Reproductive System Concerns

Endometriosis

Premenstrual Syndrome

• Sports in which performance is subjectively scored (e.g., dance, gymnastics)

• Endurance sports favoring participants with low body weight (e.g., distance running, cycling)

• Sports in which body contour–​revealing clothing is worn for competition (e.g., swimming, diving, volleyball)

• Sports with weight categories for participation (e.g., rowing, martial arts)

• Sports in which prepubertal body shape favors success (e.g., gymnastics, figure skating)

Management

When amenorrhea is a result of hypothalamic disturbances, the nurse is an ideal health professional to assist women because many of the causes are potentially reversible (e.g., stress, weight loss for nonorganic reasons). Counseling and education are primary interventions and appropriate nursing roles. When a stressor known to predispose a client to hypothalamic amenorrhea is identified, initial management involves addressing the stressor. Together the woman and the nurse plan how the woman can decrease or discontinue medications known to affect menstruation, correct weight loss, deal more effectively with psychologic stress, address emotional distress, and alter her exercise routine.

The nurse works with the woman to help her identify, cope with, and possibly resolve sources of stress in her life. Deep-breathing exercises and relaxation techniques are simple yet effective stress reduction measures. Referral for biofeedback or massage therapy also may be useful. In some instances, referrals for psychotherapy may be indicated.

If a woman’s exercise program is thought to contribute to her amenorrhea, several options exist for management. The American College of Sports Medicine (ACSM) recommends increasing nutritional intake to increase energy availability and reducing exercise energy expenditure as the first line of treatment (Nattiv, Loucks, Manore, Sandborn, Sundgot-Borgen, Warren, & ACSM, 2007). Therefore, the woman may decide to decrease the intensity or duration of her training if possible or to gain 2% to 3% in body weight. Coming to accept this alternative may be difficult for one who is committed to a strenuous exercise regimen, and the nurse and the client may have several sessions before the woman elects to try exercise reduction. Many young female athletes may not understand the consequences of low bone density or osteoporosis; nurses can point out the connection between low bone density and stress fractures. The nurse and the woman also should investigate other factors that may be contributing to the amenorrhea and develop plans for altering lifestyle and decreasing stress.

A daily calcium intake of 1000 to 1500 mg and vitamin D 400 to 600 International Units is recommended for women with amenorrhea associated with the female athlete triad (Bonci et al., 2008). Some researchers have found that low-dose oral contraceptives have a positive effect on bone density in premenopausal women with exercise-associated amenorrhea (Liu & Lebrun, 2006; Vescovi, VanHeest, & De Souza, 2008).

Primary Dysmenorrhea

Primary dysmenorrhea, a condition associated with abnormally increased uterine activity, is due to myometrial contractions induced by prostaglandins in the second half of the menstrual cycle. During the luteal phase and subsequent menstrual flow, prostaglandin F_2α (PGF_2α) is secreted. The uterine muscle of both normal and dysmenorrheic women is sensitive to prostaglandins; however, the amount of prostaglandin produced is the major differentiating factor. Excessive release of PGF_2α increases the amplitude and frequency of uterine contractions and causes vasospasm of the uterine arterioles, resulting in ischemia and cyclic lower abdominal cramps. Systemic responses to PGF_2α include backache, weakness, sweating, gastrointestinal symptoms (anorexia, nausea, vomiting, and diarrhea), and central nervous system symptoms (dizziness, syncope, headache, and poor concentration). Pain begins at the onset of menstrual flow and lasts from 8 to 48 hours (Lentz, 2007b).

Primary dysmenorrhea is not caused by underlying pathology; rather it is the occurrence of a physiologic alteration in some women. Primary dysmenorrhea usually appears within 6 to 12 months after menarche when ovulation is established. Anovulatory bleeding, common in the few months or years after menarche, is painless. Because both estrogen and progesterone are necessary for primary dysmenorrhea to occur, it is experienced only with ovulatory cycles. This problem is most common in women in their late teens and early 20s; the incidence declines with age. Psychogenic factors may influence symptoms, but symptoms are definitely related to ovulation and do not occur when ovulation is suppressed.

Secondary Dysmenorrhea

Secondary dysmenorrhea is acquired menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25 years. This condition is associated with pelvic pathology, such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids). Women with secondary dysmenorrhea often have other symptoms that may suggest an underlying cause. For example, heavy menstrual flow with dysmenorrhea suggests a diagnosis of leiomyomata, adenomyosis, or endometrial polyps. Pain associated with endometriosis often begins a few days before menses, but can be present at ovulation and continue through the first days of menses or start after menstrual flow has begun. In contrast to primary dysmenorrhea, the pain of secondary dysmenorrhea is often characterized by dull, lower abdominal aching radiating to the back or thighs. Often women experience feelings of bloating or pelvic fullness. In addition to a physical examination with a careful pelvic examination, diagnosis may be assisted by ultrasound examination, dilation and curettage, endometrial biopsy, or laparoscopy. Treatment is directed toward removal of the underlying pathology. Many of the measures described for pain relief of primary dysmenorrhea also are helpful for women with secondary dysmenorrhea.

• Symptoms consistent with PMS occur in the luteal phase and resolve within a few days of menses onset.

• Symptom-free period occurs in the follicular phase.

• Symptoms are recurrent.

• Symptoms have a negative effect on some aspect of a woman’s life.

• Other diagnoses that better explain the symptoms have been excluded.

• Five or more affective and physical symptoms are present in the week before menses and are absent in the follicular phase of the menstrual cycle.

• At least one of the symptoms is irritability, depressed mood, anxiety, or emotional lability.

• Symptoms interfere markedly with work or interpersonal relationships.

• Symptoms are not caused by an exacerbation of another condition or disorder.

Management

There is little agreement on management. A careful, detailed history and daily log of symptoms and mood fluctuations spanning several cycles may give direction to a plan of management. Any changes that assist a woman with PMS to exert control over her life have a positive effect. For this reason, lifestyle changes are often effective in the treatment of PMS.

