REPRODUCTIVE OBJECTIVES

1. Describe the male and female reproductive systems. Anatomy of the Female Reproductive System a. The female reproductive system consists of external and internal pelvic structures, hypothalamus, and pituitary gland of endocrine system. b. External Genitalia - consist of two thick folds of tissue called labia majora and two smaller lips of delicate tissue called the labia minora, which lies within labia majora. The upper portions of labia minora form a partial covering for clitoris (composed of erectile tissue). Between labia minora, below and posterior of clitoris, is the urinary meatus-the external opening of female urethra (3 cm). The area between vagina and rectum is called perineum. c. Internal Reproductive structures:
i. Vagina: extends upward and backward from vulva to the cervix-

3 to 4 in long. Anterior portion consists of bladder and urethra, and posterior lies the rectum. The anterior and posterior walls of vagina touch each other. The upper part of vagina called the fornix surrounds cervix (inferior part of uterus). ii. Uterus: 7.5 cm X 5 cm. The size of the uterus depends on number of viable births and uterine abnormalities. A nulliparous woman (never been pregnant to stage of fetal viability), has a smaller uterus than a multiparous woman (completed two or more pregnancies to the stage of fetal viability). The uterus lies posterior to the bladder, and held in position by ligaments. The uterus has two parts: cervix- projects into vagina, and larger upper part-fundus or body. iii. Ovaries: 3 cm long. lie behind broad ligaments and behind/below the fallopian tubes. At birth, ovaries contain thousands of tiny egg cells or ova. The ovaries and fallopian tubes together are referred as adnexa.

Function of the Female Reproductive System

d. Ovulation: at puberty (usually around 12-14 years of age), the ova

begins to mature and menstrual cycles begin. In the follicular phase, an ovum enlarges as a type of cyst called a graafian follicle until it reaches the surface of ovary where transport occurs. The ovum is discharged into peritoneal cavity. Discharge of matured ovum is referred to as ovulation. The ovum finds its way into fallopian tube, where it is carried into uterus. If it penetrated by a spermatozoon then conception takes place. After the discharge of ovum, the cells of graafian follicle undergo a rapid change. They become yellow (corpus luteum) and produce progesterone ( a hormone that prepares the uterus for receiving the fertilized ovum). Ovulation occurs 2 weeks prior to next menstrual period.
e. Menstrual period: the ovaries produce steroid hormones, estrogen

and progesterone. Many different esterogens are produced by ovarian follicle which consist of developing ovum and its surrounding cells. The most potent estrogens is estradiol. Estrogens are responsible for developing and maintaining the female reproductive organs and secondary sex charcateristics associated with adult female. Estrogens play a role in breast decelopment and in monthly cyclic changes in uterus. Progesterone regulates the changes that occur in uterus during menstrual cycle. It is secreted by corpus luteum. Progesterone is a hormone for coniditioning endometrium (mucous membrane lining the uterus) in preparating for implantation of a fertilized ovum. i. if pregnancy occurs, progesterone secretion becomes a function of placenta and is essential for maintaining a normal pregnancy. In addition, progesterone working with estrogen prepares breast for producting and secreting milk. ii. Androgens are produced by ovaries and adrenal glands, these hormones are involved in early development of follicle and affect female libido. iii. Two gonadotropic hormones are released by pitiuary gland: follicle stimulating hormone (FSH), and luteinizing hormone (LH). FSH stimulaes ovaries to secrete estrogen. LH stimulates progesterone production. Feedback mechanisms regulate gASh and LH sectretions. High estrogen lvels in blood inhibits FSH secretion, but promote LH secretion. On the other hand, progesterone levels inhibit LH secretion. iv. The secretion of ovarian hormones follow a parttern than results in changes in uterine endometrium and in menstruation (28 days).

1. Proliferative phase: beginning of cycle after

menstruation,FSH ouput increases, stimulating estrogen secrtion. Causes endometrium to thicken and become vascular. 2. Secretory phase: middle portion of cycle day 14-28, LH output increases, stimulating ovulation. Endometrium reaches peak of thickening and vascularization. 3. Luteal phase: after ovulation, proegesterone is secreted by corpus luteum. v. If ovum ferilizies, estrogen and progesterone levels remain high, and complex hormonal changes of pregnancy follow. If ovum didnt fertizlize, FSH and LH output dimishines, thus estrogen and progesterone secretion falls, ovum disintergratesm, endometrium which is thick and congested becomes bemorrhagic. The menstrual flow conists of old blood, mucus, endometrial tissue, discharged through cervix into vagina.
f.

Menopausal period: end of womans reproductive capacity. Usually occurs between 45 and 52 years of age. Physical, emotional, and menstrual changes may occur. Menopause is a normal part of aging and maturation. Menstruation ceases because ovaries are no longer active, and reproductive organs become smaller. Ova doesnt mature, thus no ovarian hormones are produced. An early menopause may occur if ovaries are surgically removed or destroyed.

