Gynaecology

MENSTRUAL DISORDERS

MENSTRUAL DISORDERS

Menstrual Disorders

Menstrual disorders are abnormalities in menstruation during reproductive life.

Common disorders associated with menstruation are as follows;

  1. Amenorrhoea
  2. Dysmenorrhoea
  3. Menorrhagia
  4. Metrorrhagia
  5. Polymenorrhoea (epimenorrhoea)
  6. Dysfunctional uterine bleeding
  7. Endometriosis

AMENORRHOEA

Amenorrhoea refers to absence of menstruation which occurs in female during their reproductive age.

Types of Amenorrhoea
  1. Primary amenorrhoea. This is the failure of menses to occur by 16 years of age. It could be due to imperforated hymen when she has been menstruating but  when blood does not come out.
  2. Secondary amenorrhoea. This is the cessation of menses in a woman who has previously menstruated. It is regarded as secondary when she takes a period of 6 month and above without seeing her menses.
Causes of Amenorrhoea
  • Physiological like pregnancy and lactation, during pregnancy the levels of oestrogen and progesterone remains high thus ensuring the integrity of the endometrium resulting into amenorrhoea.
  • During lactation– soon after delivery prolactin is secreted in large quantities by the anterior pituitary. There is partial suppression of LH production so that the ovarian follicles may grow but ovulation does not occur resulting into amenorrhoea.
  • Hypothalamic dysfunction-such kind of patients have lower levels of follicle stimulating hormone(FSH) and  luteinizing hormone (LH). Several congenital syndromes associated with abnormal hypothalamic- gonadal function have been described and these conditions present with primary amenorrhoea and absence of secondary sex characteristics. It is also due to failure to the development of central structures of hypothalamus.
  • Pituitary disorder, this is associated with elevated levels of prolactin (hyperplolactinemia).
  • Congenital abnormalities , like imperforated hymen, vaginal septum, no uterus, no endometrium but with uterus, absence of ovaries, cervical stenosis, and  absence of hypothalamus (kallmann’s syndrome). This is a congenital hypogonadotrophic hypogonadism disorder characterized by absence of secondary sex characteristics.
  • Change of environment or occupation.
  • Fear, anxiety or excitement
  • Pseudoamenorrhoea, pseudo means false. Here a woman psychologically thinks that she is pregnant yet she is not.
  • After hysterectomy or bilateral removal of ovaries
  • Full doses of radiation
  • Drugs ,like contraceptives especially hormonal methods
  • Debilitating diseases like, TB, HIV/AIDS, DM etc
  • Tumours of the pituitary gland, hypothalamus, ovaries and uterus
  • Early onset of menopause
  • Idiopathic
Diagnosis and investigation
  • A detailed history taking (history of change in weight, presence of stress, questions about excessive weight, presence of excessive body or facial hair) and physical examination.
  • Urine for HCG to rule out pregnancy
  • Ultra sound scans of the pelvis to visualize the contents or organs of the pelvic cavity.
  • Blood for hormone analysis to rule out hormonal imbalance.
  • Computerized tomography (CT) scans to visualize the organs.
Management of Amenorrhoea

This will depend on the cause. It may be medical, surgical, or psychological.

Nursing Management:

  • Assessment: Conducting a comprehensive evaluation of the woman\’s medical and menstrual history, as well as performing a physical examination to identify the underlying cause of amenorrhea.
  • Emotional Support: Offering empathetic and non-judgmental support to address any emotional distress associated with the condition.
  • Education: Providing information on menstrual health, reproductive anatomy and physiology, and the potential causes and treatment options for amenorrhea.
  • Lifestyle Modifications: Encouraging women to adopt a healthy lifestyle, including regular exercise, balanced nutrition, stress reduction, and sufficient sleep, as these factors can contribute to hormonal balance regulation.
  • Contraception Counseling: Discussing contraceptive methods and family planning options to prevent unintended pregnancies.

Medical Management:
Medical management of amenorrhea  encompasses treating the root cause identified through investigations done. Various medical management options include:

  • Hormone Therapy: If hormonal imbalance, such as polycystic ovary syndrome or hypothalamic dysfunction, is determined as the cause of amenorrhea, hormone therapy may be prescribed to regulate hormone levels and restore menstruation.
  • Medications: Certain medications like progestins or combined oral contraceptives may be prescribed to induce menstruation or regulate the menstrual cycle.
  • Treatment of Underlying Conditions: If amenorrhea is a result of an underlying medical condition, such as a thyroid disorder or a pituitary tumor, appropriate medical treatment will be initiated to address the specific condition.
  • Hyperprolactinaemia is treated by administration of bromocriptine. This is an ergot alkaloid which directly opposes prolactin secretion. Radiotherapy is reserved for those patients who fails to respond to medical therapy.

Surgical Management:
Surgical management is rarely required for the treatment of amenorrhea. However, in certain cases, surgery may be necessary to address structural abnormalities or correct anatomical issues contributing to the condition. For example:

  • Hysteroscopic Surgery: This minimally invasive procedure involves the insertion of a thin, illuminated tube called a hysteroscope through the vagina and cervix to visualize and treat abnormalities within the uterus, such as polyps or adhesions.
  • Imperforated hymen is treated by incision and drainage. Very large amount of blood may be released, and if the septum is particularly thick, some form of plastic operation may be required.
  • Surgical Intervention: In some instances, surgical intervention may be essential to correct structural abnormalities in the reproductive organs or to remove tumors or cysts that are interfering with normal menstruation.

Psychological Management:
Psychological management plays a crucial role in providing support for women with amenorrhea, as it significantly impacts their emotional well-being. It involves:

  • Counseling: Offering psychological counseling or referring women to mental health professionals who can assist them in coping with the emotional distress associated with amenorrhea.
  • Support Groups: Suggesting participation in support groups or facilitating connections with other women who have faced similar challenges to foster a sense of community and validation.
  • Body Image and Self-esteem: Addressing concerns related to body image and promoting a positive self-image by emphasizing that amenorrhea does not define  femininity or a woman\’s worth.

DYSMENORRHOEA

Dysmenorrhea is a medical term used to describe painful menstrual cramps that occur just before or during menstruation (the monthly shedding of the uterine lining). OR These are painful menstrual periods.

 Nearly 50% of all women have some degree of pain associated with their periods. About 10% are unable to perform their normal activities because of this pain. Dysmenorrhoea can occur at any age, though uncommon in the first 6 months after the onset of menses and relatively uncommon in the years prior to menopause. The most common ages for this problem to occur are in the late teens and early twenties.

Cause

The exact cause of primary dysmenorrhea is not fully understood, but it is believed to be related to the release of certain chemicals called prostaglandins in the uterus. This is due to release of a chemical substance called prostaglandins from the lining cells of the uterus at the time of menstrual period. The prostaglandin causes contractions of the muscle wall of the uterus, that are called menstrual cramps.

Types of dysmenorrhoea

Primary dysmenorrhoea.

This refers to painful menstruation that starts few years after puberty and usually no exact cause can be identified.

Pre-disposing factors
  • Narrow cervical OS (stenosis) ,which results into tension during contraction of muscles.
  • Reduced blood supply to the endometrium (ischaemia)
  • Hormonal imbalance
  • Retroverted uterus, that is , when the uterus leans backwards resulting into tension.
  • Psycological or social stress, fear or anxiety
Signs and symptoms

Dysmenorrhea is cyclic with pain most often occurring just before or during the first few days of each period.

  • Lower abdominal pain (LAP) that varies in severity among individuals, ranging from mild to colicky or crampy, extending to the back, thighs and legs.
  • Nausea and vomiting
  • Constipation or diarrhea
  • Fainting, headache, malaise
  • Irritability, nervousness, depression
Diagnosis
  • History taking: It is through history taking, ask about the nature of pain, duration and when it occurs. This is often confirmatory.
  • Physical examination: It is also through physical examination to rule out pelvic tumours, endometriosis which is often absent.
Treatment

Treatment options for dysmenorrhea depend on the severity of symptoms and the underlying cause.

  • For primary dysmenorrhea, Non steroidal anti inflammatory drugs (NSAIDS) like Iboprufen, mefenamic acid, diclofenac and others. These prevent the formation of prostaglandins in the uterine lining cells. They are more effective if taken before the onset of cramps.
  • Antispasmodics like Buscopan
  • Antiemetics like Phenegan for nausea and vomiting.
  • Heat therapy in the form of a hot water bottle or heating pad applied to the abdomen can also provide relief.
    • Drugs
    • Mild analgesics to relieve pain eg ibuprofen 400mg tds.
    • Prostaglandin synthetase inhibitors eg. Mefenamic acid 250-500mg tds or Flufenamic acid 100-200mg tds
    • Oral contraceptives eg COCs. These decrease endometrial proliferation.
    • Progesterones. Eg dydrogesterone 10mg b.d taken from day 5 of the cycle for 20 days. Mechanism of action is presumably myometrial relaxation.

NOTE

  • Begin treatment 2 days before menstruation periods begins and continue until 2 days after the period has stopped.
  • Avoid additive drugs since this treatment is for long period.
  • Contraceptive drugs like COCs may be given to suppress ovulation and relieve pain. Usually given for 4-6 months and many get permanent relief after this treatment has been stopped.
  • Dilatation and Curettage (D&C) may be of help to remove necrotic tissue of endometrium, but usually not encouraged since it increases the risk of infections.
  • Cervical stenosis can be treated by surgical widening of the canal.
  • Effective counseling is important since pain is usually psychological to avoid drug dependence and abuse.
  • Delivery or with age will finally treat pain since there will be relaxation of uterine muscles and reduce ischaemia.
  • Encourage enough rest and sleep as well as exercises, hygiene and good diet.
  • Other management options may include hypnotherapy and acupuncture.

Secondary dysmenorrhoea

This refers to painful periods which start many years following normal and well established menstrual periods. It is more of pathological occurrence and on investigations the cause is easily established.

Causes
  • Pelvic inflammatory diseases (PID)
  • Uterine fibroids. This results into the partial contraction of the uterus resulting into pain.
  • Endometriosis: This is the growth of the endometrial tissue in other area rather than the uterus.
  • Endometritis: This is the inflammation of the endometrium.
Signs and symptoms

In addition to signs and symptoms found in primary dysmenorrhoea, there is;

  • Lower abdominal pain (LAP) usually happens 3-4 days or even a week before menstruation and either pain becomes better or worsens with menstruation.
  • There may be backache
  • Signs and symptoms of menorrhagia
  • Painful coitus
  • Inability to conceive.
Management

Investigate and treat the cause.

NURSING MANAGEMENT

Nursing diagnosis

  1. Acute pain related to increased uterine contractility evidenced by verbalization of the girl or woman.

Nursing interventions

  • Warm the abdomen, this causes vasodilation and reduces the spasmodic contractions of the uterus.
  • Massage the abdominal area that feels pain, this reduces pain due to the stimulus of therapeutic touch.
  • Perform light exercises ,to blood flow to the uterus and improves muscle tone.
  • Perform relaxation techniques to reduce pressure to get relaxed.
  • Administer analgesics as prescribed to block nociceptive receptors
  1. Ineffective individual coping related to emotional stress evidenced by patient’s verbalization.