Education is an important component of the management of PMS. Nurses can advise women that self-help modalities often result in significant symptom improvement. Women have found a number of complementary and alternative therapies to be useful in managing the symptoms of PMS. Nurses can suggest that women:

Nutritional supplements can assist in symptom relief. Calcium (1000 to 1200 mg daily), magnesium (300 to 400 mg daily), and vitamin B₆ (100 to 150 mg daily) have been shown to be moderately effective in relieving symptoms, to have few side effects, and to be safe. Daily supplements of evening primrose oil are reportedly useful in relieving breast symptoms with minimal side effects, but research reports are conflicting (Taylor et al., 2008). Other herbal therapies have long been used to treat PMS; see Table 6-2 for specific suggestions.

Regular exercise (aerobic exercise three or four times a week), especially in the luteal phase, is widely recommended for relief of PMS symptoms (Lentz, 2007b). A monthly program that varies in intensity and type of exercise according to PMS symptoms is best. Women who exercise regularly seem to have less premenstrual anxiety than do nonathletic women. Researchers believe aerobic exercise increases beta-endorphin levels to offset symptoms of depression and elevate mood.

Yoga, acupuncture, hypnosis, light therapy, chiropractic therapy, and massage therapy have all been reported to have a beneficial effect on PMS. Further research is needed for all of these suggested therapies.

Nurses can explain the relation between cyclic estrogen fluctuation and changes in serotonin levels, that serotonin is one of the brain chemicals that assist in coping with normal life stresses, and the ways in which the different management strategies recommended help maintain serotonin levels. Support groups or individual or couples counseling may be helpful. Stress reduction techniques also may assist with symptom management (Lentz, 2007b; Taylor et al., 2008).

If these strategies do not provide significant symptom relief in 1 to 2 months, medication is often begun. Many medications have been used in treatment of PMS, but no single medication alleviates all PMS symptoms. Medications often used in the treatment of PMS include diuretics, prostaglandin inhibitors (NSAIDs), progesterone, and OCPs. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac or Sarafem), sertraline (Zoloft), and paroxetine (Paxil CR) are approved by the U.S. Food and Drug Administration (FDA) as agents for PMS. Use of these medications results in a decrease in emotional premenstrual symptoms, especially depression (Lentz, 2007b). Common side effects are headaches, sleep disturbances, dizziness, weight gain, dry mouth, and decreased libido (see Nursing Care Plan: Premenstrual Syndrome).

Management

Treatment is based on the severity of symptoms and the goals of the woman or couple. Women without pain who do not want to become pregnant need no treatment. Women with mild pain who may desire a future pregnancy may use NSAIDs for pain relief. Women who have severe pain and can postpone pregnancy may be treated with continual OCPs that have a low estrogen-to-progestin ratio to shrink endometrial tissue. However, when this therapy stops, women often experience high rates of pain recurrence and other symptoms.

Hormonal antagonists that suppress ovulation and reduce endogenous estrogen production and subsequent endometrial lesion growth are used to treat mild to severe endometriosis in women who wish to become pregnant at a future time. GnRH agonist therapy (leuprolide, nafarelin [Synarel], goserelin acetate [Zoladex]) acts by suppressing pituitary gonadotropin secretion. FSH and LH stimulation to the ovary declines noticeably, and ovarian function decreases significantly. The hypoestrogenism results in hot flashes in almost all women. In addition, minor bone loss sometimes occurs, most of which is reversible within 12 to 18 months after the medication is stopped. Leuprolide (3.75-mg intramuscular injection given once a month) or nafarelin (200 mcg administered twice daily by nasal spray) are effective and well tolerated. Both medications reduce endometrial lesions and pelvic pain associated with endometriosis and have posttreatment pregnancy rates similar to that of danazol therapy (Lobo, 2007b). Common side effects of these drugs are similar to those of natural menopause—hot flashes and vaginal dryness. Some women report headaches and muscle aches.

Danazol (Danocrine), a mildly androgenic synthetic steroid, suppresses FSH and LH secretion, thus producing anovulation with resulting decreased secretion of estrogen and progesterone and regression of endometrial tissue. Bothersome side effects include masculinizing traits in the woman—weight gain, edema, decreased breast size, oily skin, hirsutism, and deepening of the voice—all of which often disappear when treatment is discontinued. Other side effects are amenorrhea, hot flashes, vaginal dryness, insomnia, and decreased libido. Some women report migraine headaches, dizziness, fatigue, and depression. In addition, some women experience decreases in bone density that are only partially reversible. Danazol should never be prescribed when pregnancy is suspected, and contraception should be used with it because ovulation may not be suppressed. Danazol can produce pseudohermaphroditism in female fetuses. The drug is contraindicated in women with liver disease and should be used with caution in women with cardiac and renal disease (Lobo, 2007b).

Administration of NSAIDs and continuous combined hormonal therapy (oral contraceptive pills, estrogen/progestin patch, estrogen/progestin vaginal ring) for menstrual suppression are the usual treatment of adolescents younger than the age of 16 who have endometriosis. GnRH agonists are not usually used because the resultant hypoestrogenic state can affect bone mineralization (ACOG Committee on Adolescent Health Care, 2005).

Surgical intervention is often needed for severe, acute, or incapacitating symptoms. A woman’s age, desire for children, and location of the disease influence decisions regarding the extent and type of surgery. For women who do not want to preserve their ability to have children, the only definite cure is hysterectomy and BSO (total abdominal hysterectomy [TAH] with BSO). In women who are in their childbearing years and who want children if the disease does not prevent pregnancy, surgery or laser therapy is used to carefully remove as much endometrial tissue as possible to maintain reproductive function (Lobo, 2007b).

Short of TAH with BSO, endometriosis recurs in approximately 40% to 50% of women, regardless of the form of treatment. Therefore, for many women, endometriosis is a chronic disease with conditions such as chronic pain or infertility. Counseling and education are critical components of nursing care of women with endometriosis. Women need an honest discussion of treatment options with potential risks and benefits of each option reviewed. Because pelvic pain is a subjective, personal experience that can be frightening, support is important. Sexual dysfunction resulting from dyspareunia may be present and may necessitate referral for counseling. Some locations have support groups for women with endometriosis; Resolve (www.resolve.org), an organization for infertile couples, or the Endometriosis Association (www.ivf.com/endohtml.html) also may be helpful. The nursing care measures discussed in the section on dysmenorrhea are appropriate for managing chronic pelvic pain associated with endometriosis (see Nursing Care Plan: Endometriosis).