Male Reproductive System

1. Structures include external male genitalia(testes, epididymides, scrotum, and penis. Internal male genitalia (vas deferens, ejaculatory duct, and prostatic and membranous secretions of urethra, seminal vesicles, and certain accessory glands such as prostate gland and cowper glands. 2. The tests have a dual function: spermatogenesis (production of sperm) and secretion of male sex hormone-testesterone-male sex characteristics. These testes are formed in embryo. During the last month of fetal life, they descent posterior to peritoneum and pierce the abdominal wall in groin. The testes or ovoid sex glands are encased in scrotum which keeps them lower temperature than rest of the body. 3. The penis is the organ for both copulation and urination. It consist of glans penis, the body, and the root. The glans penis is soft, rounded portion at the distand end of the penis. The urethra, the tube that carried urine, opens at the top of the glans. It may be circumcised or covered by elongated penile skin. The body of the penis is composed of erectile tissues containing numerous blood vessels that become dialted, leading to an ereaction during sexual excitement. 4. The prostate gland produces a secretion that is chemically and physiollgy suitably for needs of spermatozoa in their passage from the testes.

5. Cowper glands lie below prostate, and it empties its secretions into urethra during ejacularing providing lubrication. 2. Describe approaches to sexual harrasement. Health history- menstrual history, pregnancies, medications, pain with menses, symptoms of vaginitis, problems with urinary functions, bowel problems, sexual history, STDs, sexual or physical abuse, surgeries, chronic illness or disability that affects health status, presence of or family history of genetic disorder. A sexual assessment includes subjective and objective data. The purpose of sexual history is to obtain information that provides a picture of a womans sexuality and sexual practices and to promote sexual health. The sexual history may enable a patient to discuss sexual matters openly and discuss sexual concerns with a health professional. The nurse can obtain information by moving from less sensitive areas to greater sensitivity. Nurse must not assume patient is married, or unmarried. Asking a patient to label herself as single, married, widowed, or divorced may consider some women as inappropriate. Ask patient about current or meaningful relationship may be less offensive way to initiate sexual history. PLISSIT- permission, limited information, specific suggestions, intensive therapy. Change in general physical and sexual activity Symptoms related to bladder function, and urination Sexual function-sexual dysfunction

3. Describe indicators of domestic violence and abuse o Injuries do not fit the account of how it happened. Manifestations of abuse may involve suicide attempts, drug and alcohol abuse, frequent emergency dept visits, vague pelvic pain, somatic complaints and depression. Women victims of rape or sexual abuse may be anxious about pelvic exams, labor, pelvic or breast irradiation, or any treatment or examination that involves hands on treatment or requires removal of clothing. 4. Identify methods of treating patients who are survivors of abuse. a. See chart 46-3 on page 1402 for specifics. In general: provide resources for support groups, psychologists, self-help groups etc. and referral information. Follow written protocols of their institution or agency. In the event of sexual assault: forensic evidence must be collected for criminal prosecution. Antibiotics and vaccines are

recommended as prophylactic measures. Most common method display compassion and support to care for the victim of abuse. 5. Identify the diagnostic examinations and tests used to determine alterations in female & male reproductive function. a. Female: i. Pelvic examination includes assessment of the appearance of the vulva, vagina and cervix and the size and shape of the uterus and ovaries ii. Pap Smear cytologic test for cervical cancer iii. Colposcopy uses a portable microscope that allows the examiner to visualize the cervix and obtain a sample of abnormal tissue for analysis (ordered if Pap smear result requires evaluation) iv. Cryotherapy freezing cervical tissue with nitrous oxide v. Laser treatment used in outpatient setting vi. Cone biopsy- performed surgically or with procedure called loop electrosurgical excision procedure (LEEP) 1. LEEP uses a laser beam and has high success rate in removal of abnormal cervical tissue vii. Endometrial (Aspiration) Biopsy method of obtaining endometrial tissue to permit diagnosis of cellular changes in the endometrium viii. Dilation and Curettage (D & C) diagnostic to identify the cause of irregular bleeding or therapeutic to temporarily stop irregular bleeding. Secures endometrial or endocervical tissue for cytologic examination, to control abnormal uterine bleeding and as a therapeutic measure for incomplete abortion. ix. Laparoscopy (Pelvic Peritonescopy) used for diagnostic purposes or treatment. It facilitates many surgical procedures such as tubal ligation, ovarian biopsy, myomectomy, hysterectomy, and lysis of adhesions. x. Hysteroscopy transcervical intrauterine endoscopy allows direct visualization of all parts of the uterine cavity by means of a lighted optical instrument xi. Hysterosalpingography or Uterotubography x-ray study of the uterus and the fallopian tubes after injection of a contrast agent xii. Ultrasonography (ultrasound) simple procedure based on sound wage transmission that uses pulsed ultrasonic waves at frequencies exceeding 20,000Hz by way of a transducer placed in contact with the abdomen or vaginal probe used in OB patients or with abnormal pelvic examination findings xiii. Computed Tomography (CT) more effective than ultrasound for obese patients or those with distended bowel