Nursing interventions

  • Assess patient’s understanding of the condition. This is because patient’s anxiety of the pain is greatly influenced by knowledge.
  • Provide an opportunity to discuss how the pain is. Help the patient identify coping mechanisms.
  • Provide the patient with periods of sleep or rest. Ensures relaxation of the body and mind.
  1. Risk for imbalanced nutrition less than body requirements related to nausea and vomiting.

Nursing interventions

  • Provide the patient with periods of sleep or rest ,this is to ensure relaxation of the body.
  • Encourage small frequent feeds. These are easily tolerated by the patient.
  • Administer anti-emetic drugs like promethazine. This blocks the emetic centres.
Nursing Concerns:
  • Assessing the severity and characteristics of the pain, including its location, intensity, and duration.
  • Monitoring vital signs and assessing for any signs of complications or worsening symptoms.
  • Assessing menstrual patterns, including the duration and heaviness of bleeding.
  • Evaluating the impact of dysmenorrhea on the patient\’s quality of life, emotional well-being, and ability to carry out daily activities.
  • Assessing for any associated symptoms or complications, such as nausea, vomiting, headaches, or anemia.
Nursing Interventions:
  • Providing pain management: Administering prescribed pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), as ordered by the healthcare provider. Monitoring the effectiveness of pain relief and reassessing pain levels after medication administration.
  • Applying heat therapy: Instructing the patient on the use of heat therapy, such as a hot water bottle or heating pad, to relieve pain. Educating the patient on the proper technique and duration of heat application.
  • Assisting with relaxation techniques: Teaching relaxation techniques, deep breathing exercises, and guided imagery to help the patient manage pain and reduce stress.
  • Promoting rest and comfort: Encouraging the patient to rest in a comfortable position during painful episodes. Providing supportive pillows, blankets, or cushions to enhance comfort.
  • Educating the patient about the condition: Providing information about the underlying cause of secondary dysmenorrhea, its management, and treatment options. Answering any questions or concerns the patient may have.
  • Collaborating with the healthcare team: Communicating and collaborating with the healthcare provider, gynecologist, or other specialists involved in the patient\’s care to ensure appropriate management of the underlying condition.
  • Offering emotional support: Acknowledging and validating the patient\’s pain and emotional distress. Providing a supportive environment for the patient to express her feelings and concerns. Referring to counseling or support groups if needed.

MENORRHAGIA

Menorrhagia is a condition characterized by abnormally heavy or prolonged menstrual bleeding. Can be heavy or prolonged menstrual bleeding or both.

Causes
  1. Hormonal imbalances: Fluctuations in estrogen and progesterone levels can disrupt the normal menstrual cycle and lead to excessive bleeding.
  2. Uterine fibroids: These noncancerous growths in the uterus can cause heavy menstrual bleeding.
  3. Adenomyosis: The condition where the inner lining of the uterus (endometrium) grows into the muscular wall of the uterus can result in heavy bleeding.
  4. Polyps: Small, benign growths on the lining of the uterus can contribute to menorrhagia.
  5. Endometrial hyperplasia: Abnormal thickening of the uterine lining can cause heavy bleeding.
  6. Inherited bleeding disorders: Certain inherited conditions, such as von Willebrand\’s disease, can lead to excessive bleeding during menstruation.
  7. PID (pelvic inflammatory disease)
  8. Retroverted uterus
  9. Cancers like cancer of the cervix and endometrial cancer
Signs and symptoms
  • Menstrual bleeding lasting longer than seven days.
  • Soaking through one or more sanitary pads  every hour for several consecutive hours.
  • Passing large blood clots during menstruation.
  • Fatigue and tiredness due to excessive blood loss.
  • Shortness of breath or rapid heart rate caused by anemia.
  • Feeling lightheaded or dizzy.
  • Menstrual periods that disrupt daily activities.
Investigations
  • Complete medical history and physical examination.
  • Blood tests to assess blood count, iron levels, and hormonal imbalances.
  • Transvaginal ultrasound to evaluate the structure of the uterus and detect any abnormalities.
  • Endometrial biopsy to examine a sample of the uterine lining for abnormalities or cancer.
  • Hysteroscopy, a procedure using a thin, lighted tube inserted into the uterus, to directly visualize the uterine cavity.
  •  Bleeding time to test for coagulopathy
  • Prothrombin time to test for coagulopathy.
  • Clotting time to test for availability of platelets.
  • In the above three tests, results will be abnormal.
  • Full haemoglobin levels and hormone analysis to rule out hormonal imbalance.
MANAGEMENT

The best management is to investigate  and treat the cause

Medical Management of Menorrhagia:

  1. Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and bleeding. Hormonal contraceptives, such as birth control pills or hormonal intrauterine devices (IUDs), can regulate menstrual cycles and decrease bleeding.
  2. Iron supplementation: If anemia is present due to excessive bleeding, iron supplements may be recommended to restore iron levels.
  3. Endometrial ablation: A minimally invasive procedure that destroys the lining of the uterus to reduce menstrual bleeding.
  4. Uterine artery embolization: A procedure in which small particles are injected into the blood vessels supplying the uterus to reduce blood flow and control bleeding.

Nursing management

  1. Symptom management: Assisting patients in managing pain and discomfort during heavy bleeding episodes.
  2. Emotional support: Acknowledging the emotional impact of menorrhagia and providing a safe space for patients to express their concerns.
  3. Education: Providing information on menstrual hygiene, use of sanitary products, and available treatment options.
  4. Lifestyle modifications: Advising patients to maintain a healthy lifestyle, including a balanced diet and regular exercise, to promote overall well-being.

Nursing diagnosis

Ineffective tissue perfusion related to excessive bleeding evidenced by pallor.

Nursing interventions

  • Assess patient’s vital signs. To obtain baseline data.
  • Lift the foot of the bed. To allow blood flow to vital centres of the body like brain, kidneys, lungs, heart and liver.
  • Administer intravenous fluids. To maintain the circulatory volume of fluids.
  • Administer vitamin k as prescribed to reduce bleeding. Vitamin k activates coagulation factors.
  • Administer whole blood as prescribed. To maintain circulatory volume of blood.

METRORRHAGIA

Metrorrhagia is a medical term used to describe irregular or abnormal uterine bleeding that occurs between menstrual periods. Can also be defined as cyclic bleeding at normal intervals, the bleeding is either excessive in amount (>80 ml) or duration or both.

This is a symptom of some underlying pathology which may be organic or functional.

Causes
  • Fibroid uterus
  • Adenomyosis (A disorder of the glands that secrete cervical mucus and fluids)
  • Pelvic endometriosis(The presence of endometrium elsewhere than in the lining of the uterus causing premenstrual pain and dysmenorrhea)
  • Chronic tubo-ovarian mass
  • Retroverted uterus-due to congestion
  • Uterine polyp. This is due to vast blood supply to the polyp which makes it bleed easily.
  • Cervical erosions. This is due to the presence of a wound and an increase in blood supply resulting into bleeding.
  • Cancer of the cervix or endometrial cancer.
  • Chronic threatened abortion or incomplete abortion
  • Retained pieces of placenta. This interferes with contraction of the uterus to seal off blood vessels after birth.
  • Mole pregnancy. This is due to an abnormal uterine mass which grows after fertilization and is supplied with a lot of blood capillaries resulting into bleeding.
  • Ovulation bleeding
  • Short cycles like polymenorrhoea.
Signs and symptoms
  1. Bleeding between menstrual periods.
  2. Irregular menstrual cycles.
  3. Heavier or lighter bleeding than usual during menstrual periods.
  4. Prolonged bleeding that lasts longer than normal.
  5. Pelvic pain or discomfort.
  6. Fatigue or tiredness due to excessive blood loss.
  7. Anemia symptoms, such as shortness of breath, dizziness, or weakness.
Investigations
  • Medical history and physical examination: A detailed history of menstrual cycles, symptoms, and any relevant medical conditions is obtained. A pelvic examination may be performed to assess the reproductive organs.
  • Hormone level assessment: Blood tests may be conducted to evaluate hormone levels, including estrogen, progesterone, and thyroid hormones.
  • Transvaginal ultrasound: This imaging test can provide visualization of the uterus, ovaries, and any structural abnormalities.
  • Endometrial biopsy: A sample of the uterine lining may be obtained for microscopic evaluation to check for abnormalities or cancer.
  • Hysteroscopy: A procedure in which a thin, lighted tube is inserted into the uterus to visualize the uterine cavity and detect any abnormalities. 
  • Digital and speculum examination, to visualize the cervix for any abnormality.
  • Pelvic scan, to visualize pelvic organs and rule out any abnormality.
Management

The best management to investigate and treat the cause.

Medical and Nursing Management of Metrorrhagia:

  1. Hormonal therapy: Depending on the underlying cause, hormonal medications, such as birth control pills or progestin therapy, may be prescribed to regulate the menstrual cycle and reduce abnormal bleeding.
  2. Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications can help manage pain and reduce bleeding during episodes of metrorrhagia.
  3. Treatment of underlying conditions: If metrorrhagia is caused by conditions such as fibroids, polyps, or infections, appropriate treatment strategies will be implemented to address the specific cause.
  4. Surgical interventions: In some cases, surgical procedures may be necessary to remove uterine abnormalities or address the underlying cause of metrorrhagia.
  5. Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene and symptom management, and promoting overall well-being.
  6. Monitoring and follow-up: Nurses play a vital role in monitoring patients\’ response to treatment, assessing the effectiveness of interventions, and ensuring appropriate follow-up care.

POLYMENORRHOEA/ EPIMENORRHPEA

Polymenorrhea, also known as epimenorrhoea, is a medical condition characterized by frequent menstrual periods that occur more frequently than the normal menstrual cycle. Also refers to menstruation periods that occurs at shorter intervals than usual (14-21 days), but they are frequent and regular.

Causes of Polymenorrhea/Epimenorrhoea:

  1. Hormonal imbalances: Fluctuations in estrogen and progesterone levels can disrupt the normal menstrual cycle and result in more frequent periods.
  2. Thyroid disorders: Overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism) can affect hormone production and menstrual regularity.
  3. Polycystic ovary syndrome (PCOS): This condition is characterized by hormonal imbalances, enlarged ovaries with cysts, and irregular menstrual cycles.
  4. Uterine abnormalities: Conditions such as uterine fibroids, polyps, or adenomyosis can cause abnormal bleeding and frequent periods.
  5. Stress and lifestyle factors: Chronic stress, excessive exercise, drastic weight changes, and poor nutrition can disrupt the hormonal balance and contribute to polymenorrhea.
Signs and Symptoms of Polymenorrhea/Epimenorrhoea:
  1. Menstrual cycles shorter than 21 days.
  2. More frequent periods, with menstrual bleeding occurring every two weeks or less.
  3. Lighter or heavier bleeding than usual.
  4. Increased menstrual discomfort or pain.
  5. Fatigue or tiredness due to frequent blood loss.
  6. Emotional and psychological impact, such as anxiety or mood swings.
Investigations for Polymenorrhea/Epimenorrhoea:
  1. Medical history and physical examination: A thorough evaluation of the menstrual patterns, symptoms, and any underlying medical conditions is conducted. A pelvic examination may be performed to assess the reproductive organs.
  2. Hormone level assessment: Blood tests may be done to measure hormone levels, including estrogen, progesterone, thyroid hormones, and other relevant hormones.
  3. Pelvic ultrasound: This imaging test can provide visual information about the ovaries, uterus, and any structural abnormalities.
  4. Endometrial biopsy: A sample of the uterine lining may be obtained and examined to rule out any abnormalities or cancer.

