Reproductive and Sexual Health
Nursing process is for the promotion of reproductive and sexual health.
Problems may not be evident on the first meeting
Good follow through and planning are important
Verbal and nonverbal cues
Level of knowledge
Explore
Reproductive development:
Physiologic readiness for childbearing begins during intrauterine life.
Full function is initiated at puberty.
Intrauterine development:
The sex of an individual is determined at the moment of conception by the chromosome information of the particular ovum and sperm that joined to create the new life.
Gonad- a body organ that produces sex cells
-ovary in female
-testis in male
Weeks 5-primitive gonadal tissue is already formed
Week 7-8 in males tissue differentiates into testes and forms testosterone
With testosterone influence, male reproductive organs develop and the paramesonephric duct regresses
If testosterone is not present by week 10 gonadal tissue differentiates into the ovaries and the paramesonephric duct develops into female reproductive organs
All oocytes(cells that will develop into eggs throughout the women’s mature years) are already formed in the ovaries at this stage.
Week 12-influenced by testosterone, the external genitals become visible as penile tissue elongates and the urogenital fold on the ventral surface of the penis closes to form the urethra
In females-with no testosterone present, the urogenital fold remains open to form the labia minora, what would be formed as scrotal tissue in the male becomes the labia majora in the female.
If testosterone secretion is halted in utero, a chromosomal male could be born with female-appearing genitalia.
If a women has high levels of testosterone, a chromosomal female could be born with male-appearing genitalia
Pubertal development
Secondary sex changes begin
Boys 12-14years
Girls 9-12years
Hypothalamus turns on gonadal function
Girls-theory is that girls must reach a weight of 95lbs. or critical mass of fat
-Lack of fat may delay or halt menstruation
Boys-mechanism is less understood
Androgen hormones are the hormones responsible for muscular development, physical growth, and the increase in sebaceous gland secretions that cause typical acne
Males- androgenic hormones are produced by the adrenal cortex and the testes
Females-by the adrenal cortex and the ovaries
Levels of primary androgenic hormones:
Males-testosterone is low until puberty
-age 12-14: development of testes, scrotum, penis, axillary and facial hair, laryngeal enlargement, voice change, maturation of spermatozoa, and closure of growth in long bones
Females-testosterone influences enlargement of the labia majora, and clitoris, and formation of axillary and pubic hair.
-Adrenarche-development of pubic and axillary hair due to androgen stimulation
Role of Estrogen:
Hormone released from the ovarian follicles is triggered at puberty
Influences the development of the uterus, fallopian tubes, vagina, typical fat distribution, hair patterns, breast development and closes epiphyseal lines on long bones (ends growth).
Thelarche-is the beginning of breast development.
Secondary Sex Characteristics :
Tanner Stages
There are wide variations in the time of the developmental stages.
Typical occur:
1. Growth spurt
2. Increase in transverse diameter of pelvis
3. Breast development
4. Growth of pubic hair
5. Onset of menstruation
6. Growth of axillary hair
7. Vaginal secretions
-Menarche-first menstrual period
Average age is 12.5yrs but may occur from 9-17yrs.
Irregular 1st year, may be annovulatory
Menstruation is not dependent on ovulation. This happens 1-2yrs. After menarche.
Production of spermatozoa does not begin in intrauterine life as does the production of ova. Nor are they cyclic.
They are produced in a continuous process from puberty throughout the male’s life span.
Production of mature ova stops at menopause.
Anatomy and Physiology of the Reproductive Systems:
Although the structures are different they both arise from the same embryonic origin.
Gynecology-study of the female reproductive organs.
Andrology-study of the male reproductive organs
Internal Structures:
Ovaries:
-Produce mature and discharge ova
-Produce estrogen and progesterone
-Initiate and regulate menstrual cycles
-If removed or non functional,absence of estrogen deter breast maturation and hair patterns will be more pattern then normal.
-Uterus,breasts and ovaries atrophy after menopause due to lack of estrogen.
-Necessary for maturation and maintenance of secondary sex characteristics.
-Estrogen helps prevent osteoporosis, reduce cholesterol levels and atherosclerosis.
-Cancer
Division of Reproductive Cells:
At birth each ovary contains 2 million immature ova, which are formed during the first 5 months of intrauterine life.
Mitotic division then halts until puberty.
