Care Of Clients With

Reproductive Disorders

By Ogbuka J. N
 ASSESSMENT OF CLIENTS WITH
REPRODUCTIVE DISORDERS
FEMALE REPRODUCTIVE DISORDERS
A clear and focused history is essential.

Patients may feel awkward or even reluctant to give a

full account of some aspects of the history, and may
need prompting with specific questions.

It is the skill of the clinician to obtain the relevant

history.

The history-taking should be conducted with sensitivity,

but details should be pursued according to the
importance and relevance to the presenting problem.
Be sensitive but unembarrassed.

A statement such as 'I am sorry to ask you such an

embarrassing question' may make the patient feel
worse, as it suggests that the nurse may also be
embarrassed.

Try instead to signpost - explain that you need to

ask some questions which may feel personal in
order to try to get to the bottom of the problem.

If necessary explain why you are asking the

question: for example, if asking about positional
pain during intercourse, explain that this can give
you an idea of which internal structures or organs
 History of presenting complaint
Pain

Pain: onset, nature, time course, radiation,

exacerbating or relieving factors.
These points can be remembered with the mnemonic
'SOCRATES': [Site] [Onset] [Character] [Radiation]
[Associated symptoms][Time] [Exacerbating/relieving]
[Severity].
Onset - establish how, when and where.
Ask whether the patient has had any previous
investigation or treatment.
Discuss relationship to menses (eg, dysmenorrhoea).
Discuss relationship to intercourse ( 'Dyspareunia').
Determine the effect of the pain on life and work.
Discuss the patient's ideas, concerns and expectations.
Dyspareunia
Determine whether this is superficial (eg, vaginismus,
episiotomy scar) or deep (uterine, cervical or adnexal).
Note whether there is radiation.
Ask whether it is preventing penetration or full
intercourse.
Ask whether libido and foreplay are adequate.
Discuss positional factors. Pain relating to deep
penetration may come from the ovaries.
Ask whether there is dryness/atrophy.
Note whether there is any rash.
Ask whether it is intermittent/recurrent or always
present.
Establish the degree of distress.
Note whether there is evidence of mood disorder.
Discuss relationship to menses. Note whether the
patient is postmenopausal.
Urinary symptoms
If pain is a urinary symptom, discuss relationship
to micturition.
Establish whether there is urethral discharge.
Discuss frequency of micturition (day and night).
Establish urgency.
Urge incontinence - note whether this leads to
partial or total voiding.
Stress incontinence - note what provokes this and
whether it leads to partial or total voiding.
Discuss whether there is restriction on normal
activities and plans.
Ask whether symptoms are intermittent/recurrent
or always present.
Vaginal discharge
Establish the colour of vaginal discharge and
whether or not it is bloodstained.
NB: physiological discharge is usually scanty,
mucoid and pale/colourless; it should not be
offensive. Therefore, discuss with the patient:
Discharge odour.
Consistency of discharge.
Whether there is associated itch, burn or fever.
Discuss use of gels, douches, vaginal deodorants
or perfumed bath additives.
Ask whether there is associated localised
tenderness (eg, Bartholinitis).
Abnormal vaginal bleeding
Note whether the patient has clotting and/or
flooding.
Establish whether there is intermenstrual or
postcoital bleeding.
Establish periodicity.
Discuss relationship to menses and relationship
to coitus.
Ask whether there is possibility of pregnancy.
Having obtained all relevant information
regarding the presenting complaint, ask the
patient about their:
Ideas about the problem.
Concerns or anxieties regarding the cause.
Expectations from the clinician.
 Menstrual history
 Age at menarche:
 Average age in the is approximately 12 years. There is some variation
according to ethnicity.
 Body weight is a factor (average weight at onset 48 kg).
 If there is concern about abnormal puberty (precocious puberty, delayed
puberty) ask about onset of other secondary sexual characteristics and
thelarche (onset of breast development).
 Ask whether the patient is sexually active and, if so, when last active. Ask
about contraceptive method and whether they are trying for a baby.
 In primary amenorrhoea:
 Look for presence of secondary sexual characteristics.
 Consider imperforate hymen (very rare).
 Look for features suggesting genetic abnormality - eg, Turner syndrome.
 Look for features of hyperandrogenism.
 Consider relevant causes of secondary amenorrhoea:
 Physiological: pregnancy, lactation (the only pre-menopausal patient who cannot be
pregnant is one who has not been having intercourse).
 Psychological: look for mood abnormalities.
 Record BMI (low BMI suggesting anorexia nervosa).
 Extrinsic hormonal causes: drugs such as the contraceptive pill, and progestogen-only
contraceptive methods.
 Intrinsic hormonal causes: hypothalamic, pituitary, thyroid and adrenal disorders.
 Ovarian factors: polycystic ovaries, ovarian tumours, ovarian infection,
primary ovarian failure .
The pattern of the menstrual cycle. Record:
First day of last normal menstrual period.
Days of blood loss.
Length of cycle.
Whether blood loss was heavy: number of tampons
and/or pads, whether clots were present.
What form of contraception is used.
Any discharge other than the menses.
The normal menstrual cycle:
Range is 21 to 35 days and average is 28.
Most healthy, fertile women have regular cycles with
1 or 2 days of variation.
Blood loss is 50-200 mls and averages 70 mls.
Guide to loss is use of pads and tampons.
Passage of large clots suggests excessive bleeding
.
 Abnormal patterns of bleeding:
Polymenorrhoea: unusually frequent periods.
Oligomenorrhoea: unusually infrequent or scanty periods
(common around puberty).
Menorrhagia: unusually heavy periods.
Menometrorrhagia: prolonged, excessive and irregular
uterine bleeding.
Intermenstrual bleeding (bleeding between periods):
 Breakthrough bleeding on the pill.
 Diseases of the uterus and cervix.
 Mucosal disorders.
 Postcoital bleeding (usually local cervical or uterine disease).
Postmenopausal bleeding: bleeding occurring over 12
months after amenorrhoea of menopause.
Dysfunctional uterine bleeding:
 Abnormal bleeding that cannot be ascribed to pelvic pathology.
 Regular pattern suggests ovulation occurring.
Psychosexual history
This needs to be conducted sensitively. It requires
experience, knowledge and good clinical judgement
to recognise and define underlying psychosexual
problems and differentiate them from other causes
of symptoms (dyspareunia, low abdominal or pelvic
pain, for example). A history should include enquiry
about:
Relationship details, including issues of sexuality.
Intercourse and sexual practices.
Libido.
Orgasm.
Association of other symptoms.
If it seems relevant/there are cues, ask about
previous negative sexual experiences

 Obstetric history
 Ask whether the patient has ever been pregnant.
 Record completed and unsuccessful pregnancies.
 Take details of gestation at time of any miscarriages or
terminations.
 Note complications of pregnancy, particularly gestational
diabetes, hypertension, HELLP syndrome - a condition related to
pre-eclampsia and characterised by:
H aemolysis
EL (elevated liver) enzymes
LP (low platelet) count
 Ask about features of labour which might encourage weakness of
the pelvic floor, resulting in stress incontinence):
Note length of labour and whether there was any prolonged pushing.
Note size of babies - a larger baby, particularly if there was shoulder
dystocia - may increase the chances of later stress incontinence.
Ask whether any methods of assisted delivery were required
(forceps, caesarean section).
Ask whether there was postpartum haemorrhage.
 Note complications in the puerperium - eg, depression
 Other symptoms
 Loin pain; urinary calculi can cause ureteric obstruction and lead to
severe loin pain which radiates to the symphysis pubis and groin.
The sudden onset of pain in renal colic or acute urinary retention
contrasts with the gradual build-up of pain from a renal tumour or
the slow development of urinary symptoms from outflow
obstruction. Ask about associated features such as pain, haematuria
or incontinence.
 Urinary incontinence; may be stress incontinence, detrusor
instability, detrusor underactivity or urethral obstruction.
 Urethral discharge may occur as a result of a
sexually transmitted disease.
 Systemic symptoms of acute kidney injury or chronic kidney disease
- eg, anorexia, vomiting, fatigue, pruritus and peripheral oedema.
 Some patients have no symptoms but abnormalities are discovered
on measuring blood pressure or abnormalities on routine urinalysis,
renal function or serum biochemistry.
 Occupational history
 Exposure to chemical carcinogens such as 2-naphthylamine or
benzidine in the chemical or rubber industries (these may induce
bladder cancer many years later).
 Foreign travel
 Travel to Egypt or Africa may result in exposure to schistosomiasis.
 Dehydration during time in a hot climate may lead to development of
kidney stones.
 Family history
 Any family history of chronic kidney or polycystic kidney disease
 Past medical history
 Neurological diseases may cause abnormal bladder function - eg,
Parkinson's disease, multiple sclerosis or cerebrovascular disease.
 Any previous kidney disease, hypertension, diabetes, gout or back
injury may be relevant. Abdominal or pelvic surgery can cause
denervation injury to the bladder.
 Previous surgery - eg, for urinary incontinence.
 Ureteric injury may occur following abdominal or gynaecological
operations.
 Medication history
 A full current and past medication history is important.
 Past history of prolonged analgesic use may be a cause of
chronic kidney disease.
 Dosages of some drugs may need to be adjusted or stopped in
 Female genitourinary examination
 Preparation for the examination
 Equipment should have been prepared beforehand.
 Taking the history can help establish rapport and help patients prepare for
the intrusive examination which may follow.
 Most patients will be prepared for an examination if their symptoms suggest
that such examination is likely to be required.
 Nevertheless, time should be taken to explain any examination: you need to
explain exactly what you are about to do, and why.
 Make sure that you have clear consent to proceed.
 Patients should be warned about discomfort or pain when and if this is likely.
 Advise patients that if at any point during the examination they are
uncomfortable or would like you to stop then they need to indicate this and
you will stop at once.
 Ensure comfort and privacy are maintained with basic facilities for
undressing.
 Offer chaperones, preferably nurses, who are qualified to assist and reassure
the patient. Ideally the chaperone should speak the patient's language, as
this avoids misunderstanding. Failing this, consider offering a translator
outside or inside the curtain as the patient wishes, in addition to the nurse
chaperone. If none is available offer to postpone the examination unless you
feel it is clinically urgent and cannot wait.
General examination
This should detect conditions which may either
present or complicate genitourinary disease.
Examples include:
Hirsutism and/or acne, reflecting possible endocrine
disorders.
Anaemia, which commonly accompanies menstrual
disorders.
Conditions which are associated with menstrual
symptoms:
Thyroid disease
Cushing's syndrome
Anorexia nervosa
Other chronic diseases
Breast examination.
Lymphadenopathy, especially inguinal nodes.
 Abdominal examination
 The uterus, vagina and adenax lie within the pelvis but findings
relevant to the genitourinary system may be visible, palpable and
percussible in the abdomen. Careful abdominal examination may
detect:
 Abdominal masses arising from the pelvis:
Large ovarian cysts, which can be detected by abdominal percussion
revealing central dullness.
Pregnancy (often used to equate the size of other pelvic tumours):
 12 weeks - palpable above the pubic bone.
 16 weeks - palpable midway between the pubic bone and umbilicus.
 20 weeks - just below the umbilicus.
 28 weeks - just midway between the umbilicus and xiphisternum.
 34 weeks - just below the xiphisternum.