Medical and Nursing Management of Polymenorrhea/Epimenorrhoea:

  1. Hormonal therapy: Depending on the underlying cause, hormonal medications, such as oral contraceptives or hormone-regulating medications, may be prescribed to regulate the menstrual cycle and reduce the frequency of periods.
  2. Treatment of underlying conditions: If polymenorrhea is caused by conditions such as PCOS or uterine abnormalities, appropriate treatment strategies will be implemented to address the specific cause. Carry out dilatation and curettage (D&C) to remove retained products if its the cause.
  3. Lifestyle modifications: Stress reduction techniques, maintaining a balanced diet, regular exercise, and adequate sleep can help regulate hormonal balance and promote overall well-being.
  4. Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene, symptom management, and lifestyle modifications.
  5. Monitoring and follow-up: Monitoring patients\’ response to treatment, assessing the effectiveness of interventions, and ensuring appropriate follow-up care should be put into considerations.

DYSFUNCTIONAL UTERINE BLEEDING

Dysfunctional uterine bleeding (DUB) refers to abnormal uterine bleeding that occurs in the absence of organic causes or underlying medical conditions. It is typically characterized by irregular, prolonged, or heavy menstrual bleeding. Can also refers to abnormal bleeding resulting from hormonal changes rather than from trauma, inflammation, pregnancy or a tumour.

Incidence

The prevalence varies widely  but an incidence 10% among patients attending the outpatient seems logical. The bleeding may be abnormal in frequency ,amount or duration or combination of both.

Causes
  • It is due to sustained levels of oestrogen leading to thickening of the endometrium which shed incompletely and irregularly.
Pathophysiology
  • In most cases, abnormal bleeding is caused by local causes in the endometrium.
  • However,there is some disturbance  of the endometrial blood vessels and capillaries and coagulation of blood in and around these vessels.
  • These are caused by alteration in the ratio of endometrial prostaglandins which are delicately balanced in hemostasis of menstruation  and may be related to incoordination in the  hypothalamo-pituitary –ovarian axis.
Signs and Symptoms of Dysfunctional Uterine Bleeding:
  1. Irregular menstrual cycles: Menstrual periods may occur more frequently or infrequently than usual.
  2. Prolonged bleeding: Menstrual bleeding may last longer than the typical duration.
  3. Heavy menstrual bleeding: Excessive or abnormally heavy bleeding during menstrual periods.
  4. Intermenstrual bleeding: Bleeding that occurs between menstrual cycles.
  5. Fatigue or tiredness due to excessive blood loss.
  6. Anemia symptoms: Weakness, lightheadedness, shortness of breath, or pale skin.

NOTE : A diagnosis of dysfunctional uterine bleeding is made only when all other possibilities of causes of bleeding have been excluded.

Investigations
  • Ultra sound scan to rule out new growth
  • Blood analysis for hormonal imbalance
  • Biopsy for histology
MANAGEMENT
  • Treatment depends on various factors like age, condition of the uterine lining and the woman’s plans regarding pregnancy.
  • Total hysterectomy is indicated if the woman is over 35 years, uterine lining thickened and contains abnormal cells and she does not want to become pregnant.
  • When the uterine lining is thickened but contains normal cells, heavy bleeding may be treated with high dose of oral contraceptive oestrogen and progestin(COC) or oestrogen alone usually intravenously, then followed by a progestin given by mouth. Bleeding generally stops within 12-24 hours and then low doses of oral contraceptives may be given in usual manner for atleast 3 months.
  • Women who have lighter bleeding may be given low doses from the start.
  • If a woman has contraindications to oestrogen containing drug, progestin only pills may be given by mouth for 10-14 days each month.
  • D&C may be used if response or hormonal therapy proves ineffective.
  • If a woman wants to become pregnant, clomiphene drug may be given orally to induce ovulation.

ENDOMETRIOSIS

Endometriosis is a chronic and often painful condition in which tissue similar to the lining of the uterus, called the endometrium, grows outside the uterus. This abnormal tissue growth can occur in various areas of the reproductive system, such as the ovaries, fallopian tubes, and pelvic lining.

Can also refer to growth or presence of endometrial tissue outside the uterus. It may be referred to as a misplaced endometrial tissue.

Incidence

  • 10-15% of women between 25 and 45 years. 25-50% in infertile women.

Common sites that may be affected

Abdominal organs, ovaries, ligaments, intestines, ureters, urinary bladder, vagina, vulva, naval, lungs, nose, conjunctiva and rarely on normal skin.

Cause

The actual cause is not known. But has the following predisposing factors.

  1. Retrograde menstruation: One possible cause is the backward flow of menstrual blood into the fallopian tubes and pelvic cavity, allowing endometrial tissue to implant and grow outside the uterus.
  2. Hormonal imbalance: Estrogen may play a role in promoting the growth of endometrial tissue outside the uterus.
  3. Genetic factors: Having a close relative with endometriosis increases the risk of developing the condition.
  4. Immune system dysfunction: A weakened immune response may allow the abnormal growth and survival of endometrial tissue outside the uterus.
  5. Environmental factors: Exposure to certain chemicals and toxins may contribute to the development of endometriosis.
  6. Surgery involving the uterus like C/S, D&C.
  7. Too late prime para (over 30 years)
  8. Genetic makeup (tend to run in families) especially first degree relatives like mother, sister, daughter.
  9. Race-common in Caucasians
  10. Abnormal uterus like retroverted uterus
Signs and symptoms
  • Some are asymptomatic
  • Lower abdominal pain
  • Irregular periods like spotting before periods
  • Infertility
  • Painful coitus (dyspareunia)
  • Pain during bowel opening
  • Rectal bleeding during menstruation. This is due to the presence of endometrial tissue in the rectum.
  • Bleeding from the site during menstruation
  • Palpable mass (endometrioma)
  • Adhesions
Diagnosis / investigations
  • Presence of endometrial tissue in the site after microscopic examinations confirms the disease (biopsy)
  • To view the tubes and ovaries for the presence of endometrial tissue.
  • Ultra sound scan. To visualize pelvic organs for any abnormality.
  • Barium enema with x-ray. To locate the site of the tissue.
  • Computerized Tomography (CT ) scan. To visualize the tissue.
  • Magnetic Resonance Imaging (MRI ).
  • Blood for marker cell (CA-125 ) and antibodies to endometrial tissue.
  • Medical history and symptom assessment: The healthcare provider will discuss the patient\’s symptoms, menstrual patterns, and medical history.
  • Pelvic examination: A pelvic exam may be performed to check for abnormalities or areas of tenderness.
  • Imaging tests: Transvaginal ultrasound or MRI may be used to visualize the pelvic organs and detect the presence of endometrial growths.
  • Laparoscopy: This minimally invasive surgical procedure allows for direct visualization and biopsy of the abnormal tissue, confirming the diagnosis of endometriosis. 
Nursing, Medical, and Surgical Management of Endometriosis:
  1. Pain management: Provide education on pain management strategies, including the use of over-the-counter pain relievers or prescribed medications.
  2. Hormonal therapy: Medications such as birth control pills, hormonal patches, or progestin-only therapies may be prescribed to regulate the menstrual cycle and reduce symptoms. 
  3. Drugs that suppress the activity of ovaries and slow the growth of endometrial tissue like COCs, progestin and GnRH agonists.
  4. Surgical intervention: In cases of severe pain or infertility, laparoscopic surgery may be performed to remove or destroy endometrial growths. Surgical intervention is primarily to remove as much of the misplaced endometrium tissue as possible
  5.  Combination of drugs and surgery or Total hysterectomy when all other treatments fail.
  6. Fertility treatments: Assisted reproductive technologies, such as in vitro fertilization (IVF), may be recommended for individuals experiencing infertility due to endometriosis.
  7. Supportive care: Provide emotional support, educate patients about the condition, and help individuals cope with the physical and emotional challenges associated with endometriosis.
Complications of Endometriosis:
  1. Infertility: Endometriosis can affect fertility by causing scarring, adhesions, and structural abnormalities in the reproductive organs.
  2. Ovarian cysts: Endometriomas, also known as \”chocolate cysts,\” can form on the ovaries and may require surgical removal.
  3. Adhesions: Endometriosis can lead to the formation of scar tissue, causing organs and tissues to stick together.
  4. Chronic pain: Severe and persistent pelvic pain can significantly impact a person\’s quality of life.

MENSTRUAL DISORDERS Read More »

Introduction To Gynaecology

Introduction To Gynaecology

INTRODUCTION TO GYNAECOLOGY

Gynaecology is a branch of medicine which deals with diseases of the female reproductive systems. 

OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is composed of the external genitalia, internal genitalia and the mammary glands.

EXTERNAL GENITALIA

 

The female external genitalia, also known as the vulva, is a complex structure comprising several distinct parts, each with its unique functions and characteristics:

EXTERNAL GENITALIA

Mons Pubis: The mons pubis is a rounded, fatty region located over the pubic bone. It becomes covered with hair after puberty and acts as a cushion during sexual intercourse.

Labia Majora: These are two prominent, fatty skin folds that extend from the mons pubis to the perineum. They protect the delicate structures within and typically become thinner with age or after childbirth.

Labia Minora: These are smaller, thinner, and more pigmented skin folds situated inside the labia majora. They encircle the vaginal and urethral openings and contain numerous sweat and oil glands. The labia minora are composed of erectile tissue, which becomes engorged during sexual arousal, and they are highly sensitive to touch.

Clitoris: This is a highly sensitive and erectile organ located at the top of the vulva, partially hidden beneath the upper junction of the labia minora. It is analogous to the male penis and is a central focus of sexual response, becoming swollen with blood and sensitive to stimulation during sexual arousal.

Vestibule: The vestibule is a space or cleft enclosed by the labia minora. It contains the openings to the urethra (the tube that allows urine to exit the body) and the vagina.

Vaginal Opening (Introitus): This is the entrance to the vagina, located within the vestibule. In many women, this opening is partially closed by a membrane called the hymen.

