Learning Objectives
By the end of this section, you will be able to:
- Explain the different disorders, treatment, and nursing interventions affecting menstruation
- Explain the disorders, treatment, and nursing interventions associated with menopause
- Describe the pathophysiology, symptoms, treatment, and nursing interventions associated with polycystic ovary syndrome (PCOS)
- Describe the symptoms, treatment, and nursing interventions associated with endometriosis
- Explain the risk factors, treatment, and patient education associated with chronic pelvic pain
This module focuses on key functional reproductive health disorders that can affect any person AFAB at some point in their life. The underlying mechanisms, clinical manifestations, diagnostic approaches, and evidence-based medical and nursing interventions for these conditions will be discussed. Menstrual abnormalities, the transitional phases of perimenopause and menopause, the complexities of endometriosis and polycystic ovary syndrome (PCOS), and the multidimensional aspects of chronic pelvic pain will also be reviewed. Nurses provide education on these conditions and how they relate to their patients’ pain. Nurses also provide holistic care and support to persons experiencing functional reproductive health issues.
Menstrual Disorders
The average age for menarche in the United States is approximately 12 years of age (Gruber & Modan-Moses, 2021). A normal menstrual cycle is approximately 21 to 34 days in length, with the menses lasting less than 7 days (American College of Obstetricians and Gynecologists [ACOG], 2015). Abnormal menstrual cycles can occur for many reasons. Understanding menstrual disorders is important, as these disorders can significantly impact a person’s physical and emotional well-being. Menstrual disorders encompass a wide range of conditions that affect the regularity, intensity, and duration of the menstrual cycle. From heavy or prolonged menstrual bleeding to irregular or absent periods, these disorders can present complex challenges for both patients and health-care providers.
Amenorrhea
The absence of menstruation in people who have ovaries and a uterus, who are of reproductive age, is called amenorrhea. There are two types of amenorrhea: primary and secondary amenorrhea. The absence of menarche by the age of 16 years is called primary amenorrhea, and the absence of menstruation for a duration of three or more consecutive cycles in people who reported previously experiencing regular menstrual cycles secondary amenorrhea (Nawaz & Rogol, 2022). Table 6.1 lists the most common causes of primary and secondary amenorrhea.
| Primary Amenorrhea | Secondary Amenorrhea |
|---|---|
|
|
In addition to the absence of menstrual bleeding, common signs and symptoms associated with amenorrhea may include signs of underlying hormonal imbalances, such as:
- hirsutism (excessive hair growth on unexpected areas)
- hair loss
- headache
- galactorrhea (milk production not related to pregnancy or breast-feeding)
- visual changes
Care of the patient with amenorrhea starts with a detailed history and physical examination, with the provider first determining whether the patient has primary or secondary amenorrhea. If primary amenorrhea is confirmed, the provider will assess for chromosomal abnormalities. If the patient has secondary amenorrhea, the nurse will ask focused assessment questions about menstrual and reproductive history and symptoms of hormonal changes. Diagnostic testing will vary depending on the suspected etiology and may include hormone-level assessments, such as:
- beta–human chorionic gonadotropin (beta-hCG) to rule out pregnancy;
- testosterone and dehydroepiandrosterone sulfate (DHEAS) to look for hyperandrogenism;
- follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, thyroid function, and prolactin, to evaluate for hormonal imbalances;
- imaging tests, such as pelvic ultrasound or computed tomography (CT), to evaluate the patient for adrenal tumors, pituitary tumors, anatomic variants (transverse vaginal septum or absence of ovaries, uterus, or cervix); and
- karyotyping (Nawaz & Rogol, 2022).
Treatment of amenorrhea focuses on addressing the underlying cause. Medical management can include hormonal therapies such as combined oral contraceptives or progestin therapy to induce withdrawal bleeding, regulate menstrual cycles, and correct hormonal imbalances. For specific medical causes of amenorrhea like hyperprolactinemia, targeted medications like dopamine agonists may be used (Nawaz & Rogol, 2022). Patients with ongoing amenorrhea, particularly those with hypothalamic amenorrhea, may be at risk for osteoporosis due to bone loss associated with estrogen deficiency. Hypothalamic amenorrhea can be caused by weight loss, stress, or increased physical exercise. Some patients may require bone density monitoring or treatment with bisphosphonates to reduce bone loss; patients not desiring pregnancy will improve bone loss by taking estrogen and progesterone (Altayar et al., 2017).
Nonpharmacologic approaches to managing amenorrhea include lifestyle modifications, such as maintaining a healthy weight, managing stress levels, and ensuring adequate nutrition and exercise (Nawaz & Rogol, 2022). For persons with eating disorders or excessive exercise-induced amenorrhea, a multidisciplinary approach involving dieticians, therapists, and exercise specialists is crucial (Nawaz & Rogol, 2022).
Nurses play a vital role in the care of persons with amenorrhea. They should prioritize patient education, explaining the etiology and treatment options, as well as discussing potential long-term implications such as infertility or bone health concerns. Nurses can offer emotional support, addressing any concerns or anxieties related to the condition. They should also collaborate with other health-care providers to ensure comprehensive care, monitor treatment responses, and assess for potential complications or side effects of medications.
