Female Reproductive Disorders (Adult Care Nursing) Part 3

Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS), also called premenstrual tension, is associated with cyclic affective (emotional) and physical symptoms that are common in a high percentage of menstruating women. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS affecting a much smaller percentage of women. These disorders are associated with the luteal phase of the menstrual cycle, but the exact causes are not well understood. Genetic links and levels of the neurotransmitter serotonin are suspected contributors. These conditions may be sufficiently severe to cause physical incapacitation and interfere with personal relationships.

Signs and Symptoms

Signs and symptoms of PMS are cyclic in nature, generally developing 7 to 14 days before the onset of menses and disappearing with its onset. More than 200 symptoms of PMS have been identified. They fall into general categories of mood alterations, symptoms related to fluid retention, and neurologic, vascular, gastrointestinal, and respiratory symptoms. Emotional symptoms include irritability, sadness, and moodiness; depression and suicidal ideation are possible. Common physical symptoms include abdominal distention, backache, migraine headaches, generalized edema, abnormal sleep patterns, acne, visual disturbances, food cravings, and occasional vomiting. Mastalgia (breast pain) is a common symptom.

Premenstrual syndrome and PMDD need to be differentiated from other conditions that may be exacerbated during menses, such as depression, eating disorders, seizure disorders, hypothyroidism, substance abuse, anemia, fatigue, irritable bowel syndrome, asthma, and allergies. Problems that may have symptoms similar to PMS or PMDD need to be excluded before diagnosis is made. Several conditions that mimic PMS or PMDD can be diagnosed and successfully treated. These alternate conditions include dysmenorrhea, endometriosis, perimenopause, and the side effects of oral contraceptives. No one specific laboratory test can verify PMS or PMDD.


Treatment and Nursing Considerations

Menstrual headache, in some instances, is severe and may need to be treated with medications. The use of a low-salt diet for 1 to 2 weeks during the premenstrual cycle and medications that increase the excretion of sodium ions may be useful (see In Practice: Important Medications 91-1). Decreasing the intake of sugar and caffeine and increasing protein intake may be helpful.

IN PRACTICE :IMPORTANT MEDICATIONS 91-1

FOR PREMENSTRUAL SYNDROME (PMS)

Diuretic Medications

•    hydrochlorothiazide (HCTZ) (HydroDIURIL, Esidrix)

Hormones

•    oral contraceptives

•    progesterone

Antianxiety Agents

•    alprazolam (Xanax)

•    diazepam (Valium)

Supplements

•    vitamin B supplements, especially pyridoxine

•    magnesium supplements

•    calcium and vitamin D supplements

If allergens can be identified, their elimination can greatly reduce symptoms. Positive stress management is helpful, especially when combined with an active exercise program. Pain medications should start with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDS) or acetaminophen. If the condition becomes severe, analgesics, antianxiety, and/or selective serotonin reuptake inhibitor (SSRI) agents may be prescribed. When painful symptoms are present, mild heat to the back or the abdomen often is beneficial. The nurse needs to be supportive of the client and her condition, especially because some individuals may ineffectively tell the client her symptoms are “all in your head.”

Key Concept Provide the client with reassurance and informational counseling. If the client has not had a thorough medical evaluation, suggest that she seek the advice of a healthcare provider experienced in women’s healthcare issues.

Toxic Shock Syndrome

Toxic shock syndrome (TSS) is caused by superantigen toxins that developed from bacterial skin infections from either Staphylococcus aureus or Streptococcus pyogenes. The infection manifests in typically healthy individuals who can quickly become very ill. Hospitalization is generally necessary because of the need for aggressive supportive treatments, such as intravenous (IV) fluids, medications to treat life-threatening hypotension (e.g., inotropic drugs, such as IV dopamine), endotracheal ventilation, and management of renal failure and/or multiple organ failure.

Symptoms initially seen include a characteristic rash in TSS caused by S. aureus. The rash resembles a sunburn that will blanch when touched. It can be seen in any region of the body, including palms and soles of the feet, lips, mouth, and eyes. Other symptoms include high fever, hypotension, general malaise, confusion and altered level of consciousness, which can rapidly progress to stupor and coma, followed by multiple organ failure and death. When the client’s condition improves, the rash will desquamate (peel off) in about 10 to 24 days.

Cases of TSS caused by the bacterium Streptococcus pyogenes, differ from those caused by S. aureus in that the individual generally has a pre-existing skin infection with the bacteria and may not develop a skin rash. The client complains of severe pain at the source of the skin infection that is accompanied by the TSS symptoms described above.

Treatment includes removal or drainage of the source of infection, if possible. If a woman is wearing a menstrual tampon, it must be removed. If the source of the infection is not identified, the morbidity rate increases. Antibiotic therapy needs a culture and sensitivity test to ensure treatment of the appropriate organism. Multiple antibiotics are typically required. These include cephalosporins, penicillins, vancomycin, clindamycin, and gentamicin. Recovery can occur in 2 to 3 weeks if therapy is successful. TSS can be fatal within hours if not diagnosed or treated.