xiv. Magnetic Resonance Imaging (MRI)- produces patterns that are finer and more definitive than other imaging procedures without exposing patients to radiation b. Male: i. Digital Rectal Exam (DRE) screen for prostate cancer and recommended annual for every man older than 50 assesses the size, symmetry, shape and consistency of the posterior surface of the prostate gland via the rectum ii. Testicular exam palpate the scrotum for nodules, masses or inflammation; inspect and palpate penis for ulcerations, nodules, inflammation, discharge and curvature iii. Prostate-Specific Antigen Test (PSA) measure blood level proteins produced by the prostate gland iv. Transrectal Ultrasound (TRUS) a lubricated, condom-covered, rectal probe transducer is inserted into the rectum along the anterior wall; used in detecting nonpalpable prostate cancers and in staging localized prostate cancer v. Prostate fluid or Tissue analysis obtained for culture if disease or inflammation of the prostate gland is suspected vi. Tests of male sexual function performed with patient cannot engage in sexual intercourse to his satisfaction 6. List the nursing assessment of the male & female reproductive system. a. Health history Female: menstrual history; pregnancies; exposure to medications; pain with menses or intercourse, pelvic pain; symptoms of vaginitis, odor or itching; problems with urinary function, including frequency, urgency and incontinence; bowel problems; sexual history; STDs and methods of treatment; current or previous sexual or physical abuse; past surgery or other procedures on reproductive tract structures (including female genital mutilation or female circumcision); chronic illness or disability that may affect health status, reproductive health, need for health screening, or access to health care; presence of or family history of a genetic disorder. Male: evaluation of urinary function and symptoms; usual state of health and any recent change in general physical and sexual activity; sexual function. b. Physical assessment Female: pelvic and breast examinations. Male: Digital rectal exam and testicular exam 7. Identify diagnostic tests that complement the assessment of the male & female reproductive system. a. See diagnostic tests listed in objective 5, all are combined together.

8. Identify signs and symptoms of common female reproductive disorders.

a. Pelvic floor relaxation Cystocele - Pelvic pressure, fatigue, and urinary problems such as incontinence, frequency, and urgency. Back pain and pelvic pain may occur. Rectocele rectal pressure, constipation, uncontrollable gas, and fecal incontinence. Prolapse can result in feelings of pressure and ulcerations and bleeding. Dyspareunia may occur with these disorders. b. Vulvovaginal infections: c. Vulvovaginal candidiasis vaginal discharge that causes pruritus (iteching) and subsequent irritation. Discharge may be watery or thick but has a white, cottage cheese-like appearance. Symptoms usually more severe just before menstruation and may be less responsive to treatment during pregnancy. d. Bacterial Vaginosis Can occur throughout the menstrual cycle and does not produce local discomfort or pain. More than half patients with bacterial vaginosis do not notice any symptoms. Discharge, if noticed, is heavier than normal and gray to yellowish white in color, characterized by a fishlike odor particularly noticeable after sexual intercourse or during menstruation as a result of an increase in vaginal pH, is usually greater than 4.7 because of amines that result from enzymes from anaerobes. e. Trichomoniasis Vaginal discharge that is thin (sometimes frothy), yellow to yellow-green, malodorous, and very irritating. An accompanying vulvitis may result, with vulvovaginal burning and itching. f. Human Papillomavirus (HPV) Sexually transmitted disease (STD) Most infections are self-limiting and without symptoms, and others can cause cervical and anogenital cancers - HPV 6 and 11 usually cause condylomata (warty growths) on the vulva, rarely premalignant, but are an outward manifestation of the virus, associated with a low risk for cervical cancer. HPV 16, 18, 31 and 45 may not cause condylomata but do affect the cervix, resulting in abnormal Papanicolaou (Pap) smears. Seventy percent of all cervical cancers are caused by HPV 16 and 18. g. Herpesvirus Type 2 Infection Itching and pain occur as the infected area becomes red and edematous. Primary infection may begin with macules and papules and progress to vesicles and ulcers. The vesicular state often appears as a blister, which later coalesces, ulcerates, and encrusts. In women, the labia are the usual primary site, although the cervix, vagina and perianal skin may be affected. In men, the glans penis, foreskin or penile shaft is typically affected. Influenza-like symptoms may occur 3 or 4 days after the lesions appear. Inguinal lymphadenopathy (enlarged lymps nodes in the groin), minor temperature elevation, malaise, headache, myalgia (aching muscles), and dysuria (pain on urination) are often noted. Pain is evident during the first week and

then decreases. The lesions subside in about 1 to 2 weeks unless secondary infection occurs. h. Endocervicitis and Cervicitis Chlamydia and Gonorrhea most common causes of endocervicitis. Endocervitis an inflammation of the mucosa and the glands of the cervix that may occur when organisms gain access to the cervical glands after intercourse and, loss often, after procedures such as abortion, intrauterine manipulation, or vaginal delivery. If untreated, the infection may extend into the uterus, fallopian tubes, and pelvic cavity. Inflammation can irritate the cervical tissue, resulting in spotting or bleeding and mucopurulent cervicitis. Chlamydial infections of the cervix often produce no symptoms, but cervical discharge, dyspareunia, dysuria, and bleeding may occur. Fifty percent of women with gonorrhea have no symptoms, but without treatment, 40% may develop PID. In males, urethritis and epididymitis may occur. i. Pelvic Infection (Pelvic Inflammatory Disease) Inflammatory condition of the pelvic cavity that may begin with cervicitis and may involve the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system. Infection, which may be acute, subacute, recurrent, or chronic and localized or widespread, is usually caused by bacteria but may be attributed to a virus, fungus or parasite. Gonorrheal or chlamydial organisms are most likely causes. CMV has also been implicated. Symptoms of pelvic infection vaginal discharge, dyspareunia, lower abdominal pelvic pain, and tenderness that occurs after menses. Pain may increase with voiding or with defecation. Other symptoms include fever, general malaise, anorexia, nausea, headache, and possibly vomiting. Symptoms may be acute and severe or low grade and subtle. j. Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome k. Fistulas of the Vagina A fistula is an abnormal, tortuous opening between two internal hollow organs or between an internal hollow organ and the exterior of the body. Symptoms depend on the specific defect. A vesicovaginal fistula urine escapes continuously into the vagina. A rectovaginal fistula fecal incontinence, and flatus is discharged through the vagina. The combination of fecal discharge with leucorrhea results in malodor that is difficult to control. l. Pelvic Organ Prolapse: Cystocele, Rectocele, Enterocele Cystocele downward displacement of the bladder toward the vaginal orifice, resulting from damage to the anterior vaginal support structures. Usually results from injury and strain during childbirth. Usually appears some years later when genital atrophy associated with aging occurs, but younger, multiparous,