Dysmenorrhea
Painful menstruation that occurs in the absence of a physiologic cause is called dysmenorrhea. While many people have some cramping and pain during menstruation, people with dysmenorrhea have pain so severe that it interferes with their daily life. The condition is further classified as either primary dysmenorrhea, which is typical menstrual pain that occurs before or during a period, or secondary dysmenorrhea, which is menstrual pain caused by an underlying condition (ACOG, 2022a). Common signs and symptoms of dysmenorrhea include cramping abdominal pain that may radiate to the lower back and thighs, nausea, vomiting, fatigue, headache, and diarrhea (ACOG, 2022a). Dysmenorrhea is more prevalent in younger people, smokers, people with early menarche or a family history, and people who have never been pregnant or given birth (Hickey et al., 2023).
Evaluating a patient for dysmenorrhea starts with a thorough medical history and a physical exam. In most cases, diagnostic testing is warranted only when medication is not effective at managing menstrual pain. Pelvic ultrasound is a noninvasive option to visualize the pelvic anatomy. Other options may include hysteroscopy or laparoscopy to get a better view of the reproductive structures (ACOG, 2022a).
The goals of medical management are to alleviate pain and improve quality of life. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin) or naproxen (Aleve), are commonly used as first-line pharmacologic treatment to inhibit prostaglandin synthesis and reduce pain (Smith & Kaunitz, 2022). Hormonal therapies, such as combined oral contraceptives or progestins, may also be prescribed to reduce menstrual pain by suppressing ovulation and reducing endometrial proliferation (Smith & Kaunitz, 2022). If these medications do not sufficiently relieve pain, diagnostic laparoscopy can be considered if it has not already been performed. Other surgical procedures may include hysterectomy (removal of the uterus) or endometrial ablation (destruction of the endometrial lining). A hysterectomy is a major surgery that requires general anesthesia and significant time to heal. Endometrial ablation is performed in the office under sedation and does not require extended healing time. Both procedures are appropriate only in people no longer considering having children (Smith & Kaunitz, 2022).
Nonpharmacologic approaches can complement medical treatment and include heat therapy (e.g., hot water bottle, warm bath), relaxation techniques (e.g., deep breathing, guided imagery), regular exercise, and dietary modifications (McKenna & Fogleman, 2021). Applying heat to the lower abdomen can help relax uterine muscles and reduce pain, and relaxation techniques can help manage stress and promote overall well-being. Many people also report that the use of acupuncture and transcutaneous electric nerve stimulation (TENS) are helpful in reducing dysmenorrhea (ACOG, 2022a; and Smith & Kaunitz, 2022).
Nurses play a crucial role in managing dysmenorrhea. Nursing activities for the patient with dysmenorrhea may include:
- providing education about the condition, including its causes, common symptoms, and available treatment options
- assessing pain levels, using validated pain scales, and monitoring the effectiveness of interventions
- providing emotional support and addressing any anxiety or distress associated with dysmenorrhea
- encouraging self-care practices, such as heat therapy, relaxation techniques, and exercise
Clinical Judgment Measurement Model
Evaluate Outcomes
Nurses provide a great deal of education for patients with dysmenorrhea. In order to evaluate the success of the education, nurses must consider evaluation outcomes.
The nurse provides education on nonpharmacologic pain relief. To evaluate the outcomes, the nurse can ask the following questions:
- What relaxation technique would work best for you?
- What kind of exercise could you do during your period?
- Can you think of ways to relax your uterus?
- Do you remember where to apply the TENS pads?
By asking these questions, the nurse can determine if the education was successful or if further education is warranted.
Premenstrual Syndrome
The common, cyclic, and multifaceted disorder that occurs during the luteal phase of the menstrual cycle in people who menstruate is called premenstrual syndrome (PMS). It typically occurs 1 to 2 weeks before menstruation and is characterized by a combination of physical, emotional, and behavioral symptoms that significantly impact a person’s daily life and functioning (U.S. Department of Health and Human Services [HHS] Office on Women’s Health, 2021b)., 2021b). A rare type of PMS is premenstrual dysphoric disorder (PMDD), which is similar to PMS but has a more extreme presentation, causing extreme depression and anxiety in the luteal phase of the cycle (Mishra et al., 2021).
The signs and symptoms of PMS can vary widely among people but commonly include mood swings, irritability, anxiety, fatigue, breast tenderness, bloating, and changes in appetite or sleep patterns (HHS Office on Women’s Health, 2021b). Emotional symptoms can include feelings of sadness, tension, or difficulty in concentrating, while physical symptoms may manifest as headache, joint or muscle pain, and gastrointestinal disturbances (HHS Office on Women’s Health, 2021b). It is possible for people to have only physical symptoms, only emotional symptoms, or both. Symptoms may also change throughout a person’s reproductive lifespan.
PMS is primarily diagnosed based on the presence of characteristic symptoms during the luteal phase of the menstrual cycle. However, to establish a definitive diagnosis and rule out other underlying conditions, health-care providers should conduct a thorough medical history and evaluation of symptoms along with a thorough menstrual cycle history. Laboratory tests, such as thyroid function or complete blood count, may be performed to screen for other medical conditions such as hyper- or hypothyroidism and anemia (Casper, 2023).