 Palpable bladder in urinary retention.

 Tender bowel loops suggesting irritable bowel disease or other gut
pathology. This is an important cause of dyspareunia.
 Renal angle tenderness suggesting a renal cause for pain.
 Ascites: percussion reveals lateral dullness and a tympanic central
abdomen.
Examining external genitalia
Prepare for examination:
Position the patient with help of a chaperone on to
the couch (supine, flexed hips and knees with heels
together, thighs abducted).
Cover the patient's abdomen with a sheet.
Position lighting to give a clear view of external
genitalia.
Put on disposable gloves.
Examination of the vulva
Explain the procedure to the patient.
Systematically examine the labia majora, labia
minora, introitus, urethra and clitoris.
Bartholin's glands are not normally tender or
palpable.
Examination of the vagina
It is next appropriate to assess whether further
examination (both digital and speculum) is
appropriate or possible. If the patient has never
been sexually active and is not using tampons,
further internal examination would be
inappropriate. NB: the hymen is normally always
perforate, even in babies, despite the opinion of
many courts of law.
The practice of rectal examination to assess the
genitalia indirectly (although technically possible) is
rarely necessary or appropriate. It should not be
performed in children and is often distressing and
unacceptable in adults. The advent of ultrasound
makes such an intrusive procedure unnecessary.
Separation of the labia and asking the patient to
 Examination of the cervix
 Clear explanation of procedure should again be offered.
 Vaginal wall and cervical examination is achieved using a speculum.
 The speculum also allows access for swabs and the taking of
cervical smears, if required.
 A single-use disposable speculum is now the norm.
 If a smear is to be taken, any lubricant other than tepid tap water
should be avoided. This is also true in some circumstances for other
samples - eg, in forensic examinations following rape.
 A bivalve or Cusco's speculum is usually used. The lateral position
and Sims' speculum may be used to assess prolapse.
 Position of the cervix relates to uterine position (anteverted, axial or
retroverted).
 Cervical os shape relates to whether the patient is parous or not.
 The cervix may be bluish in early pregnancy (Chadwick's sign).
 The squamocolumnar junction can be visualised.
 Taking of cervical smears and swabs should be in accordance with
local laboratory guidelines and instructions.
 The speculum should be removed carefully and without discomfort
to the patient.
Internal examination of the uterus
Offer explanation of the bimanual examination
required to examine the uterus, Fallopian tubes and
ovaries internally.
Expose introitus, holding the labia apart with a
gloved hand.
Introduce lubricated right index and middle fingers.
Palpate the uterus between abdominal (left) hand
and internal (right) hand.
Identify the cervix and uterus. The right and left
adnexa are not normally palpable.
Assess size, consistency and mobility of organs felt.
Identify tenderness.
In pregnancy the cervix softens (Hegar's sign).
Cervical excitation may occur with infection or
 Male genitourinary history
Care should again be taken to ensure privacy and
comfort for both history and examination. Establish
confidence and rapport.
Allow the patient to describe their complaint or
problem.
It may be appropriate and necessary to ask details
about sexual and psychosexual history.
Sign-posting these intimate and personal questions
and explaining their importance can facilitate better
co-operation from the historian.
Specific, closed questioning may be appropriate.
Significant symptoms and history are described
below.
 Urinary symptoms
 The history of urinary symptoms should cover the following
questions:
 Is there dysuria?
 Is there frequency of micturition? Is there any nocturia?
 Is there any terminal dribbling of micturition?
 Is there hesitancy of micturition?
 How full is the urinary stream?
 Have symptoms developed gradually or suddenly?
 Is there any incontinence or urgency of micturition? There may be
stress incontinence, detrusor instability, detrusor underactivity or
urethral obstruction.
 Abnormalities of micturition in men are most often caused by
prostatism (Benign Prostatic Hyperplasia and Prostate Cancer). This
leads to hesitancy, reduced strength of urine flow and terminal
dribbling.
 Symptoms of prostatism can be assessed by using the
International Prostate Symptom Score (I-PSS) but this does not give
an indication of the degree of prostate size or nature of underlying
pathology. Complete obstruction may lead to complete inability to
 Urethral discharge
 This is a relatively common presenting symptom. Ask about:
 Dysuria.
 Possible exposure to sexually transmitted infections :
When was contact?
Has the partner had symptoms?
Are there any other symptoms? - for example, with
reactive arthritis:
 Joint pains.
 Eye inflammation, pain or grittiness.
 Gastrointestinal symptoms.

 Testicular pain
 This can be an intense pain. Enquiry should be made about:
 Trauma.
 Speed of onset.
 Association with other conditions (for example, mumps).
 Other urinary symptoms, such as dysuria or urethral discharge.
 Possible causes include trauma, infection, torsion and
epididymitis
 Genital ulcers
 Genital ulcers are likely to be caused by sexually transmitted infection. Enquiry
should be made with this in mind.
 Impotence
 Impotence covers a number of different conditions and causes. Consider:
 Emotional and psychological factors.
 Drugs and alcohol.
 Any association with other relevant diseases (diabetes mellitus, neurological
disease, cardiovascular disease).
 Whether there is:
 Loss of libido.
 Erectile failure.
 Subfertility
 This may be primary (no conception) or secondary (past conception). Subfertility
history should cover:
 Conception history.
 Length of subfertility.
 Sexual history:
 Timing and frequency of intercourse.
 Impotence and ejaculation.
 Medication history.
 Medical history:
 Conditions affecting erectile function.
 Any chemotherapy or cancer treatment.
 Other symptoms
 Important examples include:
 Loin pain; urinary calculi can cause ureteric obstruction and lead to
severe loin pain which radiates to the symphysis pubis or testis.
The sudden onset of pain in renal colic or acute urinary retention
contrasts with the gradual build-up of pain from a renal tumour or
the slow development of urine symptoms from outflow obstruction.
Ask about associated features such as pain, haematuria or
incontinence.
 Systemic symptoms of acute kidney injury or
chronic kidney disease - eg, anorexia, vomiting, fatigue, pruritus
and peripheral oedema.
 Recent onset of back pain in an elderly patient may be indicative of
prostate cancer with bone metastases.
 Some patients have no symptoms but abnormalities are discovered
on measuring blood pressure or abnormalities on routine urinalysis,
renal function or serum biochemistry.
 Occupational history
 Exposure to chemical carcinogens such as 2-naphthylamine or
benzidine in the chemical or rubber industries may induce bladder
 Past medical history
 Neurological diseases may cause abnormal bladder function - eg,
Parkinson's disease, multiple sclerosis or cerebrovascular disease.
 Any history of kidney disease, hypertension, diabetes, gout or past
back injury may also be relevant. Abdominal or pelvic surgery can
cause denervation injury to the bladder.
 Previous surgery - eg, for prostatic hypertrophy.
 Ureteric injury may occur in abdominal operations.
 Medication history
 A full current and past medication history is important.
 Past history of analgesic abuse may be a cause of kidney failure.
 Dosages of some drugs may need to be adjusted or stopped in
kidney failure.
 Family history
 A family history of kidney failure or polycystic kidney disease may
be relevant to the underlying problem.
 Foreign travel
 Travel to Egypt or Africa may result in exposure to schistosomiasis.
 Dehydration during a holiday in a hot climate may lead to the
development of kidney stones.
 Male genitourinary examination
 The genitourinary examination should incorporate a general
examination and an abdominal examination.
 General examination
 General sexual development and secondary sexual
characteristics.
 Note whether there is evidence of gynaecomastia.
 Establish whether the patient is distressed due to pain or
appearing unwell, suggesting systemic illness and possibly kidney
failure.
 Note whether there is evidence of liver disease or thyroid disease.
 Note whether there is evidence of anaemia.
 All patients with urological symptoms should have their blood
pressure measured.
 Signs of dehydration such as a dry mouth and tongue may
indicate kidney failure or polyuria associated with diabetes.
 Lymphadenopathy; lymph nodes may be enlarged due to
metastatic spread from any urological cancer.
 Abdominal examination
 Abdomen may be distended due to large polycystic
kidneys or ascites due to nephrotic syndrome. Palpate for
an enlarged bladder or an abdominal aortic aneurysm.
 The kidneys are examined by bimanual examination with a
hand posteriorly lifting up the kidney towards the
examining abdominally placed hand.
 Tenderness over the kidney should be tested by gentle
pressure over the renal angle.
 Palpation for renal enlargement or masses. An enlarged
kidney usually bulges forwards. In polycystic kidney
disease, there may also be hepatomegaly from hepatic
cysts.
 Percussion for the presence of ascites (shifting dullness)
and for an enlarged bladder.
 Hernias and hernial orifices.
 Auscultation for a renal bruit in renal artery stenosis
(heard above the umbilicus, 2 cm to the left or right of the
Penis
The size and shape variation of the normal penis is
quite wide. Examination should involve inspection
and palpation of:
Prepuce, glans and foreskin - for example, to
exclude a phimosis and signs of hypospadias.
The skin should be examined for ulcers and rashes.
The shaft of the penis is examined for plaques of
Peyronie's disease.
Urethral discharge.
 Scrotum
 Inspect scrotal skin.
 Palpate testes:
 The testes should be equal in size, smooth and relatively firm.
 Size/volume can be estimated using an orchidometer (see image).
 Small firm testes suggest hypogonadism or testicular atrophy.
 Absence of a testis may indicate previous excision, undescended or
retractile.
 Identify scrotal swellings:Determine whether it is possible to get above the
swelling. With the patient standing, if it is not possible to define the upper
border of a mass in the scrotum then it is likely to be an inguinal hernia.
 Note whether the swelling is solid or cystic. Note whether there is a
hydrocele, varicocele or epididymal cyst. Testing for translucency with a
torch will determine whether the mass is cystic or a solid mass. Likely
diagnoses are:
 Attached to the testis:
 Solid (non-translucent): testicular tumour.
 Cystic (translucent): hydrocele.
 Separate from the testis:
 Solid (non-translucent): chronic epididymitis.
 Cystic (translucent): epididymal cyst.

