ENDOMETRIOSIS

 Endometriosis is a chronic disease affecting between 7% and 10% of women of reproductive age, occurring more frequently in women
who have never had children (Casanova et al., 2019).
 Endometriosis consists of a benign lesion or lesions that contain endometrial tissue (similar to that lining the uterus) found in the pelvic
cavity outside the uterus.
 Extensive endometriosis may cause few symptoms, or an isolated lesion may produce severe symptoms.
 It is a major cause of chronic pelvic pain and infertility.

PATHOSIOLOGY

 Misplaced endometrial tissue responds to and depends on ovarian hormonal stimulation. During menstruation, this ectopic tissue bleeds,
mostly into areas having no outlet, which causes pain and adhesions. The lesions are typically small and puckered, with a
blue/brown/gray powderburn appearance and brown or blue-black appearance, indicating concealed bleeding.

 Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as a pseudocyst or
chocolate cyst. Adhesions, cysts, and scar tissue may result, causing pain and infertility (Casanova et al., 2019). Endometriosis may
increase the risk of ovarian cancer.

 Currently, the best-accepted theory regarding the origin of endometrial lesions is the transplantation theory, which suggests that a
backflow of menses (retrograde menstruation) transports endometrial tissue to ectopic sites through the fallopian tubes. Why some
women with retrograde menstruation develop endometriosis and others do not is unknown. Endometrial tissue can also be spread by
lymphatic or venous channels.

CLINICAL MANIFESTATIONS

Symptoms vary but include

 dysmenorrhea (menstrual pain),
 Dyspareunia
 pelvic discomfort or pain.
 Dyschezia (pain with bowel movements) and radiation of pain to the back or leg may occur.
 Depression, loss of work due to pain, and relationship difficulties may result.
 Infertility may occur because of fibrosis and adhesions or because of a variety of substances (prostaglandins, cytokines, other factors)
produced by the implants of endometriosis and scar tissue on anatomic sites.

ASSESSMENT AND DIAGNOSTIC FINDINGS

 A health history, including an account of the menstrual pattern, is necessary to elicit specific symptoms.
 On bimanual pelvic examination, fixed tender nodules are sometimes palpated, and uterine mobility may be limited, indicating adhesions.
 Laparoscopic examination confirms the diagnosis and helps stage the disease.
 In stage 1, patients have superficial or minimal lesions;
 stage 2, mild involvement;
 stage 3, moderate involvement;
 and stage 4, extensive involvement and dense adhesions, with obliteration of the cul-desac.
 Ultrasonography, magnetic resonance imaging (MRI)
 CT scans may also be useful to visualize endometriosis (Casanova et al., 2019)
MEDICAL MANAGEMENT

Treatment depends on the symptoms, the patient’s desire for pregnancy, and the extent of the disease.
 If the woman does not have symptoms, routine examination may be all that is required.
 Other therapy for varying degrees of symptoms may be:
 NSAIDs
 oral contraceptive agents  GnRH agonists  Surgery.
Pregnancy often alleviates symptoms, because neither ovulation nor menstruation occurs.

PHARMACOLOGIC THERAPY

 Palliative measures include the use of medications, such as analgesic agents and prostaglandin inhibitors, for pain.
 Hormonal therapy is effective in suppressing endometriosis and relieving dysmenorrhea.
 Oral contraceptive agents provide effective pain relief and may prevent disease progression (Casanova et al., 2019).

Infrequently, side effects may occur with oral contraceptives, such as fluid retention, weight gain, and nausea. These can usually be managed by
changing brands or formulations.
Several types of hormonal therapy are also available in addition to oral contraceptive agents.
 A synthetic androgen, danazol, causes atrophy of the endometrium and subsequent amenorrhea.  The medication inhibits the release of
gonadotropin with minimal overt sex hormone stimulation. The drawbacks of this medication are that it is expensive and may cause
troublesome side effects such as fatigue, depression, weight gain, oily skin, decreased breast size, mild acne, hot flashes, and vaginal
atrophy (Casanova et al., 2019; Comerford & Durkin, 2020).
 GnRH agonists decrease estrogen production and cause subsequent amenorrhea.
 Side effects are related to low estrogen levels (e.g., hot flashes and vaginal dryness).
 Loss of bone density is often offset by concurrent use of estrogen.
 If side effects from GnRH develop, treatment is needed long term or repeated treatments are necessary, additional therapy should be
considered.
 Norethindrone acetate (low-dose hormone) given along with GnRH agonist will mitigate the bone density side effects as well as not
affect the drug’s control of pelvic pain.
 Aromatase inhibitor therapy is emerging as an alternative therapy (Casanova et al., 2019).

Most women continue treatment despite side effects, and symptoms diminish for 80% to 90% of women with mild to moderate endometriosis.

Hormonal medications are not used in patients with a history of abnormal vaginal bleeding or liver, heart, or kidney disease. Bone density is
followed carefully because of the risk of bone loss; hormone therapy is usually short term.

SURGICAL MANAGEMENT

If conservative measures are not helpful, surgery may be necessary to relieve pain and improve the possibility of pregnancy. Surgery may be
combined with the use of medical therapy. The procedure selected depends on the patient.

 Laparoscopy may be used to fulgurate (cut with high-frequency current) endometrial implants and to release adhesions. Laser surgery is
another option made possible by laparoscopy.
 Laser therapy vaporizes or coagulates the endometrial implants, thereby destroying this tissue.
 Other surgical options include endocoagulation and electrocoagulation, laparotomy, abdominal hysterectomy, oophorectomy
(removal of the ovary), bilateral salpingooophorectomy (removal of the ovary and its fallopian tube), and appendectomy.

 Many women need further intervention following conservative surgeries; therefore, total hysterectomy is the definitive procedure
(Casanova et al., 2019).

NURSING MANAGEMENT

 The health history and physical examination focus on specific symptoms (e.g., pelvic pain), the effect of prescribed medications, and the
woman’s reproductive plans. This information helps in determining the treatment plan.
 Explaining the various diagnostic procedures may help to alleviate the patient’s anxiety.
 Patient goals include relief of pain, dysmenorrhea, dyspareunia, and avoidance of infertility.
 As the treatment progresses, the woman with endometriosis and her partner may find that pregnancy is not easily possible, and the
psychosocial impact of this realization must be recognized and addressed.
 Alternatives, such as assisted reproductive technologies or adoption, may be discussed at an appropriate time and referrals offered.

GLOSSARY

 Abdominal hysterectomy - An abdominal hysterectomy is a surgical procedure that removes your uterus through an incision in your lower
abdomen. In endometriosis, the tissue lining the inside of your uterus (endometrium) grows outside the uterus on your ovaries, fallopian
tubes, or other pelvic or abdominal organs

 Appendectomy - is surgery to remove the appendix when it is infected. Patients should be counseled that appendectomy performed at the
time of laparoscopic surgical treatment of endometriosis may concomitantly treat benign or significant pathology of the appendix and
should be considered as an important component of management.

 Bilateral salpingoo ophorectomy - removal of the ovary and its fallopian tube

 Dyschezia - rectal pain during a bowel motion or rectal bleeding when you have your period. Endometriosis can cause painful bowel
movements

 Dysmenorrhea - cramping during their menstrual periods, those with endometriosis typically describe menstrual pain that's far worse than
usual

 Dyspareunia - Patients with endometriosis often find themselves experiencing physical pain when engaging in sex.

 Electrocoagulation - As a surgical technique, electrocoagulation allows for easier, more removal of endometrial implants than simple
excision with a scalpel.
 Endocoagulation - a technique opens a new area of operative gynecology.

 GnRH agonists - GnRH agonists are a group of drugs that have been used to treat women with endometriosis for over 20 years

 Hysterectomy - removal of the uterus

 Laparoscopy - can provide information about the location, extent and size of the endometrial implants.

 Magnetic resonance imaging - An MRI is an exam that uses a magnetic field and radio waves to create detailed images of the organs and
tissues within your body. For some, an MRI helps with surgical planning, giving your surgeon detailed information about the location and
size of endometrial implants.
 NSAIDs - Nonsteroidal anti-inflammatory drugs — NSAIDs are a type of pain medicine that can help to relieve the pain caused by
endometriosis.

 Oophorectomy - removal of the ovary

 Retrograde menstruation - occurs when menstrual blood and uterine tissue enters the peritoneal cavity by flowing through the fallopian
tubes.

 Ultrasound - This test uses high-frequency sound waves to create images of the inside of your body. A standard ultrasound imaging test
won't definitively tell your doctor whether you have endometriosis, but it can identify cysts associated with endometriosis
(endometriomas).

UNDESCENDED TESTES
 Testicles that don’t drop; undescended testicles are a common childhood condition where a boy's testicles are not in
their usual place in the scrotum.
 The testicles develop in the abdomen while a male baby is still in the uterus. Before birth, the testicles typically drop
from inside the abdomen down into the scrotum.
 In most cases no treatment is necessary, as the testicles will usually move down into the scrotum naturally during the
first 3 to 6 months of life. But around 1 in 100 boys has testicles that stay undescended unless treated.
 The medical term for having 1 or 2 undescended testicles is unilateral or bilateral cryptorchidism.
 Undescended testicles are usually detected during the newborn physical examination carried out soon after birth, or
during a routine check-up at 6 to 8 weeks.

Cause
 During pregnancy, the testicles form inside a baby boy's tummy (abdomen) before slowly moving down into the
scrotum about a month or 2 before birth.
 It's not known exactly why some boys are born with undescended testicles. In some cases, hormones could interfere
with the testicles’ development
 Most boys with the condition are otherwise completely healthy.
 Being born prematurely (before the 37th week of pregnancy) and having a low birth weight and a family history of
undescended testicles may increase the chances of a boy being born with the condition.

Complications
 After a boy goes through puberty, the testicles start producing sperm. To make healthy sperm, the testicles need to be
two to three degrees cooler than the body’s core temperature. That’s why the testicles hang below the body, inside the
scrotum.
 If the testicles don’t drop into the scrotum, they may not function normally and produce healthy sperm. This can lead to
infertility later in life.
 Males born with undescended testicles also have a higher risk of testicular cancer in adulthood. If the testicles are in the
abdomen and not down in the scrotum, this can make it more difficult to diagnose and treat.

Diagnosis
 Undescended testicles can usually be diagnosed after a physical examination. This will determine whether the testicles
can be felt near the scrotum (palpable) or if they can't be felt at all (impalpable).
 This physical examination can sometimes be difficult, so your doctor may need to refer your child to a pediatric surgeon.
 No further scans or tests are needed to locate the testicles if they can be felt by the doctor. If they can't be felt, part of
the initial surgical treatment may involve keyhole surgery (a diagnostic laparoscopy) to see if the testicles are inside the
abdomen.
 Treatment
 If the testicles haven't descended by 6 months, they're very unlikely to do so and treatment will usually be
recommended. This is because boys with untreated undescended testicles can have fertility problems (infertility) in
later life and an increased risk of developing testicular cancer.
 Surgery is the most common, and effective, treatment for undescended testicles. Treatment will usually involve an
operation called an orchidopexy to move the testicles into the correct position inside the scrotum. This is a relatively
straightforward operation with a good success rate. Surgery is ideally carried out before 12 months of age. If
undescended testicles are treated at an early age, the risk of fertility problems and testicular cancer can be reduced.
 Hormone therapy: In rare cases — especially when the testicles are near the scrotum — your healthcare provider may
recommend hormonal treatment. The healthcare provider gives the child a series of hCG (human chorionic
gonadotropin) injections. The hormones encourage the testicles to drop into the scrotum.
 Laparoscopy. A small tube containing a camera is inserted through a small incision in your son's abdomen. Laparoscopy
is done to locate an intra-abdominal testicle. The doctor might be able to fix the undescended testicle during the same
procedure, but an additional surgery might be needed in some cases. Alternatively, laparoscopy might show no testicle
present, or a small remnant of nonfunctioning testicular tissue that is then removed.

How Much Does it Affect Fertility

 Men with one undescended testicle can still have children, but their fertility is lower than normal by roughly half. If they
have surgery to correct it, especially when younger, their fertility is about the same as if they never had a problem.

 Without treatment, men with 2 undescended testicles will not likely be able to have children. But surgery to move both
testicles down can greatly improve their fertility.

 It won’t be the same as normal, but an earlier surgery can have a big effect. For example, boys who have the surgery by
age 2 will be about 5 times more fertile than if they have it at age 13.

Can Surgery Help a Grown Man?

 If you’re a grown man with an undescended testicle, surgery to correct it isn’t likely to change your fertility level. But you
will want to talk to your doctor about testicular cancer as an undescended testicle makes you a little more likely to get it.
 And since the undescended testicle isn’t in the scrotum, it’s not possible to do self-exams, which are key to finding
cancerous lumps early.

Male Factors
An analysis of semen provides information about the number of sperm (density), percentage of moving forms, quality of
forward movement (forward progression), and morphology (shape and form). From 2 to 6 mL of watery alkaline semen is
normal. A normal count has 60 to 100 million sperm/mL. However, the incidence of impregnation is lessened only when the
count decreases to fewer than 15 million sperm/mL (Anawat & Page, 2019).

Men may also be affected by varicoceles (varicose veins around the testicle), which decrease semen quality by increasing
testicular temperature. Retrograde ejaculation or ejaculation into the bladder is assessed by urinalysis after ejaculation.
Blood tests for male partners may include measuring testosterone, FSH, and LH (both of which are involved in maintaining
testicular function), and prolactin levels (Anawat & Page, 2019).