The management of PMS often involves a multimodal approach. Pharmacologic interventions may be considered for severe cases and can include selective serotonin reuptake inhibitors (SSRIs) or hormonal contraceptives to regulate hormone levels and alleviate symptoms (HHS Office on Women’s Health, 2021b). Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for pain relief, and diuretics can be used to help relieve bloating and water retention (HHS Office on Women’s Health, 2021b). Some people have found that certain supplements, particularly magnesium, vitamin B6, calcium, and omega-3 fatty acids, may be effective in relieving symptoms (HHS Office on Women’s Health, 2021b). It is important for the nurse to discuss any potential interactions or side effects of these supplements.
Nonpharmacologic measures play a significant role in PMS management. Helpful lifestyle modifications may include:
- regular exercise
- cognitive behavioral therapy (CBT)
- a balanced diet rich in complex carbohydrates, decreased salt, and decreased refined sugars
- sleeping 7 to 8 hours each night
- stress-reduction techniques, such as relaxation exercises, journaling, and meditation (HHS Office on Women’s Health, 2021b)
Nurses play a vital role in caring for persons experiencing PMS. Assessment of symptoms, menstrual history, and psychosocial factors can aid in identifying the severity of the condition and its impact on the patient’s life. Nurses must also collaborate with health-care providers and advocate for their patients when necessary to develop personalized care plans that incorporate pharmacologic and nonpharmacologic interventions. Patient education on symptom management, healthy lifestyle practices, and coping strategies helps patients to better manage PMS and improve their quality of life.
Abnormal Uterine Bleeding
The common gynecologic condition characterized by atypical bleeding patterns is called abnormal uterine bleeding (AUB). It encompasses various menstrual irregularities, including heavy menstrual bleeding (menorrhagia), prolonged menstrual bleeding (hypermenorrhea), irregular menstrual cycles (metrorrhagia), bleeding or spotting after sex, irregular periods that vary in length by more than 7 to 9 days, menstrual cycles longer than 35 days or shorter than 21 days, intermenstrual bleeding (between periods), and bleeding after menopause (ACOG, 2023b).
There are two types of AUB: acute and chronic. Acute AUB is a sudden onset of abnormal bleeding that lasts for 2 hours or longer and requires treatment to prevent excessive blood loss and other complications (ACOG, 2023b; Davis & Sparzak, 2022). Chronic AUB is bleeding that deviates from the normal pattern and has occurred for the past 6 months.
Potential causes of AUB include:
- trauma
- ovulatory dysfunction
- neoplasms
- malignant lesions
- reproductive tract infections
- the presence of uterine fibroids or polyps
- adenomyosis or endometriosis
- blood clotting disorders
- certain medications, such as hormonal birth control
- ectopic pregnancy or miscarriage
- pelvic inflammatory disease (PID) (ACOG, 2023b)
The hallmark sign of AUB is changes in menstrual bleeding patterns (Davis & Sparzak, 2022). People may experience excessively heavy or prolonged periods that require frequent tampon or pad changes, defined as more than once per hour (ACOG, 2023b). Other signs may include fatigue, anemia, and menstrual pain.
Diagnosing AUB begins with a comprehensive assessment of the patient’s medical history, menstrual patterns, and related symptoms. A physical examination, including pelvic examination, is essential to rule out other gynecologic conditions. Laboratory tests, such as complete blood count (CBC) to assess for anemia and thyroid function, can help identify potential underlying causes. A pregnancy test may be needed to rule out pregnancy as a potential cause for the bleeding. Imaging tests like transvaginal ultrasound, hysteroscopy, or sonohysterography may be performed to evaluate the uterine cavity, while endometrial biopsy can be used to test for endometrial hyperplasia in people at high risk (Davis & Sparzak, 2022). Postmenopausal patients with AUB are at high risk for endometrial hyperplasia and endometrial cancer. Therefore, any postmenopausal person who presents with uterine bleeding should be evaluated.
The management of AUB consists of identifying and addressing the underlying cause, alleviating symptoms, and improving the patient’s quality of life. In most cases, medical treatment is preferred to surgical options (Davis & Sparzak, 2022). Medical treatment options often include hormonal therapy, which helps to regulate menstrual cycles and reduce menstrual flow. In cases where AUB is caused by structural abnormalities like polyps or fibroids, surgical interventions, like hysteroscopic polypectomy or myomectomy, or pharmacologic treatments, such as combined birth control pills, might be necessary.
Nonpharmacologic interventions are often recommended and can complement medical treatment to improve outcomes. Lifestyle modifications, such as regular exercise and a well-balanced diet, can promote hormonal balance and overall health. Managing stress and practicing relaxation techniques may also help reduce menstrual symptoms and restore regular menstrual patterns.
Nurses play a crucial role in providing comprehensive care to patients with AUB. A thorough assessment of the patient’s menstrual history, symptoms, and concerns can aid in identifying potential contributing factors and underlying causes. Nurses can educate patients about AUB, its potential impact on health, and the importance of seeking timely medical attention. Patient education on the appropriate use of prescribed medications, potential side effects, and expected outcomes is vital. Nurses can also assist in coordinating further diagnostic tests, providing pre- and postprocedural care, and ensuring patients understand treatment plans. Empowering patients to track their menstrual cycles and symptoms using calendars or apps can facilitate better communication with health-care providers.
