Clinical Anatomy and physiology of female reproductive system. Assessment and health Promotion.
Prepared by N.Petrenko
Identify the structures and functions of the female reproductive system.
Summarize the menstrual cycle in relation to hormonal, ovarian, and endometrial response.
Identify the four phases of the sexual response cycle. Identify reasons why women enter the health care delivery system.
Discuss financial, cultural, and gender barriers to seeking health care.
Explain conditions and characteristics that increase health risks.
Define the components of taking a woman's history and performing a physical examination.
Discuss how assessment and physical examination can be adapted for women with special needs.
Identify the correct procedure for assisting with and collecting Pap smear specimens.
Review health promotion and prevention suggestions for the common health risks.
KEY TERMS AND DEFINITIONS
breast self-examination (BSE) Systematic examination of the breasts by the woman
climacteric The period of a woman's life when she is passing from a reproductive to a nonreproductive state, with regression of ovarian function; the cycle of endocrine, physical, and psychosocial changes that occurs during the termination of the reproductive years; also called climacterium or perimenopause
cycle of violence Pattern of three phases: period of increasing tension, the abusive episode, and a period of contrition and kindness
Kegel exercises Pelvic muscle exercises to strengthen the pubococcygeal muscles
menarche Onset, or beginning, of menstrual function
menopause From the Greek words mensis (month) and pausis (cessation), the actual permanent cessation of menstrual cycles; so diagnosed after 1 year without menses
menstruation Periodic vaginal discharge of bloody fluid from the nonpregnant uterus that occurs from the age of puberty to menopause
menstrual cycle A complex interplay of events that occur simultaneously in the endometrium, the hypothalamus and pituitary glands, and the ovaries that results in ovarian and uterine preparation for pregnancy
ovulation Periodic ripening and discharge of the ovum from the ovary, usually 14 days before the onset of menstrual flow
Papanicolaou (Pap) smear Microscopic examination using scrapings from the cervix, endocervix, or other mucous membranes that will reveal, with a high degree of accuracy, the presence of premalignant or malignant cells
perimenopause Period of transition of changing ovarian activity before menopause and through the first few years of amenorrhea
preconception care Care designed for health maintenance before pregnancy
prostaglandins (PGs) Substances present in many body tissues; have roles in many reproductive tract functions; used to induce abortions, cervical ripening for labor induction
sexual response cycle The phases of physical changes that occur in response to sexual stimulation and sexual tension release
squamocolumnar junction Site in the endocervical canal where columnar epithelium and squamous epithelium meet; also called transformation zone
vulvar self-examination (VSE) Systematic examination of the vulva by the woman
Many women initially enter the health care system because of some reproductive system-related situation, such as pregnancy; irregular menses; desire for contraception; or episodic illness, such as vaginal infection. Once women are in the system, however, it is incumbent on health care providers to recognize the need for health promotion and preventive health maintenance and to provide these services as part of lifelong care for women. This chapter reviews female anatomy and physiology, including the menstrual cycle. Physical assessment and screening for disease prevention for women in their reproductive years is presented. Barriers to seeking health care and an overview of conditions and circumstances that increase health risks in the childbearing years are discussed. Anticipatory guidance suggestions for health promotion and prevention are also included.
FEMALE REPRODUCTIVE SYSTEM
The external genital organs, or vulva, include all structures visible externally from the pubis to the perineum: the mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening (Fig. 1). The mons pubis is a fatty pad that lies over the anterior surface of the symphysis pubis. In the postpubertal female, the mons is covered with coarse curly hair. The labia majora are two rounded folds of fatty tissue covered with skin that extend downward and backward from the mons pubis. The labia are highly vascular structures that develop hair on the outer surfaces after puberty. They protect the inner vulvar structures. The labia minora are two flat, reddish folds of tissue visible when the labia majora are separated. Anteriorly, the labia minora fuse to form the prepuce (hoodlike covering of the clitoris) and the frenulum (fold of tissue under the clitoris). The labia minora join to form a thin flat tissue called the fourchette underneath the vaginal opening at midline. The clitoris is located underneath the prepuce. It is a small structure composed of erectile tissue with numerous sensory nerve endings.
The vaginal vestibule is an almond-shaped area enclosed by the labia minora that contains openings to the urethra, Skene glands, vagina, and Bartholin glands. The urethra is not a reproductive organ but is considered here because of its location. It usually is found approximately 2.5 cm below the clitoris. The Skene glands are located on each side of the urethra and produce mucus, which aids in lubrication of the vagina. The vaginal opening is in the lower portion of the vestibule and varies in shape and size. The hymen, a connective tissue membrane, surrounds the vaginal opening. Bartholin glands (see Fig. 1) lie under the constrictor muscles of the vagina and are located posteriorly on the sides of the vaginal opening, although the ductal openings are usually not visible. During sexual arousal the glands secrete a clear mucus to lubricate the vaginal introitus.
The area between the fourchette and the anus is the perineum, a skincovered muscular area that covers the pelvic structures. The perineum forms the base of the perineal body, a wedged-shaped mass that serves as an anchor for the muscles, fascia, and ligaments of the pelvis. The pelvic organs are supported by muscles and ligaments that form a sling.
The internal structures include the vagina, uterus, uterine tubes, and ovaries. The vagina is a fibromuscular, collapsible tubular structure that extends from the vulva to the uterus and lies between the bladder and rectum. During the reproductive years the mucosal lining is arranged in transverse folds called rugae. These rugae allow the vagina to expand during childbirth. Estrogen deprivation that occurs after childbirth, during lactation, and at menopause causes dryness and thinness of the vaginal walls and the rugae to become smooth. Vaginal secretions are acidic (pH 4 to 5), so the vagina's susceptibility to infections is reduced. The vagina serves as a passageway for menstrual flow, as a female organ of copulation, and as a part of the birth canal for vaginal childbirth. The uterine cervix projects into a blind vault at the upper end of the vagina. There are anterior, posterior, and lateral pockets called fornices that surround the cervix. The internal pelvic organs can be palpated through the thin walls of these fornices.
The uterus is a muscular organ shaped like an upside-down pear that sits midline in the pelvic cavity between the bladder and rectum above the vagina. Four pairs of ligaments support the uterus: the cardinal, uterosacral, round, and broad. Single anterior and posterior ligaments also support the uterus. The cul-de-sac of Douglas is a deep pouch, or recess, posterior to the cervix formed by the posterior ligament.
The uterus is divided into two major parts, an upper triangular portion called the corpus and a lower cylindric portion called the cervix (Fig. 2). The fundus is the dome-shaped top of the uterus and is the site where the uterine tubes enter the uterus. The isthmus (lower uterine segment) is a short, constricted portion that separates the corpus from the cervix.
Fig. 2. Midsagital viev of female pelvic organs with woman lying supine
The uterus serves for reception, implantation, retention, and nutrition of the fertilized ovum and later the fetus during pregnancy and expulsion of the fetus during childbirth. It also is responsible for cyclic menstruation.
The uterine wall consists of three layers: the en-dometrium, the myometrium, and part of the peritoneum. The endometrium is a highly vascular lining made up of three layers, the outer two of which are shed during menstruation. The myometrium is made up of layers of smooth muscles that extend in three different directions (longitudinal, transverse, and oblique) (Fig. 3). Longitudinal fibers of the outer myometrial layer are found mostly in the fundus, and this arrangement assists in expelling the fetus during the birth process. The middle layer contains fibers from all three directions, which form a figure-of-eight pattern encircling large blood vessels. This arrangement assists in constricting blood vessels after childbirth and controls blood loss. Most of the circular fibers of the inner myometrial layer are around the site where the uterine tubes enter the uterus and around the internal cervical os (opening). These fibers help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation.
Fig. 3 Schematic arrangement of directions of muscle fibers. Note that uterine muscle fibers are continuous with supportive ligaments of uterus.
The cervix is made up of mostly fibrous connective tissues and elastic tissue, making it possible for the cervix to stretch during vaginal childbirth. The opening between the uterine cavity and the canal that connects the uterine cavity to the vagina (endocervical canal) is the internal os. The narrowed opening between the endocervix and the vagina is the external os, a small circular opening in women who have never been pregnant. The cervix feels firm (like the end of a nose) with a dimple in the center, which marks the external os.
The outer cervix is covered with a layer of squamous epithelium. The mucosa of the cervical canal is covered with columnar epithelium and contains numerous glands that secrete mucus in response to ovarian hormones. The squamo-columnar junction, where the two types of cells meet, is usually located just inside the cervical os. This junction is the most common site for neoplastic changes, and cells from this site are scraped for the Papanicolaou test.
The uterine tubes (fallopian tubes) attach to the uterine fundus. The tubes are supported by the broad ligaments and range from 8 to 14 cm in length. The uterine tubes provide a passage between the ovaries and the uterus for the passage of the ovum.
The ovaries are almond-shaped organs located on each side of the uterus below and behind the uterine tubes. During the reproductive years, they are approximately 3 cm long, 2 cm wide, and 1 cm thick; they diminish in size after menopause. The two functions of the ovaries are ovulation and production of estrogen, progesterone, and androgen.
The bony pelvis serves three primary purposes: protection of the pelvic structures, accommodation of the growing fetus during pregnancy, and anchorage of the pelvic support structures. Two innominate (hip) bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis (Fig. 4).
Fig. 4 Adult female pelvis. A, Anterior view. B, External view of innominate bone (fused).
Cartilage and ligaments form the symphysis pubis, sacrococcygeal, and two sacroiliac joints that separate the pelvic bones. The pelvis is divided into two parts: the false pelvis and the true pelvis (Fig. 4-5). The false pelvis is the upper portion above the pelvic brim or inlet. The true pelvis is the lower curved bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during vaginal birth. Variations that occur in the size and shape of the pelvis are usually due to age, race, and injury. Pelvic ossification is complete by approximately 20 years of age.
Fig. 5 Female pelvis. A, Cavity of false pelvis is shallow. B, Cavity of true pelvis is an irregularly curved canal (arrows).
The breasts are paired mammary glands located between the second and sixth ribs (Fig. 6). Approximately two thirds of the breast overlies the pectoralis major muscle, between the sternum and midaxillary line, with an extension to the axilla referred to as the tail ofSpence. The lower one third of the breast overlies the serratus anterior muscle. The breasts are attached to the muscles by connective tissue called fascia.
The breasts of healthy mature women are approximately equal in size and shape but are often not absolutely symmetric. The size and shape vary depending on the woman's age, heredity, and nutrition. However, the contour should be smooth with no retractions, dimpling, or masses. Estrogen stimulates growth of the breast by inducing fat deposition in the breasts, development of stromal tissue (i.e., increase in its amount and elasticity), and growth of the extensive ductile system. Estrogen also increases the vascularity of breast tissue. The increase in progesterone at puberty causes maturation of mammary gland tissue, specifically the lobules and acinar structures. During adolescence, fat deposition and growth of fibrous tissue contribute to the increase in the gland's size.
Fig. 6 Anatomy of the breast, showing position and major structures. (From Seidel, H. et al. . Mosby's guide to physical examination [4th ed.]. St. Louis: Mosby.)
Each mammary gland is made of 15 to 20 lobes, which are divided into lobules. Lobules are clusters of acini. An acinus is a saclike terminal part of a compound gland emptying through a narrow lumen or duct. The acini are lined with epithelial cells that secrete colostrum and milk. Just below the epithelium is the myoepithelium (myo, or muscle), which contracts to expel milk from the acini.
The ducts from the clusters of acini that form the lobules merge to form larger ducts draining the lobes. Ducts from the lobes converge in a single nipple (mammary papilla) surrounded by an areola. Just as the ducts converge, they dilate to form common lactiferous sinuses, which are also called ampullae. The lactiferous sinuses serve as milk reservoirs. Many tiny lactiferous ducts drain the ampullae and exit in the nipple.
The glandular structures and ducts are surrounded by protective fatty tissue and are separated and supported by fibrous suspensory Cooper's ligaments. Cooper's ligaments provide support to the mammary glands while permitting their mobility on the chest wall (see Fig. 6). The round nipple is usually slightly elevated above the breast. On each breast the nipple projects slightly upward and laterally. It contains 15 to 20 openings from lactiferous ducts. The nipple is surrounded by fibromus-cular tissue and covered by wrinkled skin. Except during pregnancy and lactation, there is usually no discharge from the nipple.