Low sperm counts, poor sperm quality and decreased fertility are more likely to occur among men who've had an
undescended testicle. This can be due to abnormal development of the testicle, and might get worse if the condition goes
untreated for an extended period of time

The main reasons for infertility in men with a history of cryptorchidism treated by orchidopexy are maldevelopment of the
testes and an improper environment for the normal development of the testes, hyperthermia, and antisperm antibodies.

Key Diagnostic Factors

 malpositioned or absent testis
 palpable cryptorchid testis
 nonpalpable testis

Other Diagnostic Factors

 testicular asymmetry
 scrotal hypoplasia or asymmetry
 ascending cryptorchidism
 retractile testis

RETRACTILE TESTICLES
 In most boys, the testicles can move in and out of the scrotum at different times, usually changing position as a result of
temperature changes or feelings of fear or excitement.
 If the testicles move in and out of the scrotum and do not stay ascended, this is known as retractile testicles.
 Retractile testicles in young boys aren't a cause for concern, as the affected testicles often settle permanently in the
scrotum as they get older. But they may need to be monitored during childhood because they sometimes don't descend
naturally and treatment may be required.

Risk factors
 family history of cryptorchidism
 prematurity
 low birth weight (<2.5 kg) and/or small for gestational age
 environmental exposures

What Problems Can It Cause?

An undescended testicle is related to a number of conditions:
 Fertility problems. Because sperm need to be a little cooler than the rest of the body, an undescended testicle can
cause fertility issues. This is more of a problem when both are lodged in the groin. Early treatment can make a big
difference.
 Hernia. This is a condition where part of the intestine bulges through the muscles of the lower belly.
 Injury. When the testicle is out of place, it’s more likely to be damaged.
 Cancer. Men who have an undescended testicle are a little more likely to get testicular cancer, even if they have surgery
to treat it. But surgery makes routine self-exams possible, so if cancer does appear, it can be found early.
 Testicular torsion. This is when the cord that carries semen to the penis gets twisted up. It’s painful and can cut off
blood flow to the testicle.

UNDESCENDED TESTES

Testicles that don’t drop (called undescended testicles)

The testicles develop in the abdomen while a male baby is still in the uterus. Before birth, the testicles typically drop from inside
the abdomen down into the scrotum. The scrotum is the sack of skin hanging behind the penis where the testicles are housed.
Undescended testicles fail to drop into the scrotum before birth or in the first few months of life. The condition is also called
cryptorchidism.
What causes undescended testicles?

Undescended testes are more often seen in babies who are born early (preterm or premature babies).
There is no clear reason why some babies are born with undescended testicles. In some cases, hormones could interfere with the
testicles’ development.
The condition is more common in premature babies who haven’t had a full nine months to develop before birth. There is no
evidence that anything a mother does while pregnant causes a baby to have undescended testicles.
What are the symptoms of undescended testicles?

Most babies and children with this condition have no symptoms. The only sign is that the scrotum is empty.
What are the complications of undescended testicles?

After a boy goes through puberty, the testicles start producing sperm. To make healthy sperm, the testicles need to be two to three
degrees cooler than the body’s core temperature. That’s why the testicles hang below the body, inside the scrotum.
If the testicles don’t drop into the scrotum, they may not function normally and produce healthy sperm. This can lead to infertility
later in life.
Males born with undescended testicles also have a higher risk of testicular cancer in adulthood. If the testicles are in the abdomen
and not down in the scrotum, this can make it more difficult to diagnose and treat.
How are undescended testicles diagnosed?

Your child’s healthcare provider should physically examine your child’s testicles at each checkup. If the testicles are “non-
palpable” (meaning the provider cannot feel them), they may be undescended.
Your healthcare provider may recommend following up with a pediatric urologist. An ultrasound may be recommended by the
urologist, however they often are not necessary.
Undescended testicle treatment options include:

 Hormone therapy: In rare cases — especially when the testicles are near the scrotum — your healthcare provider may
recommend hormonal treatment. The healthcare provider gives the child a series of hCG (human chorionic gonadotropin)
injections. The hormones encourage the testicles to drop into the scrotum.
 Surgery: Surgery is the most common, and effective, treatment for undescended testicles. The procedure to move testicles
down into the scrotum is called orchiopexy. It’s usually best for your child to have surgery between six months and one year
old.
Key diagnostic factors
 malpositioned or absent testis
 palpable cryptorchid testis  nonpalpable testis
Other diagnostic factors
 testicular asymmetry
 scrotal hypoplasia or asymmetry
 retractile testis
 ascending cryptorchidism
Risk factors
 family history of cryptorchidism
 prematurity
 low birth weight (<2.5 kg) and/or small for gestational age  environmental exposures
What Problems Can It Cause?

An undescended testicle is related to a number of conditions:

 Fertility problems. Because sperm need to be a little cooler than the rest of the body, an undescended testicle can cause
fertility issues. This is more of a problem when both are lodged in the groin. Early treatment can make a big difference.
 Hernia. This is a condition where part of the intestine bulges through the muscles of the lower belly.
 Injury. When the testicle is out of place, it’s more likely to be damaged.
 Cancer. Men who have an undescended testicle are a little more likely to get testicular cancer, even if they have surgery to
treat it. But surgery makes routine self-exams possible, so if cancer does appear, it can be found early.
 Testicular torsion. This is when the cord that carries semen to the penis gets twisted up. It’s painful and can cut off blood
flow to the testicle.
Recommended surgery for diagnosis and potential treatment:
 Laparoscopy. A small tube containing a camera is inserted through a small incision in your son's abdomen. Laparoscopy is
done to locate an intra-abdominal testicle.
The doctor might be able to fix the undescended testicle during the same procedure, but an additional surgery might be needed in
some cases. Alternatively, laparoscopy might show no testicle present, or a small remnant of nonfunctioning testicular tissue that
is then removed.
 Open surgery. Direct exploration of the abdomen or groin through a larger incision might be necessary in some cases
Hormone treatment
Hormone treatment involves the injection of human chorionic gonadotropin (HCG). This hormone could cause the testicle to
move to your son's scrotum. Hormone treatment is not usually recommended because it is much less effective than surgery.
Results
Orchiopexy, the most common surgical procedure for correcting a single descending testicle, has a success rate of nearly 100
percent. Fertility for males after surgery with a single undescended testicle is nearly normal, but falls to 65 percent in men with
two undescended testicles. Surgery might reduce the risk of testicular cancer, but does not eliminate it

CONTRACEPTION
 Nurses who are involved in helping patients make contraceptive choices need to listen, take time to answer questions,
and educate and assist patients in choosing the contraceptive method they prefer.
 It is important for women to receive unbiased and nonjudgmental information, understand the benefits and risks of
each contraceptive method, learn about alternatives and how to use them, and receive positive reinforcement and
acceptance of their choice.
 Nurses also have the opportunity to dispel myths and misinformation surrounding contraception.
 PATIENT EDUCATION
1. The nurse provides education to enhance the chosen method of contraception.
2. The nurse instructs patients who have chosen male or female sterilization to:
 Use another contraceptive method for the first 3 months.
 Use condoms to protect against sexually transmitted infections.
3. The nurse instructs women who have chosen an injectable method to:
 Use condoms to protect against sexually transmitted infections. Obtain repeat injections
on time.
4. The nurse instructs women who have chosen pills to:
 Use condoms to protect against sexually transmitted infections.
 Take the pill at exactly the same time every day.

5. The nurse instructs women who have chosen the patch to:
 Use condoms to protect against sexually transmitted infections.
 Change the patch once a week.
6. The nurse instructs women who have chosen a ring to:
 Use condoms to protect against sexually transmitted infections.
 Remove the vaginal ring after 3 weeks.
7. The nurse instructs women who have chosen a diaphragm to:
 Use correctly each time you have sex.
8. The nurse instructs women who have chosen condoms, a sponge, withdrawal, or spermicides
to:
 Use correctly each time you have sex.

CONTRAINDICATIONS
 Coexisting medical disorders may make contraception a complex issue.
 Contraception needs to be addressed individually in women with preexisting conditions. With
the aid of a thorough history, nurses are well positioned to aid patients in choosing the safest,
most effective method of contraception to meet their individual needs.

ABSTINENCE
 Abstinence, or celibacy, is the only completely effective means of preventing pregnancy.
Abstinence may not be a desired or available option for many women because of cultural
expectations and their own and their partner’s values and sexual needs.

LONG-ACTING REVERSIBLE CONTRACEPTIVE (LARC)

METHODS
 the most effective reversible methods for
pregnancy prevention with a failure rate of less
than 1%
 help lower unintended pregnancy rates in the
 the LARC methods should be offered as first-tier
contraception to most women
 LARC methods include the IUD and the single-rod
implant

1. INTRAUTERINE DEVICE
 An IUD is a small device, usually T shaped that is
inserted into the uterine cavity to prevent
pregnancy.
 A string attached to the IUD is visible and palpable at the cervical os.

Two types of IUDs are the hormonal and non-hormonal.

Hormonal IUD releases progestin
 a 3-year type and a 5- year are approved for use
Non-hormonal IUD
 is effective for up to 10 years

Advantages:
 effectiveness over a long period of time, few if any systemic effects, and reduction of patient
error.
 Almost all women are able to use an IUD.
 This reversible method of birth control is as effective as female sterilization and more effective
than barrier methods

Disadvantages:
 possible excessive bleeding, cramps, and backaches
 a slight risk of tubal pregnancy
 slight risk of pelvic infection on insertion
 displacement of the device
 rarely, perforation of the cervix and uterus

 If a pregnancy occurs with an IUD in place, the device is removed immediately to avoid
infection. Spontaneous abortion (miscarriage) may occur on removal.

2. IMPLANTS
 One type of single-rod sub-dermal implant, effective for 3 years
 After implant insertion, changes in menstrual bleeding are common and include
amenorrhea or frequent, infrequent, or prolonged bleeding
 Women should be warned about possible discomforts that can be treated with NSAIDs.
 Heavy or prolonged bleeding should be evaluated for an underlying gynecologic problem,
such as interactions with other medications, an STI, pregnancy, or new pathologic uterine
conditions

STERILIZATION
 Among women who practice contraception, approximately 22% rely on female and 7% on male
sterilization
 Women and men who choose sterilization should be certain that they no longer wish to have
children, no matter how the circumstances in their life may change.
 Vasectomy (male sterilization) and tubal ligation (female sterilization) are compared in the table
 HIV, human immune deficiency virus; STIs, sexually transmitted infections.

HORMONAL CONTRACEPTION
 A wide variety of hormonal methods of birth control are available. Combination methods
include the combination of oral contraceptive pills, vaginal ring, and transdermal patch
 Progestin-only methods include the progestin-only pills or “mini-pills,” once-every-3-month
injection, levonorgestrel-releasing intrauterine system, and single-rod sub-dermal implant

Quality and Safety Nursing Alert

Patients need to be aware that hormonal contraceptives

protect them from pregnancy but not from STIs or HIV
infection. In addition, sex with multiple partners or sex
 without a condom may also result in chlamydial and
other infections, including HIV infection.

1. Oral Contraceptives
 Many women use oral contraceptive preparations of synthetic estrogens and progestins. A
variety of formulations are available
 Extended regimens of oral hormonal contraceptive agents are an option for women who have
heavy or uncomfortable menstrual bleeding or who wish to have fewer periods. With the use of
these regimens, women may have an increased occurrence of breakthrough bleeding; the
blood may be dark brown rather than red
 It may be more difficult to tell if a pregnancy occurs with this method, although pregnancy is
unlikely if pills are taken as prescribed

2. Transdermal Contraceptives
 Is done through a thin, beige, matchbook-size skin patch that releases an estrogen and a
progestin continuously. It is changed every week for 3 weeks, and no patch is used during the
fourth week, resulting in withdrawal bleeding.
 The effectiveness of transdermal contraception is comparable to that of oral contraceptives.
 Its risks are similar to those of oral contraceptives and include an increased risk of venous
thromboembolic formation.
o The patch may be applied to the torso, chest, arms, or thighs; it should not be applied to
the breasts
o The patch is convenient and more easily remembered than a daily pill but is not as
effective for women who weigh more than 90 kg (198 lb)

Side effects:
 possible skin reaction such as irritation, redness, pigment changes, or rash at the site of the
patch

3. Vaginal Contraceptives
 An etonogestrel/ethinyl estradiol vaginal ring is a combination hormonal contraceptive that
releases estrogen and progestin
 The ring is flexible, does not require sizing or fitting, and is effective when placed anywhere in
the vagina.

4. Injectable Contraceptives
 An intramuscular injection of a long-acting progestin every 13 weeks inhibits ovulation and
provides a reliable, private, and convenient contraceptive.
 A subcutaneous formulation is also available.
 It can be used by women who are lactating and those with hypertension, liver disease, migraine
headaches, heart disease, and hemoglobinopathies. With continued use, women must be
prepared for irregular bleeding episodes and spotting decrease, or amenorrhea.

Advantages long-acting progestin:

 reduction of menorrhagia, dysmenorrhea, and anemia due to heavy menstrual bleeding. It may
reduce the risk of pelvic infection, has been associated with improvement in hematologic status
in women with sickle cell disease, and does not interfere with the efficacy of seizure agents.
 It decreases the risk of endometrial cancer, PID, endometriosis, and uterine fibroids

Side effects:
 irregular menstrual bleeding, bloating, headaches, hair loss, decreased sex drive, bone loss,
and weight loss or weight gain. The contraceptive does not protect against STIs.
 Use of this method should be limited to 2 years of use because of loss of bone mineral density.