Perimenopause and Menopause
The phase of menstrual irregularities called perimenopause is attributed to fluctuating hormone levels that last for months up to several years and ends when menses has ceased for 12 months (North American Menopause Society, n.d.-a; Smuskiewicz, 2019). Twelve months of amenorrhea is considered menopause, which represents the culmination of this transition (World Health Organization, 2022). Menopause typically occurs between ages 40 and 59, though the average age is 51 years old (North American Menopause Society, n.d.-a). In addition to the natural transition that occurs with advancing age, menopause can also occur in some patients due to surgical removal of the ovaries or some medications that affect ovarian or hormonal function, or chemotherapy and radiation therapy to the reproductive organs (North American Menopause Society, n.d.-a). People who undergo induced menopause have the same signs and symptoms as people who go through this transition naturally.
Cultural Context
Menopause and Perimenopause
Perimenopause and menopause are very much cultural phenomena (Women’s Health Network, 2023).
Japan
The concept of “hot flashes” is relatively new in Japan. This could be due to the high-soy diet of Japanese persons AFAB. Fewer people in Japan report having hot flashes and other vasomotor symptoms than people in the West (Rei Otsuka et al., 2020). In fact, the word for menopause in Japanese translates to “a period of renewal and regeneration” (Women’s Health Network, 2023).
Mayan Descendants
Descendants of the ancient Mayan civilization still live in pockets of rural Guatemala and Mexico and have been interviewed about their view of menopause. Many said they do not experience any of the typical menopausal symptoms (such as hot flashes and insomnia), despite having FSH levels similar to those of Western people (Women’s Health Network, 2023). In addition, many of these Mayan people look forward to this transition to the next stage in their life (Women’s Health Network, 2023). These differences could be explained by diet and other health-related behaviors; attitudes about aging and perceptions about age may play a major role (Marloff, 2021).
Western Society
Western societies often revere youth and attractiveness, leading to differing views on aging and menopause (Marloff, 2021; Women’s Health Network, 2023).
Changes in Menstruation
Changes in menstruation are often the hallmark of perimenopause and can vary significantly among people. During perimenopause, the ovaries start making less estrogen and progesterone, which can cause anovulation and missed periods (ACOG, 2022b). See Chapter 4 Influences on Fertility for a review of reproductive hormones and the menstrual cycle. These changing hormones can cause cycles to become longer or shorter, menstrual flow to be heavier or lighter, or bleeding/spotting to occur between periods (Eisenberg, 2022). It is not unusual for people in perimenopause to skip periods for several months and then resume a regular pattern of menstruation.
Vasomotor Symptoms
More commonly known as hot flashes and night sweats, vasomotor symptoms (VMS) are cardinal symptoms of perimenopause and menopause. These episodes of sudden and intense heat are accompanied by skin flushing, perspiration, palpitations, and an acute feeling of discomfort and can last for several minutes (World Health Organization, 2022). Vasomotor symptoms often disturb sleep patterns and impact daily activities, making their management crucial for people experiencing this transition. Hot flashes that occur at night are known as night flushes or night sweats and can lead to insomnia and other sleep disturbances.
The pathophysiology of vasomotor symptoms is not well understood, but it is believed that persons experience a reduction in thermoregulation, which may be attributed to a reduction in several hypothalamic hormones and a narrowing of the thermoneutral zone (Jina et al., 2022). Although vasomotor symptoms have long been thought of as uncomfortable without a physiologic effect, growing research is showing that they may be associated with negative cardiovascular risk factors, including insulin resistance, diabetes, and hypertension (Jina et al., 2022). However, further research is needed to determine the actual clinical impact of VMS on cardiovascular health.
Vaginal Dryness
Declining estrogen levels during perimenopause and menopause can affect the vagina and external genitalia (the vulva). This reduction of estrogen weakens the vulvovaginal epithelium, causing it to be thinner and less elastic (The North American Menopause Society, n.d.-b). Lower estrogen levels can also cause a reduction in lubrication and an increase in vaginal pH (The North American Menopause Society, n.d.-b), This can result in discomfort, pain during intercourse (dyspareunia), and increased vulnerability to infections.
A reduction in sexual activity after menopause can cause the vagina to shorten and narrow, worsening symptoms, such as pain, tearing, and injury if sexual activity is resumed. The nurse should advise patients to continue having regular sexual activity through menopause to help reduce vulvovaginal atrophy (thinning of the skin of the vulva and vagina) and to use lubrication during intercourse to reduce pain and injury to the vagina (The North American Menopause Society, n.d.-b).
Changes in Metabolism
Metabolic shifts occur as estrogen levels decline and androgen levels increase during perimenopause and menopause, making people more likely to gain weight, particularly around the abdomen, and muscle loss (Ko & Jung, 2021). These changes affect overall metabolism and potentially increase the risk of cardiovascular disease and metabolic disorders (Ko & Jung, 2021). People often also experience increased blood pressure, blood glucose, lipid levels, and inflammatory markers, increasing their risk for metabolic syndrome and cardiovascular disease (Hyvärinen et al., 2022). Therefore, these patients should be monitored for these chronic diseases.