The nipple and surrounding areola are usually more deeply pigmented than the skin of the breast. The rough appearance of the areola is caused by sebaceous glands, Montgomery tubercles (see Fig. 6), directly beneath the skin. These glands secrete a fatty substance, thought to lubricate the nipple.
The vascular supply to the mammary gland is abundant. The skin covering the breasts contains an extensive superficial lymphatic network that serves the entire chest wall and is continuous with the superficial lymphatics of the neck and abdomen. In the deeper portions of the breasts, the lymphatics form a rich network as well. The primary deep lymphatic pathway drains laterally toward the axillae.
The breasts change in size and nodularity in response to cyclic ovarian changes throughout reproductive life. Increasing levels of both estrogen and progesterone in the 3 to 4 days before menstruation increase vascularity of the breasts, induce growth of the ducts and acini, and promote water retention. As a result, breast swelling, tenderness, and discomfort are common symptoms just before the onset of menstruation. After menstruation, cellular proliferation begins to regress, acini begin to decrease in size, and retained water is lost. In time, after repeated hormonal stimulation, small persistent areas of nodulations may develop just before and during menstruation, when the breast is most active. The physiologic alterations in breast size and activity reach their minimum level approximately 5 to 7 days after menstruation stops. There fore breast self-examination (BSE) is best carried out during this phase of the menstrual cycle (see Research box and Self-Care box).
Instruction in Breast Self-Examination Leads to Improvement in Performance
Although most women know about breast self-examination (BSE) as a recommended way to detect early breast cancer, fewer than one-fourth of them do BSE proficiently. Quality of BSE technique includes frequency, duration, depth of palpation, use of three middle finger pads in dime-sized circles, and patterns of search (concentric circle versus vertical strip). Because correct technique has been difficult to quantify, other than by observation, nurse researchers teamed up with an engineer and a computer scientist to develop a biomedical instrument. Using pressure sensors inside a breast model, they were able to measure the palpation depth and examination duration (dependent variables) of 41 healthy, young women before and after a BSE instructional program (independent variable). The researchers found significant treatment effects: depth of palpation increased by at least 38%, and duration of examination time nearly doubled to between 3.3 and 3.6 minutes per breast. No significant differences in these variables were found between the concentric circle and vertical strip patterns of search.
IMPLICATIONS FOR PRACTICE
Although the efficacy of BSE at decreasing mortality rates has yet to be firmly established, there is enough evidence to continue to recommend BSE as a complement to mammography and clinical breast examination. It is presumed that better BSE technique leads to earlier detection of lumps and more successful treatment. Nurses in all clinical sites that provide care for women should continue to assess how women perform BSE, reinforce the proper technique to use, and encourage the monthly practice.
Source: Leight, S., et al. (2000). The effect of structured training on breast self-examination search behaviors as measured using biomedical instrumentation. Nurs Res, 49(5), 283-289.
Patient Instructions for Self-Care
1. The best time to do breast self-examination is after your period, when breasts are not tender or swollen. If you do not have regular periods or sometimes skip a month, do it on the same day every month.
2. Lie down and put a pillow under your right shoulder.Place your right arm behind your head (Fig. 1).
3. Use the finger pads of your three middle fingers on your left hand to feel for lumps or thickening. Your finger pads are the top third of each finger.
4. Press firmly enough to know how your breast feels. If you're not sure how hard to press, ask your health care provider, or try to copy the way your health care provider uses the finger pads during a breast examination. Learn what your breast feels like most of the time. A firm ridge in the lower curve of each breast is normal.
5. Move around the breast in a set way. You can choose either circles (Fig. 2, A), vertical lines (Fig. 2, B), or wedges (Fig. 2, C). Do it the same way every time. It will help you to make sure that you've gone over the entire breast area and to remember how your breast feels.
6. Gently compress the nipple between your thumb and forefinger and look for discharge.
7. Now examine your left breast using the finger pads of your right hand.
8. If you find any changes, see your health care provider right away.
9. You may want to check your breasts while standing in front of a mirror right after you do your breast self-examination each month. See if there are any changes in the way your breasts look: dimpling of the skin, changes in the nipple, or redness or swelling.
10. You may also want to do an extra breast self-examination while you're in the shower (Fig. 3). Your soapy hands will glide over the wet skin, making it easy to check how your breasts feel.
11. It is important to check the area between the breast and the underarm and the underarm itself. Also examine the area above the breast to the collarbone and to the shoulder
MENSTRUATION AND MENOPAUSE
Menarche and puberty
Puberty is a broad term that denotes the entire transitional stage between childhood and sexual maturity. Although young girls secrete small, rather constant amounts of estrogen, a marked increase occurs between 8 and 11 years of age. The term menarche denotes first menstruation. In North America this occurs in most girls at about 13 years of age.
Although pregnancy can occur in exceptional cases of true precocious puberty, most pregnancies in young girls occur after the normally timed menarche. All girls would benefit from knowing pregnancy can occur at any time after the onset of menses.
Fig. 7 Menstrual cycle: hypothalamic-pituitary, ovarian, and endometrial.
Initially, menstrual periods are irregular, unpredictable, painless, and anovulatory. After the ovary produces adequate cyclic estrogen to make a mature ovum, periods tend to be regular and ovulatory. The menstrual cycle is a complex interplay of events that occur simultaneously in the endometrium, hypothalamus and pituitary glands, and ovaries. The menstrual cycle prepares the uterus for pregnancy. When pregnancy does not occur, menstruation follows. Menstruation is the periodic uterine bleeding that begins approximately 14 days after ovulation. The average length of a menstrual cycle is 28 days, but variations are common. The first day of bleeding is designated as day 1 of the menstrual cycle, or menses (Fig. 7). The average duration of menstrual flow is 5 days (range of 3 to 6 days), and the average blood loss is 50 ml (range of 20 to 80 ml), but these vary greatly. The woman's age, physical and emotional status, and environment also influence the regularity of her menstrual cycles.
The four phases of the endometrial cycle are (1) the menstrual phase, (2) the proliferative phase, (3) the secretory phase, and (4) the ischemic phase (see Fig. 7). During the menstrual phase, shedding of the functional two thirds of the endometrium (the compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. The basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in the basalis.
The proliferative phase is a period of rapid growth lasting from about the fifth day to the time of ovulation. The endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on an eightfold to tenfold thickening occurs with a leveling off of growth at ovulation. The proliferative phase depends on estrogen stimulation derived from ovarian follicles.
The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual period. After ovulation, larger amounts of progesterone are produced. The fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions, a suitable protective and nutritive bed for a fertilized ovum.
Implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation. If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses. With the rapid fall in progesterone and estrogen levels, the spiral arteries go into spasm. During the ischemic phase, the blood supply to the functional endometrium is blocked and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Fig. 7).
Hypothalamic-pituitary cycle. Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone fall. Low blood levels of these ovarian hormones stimulate the hypothalamus to secrete gonadotropin- releasing hormone (GnRH). In turn, GnRH stimulates anterior pituitary secretion of follicle-stimulating hormone (FSH). FSH stimulates development of ovarian graafian follicles and their production of estrogen. Estrogen levels begin to fall, and hypothalamic GnRH triggers the anterior pituitary release of luteinizing hormone (LH). A marked surge of LH and a smaller peak of estrogen (day 12; see Fig. 4-7) precede the expulsion of the ovum from the graafian follicle by approximately 24 to 36 hours. LH peaks at approximately the thirteenth or fourteenth day of a 28-day cycle. If fertilization and implantation of the ovum have not occurred by this time, regression of the corpus luteum follows. Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnRH. This process is termed the hypothalamic-pituitary cycle.
Ovarian cycie. The primitive graafian follicles contain immature oocytes (primordial ova). Before ovulation, from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen. The preovulatory surge of LH affects a selected follicle. The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum. This follicular phase (preovulatory phase) (see Fig. 7) of the ovarian cycle varies in length from woman to woman and accounts for almost all variations in ovarian cycle length. On rare occasions (approximately 1 in 100 menstrual cycles), more than one follicle is selected and more than one oocyte matures and undergoes ovulation.
After ovulation, estrogen levels drop. For 90% of women, only a small amount of withdrawal bleeding occurs, so it goes unnoticed. In 10% of women, there is sufficient bleeding for it to be visible, resulting in what is known as midcycle bleeding.
The luteal phase begins immediately after ovulation and ends with the start of menstruation. This postovulatory phase of the ovarian cycle usually requires 14 days (range ot 13 to 15 days). The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting both estrogen and progesterone. Coincident with this time of peak luteal functioning, the fertilized ovum is implanted in the endometrium. If no implantation occurs, the corpus luteum regresses, steroid levels drop, and menstruation occurs.
Other cyclic changes. When the hypothalamic-pituitary- ovarian axis functions properly, other tissues undergo predictable responses. Before ovulation the woman's basi body temperature (BBT) is often below 37° C; after ovulation, with rising progesterone levels, her BBT rises. Changes in the cervix and cervical mucus follow a generally predictable pattern. Preovulatory and postovulatory mucus is viscous (thick), so sperm penetration is discouraged. A: the time of ovulation, cervical mucus is thin and clear. I: looks, feels, and stretches like egg white. This stretchable quality is termed spinnbarkheit. Some women experience localized lower abdominal pain, termed mittelschmerz, that coincides with ovulation.
Climacteric. The climacteric is a transitional phase during which ovarian function and hormone productio: decline. This phase spans the years from the onset of premenopausal ovarian decline to the postmenopausal tirr.t when symptoms stop. Menopause (from the Greek words mensis, month, and pausis, to cease) refers only to the last menstrual period. Unlike menarche, however, menopause can be dated only with certainty 1 year after menstruaticr. ceases. The average age at natural menopause is 51.4 years., with an age range of 35 to 60 years.
Prostaglandins (PGs) are oxygenated fatty acids classifier as hormones. The different kinds of PGs are distinguishes: by letters (PGE, PGF), numbers (PGE2), and letters of the Greek alphabet (PGF2„). PGs are produced in most orju* of the body, but most notably by the endometrium. Menstrual blood is a potent prostaglandin source. Prostaglandins affect smooth muscle contractility and modulation ar hormonal activity. Indirect evidence supports PGs' effect on ovulation, fertility, changes in the cervix and cervical mucus that affect receptivity to sperm, tubal and uterine motility, sloughing of endometrium (menstruation), onset of abortion (spontaneous and induced), and onset of labor (term and preterm).
The hypothalamus and anterior pituitary gland in females regulate the production of FSH and LH. The target tissue for these hormones is the ovary, which produces ova and secretes estrogen and progesterone. A feedback mechanism between hormone secretion from the ovaries, hypothalamus, and anterior pituitary aids in the control of the production of sex cells and steroid sex hormone secretion.
Although the first outward appearance of maturing sexual development occurs at an earlier age in females, both females and males achieve physical maturity at approximately 17 years of age. However, individual development varies greatly. Anatomic and reproductive differences notwithstanding, women and men are more alike than different in their physiologic response to sexual excitement and orgasm. For example, the glans clitoris and the glans penis are embryonic homologues. Not only is there little difference between female and male sexual response, but the physical response is essentially the same whether stimulated by coitus, fantasy, or masturbation. Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia.
Sexual stimulation results in vasocongestion (congestion of blood vessels, usually venous) that causes vaginal lubrication and engorgement and distention of the genitals. This venous congestion occurs to a lesser degree in the breasts and other parts of the body. Arousal is characterized by myotonia (increased muscular tension), resulting in voluntary and involuntary rhythmic contractions. Examples of sexually stimulated myotonia are pelvic thrusting, facial grimacing, and spasms of the hands and feet (carpopedal spasms).
The sexual response cycle is divided into four phases: excitement phase, plateau phase, orgasmic phase, and resolution phase. The four phases occur progressively with no sharp dividing line between any two phases. Specific body changes take place in sequence. The time, intensity, and duration for cyclic completion also vary for individuals and situations. Table 1 compares male and female body changes during each of the four phases of the sexual response cycle.