Long-acting progestin
 contraindicated in women who are pregnant and those who have abnormal vaginal bleeding of
unknown cause, breast or pelvic cancer, or sensitivity to synthetic progestin.

MECHANICAL BARRIERS

1. Diaphragm
 The diaphragm is an effective contraceptive device that consists of a round, flexible spring (50
to 90 mm wide) covered with a domelike latex rubber cup.

Spermicidal (Contraceptive) Jelly or Cream

 used to coat the concave side of the diaphragm before it is inserted deep into the vagina,
covering the cervix completely.
 The spermicide inhibits spermatozoa from entering the cervical canal.
 The diaphragm is not felt by the user or her partner when properly fitted and inserted.
 Because women vary in size, the diaphragm must be sized and fitted by an experienced
clinician.
 The woman is instructed in using and caring for the device.

Disadvantages:
 allergic reactions in those who are sensitive to latex and an increased incidence of urinary tract
infections.

Quality and Safety Nursing Alert

The nurse must assess the woman for possible latex allergy because the use of latex barrier
methods (e.g., diaphragm, cervical cap, male condoms) may cause severe allergic reactions,
including anaphylaxis, in patients with latex allergy.

2. Cervical Cap
 is much smaller (22 to 35 mm) than the diaphragm and covers only the cervix.
 If a woman can feel her cervix, she can usually learn to use a cervical cap.

Disadvantages;
 the cap may be left in place for 2 days after coitus.
 Although convenient to use, the cervical cap may cause cervical irritation; therefore, before
fitting a cap, most primary providers obtain a Pap smear and repeat the smear after 3 months.

3. Female Condom
 Was developed to give control of barrier protection to women—to provide them with
protection from STIs and HIV as well as pregnancy.
 The female condom consists of a cylinder of
polyurethane enclosed at one end by a closed ring that
covers the cervix and at the other end by an open ring that
covers the perineum

Advantages:
 Degree of protection from STIs (i.e., HPV, herpes simplex
virus, and HIV)

Disadvantages:
 that female condoms are more costly than male condoms
and the inability to use the female condom with some
positions (i.e., standing).
4. Spermicides
 Made from nonoxynol-9 or octoxynol and are available over the counter as foams, gels, films,
suppositories, and sponges and also on condoms.
 Spermicides do not protect women from HIV or other STIs

Advantages:
 spermicides include they are non-hormonal, are user controlled, do not cause systemic side
effects, and are immediately effective

5. Male Condom
 is an impermeable, snug-fitting cover applied to the erect penis before it enters the vaginal
canal. The tip of the condom is pinched while being applied to leave space for ejaculate.
 If no space is left, ejaculation may cause a tear or hole in the condom and reduce its
effectiveness.
 The penis, with the condom held in place, is removed from the vagina while still erect to
prevent the ejaculate from leaking.
Latex Condom
 also creates a barrier against transmission of STIs (gonorrhea, chlamydial infection, and HIV) by
body fluids and may reduce the risk of herpes virus transmission.
Natural Condom
 those made from animal tissue do not protect against HIV infection.

 Nurses need to reassure women that they have a right to insist that their male partners use
condoms and a right to refuse sex without condoms, although women in abusive relationships
may increase their risk of abuse, maltreatment, and neglect by doing so.
 Nurses should be familiar and comfortable with instructions about using condoms because
many women need to know about this way of protecting themselves from HIV and other STIs.
 Condoms do not provide complete protection from STIs, however, because HPV may be
transmitted by skin-to-skin contact. Other STIs may be transmitted if any abraded skin is
exposed to body fluids.
 The nurse needs to consider the possibility of latex allergy. Swelling and itching can also occur.
 Possible warning signs of latex allergy include oral itching after blowing up a balloon or eating
kiwis, bananas, pineapples, passion fruit, avocados, or chestnuts.
 Because many contraceptives are made of latex, patients who experience burning or itching
while using latex contraceptives are instructed to see their primary provider. Alternatives to
latex condoms include the female condom

COITUS INTERRUPTUS OR WITHDRAWAL

 removing the penis from the vagina before ejaculation requires careful control by the male
partner.
 Although it is a frequently used method of preventing pregnancy and better than no method, it
is considered an unreliable method of contraception.

FERTILITY AWARENESS-BASED METHODS

 knowing and recognizing when the fertile time occurs in the menstrual cycle.
 couple needs to avoid having penile- vaginal intercourse or use a barrier method during the
fertile period.
 If the woman would like to get pregnant, the couple should have penile-vaginal intercourse
during the women’s fertile days.
 The most common fertility awareness–based method is the Standard Days method.
 With this method, users must avoid unprotected penile-vaginal intercourse on days 8 to 19 of
the menstrual cycle.
 The Standard Days method requires the woman to determine the fertile days of her cycle. This
method works best if the woman has a regular menstrual cycle.

Advantages:
 using fertility awareness–based methods to prevent pregnancy are that they are safe,
inexpensive, and approved by some religions that do not approve of other methods of
contraception.

Disadvantages:
 is that they require discipline by the couple, who must monitor the menstrual cycle and abstain
from penile-vaginal intercourse during the fertile phase.

EMERGENCY CONTRACEPTION
 are methods that can be used by women after unprotected penile-vaginal intercourse to
prevent pregnancy
 Nurses need to be aware of emergency contraception as an option for women and the
indications for its use.
 It is clearly not suitable for long-term avoidance of pregnancy because it is not as effective
as oral contraceptives or other reliable methods used regularly.
 It is valuable following penile- vaginal intercourse when a pregnancy is not intended and in
emergency situations such as rape, a defective or torn condom or diaphragm, or other
situations that may result in unintended conception.

METHODS OF EMERGENCY CONTRACEPTION

1. Emergency Contraceptive Pills

 A properly timed, adequate dose of medication after penile-vaginal intercourse without
effective contraception, or when a method has failed, can prevent pregnancy by inhibiting or
delaying ovulation.
 Emergency contraceptive pills should be taken as soon as possible and within 5 days of
unprotected penile-vaginal intercourse
Side effects:
 Nausea- can be minimized by taking the medication with meals and with an antiemetic agent
 Breast Soreness
 Irregular bleeding

 The nurse reviews with the patient instructions for emergency contraception based on the
medication regimen prescribed. If the woman is breast-feeding, a progestin-only formulation is
prescribed.
 To avoid exposing infants to synthetic hormones through breast milk, the patient can manually
express milk and bottle-feed for 24 hours after treatment.
 The patient should be informed that her next menstrual period may begin a few days earlier or
a few days later than expected.
 She is instructed to return for a pregnancy test if she has not had a menstrual period in 3
weeks and should be offered another visit to provide a regular method of contraception if she
does not have one currently.

2. Postcoital Intrauterine Device Insertion

 Another form of emergency contraception, involves insertion of a copper-bearing IUD within 5
days of coitus
 The copper-bearing IUD prevents fertilization by causing a chemical change in sperm and egg
before they can meet

Side Effects;
 The patient may experience discomfort on insertion and may have heavier menstrual periods
and increased cramping.

Contraindications:
 confirmed or suspected pregnancy or any contraindication to regular IUD use.

 The patient must be informed that there is a risk that insertion of an IUD may disrupt a
pregnancy that is already present.

NURSING MANAGEMENT
 Patients who use emergency contraception may be anxious, embarrassed, and lacking
information about birth control
 The nurse must be supportive and nonjudgmental and provide facts and appropriate patient
education.
 If the patient repeatedly uses this method of birth control, she should be informed that the
failure rate with this method is higher than with a regularly used method.
 Nurses can educate and inform women about emergency contraception options to reduce
unintended pregnancies and abortions

Perimenopause
Perimenopause - is the menstrual transition period before menopause that begins on average 4 years
before the last menstrual period (Casper, 2019).

Nursing Management
Women who are perimenopausal often benefit from information about the subtle physiologic changes
they are experiencing. Perimenopause has been described as an opportune time for educating women
about health promotion and disease prevention strategies. When discussing health-related concerns
with women who are in midlife, nurses should consider the following issues:

- Sexuality, fertility, contraception, and STIs

- Unintended pregnancy (if contraception is not used correctly and consistently)
- Oral contraceptive use
- Women who smoke and are 35 years or older should not take oral contraceptive agents because of
an increased risk of cerebrovascular disease.
- Breast health

Menopause

Menopause - is the permanent physiologic cessation of menses associated with declining ovarian
function evidenced by 12 consecutive months with no menstrual bleeding (Casanova et al., 2019).
Most women stop menstruating between 41 and 59 years of age. Postmenopause is the period
beginning from about 1 year after menses cease.

Postmenopausal Bleeding - Bleeding 1 year after menses cease at menopause must be investigated,
and a malignant condition must be considered until proven otherwise. A transvaginal ultrasound can
be used to measure the thickness of the endometrial lining
(Goodman, 2020). The uterine lining in women who are postmenopausal should be thin because of
low estrogen levels. A thicker lining warrants further evaluation by endometrial biopsy or a D&C.

Clinical Manifestations

 Increase in body fat and intraabdominal deposition of body fat

 Levels of total and LDL cholesterol increase

 Hot flashes occur in many women going through menopause due to alterations in
thermoregulation

 Irregular menses, breast tenderness, and mood changes long before menopause occurs

 The hot or warm flashes and night sweats

 Increased bone loss

Strategies for Women Approaching Menopause

 An annual physical examination can help screen for problems and promote general health.
 Changes in lifestyle (e.g., diet, activity) to promote health and wellness.
 A nutritious diet (decrease fat and calories, increase fiber and whole grains) and weight control
will enhance physical and emotional well-being.
 Exercise for at least 30 minutes 3 or 4 times a week to maintain good health.
 Involvement in outside activities is beneficial in reducing anxiety and tension

Strategies and methods to prevent or manage potential problems:

Hot flashes: See primary provider to discuss hormone replacement therapy indications (lowest dose
for shortest period of time) and alternative therapy (e.g., vitamin therapy,
black cohosh, and other herbal preparations).

Itching or burning of vulvar areas: See primary provider to rule out dermatologic abnormalities and, if
appropriate, to obtain a prescription for a lubricating or hormonal
cream.

Dyspareunia due to vaginal dryness: Use a water-soluble lubricant, hormone cream, or contraceptive
foam.

Decreased perineal muscle tone and bladder control: Practice Kegel exercises daily (contract the
perineal muscles as though stopping urination; hold for 5 to 10 seconds and release; repeat frequently
during the day).

Dry skin: Use mild emollient skin cream and lotions to prevent dry skin.

Weight control: Join a weight reduction support group such as Weight Watchers or a similar group if
appropriate or consult a registered dietitian for guidance about the tendency to gain weight,
particularly around the hips, thighs, and abdomen.

Osteoporosis: Observe recommended calcium and vitamin D intake, including calcium supplements, if
indicated, to slow the process of osteoporosis; avoid smoking, alcohol, and excessive caffeine, all of
which increase bone loss. Perform weight-bearing exercises. Undergo bone density testing when
appropriate.

Risk for urinary tract infection (UTI): Drink 6 to 8 glasses of water daily as a possible way to reduce the
incidence of UTI related to atrophic changes of the urethra.

Vaginal bleeding: Report any bleeding after 1 year of no menses to the primary provider
immediately, no matter how minimal.

Medical Management

Hormone Therapy
 HT or menopausal hormonal therapy (previously referred to as hormone replacement therapy
[HRT]) is medication that contains estrogen or estrogen and progestin together, to replace the
ones the body is no longer making.
 It is prescribed to treat moderate to severe menopause-relatedvasomotor symptoms (hot flashes
and night sweats) in women.

Alternative Therapy for Hot Flashes

Problematic hot flashes have been treated with:
 Low-dose venlafaxine, psychoeducational approaches, and diet and lifestyle changes.
 Vitamin B6 and vitamin E may be effective
 Complementary therapies include reflexology, aromatherapy, yoga, hypnotherapy, breathing
exercises, and meditation.

Maintaining Bone Health

 Acceleration of bone loss resulting in osteoporosis and microarchitectural deterioration of bone
tissue occurs at menopause and leads to increased bone fragility and risk of fracture.
Maintaining Cardiovascular Health
 A variety of strategies can help to lower the risk of heart disease in women, including lifestyle
changes and behavioral strategies.

Behavioral Strategies
 As stated previously, regular physical exercise is beneficial. It may also reduce stress, enhance
well-being, and improve self-image. In addition, weight bearing exercise may prevent loss of
muscle tissue and bone tissue.

Nutritional Therapy
 Women are encouraged to decrease their fat and caloric intake and increase their intake of
whole grains, fibers, fruits, and vegetables.

Nursing Management
 Nurses can encourage women to view menopause as a natural change resulting in freedom from
symptoms related to menses.
 The nurse explains to the patient that cessation of menses is a normal occurrence that is rarely
accompanied by nervous symptoms or illness.
 The current expected lifespan after menopause for the average woman is 30 to 35 years, which
may encompass as many years as the childbearing phase of her life.
 Patient education and counseling regarding healthy lifestyles, health promotion, and health
screening are of paramount importance.

