1. MENSTURAL DISORDERS Gynaecological Nursing NUR 352 Lecture 4
Mr. Othman Ta’ani
GYNCOLOGY NURSING (NUR 352)

2. GYNCOLOGY NURSING (NUR 352)
Normal Absence of Menstruation. Normal absence of periods can occur in any woman under the following circumstances:
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). Menopause usually occurs at about age 51, although smokers often go through
menopause earlier.
GYNCOLOGY NURSING (NUR 352)

3. GYNCOLOGY NURSING (NUR 352)
Menstrual Disorders
There are a number of different menstrual disorders. Problems can range from heavy, painful periods to no period at all.
GYNCOLOGY NURSING (NUR 352)

4. Dysmenorrhea (Painful Cramps)
Painful menstrual cramps
Painful menses without evidence of a physical abnormality
Believed to be normal body response to uterine contractions
GYNCOLOGY NURSING (NUR 352)

5. 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.
GYNCOLOGY NURSING (NUR 352)

6. GYNCOLOGY NURSING (NUR 352)
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.
GYNCOLOGY NURSING (NUR 352)

7. Secondary dysmenorrhea
Secondary dysmenorrhea is menstrually related pain that accompanies another medical or physical condition, such as endometriosis or uterine fibroids.
GYNCOLOGY NURSING (NUR 352)

8. Dysmenorrhea: Treatment
Identify cause & manage pain
Analgesics & NSAIDS
Oral contraceptives
Diet changes: decrease salt, sugar, caffeine (fluid consumption); increase protein, Ca, Mg & Vit B
Balance rest & exercise
GYNCOLOGY NURSING (NUR 352)

9. Menorrhagia (Heavy Bleeding)
During normal menstruation the average woman loses about (60 ml) or less of blood. Menorrhagia is the medical term for significantly heavier bleeding.
Menorrhagia occurs in % of all women and can be caused by a number of factors.
Women often overestimate the amount of blood lost during their periods.
GYNCOLOGY NURSING (NUR 352)

10. Menorrhagia (Heavy Bleeding)
However, 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.
GYNCOLOGY NURSING (NUR 352)

11. Amenorrhea (Absence of Menstruation)
Amenorrhea is the absence of menstruation. There are two categories: primary amenorrhea and secondary amenorrhea.
These terms refer to the time when menstruation stops
GYNCOLOGY NURSING (NUR 352)

12. Amenorrhea (Absence of Menstruation)
Primary amenorrhea
occurs when a girl does not begin to menstruate.
Girls who show no signs of sexual development (breast development and pubic hair) by age 14 should be evaluated.
Girls who do not have their periods by two years after sexual development should also be checked.
Any girl who does not have her period by age 16 should be evaluated for primary amenorrhea.
GYNCOLOGY NURSING (NUR 352)

13. Amenorrhea (Absence of Menstruation)
Secondary amenorrhea
occurs when periods that were previously regular become absent for at least three cycles.
GYNCOLOGY NURSING (NUR 352)

14. Oligomenorrhea (Light or Infrequent Menstruation)
Is a condition in which menstrual cycles are infrequent. It is very common in early puberty and does not usually indicate a medical problem. When girls first menstruate they often do not have regular cycles for a couple of years.
Even healthy cycles in adult women can vary by a few days from month to month. In some women, periods may occur every three weeks and in others, every five weeks.
GYNCOLOGY NURSING (NUR 352)

15. Oligomenorrhea (Light or Infrequent Menstruation)
Flow also varies and can be heavy or light.
Skipping a period and then having
a heavy flow may occur; this is most likely due to missed ovulation rather than a miscarriage. Women should be concerned when periods come less than 21 days or more than three months apart, or if they last more than ten days. Such events may indicate ovulation problems.
GYNCOLOGY NURSING (NUR 352)

16. Premenstrual Syndrome (PMS) Symptoms
Symptoms occur 7-10 days prior & are relieved when menstrual flow begins
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.
GYNCOLOGY NURSING (NUR 352)

17. Premenstrual Syndrome (PMS) Pathophysiology
Not clearly understood; thought to be from hormonal fluctuations & increase in aldosterone
Aldosterone contributes to bloating & edema
GYNCOLOGY NURSING (NUR 352)

18. Premenstrual Syndrome (PMS) Diagnosis
Must keep diary/calendar of symptoms for several months to make accurate diagnosis
GYNCOLOGY NURSING (NUR 352)

19. 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.
GYNCOLOGY NURSING (NUR 352)

20. UTERINE PROLAPSE Gynaecological Nursing NUR 352 Lecture 5
Mr. Othman Ta’ani
GYNCOLOGY NURSING (NUR 352)

21. What is uterine prolapse ?
Uterine prolapse is a condition in which a woman’s uterus (womb) 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 -the uterus slips so far out of place that some of the tissue drops outside of the vagina .
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22. GYNCOLOGY NURSING (NUR 352)22

23. GRADING UTERINE PROLAPSE
GRADE 0: No prolapse
GRADE 1: Descent towards vaginal introitus
(>1cm above hymen)
GRADE 2: Descent to vaginal introitus
(hymen +/- 1cm from hymen)
GRADE 3: Descent through introitus
(> 1cm below hymen)
GRADE 4: Prolapse totally outside introitus
(uterine grade 4 = “procidentia”)
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24. GYNCOLOGY NURSING (NUR 352)
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)
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25. GYNCOLOGY NURSING (NUR 352)25
AHMAD AL-ISSA