Oligomenorrhea/Hypomenorrhea

The term oligomenorrhea often is used to describe decreased menstruation, either in amount, time, or both. However, oligomenorrhea more correctly refers to infrequent menstrual periods characterized by intervals of 40 to 45 days or longer, and hypomenorrhea to scanty bleeding at normal intervals. The causes of oligomenorrhea are often abnormalities of hypothalamic, pituitary, or ovarian function. Oligomenorrhea also can be physiologic, or part of a woman’s normal pattern for the first few years after menarche or for several years before menopause.

Treatment is aimed at reversing the underlying cause, if possible. Hormonal therapy using progestins, with or without estrogens, also may be used to prevent complications of unopposed estrogen production (endometrial hyperplasia or carcinoma) or of absent estrogen (vaginal dryness, hot flashes or flushes, or osteoporosis).

Women with menstruation characterized by prolonged intervals between cycles need education and counseling. The cause of the condition and the rationale for a specific treatment should be discussed, as should advantages and disadvantages of hormonal therapy. If a woman chooses medical intervention, she should be provided with written instructions, taught how to take the medications, and made aware of side effects of any medications. Teaching and counseling should emphasize the importance of the woman keeping careful records of her vaginal bleeding.

One of the most common causes of scanty menstrual flow is OCPs. If a woman is considering OCPs for contraception, it is important to explain in advance that the use of OCPs can decrease menstrual flow by as much as two thirds. This effect is caused by the continuous action of the progestin component, which produces a decidualized endometrium with atrophic glands.

Hypomenorrhea also may be caused by structural abnormalities of the endometrium or the uterus that result in partial destruction of the endometrium. These conditions include Asherman syndrome, in which adhesions resulting from curettage or infection obliterate the endometrial cavity, and congenital partial obstruction of the vagina.

Metrorrhagia

Metrorrhagia, or intermenstrual bleeding, refers to any episode of bleeding, whether spotting, menses, or hemorrhage, that occurs at a time other than the normal menses. Mittlestaining, a small amount of bleeding or spotting that occurs at the time of ovulation (14 days before onset of the next menses), is considered normal. The cause of mittlestaining is not known;

however, its common occurrence can be documented by its repetition in the menstrual cycle.

Women taking OCPs may have midcycle bleeding or spotting. (See Chapter 8 for a discussion of the side effects of OCPs.) If the OCP does not maintain a sufficiently hypoplastic endometrium, the endometrium will begin to shed, usually in small amounts at a time, a process termed breakthrough bleeding. Breakthrough bleeding is most common in the first three cycles of OCPs. The reduced potency of OCPs (resulting in increased safety) has decreased the amount of available hormones, making it more important that blood levels be kept constant. Taking the pill at exactly the same time each day may alleviate the woman’s problem. If the spotting continues, a different formulation of the OCP that increases either the estrogen or progestin component of the pill can be tried.

Progestin-only contraceptive methods (oral and injectable) also may cause midcycle bleeding, especially in the first several cycles. Women should be advised of this and counseled to report continuation of breakthrough bleeding after the first three to six cycles to their health care provider.

Women with an intrauterine device (IUD) may have spotting between their periods and possibly heavier menstrual flow.

The causes of intermenstrual bleeding are varied (Table 6-3). It is important that the nurse always consider the possibility that any woman who has not undergone menopause and who seeks care for intermenstrual bleeding is or recently has been pregnant.

Treatment of intermenstrual bleeding depends on the cause and may include reassurance and education concerning mittlestaining, observation of three menstrual cycles for suspected functional ovarian cyst, adjustment of an OCP, removal of foreign bodies, and treatment for vaginal infections. More complex treatment may consist of removal of polyps; evaluation and treatment of an abnormal Papanicolaou (Pap) test, including colposcopy, biopsy, cautery, cryosurgery, or conization; and surgery, chemotherapy, or radiation treatment for malignancy. Important nursing roles include reassurance, counseling, education, and support.

Menorrhagia

Menorrhagia (hypermenorrhea) is defined as excessive menstrual bleeding, in either duration or amount. The causes of heavy menstrual bleeding are many, including hormonal disturbances, systemic disease, benign and malignant neoplasms, infection, and contraception (IUDs). A single episode of heavy bleeding may occur, or a woman may have regular flooding as a pattern in which she changes tampons or pads every few hours for several days.

Hemoglobin and hematocrit provide objective indicators to actual blood loss and should always be assessed.

A single episode of heavy bleeding may signal an early pregnancy loss. This type of bleeding is often thought to be a period that is heavier than usual, perhaps delayed, and is associated with abdominal pain or pelvic discomfort. When early pregnancy loss is suspected, a hematocrit and serum β-hCG pregnancy test should be done.

Infectious and inflammatory processes such as acute or chronic endometritis and salpingitis may cause heavy menstrual bleeding. Although rare, systemic diseases of nonreproductive origin such as blood dyscrasias, hypothyroidism, and lupus erythematosus also can cause hypermenorrhea. In obese women anovulation caused by increased peripheral conversion of androstenedione to estrogen may develop and manifest as menorrhagia. Medications also may cause abnormal bleeding. Chemotherapy, anticoagulants, neuroleptics, and steroid hormone therapy all have been associated with excessive flow.

Uterine leiomyomata (fibroids or myomas) are a common cause of menorrhagia. Fibroids are benign tumors of the smooth muscle of the uterus, the etiology of which is unknown. Fibroids are estrogen sensitive and commonly develop during the reproductive years and shrink after menopause. Other uterine growths ranging from endometrial polyps to adenocarcinoma and endometrial cancer are other common causes of heavy menstrual bleeding, as well as of intermenstrual bleeding.