Meiosis (cell reduction division).
-Males-occurs just before spermatozoa matures
-Female-just before ovulation
Following division:
-ovum has 22 autosomes and an X sex chromosome
-spermatozoon has 22 autosomes and either an X or a Y sex chromosomes
-Ovum and X-carrying spermatozoon= female XX
-Ovum and Y-carrying spermatozoon=male XY
Maturation of Oocytes:
-5-7 million are formed in utero
-5 mo. Intrauterine maturation stops
-birth 2 million
-7yrs. 500,000
-22 yrs. 300,000
-Menopause none
Fallopian tubes:
Convey ovum from ovaries to uterus
Provides a place for fertilization of ovum by sperm
Smooth, hollow tunnel that is divided into 4 separate parts:
-Interstitial- 1cm lies within the uterine wall
-Isthmus-2cm cut in tubal ligations
-Ampulla-longest 5cm fertilization occurs
-Infundibular-2cm funnel-shaped, rim covered with fimbria (sm hairs) that help guide the ovum into the fallopian tube
-Open at distal end, a direct pathway from the external organs through the vagina to the uterus and tubes exits =conception
-Has mucous-secreting and ciliated cells
-Peristaltic motion, muscles and nourishment
-Infection of the peritoneum is a risk
-Exams-use sterile technique
Uterus:
-Hollow, muscular, pear-shaped organ
-Increase size begins at age 8 matures at 17yrs.
-5-7cm. Long and 5cm wide 2.5cm. Deep 60g.
-Function is to receive ovum from fallopian tube, provide a place for implantation and nourishment, protect expel from the women’s body
-After pregnancy-9cm long, 6cm wide, 3cm thick and 80g
-Corpus-body (fundus)
expands with pregnancy
-Isthmus (between body and cervix)
Also expands with pregnancy
Most common area for cesarean birth
-Cervix-2-5cm long ½ lies above the vagina and ½ extends into the vagina
Uterine and cervical coats:
Endometrium (inner layer)
-sheds as menstrual flow
-endocervix-mucous membrane lining of the cervix (during pregnancy-becomes plugged with mucous
-pap smear taken from are that changes from epithelium to mucous membrane
Myometrium (middle muscular layer)
-constricts the tubal junctions
-prevents regurgitation of menstrual flow
-hold internal cervical os closed during pregnancy to prevent preterm birth
-constricts blood vessels thus limiting loss of blood after childbirth
-frequent site for tumors
Perimetrium (outer most layer)
-offers added strength and support to the structure
Uterine Blood Supply
-hypogastric arteries from aorta
-unwind as uterus enlarges
-close proximity of the uterine vessels and uteters (monitor urine output closely)
Uterine Nerve Supply
Nerves:
-afferent (sensory)-T11 and T12
-efferent(motor) T5 through T10
-Anesthetic solution can be injected near the spinal column and stop the pain of uterine contractions at T11 and T12 levels (epidural) without stopping motor control or contractions (registered at T5 to T10)
Uterine Supports:
Uterus is suspended by ligaments and supported by fascia and muscles
Become overstretched during pregnancy
If these supports do not return adequately it may allow cystocele or redtocele later in life
A fold of peritoneum behind the uterus is the posterior ligament which forms a pouch (Douglas’ cul-de-sac) between rectum and uterus.
-blood in the pelvis tends to collect here
-examined with culdoscopy or laparoscope
-round ligaments-steady the uterus quick movements may pull this and a quick sharp pain or burn in lower quadrants
Uterine Deviations
Relates to shape and position which may interfere with fertility or pregnancy
-bicornuate uterus-horns at junction of fallopian tubes
Positional deviations:
All malformations may decrease the ability to conceive or carry a pregnancy to term.
anteversion-fundus is tipped forward
retroversion-fundus is tipped back
anteflexion-body of uterus is bent forward at the junction with the cervix
retroflexion-body of uterus is bent sharply back just above the cervix
Uterine flexion and Version
anterior wall 6-7 cm long
posterior wall 8-9 cm long
fornix-recesses on all sides of the cervix
posterior fornix serves as a place for the pooling of semen
lined with stratified squamous epithelium
walls contain many folds or rugae which make the vagina very elastic to expand for the baby to pass through
Has both sympathetic and parasympathetic nerves from S1 to S3 levels
Excitement is not from vaginal stimulation but from clitoral stimulation
Mucus rich in glycogen, content breaks down to lactic acid which gives the vagina a normal pH of 4 (acid) that deters growth of pathologic bacteria. If this is disturbed by douches, sprays, or antibiotics vaginal infections are invited.