Table 1. Four Phases of Sexual Response
REACTIONS COMMONTO BOTH SEXES
Heart rate and blood pressure increase. Nipples become erect. Myotonia begins
Clitoris increases in diameter and swells. External genitals become congested and darken. Vaginal lubrication occurs; upper two thirds of vagina lengthen and extend. Cervix and uterus pull upward. Breast size increases.
Erection of penis begins; penis increases in length and diameter. Scrotal skin becomes congested and thickens.Testes begin to increase in size and elevate toward the body.
Heart rate and blood pressure continue to increase. Myotonia becomes pronounced; grimacing occurs
Clitoral head retracts under the clitoral hood. Lower one third of vagina becomes engorged. Skin color changes occur—red flush may be observed across breasts, abdomen, or other surfaces.
Head of penis may enlarge slightly. Scrotum continues to grow tense and thicken.Testes continue to elevate and enlarge. Preorgasmic emission of 2 or 3 drops of fluid appears on the head of the penis.
Heart rate, blood pressure, and respirations increase to maximum levels. Involuntary muscle spasms occur. External rectal sphincter contracts.
Strong rhythmic contractions are felt in the clitoris, vagina, and uterus. Sensations of warmth spread through the pelvic area.
Testes elevate to maximum level. Point of "inevitability" occurs just before ejaculation and awareness of fluid in the urethra. Rhythmic contractions occur in the penis. Ejaculation of semen occurs.
Heart rate, blood pressure, and respirations return to normal. Nipple erection subsides. Myotonia subsides.
Engorgement in external genitalia and vagina resolves. Uterus descends to normal position. Cervix dips into seminal pool. Breast size decreases. Skin flush disappears.
Fifty percent of erection is lost immediately with ejaculation; penis gradually returns to normal size. Testes and scrotum return to normal size. Refractory period (time needed for erection to occur again) varies according to age and general physical condition.
REASONS FOR ENTERING THE HEALTH CARE SYSTEM
Women's health assessment and screening focus on a systems evaluation beginning with a careful history and physical examination. During the assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness are emphasized. Nursing care includes assessment, planning, education, counseling, and referral as needed, as well as commendations of good self-care that the woman has practiced. This enables women to make informed decisions about their own health care.
Preconception health promotion provides women and their partners with information that is needed to make decisions about their reproductive future. Preconception counseling guides couples on how to prevent unintended pregnancies, stresses risk management, and identifies healthy behaviors that promote the well-being of the woman and her potential fetus. Some couples are simply desirous of information pertaining to normal physiology or the timing of coitus to achieve pregnancy or to have myths or beliefs confirmed or denied.
The initiation of activities that promote healthy mothers and babies must occur before the period of critical fetal organ development, which is between 17 and 56 days after fertilization. By the end of the eighth week after conception and certainly by the end of the first trimester, any major structural anomalies in the fetus are already present. Because many women do not realize that they are pregnant and do not seek prenatal care until well into the first trimester, the rapidly growing fetus may be exposed to many types of intrauterine environmental hazards during this most vulnerable developmental phase. Thus preconception health care should occur well in advance of an actual pregnancy.
Preconception care is important for women who have had a problem with a previous pregnancy (e.g., miscarriage, preterm birth). Although causes are not always identifiable, in many cases, problems can be identified and treated and may not recur in subsequent pregnancies. Preconception care is also important to minimize fetal malformations. There are many examples illustrating effects of maternal age or illnesses; conditions that produce anomalies in the fetus (teratogenic agents), such as drugs, viruses, chemicals, or genetically inherited diseases; or conditions that might be harmful to the woman should a pregnancy occur. In many instances, counseling can allow for behavior modification before damage is done or a woman can make an informed decision about her willingness to accept potential hazards. The components of preconception care, such as health promotion, risk assessment, and interventions, are outlined in Box 1.
BOX 1 Components of Preconception Care
HEALTH PROMOTION: GENERAL TEACHING
Healthy diet, including folic acid Optimal weight
Exercise and resAvoidance of substance abuse (tobacco, alcohol, "recreational" drugs)
Use of safer sex practices
Attending to family and social needs
RISK FACTOR ASSESSMENT
Immune status (e.g., rubella, hepatitis B)
Family history (e.g., genetic disorders)
Illnesses (e.g., infections)
Current use of medication (prescription, nonprescription)
Obstetric Psychosocial history
Spouse/partner and family situation, including domestic violence
Availability of family or other support systems
Readiness for pregnancy (e.g., age, life goals, stress) Financial resources Environmental (home, workplace) conditions
Treatment of medical conditions and results
Cessation/reduction in substance use/abuse
Immunizations (e.g., rubella, tuberculosis, hepatitis) Nutrition, diet, and weight management Exercise
Referral for genetic counseling
Referral to and use of
Family planning services
Family and social needs management
A woman's entry into health care is often associated with pregnancy, either for diagnosis or for actual care. Suspicion of pregnancy occurs most commonly when a woman is late with her menses. It is highly desirous for a woman to enter prenatal care within the first 12 weeks of pregnancy. This allows for early pregnancy counseling, espedaily for the woman who has had no preconception care. Extensive discussion of pregnancy is found in Unit Three.
Current trends in the health care of women have expanded beyond a reproductive focus. A holistic approach to women's health care includes a woman's health needs throughout her lifetime. This view is one that goes beyond simply her reproductive needs. Women's health assessment and screening focus on a multisystem evaluation emphasizing the maintenance and enhancement of wellness (Allen & Phillips, 1997).
Fertility Control and Infertility
More than half of the pregnancies in the United States each year are unintended, and the majority of these occur in the 10% of women who do not use birth control. Education is the key to encouraging women to make family planning choices based on preference and actual benefit-to-risk ratios. Women who enter the health care system seeking contraceptive counseling can be assisted to use a chosen method correctly (Hatcher et al., 1998) (see Chapter 6 for further discussion).
Women also enter the health care system because of their desire to achieve a pregnancy. Approximately 15% of couples in the United States have some degree of infertility. Infertility can cause emotional pain for many couples, and the inability to produce an offspring sometimes results in feelings of failure and inordinate stress on the relationship. Steps toward prevention of infertility should be undertaken as part of ongoing routine health care, and such information is especially appropriate in preconception counseling. For additional information about infertility, see Chapter 6.
Irregularities or problems with the menstrual period are among the most common concerns of women and often cause them to seek help within the health care system. Common menstrual disorders include amenorrhea, dys-menorrhea, premenstrual syndrome, endometriosis, and menorrhagia or metrorrhagia. These problems are discussed in Chapter 5.
Menopause is preceded by a period known as the perimenopause, during which ovarian function declines. Ova slowly diminish, and menstrual cycles are anovulatory, resulting in irregular bleeding; the ovary stops producing estrogen, and eventually menses no longer occurs. The body responds to this natural transition in a number of ways, most of which are due to the decrease in estrogen. Although fertility is greatly reduced during this period, women are urged to maintain some method of birth control because pregnancies still can occur. Most women seeking health care at this time do so because of irregular bleeding that may accompany the perimenopause. Others are concerned about vasomotor symptoms (hot flashes and flushes). All women need to have factual information, the dispelling of myths, a thorough examination, and periodic health screenings thereafter.
BARRIERS TO SEEKING HEALTH CARE
In the United States disparity occurs among races and socioeconomic classes affecting many facets of life, including health. With limited money and awareness, there is a lack of access to care, delay in seeking care, few prevention activities, and little accurate information about health and the health care system. Women use health services more often than men but are more likely than men to have difficulty in financing them; 14% of women have no health insurance and 5 million more have coverage so inadequate that it does not even include maternity care (National Women's Law Center, 2000; Rosenfeld, 1997). Women make up the majority of Medicaid recipients; however, only 42% of poor women are eligible. Medicaid includes special benefits for pregnant women, but they are limited to treatment of pregnancy-related conditions and terminate 60 days after birth (Lemcke et al., 1995).
Caucasians of all ages are more likely than African-Americans and other racial or ethnic groups to have private insurance. Caucasians possess insurance 2.5 times more often than Hispanics and 1.8 times more often than African-Americans. Single, separated, or divorced individuals are less likely to have insurance. Often unmarried teenagers who are usually covered by their parent's medical insurance do not have maternity coverage because policies have inclusion statements for only the employee or spouse.
Although they are most significant, financial considerations are not the only barriers to obtaining quality health care. As our nation becomes more racially, ethnically, and culturally diverse, the health of minority groups becomes a major issue. Providers must consider culturally based differences that could affect the treatment of diverse groups of women, and the women themselves must discuss with their health care providers the practices and beliefs that could influence their management responses or willingness to comply. For example, women in some cultures value privacy to such an extent that they are reluctant to disrobe and as a result avoid physical examination unless absolutely necessary. Other women rely on their husbands to make major decisions, including those affecting the woman's health. Religious beliefs may dictate a plan of care as with birth control measures or blood transfusions. Some cultural groups prefer folk medicine, homeopathy, or prayer to traditional Western medicine, and yet others attempt combinations of some or all practices.
Gender influences provider-patient communication and may influence access to health care in general. The most obvious gender consideration is that between men and women. Researchers have reported significant male-female differences in receipt of major diagnostic and therapeutic interventions, especially with cardiac and kidney problems. Women tend to use primary care services more often (and, some believe, more effectively) than men. The sex of the provider plays a role because studies have shown that female patients have tests such as the Papanicolaou (Pap) smear and mammogram more consistently if they are seen by female providers.
Sexual orientation may produce another barrier. Lesbian women have primary erotic attractions and relations with other women. Some lesbians may not disclose their orientation to health care providers because they may be at risk for hostility, inadequate health care, or breach of confidentiality. To offset stereotypes, it is necessary for providers to develop an approach that does not assume that all patients are heterosexual (Roberts & Sorensen, 1995). Primary care of lesbians is not different from caring for any other group of women, and lesbian patients have the same basic physical and psychologic needs as any woman.
HEALTH RISKS IN THE CHILDBEARING YEARS
Maintaining optimal health is a goal for all women. Essential components of health maintenance are identification of unrecognized problems and potential risks and the education/promotion needed to reduce them. This is especially important for women in their childbearing years because conditions that increase a woman's health risks not only are of concern to her well-being but also are potentially associated with negative outcomes for both mother and baby in the event of a pregnancy. Prenatal care is the prime example of prevention that is practiced after conception. However, prevention and health maintenance are needed before pregnancy because many of the mother's risks can be identified and then eliminated or at least modified. An overview of conditions and circumstances that increase health risks in the childbearing years follows.
All teens undergo progressive growth of sexual characteristics and also undertake developmental tasks of adolescence, such as establishing identity, developing sexual preference, emancipating from family, and establishing career goals. Some of these situations can produce great stress for the adolescent, and the health care provider should treat her very carefully. Female teenagers who enter the health care system usually do so for screening (Pap smears start at age 18 or when sexually active) or because of a problem such as episodic illness or accidents. Gynecologic problems are often associated with menses (either bleeding irregularities or dysmenorrhea), vaginitis or leuk-orrhea, sexually transmitted infections (STIs), contraception, or pregnancy.
Young and middle adulthood
Because women ages 20 to 40 have need for contraception, pelvic and breast screening, and pregnancy care, they may prefer to use their gynecologic or obstetric provider also as their primary care provider. During these years, the woman may be "juggling" family, home, and career responsibilities with resulting increases in stress-related conditions. Health maintenance includes not only pelvic and breast screening but also promotion of a healthy lifestyle, that is, good nutrition, regular exercise, no smoking, moderate or no alcohol consumption, sufficient rest, stress reduction, and referral for medical conditions and other specific problems. Common conditions in well-woman care include vaginitis, urinary tract infections, menstrual variations, obesity, sexual and relationship issues, and pregnancy.
Late reproductive age
The woman older than 35 is at risk for age-related conditions that can affect pregnancy. For example, a woman with type 2 diabetes may not have had expression of her diabetes at age 22 but may have full-blown disease at age 38. Other chronic or debilitating diseases or conditions increase in severity with time and these, in turn, may predispose to increased risks during pregnancy. Of significance to women in this age group is the risk for having a baby with certain genetic anomalies (e.g., Down syndrome), and the opportunity for genetic counseling should be available to all (see Chapter 7).