26. Reproductive Pathophysiology
GRADE 1
GRADE 2
Figure    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.
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GRADE 3
GRADE 4 26
Reproductive Pathophysiology
NURSING 621
AHMAD AL-ISSA
W. Rose

27. The symptoms of uterine prolapse
Women with mild cases of uterine prolapse may have no obvious symptoms.
However ,as the uterus slip further out of position, it can place pressure on other pelvic organs--such as the bladder or bowel--causing a variety of symptoms, including:
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28. GYNCOLOGY NURSING (NUR 352)
Signs and Symptoms
Pelvic heaviness or pressure
Pelvic pain
Sexual dysfunction, including dyspareunia
decreased libido
Lower back pain
Constipation
Difficulty walking
Difficulty urinating
Urinary frequency
Urinary urgency
Urinary incontinence
Nausea
Purulent discharge (rare)
Bleeding (rare)
Ulceration (rare)
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29. GYNCOLOGY NURSING (NUR 352)
Signs and Symptoms
A protrusion of tissue from the opening of the vagina recurrent bladder infections
Unusual or excessive discharge from the vagina
Symptoms may be worsened by prolonged standing or walking. This is due to the added pressure placed on the pelvic muscles by gravity.
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30. What causes uterine prolapse?
The uterus is held in place within the pelvis by a group of muscles and ligaments.
As these structures weaken, they become unable to hold the uterus in position, and it begins to sag.
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31. What 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)
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32. GYNCOLOGY NURSING (NUR 352)
Pathophysiology
Age
Race (Hispanic)
Pelvic structure (Anthropoid)
Uterine structure
Lifestyle (occupation)
Multiparus
Menopause
Decreased estrogen level
Obstetrical
trauma
Weakening of the
pelvic tissues, muscles,
ligaments
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33. Stage I (descent to any point Stage IV (total eversion
Uterine prolapse
Stage I (descent to any point
of the vagina above the
hymenal remnants)
Stage II (descent
to the hymen)
Stage III (descent
beyond the hymen)
Stage IV (total eversion
or procidentia)
Dysuria
Constipation
Urinary frequency
Nausea & vomiting
Urinary incontinence
Urinary urgency
Integumentary:
Protrusion of tissue
ulceration
Reproductive:
Sexual dysfunction
Decreased libido
Musculoskeletal:
Pelvic heaviness
Pelvic pain
Low back pain
Circulatory:
Bleeding
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34. 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
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35. How Common is Uterine Prolapse
Uterine prolapse is fairly common and the risk of developing the condition increases with age.
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36. GYNCOLOGY NURSING (NUR 352)
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.
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37. GYNCOLOGY NURSING (NUR 352)
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 .
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38. GYNCOLOGY NURSING (NUR 352)
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:
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39. 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 )
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40. GYNCOLOGY NURSING (NUR 352)

41. 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.
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42. GYNCOLOGY NURSING (NUR 352)

43. Treatment A- Non surgical options
3. Estrogen replacement therapy (ERT)
Taking estrogen and other connective tissues that support the uterus.
However, there are some drawbacks to taking estrogen, such as an increased risk of blood clots, gallbladder disease and breast cancer.
The decision to use ERT must be made with your doctor after carefully weighing all of the risks and benefits.
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44. Treatment B- Surgical options
1. Hysterectomy
uterine prolapse may be treated by removing the uterus in a surgical procedure called hysterectomy.
This may be done through an incision made in the vagina (vaginal hysterectomy) or through the abdomen (abdominal hysterectomy).
Hysterectomy is major surgery , and removing the uterus means pregnancy is no longer possible.
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45. Treatment B- Surgical options
2. Uterine suspenstion
This procedure involves putting the uterus back into its normal position.
This may be done by reattaching the pelvic ligaments to the lower part of the uterus to hold it in place.
Another technique uses a special material that acts like a sling to support the uterus in its proper position. Recent advances include performing this with minimally invasive techniques and laparoscopically (through small band aid sized incisions) that decrease post operative pain and speed recovery .
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46. GYNCOLOGY NURSING (NUR 352)
Complications
If left untreated, uterine prolapse can interfere with bowel, bladder and sexual functions.
Infection
Prolapse of other pelvic organs-including rectum and bladder
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 .
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47. Prevention Of Uterine Prolapsed
It may not be possible to prevent all cases of uterine prolapse, but there are steps that can be taken to help reduce the risk:
Maintain a healthy body weight
Exercise regularly (for 20 to 30 minutes, three to five times per week), including kegel exercise, which may done up to four times a day . Be sure to check with your health care provider before starting any new exercise program .
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48. GYNCOLOGY NURSING (NUR 352)
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 4. Lithotomy position for surgery
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49. GYNCOLOGY NURSING (NUR 352)
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.
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50. GYNCOLOGY NURSING (NUR 352)
Constipation
1. Administer stool softeners/laxatives as prescribed. 2. Encourage increase in fluid and fiber intake. 3. Encourage early ambulation.
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51. GYNCOLOGY NURSING (NUR 352)
Urinary Incontinence
1.Determine if client is aware of incontinence. Developmental issues/medical conditions that can impair patient’s awareness and sensory perception of voiding. 2. Determine patient’s particular symptoms (e.g. continuous dribbling). 3. Implement bladder training for incontinence management by providing ready acces to bathroom or commode, encouraging adequate fluid intake, and establishing voiding/bladder emptying.
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52. GYNCOLOGY NURSING (NUR 352)
Risk for Infection
1. Observe for localized signs infection. 2. Note for signs and symptoms for sepsis. 3. Stress proper hand hygiene.
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