 Examine the groin and lymphatics.

Prostate
This is examined by rectal examination to assess:
Size.
Consistency.
Any swelling. A hard lump in either or both lobes suggests a
cancer and a biopsy is needed to obtain histological proof.
Presence of the medial sulcus.
Any tenderness.
Neurological examination
Dermatome sensory loss of the perineum or lower limbs and
lower limb motor dysfunction suggest possible spinal cord or
root pathology.
Trauma or compression of the spinal cord may cause urinary
retention if acute, or urgency of micturition if a more chronic
process.
Acute compression of either the spinal cord or cauda equina
may cause bladder and bowel dysfunction and are both
neurosurgical emergencies, requiring urgent treatment to
 Diagnostic Procedures
Biopsy
A biopsy consists of removing a small sample of
tissue for examination under a microscope. Biopsy
of the vulva, vagina, cervix, or lining of the uterus
can be done.
Colposcopy
For colposcopy, a speculum is used to spread the
walls of the vagina and a binocular magnifying lens
(similar to that of a microscope) is used to inspect
the cervix for signs of cancer. Often, a sample of
tissue is removed for examination under a
microscope (biopsy).
Endocervical Curettage
Endocervical curettage consists of inserting a small,
Hysterosalpingography
For hysterosalpingography, x-rays are taken after a
radiopaque contrast agent, which can be seen on x-
rays, is injected through the cervix to outline the
interior of the uterus and fallopian tubes.
Hysteroscopy
To view the interior of the uterus, doctors can insert
a thin viewing tube (hysteroscope) through the
vagina and cervix into the uterus. The tube is about
1/4 inch in diameter and contains cables that
transmit light. Instruments used for a biopsy,
electrocautery (heat), or surgery may be threaded
through the tube.
Loop Electrical Excision Procedure
In a loop electrical excision procedure (LEEP), a thin
wire loop that conducts an electrical current is used
Pregnancy Testing
Most women who are of childbearing age and who have
gynecologic symptoms are tested for pregnancy. Doctors
take a sample of urine or sometimes blood from the woman
and test it to determine whether she is pregnant.
Saline Sonography
For saline sonography (sonohysterography), fluid is placed
in the uterus through a thin tube (catheter) that is inserted
through the vagina and then the cervix. Then
ultrasonography is done. The fluid fills and stretches
(distends) the uterus so that abnormalities inside the
uterus, such as polyps or fibroids, can be more easily
detected.
Ultrasonography
Ultrasonography (sonography) uses ultrasound waves,
produced at a frequency too high to be heard. The
ultrasound waves are emitted by a handheld device that is
placed on the abdomen (called abdominal ultrasonography)
Transvaginal Ultrasonography: An ultrasound
probe placed in the vagina allows the clinician to
check the uterus and ovaries for abnormalities
such as fibroids and ovarian cysts.
Ovarian Reserve Testing: When attempting to
test for a woman’s ovarian reserve, the clinician is
trying to predict whether she can produce an egg
or eggs of good quality and how well her ovaries
are responding to the hormonal signals from her
brain. The most common test to evaluate ovarian
reserve is a blood test for folliclestimulating
hormone (FSH) drawn on cycle day 3
Other Blood Tests: Thyroid-stimulating hormone
(TSH) and prolactin levels are useful to identify
thyroid disorders and hyperprolactinemia, which
may cause problems with fertility, menstrual
Other Blood Tests: Thyroid-stimulating hormone
(TSH) and prolactin levels are useful to identify
thyroid disorders and hyperprolactinemia, which
may cause problems with fertility, menstrual
irregularities, and repeated miscarriages. In women
who are thought to have an increase in hirsutism
(including
Urinary Luteinizing Hormone (LH): Over-the-
counter “ovulation predictor kits” detect the
presence of LH in urine and can detect a rise in this
hormone that occurs one to two days before
ovulation. In contrast to blood progesterone levels,
urinary LH tests can predict ovulation before it
occurs. Urinary LH testing helps define the times of
greatest fertility
Sonohysterography: This procedure uses
Laparoscopy: This is a surgical procedure in which
a lighted telescope-like instrument (laparoscope) is
inserted through the wall of the abdomen into the
pelvic cavity. Laparoscopy is useful to evaluate the
pelvic cavity for endometriosis, pelvic adhesions,
and other abnormalities. Laparoscopy is not a first
line option in the evaluation of a female patient.
Male Partner Semen Analysis: Although the
semen analysis is obtained from the male partner,
it is an essential part of the infertility evaluation. A
semen analysis should provide information about
the number, movement, and shape of the sperm. A
semen analysis is necessary even if the male
partner has fathered a child before.
DISORDERS OF FEMALE
REPRODUCTIVE SYSTEM.
VAGINITIS
 Vaginitis (inflammation of the vagina) is the most common
gynecologic condition encountered by females.
 Vaginitis is an inflammation of the vagina that can result in
discharge, itching and pain.
 It is a diagnosis based on the presence of symptoms of
abnormal discharge, vulvovaginal discomfort, or both.
 Cervicitis may also cause a discharge and sometimes occurs
with vaginitis.
 Discharge flows from the vagina daily as the body’s way of
maintaining a normal healthy environment.
 Normal discharge is usually clear or milky with no malodor.
 A change in the amount, color, or smell; irritation; or itching
or burning could be due to an imbalance of healthy bacteria
in the vagina, leading to vaginitis
 Types and Causes of Vaginitis
 Bacterial vaginosis. This most common type of vaginitis results from a
change of the bacteria found in the vagina, upsetting the balance.
 This type of vaginitis seems to be linked to but not caused by sex — especially
if one have multiple sex partners or a new sex partner — but it also occurs in
women who aren't sexually active.
 Yeast infections. These occur when there's an overgrowth of a fungal
organism — usually Candida albicans — in the vagina. C. albicans also causes
infections in other moist areas of the body, such as in your mouth (thrush),
skin folds and nail beds. The fungus can also cause diaper rash.
 Trichomoniasis. This common sexually transmitted infection is caused by a
microscopic, one-celled parasite called Trichomonas vaginalis. This organism
spreads during sex with someone who has the infection.
 In men, the organism usually infects the urinary tract, but often it causes no
symptoms. In women, trichomoniasis typically infects the vagina, and might
cause symptoms. It also increases women's risk of getting other sexually
transmitted infections.
 Noninfectious vaginitis. Vaginal sprays, douches, perfumed soaps, scented
detergents and spermicidal products can cause an allergic reaction or irritate
vulvar and vaginal tissues. Foreign objects, such as toilet paper or forgotten
tampons, in the vagina also can irritate vaginal tissues.
 Genitourinary syndrome of menopause (vaginal atrophy). Reduced
estrogen levels after menopause or surgical removal of ones ovaries can cause
the vaginal lining to thin, sometimes resulting in vaginal irritation, burning and
 PATHOPHYSIOLOGY
 The vagina is normally protected from infection by its acid PH
and the presence of normal flora such as Doderlin’s bacilus.
 Any factor that alters the normal vaginal physiology may
dispose to infection. If the PH or the vaginal mucosa is altered
or the woman’s resistance is decreased by age related
changes, stress or disease, her risk for infection increases.
 The use of antibiotics which destroys the normal protective
flora of the vagina also increases the risk of infection.
 . A number of factors can change the composition of the
vaginal flora, including the following:
 Age
 Sexual activity (or abuse)
 Hormonal status
 Hygiene
 Immunologic status
 Underlying skin diseases

Risk factors
Factors that increase the risk of developing vaginitis
include:
Hormonal changes, such as those associated with
pregnancy, birth control pills or menopause
Sexual activity
Having a sexually transmitted infection
Medications, such as antibiotics and steroids
Use of spermicides for birth control
Uncontrolled diabetes
Use of hygiene products such as bubble bath,
vaginal spray or vaginal deodorant
Douching
Wearing damp or tight-fitting clothing
Using an intrauterine device (IUD) for birth control
CLINICAL MANIFESTATION
Women with vaginitis typically present with one or
more of the following nonspecific vulvovaginal
symptoms:
●Change in the volume, color, or odor of vaginal
discharge
●Pruritus
●Burning
●Irritation
●Erythema
●Dyspareunia
●Spotting
●Dysuria
TREATMENT
Treatment depends on the cause. It may include
low-potency topical steroids, applied to the skin,
topical or oral antibiotics, antifungals, or
antibacterial creams.
Bacterial vaginitis (BV) is usually treated with
antibiotics, such as metronidazole (Flagyl), or
clindamycin.
Medications used to treat a fungal infection include
butoconazole and clotrimazole.
Other options include:
Cortisone cream to treat severe irritation.
Antihistamines, if the inflammation appears to
stem from an allergic reaction.
Topical estrogen cream, if the vaginitis is due to
low estrogen levels.
NURSING MANAGEMENT
 Nursing management focuses on the appropriate
use of prescribed therapy and measures to prevent
reinfection.
 The nurse instructs the woman to clean the genital
area thoroughly with mild soap and water and dry it
well before applying the any medication.
 The hands should be washed before and after
treatment.
 The nurse should advice the woman to remain in
recumbent position for 30mins after insertion of the
suppository or cream to facilitate absorption and
prevent loss from vagina
 Tampons should be avoided during treatment.
 If discharge is present she should be encouraged to
wear minipad.
Prevention of infection is an important consideration
The following measure reduces the incidence of vaginal infection
1. cleanse the general area thoroughly with mild soap and water
daily.
 Wipe genital from front to back after bowel movements.
 Avoid use of vaginal irritants e.g harsh deodorants and perfumed
soap, deodorant sprays and douches
 Do vaginal irrigation as ordered
 Avoid routine douching which can alter the vaginal PH
2. Use underwear with cotton croch and change panties daily,
avoid using any clothing that is tight in the crotch or thighs.
Avoid wearing underpant while sleeping.
3. Assess sexual partners for any signs of infection( e.g
discharge ,lesions, reddened areas on genitalias.)
Use a barrier method of contraception
Avoid any sexual practice that is painful or abrasive
Avoid anal genital intercourse.
Cleanse the genital area of self and partner and void before and
after intercourse
SEXUALLY TRANSMITTED INFECTIONS (STIS)
Sexually transmitted infections (STIs) are infections
that can be transferred from one person to another
through any type of sexual contact.
STIs are sometimes referred to as sexually
transmitted infections (STDs) since they involve the
transmission of a disease-causing organism from one
person to another during sexual activity
Many STIs are treatable, but effective cures are
lacking for others, such as HIV, HPV, and Hepatitis B
and Hepatitis C.
Even gonorrhea, once easily cured, has become
resistant to many of the older traditional antibiotics.
Many STIs can be present in, and spread by, people
who do not have any symptoms of the condition and
have not yet been diagnosed with an STIs.
.
COMMON STIS IN WOMEN.