Functions of the Vulva

  • Protection: The labia majora act as a protective barrier for the internal reproductive organs, helping to shield them from injury and infection.
  • Sexual Arousal: The clitoris and the highly sensitive nerve endings in the labia minora play a crucial role in sexual arousal and pleasure.
  • Reproduction: The vaginal opening allows for sexual intercourse and serves as the birth canal during childbirth.
  • Urination: The urethral opening within the vestibule allows for the passage of urine from the bladder to the outside of the body.
  • Secretion: The vulva contains numerous sweat and oil glands that secrete fluids to keep the area moist and lubricated.
  • Childbirth: During childbirth, the vulva and vaginal opening stretch to accommodate the passage of the baby.
INTERNAL GENITALIA

 

The internal reproductive system comprises the vagina, cervix, uterus, fallopian tubes, and ovaries, all situated within the pelvic region.

internal genitalia

Vagina: The vagina is a fibro-muscular tube extending from the vulva’s vestibule to the cervix. Approximately 10 cm in length, it can extend further during childbirth. The vaginal mucous membranes secrete fluids that cleanse and maintain an acidic environment. The hymen may cover the vaginal opening, typically breaking during the first penetrative sexual encounter.

Functions of the Vagina:

  • Allows the exit of blood and fluids during menstruation.
  • Serves as a passage for sperm to the fallopian tubes.
  • Receives the penis and sperm during sexual intercourse.
  • Provides the pathway for the fetus during vaginal delivery.

Cervix: The cervix, the most inferior part of the uterus, extends into the vaginal canal. It connects the uterus to the vagina, facilitating the passage of menstrual contents, sperm, and the baby during childbirth.

 The cervix has two main portions: 

  • The ectocervix (visible during gynecologic examination) and 
  • The endocervix (a tunnel through the cervix leading to the uterus).

During Childbirth: The cervix undergoes changes, becoming soft and dilating to accommodate the fetus. Cervical dilation is indicative of labor initiation.

Uterus: A pear-shaped organ, the uterus lies posterior-superior to the bladder and anterior to the rectum in the female pelvis. It consists of the fundus (top), body (middle), and cervix (lower). The uterus is composed of the endometrium (inner mucosal lining), myometrium (smooth muscular middle layer), and perimetrium.

Functions of the Uterus:

  • Responsible for menstruation as the endometrium sheds during each monthly period.
  • The endometrial cavity accommodates the fetus during pregnancy.
  • Uterine muscles facilitate contractions during labor, enabling the expulsion of the infant through the birth canal.

Fallopian Tubes: Also known as oviducts or salpinges, fallopian tubes measure approximately 10 cm and extend from the uterine fundus to the pelvic wall. They consist of the infundibulum (with fimbriae near the ovary), ampullary region, isthmus (narrowest part linking to the uterus), and interstitial part traversing the uterine musculature.

Functions of the Fallopian Tubes:

  • Facilitate sperm movement using tubal cilia and transport the ovum from the ovaries to the uterus.
  • Provide a site for fertilization and guide the zygote to the uterus for implantation.
  • Supply nutrients to the fertilized ovum during its journey to the uterus.

Ovaries: Two glands on each side of the uterus, ovaries are attached to the uterus by the ovarian ligament and the pelvic wall by the suspensory ligament. Covered by the mesovarium (part of the broad ligament), the ovary’s size varies with age and menstrual cycle stage.

Ovarian Functions:

  • Produce ova and female sex hormones—predominantly estrogen and progesterone.
  • Oestrogen promotes the development of secondary sex characteristics, growth, and maturity of reproductive organs.
  • Progesterone prepares the endometrium for pregnancy, aids in placental development, breast enlargement during pregnancy, and inhibits ovum production during gestation.
  • Together, estrogen and progesterone regulate menstrual cycle changes in the endometrium.

COMMON TERMS IN GYNAECOLOGY

Menarche: Menarche refers to the first menstrual period and is considered the first sign of puberty and may be the first sign of the possibility of fertility. The average age of menarche usually ranges from 12-13 years.

Precocious puberty: This is the onset of menstruation before the age of 8 years in girls or 9 years in boys. This is an abnormality which requires investigation.

Menorrhagia: Menorrhagia is an excessive amount or prolonged bleeding during the woman’s menstrual period. Blood loss is usually greater than 80 ml per menstrual cycle. It is common during adolescence and perimenopausal. Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or disorders of the endometrium.

Oligomenorhoea: Oligomenorhoea defines the occurrence of very light or infrequent menstrual periods usually at intervals of more than 35 days.

Post coital bleeding: Post coital bleeding is defined as vaginal bleeding that occurs after sexual intercourse.

COMMON CAUSES OF GYNECOLOGICAL ISSUES

1. Congenital Abnormalities:

  • Absence of Vagina, Ovaries, Uterus, or Uterine Division.
  • Structural anomalies present at birth impacting reproductive organs.

2. Environmental Factors:

  • Physical and Mental Well-being: Stress and anxiety may contribute to menstrual irregularities or the absence of menstruation.
  • Lifestyle Choices: Unhealthy habits, sedentary lifestyle, or exposure to environmental toxins can affect reproductive health.

3. Pathological Agents:

  • Infections: Entry of pathogenic microorganisms can result in various infections.
  • Vaginitis
  • Vulvitis
  • Other inflammatory conditions impacting the reproductive system.

4. Trauma:

  • Instrumental Trauma: Injuries caused by medical instruments during procedures, potentially leading to complications such as fistula.
  • Accidental Trauma: Physical injuries impacting the genital organs due to accidents or trauma.

5. Hormonal Imbalances:

  • Endocrine Disorders: Conditions affecting hormone production and regulation.
  • Polycystic Ovary Syndrome (PCOS): Disruption of hormonal balance affecting ovarian function.

6. Reproductive System Disorders:

  • Endometriosis: Growth of uterine tissue outside the uterus, causing pain and fertility issues.
  • Fibroids: Non-cancerous growths in the uterus affecting fertility and causing discomfort.
  • Pelvic Inflammatory Disease (PID): Infections affecting the reproductive organs.

7. Menstrual Disorders:

  • Dysmenorrhea: Painful menstruation.
  • Menorrhagia: Heavy menstrual bleeding.
  • Amenorrhea: Absence of menstruation.

8. Gynecological Cancers:

  • Cervical, ovarian, uterine, or other reproductive cancers.
  • Regular screenings and early detection are crucial for effective management.

9. Pregnancy-Related Complications:

  • Ectopic Pregnancy: Implantation outside the uterus.
  • Gestational Trophoblastic Disease (GTD): Abnormal growth of cells inside a woman’s uterus.

1O. Pelvic Floor Disorders:

  • Prolapse: Descent of pelvic organs.
  • Incontinence: Loss of bladder or bowel control.

HISTORY, PHYSICAL EXAMINATION AND INVESTIGATIONS IN GYNAECOLOGY

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Ectopic Pregnancy

Ectopic Pregnancy

ECTOPIC PREGNANCY

Ectopic pregnancy is a gestation that implants outside of the endometrial cavity. 

Ectopic pregnancy is an implantation of a fertilized ovum outside the uterine cavity.

An ectopic pregnancy most often occurs in a fallopian tube. This type of ectopic pregnancy is called a tubal pregnancy.

 

 An ectopic pregnancy is estimated to occur in 1 of every 80 spontaneously conceived pregnancies.

Ectopic Pregnancy anatomical location

ANATOMICAL LOCATION OF ECTOPIC PREGNANCY

Tubal (99%)

  • Ectopic Pregnancy occurs anywhere in the fallopian tube.
  • The most common site is the ampulla.
  • Interstitial (cornual) pregnancies occur in the most proximal tubal segment, which runs through the uterine cornua. This type of ectopic pregnancy can grow to be quite large, and rupture may cause massive haemorrhage.

Ovarian (0.5%)

  • Ectopic Pregnancy occurs in the ovary.

Abdominal (less than 0.1%)

  • Ectopic Pregnancy occurs in the abdomen.
  • With possible adherence to the peritoneum, visceral surfaces, or omentum

Cervical (0.1%)

  • Ectopic Pregnancy occurs in the cervix.
  • A cervical ectopic, in which the pregnancy implants on the cervix itself, is very rare. Most cervical pregnancies will result in miscarriage. The risk of bleeding, either with spontaneous miscarriage, or for those which require surgical intervention, is much higher

Heterotopic Pregnancy

  • This is a very rare type of multiple pregnancy, in which one viable pregnancy develops within the uterus, and another fertilised egg is implanted elsewhere as an ectopic pregnancy. 
  • It occurs in less than 1 in 30,000 naturally occurring pregnancies, and is slightly more common in couples who conceive through assisted conception.
  • Both intrauterine and ectopic pregnancies may occur concomitantly.

Caesarean Scar Pregnancy

  • Rarely, the ectopic pregnancy can be located at the site of the scar from a previous Caesarean section. This occurs in 1 in 1,800 pregnancies.

Cornual/Interstitial

  • Interstitial ectopic pregnancies are those which occur in the tissue of the Fallopian tube that lies within the muscular wall of the uterus. 
  • It can be quite difficult to diagnose through ultrasound, and may need laparoscopic (keyhole) surgery to confirm the diagnosis.

Other less common sites of ectopic implantation are the ovary,  or a rudimentary uterine horn. Rarely, an ectopic may be intraligamentous or in the peritoneal cavity

CAUSES AND RISK FACTORS FOR ECTOPIC PREGNANCY

CAUSES AND RISK FACTORS FOR ECTOPIC PREGNANCY

The occurrence of ectopic pregnancy has been associated with abnormal function of the fallopian tubes. Normally, the tubes facilitate collection and transport of the oocyte and embryo into the uterus. The integrity of the fimbria, lumen, and ciliated mucosa appears to be important for transport. Conditions thought to prevent or retard migration of the fertilized ovum to the uterus increase the risk for an ectopic pregnancy.

Abnormal Function of Fallopian Tubes: 

  • Normal function of the fallopian tubes, involving the integrity of fimbria, lumen, and ciliated mucosa, is crucial for the proper transport of the oocyte and embryo into the uterus.
  • Conditions hindering migration of the fertilized ovum to the uterus elevate the risk of ectopic pregnancy.

Pelvic Inflammatory Disease (PID):

  • Inflammation and scarring from PID affect intra and extra luminal structures, impairing normal tubal function.
  • Severe damage may result in complete tubal blockage and infertility.

Tubal Surgery and Related Procedures:

  • Tubal surgeries, bilateral tubal ligation, and tubal reanastomosis may lead to scarring, narrowing, or false passage formation.
  • Other pelvic and abdominal surgeries may cause peritubal adhesions, although not directly associated with ectopic pregnancy.

Chlamydia, Gonorrhea, Endometriosis, and Salpingitis:

  • Infections, especially Chlamydia and gonorrhoea, which causes PID, contribute to inflammation and scarring.
  • Conditions like endometriosis and salpingitis increase the risk of ectopic pregnancy.

Artificial Reproductive Techniques:

  • In-vitro fertilization and gamete intrafallopian transfer have been linked to an increased risk of ectopic pregnancy.
  • Retrograde embryo migration is considered a possible mechanism.