Treatment for menorrhagia depends on the cause of the bleeding. If the bleeding is related to the contraceptive method, the nurse provides factual information and reassurance and discusses other contraceptive options. If bleeding is related to the presence of fibroids, the degree of disability and discomfort associated with the fibroids and the woman’s plans for childbearing will influence treatment decisions. Treatment options include medical and surgical management. Most fibroids can be monitored by frequent examinations to judge growth, if any, and correction of anemia, if present. Women with menorrhagia should be warned not to use aspirin because of its tendency to increase bleeding. Medical treatment is directed toward temporarily reducing symptoms, shrinking the myoma, and reducing its blood supply (Katz, 2007). This reduction is often accomplished with the use of a GnRH agonist. If the woman wishes to retain childbearing potential, a myomectomy may be done. Myomectomy, or removal of the tumors only, is particularly difficult if multiple myomas must be removed. If the woman does not want to preserve her childbearing function, or if she has severe symptoms (severe anemia, severe pain, considerable disruption of lifestyle), hysterectomy or endometrial ablation (laser surgery or electrocoagulation) may be done (see Chapter 11). Uterine artery embolization, based on the assumption that control of arterial blood flow to the fibroid will control symptoms, has been reported to result in reduced menorrhagia, less dysmenorrhea, and reduced pelvic pressure and urinary symptoms. This method of treatment is used for women who have completed their childbearing since there is a risk for loss of fertility (see Chapter 11).

Dysfunctional Uterine Bleeding

Abnormal uterine bleeding (AUB) is any form of uterine bleeding that is irregular in amount, duration, or timing and not related to regular menstrual bleeding. Box 6-1 lists possible causes of AUB. Although often used interchangeably, the terms AUB and dysfunctional uterine bleeding (DUB) are not synonymous. Dysfunctional uterine bleeding is a subset of AUB defined as “excessive uterine bleeding with no demonstrable organic cause, genital or extragenital” (Lobo, 2007a). DUB is most frequently caused by anovulation. When there is no surge of LH, or if insufficient progesterone is produced by the corpus luteum to support the endometrium, it will begin to involute and shed. This process most often occurs at the extremes of a woman’s reproductive years—​when the menstrual cycle is just becoming established at menarche or when it draws to a close at menopause. DUB also can be found with any condition that gives rise to chronic anovulation associated with continuous estrogen production. Such conditions include obesity, hyperthyroidism and hypothyroidism, polycystic ovary syndrome, and any of the endocrine conditions discussed in the sections on amenorrhea and oligomenorrhea. A diagnosis of DUB is made only after all other causes of abnormal menstrual bleeding have been ruled out (Lentz, 2007a).

When uterine bleeding is profuse and a woman’s hemoglobin level is less than 8 g/dl (hematocrit of 23% or 24%), the woman may be hospitalized and given conjugated estrogens (e.g., Premarin), 25 mg intravenously. The dose may be repeated until bleeding stops or slows significantly (usually within 1 to 5 hours) (Behera & Price, 2009). If the bleeding has not stopped in 12 to 24 hours, dilation and curettage (D&C) may be done to control severe bleeding and hemorrhage. An endometrial biopsy may be collected at the same time to evaluate endometrial tissue or rule out endometrial cancer. After this treatment, oral conjugated estrogen, 2.5 mg, is given daily followed by the addition of progesterone (e.g., medroxyprogesterone [Provera], 10 mg by mouth), given in the final 10 days of therapy to initiate withdrawal bleeding. Alternatively, a combined OCP is given for 21 days after intravenous therapy. Once the acute phase has passed, the woman is maintained on cyclic low-dose OCPs for 3 to 6 months. Such long-term treatment will help prevent recurrence of the pattern of dysfunctional uterine bleeding and hemorrhage. If the woman wants contraception, she should continue to take OCPs. If the woman has no need for contraception, the treatment may be stopped to assess her bleeding pattern. If menstruation does not resume, a progestin regimen (e.g., medroxyprogesterone, 10 mg/day for 10 days before the expected date of her menstrual period) may be prescribed after ruling out pregnancy. This is done to prevent persistent anovulation with chronic unopposed endogenous estrogen hyperstimulation of the endometrium, which can result in eventual atypical tissue changes (Lobo, 2007a).

If the recurrent, heavy bleeding is not controlled by hormonal therapy or D&C, ablation of the endometrium through laser treatment may be performed. Nursing roles include counseling and educating women about their options as needed and referring women to the appropriate specialists and health care services.

Bleeding

During the perimenopausal years, women may have longer menstrual periods that differ in the type of bleeding. They may have 2 to 3 days of spotting followed by 1 to 2 days of heavy bleeding, or they may have regular menses followed by 2 to 3 days of spotting. Such symptoms are characteristic of degenerating corpus luteum function. After menopause women continue to have small amounts of circulating estrogen. Although the ovaries do not produce estrogen, androgens (androstenedione and testosterone) are produced for some time after menopause. Androgens produced by the adrenal glands are converted to estrone, a form of estrogen, in the liver and fat cells. With advanced age the ovaries stop producing androstenedione, which further limits the amount of estrone in the body. Obese women are more likely to have dysfunctional uterine bleeding and endometrial hyperplasia because women with more body fat have higher circulating levels of estrone. This occurs because the estrogen that is stored in the fat cells of the body is converted into a form of estrogen (estrone) that is available to the estrogen receptors within the endometrium.

Genital Changes

The vagina and urethra are estrogen-sensitive tissues, and low levels of estrogen can cause atrophy of both. Age-related vaginal changes not affected by estrogen also occur. Through both processes the vaginal membranes thin, hold less moisture, and lubricate more slowly. However, not all women have symptoms of genital atrophy. Women who are sexually active have less vaginal atrophy and fewer problems related to intercourse. Thin women are more likely to have more symptoms related to reduced estrogen levels such as vaginal dryness because of lack of adipose tissue and thus stored estrogen. Additionally, vaginal pH increases, lactobacillus growth can be depressed, and other bacteria tend to multiply. This combination of factors can lead to vaginitis.

Dyspareunia (painful intercourse) can occur because the vagina becomes smaller, the vaginal walls become thinner and drier, and lubrication during sexual stimulation takes longer. Intercourse becomes painful and may result in postcoital bleeding. Some women may decide to forgo intercourse altogether.