Some of these metabolic shifts may mimic hypothyroidism or decreased thyroid function. This is one of the most common diseases in humans, particularly in older adults (Han et al., 2022), with many people dealing with both subclinical hypothyroidism and menopausal symptoms (Xu et al., 2023). Many of the clinical manifestations of hypothyroidism are similar to those experienced during menopause, including fatigue, weight gain, and anxiety. Like menopause, hypothyroidism is associated with negative changes in the lipid profile (Han et al., 2022) and requires ongoing monitoring.
Emotional Changes
Emotional well-being can be significantly impacted during perimenopause and menopause due to hormonal fluctuations and psychosocial factors. Mood swings, irritability, and episodes of depression may occur. Many people report feeling similar to the way they feel during premenstrual syndrome: moody, low energy, tearful, easily distracted, or irritable (Silver, 2023). However, unlike PMS, these symptoms have no relationship to the menstrual cycle and may occur for a long period of time without any discernible pattern (Silver, 2023). In addition to mood swings, many people report depression and anxiety, even if they have never had them before. Potential causes may include:
- hormonal changes
- dealing with physical symptoms associated with menopause
- increased life pressures and stress (Silver, 2023)
These emotional changes can affect a person’s quality of life and interpersonal relationships, highlighting the importance of emotional support and holistic care from the entire health-care team and especially the nurse.
Management
Diagnostic testing involves assessing hormone levels, especially follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. During perimenopause and menopause, the ovaries are less responsive to these hormones, requiring increased levels to activate follicular growth (Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2021). Elevated FSH levels and decreased estradiol levels are indicative of perimenopause and menopause. However, it is important to recognize that these hormones do vary throughout the cycle, and a single elevated FSH level is not enough to definitively tell that someone is in perimenopause (Endocrine Society, n.d.). An additional test is the anti-Müllerian hormone (AMH) level. Anti-Müllerian hormone is produced by the ovarian follicles. When there are a lot of follicles (high ovarian function), the AMH level is high; when ovarian function starts to decline, the AMH level drops as well (Endocrine Society, n.d.). If a patient presents with symptoms of perimenopause, the provider may order additional testing to determine if the symptoms could be attributed to a different cause, such as thyroid dysfunction, pituitary tumor, or even possible pregnancy.
The primary medical intervention for perimenopause and menopause includes hormone replacement therapy (HRT). HRT is the administration of estrogen, progesterone, or a combination of both hormones to effectively alleviate menopausal symptoms, such as vasomotor symptoms and vaginal dryness. In the past, the use of HRT was controversial due to a study that suggested significant health risks associated with its use; however, ongoing research has shown that HRT is a safe option for most healthy, menopausal people. Some populations of people should not use hormonal therapy, including people with a history of
- breast cancer,
- uterine cancer,
- deep vein thrombosis or pulmonary embolism,
- blood clotting disorder,
- migraine with aura,
- liver disease, and
- arterial thrombotic disease (heart attack or stroke) (Harper-Harrison & Shanahan, 2023).
Patients who are not eligible for HRT have had success in reducing vasomotor symptoms using serotonin receptor reuptake inhibitors.
There are two types of HRT: estrogen only and combination estrogen/progesterone therapy. People with an intact uterus must take both estrogen and progesterone because estrogen alone can cause endometrial hyperplasia and increase the risk for uterine cancer (Harper-Harrison & Shanahan, 2023). Progesterone opposes estrogen and reduces that risk by keeping the uterine lining from uncontrolled proliferation (Harper-Harrison & Shanahan, 2023). In addition, progesterone may relieve other symptoms not affected by estrogen, such as insomnia and mood swings (Harper-Harrison & Shanahan, 2023). Estrogen and progesterone can be administered via patches, creams, pills, vaginal inserts, or subdermal pellets, depending on patient preference and clinical status. It is important for the patient to be aware of the risks of HRT, including deep vein thrombosis, strokes, and pulmonary embolism, similar to the risk of birth control pills.
Nonpharmacologic approaches can be used in lieu of or to complement medical treatments. Some lifestyle modifications may contribute to overall well-being and wellness, including:
- maintaining a balanced diet rich in calcium and vitamin D
- engaging in regular physical activity
- practicing stress reduction techniques
- quitting smoking
- reducing alcohol consumption
- managing weight (Endocrine Society, 2022a).
Cognitive behavioral therapy (CBT) and mindfulness practices aid in managing mood swings and emotional changes.
Nurses play a pivotal role in supporting people through perimenopause and menopause. Providing patient education about the physical and emotional changes, available treatment options, and self-care strategies empowers patients to actively participate in their health-care decisions. Creating a safe space for open discussions, offering emotional support, and assisting in symptom management are central to nursing care during this transitional phase.
Life-Stage Context
Nonpharmacologic Measures for Menopause
The use of hormone replacement therapy (HRT) for menopausal symptoms is a personal decision. Many people are either uncomfortable with or unable to take these drugs and must treat their menopausal symptoms using nonpharmacologic options. The nurse plays an instrumental role in helping the patient find options that work for them. These may include:
- using a fan or wearing lightweight pajamas
- wearing layers
- stress reduction
- acupuncture
- yoga to reduce hot flashes
- mind-body therapies
- biofeedback
- meditation
- cognitive behavioral therapy (Johnson et al., 2019)
In addition to discussing these different options, the nurse may help the patient find a qualified practitioner to administer these treatments.
