m unique specialty of health care

m understanding female anatomy and physiology

m physical, developmental, psychological and
socio-cultural influences on women¶s health

Scope: Health maintenance and

promotion across the life span
 growth and development
 sexuality
 contraception
 Preconception care
 conception
 Prenatal care and postpartum care
 Effects of pregnancy
 Perimenopause

enopause
 Disorders that affect women
 Gynecologic infection
 Benign and malignant tumors
m encourage women to determine their own health
goals and behaviors
m teaches about health and illnesses
m sickness prevention
m offers interventional strategies -detection of
disease
m provides support , counseling and monitoring
 emale External Genitalia
- (Vulva or pudendum )

x
  subcutaneous fats anterior to

symphysis pubis, covered by pubic hair


 two thick folds of tissue

 
 two thin folds of skin devoid
of hair forming partial covering of clitoris
á Clitoris- erectile organ corresponding to the
male penis

5. Vestibular glands- (bartholin¶s) a bean-sized

structure
that empties its mucous secretion through
the
small duct

6 erineum
area between the vagina and the

rectum
x. Vagina- a canal lined mucous membrane
- is 7.5 to x cm long
- extends upward and backward from
the
vulva to the cervix
2. Uterus- pear- shaped muscular organ
-7.5long and 5cm wide
- size varies depending on parity and
uterine abnormalities
x  
 extends anteriorly and laterally
to
the inguinal ring and down the inguinal canal
blend with tissues of the labia majora

2  
 folds of peritoneum extending

from
the lateral pelvic walls and enveloping the
fallopian
tubes
3.  
 dense of connective tissue
that
extends from the inferior and posterior portion of
á. Cardinal ligaments- dense bands of connective
tissue
located at the base of the broad ligament

2 Parts of the uterus:

undus- or body which is covered posteriorly and
partly
anteriorly by peritoneum
Cervix- projects into the vagina
extends from the isthmus ( constricted portion
of
of the uterus into the vagina

Portio- portion of cervix visible from the vagina

internal os- opening of the cervix into the isthmus

external os²opening of the cervix into the

vagina
 firm almond ±shaped organ about 3cmlong
At birth, they contain thousand of egg cells or ova

  approx x cm long and divided to

á
parts:
x.Infundibulum á. interstitium
2.Ampulla imbriae
3.Isthmus
 personal hygiene
 Strategies for detecting sexually transmitted
diseases
 issues related to sexuality, sexual function
 Health promotion- diet, exercise, role of
gynecologic
check up
 Providing information about regular examinations
 Recognizing signs and symptoms of abuse
Recognizing cultural difference and belief
 complex process involving the reproductive and
endocrine system
Ovaries- produce steroid hormones predominantly
Estrogens and progesterone
Estradiol- most potent of the ovarian estrogen
responsible for the developing and
maintaning the female reproductive
organs and reproductive characteristics

important role in breast development

in monthly cyclic changes in the uterus

 important in regulating that changes occur in the
uterus
secreted by the corpus luteum± which is the
ovarian follicle after the ovum has been released
prepares the endometrium for implantation of a
fertilized ovum
together with estrogen prepares breast for
producing and secreting milk
 from day x- á
Glandular and stromal degradation with sloughing
of the functionalis ± inner endometrial layer
Estradiol and progesterone are low from the
regressing
corpus luteum
SH level begin to rise
LH level rises slowly several days after SH
begins to rise
 ollicular phase- day á to day xá
proliferation of endometrial glands and stroma
elongation of spiral arteries
Estradiol level increases and peaks before LH
surge and ovulation
Progesterone- remains low
SH- peaks at midcycle with LH
LH-rapidly peaks at mid cycle triggers ovulation
 Luteal phase- Day xá and last day 28
stimulate glands to secrete mucus and glycogen
glands become tortuous and dilated
convoluted spiral arteries extends to superficial
layers
Estradiol level decreases after ovulation, then
rises with production from corpus luteum
progesterone- rises after ovulation ,peaks day 2 -
2x
SH and LH are low
 maintains early pregnancy source of
progesterone
 degenerates into a scar ³ corpus albicans´
if pregnancy does not occur
 is a combination of symptoms that occur before
menses and subside with the onset of menstrual
flow
cause is unknown
theory of inc in serotonin
dietary factors play a role