Women of later reproductive age are often experiencing change and reordering personal priorities. Generally, the goals of education, career, marriage, and family have been achieved, and now the woman has increased time and opportunity for new interests and activities. Conversely, divorce rates are high at this age, and children leaving home may produce an "empty nest syndrome," resulting in levels of depression. Chronic diseases also become more apparent. Most problems for the well woman are associated with perimenopause (e.g., bleeding irregularities, vasomo-tor symptoms). Health maintenance screening continues to be of importance because some conditions such as breast disease or ovarian cancer occur more often during this stage.
Differences exist among people from different socioeco-nomic levels and ethnic groups with respect to risk for illness and distribution of disease and death. Some diseases are more common among people of selected ethnicity, for example, sickle cell anemia in African-Americans, Tay-
Sachs disease in Ashkenazi Jews, adult lactase deficiency in Chinese, beta thalassemia in Mediterranean peoples, and cystic fibrosis in northern Europeans. Cultural and religious influences also increase health risks because the woman and her family may have life and societal values and a view of health and illness that dictate practices different from those expected in the Judeo-Christian Western model. These may include food taboos or frequencies, methods of hygiene, effects of climate, care-seeking behaviors, willingness to undergo screening and diagnostic procedures, and value conflicts.
Socioeconomic contrasts result in major health differences as exemplified in birth outcomes. The rates of perinatal and maternal deaths, preterm births, and low-birth-weight babies are considerably higher in disadvantaged populations (Guyer et al., 2000). Social consequences for poor women as single parents are great because many mothers with few skills are caught in the bind of having insufficient income to afford child care. These families generate fewer and fewer resources and increase their risks for health problems. Multiple roles for women in general produce overload, conflict, and stress, resulting in higher risks for psychosocial health care (Cox, 1997).
Substance Use and Abuse
The inappropriate use of illicit and prescription drugs continues to increase and is found in all ages, races, ethnic groups, and socioeconomic strata. Addiction to substances is seen as a biopsychosocial disease with several factors leading to risk. These include biogenetic predisposition, lack of resilience to stressful life experiences, and poor social support (Jessup, 1997). Women are less likely than men to abuse drugs, but the rate in women is increasing significantly. Substance-abusing pregnant women create severe problems for themselves and their offspring, including interference with optimal growth and development and addiction. In many instances, the use of substances is identified through screening programs in prenatal clinics and obstetric units (Li et al., 1999).
Cigarette smoking is a major preventable cause of death and illness. Smoking is linked to cardiovascular heart disease, various types of cancers (especially lung and cervical), chronic lung disease, and negative pregnancy outcomes. Tobacco contains nicotine, which is an addictive substance that creates a physical and a psychologic dependence. Among adolescents and young adults, more women than men smoke (Grimes, 1998). Cigarette smoking impairs fertility in both women and men, may reduce the age for menopause, and increases the risk for osteoporosis after menopause. Passive, or secondhand, smoke contains similar hazards and presents additional problems for the smoker, as well as harm for the nonsmoker (Lee, 1998). Smoking in pregnancy is known to cause a decrease in placental perfu-sion and is a cause of low birth weight (ACOG, 1997a).
Women ages 35 to 49 have the highest rates of chronic alcoholism, but women ages 21 to 34 have the highest rates of specific alcohol-related problems (Jessup, 1997). Alcohol abuse during pregnancy has been associated with fetal growth restriction, altered facies, and developmental problems, specifically mental retardation (Lundsberg, Bracken, & Saftlas, 1997). Women who are problem drinkers are often depressed, have more motor vehicle injuries, and have a higher incidence of attempted suicide than women in the general population. Also, they are at particular risk for alcohol-related liver damage.
Caffeine is a stimulant that is found in society's most popular drinks: coffee, tea, and soft drinks. It is a stimulant that can affect mood and interrupt body functions by producing anxiety and sleep interruptions. Heart arrhythmias may be made worse by caffeine, and there can be interactions with certain medications such as lithium. Birth defects have not been related to caffeine consumption; however, high intake has been related to a slight decrease in birth weight (Hinds et al., 1996) and may also increase the risk of miscarriage (Cnattingius et al., 2000).
Psychotherapeutic drugs. Stimulants, sleeping pills, tranquilizers, and pain relievers are used by an estimated 2% of American women (Epps & Stewart, 1995). Such drugs can bring relief from undesirable conditions such as insomnia, anxiety, and pain, but because the drugs have mind-altering capacity, misuse can produce psychologic and physical dependency in the same manner as illicit drugs. Risk-to-benefit ratios should be considered when such drugs are used for more than very short periods of time. All of these categories of drugs have some effect on the fetus when taken during pregnancy and should be monitored very carefully.
Psychotropic drugs. Depression is the most common mental health problem in women. Everyone has a case of the "blues" periodically, but true depression impairs the ability to live a normal life and involves symptoms of pervasive sadness, isolation, fatigue, changes in eating and sleeping patterns, and general negativity. Severely depressed people are at risk for suicide. Drugs used to treat depression include tricyclic antidepressants (see Chapter 25).
Cocaine is a powerful central nervous system stimulant that is addictive because of the tremendous sense of pleasure or feeling good that it creates. It can be snorted, smoked, or injected. Cocaine affects all of the major body systems. Among other complications, it produces cardiovascular stress that can lead to heart attack or stroke, liver disease, central nervous system stimulation that can cause seizures, and even perforation of the nasal septum. Users are often poorly nourished and commonly have STIs. If the user is pregnant, there is an increased incidence of miscarriage, preterm labor, small-for-dates babies, abruption of placenta, and stillbirth. Anomalies have also been reported (Mills, 1999; Woods, 1998).
Heroin is an opiate that is usually injected but can be smoked or snorted. It produces euphoria, relaxation, relief from pain, and "nodding out" (apathy, detachment from reality, impaired judgment, and drowsiness). Signs and symptoms are constricted pupils, nausea, constipation, slurred speech, and respiratory depression (Stuart & Lararia, 1998). Users are at increased risk for acquiring human immunodeficiency virus (HIV) and hepatitis B, C, and D viruses, primarily because of sharing needles that contain contaminated blood. Perinatal effects include interference with fetal growth, premature rupture of membranes, preterm labor, and prematurity.
Marijuana is a substance derived from the cannabis plant. It is usually rolled into cigarettes and smoked, but it may also be mixed into food and eaten. It produces an intoxicating and sensory-distorting high. Marijuana smoke has the same characteristics as tobacco smoke (Lee, 1998): both readily cross the placenta and have the effect of increasing carbon monoxide levels in the mother's blood, which reduces the oxygen supply to the fetus.
Other illicit drugs
A number of other street drugs pose risk to users. Variations of stimulants, such as speed, meth, and ice, produce signs and symptoms similar to cocaine. Sedatives such as downers, yellow jackets, or red devils are used to come off of "highs." Hallucinogens alter perception and body function. Phencyclidine hydrochloride (PCP; angel dust) and lysergic acid diethylamide (LSD) produce vivid changes in sensation, often with agitation, euphoria, paranoia, and a tendency toward antisocial behavior. Their use may lead to flashbacks, chronic psychosis, and violent behavior (Woods, 1998).
Overt disease caused by lack of certain nutrients is rarely seen in the United States. However, insufficient amounts or imbalances of nutrients do pose problems for individuals and families. Overweight or underweight status, list-lessness, fatigue, frequent colds and other minor infections, constipation, dull hair and nails, and dental caries are examples of problems that could be nutritionally related and indicate the need for an in-depth nutritional assessment. Poor nutrition, especially related to obesity and high fat/cholesterol intake, may lead to more serious conditions and is said to contribute to 6 of the 10 leading causes of death in the United States: heart disease, cancer, stroke and hypertension, arteriosclerosis, cirrhosis of the liver, and diabetes (Lean et al., 1999). Other dietary extremes can also produce risk. For example, insufficient amounts of calcium can lead to osteoporosis, too much sodium contributes to hypertension, and megadoses of vitamins can create adverse effects in several body systems.
Some women have a distorted view of their bodies and, no matter what their weight, perceive themselves to be much too heavy. As a result, they undertake strict and severe diets and rigorous extreme exercise. This chronic and rarest of eating disorders is known as anorexia nervosa. A coexisting depression usually accompanies anorexia. Women can carry this condition to the point of starvation, with resulting endocrine and metabolic abnormalities. If not corrected, significant complications of arrhythmias, cardiomyopathy, and congestive heart failure occur and, in the extreme, can lead to death. The condition commonly begins during adolescence in young women who have some degree of personality disorder. They gradually lose weight over several months, have amenorrhea, and are abnormally concerned with body image. The condition requires both psychiatric and medical interventions.
Bulimia refers to secret, uncontrolled binge eating alternating with methods to prevent weight gain: self-induced vomiting, taking laxatives or diuretics, strict diets, fasting, and rigorous exercise. Bulimia usually begins in early adulthood (ages 18 to 25) and is found primarily in females. Complications can include dehydration and electrolyte imbalance, gastrointestinal abnormalities, dental problems, and cardiac arrhythmias.
Physical Fitness and Exercise
Exercise contributes to good health by lowering risks for a variety of conditions that are influenced by obesity and a sedentary lifestyle. It is effective in the prevention of cardiovascular disease and in the management of chronic conditions such as hypertension, arthritis, diabetes, respiratory disorders, and osteoporosis. Exercise also contributes to stress reduction and weight maintenance. Women report that engaging in regular exercise improves their body image and self-esteem and acts as a mood enhancer. Aerobic exercise produces cardiovascular involvement because increasing amounts of oxygen are delivered to working muscles. Anaerobic exercise, such as weight training, improves individual muscle mass without stress on the cardiovascular system. Because women are concerned about both cardiovascular and bone health, weight-bearing aerobic exercises such as walking, running, racket sports, and dancing are preferred. Excessive or strenuous exercise can lead to hormonal imbalances, resulting in amenorrhea and its consequences. Physical injury is also a potential risk.
The modern woman faces increasing levels of stress and as a result is prone to a variety of stress-induced complaints and illnesses. Stress often occurs because of multiple roles in which coping with job and financial responsibilities conflict with parenting and home. To add to this burden, women are socialized to be caretakers, which is emotionally draining by itself. Also, they find themselves in positions of minimal power that do not allow them to have control over their everyday environments (Epps & Stewart, 1995). Some stress is normal and, in fact, contributes to positive outcomes. Many women thrive in busy surroundings. However, excessive or high levels of ongoing stress trigger physical reactions in the body, such as rapid heart rate, elevated blood pressure, slowed digestion, release of additional neurotransmitters and hormones, muscle tenseness, and weakened immune system. Consequently, constant stress can contribute to clinical illnesses such as flare-ups of arthritis or asthma, frequent colds or infections, gastrointestinal upsets, cardiovascular problems, and infertility. Psychologic signs such as anxiety, irritability, eating disorders, depression, insomnia and substance abuse also have been associated with stress.
Potential risks related to sexual activity are undesired pregnancy and STIs. The risks are particularly high for adolescents and young adults who engage in sexual intercourse at earlier and earlier ages. Adolescents report many reasons for wanting to be sexually active, among which are peer pressure, to love and be loved, experimentation, to enhance self-esteem, and to have fun (Murray & Zentner, 1997). However, many teens do not have the decision-making or values-clarification skills needed to take this important step at a young age and are also lacking the knowledge base regarding contraception and STIs. They also do not believe that becoming pregnant or getting an STI will happen to them.
Although some STIs can be cured with antibiotics, many can cause significant problems. Possible sequelae include infertility, ectopic pregnancy, neonatal morbidity and mortality, genital cancers, acquired immunodeficiency syndrome, and even death (Hatcher et al., 1998). No method of contraception offers complete protection.