Endometriosis
The chronic and often painfully debilitating gynecologic disorder characterized by the presence of endometrial-like tissue outside the uterus is called endometriosis (World Health Organization, 2023). This tissue (Figure 6.2) can develop on various pelvic structures, such as the ovaries, bladder, rectovaginal septum, fallopian tubes, and the peritoneal lining (World Health Organization, 2023). Rarely, endometrial implants have been found outside the pelvis on other structures. It is believed that at least 11 percent of persons assigned female at birth in the United States have endometriosis (HHS Office on Women’s Health, 2021a). It is most common in a person’s 30s or 40s, but endometriosis can occur in anyone having menstrual periods (HHS Office on Women’s Health, 2021a). Researchers are unsure about the cause of endometriosis but suspect that it may be related to problems with retrograde menstrual flow, hormonal or immune system abnormalities, genetic factors, or previous surgery on the uterus or abdominal area (HHS Office on Women’s Health, 2021a).
The hallmark symptoms of endometriosis include pelvic pain, dysmenorrhea, dyspareunia, and infertility. Patients may experience pain that varies in intensity and duration, often worsening during menstruation. If implants are found on the bowel or bladder, patients can have urinary or gastrointestinal symptoms as well, such as diarrhea, bloating, constipation, painful bowel movements during menstruation, or pain while passing urine (World Health Organization, 2023). Sometimes, people have pain during or after sex or spotting between menstrual periods (HHS Office on Women’s Health, 2021a). Additionally, some patients may have asymptomatic endometriosis, highlighting the variability in symptom expression.
Diagnosing endometriosis starts with taking a detailed patient history, including information about symptoms, such as menstrual changes and pelvic pain. The provider should perform a physical assessment, including a pelvic exam, to evaluate for endometrial cysts or scars on the pelvic organs (HHS Office on Women’s Health, 2021a). Diagnostic testing, such as pelvic ultrasound and magnetic resonance imaging (MRI), can be used to visualize the pelvic anatomy. Laparoscopic surgery for direct visualization of endometrial implants and histologic confirmation remains the gold standard for definitive diagnosis. However, laparoscopic surgery is highly invasive and not necessary for providers to initiate treatment options to relieve pain and improve quality of life (World Health Organization, 2023).
The management of endometriosis focuses on alleviating pain, improving quality of life, and addressing fertility concerns. Pharmacologic options include:
- NSAIDs for pain relief
- hormonal therapies such as oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists to suppress endometrial growth
In cases of severe pain or refractory symptoms, laparoscopic excision surgery can be considered to remove endometriotic lesions and improve fertility prospects (HHS Office on Women’s Health, 2021a). In many cases, the discomfort associated with endometriosis goes away during menopause, when estrogen levels decline and the endometrial lining shrinks (HHS Office on Women’s Health, 2021a). See Chapter 4 Influences on Fertility for additional information about managing endometriosis-related infertility.
Nonpharmacologic measures play a complementary role in managing endometriosis. Lifestyle modifications, including a balanced diet and regular exercise, can help manage inflammation and improve overall well-being. Some people find success from other therapies, such as:
- chiropractic care
- acupuncture
- certain herbal medications (cinnamon twig, licorice root)
- vitamin supplements (vitamin B1, magnesium, omega-3 fatty acids) (HHS Office on Women’s Health, 2021a)
Nurses play a pivotal role in caring for persons with endometriosis. Patient education is very important when caring for patients with this condition to ensure that they understand their condition, treatment options, and potential outcomes. Nurses can provide information on medication management, potential side effects, and self-care strategies.
Patient-centered care involves active listening and acknowledging the physical and emotional impact of endometriosis. Nurses can offer coping strategies, facilitate support groups, and connect patients with relevant resources. When surgery is part of the treatment plan, nurses provide preoperative education, offer emotional support, and guide patients through postoperative recovery.
Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is a common endocrine disorder found in approximately 6 percent to 12 percent of American persons assigned female at birth who are of childbearing age (Centers for Disease Control and Prevention [CDC], 2022b). PCOS is characterized by hormonal imbalances that lead to a variety of reproductive, metabolic, and cardiovascular disturbances (Figure 6.3) that present as a combination of multiple symptoms, affecting various aspects of a person’s health beyond their reproductive years (CDC, 2022b). Patients of every race and ethnicity suffer from PCOS. The cause of PCOS is not fully understood, but researchers have observed a pattern of elevated androgen levels and insulin resistance in people with the condition (CDC, 2022b). Researchers are also investigating how genetics may contribute to developing this disease, as many people with PCOS have relatives with this disorder (CDC, 2022b).
The symptoms of PCOS are diverse and vary significantly from person to person. Many people do not realize they have the condition until they struggle to conceive. Other people have the full spectrum of clinical manifestations, which can include:
- irregular menstrual cycles
- hyperandrogenism, causing hirsutism (excessive hair growth), acne, and alopecia
- polycystic ovaries seen on ultrasound
- obesity
People with PCOS are also at higher risk for several serious complications, including:
- insulin resistance and diabetes
- metabolic syndrome
- hypertension
- high cholesterol and triglycerides
- endometrial cancer due to excessive endometrial growth from irregular menstrual cycles
- depression and anxiety
- obstructive sleep apnea related to being overweight
- cardiovascular disease
- non-alcoholic fatty liver disease
- infertility (Endocrine Society, 2022b)
People with PCOS who become pregnant are at higher risk for complications such as gestational diabetes, preeclampsia, and preterm birth (Endocrine Society, 2022b).