ÿ  


 Headache
 fatigue
 low back pain
 Painful breast
 feeling of abdominal fullness
 irritability
 moods swings
 ear of losing control/ anxiety
 Binge eating
 Crying spells, anger/ depression
Exercise, avoid caffeine, high fat foods
Alternative tx; Vit B E , magnesium and Oil of
primrose oil

PHAR
ACO THERAPY
Serotonin reuptake inhibitor ( loxetine- Prozac)
GnRH agonists
Prostaglandins inhibitor ( ibuprofen)
Anti-axiety agents
diuretics
 establish rapport with the patient and obtain
health history
 show patient to develop a chart to record timing
and intensity of symptoms
 positive coping measure are facilitated
 encourages patient to use exercise, reduce stress
and take medications properly as prescribed
 discuss problems, assess suicidal tendencies,an
d psychiatric evaluation
 Painful menstruation
two main categories;
x. Primary dysmenorrhea- without associatd pelvic
disease
2. Secondary dysmenorrhea- painful menses
caused
by pelvic pathology
 Increased prostaglandin release from
endometrial cells
at the time of menstruation cause uterine
smooth muscle contraction, uterine
ischemia

TREAT
ENT:
NSAIDs- mainstay of treatment ± interfere
with cyclooxygense enzyme pathway
Propionic acids- Ibuprofen, Naproxen,
Ketoprofen
 inhibit ovulation and decrease endometrial
prostaglandins production
If NSAIDS and OCP is not effective GnRH
agonists can be considered
if no improvement,. Consider pathologic causes

Heat vasodilator that increases blood flow and

counteract constriction and muscle contraction
 Causes:
a. Chronic pelvic inflammatory disease
b. endometriosis
c. adhesions
d. fibroids
e. Strictures of cervix and vagina

ANAGE
ENT: directed at diagnosis and tx of
underlying cause
 period extending from xst sign of menopause,
usually hot flashes, vaginal dryness and irregular
menses
period around menopause to beyond the
complete cessation of menses
common symptoms of abnormal uterine
bleeding:
nurses¶ role to encourage annual pelvic
examination
perineal pruritus- common among elderly
vulvar dystrophy- thickened whitish discoloration
of tissue
relaxing pelvic musculature
m Amenorrhea- absence of menstrual flow
m Oligomenorrhea- infrequent, irregular bleeding
usually at interval of more than á days
m
enorrhagia- excessive bleeding in amount and
duration at regular intervals
m
etrorrhagia- irregular but not excessive uterine
bleeding
m
enometrorrhagia- frequent bleeding that is
excessive in amount and duration and occurs at
irregular intervals
 permanent physiologic cessation of menses
associated
with declining ovarian function
reproductive function diminishes and ends
atrophy of breast tissue and genital organs
loss of bone density and vascular changes
 cessation of menses
 Hot flashes
 Night sweats
 Vasomotor instability
 Sleep disturbance
 nervousness and palpitations
 fatigue
 osteoporosis
Changes in vulvovaginal area like;
gradual thinning of pubic hair
Shrinkage of labia
vaginal secretion decreases
dyspareunia
atrophic vaginitis- discharge, itching and urinary
symptoms
 women¶s reactions and feeling related to loss of
reproductive function

EDICAL
ANAGE
ENT:
vaginal lubrication
estrogen vaginal creams
control menopausal symptoms
 HRT- Hormone replacement therapy

 BENEITS
eliminates persistent and severe hotflashes
Reduces bone loss
Decrease risk of colon cancer
improves lipoproteins and lower fibrinogen levels
m History of breast cancer
m vascular thrombosis
m active liver disease/ chronically impaired
liver function
m uterine cancer
m undiagnosed abnormal vaginal bleeding
 signs and symptoms of deep vein thrombosis
(leg redness, tenderness)
Pulmonary embolism( chest pain and shortness
of breath)

ammogram
endometrial biopsy- irregular bleeding
 Estrogen and Progestins daily
 Estrogen for 25 consecutive days each month,
with
Progestins ± x -xá days of the month
--- experience bleeding