Most women of reproductive age are relatively healthy. However, certain medical conditions present during pregnancy can have deleterious effects on both mother and fetus. Of particular concern are risks from all forms of diabetes, urinary tract disorders, thyroid disease, hypertensive disorders of pregnancy, cardiac disease, and seizure disorders. Effects on the fetus vary and include intrauterine growth restriction, macrosomia, anemia, prematurity, immaturity, and stillbirth. Effects on the mother can also be severe. See Chapters 22 and 23 for information on specific conditions.
Gynecologic Conditions Affecting Pregnancy
Gynecologic conditions may contribute negatively to pregnancy by causing infertility, miscarriage, preterm labor, and fetal and neonatal problems. Most of these conditions are discussed in Chapter 5 and include pelvic inflammatory disease, endometriosis, STIs and other vaginal infections, uterine fibroids, and uterine deformities such as bicornuate uterus. Gynecologic cancers also affect women's health. Risk factors depend on the type of cancer.
Risks for cervical cancer include early age of first sexual intercourse, cigarette smoking, HIV infection, human pa-pillomavirus (HPV) infection and possible other STIs, and multiple sexual partners. In the United States, African-American women have the highest rate of invasive cancer of the cervix. Abnormal spotting or vaginal bleeding is the primary symptom (ACS, 2001).
The most common malignancy of the reproductive system is endometrial cancer. Estrogen-related exposures such as nulliparity, unopposed estrogen therapy, infertility, and early or late menopause are the most significant risk factors. Other risk factors include obesity, hypertension, diabetes, gallbladder disease, and family history of breast or ovarian cancer. Use of birth control pills and pregnancy appear to provide some protection against endometrial cancer. It occurs most frequently in Caucasian women and after menopause. Abnormal uterine bleeding is the cardinal sign (ACS, 2001).
Ovarian cancer is the most malignant of all gynecologic cancers, accounting for the most deaths from these cancers. Risk factors include family history of ovarian or breast cancer and having no children or having them late in life (ACS, 2001).
Other gynecologic cancers
Cancer of the vulva, vagina, and uterine tubes accounts for less than 6% of all female reproductive cancers. Cancers of the vulva and vagina have been linked to HPV and herpes simplex virus, but the cause of uterine tube cancer is unknown. These cancers occur most often in post-menopausal women. Lesions are often the first sign of vul-var cancer. Women with vaginal or uterine tube cancer may be asymptomatic or have vaginal bleeding (DiSaia & Creasman, 1997).
Lung cancer is the leading cause of cancer deaths in women. Cigarette smoking is the most important risk factor. Other risks include exposure to certain industrial substances, organic chemicals (e.g., radon, asbestos), and radiation exposure. Symptoms include a persistent cough, blood-tinged sputum, chest pain, and recurring pneumonia or bronchitis (ACS, 2001). Survival rates are low because most cancers are not detected while they are still localized.
Cancer of the breast is the second leading cause of cancer deaths in women. Mortality rates since 1991 have declined, probably as a result of earlier detection and improved treatment (ACS, 2001). Risk factors include family history, early menarche, late menopause, nulliparity or having children later in life, and possibly postmenopausal use of estrogen. The incidence is highest in Caucasian and lowest among Native American women. The earliest sign is having an abnormality that shows up on a mammogram before it can be detected by the woman or a clinician (ACS, 2001). (See further discussion in Chapter 5.)
Colon cancer is the third most common cancer in women. Risk factors include a personal or family history of colorectal cancer or polyps; inflammatory bowel disease; and a high-fat, low-fiber diet. The incidence is highest in African-American women. Signs include rectal bleeding, blood in the stool, and a change in bowel habits (ACS, 2001).
Environmental and Workplace Hazards
Environmental hazards in the home, workplace, and community can contribute to poor health at all ages. Environmental hazards can affect fertility, fetal development, live birth, and the child's future mental and physical development. Everyone is at risk from air pollutants, such as tobacco smoke, carbon monoxide, smog, suspended particles (dust, ash, and asbestos), and cleaning solvents; noise pollution; pesticides; chemical additives; and poor preparation of food. Workers also face safety and health risks caused by ergonomically poor workstations and stress. It is important that risk assessments continue to be in effect to identify and understand environmental public health problems.
Violence Against Women
Violence against women is a major health care problem in the United States, affecting 2 to 4 million women each year and costing millions of dollars in annual medical costs. Women of all races and of all ethnic, educational, religious, and socioeconomic backgrounds are affected. The magnitude of the problem is far greater than the statistics indicate, because violent crimes against women are under-reported as a result of fear, lack of understanding, and stigma surrounding violent situations (Stringham, 1999).
Maternity and women's health nurses, by the very nature of their practice, are in a unique position to conduct case finding, provide sensitive care to women experiencing abusive situations, engage in prevention activities, and influence health care and public policy toward decreasing the violence.
Wife battering, spouse or intimate partner abuse, and domestic violence ox family violence are all terms applied to a pattern of assaultive and coercive behaviors that includes physical, sexual, and psychologic attacks, as well as economic coercion inflicted by a male partner in a marriage or other heterosexual, significant, intimate relationship. The terms domestic violence and intimate partner abuse connote that abuse can occur by either partner against the other and do not address that women are the victims of abuse at a rate much greater than men are victimized.
Relationship violence rarely consists of a single episode, but rather is a pattern that may start with intimidation or threats and progress to more aggressive physical and sexual acts, resulting in injury to the woman. Common elements of battering are economic deprivation, sexual abuse, intimidation, isolation, and stalking and terrorizing victims and their children. Pregnancy is often a time when violence begins or escalates.
Characteristics of women in battering relationships. Every segment of society is represented among abused women; race, religion, social background, age, and educational level are not significant factors in differentiating women at risk. Battered women may believe they are to blame for their situations because they are "not good enough wives." Many women have low self-esteem and may have histories of domestic violence in their families of origin. Social isolation seems to be another characteristic of battered women, which may result from stigma, fear, or restrictions placed on them by their partners.
Cycle of violence: the dynamics of battering. According to the cycle of violence concept, battering is neither random nor constant; rather, it occurs in repeated cycles (Fig. 8). A three-phase cyclic pattern to the battering behavior has been described as a period of increasing tension leading to the battery, which is then followed by a period of calm and remorse in which the male partner displays kind, loving behavior and pleas for forgiveness. This "honeymoon" phase lasts until stress or other factors cause conflict and tension to mount again toward another episode of battering. Over time, the tension and battering phases last longer and the calm phase becomes shorter until there is no honeymoon phase (Walker, 1984).
Sexual abuse and rape
Female sexual abuse and assault victims appear to be the largest single group to experience posttraumatic stress disorder (PTSD) (Silva et al., 1997). It is estimated that 27% of women have experienced childhood sexual abuse (Heritage, 1998). Common psychopathologic consequences are dissociative identity disorder, borderline personality disorder, and generalized anxiety disorder. Al-Calm stage (this stage may decrease over though patients with these diagnoses may come to the attention of maternity nurses, women who experience symptoms of PTSD, sexual dysfunctions, depression, anxiety, or substance abuse problems are more likely to be seen in obstetric and gynecologic practice.
Fig. 8 Cycle of violence. (From Helton, A. . A protocol ofcare for the battered woman. White Plains, NY: March of Dimes Birth Defects Foundation.)
Rape is an act of violence rather than a sexual act. Rape is a legal and not a medical entity and in its strictest sense is the penile penetration of the female sex organ or labia without her consent. Sexual assault, a term used interchangeably with rape, is also an act of force and has a much broader definition to include unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual acts. States may also use different legal definitions of rape.
Hymenal penetration or ejaculation does not have to occur to qualify as rape. The key feature to establish rape is the absence of consent: threat or coercion implies the lack of consent. The victim who is mentally retarded, who is unconscious or otherwise physically unable to move, who has taken drugs or who has been drugged without her knowledge, or who is a minor (statutory rape) is not capable of giving consent. The court must prove absence of consent; thus the term alleged rape ox alleged sexual assault is used in medical records.
Medical considerations for the rape victim include treatment of physical injuries, prophylactic treatment for STIs, and prophylaxis for pregnancy (emergency contraception). Emergency departments and ambulatory care facilities usually follow protocols for examination, collection of evidence and photographing injuries, treatment, and providing information on community resources for victims of violence.
Fig. 4-9 Nurse interviews patient as part of annual physical examination. (From Potter, R, & Perry, A. . Fundamentals of nursing: Concepts, process, and practice [5th ed.]. St. Louis: Mosby.)
At a woman's first visit, she is often expected to fill out a form with biographic and historical data before meeting with the examiner. The nurse is usually responsible for ensuring that the woman's name, age, marital status, race, ethnicity, address, phone numbers, occupation, and date of visit are recorded. The interview should be conducted in a private, comfortable, and relaxed setting and in an unhurried manner (Fig. 9). The nurse is seated and makes sure the woman is comfortable. The woman is addressed by her title and name (e.g., Mrs. Miller), and the nurse introduces herself or himself using name and title. It is important to phrase questions in a sensitive and nonjudg-mental manner. The woman's culture should be considered in case modifications in the examinations should be needed. For example, a female examiner may be preferred or it may be inappropriate for the woman to disrobe completely for an examination. The nurse is cognizant of a woman's vulnerability and assures her of strict confidentiality. Many women are uninformed, misguided by myths, or afraid they will appear ignorant by asking questions about sexual or reproductive functioning. The woman is assured that no question is irrelevant. The history begins with an open-ended question such as, "What brings you in to the office/clinic/hospital today? Anything else? Tell me about it."
Women with Special Needs
Women with Disabilities
Women with emotional or physical disorders have special needs. Women who are visually, auditorily, emotionally, or physically disabled should be respected and involved in the assessment and physical examination to the full extent of their abilities. The assessment and physical examination can be adapted to each woman's individual needs.
Communication with a woman who is hearing impaired can be accomplished without difficulty. Most of these women read lips, write, or both; thus an interviewer who speaks and enunciates each word slowly and in full view may be easily understood. If a woman is not comfortable with lip reading, she may use an interpreter. The visually impaired woman needs to be oriented to the examination room and may have her guide dog with her. As with all patients, the visually impaired woman needs a full explanation of what the examination entails before proceeding. For example, before touching the woman, the nurse explains, "Now I am going to place a cuff on your right arm to take your blood pressure." The woman can be asked if she would like to touch each of the items that will be used in the examination to reduce her anxiety.
Many physically disabled women cannot comfortably lie in the lithotomy position for the pelvic examination. Several alternative positions may be used, including a lateral (side-lying) position, a V-shaped position, a diamond-shaped position, and an M-shaped position (Fig. 10). The woman can be asked what has worked best for her previously. If she has not had a pelvic or a comfortable examination in the past, the nurse proceeds slowly by showing her a picture of various positions and asking her which one she prefers. The nurse's support and reassurance can help the woman to relax, which will make the examination go more smoothly.
Fig. 10 Lithotomy and variable positions for women who have a disability. A, Lithotomy position. B# M-shaped position. C, Side-lying position. D, Diamond-shaped position. E, V-shaped position.
Nurses should screen all women entering the health care system for potential abuse. It is important to keep in mind the possibility that violence against this woman may have occurred. Help for the woman may depend on the sensitivity with which the nurse screens for abuse, the discovery of abuse, and subsequent intervention. The nurse must be familiar with the laws governing abuse in the state in which she or he practices.
Pocket cards listing emergency numbers (abuse counseling, legal protection, and emergency shelter) may be available by calling the local police department or women's shelter or going to an emergency department or 24-hour clinic. It is helpful to have these on hand in the setting where screening is done. An abuse assessment screen can be used as part of the interview or written history (Fig. 11). If a male partner is present, he should be asked to leave the room because the woman may not disclose experiences of abuse in his presence, or he may try to answer questions for her to protect himself.
ABUSE ASSESSMENT SCREEN
1. Have you ever been emotionally or physically abused by your partner or someone important to you?
YES □ NO □
2. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
YES □ NO □
If YES, by whom _________
Number of times _________
Mark the area of injury on body map.
3. Within the last year, has anyone forced you to have sexual activities?
YES □ NO □
If YES, who _________
Number of times _______
4. Are you afraid of your partner or anyone you listed above?
YES □ NO □
Fig. 11 Abuse assessment screen. (Modified from the Nursing Research Consortium on Violence and Abuse, 1991.)