TESTOSTERONE DEFICIENCY
Testosterone is the male sex hormone that is made in the testicles. Testosterone hormone levels are
important to normal male sexual development and functions

This is called Testosterone Deficiency Syndrome (TD) or Low Testosterone (Low-T). Deficiency
means that the body does not have enough of a needed substance. Syndrome is a group of symptoms
that, together, suggest a disease or health condition.
Symptoms or conditions may accompany Low-T:

 Low sex drive

 Fatigue
 Reduced lean muscle mass
 Irritability
 Erectile dysfunction
 Depression
 There are many other possible reasons for these symptoms, such as: opioid use, some congenital
conditions (medical conditions you are born with), loss of or harm to the testicles, diabetes, and
obesity (being overweight). See your doctor if you have any of these symptoms.

Specific Signs/Symptoms of Testosterone Deficiency (TD)

Specific symptoms are those more likely or directly linked to TD such as:

 Reduced sex drive

 Reduced erectile function
 Loss of body hair
 Less beard growth
 Loss of lean muscle mass
 Feeling very tired all the time (fatigue)
 Obesity (being overweight)
 Symptoms of depression

Non-specific Signs/Symptoms of Testosterone Deficiency

(TD)

Non-specific symptoms are those that may or may not be linked to TD such as:

 Lower energy level, endurance and physical strength

 Poor memory
 Difficulty with finding words to say
 Poor focus
 Not doing well at work

How does Testosterone Defiency affect male reproductive system?

 Testosterone (T) is a key male hormone. Low testosterone occurs when a

man’s testosterone drops below normal levels. It can directly affect fertility by
causing decreased sperm production and indirectly affect fertility by reducing
his sex drive and causing erectile dysfunction.
 Men with low testosterone levels, called hypogonadism in medical terms and
commonly known as low T, can still have enough of the hormone for sperm
production.
  Risk factors for low T include advancing age, obesity, testicular injury,
excessive alcohol consumption, chronic narcotic use, marijuana abuse,
diabetes, and cancer treatments such as chemotherapy.
 Lifestyle changes such as quitting smoking and losing weight may help
balance testosterone levels naturally.
 Testosterone replacement therapy, a popular way to treat low levels, may
actually lower sperm count and should not be used by men trying to conceive.

Causes

The two types of male hypogonadism are:

 Primary hypogonadism (testicular disorder).
 Secondary hypogonadism (pituitary/hypothalamus dysfunction).

Some persons are born with conditions that cause Testosterone Deficiency (TD) such as:

 Klinefelter syndrome
 Noonan syndrome
 Ambiguous genitalia (when the sex organs develop in ways that are not typical looking)

Some men may develop Low-T because of conditions like these:

 Damage to testicles by accident
 Removal of testicles because of cancer
 Chemotherapy or radiation
 Pituitary gland disease leading to hormone deficiency
 Infection
 Autoimmune disease (when the body makes antibodies that attack its own cells)

Basically, if your testicles keep making less testosterone than normal, your blood levels of testosterone
will fall. Many men who develop TD have Low-T levels linked to:

 Aging
 Obesity
 Metabolic syndrome (high blood pressure, high blood sugar, unhealthy cholesterol levels, and
belly fat)
 Use of medications such as antidepressants and narcotic pain medications

Men with certain health problems also tend to have low testosterone. Some of these are:

 HIV (about 30 out of 100 also have low testosterone)

 AIDS (about 50 out of 100 also have low testosterone)

Physical Examination

Your doctor will check for the following:

 BMI or waist circumference for obesity

 Metabolic syndrome. These are symptoms (seen together) of increased blood pressure, high blood
sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels
 Hair pattern, amount, and location
 Gynecomastia (enlarged breasts)
 Whether testicles are present and their size
 Prostate size and any abnormalities

Testing

Your doctor may order these blood tests:

 Total testosterone level. This test should be done at two different times on samples taken before
noon. Testosterone levels are lower later in the day. If you are ill, the doctor will wait until you are
not sick because your illness may cause a false result.

 Luteinizing hormone (LH). This test is done to help find the cause of a Low-T level. This
hormone controls how you make testosterone. Abnormal levels may mean a pituitary gland
problem.

 Blood prolactin level. If your prolactin level is high, your doctor may repeat the blood test to
make sure there is no error. High prolactin levels also may be a sign of pituitary problems or
tumors.

 Blood hemoglobin or Hgb. Before doing this test, your doctor will look for other reasons for low
Hgb such as climate level (like climate altitude), sleep apnea, or tobacco smoking.

The following also may be done to help with further diagnosis:

 Follicle stimulating hormone (FSH). This test is to check for sperm-making function if you want
to have children. You may also need to have semen tests. These tests will be done before any
hormone therapy.
 Estradiol hormone test is done if there are breast symptoms.
 HbA1C blood test may be done for diabetes.  MRI ( magnetic resonance imaging) of the
pituitary gland  Bone density tests.  Karyotype (Chromosome tests)

How Do I Take Testosterone?

There are generally five different ways to take testosterone. They are: transdermal (through the skin),
injection, oral/buccal (by mouth), intranasal (through the nose), and by pellets under the skin. No
method is better than another. While you are taking TT, your doctor will test your blood to determine
testosterone levels.

Here are some details about the five different methods:

 Transdermal (Topical). There are topical gels, creams, liquids and patches. Topical medicines
most often last for about four days. They absorb better if covered with an air- or water- tight
dressing.
 Apply liquids and gels, creams or patches to skin that is dry and without cuts or scratches.
 Do not wash the area until it is time for the next dose.
 Wash your hands after you apply liquids, gels or creams.
 Make sure that other people, especially women and children, do not touch the medicines.

A topical patch is like a band-aid with medicine on it. You put it on and leave it until
the next dose is due. The medicine on the patch is less likely than liquids, gels and
creams to transfer to others.
 Injection. There are short-acting and long-acting forms of testosterone injection. The shortacting
medicine may be given under the skin or in the muscle. The long-acting one is usually given in the
muscle. Injections are usually given either weekly, every two weeks, or monthly.

 Oral/buccal (by mouth). The buccal dose comes in a patch that you place above your incisor
(canine or "eyetooth"). The medication looks like a tablet but you should not chew or swallow it.
The drug is released over 12 hours. This method has fewer harmful side effects on the liver than if
the drug is swallowed, but it may cause headaches or cause irritation where you place it.

 Intranasal. This form of testosterone comes in a gel. You pump the dose into each nostril, as
directed. It is usually taken three times daily.

 Pellets. Your doctor will place the testosterone pellets under the skin of your upper hip or
buttocks. Your doctor will give a shot of local anesthesia to numb your skin, then make a small cut
and place the pellets inside the fatty tissues underneath your skin. This medication dissolves
slowly and is released over about 3-6 months, depending on the number of pellets.

Are There Side Effects of TESTOSTERONE

TREATMENT?

There are some side effects of TT. Some side effects are mild while others are more serious. You should
ask your doctor or pharmacist about these side effects and watch for them while you are taking TT.
Some of the side effects are as follows:

 For gels and liquids, there may be some redness at the skin site. With patches, you may have
itching and a rash around the area. A very small number of patients report back pain.

 For short-acting injections, you may have some reaction at the injection site. Some persons have
had serious allergic reactions to the long-acting injection. Because of this, when you get the long-
acting injection they will watch you closely for a while afterwards in the medical office.
 For testosterone pellets, possible adverse effects include swelling, pain, bruising and, rarely,
hematoma (clotted blood under the skin).

 During TT, there is increased risk of erythrocytosis (abnormal raising of blood hemoglobin and
hematocrit).

 TT may interrupt normal sperm production. You should not have TT if you plan on having
children soon. If you are being treated for Low-T your doctor may suggest added treatment for
sperm production.

 Topical testosterone, specifically gels, creams and liquids, may transfer to others. Women and
children are most at risk of harmful effects from contact with them. You should take care to cover
the area and wash your hands well after putting on the medication. Be careful not to let the site
with the topical TT touch others because that could transfer the drug.

 The FDA suggests watching for signs and symptoms of early puberty in a child you live with or
have contact with if you use topical testosterone. Do not let children touch the unwashed or
unclothed area where you put the drug.

Here are some things you should know:

 There is no evidence linking TT to prostate cancer.
 There is no strong evidence linking TT to increase in vein clots.
 At this time, there is no strong evidence that TT either increases or decreases the risk of
cardiovascular events. However, while you are on TT, you should call your doctor right away if
you have signs or symptoms of stroke or heart attack.
MEDICATIONS

 Androderm (testosterone)
- drug class: hormone replacement therapy
- administration route: transdermal patch
- dosage: 1, 2 mg patch applied to the skin daily - side effects:
Skin reactions, back pain, acne

 Aveed (testosterone undecanoate)

- drug class: hormone replacement therapy
- administration route: injection
- dosage: 3 ml of 750 mg / 3 ml every 10 weeks
- side effects: Acne, hypogonadism, fatigue

 Natesto (testosterone)
- drug class: hormone replacement therapy
- administration route: nasal gel
- dosage: 2 pumps per nostril 3x a day
- side effects: Headache, runny nose, nasal hemorrhage

 Clomid (clomiphene citrate)

- drug class: estrogen blocker
- administration route: oral
- dosage: 1, 50 mg tablet daily
- side effects: Abdominal pain, nausea, vomiting

 Arimidex (anastrozole)
- drug class: Aromatase inhibitor
- administration route: oral
- dosage: 1, 1 mg tablet daily
- side effects: Joint pain, high blood pressure, nausea

Erectile Dysfunction

- Erectile dysfunction, also called impotence, is the inability to achieve or maintain an erect penis
(Norris, 2019). The man may report decreased frequency of erections, inability to achieve a firm
erection, or rapid detumescence (subsiding of erection).
- The physiology of erection and ejaculation is complex and involves parasympathetic and sympathetic
components. Erection involves the release of nitric oxide into the corpus cavernosum during sexual
stimulation. Its release activates cyclic guanosine monophosphate (cGMP), causing smooth muscle
relaxation. This allows flow of blood into the corpus cavernosum, resulting in erection (Cheng,
MacLennan, & Bostwick, 2019; Norris, 2019).
- Erectile dysfunction has both psychogenic and organic causes. Psychogenic causes include anxiety,
fatigue, depression, pressure to perform sexually, negative body image, absence of desire, and
privacy, as well as trust and relationship issues.
- Organic causes include cardiovascular disease, endocrine disease (diabetes, pituitary tumors,
testosterone deficiency, hyperthyroidism, and hypothyroidism), cirrhosis, chronic kidney injury,
genitourinary conditions (radical pelvic surgery), hematologic conditions (Hodgkin lymphoma,
leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury [SCI], multiple
sclerosis), trauma to the pelvic or genital area, smoking, medications, and substance use disorder.

Assessment and Diagnostic Findings

- sexual and medical history
- analysis of presenting symptoms
- physical and neurological examination
- detailed assessment of all medications, alcohol and drugs used
- Nocturnal penile tumescence tests - conducted to monitor changes in penile circumference to
determine if erectile dysfunction has an organic or a psychogenic cause.
- Doppler probe - use to measure the arterial blood flow to the penis

Medical Management
- Treatment can be medical, surgical, or both, depending on the cause. Treatment of erectile
dysfunction includes therapy for associated disorders (e.g., alcoholism, diabetes) or adjustment of
medications (McMahon, 2019). Endocrine therapy instituted to treat erectile dysfunction secondary to
hypothalamic–pituitary–gonadal dysfunction may reverse the condition. Insufficient penile blood flow
may be treated with vascular surgery. Patients with erectile dysfunction from psychogenic causes are
referred to a health care provider or therapist who specializes in sexual dysfunction. Patients with
erectile dysfunction secondary to organic causes may be candidates for penile implants.