In some women the shrinking of the uterus, the vulva, and the distal portion of the urethra associated with aging leads to disturbing symptoms, including urinary frequency, dysuria, uterine prolapse, and stress incontinence. Vaginal relaxation with cystocele, rectocele, and uterine prolapse is not caused by reduced estrogen levels but may be a delayed result of childbearing or other cause of weakness of pelvic support structures. Urinary frequency sometimes occurs after menopause because the distal portion of the urethra, which has the same embryologic origin as the reproductive organs, shortens and shrinks. Irritants have easier access to the urinary tract with its shorter urethra and may cause frequency and urinary tract infections.

Urinary incontinence and uterine displacement are two other common age-related rather than menopause-related findings in the postmenopausal period. These conditions are discussed in Chapter 11.

Vasomotor Instability

During the past three decades investigators have devoted significant attention to identifying ovarian, hypothalamic, and pituitary hormonal mechanisms that produce symptoms related to menopause. Two symptoms appear to increase in incidence as women progress through menopause: hot flashes and night sweats. Many of the other changes commonly associated with menopause, such as decrease in size of genital structures, skin changes, and changes in breast size, are more correctly attributed to aging.

Vasomotor instability in the form of hot flashes or flushes is a result of fluctuating estrogen levels and is the most common disturbance of the perimenopausal years, occurring in up to 75% of women having natural menopause and 90% of women who have a surgical menopause. In the United States, Hispanic and African-American women report a higher incidence of these symptoms than Caucasian women; Asian women have the lowest incidence (Lobo, 2007c). Vasomotor instability occurs most frequently in the first 2 postmenopausal years; the number of episodes decreases over time. However, some women have hot flashes before menopause and continue to have them for 10 or more years afterward. During this time women experience changeable vasodilation and vasoconstriction as a hot flush (visible red flush of skin and perspiration) or hot flash (sudden warm sensation in neck, head, and chest) and night sweats. These disturbances vary widely in severity, and only about 40% of women seek health care for them (Nedrow, Miller, Walker, Nygren, Huffman, & Nelson, 2006). For some women hot flashes may be an infrequent, possibly pleasant, sensation of warmth; for others, they may be an intensely unpleasant sensation of heat or warmth that may occur 20 to 50 times a day, create intense anxiety, and significantly decrease quality of life. Several factors can precipitate or aggravate an episode, including crowded or warm rooms, alcohol, hot drinks, spicy foods, proximity to a heat source, and stress.

Night sweats, characterized by profuse perspiration and heat radiating from the body during the night, are another form of vasomotor instability experienced by many women. Sleep may be interrupted nightly because nightclothes and bed linens may be soaked. Women may find that they are not able to go back to sleep. Sleep deprivation is a primary complaint of women experiencing hot flashes (Lobo, 2007c). Other problems that may be associated with perimenopausal fluctuations of vasoconstriction or vascular spasms include dizziness, numbness and tingling in fingers and toes, and headaches.

Mood and Behavioral Responses

The tendency to associate hormonal changes with psychologic symptoms in midlife that has been prevalent in medical literature for decades and continues today was fueled by a belief that postmenopausal women have “estrogen deficiency.” Contrary to this common belief, there is no concrete evidence that menopause has a deleterious effect on mental health of midlife women. Reviews of epidemiologic studies on menopause and depression found no causal association between menopause and depression (Lobo, 2007c). Women with hot flashes and night sweats do report insomnia, fatigue from loss of sleep, and depressed mood. Women complain of feeling more emotionally labile, nervous, or agitated, with less control of their emotions. However, the interaction of psychologic, biologic, and sociocultural factors is so complex that it is difficult to determine whether a woman’s reported mood shifts are the result of hormonal changes, normal aging, or cultural conditioning. Most likely a woman’s psychologic makeup, cultural background, intercurrent stresses, and changing life roles and circumstances are more important than estrogen levels. Dealing with teenage children; having teenagers leave home; helping aging parents; becoming widowed or divorced; the onset of a major illness or disability (even death) in a spouse, relative, or friend; grieving for friends and family who are ill or dying; retirement; and financial insecurity are among the many stresses of women in their 40s and 50s.

Cultural messages also influence a woman’s perception of menopause. Women’s experiences with menopause are not universal and vary among cultural groups. Most North American women do not believe that menopause interferes with their quality of life (National Institutes of Health [NIH], 2005). Women do not find symptoms to be a cause for concern; however, they do report that symptoms are bothersome. Many women have accepted childbearing and child rearing as their major role in life, and the inability to bear children is a significant loss. Others see menopause as the first step to old age and associate it with a loss of attractiveness, physical ability, and energy. Western culture values youth and physical attractiveness; the wisdom gained from life experience is not valued, and older adults have a loss of status, function, and role. No rituals give older women a special place and function. In cultures where postmenopausal women gain status, such as India, the Far East, and the South Pacific islands, depression among menopausal women is not observed. Western women, however, may have little to compensate for their losses.

For other women, menopause is not a loss or a symbol of losses, but a relief. For some, menopause is a relief from the fear of pregnancy, the discomfort and bother of menstruation, and the inconveniences of contraception.

The ability to cope with any stress involves three factors: the person’s perception or understanding of the event, the support system, and coping mechanisms. Nurses counseling women in their perimenopausal years must therefore assess their understanding of perimenopausal changes, their perceptions of stressful experiences, their support systems, and their repertoire of coping skills.

Osteoporosis

Aging is associated with a progressive decrease in bone density in men and women. Osteoporosis is a generalized, metabolic disease characterized by decreased bone mass and increased incidence of bone fractures. Normally there is a dynamic balance between bone formation (osteoblastic activity) and bone resorption (osteoclastic activity). Because one of the functions of estrogen is to stimulate the osteoblasts, the postmenopausal decrease in estrogen levels causes an imbalance between bone formation and resorption. Old bone deteriorates faster than new bone is formed, resulting in a slow thinning of the bones. Estrogen also is required for the conversion of vitamin D into calcitonin, which is essential in the absorption of calcium by the intestine. Reduced calcium absorption from the gut, in addition to the thinning of the bones, places postmenopausal women at risk for problems associated with osteoporosis.