Breasts:
Mammary glands-rise in estrogen at puberty increases the size
Glandular tissue develops after pregnancy
Gynecomastia-increase in male breasts
Milk glands are divided by connective tissue partitions-20 lobes. All glands deliver milk to the nipple by the lactiferous duct.
The nipple has approx. 20 sm. openings
Oxytocin- releases from posterior pituitary with stimulation to constrict milk gland cells to push milk forward through ducts.
Blood supply is profuse and supplies nutrients for breast-feeding but aids in metastasis of CA
Pelvis:
Innominate bone is divided into 3 parts:
Ilium-upper and lateral hip bones
Ischium-inferior portion
Ischial tuberosities- where you sit
Pubis-anterior portion of innominate bone
Symphysis pubis-junction of the innominate bones at the front of the pelvis
Sacrum-upper posterior portion of the pelvic ring
Sacral prominence-anterior projection where it touches the lower lumbar vertebrae (used for pelvic measurements)
Coccyx-bottom point of sacrum, has 5 sm. bones that will move slightly.
Pelvic measurements:
-false pelvis-superior portion, supports the uterus and aids in directing the fetus into the true pelvis for birth
It is divided from the true pelvis (lower ischeal) by an imaginary line from the sacral prominence to the superior aspect of the symphysis pubis Diagonal conjugate-10 cm.
Obstetric conjugate- distance sacral prominence to inferior aspect of the symphysis pubis (11.5cm)
Inlet-entrance to the true pelvis or the upper ring of bone through which the fetus must first pass (heart shaped) wider transversely(sideways) than antero-posterior diameter.
Outlet-inferior portion of the pelvis, coccyx on the back, ischeal tuberosities on the sides, in front by the inferior aspect of the symphysis pubis.
Marks the midpoint of the pelvis
Used to gauge the station of the fetus in pelvis
Pelvic cavity-space between the inlet and outlet
-curved
-slows and controls the speed of birth which reduces sudden pressure changes in the fetal head
-snugness compresses the chest helping to expel lung fluid and mucus caused a neg. pressure to initiate the 1st breath.
Menstruation:
Episodic uterine bleeding in response to cyclic hormonal changes
It allows for conception and implantation of a new life
Brings an ovum to maturity and renew a uterine tissue bed that will be responsible for its growth if fertilized
Teach in fourth grade
Length-28 days (from beginning of one flow to the beginning of the next flow
Not unusual if 23 days to 35 days
Average flow(menses) duration-2 to 7 days (1 to 9)
Amount-30 to 80 ml.
Characteristics
Menstrual Cycle
Physiology of Menstruation:
Hypothalamus- releases luteinizing hormone-releasing hormone LHRH (sometimes called GnRH gonadotropin-releasing hormone) initiates the menstrual cycle
Pituitary Gland
Under the influence of LHRH, the anterior lobe of the pituitary gland produces 2 hormones that act on the ovaries
FSH-follicle stimulating hormone (matures ovum)
LH-lutenizing hormone (releases ovum from ovary or ovulation and growth of uterine lining)
Ovary
FSH stimulates growth of ova (oocytes)
Follicular fluid contains estrogen and some progesterone (graafian folicle)
Ovulation-14 days before menstruation
releases graafian follicle from ovary
LH rises and causes ovary to produce lutein (yellow follicular fluid) high in progesterone and some estrogen
Lutein fill the follicle termed Corpus Luteum
BMT drops just before ovulation due to extremely low levels of progesterone
if the egg is fertilized the corpus luteum remains to provide progesterone to maintain pregnancy until placental function can maintain progesterone
If there is no conception, ovum atrophies 4 to 5 days and the corpus luteum regresses to the corpus albicans after 10 to 12 days
Uterus:
1st phase-proliferative
4 to 5 days after menses
Endometrium-(lining of the uterus) is very thin, one cell layer in depth
As the ovary begins to produce estrogen, the endometrium begins to proliferate
Growth is rapid, increases the thickness eightfold from day 5 to 14
Interchangeable terms-estogenic, follicular, postmenstrual, proliferative phases
2 nd Phase - Secretory
After ovulation
Increase LH-corpus luteum produces progesterone
This causes the lining to become corkscrew or twisted in appearance and dilated with glycogen and mucin
Increased blood flow
Lining is rich, spongy velvet
Termed-progestational, luteal, premenstrual
Increased fluid retension and vasocongestion in lower pelvis (achieve orgasm easily)
Initiates more sexual relations
3 rd Phase Ischemic
If fertilization does not occur, the corpus luteum begins to regress after 8 to 10 days
Production of progesterone and estrogen decreases
Endometrium degenerates-day 24-25
Capillaries rupture
Endometrium sloughs off
4th Phase Final Menses:
Products are discharged from the uterus as menstrual flow or menses
Blood from ruptured capillaries
Mucin from glands
Fragments of endometrial tissues
Microscopic, atrophied, and unfertilized ovum
Menses is the end of the menstrual cycle
It is the only external marker
The first day of menstrual flow is used to mark the beginning day of a new menstrual cycle
Iron loss is approx. 11 mg.
