at least 1 year of engaging in unprotected coitus. Sterility: Is a lessened ability to conceive. About 14% of couples in USA are infertile

TYPES OF INFERTILITY 1- PRIMARY : When there is no previous conceptions 20% 2- SECONDARY : When there has been a previous viable pregnancy but the couple is unable to conceive at present 80%

Male infertility factors LECTURE 7 Male infertility factors 1- Disturbance in spermatogenesis 2- Obstruction in the seminiferous tubules, ducts or vessels preventing movements of spermatozoa. 3- changes in the seminal fluid preventing sperm motility. 4- Problems in ejaculation or deposition preventing spermatozoa from being placed close enough to woman's cervix. Myxoedema: A disease caused by decreased activity of the thyroid gland in adults and characterized by dry skin, swellings around the lips and nose, mental deterioration, and a subnormal basal metabolic rate. iatrogenic : Induced in a patient by a physician's activity, manner, or therapy. Used especially of an infection or other complication of treatment. AHMAD AL-ISSA

In Adequate Sperm Count The sperm count is the number of sperm in a single ejaculation or in a milliliter of sperm. Minimum sperm count considered normal is 20 million per milliliter of seminal fluid or 50 million per ejaculation. At least 50% of sperm should be motile and 30% of sperm should be normal in shape and form

FACTORS AFFECTING SPERM LECTURE 7 FACTORS AFFECTING SPERM 1- Body Temperature. 2- Congenital Abnormalities e.g (undescended testes). 3- Varicocele ( varicosity of the spermatic vein). 4- Trauma to the testes. 5- Drug use 6- Environmental Factors e.g X-Ray Varicocele : Dilatation of the veins associated with the spermatic cord. AHMAD AL-ISSA

FEMALE INFERTILITY FACTORS 1- Anovulation: ( absence of ovulation) Most Common cause of infertility in women. 2- Tubal transport problems 3- Uterine Problems : e.g Tumors , Uterine malformations 4- Cervical Problems: Normal Cervical mucus is thin & watery that help sperm to penetrate the cervix when become this mucus too thick difficulty to allow sperm to penetrate to cervix. Cervix Stenosis. D&C several times. 5- Vaginal Problems: Infection, PH of vaginal secretion become acidic destroying the motility of spermatozoa.

DIAGNOSIS OF INFERTILITY Semen analysis Ovulation Monitoring 1- By Recording Basal Body Temperature for at least 1 month every day each morning before getting out of bed. 2- Assessing the upsurge of LH that occurs before ovulation by urine sample using kit. Tubal Patency : Ultrasound X-Ray imaging

MANAGEMENT OF INFERTILITY LECTURE 7 MANAGEMENT OF INFERTILITY Correction of underlying problem: Sperm count & motility. Presence of infection. Hormone Therapy. Surgery: e.g Fibroid Tumor Myomectomy Myomectomy: is the removal of fibroids (noncancerous tumors) from the wall of the uterus AHMAD AL-ISSA

MANAGEMENT OF INFERTILITY LECTURE 7 MANAGEMENT OF INFERTILITY Artificial Insemination: Instillation of sperm into the female reproductive tract to aid conception This technique can be done in case of : 1- In adequate amount of sperm count 2- Woman has vaginal or cervical factors In Vitro Fertilization ( IVF ): This technique used in Blocked or Damaged fallopian tubes. Oligospermia. In vitro fertilization (IVF): is a procedure in which eggs (ova) from a woman's ovary are removed. They are fertilized with sperm in a laboratory procedure, and then the fertilized egg (embryo) is returned to the woman's uterus. AHMAD AL-ISSA

Social and Psychological Implications Related to Infertility LECTURE 7 Social and Psychological Implications Related to Infertility Psychological reactions Guilt Isolation Depression Stress on the relationship Cultural and religious considerations Slide 44 AHMAD AL-ISSA

NURSING MANAGEMENT The Major focus of nursing care are: LECTURE 7 NURSING MANAGEMENT The Major focus of nursing care are: 1- Providing support for couple as they undergo diagnosis and their chosen treatment. 2- Therapeutic communication skills. AHMAD AL-ISSA