Treatments for Erectile Dysfunction

PREGNANCY
pregnancy, process and series of changes that take place in a woman’s organs and tissues as a result
of a developing fetus.
The unborn baby spends around 38 weeks in the womb, but the average length of pregnancy
(gestation) is counted as 40 weeks. This is because pregnancy is counted from the first day of the
woman’s last period, not the date of conception, which generally occurs two weeks later.
Symptoms of pregnancy

You may notice some signs and symptoms before you even take a pregnancy test. Others will appear
weeks later, as your hormone levels change.
l Missed period

A missed period is one of the earliest symptoms of pregnancy (and maybe the most classic one).
However, a missed period doesn’t necessarily mean you’re pregnant, especially if your cycle tends to
be irregular.
There are many health conditions other than pregnancy that can cause a late or missed period.
l Headache

Headaches are common in early pregnancy. They’re usually caused by altered hormone levels and
increased blood volume. Contact your doctor if your headaches don’t go away or are especially
painful.
l Spotting

Some women may experience light bleeding and spotting in early pregnancy. This bleeding is most
often the result of implantation. Implantation usually occurs one to two weeks after fertilization.
Early pregnancy bleeding can also result from relatively minor conditions such as an infection or
irritation. The latter often affects the surface of the cervix (which is very sensitive during pregnancy).
Bleeding can also sometimes signal a serious pregnancy complication, such as miscarriage, ectopic
pregnancy, or placenta previa. Always contact your doctor if you’re concerned.
Weight gain

You can expect to gain between 1 and 4 pounds in your first few months of pregnancy. Weight gain
becomes more noticeable toward the beginning of your second trimester.
Pregnancy-induced hypertension

High blood pressure, or hypertension, sometimes develops during pregnancy. A number of factors can
increase your risk, including:
 being overweight or obese
 smoking
 having a prior history or a family history of pregnancy-induced hypertension

l Heartburn

Hormones released during pregnancy can sometimes relax the valve between your
stomach and esophagus. When stomach acid leaks out, this can result in heartburn.
l Constipation

Hormone changes during early pregnancy can slow down your digestive system. As a result, you may
become constipated.
l Cramps

As the muscles in your uterus begin to stretch and expand, you may feel a pulling sensation that
resembles menstrual cramps. If spotting or bleeding occurs alongside your cramps, it could signal a
miscarriage or an ectopic pregnancy.
l Back pain

Hormones and stress on the muscles are the biggest causes of back pain in early pregnancy. Later on,
your increased weight and shifted center of gravity may add to your back pain. Around half of all
pregnant women report back pain during their pregnancy.
l Anemia

Pregnant women have an increased risk of anemia, which causes symptoms such
as lightheadedness and dizziness.
The condition can lead to premature birth and low birth weight. Prenatal care usually involves
screening for anemia.
l Depression

Between 14 and 23 percent of all pregnant women develop depression during their pregnancy. The
many biological and emotional changes you experience can be contributing causes. Be sure to tell
your doctor if you don’t feel like your usual self.
l Insomnia

Insomnia is another common symptom of early pregnancy. Stress, physical discomfort, and hormonal
changes can be contributing causes. A balanced diet, good sleep habits, and yoga stretches can all
help you get a good night’s sleep.
l Breast changes

Breast changes are one of the first noticeable signs of pregnancy. Even before you’re far enough along
for a positive test, your breasts may begin to feel tender, swollen, and generally heavy or full. Your
nipples may also become larger and more sensitive, and the areolae may darken.
l Acne

Because of increased androgen hormones, many women experience acne in early pregnancy. These
hormones can make your skin oilier, which can clog pores. Pregnancy acne is usually temporary and
clears up after the baby is born.
l Vomiting

Vomiting is a component of “morning sickness,” a common symptom that usually appears within the
first four months. Morning sickness is often the first sign that you’re pregnant. Increased hormones
during early pregnancy are the main cause.
l Hip pain

Hip pain is common during pregnancy and tends to increase in late pregnancy. It can have a variety of
causes, including:
 pressure on your ligaments
 sciatica
 changes in your posture
 a heavier uterus
l Diarrhea

Diarrhea and other digestive difficulties occur frequently during pregnancy. Hormone changes, a
different diet, and added stress are all possible explanations. If diarrhea lasts more than a few days,
contact your doctor to make sure you don’t become dehydrated.
Stress and pregnancy

While pregnancy is usually a happy time, it can also be a source of stress. A new baby means big
changes to your body, your personal relationships, and even your finances. Don’t hesitate to ask your
doctor for help if you begin to feel overwhelmed.
The bottom line

If you think you may be pregnant, you shouldn’t rely solely on these signs and symptoms for
confirmation. Taking a home pregnancy test or seeing your doctor for lab testing can confirm a
possible pregnancy.
Many of these signs and symptoms can also be caused by other health conditions, such as
premenstrual syndrome (PMS). Learn more about the early symptoms of pregnancy — such as how
soon they’ll appear after you miss your period

Pregnancy is divided into three trimesters:

l First trimester – conception to 12 weeks
- A baby grows rapidly during the first trimester (weeks 1 to 12). The fetus begins developing their
brain, spinal cord, and organs. The baby’s heart will also begin to beat.
l Second trimester – 12 to 24 weeks

- During the second trimester of pregnancy (weeks 13 to 27), your healthcare provider will likely
perform an anatomy scan ultrasound.
This test checks the fetus’s body for any developmental abnormalities. The test results can also reveal
the sex of your baby, if you wish to find out before the baby is born.
You’ll probably begin to feel your baby move, kick, and punch inside of your uterus.
After 23 weeks, a baby in utero is considered “viable.” This means that it could survive living outside
of your womb. Babies born this early often have serious medical issues. Your baby has a much better
chance of being born healthy the longer you are able to carry the pregnancy.
l Third trimester – 24 to 40 weeks.
- During the third trimester (weeks 28 to 40), your weight gain will accelerate, and you may feel more
tired.
Your baby can now sense light as well as open and close their eyes. Their bones are also formed.
As labor approaches, you may feel pelvic discomfort, and your feet may swell. Contractions that don’t
lead to labor, known as Braxton-Hicks contractions, may start to occur in the weeks before you deliver.
Conception

The moment of conception is when the woman’s ovum (egg) is fertilised by the man’s sperm. The
gender and inherited characteristics are decided in that instant.
Week 1

This first week is actually your menstrual period. Because your expected birth date (EDD or EDB) is
calculated from the first day of your last period, this week counts as part of your 40-week pregnancy,
even though your baby hasn’t been conceived yet.
Week 2
Fertilisation of your egg by the sperm will take place near the end of this week.
Week 3

Thirty hours after conception, the cell splits into two. Three days later, the cell (zygote) has divided
into 16 cells. After two more days, the zygote has migrated from the fallopian tube to the uterus
(womb). Seven days after conception, the zygote burrows itself into the plump uterine lining
(endometrium). The zygote is now known as a blastocyst.
Week 4

The developing baby is tinier than a grain of rice. The rapidly dividing cells are in the process of
forming the various body systems, including the digestive system.
Week 5
The evolving neural tube will eventually become the central nervous system (brain and spinal cord).
Week 6

The baby is now known as an embryo. It is around 3 mm in length. By this stage, it is secreting special
hormones that prevent the mother from having a menstrual period.
Week 7

The heart is beating. The embryo has developed its placenta and amniotic sac. The placenta is
burrowing into the uterine wall to access oxygen and nutrients from the mother’s bloodstream.
Week 8

The embryo is now around 1.3 cm in length. The rapidly growing spinal cord looks like a tail. The head
is disproportionately large.
Week 9

The eyes, mouth and tongue are forming. The tiny muscles allow the embryo to start moving about.
Blood cells are being made by the embryo’s liver.
Week 10

The embryo is now known as a fetus and is about 2.5 cm in length. All of the bodily organs are formed.
The hands and feet, which previously looked like nubs or paddles, are now evolving fingers and toes.
The brain is active and has brain waves.
Week 11
Teeth are budding inside the gums. The tiny heart is developing further.
Week 12

The fingers and toes are recognisable, but still stuck together with webs of skin. The first trimester
combined screening test (maternal blood test + ultrasound of baby) can be done around this time.
This test checks for trisomy 18 (Edward syndrome) and trisomy 21 (Down syndrome).
Week 13
The fetus can swim about quite vigorously. It is now more than 7 cm in length.
Week 14

The eyelids are fused over the fully developed eyes. The baby can now mutely cry, since it has vocal
cords. It may even start sucking its thumb. The fingers and toes are growing nails.
Week 16

The fetus is around 14 cm in length. Eyelashes and eyebrows have appeared, and the tongue has
tastebuds. The second trimester maternal serum screening will be offered at this time if the first
trimester test was not done (see week 12).
Week 18-20

An ultrasound will be offered. This fetal morphology scan is to check for structural abnormalities,
position of placenta and multiple pregnancies. Interestingly, hiccoughs in the fetus can often be
observed.
Week 20

The fetus is around 21 cm in length. The ears are fully functioning and can hear muffled sounds from
the outside world. The fingertips have prints. The genitals can now be distinguished with an
ultrasound scan.
Week 24

The fetus is around 33 cm in length. The fused eyelids now separate into upper and lower lids,
enabling the baby to open and shut its eyes. The skin is covered in fine hair (lanugo) and protected by
a layer of waxy secretion (vernix). The baby makes breathing movements with its lungs.
Week 28

Your baby now weighs about 1 kg (1,000 g) or 2 lb 2oz (two pounds, two ounces) and measures about
25 cm (10 inches) from crown to rump. The crown-to-toe length is around 37 cm. The growing body
has caught up with the large head and the baby now seems more in proportion.
Week 32

The baby spends most of its time asleep. Its movements are strong and coordinated. It has probably
assumed the ‘head down’ position by now, in preparation for birth.
Week 36

The baby is around 46 cm in length. It has probably nestled its head into its mother’s pelvis, ready for
birth. If it is born now, its chances for survival are excellent. Development of the lungs is rapid over
the next few weeks.
Week 40

The baby is around 51 cm in length and ready to be born. It is unknown exactly what causes the onset
of labour. It is most likely a combination of physical, hormonal and emotional factors between the
mother and baby.
Where to get help

 Your doctor
 Obstetrician l Midwife

Things to remember

 Pregnancy is counted as 40 weeks, starting from the first day of the mother’s last menstrual
period. Your estimated date to birth is only to give you a guide. Babies come when they are
ready and you need to be patient.
 The gender and inherited characteristics of the baby are decided at the moment of conception.

Pregnancy tests

 Home pregnancy tests are very accurate after the first day of your missed period. If you get a
positive result on a home pregnancy test, you should schedule an appointment with your doctor
right away. An ultrasound will be used to confirm and date your pregnancy.
 Pregnancy is diagnosed by measuring the body’s levels of human chorionic gonadotropin (hCG).
Also referred to as the pregnancy hormone, hCG is produced upon implantation. However, it
may not be detected until after you miss a period.

 After you miss a period, hCG levels increase rapidly. hCG is detected through either a urine or a
blood test.

 Blood tests can be performed in a laboratory. hCG blood tests are about as accurate as home
pregnancy tests. The difference is that blood tests may be ordered as soon as six days after
ovulation.

Pregnancy and vaginal discharge

 An increase in vaginal discharge is one of the earliest signs of pregnancy. Your production of
discharge may increase as early as one to two weeks after conception, before you’ve even
missed a period.

 As your pregnancy progresses, you’ll continue to produce increasing amounts of discharge. The
discharge will also tend to become thicker and occur more frequently. It’s usually heaviest at the
end of your pregnancy.

 During the final weeks of your pregnancy, your discharge may contain streaks of thick mucus
and blood. This is called “the bloody show.” It can be an early sign of labor. You should let your
doctor know if you have any bleeding.

 Normal vaginal discharge, or leukorrhea, is thin and either clear or milky white. It’s also
mildsmelling.
 If your discharge is yellow, green, or gray with a strong, unpleasant odor, it’s considered
abnormal.

 Abnormal discharge can be a sign of an infection or a problem with your pregnancy, especially if
there’s redness, itching, or vulvar swelling.

 If you think you have abnormal vaginal discharge, let your healthcare provider know
immediately.

Pregnancy and urinary tract infections (UTIs)

Urinary tract infections (UTIs) are one of the most common complications women experience during
pregnancy. Bacteria can get inside a woman’s urethra, or urinary tract, and can move up into the
bladder. The fetus puts added pressure on the bladder, which can cause the bacteria to be trapped,
causing an infection.
Symptoms of a UTI usually include pain and burning or frequent urination. You may also experience:
 cloudy or blood-tinged urine
 pelvic pain
 lower back pain
 fever
 nausea and vomiting

Nearly 18 percent of pregnant women develop a UTI. You can help prevent these infections by
emptying your bladder frequently, especially before and after sex. Drink plenty of water to stay
hydrated. Avoid using douches and harsh soaps in the genital area.
Contact your healthcare provider if you have symptoms of a UTI. Infections during pregnancy can be
dangerous because they increase the risk of premature labor.
When caught early, most UTIs can be treated with antibiotics that are effective against bacteria but
still safe for use during pregnancy. Follow the advice here to prevent UTIs before they even start.
Pregnancy or PMS

The symptoms of early pregnancy can often mimic those of premenstrual syndrome (PMS). It may be
difficult for a woman to know if she’s pregnant or simply experiencing the onset of another menstrual
period.
It’s important for a woman to know as soon as possible if she’s pregnant so that she can get proper
prenatal care. She may also want to make certain lifestyle changes, such as abstaining from alcohol,
taking prenatal vitamins, and optimizing her diet.
Taking a pregnancy test is the best, and easiest, way to determine if it’s PMS or early pregnancy. You
can take a home test or visit your healthcare provider.
Some common symptoms of both PMS and early pregnancy include:
 breast pain
 bleeding
 mood changes
 fatigue
 food sensitivities l cramping

Pregnancy diet

A healthy pregnancy diet should be much the same as your typical healthy diet, only with 340 to 450
additional calories per day. Aim for a healthy mix of foods, including:
 complex carbohydrates
 protein
 vegetables and fruits
 grains and legumes
 healthy fats

If you already eat a healthy diet, you’ll only need to make slight changes. Fluids, fiber, and iron-rich
foods are especially important during pregnancy.
Vitamins and minerals

Pregnant women require larger amounts of some vitamins and minerals than women who aren’t
pregnant. Folic acid and zinc are just two examples.
Once you find out you’re pregnant, you may wish to increase your vitamin and mineral intake with
the help of supplements.
Pregnancy and exercise

Exercise is essential to keeping you fit, relaxed, and ready for labor. Yoga stretches in particular will
help you stay limber. It’s important not to overdo your stretches, however, as you could risk injury.
Other good exercises for pregnancy are gentle Pilates, walking, and swimming.
Pregnancy massage

Practicing relaxation techniques can help relieve some of the stress and anxiety you may feel
throughout your pregnancy.
If you’re searching for ways to stay calm, consider trying a prenatal massage. A prenatal massage is
good for relieving mild tension. It may also help ease your body and muscle aches.
Massages are generally safe at any time during your pregnancy. Some facilities avoid performing them
in the first trimester because the risk of miscarriage is highest during this period.
Essential oils