1. CHLAMYDIA is a sexually transmitted infection caused

by the bacterium Chlamydia trachomatis.
In women, symptoms may include abnormal vaginal
discharge, burning during urination, and bleeding in
between periods, although most women do not
experience any symptoms.
Symptoms in men include pain when urinating, and
abnormal discharge from their penis. If left untreated in
both men and women, Chlamydia can infect the urinary
tract and potentially lead to pelvic inflammatory disease
(PID).
PID can cause serious problems during pregnancy and
even has the potential to cause infertility. It can cause a
woman to have a potentially deadly ectopic pregnancy,
in which the egg implants outside of the uterus.
However, Chlamydia can be cured with antibiotics.
HERPES SIMPLEX VIRUS
The two most common forms of herpes are caused by infection with
herpes simplex virus (HSV). HSV-1 is typically acquired orally and
causes cold sores, HSV-2 is usually acquired during sexual contact
and affects the genitals, however either strain may affect either
site .
Some people are asymptomatic or have very mild symptoms. Those
that do experience symptoms usually notice them 2 to 20 days after
exposure which last 2 to 4 weeks.
Symptoms can include small fluid-filled blisters, headaches,
backaches, itching or tingling sensations in the genital or anal area,
pain during urination, Flu like symptoms, swollen glands, or fever.
Herpes is spread through skin contact with a person infected with the
virus. The virus affects the areas where it entered the body. This can
occur through kissing, vaginal intercourse, oral sex or anal sex.
The virus is most infectious during times when there are visible
symptoms, however those who are asymptomatic can still spread
the virus through skin contact.
The initial infection and symptoms are usually the most severe
because the body does not have any antibodies built up.
After the primary attack, one might have recurring attacks that are
THE HUMAN PAPILLOMA VIRUS (HPV)
 The human papilloma virus (HPV) is the most common STI in
the United States
 There are more than 40 different strands of HPV and many do
not cause any health problems.
 In 90% of cases the body's immune system clears the
infection naturally within 2 years. Some cases may not be
cleared and can lead to genital warts (bumps around the
genitals that can be small or large, raised or flat, or shaped
like cauliflower) or cervical cancer and other HPV related
cancers.
 Symptoms might not show up until advanced stages.
 It is important for women to get pap smears in order to check
for and treat cancers.
 There are also two vaccines available for women (Cervarix and
Gardasil) that protect against the types of HPV that cause
cervical cancer.
 HPV can be passed through genital-to-genital contact as well
as during oral sex. It is important to remember that the
GONORRHEA
Gonorrhea is caused by bacterium that lives on moist
mucous membranes in the urethra, vagina, rectum, mouth,
throat, and eyes.
The infection can spread through contact with the penis,
vagina, mouth or anus. Symptoms of gonorrhea usually
appear 2 to 5 days after contact with an infected partner.
However, some men might not notice symptoms for up to a
month. Symptoms in men include burning and pain while
urinating, increased urinary frequency, discharge from the
penis (white, green, or yellow in color), red or swollen
urethra, swollen or tender testicles, or sore throat.
Symptoms in women may include vaginal discharge, burning
or itching while urinating, painful sexual intercourse, severe
fever or pain in lower abdomen (if infection spreads to
fallopian tubes), or however, many women do not show any
symptoms.
There are some antibiotic resistant strains for Gonorrhea but
most cases can be cured with antibiotics.
SYPHILIS
Syphilis is an STI caused by a bacterium. Untreated,
it can lead to complications and death.
Clinical manifestations of syphilis include the
ulceration of the uro-genital tract, mouth or rectum.
 If left untreated the symptoms worsen.
 In recent years, the prevalence of syphilis has
declined in Western Europe, but it has increased in
Eastern Europe (former Soviet states).
A high incidence of syphilis can be found in places
such as Cameroon, Cambodia, Papua New Guinea.
TRICHOMONIASIS
Trichomoniasis is a common STI that is caused by infection
with a protozoan parasite called Trichomonas vaginalis
Trichomoniasis affects both women and men, but
symptoms are more common in women.
Most patients are treated with an antibiotic called
metronidazole, which is very effective.
HIV (HUMAN IMMUNODEFICIENCY VIRUS)
HIV (Human Immunodeficiency Virus) damages the body's
immune system, which interferes with its ability to fight
off disease-causing agents.
The virus kills CD4 cells, which are white blood cells that
help fight off various infections.
HIV is carried in body fluids, and is spread by sexual
activity.
It can also be spread by contact with infected blood,
breast feeding, childbirth, and from mother to child
 ENDOMETRIOSIS
 Endometriosis is the abnormal growth of endometrial tissue similar
to that which lines the interior of the uterus, but in a location
outside of the uterus.
 Endometriosis is a common gynecological condition affecting an
estimated 2 to 10 percent of women of childbearing age. The
name of this condition comes from the word "endometrium," which
is the tissue that lines the uterus.
 During a woman's regular menstrual cycle, this tissue builds up
and is shed if she does not become pregnant. Women with
endometriosis develop tissue that looks and acts like endometrial
tissue outside of the uterus, usually on other reproductive organs
inside the pelvis or in the abdominal cavity.
 Each month, this misplaced tissue responds to the hormonal
changes of the menstrual cycle by building up and breaking down
just as the endometrium does, resulting in small bleeding inside of
the pelvis.
 This leads to inflammation, swelling and scarring of the normal
tissue surrounding the endometriosis implants.
COMMON SITES OF ENDOMETRIOSIS INCLUDE:
 The ovaries
 The fallopian tubes
 Ligaments that support the uterus (uterosacral ligaments)
 The posterior cul-de-sac, i.e., the space between the uterus and
rectum
 The anterior cul-de-sac, i.e., the space between the uterus and
bladder
 The outer surface of the uterus
 The lining of the pelvic cavity
 Occasionally, endometrial tissue is found in other places, such as:
 The intestines
 The rectum
 The bladder
 The vagina
 The cervix
 The vulva
 Abdominal surgery scars
 Pathophysiology of Endometriosis
 Endometrial cells are transported from the uterine cavity during
menstruation and subsequently become implanted at ectopic sites.
 Retrograde flow of menstrual tissue through the fallopian tubes is
common and could transport endometrial cells intra-abdominally; the
lymphatic or circulatory system could transport endometrial cells to
distant sites (eg, the pleural cavity).
 Another hypothesis is metaplasia: Coelomic epithelium is transformed
into endometrium-like glands.
 Microscopically, endometriotic implants consist of glands and stroma
identical to intrauterine endometrium.
 These tissues contain estrogen and progesterone receptors and thus
usually grow, differentiate, and bleed in response to changes in
hormone levels during the menstrual cycle; also, these tissues can
produce estrogen and prostaglandins.
 Implants may become self-sustaining or regress, as may occur during
pregnancy (probably because progesterone levels are high).
 Ultimately, the implants cause inflammation and increase the
number of activated macrophages and the production of
proinflammatory cytokines.
SIGNS AND SYMPTOMS
 The following are the most common symptoms for endometriosis, but
each woman may experience symptoms differently or some may not
exhibit any symptoms at all. Symptoms of endometriosis may
include:
 Pain, especially excessive menstrual cramps that may be felt in the
abdomen or lower back
 Pain during intercourse
 Abnormal or heavy menstrual flow
 Infertility
 Painful urination during menstrual periods
 Painful bowel movements during menstrual periods
 Other gastrointestinal problems, such as diarrhea, constipation and/or
nausea
 It is important to note that the amount of pain a woman experiences
is not necessarily related to the severity of the disease. Some women
with severe endometriosis may experience no pain, while others with
a milder form of the disease may have severe pain or other
symptoms.
DIAGNOSIS
It can be difficult for a medical professional to
diagnose endometriosis because no specific test
can confirm it, and the symptoms may be hard to
see. The symptoms can also resemble the
symptoms of other conditions.
Possible diagnostic strategies:
a pelvic exam
imaging tests, such as an ultrasound or MRI scan
laparoscopy
a biopsy
Surgical laparoscopy is the only way to confirm a
diagnosis of endometriosis. This is a
minimally invasive procedure in which a doctor
inserts a laparoscope through a small incision in the
pelvic area. This provides images of tissue changes.
Stage Category Features

Isolated implants and no

1 Minimal
significant adhesions

Superficial implants on
the peritoneum and
2 Mild
ovaries; no significant
adhesions.

Multiple implants, both

superficial and deeply
3 Moderate invasive. Adhesions may
be present about the
tubes and ovaries.