Vaginal treatment with estrogen cream, suppository

Prevents dryness and atrophy
 SER
S- Selective estrogen receptor modulators

**Raloxifen(Evista)
--- prevents and treat osteoporosis
 Diet as alternative (natural estrogens and
progestins)
---black cohosh, ginseng, soy products
 Vitamins E and B / Calcium supplements
 Alendronate (osamax)
 Encourage that the condition is natural
 cessation of menses is physiologic
function
 Normal sex urges continuous
 Teaching and couselling of healthy life
style
 promotion and health screening
 u
  
to help patient make contraceptive choices,
Needs to listen , educate, and spends time
answering Questions and assist patients
in choosing the method they prefer
x. birth spacing, in order for the mother to rest
and regain their health before the next
pregnancy
2. Birth limitation- desire number of children has
been reached
3. helping infertile couple to have children
 is the completely effective means of preventing
pregnancy

Sterilization: Surgical/ Permanent

bilateral tubal ligation
Vasectomy
 Vasectomy- the vas deferens is cut
does not cause instant
sterility
-patient have to wait x5-2
ejaculations before the tract is
devoid of sperm
- safe and effective
 expensive in short term
 Permanent
 No protection against STD
 not effective until sperm remain the
reproductive tracts
 Tubal ligation- one of the most common
operations performed on women
 patient received general anesthesia or
local
 tubes may be coagulated, sutured or
ligated
 ovulation and menstruation are not
affected by sterilization
 Combined oral Contraceptive- contains an
estrogen
and progesterone

I.
onophasic pill preparation- contain same
amount
amount of estrogen and progesterone
throughout
the cycle
available in 2x or 28 day pill pack.
withdrawal bleeding occurs within the 7 day
freepill or 7 placebo tablets

ultiphasic pills-
modifications of the combined oral
contraceptives
- Varying amounts of estrogen and
progesterone
are administered in three consecutive
phases
 inhibition of ovulation
 suppression of GnRH from the hypothalamus
 inhibition of secretion of SH- follicle stimulating
hormone---preventing follicular maturation

PROGESTERONE
makes cervical mucus thick, viscid and scanty
retarding
And impairing sperm transport and penetration into
the uterus

 Indications:

 Women who desire a short term or long term

reversible method of contraception
 Non-lactating postpartum
 heavy or painful or irregular menstruation
 recurrent funtional ovarian cyst
 decreased risk of endometrial cancer
 dec risk of epithelial ovarian cancer
 prevention of ectopic pregnancy
 lower incidence of pelvic inflammatory disease
 Less incidence of iron deficiency anemia
 less incidence of dysmenorrhea
 improvement of bone mineral density
 protection from functional ovarian cyst
 known or suspected pregnancy
 thrombophlebitis or throboembolic disorders
 cerebrovascular or coronary artery disease
 known or suspected breast cancer
 undiagnosed abnormal uterine bleeding
 Hypertension
 Hepatic adenoma or history of jaudice

igraine headaches
 Nausea
 hyperpigmentation
 Acne- may either improved or worsen
 weight gain/ bloatedness
 breast fullness or tenderness
 headache
 decreased libido

inipill
INDICATIONS:
 Appropriate for breastfeeding women and will not
interfere with the quality of milk production nor
shorten the duration of lactation
 started xst day of menstrual cycle and taken
everyday
without break whether mense occur or not
less effective than the combined oral
contraceptive
 nausea
 dizziness
 headache
 breast tenderness
 irregularities and intermittent
breakthrough bleeding
 Depot medroxyprogesterone acetate
 Norethisterone enantrate

 Inhibit ovulation
 produce thick and viscid mucous and make
endometrium shallow and atrophic with inactive
glands
 long acting , long term contraception
 ease of administration
 does not affect lactation
 menstrual disturbance , with prolonged used²
amenorrhea
 headache
 dizziness
 bloating of breast and abdomen
 weight gain
 glucose metabolism is modified slightly
 suppression of the production of estradiol
--loss of bone mass density
 x. Chemically ± inert± made of flexible
polyethylene
non-absorbable material (lippes loop)