Cervix:
Mucus of the uterine cervix and body change each month.
1st half of the cycle, when hormone secretion is low, mucus is thick and scant
Sperm survival is poor
At ovulation, when estrogen level is high, mucus is thin and copious
Sperm penetration and survival are excellent
2nd half, progesterone becomes the major influencing hormone
Mucus again becomes thick and sperm survival is poor
Teach about fertility
Menopause-the cessation of menstrual cycles
Perimenopause-denotes the period during menopausal changes are occurring
Age ranges from 40 to 55 years
“Change of life”(ova in ovary are used)
Stress (end of ability to bear children)
HRT-hormone replacement therapy
hot flashes, osteoporosis, uterine CA,
mood swings. When incorporated with cholesterol, causes the body to produce more cholesterol.
Controversial HRT
Estrogen(Premarin and Prempro) meds with progesterone added for the last 10 days of a month to reduce the risk of endometrial CA
Sexuality and sexual identity:
Multidimensional sexual responses
Includes feelings, attitudes and actions
Biological and cultural components
Biologic gender-denotes chromosomal sexual development (male XY, female XX)- sexual typing
Gender identity- sexual identity- inner sense a person has being male or female
Gender role-behavior a person conveys about being male or female
Development of Gender Identity:
Whether gender identity arises from primarily a biologic or psychosocial focuses are controversial.
amount of testosterone secreted in utero
role models
the stage is set before the child is born
Infancy-treated differently at birth
Preschool-age 3-4 know what sex they are and have absorbed cultural expectations of that sex role
Fixed role identification by some parents
School-age child-spend play time imitating adult roles as a way of learning gender roles
Adolescent-at puberty, begins the process of establishing a sense of identity
Interviewing for a sexual history needs to be done tactfully and with confidentiality
guidelines for safe sex
stressful time-high suicide rate
Young adult-choose a partner, parenting
expression of homosexuality or bisexuality for the first time
Middle- age adult-comfortable patterns of behavior have been established
allow more freedom in exploring and satisfying sexual needs
menopause-education in what to expect
men experience changes in sperm production, erectile power, sex drive and achievement of orgasm
Older adult-enjoy active sexual relationship
erectile dysfunction in males (still fertile)
decreased estrogen in females
Physically challenged individuals have sexual desires and needs also
Encourage them to ask questions and work on specific difficulties
Human Sexual Response:
Sexual experience is unique to each person
Sexual response cycle:
Excitement-physical and psychological
Plateau-just before orgasm
Orgasm-suddenly discharges accumulated sexual tension
Resolution-external and internal genital organs return to an unaroused state
Types of Sexual Orientation:
Heterosexuality-sexual fulfillment with a member of the opposite sex
Homosexuality-sexual fulfillment with a member of the same sex
Bisexuality-achieve sexual satisfaction from both the same and opposite sex
Transsexuality-physically one gender but feels as if they are the opposite on inside
sex change operation
Types of Sexual Expression:
Celibacy-abstinence from sexual activity
Masturbation-self-stimulation for erotic pleasure
Erotic Stimulation-use of visual materials
Fetishism-use of certain objects or situations
Transvestism- individual who dresses to take on the role of the opposite sex
Voyeurism- arousal by looking at another’s body