premenopausal women may also be affected. Rectocele an upward pouching of the rectum that pushes the posterior wall of the vagina forward. Both rectoceles and perineal lacerations, which occur because of muscle tears below the vagina, may affect muscles of the pelvic floor and may occur during childbirth. Sometimes the lacerations may completely sever the fibers of the anal sphincter (complete tear). Enterocele A protrusion of the intestinal wall into the vagina. Prolapse results from a weakening of the support structures of the uterus itself; the cervix drops and may protrude from the vagina. Complete prolapsed is referred to as procidentia. m. Uterine Prolapse Pressure and urinary problems (incontinence or retention) from displacement of the bladder. The symptoms are aggravated when a woman coughs, lifts a heavy object, or stands for a long time. Normal activities, even walking up stairs, may aggravate the symptoms. n. Vulvitis an inflammation of the vulva may occur with diabetes, dermatologic problems, or poor hygiene, or secondary to irritation from a vaginal discharge related to a specific vaginitis. Vulvodynia burning, stinging, irritation, or stabbing pain. Vestibulodynia sharp pain on pressure of the vestibule. o. Vulvar Cysts Can be asymptomatic, but an infected cyst or abscess may cause discomfort. Skenes duct cysts may result in pressure, dyspareunia, altered urinary stream, or pain. p. Vulvar Dystrophy found in older women that causes dry, thickened skin on the vulva or slightly raised, whitish papules, fissures or macules. Symptoms include varying degrees of itching or some are without symptoms. q. Ovarian Cysts Patient may or may not report acute or chronic abdominal pain. Symptoms of a ruptured cyst mimic various acute abdominal emergencies, such as appendicitis or ectopic pregnancy. Larger cysts may produce abdominal swelling and exert pressure on adjacent abdominal organs. r. Fibroid Tumors May cause no symptoms or produce abnormal vaginal bleeding, pain, backache, pressure, bloating, constipation, and urinary problems. Menorrhagia (excessive bleeding) and metrorrhagia (irregular bleeding) may occur because fibroids may distort the uterine lining. Can also interfere with fertility. s. Endometriosis dysmenorrheal, dyspareunia, and pelvic discomfort or pain. Dyschezia (pain with bowel movements) and radiation of pain to the back or leg may occur. Depression, loss of work due to pain, and relationship difficulties may result. t. Chronic Pelvic Pain Dysmenorrhea, dyspareunia, and lower abdominal pain, may also be associated with sexual and physical abuse.

u. Adenomyosis hypermenorrhea (excessive and prolonged bleeding), acquired dysmenorrheal, polymenorrhea (abnormally frequent bleeding), and premenstrual staining. v. Endometrial Hyperplasia abnormal bleeding is the most common symptom. 9. Identify testicular disorders and disorders of the prostate. a. Prostatitis Inflammation of the prostate gland often associated with lower urinary tract symptoms. Affects 5 to 10% of men. Most common urologic diagnosis of men younger than 50 years of age and the third most common diagnosis in men older than 50. Acute prostatitis sudden onset of fever, dysuria, perineal prostatic pain and severe lower urinary tract symptoms: dysuria, frequency, urgency, hesitancy, and nocturia. Four types Type I acute bacterial prostatitis, Type II Chronic bacterial prostatitis, Type III Chronic prostatitis/chronic pelvic pain syndrome, Type IV asymptomatic inflammatory prostatitis. b. BPH (benign prostatic hypertrophy) Enlarged prostate BPH may or may not lead to lower urinary tract symptoms; if symptoms occur, they may range from mild to severe. Severity of symptoms increases with age, and half of men with BPH report having moderate to severe symptoms. Obstructive and irritative symptoms may include urinary symptoms may include urinary frequency, urgency, nocturia, hesitancy in starting urination, decreased and intermittent force of stream and the sensation of incomplete bladder emptying, abdominal straining with urination, a decrease in the volume and force of the urinary stream, dribbling (urine dribbles out after urination), and complications of acute urinary retention (more than 60 mL of urine remaining in the bladder after urination), and recurrent UTIs. Ultimately, chronic urinary retention and large residual volumes can lead to azotemia (accumulation of nitrogenous waste products) and renal failure. Describe abnormal conditions affecting the penis. Erectile Dysfunction Impotence, inability to achieve or maintain an erect penis. The man may report decreased frequency of erections, inability to achieve a firm erection, or rapid detumescence (subsiding of erection). In the US, 30 million men experience ED; more than half of men 40 to 70 years of age are unable to attain or maintain an erection sufficient for satisfactory sexual performance. o Disorders of Ejaculation Premature ejaculation occurrence of ejaculation sooner than desired, either before or shortly after penetration, causing distress to either one or both partners. Affects 20 to 30% of men. Lifelong PE caused by neurobiological or genetic conditions, acquired PE medical or psychological, natural variable PE normal variation, premature-like ejaculatory dysfunction psychological. Retrograde ejaculation occurs when
o

10.