Multiple superficial and

deep implants and large
4 Severe ovarian endometriomas;
dense, filmy adhesions
in most cases.
 CAUSES AND RISK FACTORS
 Experts do not know exactly why endometriosis happens.
 Two known risk factors are starting menstruation before the age of 11 years
and heavy and prolonged menstruation, but other factors may play a role.
 These include
 genetic factors, as it appears to run in families
 problems with menstrual flow, resulting in blood and tissue not leaving the
body
 immune system problems, in which the immune system does not eliminate
unwanted tissue
 high levels of the hormone estrogen in the body
 surgery to the abdominal area, such as a cesarean delivery or hysterectomy
 shorter menstrual cycle
 alcohol and caffeine consumption
 Experts have linked some health conditions with endometriosis. These
include:
 allergies
 asthma
 sensitivity to some chemicals
 some autoimmune diseases
 chronic fatigue syndrome
 ovarian cancer and breast cancer
TREATMENT
There is currently no cure for endometriosis, but
various treatment options may help manage symptoms.
They include:
Pain relief
Medications can help manage pain. They include
nonsteroidal anti-inflammatory drugs such as ibuprofen
and drugs to relieve painful menstruation.
If over-the-counter options do not help, a doctor may
prescribe stronger drugs.
Hormonal treatment
A doctor may recommend birth control pills or other
hormonal methods of birth control, such as the In some
cases, they may recommend gonadotrophin-releasing
hormone.
These may reduce estrogen levels and help limit the
development of unwanted tissue. However, they cannot
Surgery
 If other treatments do not work, a doctor may recommend
surgery to remove unwanted tissue. In some cases, a
hysterectomy with removal of both ovaries may be necessary.
Fertility treatment
 If endometriosis affects fertility, in-vitro fertilization may be
an option.

Natural remedies
 Some complementary and alternative treatments and
lifestyle choices may help manage endometriosis symptoms.
T
 acupuncture
 herbal medicine
 avoiding caffeine
 counseling

NURSING MANAGEMENT
Endometriosis is a lifelong, chronic, progressive
disease that requires ongoing, supportive,
collaborative management with the patient
because pain can recur despite treatment.
Understanding that pain management and fertility
issues greatly impact the patient's quality of life,
the Nurse must address these needs to reduce pain
and prevent infertility by providing the necessary
patient education about their disease process,
diagnosis, current treatment options, and
medication side effects.
As nurses play a key role in patient teaching and
health promotion to reduce disease progression, it
is essential for practitioners to cultivate
partnerships with patients, in order to provide
 PELVIC INFLAMMATORY DISEASE (PID)

 Pelvic inflammatory disease (PID) is an infection of the

female reproductive organs.
 Pelvic inflammatory disease (PID) is an infection occurring predominantly
in sexually active young women. Chlamydia trachomatis and Neisseria
gonorrhoeae are common causes; however, other cervical, enteric,
bacterial vaginosis–associated, and respiratory pathogens,
including Mycobacterium tuberculosis, may be involved.
 PID can be acute, chronic, or subclinical and is often underdiagnosed.
 Untreated PID can lead to chronic pelvic pain, infertility, ectopic
pregnancy, and intra-abdominal infections.
 It most often occurs when sexually transmitted bacteria spread from the
vagina to the uterus, fallopian tubes or ovaries.
 Several different types of bacteria can cause PID, including the same
bacteria that cause the sexually transmitted infections (STIs), gonorrhea
and chlamydia.
 What commonly occurs is that bacteria first enter the vagina and cause an
infection. As time passes, this infection can move into the pelvic organs.
 PID can become extremely dangerous, even life-threatening, if the
infection spreads to the blood.
Women with PID may present with a variety of clinical signs
and symptoms that range from unnoticeable or subtle and
mild to severe.

PID can go unrecognized by women and their health care

providers when the symptoms are mild.

Despite lack of symptoms, histologic evidence of

endometritis has been demonstrated in women with
subclinical PID.

When present, signs and symptoms of PID are nonspecific,

so other reproductive tract illnesses and diseases of both
the urinary and the gastrointestinal tracts should be
considered when evaluating a sexually active woman with
lower abdominal pain.

Pregnancy (including ectopic pregnancy) must also be

causes pelvic inflammatory disease (PID)
Bacteria entering the reproductive tract often cause pelvic
inflammatory disease. These bacteria are passed from the
vagina, through the cervix, into the uterus, fallopian tubes
and ovaries, and into the pelvis.
Normally, when bacteria enter the vagina, the cervix keeps
them from spreading deeper to other reproductive organs.
But sometimes, the cervix becomes infected from an STI like
gonorrhea and chlamydia. When that happens, it’s less able
to keep bacteria out.
Untreated gonorrhea and chlamydia cause about 90% of PID
cases. Other causes include:
Abortion.
Childbirth.
Pelvic procedures.
Insertion of an intrauterine device (IUD), either copper or
hormonal. The risk is highest in the few weeks after
insertion. Many times this type of infection is preventable
Pathophysiology
PID is often the result of untreated cervicitis. The
organism infecting the cervix ascends higher into the
uterus, fallopian tubes, ovaries, peritoneal cavity
pathogenic organisms usually are introduced from
outside the body and pass up the cervical canal into the
uterus .

The common causative organisms include: Chlamydia

trachomatis , N. gonorrhoeae and hemophilus , as
wellas Mycoplasma genitalium, Gardnerella vaginalis,
and Ureaplasma urealyticum in streptococci and
anaerobes.

These organisms may gain entrance during sexual

intercourse or after pregnance or termination of
pregnancy.
Infection can also reach the upper genital tract from
the parametrium through the lymphatic system or,
rarely, through hematogenous routes, such as in
patients with tuberculosis.

 Many of the pathogens lodge in the fallopian tube

and create an acute or chronic inflammatory
reactions. purulent materials collect in the tubes,
adhesions and strictures form and sterility which is
the one of the most consequences of PID occurs.

Partial obstruction of the tubes may cause ectopic

pregnancy because the ovum can not reach the
uterus .

 Inflammatory adhesions may become so severe

Symptoms of pelvic inflammatory disease
(PID)
PID often does not cause any obvious symptoms.
Most symptoms are mild and may include 1 or more
of the following:
pain around the pelvis or lower tummy
discomfort or pain during sex that's felt deep inside
the pelvis
Dysuearia
bleeding between periods and after sex
menorrhagia
dysmenorrhea
unusual vaginal discharge, especially if it's yellow,
green or smelly
A few people become very ill with:
INCIDENCE OF PID
PID is a frequent and important infection that occurs
among women of reproductive age. Based on data from
the National Health and Nutrition Examination Survey
(NHANES) 2013-2014 cycle, the estimated prevalence
of self-reported lifetime PID was 4.4% in sexually
experienced women of reproductive age (18–44 years).
 This equates to an estimated 2.5 million women in the
United States with a reported lifetime history of PID
diagnosis. The prevalence was highest in women at
increased risk, such as those with previous sexually
transmitted infections (STIs).
The significant burden of disease attributed to PID
comes predominantly from the long-term reproductive
sequelae of tubal infection: tubal factor infertility,
ectopic pregnancy, and pelvic adhesions, which can
lead to chronic pelvic pain.
 DIAGNOSIS
 There is no one test that can accurately diagnose pelvic inflammatory
disease. Instead, the doctor will rely on a combination of findings from:
 medical history. The doctor will likely ask about the patients sexual habits,
history of sexually transmitted infections and method of birth control.
 Signs and symptoms. The patient should telldoctor about any symptoms
she is experiencing, even if they're mild.
 A pelvic exam. During the exam, the doctor will check her pelvic region for
tenderness and swelling. The doctor may also use cotton swabs to take fluid
samples from the vagina and cervix. The samples will be tested at a lab for
signs of infection and organisms such as gonorrhea and chlamydia.
 Blood and urine tests. These tests may be used to test for
pregnancy, HIV or other sexually transmitted infections, or to measure white
blood cell counts or other markers of infection or inflammation.
 Ultrasound. This test uses sound waves to create images of the
reproductive organs.
 If the diagnosis is still unclear, the doctor may recommend additional tests,
such as:
 Laparoscopy. During this procedure, the doctor inserts a thin, lighted
instrument through a small incision in your abdomen to view your pelvic
organs.
 Endometrial biopsy. During this procedure, the doctor inserts a thin tube
into the uterus to remove a small sample of endometrial tissue. The tissue is
tested for signs of infection and inflammation.
TREATMENT
Prompt treatment with medicine can get rid of the
infection that causes pelvic inflammatory disease. But
there's no way to reverse any scarring or damage to the
reproductive tract that PID might have caused. Treatment
for PID most often includes:
Antibiotics. the doctor will prescribe a combination of
antibiotics to start immediately. After receiving lab test
results, the doctor might adjust the prescription to better
match what's causing the infection. patient‘ ll likely follow
up with the doctor after three days to make sure the
treatment is working. Be sure to take all of the medication,
even if start to feel better after a few days.
Treatment for partner. To prevent reinfection with
an STI, sexual partner or partners should be examined
and treated. Infected partners might not have any
noticeable symptoms.
Temporary abstinence. Avoid sexual intercourse until
Abnormal uterine bleeding (AUB)
Abnormal uterine bleeding (formerly, dysfunctional uterine
bleeding [DUB] [1] ) is irregular uterine bleeding that occurs in
the absence of recognizable pelvic pathology, general medical
disease, or pregnancy. It reflects a disruption in the normal
cyclic pattern of ovulatory hormonal stimulation to the
endometrial lining. The bleeding is unpredictable in many
ways. It may be excessively heavy or light and may be
prolonged, frequent, or random It usually results from
disordered functioning of the hypothalamic-pituitary-ovarian
(HPO) axis and is often associated with anovulatory
cycles. [3] This classic definition highlights that anovulatory
uterine bleeding (as part of the etiologic spectrum of AUB) is a
diagnosis of exclusion.