Using essential oils during pregnancy is controversial. Some healthcare professionals say that certain
oils can be safe and helpful for relaxing and alleviating pain during pregnancy and labor. However,
they also warn against using the oils in the first trimester.
Other risk factors

Other factors that can affect an otherwise healthy pregnancy include:

 multiple-birth pregnancies, such as twins or triplets
 infections, including STDs
 being overweight or obese l anemia

Pregnancy complications

Pregnancy complications can involve the baby’s health, the mother’s health, or both. They can occur
during pregnancy or delivery.
Common pregnancy complications include:
 high blood pressure
 gestational diabetes
 preeclampsia
 preterm labor
 Miscarriage

Addressing them early can minimize the harms done to the mother or the baby. Know your options
when it comes to treating pregnancy complications.
Pregnancy and labor

Sometime after your fourth month of pregnancy, you may begin to experience Braxton-Hicks
contractions, or false labor. They’re completely normal and serve to prepare your uterus for the job
ahead of real labor.
Braxton-Hicks contractions don’t occur at regular intervals, and they don’t increase in intensity. If you
experience regular contractions before week 37, it could be preterm labor. If this occurs, call your
healthcare provider for help.
Early labor

Labor contractions are generally classified as early labor contractions and active labor contractions.
Early labor contractions last between 30 and 45 seconds. They may be far apart at first, but by the
end of early labor, contractions will be about five minutes apart.
Your water might break early during labor, or your doctor may break it for you later on during your
labor. When the cervix begins to open, you’ll see a blood-tinged discharge coating your mucous plug.
Active labor

In active labor, the cervix dilates, and the contractions get closer together and become more intense.
If you’re in active labor, you should call your healthcare provider and head to your birth setting. If
you’re unsure whether it’s active labor, it’s still a good idea to call and check in.
Labor pain

Pain will be at its height during active labor. Have a discussion with your doctor about your preferred
method of dealing with pain.
You may choose drug-free measures such as meditation, yoga, or listening to music. If you
choose to manage your pain with drugs, your doctor will need to know whether to use
analgesics or anesthetics.
Analgesics, such as meperidine (Demerol), dull the pain but allow you to retain some feeling.
Anesthetics, such as an epidural, prevent certain muscle movement and completely block the pain.
Prognosis

You’re likely to move through each week of your pregnancy without too much trouble. Pregnancy
brings with it many changes to your body, but those changes don’t always have a serious impact on
your health.
However, certain lifestyle choices can either help or actively harm your baby’s development.
Some actions that can keep you and your baby healthy include:
 taking a multivitamin
 getting sufficient sleep
 practicing safe sex
 getting a flu shot
 visiting your dentist

Some things you’ll want to avoid include:

 smoking
 drinking alcohol
 eating raw meat, deli meat, or unpasteurized dairy products
 sitting in a hot tub or sauna
 gaining too much weight

MEDICATIONS

Safe Medications to Take During Pregnancy

Type of Remedy: Allergy

 Diphenhydramine (Benadryl®)
 Loratidine (Claritin®) l Cetirizine (Zyrtec®)

Type of Remedy: Cold and Flu

 Diphenhydramine (Benadryl)*
 Dextromethorphan (Robitussin®)*
 Guaifenesin (Mucinex® [plain]) *
 Vicks Vapor Rub® mentholated cream
 Mentholated or non-mentholated cough drops
 (Sugar-free cough drops for gestational diabetes should not contain blends of herbs or
aspartame)
 Pseudoephedrine ([Sudafed®] after 1st trimester)
 Acetaminophen (Tylenol®)*
 Saline nasal drops or spray
 Warm salt/water gargle

*Note: Do not take the "SA" (Sustained Action) form of these drugs or the "Multi-Symptom" form of
these drugs. Do not use Nyquil® due to its high alcohol content
Type of Remedy: Diarrhea

 Loperamide ([Imodium®] after 1st trimester, for 24 hours only)

Type of Remedy: Constipation

 Methylcellulose fiber (Citrucel®) l Docusate (Colace®)

 psyllium (Fiberall®, Metamucil®)
 polycarbophil (FiberCon®)
 polyethylene glycol (MiraLAX®)*

*Note: *Occasional use only

Type of Remedy: First Aid Ointment

 Bacitracin
 Neomycin/polymyxin B/bacitracin (Neosporin®)

Type of Remedy: Headache

 Acetaminophen (Tylenol)
 Type of Remedy: Heartburn
 Safe Medications to Take During Pregnancy
 Aluminum hydroxide/magnesium carbonate (Gaviscon®)*
 Famotidine (Pepcid AC®)
 Aluminum hydroxide/magnesium hydroxide (Maalox®)
 Calcium carbonate/magnesium carbonate (Mylanta®)
 Calcium carbonate (Titralac®, Tums®)
 Ranitidine (Zantac®)

*Note: *Occasional use only

Type of Remedy: Hemorrhoids

 Phenylephrine/mineral oil/petrolatum (Preparation H®)

 Witch hazel (Tucks® pads or ointment)

Type of Remedy: Insect repellant

 N,N-diethyl-meta-toluamide (DEET®)

Type of Remedy: Nausea and Vomiting

l Diphenhydramine (Benadryl) l
Vitamin B6
Type of Remedy: Rashes

 Diphenhydramine cream (Benadryl)

 Hydrocortisone cream or ointment
 Oatmeal bath (Aveeno®)

Type of Remedy: Sleep

 Diphenhydramine (Unisom SleepGels®, Benadryl)

Type of Remedy: Yeast Infection

l Miconazole (Monistat®)
*Please note: No drug can be considered 100% safe to use during pregnancy.
[DOCUMENT TITLE]
POLYCYSTIC OVARIAN SYNDROME

- Polycystic ovary syndrome (PCOS) is a kind of ovarian cyst illness or hormonal imbalance. A
malfunction in the hypothalamic-pituitary ovarian network or axis causes endocrine illness
which includes tiny ovarian cyst and persistent anovulation and hyperandrogenism. It is
common and occurs in approximately 6% to 15% women of childbearing age
- PCOS increases a woman’s risk for infertility, endometrial hyperplasia or carcinoma, and
cardiovascular disease.
FEATURES OF PCOS ARE:

• obesity
• insulin resistance
• glucose intolerance
• dyslipidemia
• sleep apnea
• infertility
S/s of PCOS

• Irregular menstrual
• periods, resulting from lack of regular ovulation
• infertility
• obesity, and;
• hirsutism, may be a presenting complaint.

Women with PCOS are at increased risk for diabetes, increased

blood lipids, cardiovascular disease, nonalcoholic fatty liver disease as well as

anxiety and depression (Pfieffer, 2019).

MEDICAL MANAGEMENT OF PCOS

- The treatment of polycystic ovary syndrome consists of lifestyle changes including weight loss
and pharmacotherapy. Oral contraceptive agents are often prescribed to treat PCOS (ACOG,
2018b; Pfieffer, 2019).
- When pregnancy is desired, medications to stimulate ovulation (clomiphene citrate) are often
effective. Lifestyle modification is critical, and weight management is part of the treatment
plan.
- Weight loss as little as 5% to 10% of total body weight can help with hormone imbalance and
infertility. Metformin often regulates periods and can help with weight loss (ACOG, 2018b;
Pfieffer, 2019).
- Women with this diagnosis are at increased risk for endometrial cancer due to anovulation.
 INFERTILITY
In general, infertility is defined as not being able to get pregnant (conceive) after one year (or longer)
of unprotected sex. Because fertility in women is known to decline steadily with age, some providers
evaluate and treat women aged 35 years or older after 6 months of unprotected sex

⚫ Primary infertility is when someone is not able to conceive at all.

⚫ Secondary infertility is when someone has previously conceived but is no longer able to.
Infertility causes
Infertility is defined as the inability to get pregnant after 12 months of trying. Any person of either sex
who fits this definition is experiencing infertility.
Causes in females
Infertility in females can also have a range of causes.
Problems with ovulation
Ovulation disorders make up about 25%Trusted Source of infertility cases in females. Ovulation is the
monthly release of an egg. The eggs may never be released, or they may only be released in some
cycles.
Ovulation disorders can occur due to:
⚫ Hyperprolactinemia: If prolactin levels are high and the female is not pregnant or breastfeeding,
it may affect ovulation and fertility.

⚫ Thyroid problems: An overactive or underactive thyroid gland can lead to a hormonal imbalance
that interferes with ovulation.

⚫ Polycystic ovary syndrome (PCOS): This is a hormonal condition that can cause frequent or
prolonged menstruation and can interfere with ovulation.
Problems in the uterus or fallopian tubes can also prevent the egg from traveling from the ovary to the
uterus, or womb. If the egg does not travel, it can be harder to conceive naturally.
Other causes include:
⚫ Chronic conditions: These include AIDS or cancer.

⚫ Primary ovarian insufficiency (POI): The ovaries stop working normally before the age of 40
years.

⚫ Poor egg quality: The quality of the eggs may interfere with conception. As a female ages, the
number and quality of the eggs declines. Eggs that are damaged or develop genetic abnormalities
may also not be able to sustain a pregnancy. The older a female is, the higher the risk.

⚫ Surgery: Pelvic surgery can sometimes cause scarring or damage to the fallopian tubes. Cervical
surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the
uterus.

⚫ Submucosal fibroids: Benign or noncancerous tumors occur in the muscular wall of the uterus.
They can interfere with implantation or blockTrusted Source the fallopian tube, preventing sperm
from fertilizing the egg.
⚫ Endometriosis: Cells that normally occur within the lining of the uterus start growing elsewhere
in the body.

⚫ Tubal ligation: In females who have chosen to have their fallopian tubes blocked, the process can
be reversed, but the chances of becoming fertile again are not high.
Infertility tests for females
A female will undergo a general physical examination, and the doctor will ask about medical history,
medications, menstruation cycle, and sexual habits.
They will also undergo a gynecologic examination and a number of tests:

⚫ Blood test: This can assess hormone levels and whether a female is ovulating.

⚫ Hysterosalpingography: A technician injects fluid into the uterus and takes X-rays to determine
whether the fluid travels properly out of the uterus and into the fallopian tubes. If a blockage is
present, surgery may be necessary.

⚫ Laparoscopy: A thin, flexible tube with a camera at the end is inserted into the abdomen and
pelvis, allowing a doctor to look at the fallopian tubes, uterus, and ovaries. This can reveal signs
of endometriosis, scarring, blockages, and some irregularities in the uterus and fallopian tubes.

⚫ Transvaginal ultrasound: Unlike an abdominal ultrasound (where the probe is placed over the
belly), this test is done by inserting an ultrasound wand into the vagina. It allows the healthcare
provider a better view of organs like the uterus and ovaries.

⚫ Saline sonohysterogram (SIS): This test is used to look at the lining of the uterus and assess for
polyps, fibroids or other structural abnormalities. Saline (water) is used to fill the uterus, allowing
the healthcare provider to get a better view of the uterine cavity during a transvaginal
ultrasound.

⚫ Hysteroscopy: In this test, a device called a hysteroscope (a flexible, thin device with a camera on
it) is inserted into the vagina and through the cervix. The healthcare provider moves it into the
uterus to view the inside of the organ.

Other tests can include:

⚫ ovarian reserve testing to count the eggs after ovulation

⚫ pelvic ultrasound to produce an image of the uterus and ovaries
⚫ thyroid function test, as this may affect the hormonal balance
What are some complications of infertility?
If conception does not occur, it can lead to stress and possibly depression. Some physical effects may
also result from treatment for infertility. For example, a female could getTrusted Source ovarian
hyperstimulation syndrome (OHSS) from taking medications to stimulate the ovaries. Another
complication can be an ectopic pregnancy.
Multiple pregnancies may also result from fertility treatment. If there are too many embryos, carrying
all of them to term may causeTrusted Source health problems during the pregnancy.
How is female infertility treated?
Once your healthcare provider has diagnosed female infertility and pinpointed the cause, there are a
variety of treatment options. The cause of the infertility guides the type of treatment. For example,
structural problems may be treated through surgery, while hormonal medications can be used for
other issues (ovulation issues, thyroid conditions).
Many patients will require artificial insemination (injecting washed sperm into the uterus after
ovulation) or in vitro fertilization (fertilizing eggs with sperm in the lab to make embryos, then
transferring the embryo into the uterus).
Adoption and gestational surrogacy may also be options for women with infertility who wish to start a

family.

How is female infertility treated?

Treatments for infertility include:
⚫ Medications: Fertility drugs change hormone levels to stimulate ovulation.
⚫ Surgery: Surgery can open blocked fallopian tubes and remove uterine fibroids and polyps.
Surgical treatment of endometriosis doubles a woman’s chances of pregnancy.
Types of fertility drugs for women
Some fertility drugs try to prompt ovulation in a woman who is not ovulating regularly. Others
are hormones a woman must take before artificial insemination.
Drugs to cause ovulation
Some women ovulate irregularly or not at all. About 1 in 4 women with infertility have issues with
ovulation.
Drugs that can treat ovulation issues include:

⚫ Metformin (Glucophage): This can decrease insulin resistance. Women with polycystic ovary
syndrome (PCOS), especially those with a body mass index over 35, may be insulin resistant,
which can cause problems with ovulation.