Discomforts of Menopause

Menopause (climacteric), the cessation of menstruation, usually occurs between the ages of 45 and 50, although it may occur earlier or later. Menopause signifies that the woman’s production of estrogen and progesterone has stopped and that ovulation has ceased. Menopause is a normal body change that should not be viewed as an illness. However, some women experience difficulties as a result of changes in hormonal balance, particularly the decrease in estrogen and progesterone.

One of the first signs of approaching menopause is a change in the menses. The amount of flow lessens, and the cycle becomes irregular. Finally, the menses stop altogether. In a few women, bleeding becomes heavier for a time. Because the ovaries produce less estrogen, levels may be inadequate, resulting in symptoms.

The most common symptom is the hot flash, with accompanying perspiration, palpitations, and fatigue. Although hot flashes are not serious, they are annoying and may embarrass the woman. Another possible symptom of menopause is vaginal dryness and atrophy. The vagina loses its normal lubrication and elasticity. Some women also experience weight gain, skin dryness, sagging breasts, and signs of calcium deficiency (osteoporosis).

Sometimes women experience symptoms during menopause that affect their sense of psychological well-being or quality of life. These include insomnia, anxiety, crying spells, fatigue, mood swings, and depression.

Treatment

Hormone replacement therapy (HRT) may be prescribed to treat severe symptoms and discomforts. This therapy delays menopausal symptoms and can help the woman’s body adjust more gradually. Some researchers have theorized that hormone use increases a woman’s tendency toward uterine cancer. Other research shows that conjugated estrogens, in combination with medroxyprogesterone acetate (Provera), help reduce the risk of later cervical cancer. Estrogen replacement therapy lasting longer than 8 years has been associated with a higher risk of breast cancer.

Vaginal dryness is a particularly distressing symptom accompanying menopause. It is so extreme in some women that they have difficulty walking. Many over-the-counter products are available for treatment of symptoms. The woman may use other products to make sexual intercourse easier, such as water-based lubricants (e.g., K-Y jelly). For women with vaginal atrophy, a vaginal dilator may be helpful before intercourse.

To ease menopausal symptoms, many women are interested in herbal therapies, some of which contain plant estrogens. Women are generally encouraged to begin treatment with 400 International Units (IU) of vitamin E twice daily. If this is ineffective, the woman may try ginseng root, evening primrose oil, soy, or other herbals. The safety and effectiveness of these treatments have not been completely established.

Nursing Considerations

A woman often needs emotional support during menopause. Teach her to realize that menopause is a normal physiologic function. Instruct her about helpful health measures: a balanced diet, stress-relieving exercise, adequate rest, leisure activities, and relaxation techniques.

Induced Menopause

After hysterectomy and bilateral oophorectomy (removal of both ovaries) or radiation therapy for cancer, an artificial or surgical menopause occurs. If only the uterus is removed, the woman will have no menstrual flow; however, normal hormonal cycles will continue. A young woman who has had both ovaries and the uterus removed will often be maintained on estrogen therapy.

Key Concept The premenopausal woman who experiences surgical menopause may have more difficulties than the older woman who undergoes a normal menopause.

The younger the woman is, the more likely she is to have difficulties with surgical menopause without estrogen-replacement therapy

STRUCTURAL DISORDERS

Vaginal Fistula

A fistula is an opening between two organs that normally do not open into each other. It results from an ulcerating process, such as cancer or irritation, or from a childbirth injury. A fistula may develop between the ureter and vagina (ureterovaginal), bladder and vagina (vesicovaginal), or vagina and rectum (rectovaginal).

Any fistula is troublesome. If it is ureterovaginal or vesicovaginal, urine will leak into the vagina. If it is rectovaginal, it will cause fecal incontinence. A long-standing fistula is difficult to repair successfully because the tissues are eroded. Infection can become an additional problem.

In many cases, particularly in young women, an attempt is made to repair the fistula surgically. A successful repair is difficult because of the associated problems. The incision must granulate from the inside out to prevent an abscess. The closeness of the urinary tract to the bowel makes infection a common postoperative complication. Repaired fistulas tend to recur because of continued irritation.

Make efforts to assist the healing process by building up the woman’s resistance and by keeping her as clean as possible, without perineal irritation. The woman with a fistula that cannot be repaired is distressed by the odor and constant drainage. Sitz baths and deodorizing douches help maintain cleanliness.

Cystocele

Cystocele is the downward displacement of the bladder toward the vaginal orifice. It is most often seen in women who have experienced frequent deliveries or deliveries close together. Sometimes it results from injuries during childbirth.