 2 medicated- Newer IUD s where in copper and

progestins are added ( copper T 38 )
- approve x years of use
 all IUDs stimulate a foreign body reaction in the
endometrium
 prevents sperm from fertilizing the ovum
 increase in uterine and tubal fluids that alters
tubal and uterine transport and affects the sperm
and ovum so that fertilization does not occur
Progestins to IUD²
thickened cervical mucus and suppression of the
endometrium
 highly effective, same and long acting reversible
 older women who are shifting off the pill

 CONTRAINDICATIONS:
m known or suspected pregnancy
m Acute pelvic infections
m genital bleeding
m Puerperal sepsis
m Untreated acute cervicitis
m Allergy to copper
m
ultiple sexual partner
 Uterine pain and cramps
 Abnormal bleeding
 iron deficiency anemia
 pelvic infection
 Pregnancy with IUD in utero
 Ectopic pregnancy
 Perforation
 Lost thread and lost device
 Condom²and sheath made of latex, plastic
designed
to envelop the penis during intercourse
-- can prevent pregnancy and sexually
transmitted disease
SPER
ICIDE- interfere with the functional
activity
of the spermatozoa by destroying them
and making them immobile
³Nonoxynol-9´
- foaming tablets,creams. Jellies and
lubricants
 Diaphragm- has a thin nearly hemispherical,
rubber
dome with a circular rubber covered, metal
spring reinforced rim
- diameter of the rim fitted inside the vagina
to cover the cervix like a cup
emale condom- soft loose fitting polyurethane
sheath , closed end inserted close to the
cervix
and serve as anchor
 Safe- no interference with natural body
processes
 inexpensive
 Improves mutual relationship
 remain faithful to religious and ethical
beliefs
m Symptothermal-
ethod
m Cervical
ucus (Billing¶s
method)
m Calendar method
m basal body temperature
 fertility periods are calculated after six to twelve
cycles

Subtracting 2 or x8 from shortest cycle

Then xx from the longest cycle
Ex. SC= 27-2 =7
LC= 32-xx= 2x
D 7- D2x ---unsafe
 Breastfeeding is thought to prevent pregnancy
by inhibition of ovarian activity.
tactile stimulus increases induced nervous
impulses
to the hypothalamus
LA
- effective for short term birth control about
6 months after birth
safe for women with medical problems
encourages maternal- infant bonding
 expulsion of the conceptus before viability has
been achieved ( 2 th weeks of gestation)
 process is heralded by bleeding into the decidua
basalis

 Blighted ovum- absence of fetus within

the gestational sac
 pregnancy wastage can take any time after
implantation of the blastocyst
 ETIOLOGIES:
m etal factors
x. Abnormal zygote/ embryo development-
chromosomal anomalies
m
aternal actors
x. Age and Parity- increase with parity
- increase with maternal and
paternal age
2. Timing of previous pregnancy- increase with 3
mos
of a live birth
3. Chronic Infections
á. Chronic Debilitating disease
5. malnutrition
6. Uterine defects- Leiomyoma, incompetent
cervix
7. Drugs and environmental factors- tobacco,
alcohol,caffeine, radiation, anesthetic gases
 Threatened Abortion- any vaginal bleeding or
bloody
vaginal discharge during xst half of
pregnancy
- may be accompanied by mild cramping
abdominal pain or low back ache
IE: cervix is closed and uterine size Is
compatible with age of gestation
 Inevitable Abortion- there is rupture of the mem-
brane in the presence of cervical dilatation
TX: evacuation of product of conception

 Blighted Ovum- gestational sac with absence of

fetal
pole
- mean gestational sac is smaller than appro-
priate for gestational sac
 with history of passage of meaty materials
 parts of placenta retained in the uterus
 Bleeding may often been heavy
 on examination: cervix is dilated
 uterine size in incompatible with the age of
gestation