⚫ Dopamine agonists: These drugs reduce levels of a hormone called prolactin. In some women,
having too much prolactin causes ovulation issues.

⚫ Clomiphene (Clomid): This drug can trigger ovulation. Many doctors recommend it as the first
treatment option for a woman with ovulation problems.

⚫ Letrozole (Femara): Like clomiphene, letrozole can trigger ovulation. Among women with PCOS,
especially those with obesity, letrozole may work better. A 2014 studyTrusted Source found that
27.5 percent of women with PCOS who took letrozole eventually gave birth, compared to 19.1
percent of those who took clomiphene.

⚫ Gonadotropins: This group of hormones stimulates activity in the ovaries, including ovulation.
When other treatments do not work, a doctor may recommend using a follicle-stimulating
hormone and a luteinizing hormone in the group. People receive this treatment as an injection or
nasal spray.
Hormones before artificial insemination

Drugs cannot treat some causes of infertility.

When this occurs, or when a doctor cannot identify the cause of infertility, they may recommend
artificial insemination.
Intrauterine insemination (IUI) involves inserting sperm directly into the uterus around the time of
ovulation.
It may improve the chances of conceiving when there is an issue with the cervical mucus or the
mobility of the sperm, or when the doctor cannot detect the cause of infertility.
A doctor may recommend taking the following before IUI:

⚫ Ovulation drugs: Clomiphene or letrozole, for example, can induce the body to ovulate and,
possibly, to release extra eggs.

⚫ Ovulation trigger: Because timing the moment of ovulation is essential, many doctors
recommend an ovulation “trigger” shot of the hormone human chorionic gonadotropin (hCG).

⚫ Progesterone: This hormone can help sustain early pregnancy, and a woman usually takes it via a
vaginal suppository.
In vitro fertilization (IVF) involves removing one or more eggs so that a doctor can fertilize them with
sperm in a petri dish. If the eggs grow into embryos, the doctor implants them into the uterus. IVF
requires several drugs, including:
⚫ Ovulation suppression: If a woman ovulates too early, IVF may not work. Many doctors prescribe
gonadotropin antagonist hormones to prevent early ovulation.

⚫ Ovulation drugs: IVF is more likely to succeed, like IUI, if the ovaries to release several eggs. A
doctor will prescribe clomiphene or letrozole to cause this.

⚫ Ovulation trigger shot: IVF also has a better chance of success if the doctor can control the
moment of ovulation using a trigger shot with the hormone hCG.

⚫ Progesterone: A woman receiving IVF will take progesterone to help support early pregnancy.
When treating infertility, a doctor may recommend taking hormonal birth control temporarily to help
regulate the menstrual cycle. It can also help prepare the body for artificial insemination
Side effects
Many women experience side effects of fertility drugs, especially those that contain hormones. The
most common side effects include:

⚫ mood changes, including mood swings, anxiety, and depression

⚫ temporary physical side effects, including nausea, vomiting, headaches, cramps, and breast
tenderness
⚫ ovarian hyperstimulation syndrome
⚫ multiple births
⚫ increased risk of pregnancy loss
Injected Hormones

If Clomid on its own doesn't work, your doctor may recommend hormones to trigger ovulation. Some
of the types are:
⚫ Human chorionic gonadotropin(hCG), such as Novarel, Ovidrel, Pregnyl, and Profasi. This
medication is usually used along with other fertility drugs to trigger your ovaries to release an
egg.

⚫ Follicle-stimulating hormone (FSH), such as Bravelle, Fertinex, Follistim, and Gonal-F. These
drugs trigger the growth of eggs in your ovaries.

⚫ Human menopausal gonadotropin (hMG), such as Menopur, Metrodin, Pergonal, and Repronex.
This drug combines FSH and LH (luteinizing hormone).

⚫ Gonadotropin-releasing hormone (GnRH), such as Factrel and Lutrepulse. This hormone triggers
the release of FSH and LH from your pituitary gland, but it's rarely prescribed in the U.S.

⚫ Gonadotropin-releasing hormone agonist (GnRH agonist), such as Lupron, Synarel, and Zoladex.

⚫ Gonadotropin-releasing hormone antagonist (GnRH antagonist), such as Antagon and Cetrotide.

These drugs aren't pills that you swallow. Instead, you take them as shots. The dose varies, depending
on how they're being used.
Some are given beneath the skin, while others are injected into the muscle. You can get the injections
on your stomach, upper arm, upper thigh, or buttocks.
You usually start taking them during your cycle, the second or third day after you see bright red blood,
and continue taking them for 7 to 12 straight days. Sometimes, you may need to get injections along
with Clomid that you take by mouth.
Side effects: Most are mild and include problems like tenderness, infection, and blood blisters,
swelling, or bruising at the injection site. There's also a risk of a condition called ovarian
hyperstimulation, which makes your ovaries grow and become tender.
Diagnostic Evaluation (Cervical Screening)
• Performed in the management of female physiologic processes
• The nurse should educate the patient about the purpose, what to expect, and any possible side
effects related to these examinations prior to testing.
• The nurse should be aware of contraindications, potential complications, and trends in results.
• Trends provide information about disease progression as well as the patient’s response to
therapy.

Pap Smear - Cytologic Test for Cancer

• To detect cervical cancer by;
• Gently removing cervical secretions from the cervical os, transferred to a glass slide, and fixed
immediately by spraying with a fixative or immersed in solution.
• If the Pap smear reveals atypical cells, the liquid method allows for HPV testing.
• Terminologies to describe findings:
✓ No abnormal or atypical cells
✓ Atypical squamous cells of undetermined significance
✓ Inflammatory reactions and microbes identified
✓ Positive DNA test for HPV
✓ Precancerous and cancerous lesions of the cervix identified
• If the Pap smear (liquid immersion method) shows atypical cells and no high-risk HPV types, the
next Pap smear is performed in 1 year.
• If a specific infection is causing inflammation, it is treated appropriately, and the Pap smear is
repeated.
• If the repeat Pap smear reveals atypical squamous cells with high-risk HPV types; colposcopy
may be indicated.
• Pap smears that indicate precancerous lesions should be repeated in 4 to 6 months; unresolved
lesions = colposcopy
• Pap smears that indicate cancerous lesions; prompt colposcopy.
• If the Pap smear results are abnormal; prompt notification, evaluation, and treatment.
• Notification of px; responsibility of a nurse
• Pap smear follow-up is essential for early detection of cervical cancer.
• Intensive telephone counseling, tracking systems, brochures, videos, and financial incentives
have all been used to encourage follow-up.
• The nurse provides clear explanations and emotional support along with a carefully designed
setting-specific follow-up protocol designed to meet the needs of the patient.

Colposcopy and Cervical Biopsy

• colposcopy is performed when cervical cytology screening result requires evaluation

• colposcope - instrument with a magnifying lens that allows the examiner to visualize the cervix
and obtain a sample of abnormal tissue for analysis.
• Requires special training in this diagnostic technique for nurse practitioners.
 • After inserting a speculum and visualizing the cervix and vaginal walls, the examiner applies
acetic acid to the cervix
• Subsequent abnormal findings; need for biopsy include:
✓ Leukoplakia – white plaque visible before applying acetic acid
✓ acetowhite tissue - white epithelium after applying acetic acid
✓ punctation - dilated capillaries occurring in a dotted or stippled pattern
✓ mosaicism – a tilelike pattern
✓ atypical vascular patterns
• Biopsy specimens show precancerous cells, the patient usually requires cryotherapy, laser
therapy, or a cone biopsy (excision of an inverted tissue cone from the cervix)

Cryotherapy and Laser Therapy

• Cryotherapy - freezing cervical tissue with nitrous oxide; may result in cramping and
occasional feelings of faintness (vasovagal response)
• A watery discharge is normal for a few weeks after the procedure as the cervix heals;
however, excessive bleeding, pain, or fever should be reported to the primary provider. •
laser treatment - used in the outpatient setting

Cone Biopsy and Loop Electrosurgical Excision Procedure

• If the lesion extends into the canal or if endocervical curettage findings indicate abnormal
changes; px may undergo a cone biopsy.
• can be performed surgically or with a procedure called loop electrosurgical excision procedure
(LEEP) which uses a laser beam
• performed in the outpatient setting
• LEEP is associated with a high success rate in removal of abnormal cervical tissue
• Procedure: gynecologist excises a small amount of cervical tissue, and the pathologist examines
the borders of the specimen to determine if disease is present
• Patient received anesthesia for a surgical cone biopsy is advised to rest for 24 hours after the
procedure and to leave any vaginal packing in place until it is removed (usually the next day).
The patient is instructed to report any excessive bleeding.
• Nurse should provide guidelines regarding postoperative sexual activity, bathing, and other
activities.
✓ Patient is cautioned to avoid penile-vaginal intercourse until healing is complete and
verified at follow-up because open tissue may be potentially exposed to HIV and other
pathogens.

Endometrial (Aspiration) Biopsy

• method of obtaining endometrial tissue

• performed as an outpatient procedure
• usually indicated in cases of midlife irregular bleeding, postmenopausal bleeding, and irregular
bleeding while taking hormone therapy or tamoxifen.
• Contraindication: presence of a viable and desired pregnancy
• Patient may experience slight discomfort in this procedure
• The examiner may apply a tenaculum (a clamplike instrument that stabilizes the uterus) after the
pelvic examination and then inserts a thin, hollow, flexible suction tube (Pipelle or sampler)
through the cervix into the uterus.
• Findings: normal endometrial tissue, hyperplasia, or endometrial cancer
• Simple hyperplasia - overgrowth of the uterine lining and is usually treated with progesterone.
• Complex hyperplasia - overgrowth of cells with abnormal features; risk factor for uterine
cancer and is treated with progesterone and careful follow-up.
• Women who are overweight, who are older than 45 years, who have a history of nulliparity and
infertility, or who have a family history of colon cancer seem to be at higher risk for hyperplasia.

Dilation and Curettage (D&C)

• may be diagnostic (identifies the cause of irregular bleeding) or therapeutic (often temporarily
stops irregular bleeding).
• Procedure - The cervical canal is widened with a dilator, and the uterine endometrium is scraped
with a curette
• Purpose: to secure endometrial or endocervical tissue for cytologic examination, to control
abnormal uterine bleeding, and as a therapeutic measure for incomplete abortion.
• D&C is usually carried out under anesthesia and requires surgical asepsis; usually performed in
the operating room
• The nurse explains the procedure, preparation, and expectations regarding postoperative
discomfort and bleeding
• Patient is instructed to void before the procedure
• The patient is placed in the lithotomy position; a perineal pad is placed over the perineum after
the procedure, and excessive bleeding is reported.
• No restrictions are placed on dietary intake. If pelvic discomfort or low back pain occurs, mild
analgesic medications usually provide relief
• The primary provider indicates when sexual activity may be safely resumed.
• To reduce the risk of infection and bleeding, most gynecologists advise no vaginal penetration or
use of tampons for 2 weeks.

Prostatitis
• inflammation of the prostate gland
• associated with lower urinary tract symptoms and symptoms of sexual discomfort and
dysfunction.
• may be caused by infectious agents (bacteria, fungi, mycoplasma) or other conditions (e.g.,
urethral stricture, BPH)
• Escherichia coli is the most commonly isolated organism, although Klebsiella and Proteus
species are also found.
• four types of prostatitis:
✓ acute bacterial prostatitis (type I)
✓ chronic bacterial prostatitis (type II)
✓ chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (type III)
- classified as type IIIA(presence) or type IIIB(absence) of WBC in semen after prostate
massage.
✓ asymptomatic inflammatory prostatitis (type IV)
• Contributing factors: stress, neuromuscular factors, and myofascial pain
 Clinical Manifestations

• Acute prostatitis(Type I): sudden onset of fever, dysuria, perineal prostatic pain, and severe
lower urinary tract symptoms(dysuria, frequency, urgency, hesitancy, and nocturia)
• Type II: typically asymptomatic between episodes
• Type III: have no bacteria in the urine in the presence of genitourinary pain.
• Type IV: diagnosed incidentally during a workup for infertility, an elevated PSA test, or other
disorders.

Assessment

• thorough history and examination

Medical Management

- GOAL: eradicate the causal organisms

- Hospital admission: for patients with unstable vital signs, sepsis, or intractable pelvic pain; frail or
immunosuppressed; diabetes or renal insufficiency

- antibiotic agents, including trimethoprim-sulfamethoxazole or a fluoroquinolone(ciprofloxacin)

prescription if bacteria are cultured from the urine - continuous therapy: low-dose antibiotic

agents

- afebrile, normal urinalysis: anti-inflammatory agents

- bladder and prostate relaxation: Alpha-adrenergic blocker therapy (tamsulosin)

-nonpharmacologic therapies for stress, neuromuscular factors, and myofascial pain: biofeedback,
pelvic floor training, physical therapy, reduction of prostatic fluid retention by ejaculation through
penile-vaginal intercourse or masturbation, sitz baths, stool softeners, and evaluation of sexual
partners to reduce the possibility of cross-infection.