Osteoporosis is a major health problem in the United States, affecting more than 8 million women older than 45 years (National Osteoporosis Foundation [NOF], 2010). Approximately 50% of U.S. women have some degree of osteoporosis. One in two Caucasian women will have changes severe enough to predispose them to fractures. In the United States, the incidence of osteoporosis-related fractures has increased in the past 20 years. Postmenopausal women with a hip or symptomatic vertebral fracture have a 25% increased risk of death in the year following their fracture. After a hip fracture 25% of women will need long-term care and 50% will have long-term loss of mobility (North American Menopause Society [NAMS], 2010b). During the first 5 to 6 years after menopause, women lose bone six times more rapidly than men. By age 65, one third of women have had a vertebral fracture; by age 81, one third have had a hip fracture. By the time women reach age 80, they have lost 47% of their trabecular bone, concentrated in the vertebrae, the pelvis and other flat bones, and the epiphyses. The most well-defined risk factor for osteoporosis is the loss of the protective effect of estrogen associated with cessation of ovarian function, particularly at menopause. Women at risk are likely to be Caucasian or Asian, small boned, and thin. Obese women have higher estrogen levels resulting from the conversion of androgens in adipose tissue; mechanical stress from extra weight also helps preserve bone mass. A family history of the disease is common. The influences of heredity, race, and sex may result in differences in peak bone mass (NOF, 2010).

Inadequate calcium intake is a risk factor, particularly during adolescence and into the third and fourth decades, when peak bone mass is attained. An excessive caffeine intake increases calcium excretion, causing a systemic acidosis that stimulates bone resorption. Vitamin D deficiency can affect the physiologic regulation and stimulation of intestinal absorption of calcium (NOF, 2010). Smoking is associated with earlier and greater bone loss and decreases estrogen production. Excessive alcohol intake interferes with calcium absorption and depresses bone formation. A greater phosphorus than calcium intake, which occurs with soft drink consumption, may be a risk factor. Other risk factors include steroid therapy and disorders such as hypogonadism, hyperthyroidism, and diabetes mellitus (NOF).

The first sign of osteoporosis is often loss of height resulting from vertebral fracture and collapse (Fig. 6-2). Back pain, especially in the lower back, may or may not be present. Later signs include “dowager’s hump,” in which the vertebrae can no longer support the upper body in an upright position, and fractured hip, in which the fracture often precedes a fall. Damage to the vertebrae usually precedes bone loss in the hip by an average of 10 years. Osteoporosis cannot be detected by radiographic examination until 30% to 50% of the bone mass has been lost; thus routine screening is not warranted in women younger than age 65. However, bone density testing is recommended for women at high risk for osteoporosis at age 60 and for all women older than 65 to assess fracture risk (NOF, 2010; U.S. Public Health Services Task Force, 2002). Medicare will pay for tests for high risk women once every 2 years (NOF, 2008). Insurance reimbursement for the tests varies among insurance carriers and from state to state.

Coronary Heart Disease

A woman’s risk of developing and dying of cardiovascular disease increases after menopause. Diseases of the heart are the leading cause of death for women in the United States. The lifetime risk is 31% versus 3% for breast cancer in postmenopausal women (Lobo, 2007c). Known risk factors for coronary heart disease include obesity, cigarette smoking, elevated cholesterol and blood pressure levels, diabetes mellitus, family history of cardiac disease, alcohol abuse, and the effects of aging on the cardiovascular system (Cunningham, 2008; Lobo). Estrogen has a favorable effect on circulating lipids, decreasing low-density lipoprotein (LDL) and total cholesterol and increasing high-density lipoprotein (HDL), and has a direct antiatherosclerotic effect on arteries. Postmenopausal women are at risk for coronary artery disease because of changes in lipid metabolism: a decline in serum levels of HDL cholesterol and an increase in LDL levels (Lobo). These changes can be favorably reduced by diet and exercise.

Decision to Use Hormone Therapy

All women considering ET or HT must understand that studies on MHT are ongoing, and there is still much to be learned. Nurses can provide information and counseling to assist women to make decisions regarding MHT use. Important teaching points include the following (National Women’s Health Information Center, 2006 [www.4women.gov]; NAMS, 2010a [www.menopause.org]; Santoro & Steunkel, 2009):

Nurses are encouraged to stay current with ongoing MHT research findings. As other Women’s Health Initiative (WHI) data on MHT are analyzed, further clarification of the issues will be published.

Side Effects

Side effects associated with estrogen use include headaches, nausea and vomiting, bloating, ankle and feet swelling, weight gain, breast soreness, brown spots on the skin, eye irritation with contact lenses, and depression. The type of estrogen used for postmenopausal hormonal therapy is much less potent than ethinyl estradiol used in OCPs and has fewer serious side effects. Side effects that occur with MHT may disappear with a change in estrogen preparation or a decrease in the dose prescribed.

Treatment Guidelines

Research in MHT continues; however, nurses who counsel women about MHT must understand what is available and teach women who choose to continue MHT how to take the medications correctly. Thus the following discussion about the different regimens of MHT is included.

Many different estrogen preparations, natural and synthetic, and ways of administering them—​oral tablets, topical creams, transdermal preparations, suppositories, and vaginal rings—​exist (Table 6-4). However, most women today in the United States use tablets (Carroll, 2010).

There are multiple dosing regimen options for combining progesterone with estrogen for women who have a uterus. According to NAMS (2010a), there is insufficient research to recommend one regimen over another; however, there is evidence to recommend keeping exposure to progesterone at a minimum. An oral continual-cyclic regimen that is most commonly prescribed is estrogen on days 1 to 28 and a progestogen (e.g., medroxyprogesterone) on days 14 to 28. Women usually do not have cyclic bleeding with this regimen and are less likely to have progestin side effects. There are also multiple regimen options for ET for women who have had a hysterectomy.