Delayed Fertilization:

  • Possible transmigration of the oocyte to the contralateral tube and slowed tubal transport can delay the passage of the morula to the endometrial cavity.

Chromosomal and Structural Anomalies of the Conceptus:

  • Anomalies in the chromosomes or structure of the conceptus may predispose individuals to ectopic pregnancy.

Developmental Abnormalities of the Tube:

  • Abnormalities like diverticula, accessory ostia, and hypoplasia in the tube can elevate the risk of ectopic pregnancy.
  • Exposure to diethylstilbestrol increases the risk four to five times.

RISK FACTORS FOR ECTOPIC PREGNANCY:

  • Increased Maternal Age: Advanced maternal age is identified as a risk factor for ectopic pregnancy.
  • History of Previous Ectopic Pregnancy: Individuals with a history of ectopic pregnancy have a 15% to 20% risk of recurrence in subsequent pregnancies, in either the same or opposite tube.
  • History of Infertility: Infertile couples exhibit an increased proportion of ectopic pregnancies compared to the total number of pregnancies, regardless of the cause of infertility.
  • Contraceptive Methods: Certain contraceptive methods carry a higher risk, including Progestasert IUD (15%), intrauterine devices (5%), and diaphragms. Oral contraceptives have a 1% risk, while intrauterine devices are highly effective at preventing intrauterine pregnancy, making any pregnancy in an IUD user more likely to be tubal.
  • Progestin-only Contraceptives: Users of progestin-only oral contraceptives and injectable progestins face an increased risk of ectopic pregnancy if pregnancy occurs, possibly due to altered tubal motility.
  • Peritubal Adhesions: Adhesions following post-abortal or puerperal infections, appendicitis, or endometriosis contribute to the risk of ectopic pregnancy.
  • Cigarette Smoking: Studies indicate that cigarette smoking causes tubal ciliary dysfunction, contributing to the risk of ectopic pregnancy.
  • Endometriosis: Endometriosis can make the uterus unsuitable for implantation, increasing the likelihood of ectopic pregnancy.

WHY AN ECTOPIC PREGNANCY HAPPENS?

Pathophysiology of an Ectopic Pregnancy.

  • Fertilization occurs at the usual distal third of the fallopian tube.
  • After the union, zygote begins to divide and grow.
  • However, due to an obstruction by several factors (see Risk Factors), the zygote cannot travel through the length of the tube.
  • It lodges on that constricted part and implantation takes place at that area instead of the uterus.

In a normal pregnancy, an egg is fertilized by sperm in one of the fallopian tube which connect the ovaries to the womb .The fertilized egg moves and implants itself into the womb lining endometrial ,where it grows and develops 

So for an ectopic pregnancy, it occurs when a fertilized egg implants itself outside the womb.

CLINICAL PRESENTATION OF ECTOPIC PREGNANCY

An ectopic pregnancy does not cause noticeable symptoms and is only detected during routine pregnancy testing. However, most women do have symptoms and these usually become apparent between 5 to 14 weeks of gestation.

The Classic Triad of symptoms of ectopic pregnancy consists of

  • Amenorrhea,
  • Vaginal bleeding, and
  • Lower abdominal pain. 

Acutely ruptured ectopic pregnancy.

 This clinical scenario represents a surgical emergency. The patient who has experienced rupture of her ectopic pregnancy will most likely have:

On History Taking:

  • History of amenorrhoea 6 – 10 weeks.
  • Patient complains of a feeling of fainting, dizziness, thirst, light vaginal bleeding and pelvic pain.
  • Abdominal distension, Guarding and rebound tenderness.
  • Patient complains of acute abdominal pain localized in the iliac fossa which is colicky in nature.
  • She may also complain of ipsilateral shoulder pain from phrenic nerve irritation due to hemoperitoneum from the blood in her abdomen and it occurs in up to 25% of patients.

On Examination:

  • Signs of pregnancy are present.eg darkening of areolar.
  • Signs of shock e.g. cold clammy skin, rapid thread pulse, low blood pressure and low temperature
  • Patient is anxious and restless
  • Pallor of mucous membranes

On Palpation:

  • Abdominal tenderness especially on the affected side.
  • Abdominal muscles become rigid due to mother guarding against pain.
  • Abdominal distention due to presence of blood in the abdominal cavity.

On Vaginal Examination:

  • Amount of bleeding does not correspond to the mother’s condition.
  • Tenderness on movement of the cervix and a mass is felt in the lateral fornix.
  • Painful mass in the pouch of Douglas.
  • Dark brown blood on the examining finger.

DIAGNOSIS OF ECTOPIC PREGNANCY

Ultrasound Confirmation: Utilization of ultrasound imaging as a primary diagnostic tool(golden standard).

  •  An ultrasound would reveal an empty uterus and free fluid (blood) in the peritoneal cavity. The diagnosis of ectopic pregnancy may be confirmed by the absence of intrauterine pregnancy (IUP) on ultrasound in a woman with a level of HCG sufficient to normal pregnancy, the absence of intrauterine pregnancy on ultrasound examination is diagnostic for ectopic pregnancy if the gestational age is known for certain or if the HCG level is >2500 IU per ml.
  • Cordocentesis(Percutaneous umbilical cord blood sampling) , Aspiration of fluid from the cul-de-sac for evidence of intra-abdominal bleeding. It is a technique by which a needle attached to a syringe is inserted transvaginally through the posterior vaginal fornix into the pouch of Douglas to detect any fluid within the peritoneal cavity.

  • Laparoscopy: Commonly performed surgical procedure for diagnosis. Follows symptoms of bleeding and a positive pregnancy test.
  • Positive Pregnancy Test: Presence of human chorionic gonadotropin (hCG) in the blood or urine.
  • Cullen’s Sign: Specific clinical manifestation suggesting a ruptured ectopic pregnancy. Periumbilical bruising due to blood tracking from the ruptured fallopian tube.

Cullen's Sign ectopic

  • Magnetic Resonance Imaging. This is also another way to detect the presence of ectopic pregnancy and it is safer than undergoing a CT scan for pregnant women.
  • Hematocrit and Haemoglobin Levels: Routine blood tests to assess for signs of anaemia due to internal bleeding.

DIFFERENTIAL DIAGNOSIS OF ECTOPIC PREGNANCY.

Gynecologic problems

  • Threatened or incomplete abortion 
  • Ruptured corpus luteum cyst 
  • Endometriosis
  • Gestational trophoblastic diseases 
  • Ruptured corpus luteal cyst
  • Dysfunctional uterine bleeding
  • Acute pelvic inflammatory disease 
  • Adnexal torsion 
  • Degenerating leiomyoma (especially in pregnancy)
  • Salpingitis

Non Gynecologic Problems 

  • Acute appendicitis
  • Pyelonephritis 
  • Pancreatitis

MANAGEMENT OF ECTOPIC PREGNANCY.

Management has two modalities:

  • Surgical approach.
  • Medical approach.

In maternity center

Aims

  1. To prevent shock
  2. To relieve pain
  3. To reassure the patient
  • Admission: The patient is admitted temporarily in a gynecological ward in a well-made warm bed.
  • Histories: These are taken including personal, social, surgical, medical, obstetrical history, how the condition started etc
  • Examination: This is carried out from head to toe to rule out anaemia, dehydration, shocketc
  • Observation:  Temperature, pulse, respiration and blood pressure are taken and recorded to assess functioning of vital organs.  The foot of the bed should be raised to allow blood to move to vital centres.
  •  Send for transport as soon as possible and inform the patient and relatives about the decision made and why it is necessary.

Treatment

  • Put up intravenous infusion of normal saline to prevent or treat shock.. This is to elevate low blood pressure.
  • Administer morphine or pethidine to relieve pain as prescribed.
  • Nursing care: The vulva is swabbed and a clean pad is applied.
  • Send the patient to hospital with a written note stating when the patient reported to the centre, condition on admission and at time leaving and treatment given.

In the Hospital

Aims:

  • To treat anaemia
  • To prevent or treat shock
  • To reassure the patient
  • To prevent complications

It  is a gynaecological emergency, requiring swift action. 

Management

Admission: Admit the patient to a well-ventilated room and a warm admission bed. Establish a good nurse-patient relationship.

Histories: Take comprehensive history, including personal data, presenting complaints, and obstetrical and medical history.

General Examination: Perform a head-to-toe examination to rule out anaemia, shock, dehydration, etc.

Observations: Monitor vital signs like temperature, pulse, respiration, and blood pressure. Inform the doctor about the patient.

Investigations: Conduct investigations as required by the doctor, including Hb, grouping and cross-match, ultrasound scan, and urinalysis.

Resuscitation:

  • Administer intravenous fluids (e.g., normal saline) and maintain a fluid balance chart.
  • Consider blood transfusion based on haemoglobin results.
  • Provide pain relief with analgesics like morphine as prescribed by the doctor.
  • The doctor will determine the operation.

Preparation for Theatre:

  1. Explain the nature of the operation and obtain informed consent.
  2. Reassure the patient to allay anxiety.
  3. Inform theatre staff.
  4. Pass an intravenous line for infusion.
  5. Perform vulva swabbing to minimize infections.
  6. Catheterization is done, and a fluid balance chart is started.
  7. Pass a naso-gastric tube for aspiration of gastric contents or administer an anti-acid like magnesium trisilicate to alkalize stomach contents and prevent aspiration into the lungs.
  8. Pre-medication is given, such as atropine to dry secretions.
  9. Repeat vital observations and compare with baseline observations, recording all findings.
  10. Compile clinical charts and notes, dress the patient in a gown, and transport her carefully to the theatre.
  11. In the theatre, give a full report to the theatre nurse about the patient.
  12. Book about 1-2 units of blood.
SURGICAL APPROACH

Surgical treatment of ectopic pregnancy has the advantage of taking care of the ectopic immediately. It is suitable for emergency care of ectopic pregnancy.  It is critical to establish large-bore intravenous lines and to start fluid resuscitation.  

Salpingectomy, the removal of the fallopian tube containing the ectopic pregnancy, is the treatment of choice in the following situations:

  • Future childbearing is not desired.
  • The tube is severely damaged.
  • Bleeding cannot be controlled.
  • The ectopic is in a fallopian tube where an ectopic occurred previously.

Linear salpingostomy, the removal of the gestation through a linear incision in the fallopian tube, may be performed if future fertility is desired.

  • This procedure is associated with a persistent ectopic pregnancy rate of 3% to 20%.
  • Therefore, serial quantitative HCG values must be followed to ensure resolution.

Operative laparoscopy may be performed to confirm the diagnosis of ectopic pregnancy and to remove the abnormal gestation via salpingectomy or salpingostomy.  This method is used in hemodynamically stable patients. Advantages of this technique over laparotomy include:

  • Shorter hospital stay
  • Faster postoperative recovery
  • Better cosmetic result
  • Potentially shorter operative time

Laparotomy is reserved for hemodynamically unstable patients who require emergent surgery for a ruptured ectopic pregnancy. This method may also be appropriate when laparoscopy is contraindicated or technically challenging because of extensive adhesive disease from prior surgery.