semen travels toward the bladder instead of exiting through the penis, resulting in infertility can occur after prior prostate or urethral surgery or with diabetes and use of medications such as antihypertensives. o Infections of the male genitourinary tract acute uncomplicated cystitis in adult men is uncommon, but occasionally occurs in men whose sexual partners have vaginal infections with Eschericia coli. Asymptomatic bacteriuria may also result from genitourinary manipulation, catheterization, or instrumentation. 11. Describe pathophysiology, etiology and signs & symptoms for the following Sexually Transmitted Diseases. a. Syphilis Usual incubation period 10 days to 10 weeks. Syphilis is an acute and chronic infectious disease caused by the spirochete Treponema pallidum. It is acquired through sexual contact or may be congenital in origin. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. Secondary syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. The rash of secondary syphilis occurs about 2 to 8 weeks after the chancre and involves the trunk and the extremities, including the palms of the hands and the soles of the feet. Transmission of the organism can occur through contact with these lesions. Generalized signs of infection may include lymphadenopathy, arthritis, meningitis, hair loss, fever, malaise, and weight loss. After the secondary stage, there is a period of latency, when the infected person has no signs or symptoms of syphilis. Latency can be interrupted by a recurrence of secondary syphilis symptoms. Tertiary syphilis the final stage in the natural history of the disease. It is estimated that between 20 and 40% of those infected do not exhibit signs and symptoms in this final stage. Tertiary syphilis present as a slowly progressive inflammatory disease with the potential to affect multiple organs. The most common manifestations at this level are aortitis and neurosyphilis, as evidenced by dementia, psychosis, pareses, stroke, or meningitis. b. Gonorrhea Neisseria gonorrhoeae (organism). Transmitted through sexual contact or perinatal. Infection to first symptoms 2 to 7 days. Symptoms include purulent discharge, dysuria and urinary frequency. Chlamydial infection and gonorrhea often coexist. Gonorrhea is a major cause of PID, tubal infertility, ectopic pregnancy and chronic pelvic pain. Women may have no symptoms. In men, urethritis, epididymitis and sterility may occur.

c. genital herpes (Type 2 herpes simplex) A common skin infection with two types. Genital herpes (Type 2) which usually appears at the onset of sexual activity. Classified as a true primary infection, a non-primary initial episode, or a recurrent episode. True primary infection is the initial exposure to the virus. A non-primary initial episode is the initial episode of either type 1 or type 2 in a person previously infected with the other type. Recurrent episodes are subsequent episodes of the same viral type. Minor infections may produce no symptoms; severe primary infections with type 1 can cause systemic flulike illness. Lesions appear as grouped vesicles on an erythematous base initially involving the vagina, rectum, or penis. New lesions can continue to appear for 7 to 14 days. Lesions are symmetric and usually cause regional lymphadenopathy. Fever and flulike symptoms are common. Typical recurrences begin with a prodrome of burning, tingling, or itching about 24 hours before the vesicles appear. As the vesicles rupture, erosions and ulcerations begin to appear. Severe infections can cause extensive erosions of the vaginal or anal canal. S&S Females purulent vaginal discharge. Multiple vesicles on genital area, buttocks or thighs, painful dysuria, fever, headache or malaise. d. HPV (genital warts) More than 100 types of HPV. Most common are 6 and 11 warty growths on vulva, often visible or may be palpable by patient, rarely premalignant. HPV 16, 18, 31, 33 and 45 may not cause warty growths, but do affect the cervix, resulting in abnormal Pap smears. Usually invisible on exam, but may be seen on colposcopy. The incidence of HPV in young, sexually active women is high. The infection often disappears as the result of an effective immune system response. S & S pink-gray soft lesions, singularly or in clusters. e. Chlamydia Transmitted through sexual intercourse, can result in serious complications, including pelvic infection, an increased risk for ectopic pregnancy, and infertility, and can develop PID. Chlamydial infections of the cervix often produce no symptoms, but cervical discharge, dyspareunia, dysuria, and bleeding may occur. Other complications include conjunctivitis and perihepatitis. If pregnant women are infected, stillbirth, neonatal death and premature labor may occur. Infants born to infected mothers may experience prematurity, conjunctivitis, and pneumonia. f. bacterial vaginosis An overgrowth of anaerobic bacteria and Gardnerella vaginilis normally found in the vagina and an absence of lactobacilli. Risk factors include douching after menses, smoking, multiple sex partners, and other STDs. BV can occur throughout menstrual cycle and does not produce local

discomfort or pain. Discharge, if noticed, is heavier than normal and gray to yellowish-white in color, characterized by a fishlike odor. Lactobacilli, which serve as a natural host defense, are usually absent. BV is not usually considered a serious condition, however, it can be associated with premature labor, premature rupture of membranes, endometritis, and recurrent urinary tract infection. g. HIV A retrovirus, which carries its genetic material as RNA rather than DNA. Strikes helper T cells bearing the CD4+ antigen. Normally a receptor for major histocompatability complex molecules, the antigen serves as a receptor for the retrovirus and allows it to enter the cell. After invading the cell, HIV either replicates, leading to cell death, or the virus becomes latent. The HIV virus may enter the body by any of several routes involving the transmission of blood or body fluids. During the first stage, patient may be asymptomatic or may exhibit various signs and symptoms. Fever, lymphadenopathy, pharyngitis, skin rash, and myalgias/arthralgias. 12. Summarize the guidelines for the early detection of breast cancer.