Cystocele can cause nagging discomforts—pelvic pain, backache, fatigue, and a sagging pelvic weight. The client may experience stress incontinence, or dribbling of urine on coughing, straining, sneezing, or laughing. She also may have urinary urgency and frequency and residual urine.

If the condition is not advanced, perineal exercises (Kegel exercises) may be prescribed to strengthen the muscles (see In Practice: Educating the Client 91-3). Surgery may be necessary, whereby the anterior vaginal wall is repaired (anterior colporrhaphy or anterior repair) and the bladder is returned to and secured in its normal position.

IN PRACTICE :EDUCATING THE CLIENT 91-3

KEGEL EXERCISES

•    Locate the muscles surrounding the vagina by sitting on the toilet and starting and stopping the flow of urine.

•    Test the baseline strength of the muscles by inserting a finger in the opening of the vagina and contracting the muscles.

•    Exercise A: Squeeze the muscles together and hold the squeeze for 3 seconds. Relax the muscles. Repeat.

•    Exercise B: Contract and relax the muscles as rapidly as possible 10 to 25 times. Repeat.

•    Exercise C: Imagine sitting in a pan of water and sucking water into the vagina. Hold for 3 seconds.

•    Exercise D: Push out as during a bowel movement, only with the vagina. Hold for 3 seconds.

•    Repeat exercises A, C, and D 10 times each and exercise B once. Repeat the entire series three times a day

Regular practice of Kegel exercises can restore muscle tone.

Benefits include control of stress incontinence, increased vaginal lubrication during sexual arousal, relief of constipation, increased flexibility of episiotomy scars, and stronger gripping of the base of the penis during intercourse.

Rectocele

Rectocele is the upward displacement of the rectum toward the vaginal orifice. Rectocele is most often the result of injuries during childbirth. The woman with rectocele will experience backache, fatigue, heaviness in the pelvic region, and bowel difficulties. She will have incontinence, flatus, and alternating constipation and diarrhea. Surgical repair of the posterior vaginal wall, with a return of the rectum to its normal position, is known as posterior colporrhaphy or posterior repair and it is often very painful. The woman who has had repair of a cystocele and a rectocele is said to have had an anteroposterior (AP) repair.

Another procedure sometimes performed is called the Marshall-Marchetti. In this surgery, the urethra is supported by sutures through the anterior wall of the vagina on either side of the urethra. The sutures are then passed through the outer covering layer (periosteum) of the pubic bone and secured.

Nursing Considerations

Before an AP repair or other gynecologic procedure, the client may receive an enema and have a catheter inserted, unless a suprapubic Cystocath will be used. For the anterior colporrhaphy, the catheter is left in place for several days, and a residual urine volume test or culture may be ordered when the catheter is removed. Showers and sitz baths promote comfort and healing. Instruct the client to avoid lifting, sexual intercourse, and prolonged sitting and standing until full healing has occurred (usually, 6-8 weeks).

Prolapsed Uterus

A prolapsed uterus is one that sags or herniates into the vagina or, in severe cases, even falls outside the vagina. The most common cause is damage during childbirth. A prolapsed uterus is most frequently seen in menopausal women or women nearing menopause. The woman is examined while standing or bearing down. The prolapse is classified as first degree (the cervix can be seen when labia are spread, without straining or traction); second degree (the cervix protrudes out to the level of the perineum); or third degree (also called procidentia) (the entire uterus or most of it protrudes out the vagina onto the perineum).

 Variations in uterine position. (A) Anteversion. (B) Anteflexion. (C) Retroversion. (D) Retroflexion.

FIGURE 91-3 · Variations in uterine position. (A) Anteversion. (B) Anteflexion. (C) Retroversion. (D) Retroflexion.

The client with a prolapsed uterus complains of nagging backache, constipation, and stress incontinence. She may feel pain with intercourse (dyspareunia). Underwear rubbing may irritate the cervix. A hysterectomy may be performed to eliminate a severe prolapse. Some surgeons prefer to resuspend the uterus back into its normal position, particularly for younger women.

If surgery is contraindicated because the woman is elderly or in poor physical condition, one of several types of pessaries (pessary—a ring-shaped device) may be needed. It is inserted snugly, similarly to a diaphragm, against the cervix and prevents the uterus from moving downward. The woman may feel some discomfort when the pessary presses on the vaginal muscles because it is larger and firmer than a diaphragm. Teach the woman how to insert and remove the pessary, and to clean it with warm, soapy water at least once a week. Most pessaries also must be removed for comfortable sexual intercourse and sometimes for bowel movements.

Abnormal Flexion of the Uterus

A displaced uterus is usually congenital, but it may result from childbearing. Forward displacement can be termed anteversion or anteflexion. Backward displacement can be termed retroversion or retroflexion (Fig. 91-3).

A displaced uterus may cause backache, dysmenorrhea, or sterility. Surgery can correct uterine displacement. With surgery, the uterus is sutured in its proper position.

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