Cornual resection, may be performed when an interstitial pregnancy occurs. The interstitial portion of the tube is removed via wedge resection into the uterine cornua. Cornual ectopic pregnancies have a higher failure rate with methotrexate and a surgical approach may be more effective.

Oophorectomy is indicated only when an ovarian ectopic pregnancy occurs and salvage of the affected ovary is not possible.

Post-Operative Care:

Post-operative Bed Preparation: Set up the bed with all necessary accessories ready to receive the patient.

Patient Transfer: Inform ward staff, and two qualified nurses go to the theatre to collect the patient. In theatre, receive a full report from the anaesthetist and theatre nurse in a recovery room, reporting the patient’s condition.

Confirm the Report:

  • Check airway, breathing, and circulation.
  • Take vital observations.
  • Observe the site of operation for bleeding.
  • Observe the catheter to see if it is draining well and in a good position.

Patient Transfer to Ward: After confirming, gently wheel the patient to the ward in a recumbent position with the head turned to one side, observing the airway.

On Ward: Lift the patient from the trolley carefully to a well-made post-operative bed near the nurse’s station for close observations.

  • Place the patient in a recumbent position with the head turned to one side for drainage of secretions and to prevent the falling back of the tongue.
  • Conduct observations and record vital signs (temperature, respiration, blood pressure, and pulse) every 1/4, 1/2, 1, 2 hours as per surgeon’s instructions. Adjust the duration based on patient stabilization. Continue observations until the patient is discharged.
  • Observe the site of operation for bleeding.
  • Observe the catheter for drainage, color, and the quantity of urine passed.
  • Maintain a fluid balance chart and balance it every 24 hours to rule out renal failure.
  • On regaining consciousness, welcome the patient from the theatre, sponge the face, change the theatre gown, conduct mouthwash to remove the anesthetic smell, and offer a pillow.

Fluid/Hydration:

  • Continue intravenous fluid (e.g., 0.9%) to replace lost fluids.
  • Observe IV infusion, including cannular site for swelling and drip rate; correct any issues.
  • Monitor fluid intake and output to avoid overhydration.
  • Stop IV fluids when bowel sounds are heard, and the patient can take by mouth.
  • Remove the cannula when necessary, e.g., if the patient has completed intravenous drugs.

Drug Therapy:

  • Administer prescribed strong analgesics (e.g., pethidine for 48 hours, then switch to mild analgesics like diclofenac 50-100mg tds).
  • Administer prescribed antibiotics (e.g., x-pen 2mu qid for 72 hours, then change to oral antibiotics if necessary, such as amoxyl 250-500mg tds for 5 days).
  • Monitor the patient for side effects of the drugs given.
  • Provide supportive drugs like ferrous and folic acid to prevent anemia.

Wound Care:

  • Observe the wound for bleeding and add more dressing if needed. Change the dressing if soiled and check for signs of infections.
  • Conduct daily wound dressing.
  • Remove stitches on the 7th and 8th day alternately.

Physiology:

  • Encourage the patient to do deep breathing exercises to prevent chest complications like hypostatic pneumonia.
  • Encourage passive exercises, such as limb movement, and later active exercises like walking around to prevent deep vein thrombosis.
  • Provide psychotherapy for continuous reassurance.

Diet:

  • Conduct a digestion test, and if positive with bowel sounds heard, start the patient on small sips of water.
  • Introduce soft foods according to tolerance, rich in proteins for tissue repair, roughages to prevent constipation, and carbohydrates for energy.
  • Note: The nasogastric tube is removed as long as the patient can take orally without any complaint.

Hygiene:

  • Conduct a bed bath on the first day of operation when the patient is still weak, and later assist her to the bathroom.
  • Conduct mouth care to prevent neglected mouth complaints like stomatitis, halitosis, etc.
  • Ensure that the patient’s clothing, bed linen, and the surrounding environment are clean.

Bowel and Bladder Care:

  • If urine is clear in 24-48 hours, remove the urethral catheter and encourage the patient to pass urine.
  • Encourage the patient to pass stool, offer privacy, and provide foods rich in roughages to prevent constipation.
  • In case of constipation and failed conservative measures, give purgatives such as bisacodyl 5-10mg o.d or nocte.

Rest and Sleep:

  • Keep the patient in a quiet, well-ventilated room.
  • Restrict visitors, avoid bright light to create a conducive environment for the patient to sleep and rest.

Advice on Discharge: When the patient is fit for discharge, advise on:

  • Having enough rest at home.
  • Avoiding heavy lifting to prevent straining the abdominal muscles.
  • Coming back for review on appointed dates.
  • Attending ANC clinics when pregnant.
  • Bringing the husband for treatment if the cause of ectopic pregnancy was PIDs.
  • Completing the prescribed medications.

In case of Unruptured Ectopic Pregnancy, Medical Approach can be used.

MEDICAL APPROACH

Methotrexate, a chemotherapeutic agent, has been used successfully to treat small, unruptured ectopic pregnancies. This approach has the advantage that it avoids surgery, but the patient must be counselled that it may take 3 to 4 weeks for the ectopic to resolve with methotrexate therapy. Early diagnosis is very paramount for successful management. 

Mechanism of action

  • Methotrexate is a folic acid antagonist that interferes with DNA synthesis. Its action is principally directed at rapidly dividing cells, such as trophoblastic cells.
  • Once an ectopic pregnancy has been confirmed, 50 mg/m2 is administered intramuscularly in a single or multiple doses with folic acid.
  • Serial HCG levels are followed every 2 to 4 days after treatment until the HCG level starts to decrease. This is to ensure resolution of the pregnancy
  • If a 15% reduction is not achieved during the first week, or in subsequent weeks a plateau occurs, then an additional injection of Methotrexate is given or surgical exploration is advocated.
  • Decreased success has been noted with ectopic pregnancies of greater than 3.5 cm, with fetal cardiac activity, or with high HCG levels (greater than 5000).
  • After treatment failures, surgical management is usually necessary. 
  • After an ectopic gestation, pregnancy should be avoided for at least 3 months to allow for the fallopian tube architecture to normalize.
  • Contraception should be provided

Side effects (approximately 5% of patients).

  1.  Mild gastrointestinal symptoms such as nausea, vomiting, diarrhoea, and stomatitis are typical. 
  2. Potential life-threatening complications include pneumonitis, thrombocytopenia, neutropenia, elevated liver function tests, and renal failure.

Contraindications,

  • Women who are breastfeeding 
  • Immunodeficiency, 
  • Liver disease, renal disease, 
  • Blood disorders, 
  • Peptic ulcer disease,
  • Active pulmonary disease should not receive methotrexate.

Criteria for medical management of ectopic pregnancy

Criteria for receiving methotrexate(MTX) (Absolute indications)

Contraindications to medical therapy (Absolute contraindications)

  • Hemodynamically stable without active bleeding or signs of hemoperitoneum 

  • Non Laparoscopic diagnosis 

  • Patient desires future fertility 

  • General anaesthesia poses a significant risk 

  • Patient is able to return for follow-up care 

  • No contraindications to MTX

Relative indications

  • Unruptured mass ≤3.5 cm at its greatest dimension 

  • No fetal cardiac motion detected 

  • Patients whose hCG level does not exceed a predetermined value (6000-15,000 mIU/Ml

  • Breastfeeding 

  • Laboratory evidence of immunodeficiency 

  • Alcoholism, alcoholic liver disease, or other chronic liver disease 

  • Preexisting blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia or significant anaemia 

  • Known sensitivity to MTX 

  • Active pulmonary disease 

  • Peptic ulcer disease  Hepatic, renal, or hematologic dysfunction

Relative contraindications

  • Gestational sac =3.5 cm 

  • Embryonic cardiac motion

COMPLICATIONS OF ECTOPIC PREGNANCY

The most common complication is rupture with internal haemorrhage which may lead to hypovolemic shock. Death from rupture is rare in women who have access to modern medical facilities.

  • Infertility
  • Recurrence 
  • Severe haemorrhage leading to shock 
  • Anaemia due to bleeding.
  • Infections following operation.
  • Adhesions due to scar formation during healing process.
  • Re-occurrence of another ectopic pregnancy.
  • Infertility if both tubes are affected.

Nursing Diagnosis

  1. Risk for Deficient Fluid Volume related to bleeding from a ruptured ectopic pregnancy.
  2. Fatigue related to early loss of pregnancy secondary to ectopic pregnancy.

Nursing Interventions

  1. Upon arrival at the emergency room, place the woman flat in bed.
  2. Assess the vital signs to establish baseline data and determine if the patient is under shock.
  3. Maintain accurate intake and output to establish the patient’s renal function.

Evaluation

  1. The goal of the evaluation is to ensure that maternal blood loss is replaced and the bleeding would stop.
  2. The patient must maintain adequate fluid volume at a functional level as evidenced by normal urine output at 30-60mL/hr and a normal specific gravity between the ranges of 1.010 to 1.021.
  3. Vital signs, especially the blood pressure and pulse rate, should be stable and within the normal range.
  4. Patient must exhibit moist mucous membranes, good skin turgor, and adequate capillary refill.

Ectopic Pregnancy Read More »

Hormonal Contraceptive Methods

Hormonal Contraceptive Methods

HORMONAL CONTRACEPTIVE METHODS

Hormonal family planning refers to the use of hormonal methods to prevent pregnancy. 

Hormonal contraceptive refers to birth control methods that act on the endocrine system (hormones).

These methods involve the use of hormones, usually synthetic versions of those naturally produced by the body, to regulate a woman’s menstrual cycle and prevent ovulation (the release of an egg from the ovaries). By preventing ovulation, hormonal methods make it difficult for sperm to fertilize an egg and thus prevent pregnancy.

These include;

  1. Oral contraceptive pills
  2. Implants
  3. Injectable contraceptive
  4. Emergency contraceptive pills

Hormonal Methods:

i. Oral Pills:

Method

Description

Combined Oral Contraceptives

Pills containing both oestrogen and progestin hormones

Progesterone-Only Pills

Pills containing only progestin hormone

Emergency Contraceptive Pills

Pills taken after unprotected sex to prevent pregnancy

ii. Implants:

Method

Description

Implanon (1 Rod Capsule)

Subdermal contraceptive rod

Jadelle (2 Rod Capsules)

Subdermal contraceptive rods

Norplant (6 Rod Capsules)

Subdermal contraceptive rods

iii. Injectable Contraceptives:

Method

Description

Depo Provera

Injectable contraceptive administered every three months

Injector Plan

Injectable contraceptive

Sayana Press

Injectable contraceptive

Noristrate

Injectable contraceptive

iii. Emergency Contraceptives:

Emergency Contraceptive

Mechanism of Action

Lofemenal/Microgynon 4BD for 1 day (Low Dose COC)

Inhibits ovulation, thickens cervical mucus

Eugynon (High Dose COC) 2BD for 1 day

Inhibits ovulation, thickens cervical mucus

Regular POP (Ovrette/Microval) at Recommended Dose

Alters cervical mucus, inhibits sperm function

Levonorgestrel 2 stat

Delays ovulation, inhibits fertilization

Postinar 2 BD for 1 day

Alters cervical mucus, inhibits sperm function

Vikela/Levonelle-2/Norlevo Plan B

Delays ovulation, inhibits fertilization

Oral Contraceptive Pills

Oral Contraceptive Pills

There are two main types of hormonal oral contraceptive formulations:

  1. Combined hormonal contraceptive methods which contain both oestrogen and progestin thus, they are called combined oral contraceptives (COCs)
  2. One which contains only progesterone or one of its synthetic analogues (Progestins) thus, it is called progestogen-only pills (POPs) method.