Diagnosing PCOS involves a thorough assessment of a patient’s medical history and clinical symptoms, as well as diagnostic testing when necessary. The diagnostic tool for PCOS is the Rotterdam criteria, which require the presence of two out of three factors: menstrual irregularity, evidence of hyperandrogenism (by either clinical symptoms or laboratory testing), and polycystic ovaries visualized on ultrasound (Christ & Cedars, 2023). To be diagnostic of PCOS, these symptoms must also occur without any other clinical cause. Blood tests can be used to rule out other diagnoses, including pregnancy, elevated prolactin levels, and abnormal levels of thyroid hormones and follicle-stimulating hormone. Testing of androgen levels, such as testosterone and dehydroepiandrosterone sulfate (DHEAS), may also aid in the diagnosis (Barbieri & Ehrmann, 2023). After diagnosis of PCOS, patients may undergo testing for insulin resistance, diabetes, and cholesterol/triglyceride levels to determine if other complications are present (Barbieri & Ehrmann, 2023).
The management of PCOS is multifaceted, focusing on alleviating symptoms, improving metabolic outcomes, and addressing reproductive concerns. Combined oral contraceptives (COCs), in the form of pills, patches, or the vaginal ring, are frequently used to help regulate menstrual cycles, lower the risk of endometrial hyperplasia, and reduce hyperandrogenism (Barbieri & Ehrmann, 2023). COCs can be used in combination with antiandrogens, such as spironolactone (Aldactone), to help further reduce symptoms of hyperandrogenism, like hirsutism and acne. Hair removal therapies, such as depilatories, laser therapy, waxing or shaving, and electrolysis, are also effective in removing excess hair. Hair loss, on the other hand, can be treated with medications or hair replacement therapies. Weight loss is a common concern for people with PCOS and should be approached with reducing insulin resistance in mind. While diet and exercise are key, weight loss medication or surgery may also be necessary due to the complicated metabolic disturbances that may be present. Metformin (Glucophage), an insulin-sensitizing medication, can be effective in improving insulin resistance and may help to restore ovulation in people with abnormal menstrual cycles. See Chapter 4 Influences on Fertility for additional information about addressing fertility concerns for people with PCOS.
Lifestyle modifications are essential in managing PCOS, particularly for improving metabolic health and fertility outcomes. Regular physical activity and a balanced diet can help manage weight, reduce insulin resistance, and promote overall well-being. Weight loss, even modest, can lead to improvements in menstrual regularity, hormonal profiles, and fertility (Barbieri & Ehrmann, 2023). Nurses play a vital role in supporting patients with PCOS through education, counseling, and emotional support. Patient education is crucial in helping persons understand their condition, treatment options, and potential long-term health implications. Nurses can offer guidance on lifestyle modifications, emphasizing the importance of regular exercise, balanced nutrition, and weight management.
For people experiencing infertility due to PCOS, nurses can provide emotional support during fertility treatments and assist in coordinating care with fertility specialists. Educating patients about potential fertility interventions, such as ovulation induction and in vitro fertilization (IVF), enables informed decision making. Chapter 4 Influences on Fertility provides additional information about nursing care for the patient undergoing diagnostic testing or treatment for infertility. Furthermore, nurses collaborate with multidisciplinary health-care teams, including endocrinologists, dieticians, and mental health professionals, to ensure comprehensive care.
Pharmacology Connections
Metformin
Metformin is a medication commonly prescribed for people with PCOS to help improve insulin sensitivity. It can also help restore ovulation in PCOS with insulin resistance and is sometimes used in the infertility setting for that purpose.
- Generic Name: metformin
- Trade Name: Fortamet, Glucophage, Glumetza
- Class/Action: biguanide drug
- Route/Dosage: Oral medication prescribed at daily doses between 500 and 2,550 mg. Immediate-release formulations are administered twice daily, preferably with a meal, and extended-release formulas are taken once a day with the evening meal. Dosages typically start at 500 mg once or twice each day and are titrated each week in increments of 500 mg (Corcoran & Jacobs, 2023).
- High Alert/Black Box Warning: Lactic acidosis is a rare complication that can occur in some people with metformin use. It is characterized by elevated lactate levels, decreased pH, and other electrolyte abnormalities. This complication occurs rarely, at approximately 0.03 cases per 1,000 patient-years (Crowley et al., 2016).
- Indications: Indicated for the treatment of type 2 diabetes. It is used off-label to manage gestational diabetes, weight gain from antipsychotic medication, and polycystic ovary syndrome (Corcoran & Jacobs, 2023).
- Mechanism of Action: Biguanides lower blood glucose levels by three mechanisms: (1) improving insulin sensitivity, (2) reducing absorption of glucose in the gut, and (3) lowering glucose production in the liver (Corcoran & Jacobs, 2023). In people with PCOS, metformin reduces insulin levels, which normalizes luteinizing hormone (LH) and androgens, which helps in restoring regular ovulation (Corcoran & Jacobs, 2023).