The transdermal estrogen patch is applied once or twice a week to a hairless area of skin. Transdermal gels and sprays are applied daily. Any site on the trunk or upper arms provides adequate absorption. Sites should be rotated. The patches should not be placed on the breasts because of their sensitivity. Some women report minor skin irritation and reddening at the patch site. Generally transdermal estrogen offers the same relief of menopausal symptoms as the oral preparation. The transdermal method of delivery of estrogen does not have the same side effects such as breast tenderness and fluid retention. Oral progestin therapy can be used with transdermal ET. Combined estrogen-progestin transdermal patches also are available.

Vaginal creams and tablets are inserted daily or twice a week. Usually these local administrations of low-dose estrogen are used for vaginal symptoms of dryness and atrophy. Vaginal rings are inserted and left in place for 90 days. Although minimal systemic absorption is possible, there are no reports of adverse effects when a low dose is used (NAMS, 2010a).

Bioidentical and Custom-Compounded Hormones

Bioidentical hormones, sometimes referred to as natural hormones, are structurally identical to those produced by the ovary. Bioidentical hormone preparations are available as government approved well-tested brand-name prescription medications. Others are made at compounding pharmacies. Custom-compounded hormones are custom mixes of one or more hormones in varying amounts. These mixes can provide individualized doses and mixtures of hormones that are not available commercially. They also include ingredients that are nonhormonal (e.g., dyes, preservatives). The risks are that these mixtures have not been studied to confirm whether appropriate absorption occurs or if predictable levels can be detected in blood and tissue (NAMS, 2006). Preparations may vary from one pharmacy to another, meaning that a woman may not get consistent amounts of medication. These preparations are not approved by any regulatory agency (NAMS, 2010a). Although these hormones may relieve menopausal symptoms, more research is needed to determine their effects on the body. Women who choose to take these hormones need to understand and accept the potential risks. Expense is also an issue because these drugs often are more expensive and are not covered by third-party payers.

Alternative Therapies

Many complementary and alternative therapies are useful for relieving some of the changes associated with altered estrogen levels. Homeopathy, acupuncture, and herbs have been used with varying degrees of success for menopausal problems such as heavy bleeding, hot flashes, irritability, and headaches.

Homeopathy views menopausal symptoms as the body’s efforts to heal itself from the hormonal changes it is experiencing. Examples of remedies commonly prescribed during menopause by homeopaths are sepia, made from the inky juice of the cuttlefish, to relieve symptoms such as dry mouth, eyes, and vagina; nux vomica, derived from the poison nut, to relieve backaches, constipation, and frequent awakenings; and pulsatilla, made from the windflower, to relieve severe menstrual symptoms and hot flashes. Homeopathic remedies are subject to regulation by the U.S. Food and Drug Administration (FDA), although the FDA does not require proof of effectiveness. Most studies have not proven homeopathy to be any more effective than a placebo for relieving menopausal symptoms (Martin, Pinkerton, & Santen, 2009).

Acupuncturists also treat hot flashes, but it is important that women evaluate their acupuncturists carefully. The American Association of Acupuncturists and Oriental Medicine will supply a list of acupuncturists in a given state. Questions to ask are: Is the acupuncturist certified by the National Commission for the Certification of Acupuncture? Is the acupuncturist certified in the state in which he or she practices? Does the acupuncturist carry malpractice insurance? Some clinical trials have shown some improvement in mood and decreased frequency of hot flashes but others have not found hot flashes to be improved (Nedrow et al, 2006).

Herbal therapy also has been used to treat menopausal discomforts (see Table 6-2). Herbs can be ingested as teas or tinctures. Many herbal preparations also are available in capsule form. It is important that women understand mechanisms of action, contraindications, and potential side effects of each herb.

In addition to resolving physical symptoms, herbs also are used to combat mood swings and depression. Ginseng has been claimed to be helpful in alleviating hot flashes, although research studies have not supported this assertion. Women should be advised against prolonged use of ginseng in high doses because it can increase blood pressure. Oriental herbal teas composed of licorice, ginseng, coptis, red raspberry leaf, and Chinese rhubarb may be of some help in relieving hot flashes.

Dong quai and black cohosh have been used to treat menopausal discomforts; both have been investigated for effectiveness, with varying results (Martin et al., 2009; Palacio, Masri, & Mooradian, 2009; Shams, Setia, Hemmings, McCusker, Sewitch, & Ciampi, 2010).

Some plant foods contain phytoestrogens (isoflavones) and are capable of interacting with estrogen receptors in the body. These foods include red clover, wild yams, dandelion greens, cherries, alfalfa sprouts, black beans, and soybeans. Use of soy-rich foods as an alternative to traditional hormonal therapy for menopause has been studied, and beneficial effects on menopausal symptoms and on reducing cholesterol have been reported although results for relief of hot flashes have been inconsistent (Albertazzi, 2005; Martin et al., 2009; Nedrow et al., 2006). More research is needed to better understand the potential effects of soy intake on prevention of osteoporosis and reducing risks of coronary heart disease (Alekel, Van loan, Loehler, Hanson, Stewart, & Hanson 2010; NAMS, 2010a).

For women who want to add soy to their diets, tofu, roasted soy nuts, and soy milk are good sources. Foods should be added gradually because some women have gastrointestinal discomfort from the high fiber content of these foods. Spreading out the daily intake over several meals may be the best way to include soy products in the diet.

Vitamin E is a popular alternative among women who do not take MHT. Women who take vitamin E report relief from hot flushes, leg cramps, and loss of energy; however, research has not supported this clinical finding (Martin et al., 2009; Nedrow et al., 2006). Vitamin E is found in a variety of foods, including spinach, peanuts, wheat germ, vegetable oils, and soybeans, or may be taken as a supplement. Dosage varies widely, from 400 to 800 International Units/day.

Layered clothing, ice packs, ice water, and fans may offer symptomatic relief from hot flashes (see Teaching for Self-Management box: Comfort Measures for Menopausal Symptoms). Women can be counseled to avoid hot curries and other spicy foods. Reassurance that hot flashes will not last forever may be of comfort even if duration of the problem cannot be predicted accurately. Many women find that hot flashes lessen in frequency and intensity or disappear within 4 to 6 years after menopause.

Nurses should be aware of the availability of natural remedies for menopausal symptoms and be knowledgeable about the indications for complementary and alternative therapies so clients can be counseled appropriately.