Fear, guilt, and embarrassment may keep many women from giving information about family violence. Clues in the history and evidence of injuries on physical examination should give a high index of suspicion. The areas most commonly injured in women are the head, neck, chest, abdomen, breasts, and upper extremities. Burns and bruises in patterns resembling hands, belts, cords, or other weapons and multiple traumatic injuries may be seen.
As a young woman matures, she should be asked the same questions that are included in any history. Particular attention should be paid to hints about risky behaviors, eating disorders, and depression. Do not assume that a teenager is not sexually active. After rapport has been established it is best to talk to a teen with the parent (partners or friend) out of the room. Questions should be asked with sensitivity and in a gentle and nonjudgmental manner (Seidel et al., 1999).
A medical history usually includes the following:
1. Identifying data. Name, age, race, living household preference, occupation, religion, culture, and ethnicity are obtained.
2. Chief complaint(s). A verbatim response to the question, "What problem or symptom brought you here today?"
3. History of present illness. A chronologic narrative that includes onset of the problem, the setting in which it developed, its manifestations, and any treatments received are noted. The woman's state of health before the onset of the present problem is determined. If the problem is long standing, the reason for seeking attention at this time is elicited. The principal symptoms should be described as to the following:
• Quantity or severity
• Timing (onset, duration, frequency)
• Factors that aggravate or relieve
• Associated manifestations
4. Past medical history. Determine general state of health and strength:
• Infectious diseases: measles, mumps, rubella, whooping cough, chicken pox, rheumatic fever, scarlet fever, diphtheria, polio, tuberculosis (TB), hepatitis
• Chronic disease and system disorders: arthritis, cancer, diabetes, heart, lung, kidney, seizures, stroke, or ulcers
• Adult injuries, accidents, illnesses, disabilities, hospitalizations, or blood transfusions
5. Present health status.
• Allergies: medications, previous transfusion reactions, or environmental allergies
• Immunizations: diphtheria, pertussis, tetanus, polio; measles, mumps, rubella (MMR); hepatitis B, varicella, influenza, and pneumococcal vaccine; last TB skin test
• Screening tests: Pap smear, mammogram, stool for occult blood, sigmoidoscopy/colonoscopy, chest x-ray study, hematocrit, hemoglobin, rubella titer, urinalysis and cholesterol test; blood type/Rh; last eye examination; last dental examination
• Environmental/chemical hazards: home, school, work, and leisure setting; exposure to extreme heat/cold, noise, industrial toxins such as asbestos or lead, pesticides, diethylstilbestrol (DES), radiation exposure, cat feces, or cigarette smoke
• Use of safety measures: seat belts, bicycle helmets, designated driver
• Exercise and leisure activities: regular
• Sleep patterns: length and quality
• Sexuality: Is she sexually active? With men, women, or both?
• Diet, including beverages: 24-hour dietary recall
• Medications: name, dose, frequency, duration, reason for taking, and compliance with prescription medications; home remedies, over-the-counter drugs, vitamin and mineral supplements used over a 24-hour period; herbal therapies
• Nicotine, alcohol, illicit or recreational drugs: type, amount, frequency, duration, and reactions
• Caffeine: coffee, tea, cola, or chocolate intake
6. Past surgical history. Type, date, reason, outcome, and any complications should be noted.
7. Family history. Information about age and health of family members may be presented in narrative or genogram: age, health/death of parents, siblings, spouse, children. Check for history of diabetes, heart disease, hypertension, stroke, respiratory, renal, thyroid, cancer, bleeding disorders, hepatitis, allergies, asthma, arthritis, TB, epilepsy, mental illness, HIV, or other disorders.
8. Social history. Note birthplace, education, employment, marital status, living accommodations, children, persons at home, and hobbies. Does she enjoy what she is doing?
• Screen for abuse: Has she ever been hit, kicked, slapped or forced to have sex against her wishes? Verbally or emotionally abused? History of childhood sexual abuse? If yes, has she received counseling or does she need referral?
9. Review of systems. It is probable that all questions in each system will not be included every time a history is taken. Some questions regarding each system should be included in every history. The essential areas to be explored are listed in the following head-to-toe sequence. If a woman gives a positive response to a question about an essential area, more detailed questions should be asked.
• General: weight change, fatigue, weakness, fever, chills, or night sweats
• Skin: skin, hair and nail changes, itching, bruising, bleeding, rashes, sores, lumps, or moles
• Lymph nodes: enlargement, inflammation, pain, suppuration (pus), or drainage
• Head, eyes, ears, nose, and throat (HEENT): headtrauma, vertigo (dizziness), convulsive disorder, syncope (fainting), headache location, frequency, pain type, nausea/vomiting, or visual symptoms; eyesglasses, contact lenses, blurriness, tearing, itching, photophobia, diplopia, inflammation, trauma, cataracts, glaucoma, or acute visual loss; ears—hearing loss, tinnitus (ringing), vertigo, discharge, pain, fullness, recurrent infections, or mastoiditis; nose/sinuses—trauma, rhinitis, nasal discharge, epistaxis, obstruction, sneezing, itching, allergy, or smelling impairment; mouth/throat/neck—hoarseness, voice changes, soreness, ulcers, bleeding gums, goiter, swelling, or enlarged nodes
• Breasts: masses, pain, lumps, dimpling, nipple discharge, fibrocystic changes or implants; BSE practice
• Respiratory: shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, pleurisy, asthma, bronchitis, emphysema, or TB; last chest x-ray film
• Cardiac: hypertension, rheumatic fever, murmurs, angina, palpitations, dyspnea, tachycardia, orthopnea, edema, chest pain, cough, cyanosis, cold extremities, ascites, intermittent claudication (calf pain), phlebitis, or skin color changes
• Gastrointestinal (GI): appetite, nausea, vomiting, indigestion, dysphagia, abdominal pain, ulcers, hematochezia (bleeding with stools), melena (black, tarry stools), bowel habit changes, diarrhea, constipation, bowel movement frequency, food intolerance, hemorrhoids, jaundice, or hepatitis; sigmoidoscopy, colonoscopy, barium enema, or ultrasound
• Genitourinary (GU): frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infection, or urethral discharge; dysmenorrhea, intermenstrual bleeding, dyspareunia, discharge, sores, itching, STIs, gravidity (G), parity (P), problems in pregnancy, contraception, menopause, hot flashes, or sweats (may be included here or as part of endocrine)
• Vascular: leg edema, claudication, varicose veins, thromboses, or emboli
• Endocrine: heat/cold intolerance, dry skin, excessive sweating, polyuria, polydipsia, polyphagia, thyroid problems, diabetes, or secondary sex characteristic changes; age at menarche, length/flow of menses, last menstrual period (LMP), age at menopause, libido, or sexual concerns
• Hematologic: anemia, easy bruising, bleeding, petechiae, purpura, or transfusions
• Musculoskeletal: muscle weakness, pain, joint stiffness, scoliosis, lordosis, kyphosis, range-of-motion instability, redness, swelling, arthritis, or gout
• Neurologic: loss of sensation, numbness, tingling, tremors, weakness, vertigo, paralysis, fainting, twitching, blackouts, seizures, convulsions, loss of consciousness or memory
• Psychiatric: moodiness, depression, anxiety, obsessions, delusions, illusions, or hallucinations
Objective data are recorded by system or location. A general statement of overall health status is a good way to start. Findings are described in detail.
• General appearance: age, race, sex, state of health, stature, development, dress, hygiene, affect, alertness, orientation, cooperativeness, and communication skills
• Vital signs: temperature, pulse, respiration, blood pressure
• Height and weight
• Skin: color; integrity; texture; hydration; temperature; edema; excessive perspiration; unusual odor; presence and description of lesions; hair texture and distribution; nail configuration; color, texture, condition, or presence of nail clubbing
• Head: size, shape, trauma, masses, scars, rashes or scaling; facial symmetry; presence of edema or puffmess
• Eyes: pupil size, shape, reactivity, conjunctival injection, scleral icterus, fundal papilledema, hemorrhage, lids, extraocular movements, visual fields and acuity
• Ears: shape/symmetry, tenderness, discharge, external anal, and tympanic membranes; hearing: Weber should be midline (loudness of sound equal in both ears) and Rinne negative (no conductive or sensorineural hearing loss); should be able to hear whisper at 3 feet
• Nose: symmetry, tenderness, discharge, mucosa, turbinate inflammation, frontal/maxillary sinus tenderness; discrimination of odors
• Mouth, throat: hygiene, condition of teeth, dentures, appearance of lips, tongue buccal and oral mucosa, erythema, edema, exudate, tonsillar enlargement, palate, uvula, gag reflex, or ulcers
• Neck: mobility, masses, range of motion, trachea deviation, thyroid size, carotid bruits
• Lymphatic: cervical, intraclavicular, axillary, trochlear, or inguinal adenopathy; size, shape, tenderness, and consistency
• Breasts: skin changes, dimpling, symmetry, scars, tenderness, discharge or masses; characteristics of nipples and areolae
• Heart: rate, rhythm, murmurs, rubs, gallops, clicks, heaves, or precordial movements
• Peripheral vascular: jugular vein distention, ruits, edema, swelling, vein distention, Homans' sign, or tenderness of extremities
• Lungs: chest symmetry with respirations, wheezes, crackles, rhonchi, vocal fremitus, whispered pectoriloquy, percussion, and diaphragmatic excursion; breath sounds equal and clear bilaterally
• Abdomen: shape, scars, bowel sounds, consistency, tenderness, rebound, masses, guarding, organomegaly, liver span, percussion (tympany, shifting, dullness), costovertebral angle tenderness
• Extremities: edema, ulceration, tenderness, varicosities, erythema, tremor, or deformity
• Genitourinary: external genitalia, perineum, vaginal mucosa, cervix, inflammation, tenderness, discharge, bleeding, ulcers, nodules, masses, internal vaginal support, bimanual, and rectovaginal; palpation of cervix, uterus, and adnexa
• Rectal: sphincter tone, masses, hemorrhoids, rectal wall contour, tenderness, and stool for occult blood
• Musculoskeletal: posture, symmetry of muscle mass, muscle atrophy, weakness, appearance of joints, tenderness or crepitus, joint range of motion, instability, redness, swelling, or spine deviation
• Neurologic: mental status, orientation, memory, mood, speech clarity and comprehension, cranial nerves II through XII, sensation, strength, deep tendon and superficial reflexes, gait, balance, and coordination with rapid alternating motions
Many women are intimidated by the gynecologic portion of the physical examination. The nurse in this instance can take an advocacy approach that supports a partnership relationship between the woman and the care provider (see Guidelines/Guias box). It is especially important to prepare the adolescent for her first speculum examination because she will develop perceptions that will remain with her for future examinations. What the examination entails should be discussed with the teen while she is dressed. Models or illustrations can be used to show exactly what will happen. All of the necessary equipment should be assembled so that there are no interruptions. Pediatric specula that are 1 to 1.5 cm wide can be inserted with minimal discomfort. If the teen is sexually active, a small adult speculum may be used.
The woman is assisted into the lithotomy position (see Fig. 10, A) for the pelvic examination. When she is in the lithotomy position, the woman's hips and knees are flexed with the buttocks at the edge of the table, and her feet are supported by heel or knee stirrups.
Some women prefer to keep their shoes or socks on, especially if the stirrups are not padded. Many women express feelings of vulnerability and strangeness when in the lithotomy position. During the procedure the nurse assists the woman with relaxation techniques.
One method of helping the woman relax is to have her place her hands on her chest at about the level of the diaphragm, breathe deeply and slowly (in through her nose and out through her O-shaped mouth), concentrate on the rhythm of breathing, and relax all body muscles with each exhalation (Barkauskas, Baumann, & Darling-Fisher, 2002). This breathing technique is particularly helpful for the adolescent or the woman whose introitus may be especially tight or for whom the experience may be new or may provoke tension. Some women relax when they are encouraged to become involved with the examination with a mirror placed so that they can view the area being examined. This type of participation helps with health teaching as well. Distraction is another technique that can be used effectively (e.g., placement of interesting pictures on the ceiling over the head of the table).