Of these cases of AUB, about 90% are due to menstrual

periods when ovulation does not occur. Adolescent females
have several anovulatory cycles per year; hence, anovulatory
uterine bleeding is the primary cause of AUB in the female
adolescent population.
 Pathophysiology
 The normal menstrual cycle, characterized by sequential growth,
maturation, and eventual sloughing of the endometrial mucosa,
is produced by the cyclic release of estrogen and progesterone
from the ovary.
 This process (orchestrated by the HPO axis) occurs with amazing
regularity throughout most of a woman's reproductive lifetime.
 Patients with abnormal uterine bleeding (AUB) have lost cyclic
endometrial stimulation that arises from the ovulatory cycle.
 As a result, these patients have constant, noncycling estrogen
levels that stimulate endometrial growth.
 Proliferation without periodic shedding causes the endometrium
to outgrow its blood supply.
 The tissue breaks down and sloughs from the uterus.
 Subsequent healing of the endometrium is irregular and
dyssynchronous.
 Chronic stimulation by low levels of estrogen will result in
infrequent, light AUB.
 Chronic stimulation from higher levels of estrogen will lead to
Etiology
Estrogen breakthrough bleeding
Anovulatory cycles have no corpus luteal formation.
Progesterone is not produced. The endometrium continues
to proliferate under the influence of unopposed estrogen.
Eventually, this out-of-phase endometrium is shed in an
irregular manner that might be prolonged and heavy. This
pattern is known as estrogen breakthrough bleeding and
occurs in the absence of estrogen decline.
Estrogen withdrawal bleeding
This frequently occurs in women approaching the end of
reproductive life. In older women, the mean length of
menstrual cycle is shortened significantly due to aberrant
follicular recruitment, resulting in a shortened proliferative
phase. Ovarian follicles in these women secrete less
estradiol. Fluctuating estradiol levels might lead to
insufficient endometrial proliferation with irregular
menstrual shedding. This bleeding might be experienced as
light, irregular spotting.
Oral contraceptives, progestin-only preparations, or
postmenopausal steroid replacement therapy
 Treatment with oral contraceptives, progestin-only preparations, or
postmenopausal steroid replacement therapy might be associated
with iatrogenically induced uterine bleeding.
 Progesterone breakthrough bleeding occurs in the presence of an
unfavorably high ratio of progestin to estrogen.
 Intermittent bleeding of variable duration can occur with progestin-
only oral contraceptives, depo-medroxyprogesterone, and depo-
levonorgestrel.
Adolescents
 The primary defect in the anovulatory bleeding of adolescents is
failure to mount an ovulatory luteinizing hormone (LH) surge in
response to rising estradiol levels. Failure occurs secondary to
delayed maturation of the hypothalamic-pituitary axis. Because a
corpus luteum is not formed, progesterone levels remain low.
 The existing estrogen primed endometrium does not become
secretory. Instead, the endometrium continues to proliferate under
the influence of unopposed estrogen. Eventually, this out-of-phase
endometrium is shed in an irregular manner that might be
prolonged and heavy, such as that seen in estrogen breakthrough
Climacteric
 Anovulatory bleeding in menopausal transition is related to
declining ovarian follicular function.
 Estradiol levels will vary with the quality and state of
follicular recruitment and growth. Bleeding might be light
or heavy depending on the individual cycle response.
Bleeding disorders
Historically, a lack of awareness of underlying bleeding
disorders has led to underdiagnosis in women with
abnormal reproductive tract bleeding.
 An underlying bleeding disorder should be considered
when a patient has any of the following:
 Menorrhagia since menarche
 Family history of bleeding disorders
 Personal history of 1 or more of the following: (1) Notable
bruising without known injury; (2) bleeding of the oral
cavity or gastrointestinal tract without obvious lesion; or(3)
Nursing care
The goals of therapy for abnormal uterine bleeding
(AUB) are to control and prevent recurrent bleeding,
correct or treat any pathology present, and induce
ovulation in patients who desire pregnancy. Age,
past history, and bleeding amount influence
management.
After initial treatment and resolution of an episode
of AUB, patients need to be educated that most
often chronic therapy is mandatory to prevent
further episodes.
Reassure patients that most bleeding stops with the
appropriate hormonal therapy. Explain the
physiologic reason for the anovulatory bleeding
pattern. This is particularly true for the adolescent
patient who establishes a predictable ovulatory
DYSMENORRHEA
Dysmenorrhea is defined as difficult menstrual flow
or painful menstruation. It is one of the most
common gynecologic complaints in young women
who present to clinicians. Optimal management of
this symptom depends on an understanding of the
underlying cause. Dysmenorrhea can be divided
into 2 broad categories:
primary (spasmodic)
 secondary (congestive)
Primary dysmenorrhea is defined as menstrual
pain that is not associated with macroscopic pelvic
pathology (ie, occurs in the absence of pelvic
disease). It typically occurs in the first few years
after menarche and affects as many as 50% of
postpubertal females
Pathophysiology
Current evidence suggests that the pathogenesis of
primary dysmenorrhea is due to prostaglandin F2α
(PGF2α), a potent myometrial stimulant and
vasoconstrictor, in the secretory endometrium. The
response to prostaglandin inhibitors in patients with
dysmenorrhea supports the assertion that
dysmenorrhea is prostaglandin-mediated.
Substantial evidence attributes dysmenorrhea to
prolonged uterine contractions and decreased
blood flow to the myometrium.
Elevated prostaglandin levels were found in the
endometrial fluid of women with dysmenorrhea and
correlated well with the degree of pain. A 3-fold
increase in endometrial prostaglandins occurs from
the follicular phase to the luteal phase, with a
2Etiology
Risk factors for primary dysmenorrhea include the
following:
Early age at menarche (< 12 years)
Nulliparity
Heavy or prolonged menstrual flow
Smoking
Positive family history
Obesity
Risk factors for secondary dysmenorrhea include
the following :
Leiomyomata (fibroids)
PID
Tubo-ovarian abscess
Ovarian torsion
 CLINICAL FEATURES
 Clinical features of primary dysmenorrhea include the following
 Onset shortly after menarche (≤6 months)
 Usual duration of 48-72 hours (often starting several hours before or
just after the menstrual flow)
 Cramping or laborlike pain
 Background of constant lower abdominal pain, radiating to the back or
thigh
 Often unremarkable pelvic examination findings (including rectal)
 The following may indicate secondary dysmenorrhea
 Dysmenorrhea beginning in the 20s or 30s, after previous relatively
painless cycles
 Heavy menstrual flow or irregular bleeding
 Dysmenorrhea occurring during the first or second cycles after
menarche
 Pelvic abnormality with physical examination
 Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral
contraceptives (OCs)
 Infertility
 Dyspareunia
 Diagnosis
 No tests are specific to the diagnosis of primary dysmenorrhea. The
following laboratory studies may be performed to identify or exclude
organic causes of secondary dysmenorrhea:
 Complete blood count with differential
 Gonococcal and chlamydial cultures, enzyme immunoassay, and DNA
probe testing
 Quantitative human chorionic gonadotropin level
 Erythrocyte sedimentation rate
 Urinalysis
 If pelvic pathology is suspected, the following imaging studies may be
considered:
 Abdominal or transvaginal ultrasonography
 Hysterosalpingography
 Intravenous pyelography
 Computed tomography
 Magnetic resonance imaging
 Other more invasive studies that may be considered are as follows:
 Laparoscopy
 Hysteroscopy
 Dilatation and curettage
 Management
 Pharmacotherapy is the most reliable and effective treatment for relieving
dysmenorrhea. Treatment of secondary dysmenorrhea involves correction of the
underlying organic cause.
 NSAIDs specifically approved by the FDA for treatment of dysmenorrhea are as follows:
 Diclofenac
 Ibuprofen
 Ketoprofen
 Meclofenamate
 Mefenamic acid
 Naproxen
 Other NSAIDs and analgesics that have been used include the following:
 Aspirin
 Acetaminophen
 COX-2 inhibitors
 Narcotics
 Although not approved for treating dysmenorrhea, the following hormonal treatments
are also used:
 Combination OCs (eg, ethinyl estradiol with progestin or drospirenone)
 Levonorgestrel intrauterine device
 Depot medroxyprogesterone acetate
 Preventive measures for outpatient management of dysmenorrhea include the following:
 Lifestyle modification
 Smoking cessation
 Exercise
NURSING CARE
For the best relief, take ibuprofen as soon as
bleeding or cramping starts.
Place a heating pad or hot water bottle on your
lower back or abdomen.
Rest when needed.
Avoid foods that contain caffeine.
Avoid smoking and drinking alcohol.
Massage your lower back and abdomen.
AMENORRHEA
Amenorrhea is the absence of menstrual bleeding.
Amenorrhea is a normal feature in prepubertal,
pregnant, and postmenopausal females. In females
of reproductive age, diagnosing amenorrhea is a
matter of first determining whether pregnancy is
the etiology. In the absence of pregnancy, the
challenge is to determine the exact cause of absent
menses.
Primary amenorrhea is the failure of menses to
occur by age 16 years, in the presence of normal
growth and secondary sexual characteristics. If by
age 13 menses has not occurred and the onset of
puberty, such as breast development, is absent, a
workup for primary amenorrhea should start.
Secondary amenorrhea is defined as the cessation
Pathophysiology
The menstrual cycle is an orderly progression of
coordinated hormonal events in the female body
that stimulates growth of a follicle to release an egg
and prepare a site for implantation if fertilization
should occur. Menstruation occurs when an egg
released by the ovary remains unfertilized;
subsequently, the soggy decidua of the
endometrium (which was primed to receive a
fertilized egg) is sloughed in a flow of menses in
preparation for another cycle.
Menarche and sustained menstrual cycles requires
normal function of the endocrine axis comprising
the hypothalamus, pituitary, and ovaries . Any
disruption in this axis may result in amenorrhea.
Defining the level of primary dysfunction is critical
 Causes of primary amenorrhea
 First and foremost, it is imperative to rule out pregnancy. Additional diagnoses of
primary amenorrhea usually result from a genetic or anatomic abnormality.
 The hypergonadotropic hypogonadism category includes patients with abnormal
sex chromosomes (ie, Turner syndrome), who make up 29.7% of all primary
amenorrhea cases, and those with normal sex chromosomes. The latter group
includes both patients who are 46,XX (15.4%) and those who are 46,XY (3.4%).
Hypogonadotropic hypogonadism includes the following:
 Congenital abnormalities
 Endocrine disorders
 Tumor
 Systemic illness
 Eating disorder
Congenital abnormalities that can cause hypogonadotropic hypogonadism include
the following:
 Isolated GnRH deficiency (8.3%)
 Forms of hypopituitarism (2.3%)
 Congenital central nervous system (CNS) defects (0.8%)
Endocrine disorders that can cause hypogonadotropic hypogonadism include the
following:
 Congenital adrenal hyperplasia (CAH) (0.8%)
 Cushing syndrome (0.4%)
 Pseudohypoparathyroidism (0.4%)
 Hyperprolactinemia (1.9%)
CAUSES OF SECONDARY AMENORRHEA
 Disorders associated with a low or normal FSH, which account for 66% of
cases of secondary amenorrhea, include the following: [21]
 Weight loss/anorexia
 Nonspecific hypothalamic
 Chronic anovulation including PCOS
 Hypothyroidism
 Cushing syndrome
 Pituitary tumor, empty sella, Sheehan syndrome
 Disorders in which the FSH is high (12%) include the following:
 46XX
 Premature ovarian failure due to abnormal karyotype (45,X mosaic/ring
chromosome)
 Pure gonadal dysgenesis
 Disorders associated with a high prolactin level make up 13% of cases.
Anatomic disorders account for 7%.
 Hyperandrogenic states as a cause of secondary amenorrhea (2%)
include the following:
 Polycystic ovarian syndrome (PCOS)
 Ovarian tumor
 Undiagnosed
TREATMENT
 treatment will depend on the cause and may include:
 Losing weight through dieting and exercise (if excess weight is the
cause).
 Gaining weight through an individualized diet plan (if extreme
weight loss is the cause).
 Stress management techniques.
 Changing exercise levels.
 Hormonal treatment (medication), as prescribed by your
healthcare provider.
 Surgery (in rare cases).
 In addition, the healthcare provider may recommend some
treatments to help with the side effects of amenorrhea:
 Estrogen therapy to relieve hot flashes and vaginal dryness.
 Calcium and vitamin D supplements to keep bones strong.
 Strength training.
 Amenorrhea may be a symptom of anorexia nervosa, an eating
disorder. consult a healthcare provider immediately so one can
get the right treatment.
INFERTILITY
Infertility is the failure to conceive (regardless of cause)
after 1 year of unprotected intercourse.
Infertility is a disease of the male or female reproductive
system defined by the failure to achieve a pregnancy
after 12 months or more of regular unprotected sexual
intercourse.
Infertility affects millions of people of reproductive age
worldwide – and has an impact on their families and
communities.
Infertility affects approximately 10-15% of reproductive-
aged couples. Its overall prevalence has been stable
during the past 50 years; however, a shift in etiology and
patient age has occurred.
As a woman's age increases, the incidence of infertility
also increases. Estimates suggest that between 48 million
couples and 186 million individuals live with infertility
globally.
CAUSES INFERTILITY
 Causes of female infertility
 Causes of female infertility may include:
 Ovulation disorders, which affect the release of eggs from the
ovaries. These include hormonal disorders such as polycystic
ovary syndrome. Hyperprolactinemia, a condition in which you
have too much prolactin — the hormone that stimulates breast
milk production — also may interfere with ovulation. Either too
much thyroid hormone (hyperthyroidism) or too little
(hypothyroidism) can affect the menstrual cycle or cause
infertility. Other underlying causes may include too much
exercise, eating disorders or tumors.
 Uterine or cervical abnormalities, including abnormalities
with the cervix, polyps in the uterus or the shape of the uterus.
Noncancerous (benign) tumors in the uterine wall (uterine
fibroids) may cause infertility by blocking the fallopian tubes or
stopping a fertilized egg from implanting in the uterus.
 Fallopian tube damage or blockage, often caused by
inflammation of the fallopian tube (salpingitis). This can result
from pelvic inflammatory disease, which is usually caused by a
Endometriosis, which occurs when endometrial
tissue grows outside of the uterus, may affect the
function of the ovaries, uterus and fallopian tubes.
Primary ovarian insufficiency (early
menopause), when the ovaries stop working and
menstruation ends before age 40. Although the
cause is often unknown, certain factors are
associated with early menopause, including
immune system diseases, certain genetic
conditions such as Turner syndrome or carriers of
Fragile X syndrome, and radiation or chemotherapy
treatment.
Pelvic adhesions, bands of scar tissue that bind
organs that can form after pelvic infection,
appendicitis, endometriosis or abdominal or pelvic
surgery.
Causes of male infertility
 These may include:
 Abnormal sperm production or function due to undescended
testicles, genetic defects, health problems such as diabetes, or
infections such as chlamydia, gonorrhea, mumps or HIV. Enlarged
veins in the testes (varicocele) also can affect the quality of
sperm.
 Problems with the delivery of sperm due to sexual problems,
such as premature ejaculation; certain genetic diseases, such as
cystic fibrosis; structural problems, such as a blockage in the
testicle; or damage or injury to the reproductive organs.
 Overexposure to certain environmental factors, such as
pesticides and other chemicals, and radiation. Cigarette smoking,