Combined Oral Contraceptive Pills (COC)

(i) Combined Oral Contraceptive Pills (COC)

Combined oral contraceptives contain both oestrogen and progesterone. It achieves effects of both hormones. Oestrogen suppresses ovulation and progesterone creates unfavourable conditions for egg transport and thickening of the cervical mucus to impair sperm entrance into the canal.

Examples
  • Lo-femenal
  • Pill Plan (Duofen)
  • Microgynon

Mechanism of Action:

Combined methods work by:

  • Suppressing ovulation (estrogenic effect)
  • Thickening cervical mucus, making it difficult for sperm to penetrate the uterus
  • Making the endometrium unsuitable for implantation of a fertilized egg (thin and atrophic due to constant progestogenic action)
  • Reducing sperm transport in the upper genital tract (fallopian tubes).

Effectiveness:

  • 92 – 99.9% effective, depending on user compliance.
  • In very young women, typical effectiveness can be as high as 95.3%.
  • Failure rates decline with the duration of use and age of the user.
  • Failures may be due to method failure, client error, incomplete information from service providers, drug interactions, severe vomiting/diarrhoea, or expired pills.

Advantages:

  • Very effective if taken correctly.
  • Effective immediately.
  • Easily reversible.
  • Few side effects.
  • Convenient and easy to use.
  • Does not interfere with intercourse.
  • Causes regular and predictable periods.
  • May improve anemia.
  • Reduces dysmenorrhea and premenstrual tension.
  • Protects against ovarian and endometrial cancer, and some causes of PID.
  • Reduces the risk of ovarian cysts, benign breast disease, and ectopic pregnancy.
  • Can be provided by trained non-medical staff.

Disadvantages:

  • Effectiveness depends on daily pill intake, requiring strong motivation.
  • Increases chances of promiscuity.
  • Can cause Candida vulvitis and vaginitis.
  • May lead to thromboembolism and benign/malignant liver tumors.
  • Requires regular and dependable supply.
  • Reduces breast milk, especially in the first 6 months after delivery.
  • Not the most appropriate choice for lactating women unless no other method is available and there is a high risk of pregnancy.

Indications:

  • Women requiring a highly effective method.
  • Women wanting an easily reversible method.
  • Non-breastfeeding women or breastfeeding women after 6 months.
  • Women who are anaemic with heavy menstrual bleeding.
  • Women with a history of ectopic pregnancy.
  • Nulliparous women.
  • Women with a history of benign, functional ovarian cysts.
  • Women with a family history of ovarian cancer.
  • Women with menstrual cycle symptoms or irregular menstrual cycles.

Contraindications:

  • Absolute contraindications include cardiovascular diseases, liver disease, pregnancy, undiagnosed per vaginal bleeding, and oestrogen-dependent neoplasms.
  • Relative contraindications include obesity, varicosities, epilepsy, asthma, mood disorders, nursing mothers in the first 6 months, smoking, and gallbladder disease.

Side Effects:

  • Major side effects include hypertension, venous thromboembolism, and cholestatic jaundice.
  • Minor side effects can be due to oestrogen, progestin, or both, including nausea, vomiting, headache, leg cramps, weight gain, chloasma & acne, breakthrough bleeding, hypomenorrhea, amenorrhea, leucorrhea, and decreased libido.

Danger Signs of COCs:

  • Acute abnormal pain.
  • Severe headaches with blurred vision.
  • Pain in the chest with difficulty in breathing.
  • Pain in the calf muscles.

Indications for Withdraw:

  • Severe migraine.
  • Visual disturbance.
  • Sudden chest pain.
  • Severe cramps.
  • Excessive weight gain.
  • Severe depression.
  • Patient wanting pregnancy.
  • Awaiting major surgery.

Drug Interaction:

  • Decreases effectiveness of methyldopa, oral anticoagulants, and oral hypoglycemics.
  • Increases effectiveness of B blockers, corticosteroids, diazepam, aminophylline, and alcohol.
  • Other drugs that increase COC metabolism include phenobarbitone, antiepileptics (except sodium valproate and clozapine), rifampicin, griseofulvin, spironolactone, and ketoconazole.

WHO Medical Eligibility Criteria for Contraceptive Use. 

Category 1: A condition for which there is no restriction for use of the contraceptive 

Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks

Category 3: A condition where the theoretical or proven risk outweigh the advantages of using the method.

Category 4: A condition that represents unacceptable health risk if the contraceptive is used.

Who can use only if more appropriate methods are not available (WHO class3) 

  • Women with high BP (greater than 160/100 but less than 180/110) and no vascular disease.
  • Women with symptomatic gall bladder disease.
  • Women age 35 yrs or older and light smokers (under 20 cigarettes a day)
  • Women taking drugs for epilepsy or anti-TB.
  • Women with unexplained vaginal bleeding (only if serious problem suspected)
  • Women who are fully b/feeding (6 wks to 6 months postpartum)
  • Women who are not b/feeding who are less than 3 weeks postpartum.
  • Women with h/o breast cancer and no current evidence of the disease.

Who should not use COCs (WHO Class 4)

  • Women with hypertension: blood pressure diastolic above 110 mm Hg. The health risk/benefit ratio is dependent upon the severity of the condition
  • Women with current or history of cardiac disease (heart disease or stroke). Among women with underlying vascular disease due to thrombosis, the increased risk of thrombosis with COCs should be avoided; 
  • Women with thrombo-embolic disease (current and a history of or major surgery with prolonged immobilization). The increased risk of venous thromboembolism associated with COCs should have little impact on healthy women, but may have a big impact on women otherwise at risk for it;
  • Women within 2 weeks of child birth (Postnatal) and within 4 weeks or elective surgery;
  • Women with known or suspected cervical cancer. Theoretical concern that COC use may affect prognosis of the existing disease. In general, treatment of these conditions renders a woman sterile; 
  • Women who are pregnant. As no method is indicated, any health risk is considered unacceptable. However, there is no known harm from COCs; 
  • Women with undiagnosed breast lumps or breast cancer. Breast cancer is a hormonally sensitive tumor. The risk for progress of the condition may be increased among women with current or past history of breast cancer;
  • Women who are taking long-term drugs that could affect the pill’s efficacy. Commonly used liver enzyme inducers are likely to reduce the efficacy of COCs. Drugs which affect liver enzymes are the antibiotic rifampicin (note that other antibiotics will not affect pill efficacy), other drugs where another method should be used are:  —griseofulvin, and anticonvulsants (such as phenytoin, carbamazepine, barbiturates, and primidone).
  • Women with severe headache (recurrent, including migraine with focal neurological symptoms). Focal neurological symptoms may be an indication for an increased risk of stroke( or cerebrovascular accident (CVA) is sudden damage to brain  tissue caused either by a lack of blood supply or rupture of a blood vessel . The affected brain cells die and the parts of the body they control or receive sensory messages from ceaseto function.)
  • Women who are retarded or forgetful.
  • Women with sickle cell disease, as they have increased risk of thrombosis;
  • Women with trophoblast disease (current trophoblastic tumor)
  • Women who are to undergo major elective surgery with prolonged bed rest.

Client Information

  • Start between 1st and 7th day of monthly period
  • Take pills daily at the same time – at bed time if possible
  • Do not miss taking the pill any day
  • If you start after the 7th day of monthly period; you need to use another FP method such condoms or to abstain from sex for one week.
  • Contraception is 7 days after initiation
  • You will have your monthly period when you are taking the brown pills. Do not stop taking the pills.

If a client misses, they should do the following:

  • If you miss one white pill, take it as soon as you remember, then continue normally.
  • If you miss 2 white or more days in a row; take two pills each day until all missed pills are taken and you are back on schedule. You must also use a condom for the next 7 days.
  • If you miss the brown pill, no worry. Just skip and continue
  • If you keep forgetting – may need to change method
Progesterone Only Pills (POP)

ii)  Progesterone Only Pills (POP)

Progestin-Only Pills are oral contraceptive pills which contain synthetic progestin and are taken orally every day at the same time of day to prevent pregnancy. 

Mechanism of Action:

  • Reduces the frequency of ovulation.
  • Thickens cervical mucus, making it difficult for sperm to penetrate the uterus.
  • Partially inhibits ovulation.

Types of POPs available in Uganda:

  1. Microval: 35 white pills, each containing 0.03 mg Levonorgestrel.
  2. Ovrette: 28 yellow pills, each containing 0.075 mg Norgestrel.

Effectiveness:

  • Depends on user compliance.
  • Very effective if used correctly (83%-99%).
  • Crucial to take POPs at the same time every day, as effectiveness decreases even with a few hours’ delay.
  • In lactating women, POPs are nearly 100% effective, and they do not alter the quantity of milk.

Advantages of POPs:

  • Do not suppress lactation.
  • No estrogenic side effects.
  • Suitable for women with hypertension, thrombotic, cardiac, and sickle cell diseases.
  • Can be started at any time of the menstrual cycle and in the early postpartum period.
  • Decreased menstrual cramps.
  • Decreased amount of bleeding during periods.
  • Decreased severity of anaemia.
  • Do not increase blood clotting.
  • Some protection against pelvic inflammatory disease (progestins make cervical mucus thicker, reducing the likelihood of infection reaching the uterus and tubes).

Disadvantages of POPs:

  • Amenorrhea.
  • Must be taken at the same time every day.
  • Irregular periods, including spotting or bleeding between periods.
  • Prolonged or heavy vaginal bleeding.
  • For women who have had ectopic pregnancy, POPs do not prevent ectopic pregnancy as well as intrauterine pregnancy.
  • For women with a history of ovarian cysts, POPs do not protect against the development of future ovarian cysts.

Indications:

  • Women of any reproductive age or parity seeking pregnancy protection.
  • Breastfeeding women (6 weeks or more postpartum).
  • Post-abortion women (may start immediately).
  • Women who smoke.
  • Women with high blood pressure, blood clotting problems, or sickle cell disease.
  • Women unable to take Combined Oral Contraceptives (COCs) but want to take Pills.

Who should not use POPs (Class 3):

  • Women breastfeeding and less than 6 weeks postpartum.
  • Women with jaundice.
  • Women taking anti-epileptic and anti-TB medication.
  • Women with unexplained vaginal bleeding.
  • Women with breast cancer.
  • Women concerned about changes in their menstrual bleeding pattern.
  • Women unable to remember taking a pill every day (no more than 3 hours late).