Nutrition

Obesity and osteoporosis are common health problems of midlife and older women. As women move out of their childbearing years, they may need to change their diets. Because metabolic rates decrease with age and many women exercise less, fewer calories are needed for weight maintenance as women age. In general, foods chosen should be high in nutrients, fiber, and calcium but moderate in calories and low in fat to allow adequate nutritional intake while maintaining body weight. Nurses can suggest that women substitute skim for whole milk or chicken without skin for steak. Excessive protein should be avoided. Fat-free milk and yogurt are good sources of calcium and vitamin D. Women should avoid excessive intake of alcohol, soft drinks, and caffeinated coffee.

Calcium is an essential part of any therapeutic regimen for women with osteoporosis and those who want to prevent osteoporosis. The best source of calcium is food; however, it is difficult to eat other foods that contain calcium (sesame seeds, spinach, greens, broccoli, and seaweed) in quantities sufficient to meet daily requirements. Calcium supplements are recommended when a woman’s diet does not supply recommended amounts of calcium. Although calcium cannot reverse loss of bone mass or prevent fractures, calcium supplementation may retard the development of osteoporosis after menopause. Menopausal women without contraindications to calcium supplementation (history of kidney stones, kidney failure, hypercalcemia) should be encouraged to consume a diet that has 1200 to 1500 mg of calcium a day or to add an amount of calcium supplementation that will increase their daily intake to this level. Calcium supplements are best taken in divided doses and with meals because of the increase in acid secretions and extended time in the stomach. At least 8 ounces of water to increase solubility is recommended. Calcium supplements should not be taken with caffeinated beverages. Calcium is most commonly available as calcium carbonate, calcium lactate, and calcium phosphate.

The NOF (2010) recommends that women older than age 50 take vitamin D 800 to 1000 International Units daily. Sources of vitamin D include sunlight, food (e.g., fortified dairy products, fatty fish, liver, egg yolks), and supplements. Usually a supplement is needed to get the required daily dose. A combination of vitamin D and calcium is available, and most multivitamins contain some vitamin D.

Exercise

All too often midlife women are sedentary—​the demands of family and work constraints increase, and energy levels decrease. Unfortunately little or no exercise predisposes women to weight gain and does not help prevent cardiac disease or osteoporosis. Exercise alone cannot prevent or reverse osteoporosis, but data indicate that weight-bearing exercise, such as walking and stair climbing, may delay bone loss and increase bone mass at any age. Muscle strengthening exercises combined with weight-bearing exercises also help improve agility, balance, and strength and may reduce the risk of falls and fractures (NOF, 2010). A study by Vallance, Murray, Johnson, and Elavsky (2010) found that women who engage in moderate intensity physical exercise for a minimum of 30 minutes for 5 days a week or vigorous intensity activity for 20 minutes 3 days a week reported higher scores in quality of life and psychosocial health than women who exercised less than the American Heart Association physical activity recommendations.

Water aerobics is excellent for cardiovascular fitness and is a good choice for older women who may be unable to engage in weight-bearing exercises. The nurse can help women plan an exercise program. Examples of exercises are available from the NOF (Fig. 6-3).

Medications for Osteoporosis

In addition to calcium and exercise, there are a number of FDA-approved medications for the prevention and treatment of osteoporosis (Box 6-2). The medications assist in delaying bone loss, increasing bone mass, and preventing fractures. These include salmon calcitonin (Miacalcin); bisphosphonates (alendronate sodium [Fosamax], risedronate sodium [Actonel]), ibandronate [Boniva], zoledronic acid [Reclast]); estrogen agonist/antagonists such as raloxifene (Evista), parathyroid hormone (teriparatide [Fortéo]), and estrogen or hormone therapy (NOF, 2010).

Calcitonin reduces the rate of bone turnover and stabilizes bone mass in women with osteoporosis and may have some analgesic effects. Although calcitonin can reduce the incidence of spinal fractures, no data are available about the use of calcitonin to protect against hip fractures. Calcitonin may be used with women who are at least 5 years postmenopausal and in whom estrogen is contraindicated or not tolerated. The drug usually is administered intranasally on a daily basis; subcutaneous administration is also available. The medication is considered safe; however, side effects of nausea, vomiting, anorexia, and rhinitis (if used intranasally) have been reported (NOF, 2010).

Bisphosphonates are approved for prevention and treatment of osteoporosis, especially in reducing the incidence of spinal fractures. Side effects include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcer. Depending on the medication used, the oral drugs may be taken daily or monthly. Some formulations contain vitamin D (NOF, 2010). Alendronate is available in the United States in a generic preparation. Ibandronate is available as an intravenous injection every 3 months; zoledronic acid is given intravenously yearly for treatment of osteoporosis and every 2 years for prevention (NOF).

Raloxifene is approved by the FDA for osteoporosis prevention and treatment in postmenopausal women only. This medication seemingly preserves the beneficial effects of estrogen, including protection against cardiovascular diseases and osteoporosis, without stimulating breast and uterine tissues. However, the effects of raloxifene and the risks of breast cancer and heart disease are still under study (NOF, 2006). The medication modestly increases bone density. Calcium supplements up to 1500 mg should be taken if dietary intake is inadequate.

Parathyroid hormone is approved for the treatment of osteoporosis in postmenopausal women at high risk for fractures. It is administered by daily subcutaneous injection. It can be used for a maximum of 2 years. The drug is well tolerated although some women report dizziness and leg cramps (NOF, 2010).

Estrogen/hormone therapy is approved for the prevention of osteoporosis. It should be used in the lowest effective doses for the shortest treatment time. The FDA recommends that it should not be used solely for the prevention of osteoporosis until after approved non-estrogen treatments are tried (NOF, 2010).

Midlife Support Groups

Nurses should be familiar with local resources and direct women to classes that supply appropriate information and support. They can encourage women to develop a supportive network with other women with whom they can share their concerns (Fig. 6-4).

Women’s centers and clinics may have support groups and classes for women who want to discuss menopause and other midlife events. If no group or class is available in the community, nurses should consider starting one.