Many women find it distressing to attempt to converse in the lithotomy position. Most women appreciate an explanation of the procedure as it unfolds, as well as coaching for the type of sensations they may expect. Generally, however, women prefer not to have to respond to questions until they are again upright and at eye level with the examiner. Questioning during the procedure, especially if they cannot see their questioner's eyes, may make women tense.
The examiner sits at the foot of the table for the inspection of the external genitals and for the speculum examination. To facilitate open communication and to help the woman relax, the woman's head is raised on a pillow and the drape is arranged so that eye-to-eye contact can be maintained. In good lighting, external genitals are inspected for sexual maturity, clitoris, labia, and perineum. After childbirth or other trauma there may be healed scars.
The examiner proceeds with the examination using palpation and inspection. The examiner wears gloves for this portion of the assessment. Before touching the woman, the examiner explains what is going to be done and what the woman should expect to feel (e.g., pressure). The examiner may touch the woman in a less sensitive area such as the inner thigh to alert her that the genital examination is beginning. This gesture may put the woman more at ease. The labia are spread apart to expose the structures in the vestibule: urinary meatus, Skene glands, vaginal orifice, and Bartholin glands (Fig. 12). To assess the Skene glands, the examiner inserts one finger into the vagina and "milks" the area of the urethra. Any exudate from the urethra or the Skene glands is cultured. Masses and erythema of either structure are assessed further. Ordinarily the openings to the Skene glands are not visible; prominent openings may be seen if the glands are infected (e.g., with gonorrhea). During the examination, the examiner keeps in mind the data from the review of systems, such as history of burning on urination.
Fig. 4-12 External examination. Separation of the labia. (From Edge, V., & Miller, M. . Women's health care. St. Louis: Mosby.)
The vaginal orifice is examined. Hymenal tags are normal findings. With one finger still in the vagina, the examiner repositions the index finger near the posterior part of the orifice. With the thumb outside the posterior part of the labia majora, the examiner compresses the area of Bartholin glands located at the 8 o'clock and 4 o'clock positions and looks for swelling, discharge, and pain.
The support of the anterior and posterior vaginal wall is assessed. The examiner spreads the labia with the index and middle finger and asks the woman to strain down. Any bulge from the anterior wall (urethrocele or cystocele) or posterior wall (rectocele) is noted and compared with the history, such as difficulty to start the stream of urine or constipation.
The perineum (area between the vagina and anus) is assessed for scars from old lacerations or episiotomies, thinning, fistulas, masses, lesions, and inflammation. The anus is assessed for hemorrhoids, hemorrhoidal tags, and integrity of the anal sphincter. The anal area is also assessed for lesions, masses, abscesses, and tumors. If there is a history of STI, the examiner may want to obtain a culture specimen from the anal canal at this time. Throughout the genital examination, the examiner notes the odor. Odor may indicate infection or poor hygiene.
Vulvar self-examination. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination (VSE) and to teach this procedure. Because there has been a dramatic increase in cancerous and precancerous conditions of the vulva in recent years, a VSE should be performed as an integral part of preventive health care by all women who are sexually active or 18 years of age or older, monthly between menses or more frequently if there are symptoms or a history of serious vulvar disease. Most lesions, including malignancy, condyloma acuminatum (wartlike growth), and Bartholin cysts, can be seen or palpated and are easily treated if diagnosed early.
The examination can be performed by the practitioner and woman together, using a mirror. A simple diagram of the anatomy of the vulva can be given to the woman, with instructions to perform the examination herself that evening to reinforce what she has learned. She does the examination in a sitting position with adequate lighting, holding a mirror in one hand and using the other hand to expose the tissues surrounding the vaginal introitus. She then systematically examines the mons pubis, clitoris, urethra, labia majora, perineum, and perianal area and palpates the vulva, noting any changes in appearance of abnormalities, such as ulcers, lumps, warts, and changes in pigmentation.
A vaginal speculum consists of two blades and a handle and comes in a variety of types and styles. A vaginal speculum is used to view the vaginal vault and cervix (Fig. 13) (see Procedure box). It is gently placed into the vagina and inserted to the back of the vaginal vault. The blades are opened to reveal the cervix and are locked into the open position. The cervix is inspected for position and appearance of the os: color, lesions, bleeding, and discharge (Fig. 14). Cervical findings that are not within normal limits include ulcerations, masses, inflammation, and excessive protrusion into the vaginal vault. Anomalies, such as a cockscomb (a protrusion over the cervix that looks like a rooster's comb), a hooded or collared cervix (seen in DES daughters), or polyps are noted.
Procedure Assisting with Pelvic Examination
Wash hands. Assemble equipment (see Fig. 13).
Fig. 13 Equipment used for pelvic examination. (Courtesy Michael S. Clement, MD, Mesa, AZ.)
Ask woman to empty her bladder before the examination (obtain clean-catch urine specimen as needed).
Assist with relaxation techniques. Have the woman place her hands on her chest at about the level of the diaphragm, breathe deeply and slowly (in through her nose and out through an O-shaped mouth), concentrate on the rhythm of breathing, and relax all body muscles with each exhalation (Barkauskas et al., 2002).
Encourage the woman to become involved with the examination if she shows interest. For example, a mirror can be placed so that she can see the area being examined.
Assess for and treat signs of problems such as supine hypotension.
Warm the speculum in warm water if a prewarmed one is not available.
Instruct the woman to bear down when the speculum is being inserted.
Apply gloves and assist the examiner with collection of specimens for cytologic examination, such as a Pap test. After handling specimens, remove gloves and wash hands.
Lubricate the examiner's gloved fingers with water or water-soluble lubricant before bimanual examination.
Assist the woman at completion of the examination to a sitting position and then a standing position.
Provide tissues to wipe lubricant from perineum.
Provide privacy for the woman while she is dressing.
Fig. 14 Insertion of speculum for vaginal examination. A, Opening of the introitus. B, Oblique insertion of the speculum. C, Final insertion of the speculum. D, Opening of the speculum blades. (From Barkauskas, V., Baumann, L, & Darling-Fisher, C. . Health and physical assessment [3rd ed.]. St. Louis: Mosby.)
Collection of specimens. The collection of specimens for cytologic examination is an important part of the gynecologic examination. Infection can be diagnosed through examination of specimens collected during the pelvic examination. Possible infections include Candida albicans, Tri-chomonas vaginalis, bacterial vaginosis, hemolytic streptococci, Neisseria gonorrhoeae, Chlamydia trachomatis, and herpes simplex virus. Once the diagnoses have been made, treatment can be instituted. Carcinogenic conditions, potential or actual, can be determined by examination of cells from the cervix (Pap smear) collected during the pelvic examination (see Procedure box) (Fig. 4-15).
Fig. 15 Pap smear. A, Collecting cells from endocervix using a cytobrush. B, Obtaining cells from the transformation zone using a wooden spatula. (From Stenchever, M. et al. . Comprehensive gynecology [4th ed.]. St. Louis: Mosby.)
Procedure Papanicolau smear
In preparation, make sure the woman has not douched, used vaginal medications, or had sexual intercourse for at least 24 hours before the procedure. Reschedule the test if the woman is menstruating.
The woman is assisted into a lithotomy position. A speculum is inserted into the vagina.
Explain to the woman the purpose of the test and what sensations she will feel as the specimen is obtained (e.g., pressure but not pain).
The cytologic specimen is obtained before any digital examination of the vagina is made or endocervical bacte-riologic specimens are taken with cotton swabbing of the cervix.
The Pap smear is obtained by using an endocervical sampling device (Cytobrush, Cervex-Brush, papette, or broom) (see Fig. 15). If the two-sample method of obtaining cells is used, the cytobrush is inserted into the canal and rotated 90 to 180 degrees, followed by a gentle smear of the entire transformation zone using a spatula. Broom devices are inserted and rotated 360 degrees five times. They obtain endocervical and ectocervical samples at the same time. If the patient has had a hysterectomy, the vaginal cuff is sampled. Areas that appear abnormal on visualization will require colposcopy and biopsy. If using a one-slide technique, the spatula sample is smeared first.This is followed by applying the cytobrush sample (rolling the brush in the opposite direction from which it was obtained), which is less subject to drying artifact, and then the slide is sprayed with preservative within 5 seconds.
TheThinPrep PapTest is an improved method of preserving cells that reduces blood, mucus, and inflammation. The Pap specimen is obtained in the manner described above and the collection device (brush, spatula, or broom) is simply rinsed in a vial of preserving solution that is provided by the laboratory. The sealed vial with solution is sent off to the appropriate laboratory. A special processing device filters the contents and a thin layer of cervical cells is deposited on a slide, which is then examined microscopically. Initial reports state that specimen adequacy is improved by 50% and improved detection of low-grade and more severe lesions by 65%.
Label the slides with the woman's name and site. Include on the form to accompany the slides the woman's name, age, parity, and chief complaint or reason for taking the cytologic specimens.
Send specimens to the pathology laboratory promptly for staining, evaluation, and a written report, with special reference to abnormal elements, including cancer cells.
Advise the woman that repeat smears may be necessary if the specimen is not adequate.
Instruct the woman concerning routine checkups for cervical and vaginal cancer. The American Cancer Society advises that women older than 18 years of age and those younger than 18 who are sexually active have the test at least every 3 years, but only after they have had three negative Pap tests a year apart. A pelvic examination is recommended every 3 years from age 20 to 40 and every 1 to 3 years thereafter.
Record the examination date on the woman's record.
After the specimens are obtained, the vagina is viewed when the speculum is rotated. The speculum blades are unlocked and partially closed. As the speculum is withdrawn, it is rotated and the vaginal walls are inspected for color, lesions, rugae, fistulas, and bulging.
The examiner stands for this part of the examination. A small amount of lubricant is placed on the first and second fingers of the gloved hand for the internal examination. To prevent tissue trauma and contamination, the thumb is abducted and the ring and little fingers are flexed into the palm (Fig. 16).
Fig. 16 Bimanual palpation of the uterus
The vagina is palpated for distensibility, lesions, and tenderness. The cervix is examined for position, shape, consistency, motility, and lesions. The fornix around the cervix is palpated.
The other hand is placed on the abdomen halfway between the umbilicus and symphysis pubis and exerts pressure downward toward the pelvic hand. Upward pressure from the pelvic hand traps reproductive structures for assessment by palpation. The uterus is assessed for position, size, shape, consistency, regularity, motility, masses, and tenderness.
With the abdominal hand moving to the right lower quadrant and the fingers of the pelvic hand in the right lateral fornix, the adnexa is assessed for position, size, tenderness, and masses. The examination is repeated on the woman's left side.
Just before the intravaginal fingers are withdrawn, the woman is asked to tighten her vagina around the fingers as much as she can. If the muscle response is weak, the woman is assessed for her knowledge about Kegel exercises.
To prevent contamination of the rectum from organisms in the vagina (e.g., N. gonorrhoeoe) it is necessary to change gloves, add fresh lubricant, and then reinsert the index finger into the vagina and the middle finger into the rectum (Fig. 17). Insertion is facilitated if the woman strains down. The maneuvers of the abdominovaginal examination are repeated. The rectovaginal examination permits assessment of the rectovaginal septum, the posterior surface of the uterus, and the region behind the cervix and the adnexa. The vaginal finger is removed and folded into the palm, leaving the middle finger free to rotate 360 degrees. The rectum is palpated for rectal tenderness and masses.
After the rectal examination, the woman is assisted into a sitting position, given tissues or wipes to cleanse herself, and given privacy to dress. The woman often returns to the examiner's office for a discussion of findings, prescriptions for therapy, and counseling.
Fig. 17 Rectovaginal examination. (From Seidel, H. et al. . Mosby's guide to physical examination [4th ed.]. St. Louis: Mosby.)
Laboratory and Diagnostic Procedures
The following laboratory and diagnostic procedures are ordered at the discretion of the clinician: complete blood count or hemoglobin/hematocrit, total blood cholesterol, fasting plasma glucose, urinalysis for bacteria, syphilis serology (Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin test [RPR]) and other screening tests for STIs, mammogram, tuberculin skin test, hearing, electrocardiogram, chest x-ray film, fecal occult blood, and bone mineral density. HIV and drug screening may be offered or encouraged with informed consent, especially in high risk populations.