-Beginning in their early 20s, women should be told about the benefits and limitations of breast self-examination (BSE). The importance of prompt reporting of any new breast symptoms to a health professional should be emphasized. Women who choose to do BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination. For women in their 20s and 30s, it is recommended that CBE be part of a periodic health examination, preferably at least every 3 years. Asymptomatic women aged 40 years of age or above should continue to receive a clinical breast examination as part of a periodic health examination, preferably annually. Women age 40 and older should have yearly mammograms. Women at high risk should undergo MRI and mammography every year. 13. Summarize the guidelines for the early detection of testicular cancer. 14. Apply the nursing process for pts suffering from disorders of the reproductive system.

15. List the s/s of reproductive cancers. Uterine (endometrium cancer) -The most common symptom of uterine cancer is abnormal vaginal bleeding. It may start as a watery, blood-streaked flow that gradually contains more blood. After menopause, any vaginal bleeding is abnormal.

Abnormal vaginal bleeding, spotting, or discharge Pain or difficulty when emptying the bladder Pain during sex Pain in the pelvic area

1. Cervical Cancer -Early cervical cancers usually don't cause symptoms. When the cancer grows larger, women may notice one or more of these symptoms:

Abnormal vaginal bleeding Bleeding that occurs between regular menstrual periods Bleeding after sexual intercourse, douching, or a pelvic exam Menstrual periods that last longer and are heavier than before Bleeding after going through menopause Increased vaginal discharge Pelvic pain Pain during sex

2. Ovarian Cancer Symptoms of ovarian cancer are not specific to the disease, and they often mimic those of many other more-common conditions, including digestive and bladder problems. When ovarian cancer symptoms are present, they tend to be persistent and worsen with time. Signs and symptoms of ovarian cancer may include:

Abdominal pressure, fullness, swelling or bloating Pelvic discomfort or pain Persistent indigestion, gas or nausea Changes in bowel habits, such as constipation Changes in bladder habits, including a frequent need to urinate Loss of appetite or quickly feeling full Increased abdominal girth or clothes fitting tighter around your waist A persistent lack of energy Low back pain

3. Breast Cancer -Signs and symptoms of breast cancer may include:

A breast lump or thickening that feels different from the surrounding tissue Bloody discharge from the nipple Change in the size or shape of a breast Changes to the skin over the breast, such as dimpling Inverted nipple Peeling or flaking of the nipple skin Redness or pitting of the skin over your breast, like the skin of an orange 4. Testicular Cancer

-Signs and symptoms of testicular cancer include:

A lump or enlargement in either testicle A feeling of heaviness in the scrotum A dull ache in the abdomen or groin A sudden collection of fluid in the scrotum Pain or discomfort in a testicle or the scrotum Enlargement or tenderness of the breasts Unexplained fatigue or a general feeling of not being well

Cancer usually affects only one testicle 5. Prostate Cancer -Prostate cancer may not cause signs or symptoms in its early stages. Prostate cancer that is more advanced may cause signs and symptoms such as:

Trouble urinating Decreased force in the stream of urine Blood in your urine Blood in your semen Swelling in your legs Discomfort in the pelvic area Bone pain

16. List effective methods of contraception. To be effective, any method of contraception must be used consistently and correctly. - Abstinence- is the only completely effective means of preventing a pregnancy -sterilization- tubal ligation/vasectomy A tubal ligation also known as having your tubes tied or tubal sterilization is a type of permanent birth control. During a tubal ligation, the fallopian tubes are cut or blocked to permanently prevent pregnancy. A tubal ligation disrupts the movement of the egg to the uterus for fertilization and blocks sperm from traveling up the fallopian tubes to the egg. A tubal ligation doesn't affect your menstrual cycle. A tubal ligation can be done at any time, including after childbirth or in combination with another abdominal surgical procedure, such as a C-section. It's possible to reverse a tubal ligation but reversal requires major surgery and isn't always effective. Vasectomy- is a form of male birth control that cuts the supply of sperm to your semen. It's done by cutting and sealing the tubes that carry sperm. Vasectomy is straightforward and has a low risk of problems. Before getting a vasectomy, however, you need to be certain you don't want to father a child in the future. Vasectomy is considered a permanent form of male birth control. Oral Contraception- Traditional birth control pills make your reproductive system mimic a regular 28-day monthly cycle. For the first 21 days, you take active pills containing reproductive hormones. For the last seven days, you take a placebo. While