- Contraindications: Metformin is contraindicated in patients with renal disease, people with hypersensitivity to metformin, or people with metabolic acidosis.
- Adverse Reactions/Side Effects: The most common adverse effects with metformin use are gastrointestinal effects, including diarrhea, nausea, and vomiting. This is mitigated by having patients take the medication with food and titrating doses slowly. Other side effects may include headache, hypoglycemia, weakness, and rhinitis.
- Nursing Implications: It is important for the nurse to educate the patient about this drug, especially about the signs and symptoms of lactic acidosis, and the expected side effects. The nurse should also warn the patient about the potential GI side effects and offer advice on how to reduce these. The nurse should also review lifestyle modifications that can be helpful in people with PCOS and insulin resistance.
Chronic Pelvic Pain
Chronic pelvic pain (CPP) is a condition characterized by persistent or recurrent pain in the pelvic region lasting for at least 6 months. This type of pain can come and go over that 6-month period or occur at regular intervals, such as during particular events of the menstrual cycle or with certain activities, such as during sex (ACOG, 2022c). The diversity of symptoms highlights the complexity of CPP and its potential underlying causes. CPP can be related to disorders of the reproductive organs, bladder or urinary tract, or the bowel and can be caused by conditions such as:
- endometriosis
- fibroids
- irritable bowel syndrome
- interstitial cystitis
- urinary tract infection
- dysmenorrhea
- pelvic inflammatory disease (PID)
- cancer of the urinary or gastrointestinal tract
- poor posture
- strain of the structures in the low back related to pregnancy
- musculoskeletal problems or low back pain and disc injuries (ACOG, 2022c)
CPP can significantly impact a person’s physical, emotional, and social well-being. In many cases, up to 50 percent, the cause of CPP is never diagnosed (Dydyk & Gupta, 2023).
Diagnosing CPP requires a comprehensive evaluation involving medical history, physical examination, and targeted diagnostic tests. The provider will explore the patient’s symptoms and their relationship with precipitating and alleviating factors, such as menses, urination, sexual activity, and bowel movements (Dydyk & Gupta, 2023). If connections are found, they should be explored further. For example, if the patient experiences pain related to urination, diagnostic testing for urinary tract infection, interstitial cystitis, and other urinary abnormalities should be the next step. Most importantly, the provider should also ask about symptoms that may signal systemic disease, such as unexplained weight loss, bleeding in the urine or stool, bleeding after sex, or bleeding between periods or after menopause. The physical exam should include assessment of the abdomen and reproductive structures, including a gynecologic exam (Dydyk & Gupta, 2023). Pelvic ultrasound, computed tomography (CT) scans, and magnetic resonance imaging (MRI) can help identify structural abnormalities, such as ovarian cysts, fibroids, or endometriosis. Diagnostic laparoscopy, a minimally invasive surgical procedure, can provide direct visualization and potential treatment of underlying conditions.
The management of CPP focuses on addressing the underlying cause:
- antibiotics for pelvic inflammatory disease or urinary tract infection
- hormonal contraceptives for dysmenorrhea or endometriosis
- surgical removal of cysts and fibroids
- physical therapy for musculoskeletal issues
- medication for irritable bowel disease or interstitial cystitis
If no specific cause for the pain is found, treatment shifts to managing the pain and improving quality of life. This may include the use of NSAIDs for pain relief or gabapentin (Neurontin) or pregabalin (Lyrica) for neuropathic pain (ACOG, 2022c). In some cases, surgical interventions may be considered to address structural issues contributing to CPP.
Nonpharmacologic measures play a pivotal role in managing CPP and can be used to complement other medical treatments. Strategies such as physical therapy, pelvic floor exercises, and relaxation techniques can help improve muscular function, alleviate pain, and reduce stress. Regular exercise and weight loss can improve posture and some musculoskeletal issues contributing to CPP (ACOG, 2022c). Nutritional interventions and dietary modifications can contribute to managing bowel and urinary symptoms associated with CPP. Other pain management strategies, such as acupuncture, acupressure, nerve stimulation, biofeedback therapy, and even nerve blocks can also be helpful in some cases (ACOG, 2022c).
Nurses play a vital role in providing comprehensive care and support to persons with CPP. Assessment is key, involving a thorough evaluation of the patient’s pain history, symptoms, and psychosocial factors contributing to pain perception. Fifty-three percent of patients with CPP experience moderate to severe depression and anxiety (Bryant et al., 2016). Empathetic listening and effective communication are essential to understanding the impact of CPP on the patient’s daily life. Patient education is a cornerstone of nursing interventions. Nurses can educate patients about their condition, potential treatment options, and strategies for managing pain and associated symptoms. Teaching relaxation techniques, guiding patients through pelvic exercises, and providing information about available resources empower persons to actively participate in their care. Furthermore, nurses collaborate with interdisciplinary teams, including physicians, physical therapists, psychologists, and pain specialists, to develop comprehensive treatment plans tailored to the patient’s needs. Emotional support, counseling, and facilitating support groups can help address the psychologic impact of CPP.