ANTICIPATORY GUIDANCE FOR HEALTH PROMOTION AND PREVENTION
Knowledge alone is not enough to bring about healthy behaviors. The woman must be convinced that she has some control over her life and that healthy life habits, including periodic health examinations, are a sound investment. She must believe in the efficacy of prevention, early detection, and therapy and in her ability to perform self-care practices, such as BSE. The model illustrated in Fig. 4-18 incorporates the major aspects to be included when counseling women.
To maintain good nutrition, women should be counseled to include recommended servings from the major food categories of the Food Guide Pyramid (see Fig. 10-4). Recommended servings from the food groups also provide for adequate vitamins, minerals, iron, and fiber. Fluid intake is not included in the Food Guide Pyramid, but individuals should be encouraged to drink at least four to six glasses of water every day in addition to other fluids such as juices. Coffee, tea, soft drinks, and alcoholic beverages should be used in moderation.
Most women do not recognize the importance of calcium to health, and their diets are insufficient in calcium. Women who are unlikely to get enough calcium in the diet may need calcium supplements in the form of calcium carbonate, which contains more elemental calcium than other preparations.
The diet can be assessed using a standard assessment form—a 24-hour recall is adequate and quick—and then food likes and dislikes, including cultural variations and typical food portions and dietary habits, should be discussed and incorporated into counseling.
Physical activity/exercise counseling for persons of all ages should be undertaken at schools, work sites, and primary care settings. The nurse should stress the importance of daily exercise throughout life for weight management and health promotion, suggesting exercises that are enjoyable to the individual (Figs. 19 and 20).
Fig. 19 Weight-bearing exercise may delay bone loss and increase bone mass. (Courtesy Jonas McCoy, Raleigh, NC.)
Fig. 20 Water aerobics improves cardiovascular function. (Courtesy Jonas McCoy, Raleigh, NC.)TEACHING GUIDELINES
Kegel exercises, or pelvic muscle exercises, were developed to strengthen the supportive pelvic floor muscles to control or reduce incontinent urine loss. These exercises are also beneficial during pregnancy and postpartum. They strengthen the muscles of the pelvic floor, providing support for the pelvic organs and control of the muscles surrounding the vagina and urethra.
The Association of Women's Health, Obstetric and Neonatal Nurses conducted a research utilization project focused on continence for women (Sampselle et al., 1997). Educational strategies for teaching women how to perform Kegel exercises that were compiled by nurse researchers involved in the project are described in the Teaching Guidelines box.
Teaching for self care
DESCRIPTION AND RATIONALE
Kegel exercise, or pelvic muscle exercise, is a technique used to strengthen the muscles that support the pelvic floor. This exercise involves regularly tightening (contracting) and relaxing the muscles that support the bladder and urethra. By strengthening these pelvic muscles, a woman can prevent or reduce accidental urine loss.
The woman needs to learn how to target the muscles for training and how to contract them correctly. One suggestion for teaching is to have the woman pretend she is trying to prevent the passage of intestinal gas. Have her use this tightening motion on the muscles around her vagina and the upper pelvis. She should feel these muscles drawing inward and upward. Other suggested techniques are to have the woman pretend she is trying to stop the flow of urine in midstream or to have her think about how her vagina is able to contract around and move up the length of the penis during intercourse.
The woman should avoid straining or bearing-down motions while performing the exercise. She should be taught how bearing down feels by having her take a breath, hold it, and push down with her abdominal muscles as though she were trying to have a bowel movement.Then the woman can be taught how to avoid straining down by exhaling gently and keeping her mouth open each time she contracts her pelvic muscles.
Each contraction should be as intense as possible without contracting the abdomen, thighs, or buttocks.
Contractions should be held for at least 10 seconds. The woman may have to start with as little as 2 seconds per contraction until her muscles get stronger.
woman should rest for 10 seconds or more between contractions so that the
muscles have time to recover and each contraction can be as strong as the
The woman should feel the pulling up over the three muscle layers so that the contraction reaches the highest level of her pelvis.
OTHER SUGGESTIONS FOR IMPLEMENTATION
At first the woman should set aside about 15 minutes a day to do the Kegel exercises.
The woman may want to put up reminders, such as notes on her bathroom mirror, her refrigerator, her TV, or on a calendar, to do the exercises.
Guidelines for practicing Kegel exercises suggest performing between 30 and 80 contractions a day; however, positive results can be achieved with only 30 a day.
The best position for learning how to do Kegel exercises is to lie supine with the knees bent. Another position to use is on the hands and knees. Once the woman learns the proper technique, she can perform the exercises in other positions such as standing or sitting.
Source: Sampselle, C. (2000). Behavioral interventions for urinary incontinence in women: Evidence for practice. J Midwifery Womens Health, 45(21,94-103; and Sampselle, C. et al. (1997). Continence for women: Evidence-based practice. J Obstet Gynecol Neonatal Nurs, 26(4), 375-385.
Because it is neither possible nor desirable to avoid all stress, women need to learn how to manage stress. The nurse should assess each woman for signs of stress, using therapeutic communication skills to determine risk factors and the woman's ability to function.
Some women must be referred for counseling or other mental health therapy. Women are twice as likely as men to suffer from depression, anxiety, or panic attacks (Japenga, 1998). Nurses need to be alert to the symptoms of serious mental disorders, such as depression and anxiety, and make referrals to mental health practitioners when necessary. Women experiencing major life changes, such as divorce and separation, bereavement, serious illness, and unemployment, also need special attention.
For many women the nurse is able to provide comfort, reassurance, and advice concerning helping resources, such as support groups. Many centers offer support groups to help women prevent or manage stress. The nurse can help them become more aware of the relationship between good nutrition, rest, relaxation, and exercise or diversion and their ability to deal with stress. In the case of role overload, determining what needs immediate attention and what can wait is important. Practical advice includes regular breaks, taking time for friends, developing interests outside of work or the home, setting realistic goals, and learning self-acceptance. Anticipatory guidance for developmental or expected situa-tional crises can help women plan strategies for dealing with potentially stressful events.
Role-playing, relaxation techniques, biofeedback, meditation, desensitization, imagery, assertiveness training, yoga, diet, exercise, and weight control are techniques nurses can include in their repertoire of helping skills. Insufficient time prevents one-on-one assistance in many situations, but the more nurses know about these resources, the better able they are to intervene, counsel, and direct women to appropriate resources. Careful follow-up of all women experiencing difficulty in dealing with stress is important.
Substance Use Cessation
All women at all ages will receive substantial and immediate benefits from smoking cessation. However, this is not easy, and most people stop several times before they accomplish their goal (Box 4-2). Many are never able to do so. Those who wish to stop smoking can be referred to a smoking cessation program where individualized methods can be implemented. At the very least, individuals should be guided to self-help materials available from the March of Dimes Birth Defects Foundation, American Lung Association, and American Cancer Society. During pregnancy, women seem to be highly motivated to stop or at least to limit smoking to 10 or fewer cigarettes per day. Insult to the fetus can be reduced or even avoided if this is done by the end of the first trimester.
Counseling women who appear to be drinking excessively or using drugs may include strategies to increase self-esteem and teaching new coping skills to resist and maintain resistance to alcohol abuse and drug use. Appropriate referrals should be made, with the health care provider arranging the contact and then following up to be sure that appointments are kept. General referral to sources of support should also be provided. National groups that provide information and support for those who are chemically dependent are listed in the Resources section at the end of the chapter. Many of these organizations have local branches or contacts that are listed in the telephone book.
BOX 2 Interventions for Smoking Cessation: The Four A's
• What was her age when she started smoking? How many cigarettes does she smoke a day? When was her last cigarette? Has she tried to quit? Does she want to quit?
• What are her reasons for not being able to quit before, or what made her start again? Does she have anyone who can help her? Does anyone else smoke at home? Does she have friends or family who have quit successfully?
• Give her information about the effects of smoking on pregnancy and her fetus, on her own future health, and on the members of her household.
• Provide support; give self-help materials. Encourage her to set a quit date. Refer to a smoking cessation program or provide information about nicotine replacement products (not recommended during pregnancy) if she is interested. Teach and encourage use of stress reduction activities. Provide for follow-up with a phone call, letter, or clinic visit.
Source: American College of Obstetricians and Gynecologists. (1997a). Smoking and women's health. ACOE Technical Bulletin no. 240. Washington, DC: ACOG.
Safer Sexual Practices
Prevention of STIs is predicated on the reduction of high risk behaviors by educating toward a behavioral change. Behaviors of concern include multiple and casual sexual partners and unsafe sexual practices. The abuse of alcohol and drugs is also a high risk behavior resulting in impaired judgment and thoughtless acts. Specific self-care measures for "safer sex" are described in Chapter 5.
In addition to the prevention of STIs, women of child-bearing years need information regarding contraception and family planning (see Chapter 6).
Health Screening Schedule
Periodic health screening includes history, physical examination, education, counseling, and selected diagnostic and laboratory tests. This regimen provides the basis for overall health promotion, prevention of illness, early diagnosis of problems, and referral for appropriate management. Such screening should be customized according to a woman's age and risk factors. In most instances, it is completed in health care offices, clinics, or hospitals; however, portions of the screening are now being carried out at events such as Community Health Fairs. An overview of health screening recommendations for women older than 18 years of age is found in Table 2.
Health Risk Prevention
Often, simple safety factors are forgotten or perceived not to be important; yet injuries continue to have a major impact on health status among all age groups. Being aware of hazards and implementing safety guidelines will reduce risks. The nurse should frequently reinforce commonsense concepts that will protect the individual, such as wearing seat belts at all times in a moving vehicle and protecting the skin from ultraviolet light via sunscreen and clothing.
TABLE 2 Health Screening Recommendations for Women 18+ Years of Age
Nurses can make a difference in stopping violence against women and preventing further injury. Educating women that abuse is a violation of their rights and facilitating their access to protective and legal services constitute a first step. Also, encouraging health care institutions to implement appropriate domestic violence screening programs is of great value (Gantt & Bickford, 1999). Other helpful measures for women to discourage their fall into abusive relationships are promoting assertiveness and self-defense courses; suggesting support and self-help groups that encourage positive self-regard, confidence, and empowerment; and recommending educational and skills development classes that will enhance independence or at least the ability to take care of oneself. Numerous national and local organizations provide information and assistance for women experiencing abusive situations. Nurses and victims may find these resources helpful. National resources and hotlines are listed at the end of this chapter. All nurses who work in women's health care should become familiar with local services and legal options.
Height and weight
Clinical breast examinationt
Oral cavity examination
Every visit, but at least every 2 years
Every visit, but at least every 2 years
Annually until age 70; recommended for any who has ever been sexually active
Initiated/taught at time of first pelvic examination; done monthly at end of menses
Every 1 to 3 years starting at age 30; annually over age 40
Annually over 18 with history of premenopausal breast cancer in first-degree relative
At least annually:
Family history of skin cancer or increased exposure to sunlight
Mouth lesion or exposure to tobacco or excessive alcohol
Fasting blood sugar
Tuberculin skin test
Every 5 years
More often per clinical judgment with potential for cardiac or lipid abnormalities
Initially, 3 years after becoming sexually active but no later than 21 years; yearly with convertational Pap test or every 2 years with liquid-based Pap test. After age 30 and after three normal test results in a row, every 2-3 years; after age 70 and no abnormal test results in 10 years, screening may be stopped
Annually over age 50t
Annually over age 40§
Every 1 to 2 years, ages 40 to 49 and annually thereafterll
Annually with family history of diabetes, gestational diabetes, or significantly
Annually with exposure to excessive noise
As needed with multiple sexual partners
Annually with exposure to persons withTB or in risk categories for close
contact with the disease
Measles, mumps, rubella
Booster is given every 10 years after primary series
Once if born after 1956 and no evidence of immunity
Primary series of three for all who are in risk categories
Annually after age 65 or in risk categories, such as chronic diseases, immunosuppression, renal dysfunction
From the United States Preventive Services Task Force (1996).
STI, Sexually transmitted infection; TB, tuberculosis.