 TX; Completion curretage

 dead products of conception are retained inside
the
the uterus for 8 weeks or more

after fetal death bleeding may or may not occur

usually signs of early pre like nausea and
vomiting
cease
 three or more consecutive spontaneous abortions

 Causes:
? Congenital (incompetent cervix)
? Acquired ( endocrine disorders, Diabetes
mellitus,
? thyroid dysfunction , antiphospholipids
antibodies, hemophilias

Tx: parental karyotyping , Cerclage

 termination of pregnancy within first 2 wks with
infection of the product of conception, uterus and
adnexae
 Endotoxin released by gm negative organism
causing coagulation and fibrinolysis
Diagnostic Criteria:
x. temp of 38 C and up at least 2á hrs
2. hx of mechanical interference
3. septic discharge from cervix
á. tenderness of the uterus, adnexae
 prompt evacuation of infected product of
conceptus
 antibiotic treatments
 monitor vital signs/ stabilize patient
 laboratory test
 emotional support and understanding
 be aware of patient¶s grieving condition
 providing opportunities for patient¶s to talk
and express emotions
***
Dysfuntional grief- requires assistance of skilled
therapies
INERTILITY
 defined as a couple¶s inability to achieve
pregnancy after x year of unprotected
intercourses
 Primary- refers to a couple ho has never
had a child or have not been
pregnant
Secondary-means at least one
conception has occurred, but currently the
couple cannot
achieved pregnancy
 anovulation
 uterine or cervical factors
 blocked fallopian tubes
 endometriosis
 congenital abnormalities
 sperm quality or sperm production

 SE
INALYSIS: obtain after 2-3 days of sexual
abstinence
 Normal result of seminalysis:
m Volume: more than x ml
m Concentration: more than 2 million
m motility: more than 5 %
m morphology : more than 6 % normal
m no sperm clumping, significant red or white blood
cells
m No hyperviscousity

ale fertility = 35%
 ovulatory factors 25%=
 peritoneal factors 25 %
 cervical factors 5%
 uterine factors 5%
 Idiopathic 5%
 History-
m age of partner
m length of time attempted/ frequency of intercourse
m previous surgery or illnesses
m
ale:
m Testicular surgery
m Hypospadias
m varicocoele
m postpubertal mumps or orchitis
m detailed menstrual history
m history of infections like PID
m History of amenorrrhea/ menstrual irregularities
m previous Surgery-
m ectopic pregncy, rupture AP
m previous pregnancy
m IUD use
m pituitary adenoma
 look for signs of androgen excess
 Signs and symptoms of hyperthyroidism
 obesity
 galactorrhea
 pelvic tenderness
 cervical discharge
 Semen analysis
 Documentation of ovulation
 Postcoital test---
couple instructed to have intercourse after
2á-á8 hours of abstinence and 2 days after
ovulation
Cervical mucus and semen interaction are
analyzed within x2 hours
´ cervical mucus 6-8 cm stretch

´
ore than 2 sperm/ HP
 surgery to correct malformation
 hormonal supplements
 attention to proper timing
 recognition and correction of psycological or
Emotional factors
 Clomiphene Citrate- enhance the release of
pituitary
Gonadotrophins resulting to ovulation


enotropin - combination of SH and LH
used for women with deficiencies of these
hormones.
onitoring by ultrasound is
necessary because overstimulation may
occur
chorionic gonadotrophin- used to stimulate
release
of the egg from the ovary
 condition characterized by enlarged multi-cystic
ovaries and is complicated by a shift of fluid from
the
intravascular space into the abdominal cavity
fluid shift can cause ascites. Pleural effusion,
edema
and hypovolemia

Signs: abdominal distention, weight gain and

ovarian enlargement,, severe case ARDS
 requires hospitalization
 catherization to monitor urine output
 daily measurement of abdominal circumference
 Heparin
 Diuretics
 hemodialysis
depositing semen into the female tract by artificial

eans.

Indications::
x. man¶s inability to deposit semen in the vagina
due
to premature ejaculation, hypospadias
2. Inability of semen to be transported from the
vagina
Through the uterine cavity-