alcohol, marijuana, anabolic steroids, and taking medications to
treat bacterial infections, high blood pressure and depression
also can affect fertility. Frequent exposure to heat, such as in
saunas or hot tubs, can raise body temperature and may affect
sperm production.
 Damage related to cancer and its treatment, including
radiation or chemotherapy. Treatment for cancer can impair
Testicular failure to produce sperm, for example due to
varicoceles or medical treatments that impair sperm-
producing cells (such as chemotherapy).
Abnormal sperm function and quality. Conditions or
situations that cause abnormal shape (morphology) and
movement (motility) of the sperm negatively affect fertility.
For example, the use of anabolic steroids can cause
abnormal semen parameters such sperm count and shape.
Environmental and lifestyle factors such as smoking,
excessive alcohol intake and obesity can affect fertility.
 In addition, exposure to environmental pollutants and
toxins can be directly toxic to gametes (eggs and sperm),
resulting in their decreased numbers and poor quality,
leading to infertility.
 Unexplained factors: Sometimes a full evaluation does
not reveal the cause of infertility. This occurs
approximately 15% of the time.
 Risk factors
 Many of the risk factors for both male and female infertility are the same.
They include:
 Age. Women's fertility gradually declines with age, especially in the mid-30s,
and it drops rapidly after age 37. Infertility in older women is likely due to the
lower number and quality of eggs, and can also be due to health problems
that affect fertility. Men over age 40 may be less fertile than younger men.
 Tobacco use. Smoking tobacco or marijuana by either partner may reduce
the likelihood of pregnancy. Smoking also reduces the possible effectiveness
of fertility treatment. Miscarriages are more frequent in women who smoke.
Smoking can increase the risk of erectile dysfunction and a low sperm count
in men.
 Alcohol use. For women, there's no safe level of alcohol use during
conception or pregnancy. Alcohol use may contribute to infertility. For men,
heavy alcohol use can decrease sperm count and motility.
 Being overweight. Among American women, an inactive lifestyle and being
overweight may increase the risk of infertility. For men, sperm count also may
be affected by being overweight.
 Being underweight. Women at risk of fertility problems include those with
eating disorders, such as anorexia or bulimia, and those who follow a very
low-calorie or restrictive diet.
 Exercise issues. A lack of exercise contributes to obesity, which increases
the risk of infertility. Less often, ovulation problems may be associated with
frequent strenuous, intense exercise in women who are not overweight.
Infertility Tests
History and physical examination
Transvaginal ultrasound
Laboratory testing
Hysterosalpingogram (HSG)
Semen analysis
 Treatment for Infertility
 Education: We strongly believe that educating our patients about
the normal process of fertility, problems that affect fertility, and
treatment options will empower our patients to make the best
choices. Understanding the normal reproductive process is essential
in knowing when to seek help.
 Medications to induce egg development and ovulation: The
medications that help stimulate the ovary to develop mature eggs
for ovulation come in two forms: pills taken by mouth and injections.
 The most commonly prescribed pill to stimulate ovulation
(generally of one mature egg) is clomiphene citrate.
 This pill generally is taken from menstrual cycle days 3 – 7. It works
in the following way: Clomiphene is an anti-estrogen.
 It binds in hypothalamus, which is essential in stimulating the
ovary to grow and release an egg.
 When clomiphene binds to estrogen receptors in the hypothalamus,
it leads to an increase release of hormone called GnRH
(gonadotropin releasing hormone).
 This hormone then binds to pituitary gland and leads to the release
of FSH (follicle stimulating hormone), a hormone that directly binds
to cells in the ovary, leading to egg growth and maturation.
Insemination: Intrauterine insemination, also
known as IUI, is a process by which sperm is
washed and prepared for placement into the
uterine cavity, therefore bypassing the cervix and
bringing a higher concentration of motile sperm
closer to the tubes and ovulated egg.
In order to accomplish this, the semen is washed
with a solution safe to sperm and eggs, and then
centrifuged to separate motile sperm from immotile
sperm and other cells.
Those motile and viable sperm are then placed in a
very small amount of solution, and then very gently
and painlessly injected into the uterine cavity using
a very thin, soft, and flexible catheter.
 At least one open tube is required for IUI, and any
sperm abnormality cannot be severe, otherwise the
 In Vitro Fertilization (IVF): In vitro means “outside the
body.” IVF is a process whereby eggs are collected and
then fertilized by sperm outside the body, in an embryology
laboratory.
The first IVF baby was born in 1978 in England, Not long
after, the United States delivered its first IVF baby, and the
use of IVF has grown dramatically.
IVF was a major breakthrough because it allowed for
successful pregnancies in women that were previous
deemed permanently infertile, such as when the fallopian
tubes are both markedly damaged.
IVF involves removal of eggs directly from the ovary,
fertilization with sperm in the laboratory, followed by
transfer of the embryos directly into the uterus, thereby
bypassing the tubes.
Although tubal disease was the original indication for IVF,
many more indications have developed over the years.
 These include advancing maternal age, severe male factor
infertility and endometriosis, amongst many others.
 Third party reproduction: This is a general reference to a general
process where another person provides sperm or eggs, or where
another woman acts as a gestational surrogate, with the purpose of
helping another person or couple have a child.
 The four types of third party reproduction are
 1) sperm donation – a process by which donated sperm is used for
insemination in the uterus, or for fertilization of eggs in the IVF
process;
 2) egg or ovum donation – a process by which an egg donor
undergoes an IVF cycle in order to obtain her eggs which are then
donated and fertilized.
 The resulting embryos are then transferred into the uterus of the
future mother, known as the recipient. Usually no more than 1 – 2
embryos are transferred, and therefore additional embryos can be
frozen, or cryopreserved, for future use;
 3) embryo donation – a process where a fully developed embryo
from another person in combination with donor sperm, or couple
who underwent IVF, are donated to another woman, the future
intended mother, for transfer into her uterus.
 4) gestational surrogacy – a process where another woman will
undergo an embryo transfer and carry the pregnancy for another
Surgery – After a thorough history, physical
examination, and ultrasound are performed, the
doctor may recommend surgery to correct any
abnormality. In reproductive medicine, the most
common surgical procedures are laparoscopy,
hysteroscopy, and abdominal myomectomy
(removal of uterine fibroids).
Laparoscopy is an operation performed in the
abdomen or pelvis through small incisions,
generally no more than a centimeter, with the
assistance of a laparoscope attached to a camera
which projects to a screen. It can either be used to
inspect and diagnose certain conditions or to
surgically correct an abnormality such as removing
scar tissue, endometriosis, or a damaged fallopian
tube.
NURSING CARE
Infertility treatment involves many health care
workers, nurses are constantly in contact with
patients starting from the beginning, till the end of
the treatment.
Whether the result is position or negative, nurses
rejoice or grieve with the patient.
Nurses help to connect and coordinate different
units
Nurses’ role during infertility treatment, involving
adequate collection of patient history, recording of
vitals, medical investigation, encouraging patients
taking medication as prescribed, listening to
patients’ complaints, providing emotional support,
and showing empathy when needed.
Nursing intervention can be made outside nursing
ABORTION
Abortion is the expulsion of a fetus from
the uterus before it has reached the stage of
viability (in human beings, usually about the 20th
week of gestation).
An abortion may occur spontaneously, in which
case it is also called a miscarriage, or it may be
brought on purposefully, in which case it is often
called an induced abortion.
Spontaneous abortions, or miscarriages, occur for
many reasons, including disease, trauma, genetic
defect, or biochemical incompatibility of mother
and fetus.
Occasionally a fetus dies in the uterus but fails to
be expelled, a condition termed a missed abortion.
Spontaneous abortion is the loss of pregnancy
naturally before twenty weeks of gestation.
Spontaneous abortion is referred to as a
‘miscarriage’ to avoid association with induced
abortion. Early pregnancy loss refers only to
spontaneous abortion in the first trimester.
However, the first trimester is when most
spontaneous abortions occur
Spontaneous abortion can be subdivided into
threatened abortion, inevitable abortion,
incomplete abortion, missed abortion, septic
abortion, complete abortion, and recurrent
spontaneous abortion.
Spontaneous abortions, or miscarriages, occur for
many reasons, including disease, trauma, genetic
defect, or biochemical incompatibility of mother
Spontaneous Abortion: Definitions of Subcategories
Threatened Abortion
Vaginal bleeding, abdominal/pelvic pain of any degree, or
both during early pregnancy represents a threatened
abortion.
 About half of these cases progress to an actual miscarriage.
 Bleeding and pain accompanying threatened abortion is
usually not very intense.
 Threatened abortion rarely presents with severe vaginal
bleeding. On vaginal examination, the internal cervical os is
closed and no cervical motion tenderness or tissue is found.
Threatened miscarriage is defined by the absence of
passing/passed tissue and the presence of a closed internal
cervical os.
 INEVITABLE ABORTION
Vaginal bleeding is accompanied by dilatation of the cervical
canal. Bleeding is usually more severe than with threatened
miscarriage and is often associated with abdominal pain and
 Complete abortion
 Patients may present with a history of bleeding, abdominal pain, and
tissue passage. By the time the abortion is complete, bleeding and
pain usually have subsided. Ultrasonography reveals a vacant uterus.
Diagnosis may be confirmed by observation of the aborted fetus with
the complete placenta, although caution is recommended in making
this diagnosis without ultrasonography because it can be difficult to
determine if the miscarriage is complete.
 INCOMPLETE ABORTION
 Vaginal bleeding may be intense and accompanied by abdominal pain.
The cervical os may be open with products of conception being
passed, or the internal cervical os may be closed. Ultrasonography is
used to reveal whether some products of conception are still present in
the uterus.
 Missed abortion: a pregnancy in which there is a fetal demise
(usually for a number of weeks) but no uterine activity to expel the
products of conception
 Recurrent spontaneous abortion: three or more consecutive
pregnancy losses
 Septic abortion: a spontaneous abortion that is complicated by
intrauterine infection
 Threatened abortion: a pregnancy complicated by bleeding before
CAUSES
Problems with the genes or chromosomes
Most miscarriages occur because the fetus isn't
developing as expected. About 50 percent of
miscarriages are associated with extra or missing
chromosomes. Most often, chromosome problems result
from errors that occur by chance as the embryo divides
and grows — not problems inherited from the parents.
Maternal health conditions
In a few cases, a mother's health condition might lead
to miscarriage. Examples include:
Uncontrolled diabetes
Infections
Hormonal problems
Uterus or cervix problems
Thyroid diseas
RISK FACTORS
Various factors increase the risk of miscarriage, including:
 Age. Women older than age 35 have a higher risk of miscarriage than
do younger women. At age 35, you have about a 20 percent risk. At
age 40, the risk is about 40 percent. And at age 45, it's about 80
percent.
 Previous miscarriages. Women who have had two or more
consecutive miscarriages are at higher risk of miscarriage.
 Chronic conditions. Women who have a chronic condition, such as
uncontrolled diabetes, have a higher risk of miscarriage.
 Uterine or cervical problems. Certain uterine conditions or weak
cervical tissues (incompetent cervix) might increase the risk of
miscarriage.
 Smoking, alcohol and illicit drugs. Women who smoke during
pregnancy have a greater risk of miscarriage than do nonsmokers.
Heavy alcohol use and illicit drug use also increase the risk of
miscarriage.
 Weight. Being underweight or being overweight has been linked with
an increased risk of miscarriage.
 Invasive prenatal tests. Some invasive prenatal genetic tests, such
as chorionic villus sampling and amniocentesis, carry a slight risk of
 Environmental Hazards
 In addition to secondhand smoke, certain substances in the
environment at home or at work could put pregnancy at risk. These
include:
 Lead in old water pipes or paint in homes built before 1978
 Mercury released from broken thermometers or fluorescent light
bulbs
 Solvents such as paint thinners, degreasers, and stain and varnish
removers
 Pesticides for killing insects or rodents
 Arsenic found near waste sites or in some well water
 Medications
 Several prescription and over-the-counter medications can raise
the chances of miscarriage and pregnancy loss, including:
 Misoprostol It's used for conditions such as peptic
ulcers and rheumatoid arthritis
 Methotrexate, a medication for rheumatoid arthritis
 Retinoids. They're used for skin conditions such
as eczema and acne
 Non-steroidal anti-inflammatory drugs (NSAIDs)
Food Poisoning
Several types of food poisoning during
pregnancy can raise your risk for miscarriage or
pregnancy loss.
 Listeriosis. Typically found in unpasteurized soft
cheeses such as blue, Brie, or queso fresco, and
raw or undercooked seafood
 Salmonella. Usually found in raw or
undercooked eggs
 Toxoplasmosis. Most often caused by eating
infected raw meat
Some food poisoning illnesses, including
listeriosis and toxoplasmosis, can infect your
unborn baby even if you don’t have symptoms
yourself.
Follow your doctor’s guidelines about cooking and
PATHOPHYSIOLOGY
The pathophysiology of a spontaneous abortion
may be suggested by its timing. Chromosomal
defects are commonly seen in spontaneous
abortion, especially those that occur during 4-8
weeks' gestation. Genetic etiologies are common
in early first-trimester loss but may be seen
throughout gestation. Trisomy chromosomes are
the most common chromosomal anomaly.
Insufficient or excessive hormonal levels usually
result in spontaneous miscarriage before 10
weeks' gestation. Infectious, immunologic, and
environmental factors are generally seen in first-
trimester pregnancy loss. Anatomic factors are
usually associated with second-trimester loss.
Factor XIII deficiency and a complete or partial
deficiency of fibrinogen are associated with
Clinical Manifestation
Patients with spontaneous miscarriage usually present to
the clinic with vaginal bleeding, abdominal pain, or both.
Note the following:
Vaginal bleeding may vary from slight spotting to a
severe life-threatening hemorrhage.
The patient's history should include the number of pads
or tampons used.
 Most heavy bleeding in the first trimester, particularly
when associated with abdominal pain, is associated with
higher risk of miscarriage.
Presence of blood clots or tissue may be an important
sign indicating progression of spontaneous miscarriage.
Abdominal pain is usually located in the suprapubic area
or in one or both lower quadrants.
Pain may radiate to the lower back, buttocks, genitalia,
and perineum.
Signs of threatened miscarriage include the
following:
Vital signs should be within reference ranges unless
infection is present or hemorrhage has caused
hypovolemia.
The abdomen usually is soft and nontender.
Pelvic examination reveals a closed internal cervical
os. The bimanual examination is unremarkable.