Key word:
Colposcopy – colcoscope, acetic acid

Cryotherapy – nitrous oxide

Cone biopsy – laser beam, anesthesia

Endometrial biopsy – tennaculum, pipelle/sampler

SEXUALLY TRANSMITTED INFECTIONS / SEXUALLY TRANSMITTED

DISEASES
  Sexually transmitted infections (STIs) are also commonly called sexually
transmitted diseases (STDs). They are the infections you get from another
person through sexual contact.
 STDs always begin as an STI. The initial infection occurs when bacteria,
viruses, or parasites infiltrate the body.
 A STI can become a disease if the foreign bodies begin to disrupt normal
processes —this usually means symptoms start appearing.
 Examples of STDs include pelvic inflammatory disease (PID), which results
from an untreated chlamydia or gonorrhea infection, and cervical cancer,
which can be caused by the human papillomavirus (HPV).
 Remember, not all STIs will become an STD, even if they are left untreated.

How do the male reproductive organs work?

The male reproductive system is specialized for the following functions:

 To produce, maintain and transport sperm (the male reproductive cells) and protective fluid
(semen)
 To discharge sperm within the female reproductive tract  To produce and secrete male sex
hormones

The male reproductive anatomy includes external structures which include the:

 Penis
 Scrotum
 Testicles (testes)

The male reproductive anatomy includes internal structures which include the:

 Vas Deferens
 Ejaculatory ducts
 Urethra
 Seminal Vesicles
 Prostate Gland
 Bulbourethral Glands (Cowper’s Gland)

How do the female reproductive organs work?

 The female reproductive system provides several functions. The ovaries
produce the female egg cells, called the ova or oocytes. The oocytes are then
transported to the fallopian tube where fertilization by a sperm may occur. The
fertilized egg then moves to the uterus, where the uterine lining has thickened
in response to the normal hormones of the reproductive cycle. Once in the
uterus the fertilized egg can implant into thickened uterine lining and continue
to develop. If fertilization does not take place, the uterine lining is shed as
menstrual flow. In addition, the female reproductive system produces female
sex hormones that maintain the reproductive cycle.
 During menopause the female reproductive system gradually stops making the
female hormones necessary for the reproductive cycle to work. At this point,
menstrual cycles can become irregular and eventually stop. One year after
 menstrual cycles stop, the woman is considered to be menopausal. The female
reproductive anatomy includes both external and internal structures.
 The function of the external female reproductive structures (the genital) is
twofold: To enable sperm to enter the body and to protect the internal genital
organs from infectious organisms.

The main external structures of the female reproductive system include:

 Labia Majora 
Labia minora
 Bartholin Glands 
Clitoris

The female reproductive anatomy includes internal structures which include the:
 Vagina
 Uterus (Womb) 
Ovaries
 Fallopian Tubes

Symptoms

Often, there are no symptoms at all.

Men may experience the following symptoms:
 Burning or itching in the penis
 A drip (discharge) from the penis
 Pain around pelvis
 Sores, bumps or blisters on penis, anus, or mouth
 Burning and pain with urine or with bowel movements  Having to go to the bathroom often

Women may experience the following symptoms:

 Burning or itching in the vagina
 A discharge or odor from the vagina
 Pain around the pelvis
 Bleeding from the vagina that is not normal
 Pain deep inside during sex
 Sores, bumps or blisters in the vagina, anus, or mouth
 Burning and pain with urine or with bowel movements
 Having to go to the bathroom often

Complications

STD complications for women and anyone assigned female at birth include:
 Pelvic inflammatory disease.
 Ectopic pregnancy.
 Infertility.
 Chronic pelvic pain.

In men and people assigned male at birth, untreated STDs can lead to:
 Infections in the urethra.
 Swollen, sore testicles.  Infertility.

Causes
What causes STDs?
  Bacteria and viruses that grow in warm, moist places in the body cause STDs.
They are passed from one person to another through sex. Infections can spread
from the penis, vagina, mouth or anus. These infections can be minor or they
can be very painful, even life threatening.

How do sexually transmitted infections spread?

 They are spread through fluids in the body. Most often shared during vaginal,
oral or anal sex. Some STDs pass from one person to another through infected
blood. For example, among people who share infected drug needles. Or a
mother may infect her child during pregnancy, childbirth or nursing. STDs are
not spread through casual contact. Shaking hands, sharing clothes, or sharing a
toilet seat, for example, would not lead to STDs.

Who is at risk?

 Anyone can get a STD. Teenagers and young adults have the highest risk.
They are more likely to have many sex partners, and they may not know how
to prevent problems. Street-drug users who use dirty needles are also at risk

Diagnosis

A health care professional can diagnose STIs. They will ask personal questions about your sex history.
It’s important to be honest so you can get help. They may take a sample of fluid from the vagina or
penis, or a blood test to confirm the problem. Laboratory tests can show what, if any, bacterial or viral
STIs are present.
 Blood tests can show if you have a disease that infects the blood.
 Urine samples can show if you have a bacteria in your urine from an STI.
 Fluid samples can show if you have active sores and help diagnose the type of infection.

Treatment
Chlamydia

 Sometimes people have no sign that they have this disease. A man with
chlamydia may feel pain when urinating or see fluid drip from the penis. A
woman may bleed between periods, feel pain when urinating, see a discharge or
feel mild pain in the lower belly. From anal sex, a patient may have anal bleeding
or pain.
 Once diagnosed, a person can be treated with an antibiotic. If untreated, it can
cause serious damage to a woman's reproductive system. It can make it difficult or
impossible to get pregnant.

Gonorrhea

 Gonorrhea can cause infections in the genitals, rectum, and throat. Young
people, age 15-24, are most often affected. You can get it by having unprotected
vaginal, anal, or oral sex with someone who has the disease.
 It may show no symptoms. Or, a person may find a discharge from the penis or
vagina, and feel pain when urinating.
  Gonorrhea is treated with antibiotics. If untreated, it can cause serious damage
to a woman's reproductive system. It can make it difficult or impossible to get
pregnant. In men, if this is left untreated it may cause urethral stricture.

Syphilis

 This is a potentially life-threatening bacterial infection from vaginal, anal or

oral sex. It could spread if the sores caused by syphilis touch the skin of a healthy
person. Sores can be found on the penis, vagina, anus, in the rectum, or on the lips
and mouth. Syphilis can also spread from an infected mother to her unborn baby.
 Usually, the first symptom is a painless open sore. Sores can form on your
genitals, or the palms of your hands and soles of your feet. The second stage rash
can look like rough, red, or reddish-brown spots.
 Penicillin is a successful treatment. If syphilis is not treated, it can remain in
the body for years. It can cause serious problems including paralysis (unable to
move body parts), mental disorders, damage to organs and even death.

Genital Herpes

 This infection is very common. One in six people (age 14-49) has genital
herpes. Many people don’t know they have it. This infection, caused by two
viruses, Herpes Simplex Virus Type 1 (HSV-1) and Herpes Simplex Virus Type 2
(HSV-2).
 The Herpes Simplex Virus Type 1 (HSV-1) is mostly spread by nonsexual
contact but it can spread with oral sex. HSV-1 usually causes sores on the lips.
 The Herpes Simplex Virus Type 2 (HSV-2) spreads when fluid from the
infection touches a partner, often during sex. Genital blisters from HSV-2 may not
be seen.
 Blisters can form, break, cause pain and take weeks to heal. There is no known
cure for HSV, but symptoms can be treated with antiviral medicine.

Acquired Immune Deficiency Syndrome (AIDS)

 AIDS results from an infection with the human immunodeficiency virus (HIV).
It is not curable, and potentially deadly. It attacks the body's immune system.
 Only blood, semen ( cum), pre-seminal fluid ( pre-cum), rectal fluids, vaginal
fluids, and breast milk carry the virus. Infected needles or other sharp tools can
spread AIDS as well. An infected mother can give her baby the virus during
pregnancy, childbirth or nursing.
 Some people have no signs if they get it. Others may feel like they have a bad
flu for a long time. The virus can go un-noticed for many years. If you think
you’ve been in contact with an infected person, you should get tested.
 Antiviral, HIV medicines are available to improve the life and health of an
infected person.
Hepatitis B (HBV)

 This STI is a serious virus that attacks the liver. Effective vaccines since the
1990s have helped to prevent this infection. There are fewer cases every year.
Blood, semen and body fluids shared during sex can spread the virus. Many
people are born with the disease from their infected mother. Getting care to
people with long-term HBV is important but often people have no clear
symptoms.
 When symptoms are present, they can include fever, headache, muscle aches,
fatigue, poor appetite, vomiting and diarrhea. Since HBV attacks liver cells, it
can lead to cirrhosis, liver cancer, liver failure and possibly death. Dark urine,
abdominal pain and yellowing of the skin or eyes are signs of liver damage.
 There is no known cure for hepatitis B. Still, medications to treat chronic
infection will help. Vaccine is the best protection. Acute HBV has no
treatment. Chronic HBV is treated with antiviral medicines, interferon
treatment, or a liver transplant. Vaccine is the best prevention.

Genital Warts

 These warts are caused by the human papillomavirus (HPV). HPV is the most
common viral STI the United States. It is spread through vaginal or anal sex. It
can be passed even when an infected person has no symptoms.
 The warts that develop are painless, fleshy, cauliflower-looking bumps. They
grow on the penis or in and around the entrance of the vagina or anus. HPV
may eventually cause cervical cancer.
 Fortunately, there is a successful vaccine to prevent HPV and genital warts.
The vaccine is given to children age 11 or 12, or for people age 20-26. There is
no known cure for genital warts. However, they can be treated with topical
ointments. Sometimes they can be removed with minor surgical procedures
(e.g., cautery (freezing or burning off the wart), chemicals, or laser). Vaccine is
the best prevention.

Trichomoniasis

 This STI results from a parasite. It is spread through sexual contact from the
penis or vagina. It mainly affects young, sexually active women.
Uncircumcised men are found to spread the infection more. Only about 30% of
people with this STI have symptoms.
 Men with this STI may feel itching or irritation inside the penis. They may see
discharge or feel burning after urination or ejaculation. Women may notice
itching, burning, redness or soreness, discomfort with urination. Or, they may
have an unusual discharge with a bad smell. Having trichomoniasis can make it
feel unpleasant to have sex.
 Without treatment, the infection can last for months or even years. Women
with it may deliver underweight babies. Trichomoniasis can be easily treated
with antibiotics
After Treatment
Most STIs/STDs are cured after treatment. Some require life-long management with antiviral medicine.
STDs can return with risky sexual behavior. Some people chose to get tested often, to ensure that they
don’t have a STI. It is possible to prevent STIs and limit your chances of getting another
How can STIs/STDs be prevented?

The only way to avoid a STI or STD is to have no sexual contact with an infected person. Other
protections include:
 Using a condom correctly, and always with sex
 Having a sexual relationship with only one, long-term partner who has no infections
 Limiting the number of sexual partners you have
 Using clean needles if you are injecting drugs

Treatment

STDs or STIs caused by bacteria are generally easier to treat. Viral infections can be managed but not
always cured.
If you are pregnant and have an STI, getting treatment right away can prevent or reduce the risk of your
baby becoming infected.
Treatment for STIs usually consists of one of the following, depending on the infection:
 Antibiotics. Antibiotics, often in a single dose, can cure many sexually transmitted bacterial and
parasitic infections, including gonorrhea, syphilis, chlamydia and trichomoniasis. Typically, you'll
be treated for gonorrhea and chlamydia at the same time because the two infections often appear
together.

Once you start antibiotic treatment, it's necessary to finish the prescription. If you don't think you'll be
able to take medication as prescribed, tell your doctor. A shorter, simpler course of treatment may be
available.
In addition, it's important to abstain from sex until seven days after you've completed antibiotic
treatment and any sores have healed. Experts also suggest women be retested in about three months
because there's a high chance of reinfection.

 Antiviral drugs. If you have herpes or HIV, you'll be prescribed an antiviral drug. You'll have
fewer herpes recurrences if you take daily suppressive therapy with a prescription antiviral drug.
However, it's still possible to give your partner herpes.

Antiviral drugs can keep HIV infection in check for many years. But you will still carry the virus and
can still transmit it, though the risk is lower.
The sooner you start HIV treatment, the more effective it is. If you take your medications exactly as
directed, it's possible to reduce the viral load in the blood so that it can hardly be detected.
Medications

Medications for Sexually Transmitted Infections

HIV/AIDS

Nucleoside Reverse Transcriptase Inhibitors abacavir, didanosine (ddl), lamivudine (3TC),

stavudine (d4T), zalcitabine (ddC), zidovudine (ZDV)
Protease Inhibitors indinavir, nelfinavir, ritonavir, saquinavir,
lopinavir plus ritonavir
Nonnucleoside Reverse Transcriptase Inhibitors
delavirdine, efavirenz, nevirapine
Chlamydia

Antibiotics
azithromycin,erythromycin,doxycycline
Gonorrhea

Antibiotics ceftriaxone, cefixime,

ciprofloxacin, ofloxacin
Gonorrhea and chlamydia can occur in tandem, in which event the doctor might prescribe a regimen of
ceftriaxone plus doxycycline or azithromycin.
Pelvic Inflammatory Disease (PID)

Antibiotics cefotetan or cefoxitin plus doxycycline, clindamycin plus gentamicin, ofloxacin plus
metronidazole
Typically, two antibiotics are prescribed.
Human Papillomavirus (HPV)

Topical Preparations (creams and solutions that the patient applies directly to the affected area)
imiquimod, podophyllin, podofilox, fluorouracil (5-FU), trichloroacetic acid (TCA), interferon
Genital Herpes

Antivirals acyclovir, famciclovir,

valacyclovir
Syphilis

Antibiotics
penicillin—doxycycline or tetracycline only if allergic to penicillin