you're taking the placebo pills, you bleed vaginally, as if you were having a regular menstrual period. By contrast, extended-cycle birth control pills contain active hormones for every day of the month. The newest extended-cycle regimen, Lybrel, is a low-dose pill that's designed to be taken continuously for one year, with no breaks for hormone-free intervals. Lybrel is meant to suppress all menstrual bleeding. Transdermal- Ortho Evra is a thin, beige, matchbook-size skin patch thatr eleases an estrogen and a progestin continuously. It is changed every week for 3 weeks, and no patch is used during the fourth week, resulting in withdrawal bleeding. The effectiveness of Ortho Evra is comparable to that of oral contraceptives. Its risks are similar to those of oral contraceptives and include an increased risk of blood clots. The patch may be applied to the torso, chest, arms, or thighs; it should not be applied to the breasts. The patch is conven-ient and more easily remembered than a daily pill but is not as effective for women who weigh more than 198 lb (90 kg).In addition, it may also irritate skin conditions (eg, psoriasis) in some women and results in higher blood estrogen levels than oral contraceptives. Vaginal Contraceptives- NuvaRing (etonogestrel/ethinyl estradiol vaginal ring) is a combination hormonal contraceptive that releases estrogen and progestin. It is inserted in the vagina for 3 weeks and then removed, resulting in withdrawal bleeding. It is as effective as oral contraceptives and results in lower hormone blood levels than oral contraceptives. NuvaRing is exible,does not require sizing or fitting, and is effective when placed anywhere in the vagina. Patients are occasionally reluctant to consider vaginal methods of contraception unless discussed openly and as a convenient alternative to other routes of administration. Some women are uncomfortable with this method and may fear that the ring may migrate or be uncomfortable or be noticed by a partner. The nurse can be helpful in dispelling misconceptions. The patient can be informed that while some women notice a slight increase in vaginal discharge, this effective method of contraception has been found to increase the vaginal health-promoting lactobacillus. Injectables- An intramuscular injection of Depo-Provera (a long-actingprogestin) every 3 months inhibits ovulation and provides are liable, private, and convenient contraceptive method. A subcutaneous formulation is also available. It can be used by lactating women and those with hypertension, liver disease, migraine headaches, heart disease, and hemoglobinopathies With continued use, women must be prepared for irregular bleeding episodes and spotting decrease, or amenorrhea. Advantages of Depo-Provera include

reduction of menorrhagia, dysmenorrhea, and anemia due to heavy menstrual bleeding. It may reduce the risk of pelvic infection, has been associated with improvement in hematologic status in women with sickle cell disease, and does not interfere with the efcacy of antiseizure agents. It decreases the risk of endometrial cancer, PID, endometriosis, and uterine broids. Possible side effects of Depo-Provera include irregular menstrual bleeding, bloating, headaches, hair loss, de-creased sex drive, bone loss, and weight loss or weight gain. The contraceptive does not protect against STDs. Fertility may be delayed when women discontinue this method; therefore, other methods of contraception may be more appropriate for the woman who wishes to conceive within a year of discontinuing contraception. While Depo-Provera is used, bone density is decreased, and this may be a risk factor for future osteoporosis. Severe allergic response is rare but possible following injection. Depo-Provera is contraindicated in women who are pregnant and those who have abnormal vaginal bleeding of unknown cause, breast or pelvic cancer, or sensitivity to synthetic progestin. Implants- Implanon is a single-rod subdermal implant that is usually placed inside the upper arm via a small incision. It is effective for 3 years. Implanon may cause irregular bleeding but may improve dysmenorrhea, and it does not affect bone density. This contraceptive can be used by lactating women. IUD- An IUD is a small plastic device, usually T-shaped, that is inserted into the uterine cavity to prevent pregnancy. A string attached to the IUD is visible and palpable at the cervical os. An IUD prevents conception by causing a local inammatory reaction that is toxic to spermatozoa and blastocysts, thus preventing fertilization. The IUD does not work by causing abortion. Advantages include effectiveness over a long period of time, few if any systemic effects, and reduction of patient error. This reversible method of birth control is as effective as sterilization and more effective than barrier methods. Disadvantages include possible excessive bleeding, cramps, and backaches; a slight risk of tubal pregnancy; slight risk of pelvic infection on insertion; displacement of the device; and, rarely, perforation of the cervix and uterus. If a pregnancy occurs with an IUD in place, the device is re-moved immediately to avoid infection. Spontaneous abortion (miscarriage) may occur on removal. An IUD is not usu-ally used in women who have not had children because a small nulliparous uterus may not tolerate it. Diaphram-The diaphragm is an effective contraceptive device that consists of a round, exible spring (50 to 90 mm wide) covered with a domelike latex rubber cup. A spermicidal (con-traceptive) jelly or cream is used to coat the concave side of the

diaphragm before it is inserted deep into the vagina, covering the cervix completely. The spermicide inhibits spermatozoa from entering the cervical canal. The diaphragm is not felt by the user or her partner when properly tted and inserted. Because women vary in size, the diaphragm must be sized and tted by an experienced clinician. The woman is instructed in using and caring for the device. A return demonstration ensures that the woman can insert the diaphragm correctly and that it covers the cervix. Each time the woman uses the diaphragm, she should examine it carefully. By holding it up to a bright light, she should ensure that it has no pinpoint holes, cracks, or tears. She then applies spermicidal jelly or cream and inserts the diaphragm. The diaphragm should remain in place at least6 hours after coitus (no more than 12 hours). Additional spermicide is necessary if more than 6 hours have passed be-fore intercourse occurs and before each act of repeated intercourse. On removal, the diaphragm should be cleansed thoroughly with mild soap and water, rinsed, and dried be-fore being stored in its original container. Disadvantages include allergic reactions in those who are sensitive to latex and an increased incidence of urinary tract infections. Toxic shock syndrome has been reported in some diaphragm users but is rare. Contraceptive Sponge- The sponge, another barrier method of contraception, is made of soft, disposable polyurethane foam that is moistened with water and inserted into the vagina before intercourse. It contains and releases a spermicide (eg,nonoxynol-9) that is continuously released into the vagina in small amounts through a 24-hour wear time. The sponge is left in place in the vagina for at least 6 hours after inter-course and can be kept in place for up to 24 additional hours without the need to replace it with repeated acts of inter-course during that period of time. The sponge is sold over the counter and does not require a prescription or special tting by a health care provider. The sponge should not be used by women with allergy to polyurethane. It should not be used during menstruation. Women who have a history of toxic shock syndrome should not use the contraceptive sponge. Female Condom- The female condom was developed to give control of barrier protection to womento provide them with protection from STDs and HIV as well as pregnancy. The female condom (Reality) consists of a cylinder of polyurethane en-closed at one end by a closed ring that covers the cervix and at the other end by an open ring that covers the perineum (New, improved models are currently pending approval by the FDA.) Advantages include some degree of protection from STDs (HPV, herpes simplex virus, and HIV). Disadvantages include the inability to use the female condom with some positions (ie, standing). Women have found that it can be noisy and slippery.