Signs of incomplete miscarriage include the

following:
The cervix may appear dilated and effaced, or it
may be closed.
Bimanual examination may reveal an enlarged and
soft uterus.

Signs Of Complete Miscarriage: On pelvic
examination, the cervix should be closed, and the
uterus should be contracted.
Signs of missed miscarriage include the following:
Vital signs usually are within reference ranges.
Abdominal examination may or may not reveal a
palpable uterus. If palpable, the uterus usually is
small for the presumed gestational age.
Fetal heart tones are inaudible or unseen on
sonogram.
The cervical os is closed upon pelvic examination.
The uterus may feel soft and enlarged.

Treatment of Spontaneous Abortion
 Observation for threatened abortion
 Uterine evacuation for inevitable, incomplete, or missed abortions
 Emotional support
 For threatened abortion, treatment is observation. No evidence
suggests that bed rest decreases risk of subsequent completed
abortion.
 For inevitable, incomplete, or missed abortions, treatment is
uterine evacuation or waiting for spontaneous passage of the products
of conception.
 Evacuation usually involves suction curettage at < 12 weeks, dilation
and evacuation at 12 to 23 weeks, or medical induction at > 16 to 23
weeks (eg, with misoprostol).
 The later the uterus is evacuated, the greater the likelihood of
placental bleeding, uterine perforation by long bones of the fetus, and
difficulty dilating the cervix.
 These complications are reduced by preoperative use of osmotic
cervical dilators (eg, laminaria), misoprostol, or mifepristone (RU 486).
Complications
Complications of spontaneous abortion include:
Septic abortion
Retained products of conception
Cervical laceration
Disseminated intravascular coagulation
Post-abortion triad (i.e., low-grade fever, pain,
bleeding)
Hematoma
Prevention

Often, there's nothing you can do to prevent a

miscarriage. Simply focus on taking good care of
yourself and your baby:
Seek regular prenatal care.
Avoid known miscarriage risk factors — such as
smoking, drinking alcohol and illicit drug use.
Take a daily multivitamin.
Limit your caffeine intake. A recent study found that
drinking more than two caffeinated beverages a
day appeared to be associated with a higher risk of
miscarriage.