Spermicides- Spermicides are made from nonoxynol-9 or octoxynol and are available over the counter as foams, gels, lms, and suppositories and also on condoms. Spermicides do not protect women from HIV or other STDs. In fact, nonoxynol-9 has been found to be associated with minute tears in vaginal tissue with frequent use (eg, daily), possibly increasing the possibility of contracting HIV from an infected partner. Male Condom- The male condom is an impermeable, snug-fitting cover applied to the erect penis before it enters the vaginal canal. The tip of the condom is pinched while being applied to leave space for ejaculate. If no space is left, ejaculation may cause a tear or hole in the condom and reduce its effectiveness. The penis, with the condom held in place, is re-moved from the vagina while still erect to prevent the ejaculate from leaking. Condoms are now available in large and small size. The latex condom also creates a barrier against transmission of STDs (gonorrhea, chlamydial infection, and HIV) by body uids and may reduce the risk of herpes virus transmission. However, natural condoms (those made from animal tissue) do not protect against HIV infection. Nurses need to reassure women that they have a right to insist that their male partners use condoms and a right to refuse sex without condoms, although women in abusive relationships may increase their risk of abuse by doing so. Some women carry condoms with them to be certain that one is available. Nurses should be familiar and comfortable with instructions about using condoms because many women need to know about this way of protecting themselves from HIV and other STDs. Condoms do not provide complete protection from STDs because HPV may be transmitted by skin-to-skin contact. Other STDs maybe transmitted if any abraded skin is exposed to body uids. This information should be included in patient teaching. The nurse needs to consider the possibility of latex allergy. Swelling and itching can also occur. Possible warning signs of latex allergy include oral itching after blowing up a balloon or eating kiwis, bananas, pineapples, passion fruit, avocados, or chestnuts. Because many contraceptives are made of latex, patients who experience burning or itching while using latex contraceptives are instructed to see their primary health care provider. Alternatives to latex condoms may include the female condom (Reality) and the male condom (Avanti), made of polyurethane.

COITUS INTERRUPTUS ORWITHDRAWAL- Coitus interruptus (removing the penis from the vagina be-fore ejaculation) requires careful control by the male partner. Although it is a frequently used method of preventing pregnancy and better than no method, it is considered an unreliable method of contraception.

RHYTHM AND NATURAL METHODS- Natural family planning is any method of conception regulation that is based on awareness of signs and symptoms of fertility during a menstrual cycle. The advantages of natural contraceptive methods include: (1) they are not hazardous to health, (2) they are inexpensive, and (3) they are approved by some religions that do not approve of other methods of contraception. The disadvantage is that they require discipline by the couple, who must monitor the menstrual cycle and abstain from sex during the fertile phase. Current methods include the calendar method, the basal body temperature method, the ovulation method, and the symptothermal method. The calendar and basal body temperature methods are older than the ovulation method and the symptothermal method. Combinations of these methods are often used The fertile phase (in which sexual abstinence is required) is estimated to occur about 14 days before menstruation, although it may occur between the 10th and 17thdays. Spermatozoa can fertilize an ovum up to 72 hours after intercourse, and the ovum can be fertilized for 24 hours after leaving the ovary. The pregnancy rate with the rhythm (ie, calendar) method is about 40% yearly. Women who carefully determine their safe period, based on a precise recording of menstrual dates for at least 1 year, and who follow a carefully worked-out formula may achieve very effective protection. A long abstinence period during each cycle is required. These prerequisites require more time and control than many couples have. Changes in cervical mucus and basal body temperature due to hormonal changes related to ovulation form the scientic basis for the symptothermal method of ovulatory timing. Courses in natural family planning are offered at many Catholic hospitals and some family planning clinics. Ovulation detection methods (eg, Clearblue Easy Fertility Monitor) are available in most pharmacies. The presence of the enzyme guaiacol peroxidase in cervical mucus signals ovulation 6 days beforehand and also affects mucosal viscosity. Over-the-counter test kits are easy to use and reliable but can be expensive. Ovulation prediction kits are more effective for planning conception than for avoiding it. But if they are used in combination with cervical mucus changes and the calendar method, they may be effective; further research is needed. Douching is not a contraceptive method and may enhance rather than decrease the chances of conception. EMERGENCY CONTRACEPTION- The need for emergency contraception may arise after an episode of unprotected sexual intercourse. Therefore, nurses need to be aware of emergency contraception as an option for women and the indications for its use. It is clearly not suitable for long-term avoidance of pregnancy because it is not as effective as oral contraceptives or other reliable methods used regularly. However, it is valuable following intercourse when a pregnancy is not intended and in emergency situations such

as rape, a defective or torn condom or diaphragm, or other situations that may result in unwanted conception. Women need to be made aware of emergency contraception and how to obtain it.