Who should not use POPs (Class 4):

  • Women known or suspected to be pregnant.
  • Women who are known or suspected to be pregnant. POPs should not be initiated if a woman is pregnant. However, there is no known harm to mother or fetus if POPs are used during pregnancy;
  • Signs of problems from POPs warranting immediate return to clinic
  • Severe lower abdominal pain.
  • Heavy bleeding (twice as long and as much).
  • Migraine headaches, repeated very painful headaches, or blurred vision.

Signs of problems from POPs warranting immediate return to clinic:

  • Severe lower abdominal pain.
  • Heavy bleeding (twice as long and as much).
  • Migraine headaches, repeated very painful headaches, or blurred vision.

Client Instructions:

  1. Start between the 1st and 7th day of the monthly period.
  2. If started after the 1st day of bleeding, abstain from intercourse or use another method for the next 48 hours.
  3. Take pills daily at the same time.
  4. Do not miss taking the pill any day.
  5. Return to the clinic for more pills before finishing the last pack.
  6. Severe diarrhoea or vomiting reduces pill effectiveness. Use a backup method or abstain from sex while taking the pills and for 48 hours after.
  7. If client misses taking pills:
  • If more than 3 hours late, take it as soon as remembered and the next pill at the usual time. Use a backup method or abstain for the next 48 hours.
  • If miss two or more days, take one as soon as remembered, continue as usual, and use a backup method or abstain for the next 48 hours.
  • If consistently forgetting, consider another method and seek counseling.

Contraindications:

  1. Pregnancy: Progestin-Only Pills (POPs) should not be initiated if a woman is pregnant. 
  2. Unexplained vaginal bleeding: POPs are contraindicated in cases of unexplained vaginal bleeding, and immediate medical attention is advised to determine the cause.
  3. Recent history of breast cancer: Women with a recent history of breast cancer are advised against using POPs due to potential hormonal interactions that could affect cancer progression.
  4. Arterial diseases: Individuals with arterial diseases, such as a history of stroke or cardiovascular issues, should avoid POPs as they may pose additional risks to vascular health.
  5. Thromboembolic diseases: Those with a history of thromboembolic diseases, involving blood clotting, are at an increased risk when using POPs, making it a contraindicated option.
  6. Active hepatic diseases: Presence of active liver diseases is a contraindication, as POPs can impact liver function, and their use might exacerbate hepatic conditions.
  7. Hypertension: Women with hypertension are advised against using POPs, as the hormonal components may contribute to increased blood pressure.

Side Effects:

  1. Amenorrhea: Some women may experience amenorrhea (absence of menstruation) as a side effect of POPs, which is generally considered a normal response to hormonal changes.
  2. Spotting: Spotting, or irregular bleeding between periods, can occur, and individuals should be aware that this is a common side effect that usually diminishes with time.
  3. Prolonged or heavy bleeding: While some may experience prolonged or heavy bleeding, this side effect should be discussed with a healthcare provider to ensure it is not indicative of an underlying issue.
  4. Lower abdominal pain: Lower abdominal pain may occur.
  5. Weight gain or loss: Changes in weight, either gain or loss, may be observed.
  6. Jaundice: Jaundice, characterized by yellowing of the skin or eyes, is a rare but serious side effect.
  7. Nausea and vomiting: Nausea and vomiting may occur initially but often subside. 
  8. Headache with blurred vision: Headaches with blurred vision may be experienced.
  9. Excessive hair growth: Some individuals may notice changes in hair growth patterns.
  10. Breast fullness or tenderness: Breast fullness or tenderness is a common side effect that usually resolves over time.
  11. High blood pressure: An increase in blood pressure may occur in some individuals

Implants

Implants are small, flexible rods or capsules that are inserted under the skin of a woman’s upper arm.

 These implants release a steady, low dose of hormones (usually a progestin hormone) into the bloodstream over an extended period. The most common types of contraceptive implants include Implanon, Jadelle, and Norplant.

Implants are considered a reversible form of contraception, and their effectiveness is not dependent on user compliance once inserted. They are suitable for women who want a reliable, long-term birth control option without the need for daily or frequent intervention.

Types:

  1. Implanon: A single rod capsule effective for 3 years.
  2. Jadelle: Two rods of levornogestrel each 75mg capsules providing protection for 5 years.
  3. Norplant: Consists of 6 rods each with 36mg levornogestrel capsules labelled for 5-7 years.

Modes of Action:

The hormonal release from these implants serves to prevent pregnancy by thickening the cervical mucus within 24 hours, hindering sperm entry into the uterus, inhibiting ovulation (the release of eggs from the ovaries), and altering the uterine lining to make it less receptive to a fertilized egg. Implants are highly effective and offer long-term contraception, ranging from three to seven years, depending on the specific type.

Implants

Insertion: Inner aspect of non dominant arm, 6 – 8 cm above elbow fold under local anesthesia. This is at day1, immediate after abortion or 3weeks postpartum.

Removal: Approximately 3 to 5 years

Advantages:

  • Very effective within 24 hours after insertion.
  • Easily reversible with no delay in returning to fertility after removal.
  • Reduces frequency and intensity of sickle cell crises.
  • Highly effective for long-term contraception.
  • Shares benefits with Depo Provera.

Common Side Effects and Disadvantages:

  • Changes in menstruation patterns.
  • Spotting.
  • Rare instances of heavy bleeding.
  • Amenorrhea.
  • Does not protect against STIs, including HIV/AIDS.
  • Discomfort in the hand after insertion.
  • Possible weight changes (overweight or weight loss).
  • Minor surgical procedure required for both insertion and removal.

Indications:

  • Breastfeeding post-partum mothers.
  • Adolescents.
  • Post-abortion contraception.
  • Women with sickle cell disease.
  • Women awaiting surgical contraception.
  • Women on treatment, e.g., ARVs.

Contraindications:

  • Serious problems with the heart or blood vessels.
  • Breast cancer history.
  • Liver diseases leading to jaundice.
  • Pregnancy.

Signs and Problems Requiring Medical Attention:

  1. Soreness at the site of insertion.
  2. Capsules coming out.
  3. Severe headaches.
  4. Heavy bleeding, exceeding the usual amount and duration.
  5. Pregnancy.
  6. Missed period after several regular cycles.

Injectable Contraceptives

Examples

  • Depo Provera (Depo Medroxyprogesterone acetate (DMPA), single dose of 150 mg I.M every 12 weeks. (Injecta Plan)
  • Sayana Press 104mg, 0.65ml Subcutaneously
  • Noristerat (Norethisterone) 200mg every 8 weeks for 24 weeks, then every 12 weeks.
  • Norigynon/Mesigyna (50 mg norethindrone enanthate plus 5 mg estradiol valerate) ; Both given monthly.

These contraceptives contain a single type of hormone, progestin.

Injectable Contraceptives depo

Depo Provera

Depo Provera is a hormone used for contraception. It is given by injection and its effects will last for three months at a time.

Mode of Action

  • Inhibits ovulation.
  • Thickens cervical mucus, hindering sperm entry.
  • Thins the uterine lining, reducing chances of fertilized egg implantation.

Indications

  • Breastfeeding mothers after 6 weeks or immediately if not breastfeeding.
  • Women needing long-term contraception.
  • Known/suspected HIV-positive women.
  • Women with sickle cell disease.
  • Women unable to use COC due to oestrogen content.
  • Women awaiting surgical contraception.

Advantages

  • Very effective.
  • Does not suppress lactation.
  • Easy to remember return dates.
  • Private usage.
  • No oestrogen-related side effects.
  • Reduces sickle cell crisis frequency.
  • Non-interference with sex.

Disadvantages

  • Changes in menstrual bleeding.
  • Spotting (common in the first 3 months).
  • Amenorrhea (common after 1st injection and after 9-12 months).
  • Prolonged heavy vaginal bleeding.
  • Weight changes.
  • Irreversible injection.
  • Delayed return of fertility.
  • Loss of libido.
  • Does not protect against STIs/HIV/AIDS.

Management

  • Depo Provera 150mg deep IM into deltoid or buttock muscle.
  • No rubbing to avoid increased absorption.
  • Advise abstinence or backup FP method for the first 7 days after injection.
  • Return for the next dose 12 weeks after the injection.

Injectable Contraceptives sayana

Sayana Press

Sayana Press is a contraceptive injection that women can give to themselves to prevent pregnancy. It’s given under the skin, at the front upper thighs or abdomen. The injection releases medication that runs through your bloodstream over a period of 13 weeks.

  • Sayana press ® is a single-dose container with 104 mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension (104mg) formulated for subcutaneous.
  • It is administered subcutaneously into the anterior thigh or abdomen or arm.
  • The efficacy of Sayana press depends on adherence to the recommended dosage schedule of administration.

 

Composition

  • Single-dose container with 104 mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension.

Administration

  • Subcutaneously into the anterior thigh, abdomen, or arm

Mechanism of Action

  • Suppresses ovulation.
  • Renders endometrium unsuitable for implantation.
  • Increases cervical mucus viscosity, impeding sperm penetration.

Indications

Nearly all women can use it safely & effectively including women:-

  • Women whose partners have undergone vasectomy until vasectomy is effective.
  • Have or have not had children.
  • Any age including adolescents & women over 40 years old.
  • Have just had an abortion/miscarriage.
  • Breastfeeding women 6 weeks postpartum.
  • HIV infected whether or not on ART.

Advantages and Non contraceptive benefits.

  • New formulation for S/C injection.
  • 30% low side effects compared to Depo-Provera.
  • Do not interfere with sex.
  • Private & no one else can tell that a woman is using it.
  • May help women gain weight.
  • Do not require daily action.
  • Prevents pregnancy.
  • Protects against endometrial cancer, uterine fibroids.
  • Reduces sickle cell crisis among women with sickle cell anaemia.
  • Protects against symptomatic PID & iron deficiency anaemia.

Disadvantages

  • Weight changes.
  • No protection against STIs/HIV/AIDS.
  • Delayed fertility return.
  • Potential side effects like hypersensitivity reactions, decreased/increased appetite, loss of libido, dizziness, headache, and more.

Problems that may need medical attention

  • Loss of bone mineral density.
  • Menstrual irregularities.
  • Thromboembolic disorders.
  • Anaphylaxis & anaphylactoid reactions.
  • Sudden partial or complete loss of vision.
Disadvantages & Side effects
  • Weight gain or loss
  • Does not protect against STI/HIV/AIDs
  • Delayed fertility return
  • Hypersensitivity reactions
  • Decreased/increased appetite
  • Loss of libido & irritability
  • Dizziness, headache & migraine
  • Thromboembolic disorders
  • Nausea & vomiting
  • Jaundice
  • Alopecia & urticaria
  • Loss of bone mineral density
  • Back & leg pains
  • Mood changes
  • Abdominal bloating & discomfort
Emergency Contraception / Post-Coital Contraception

Emergency Contraception / Post-Coital Contraception

Emergency contraception (EC) serves as a preventive measure for unintended pregnancies following unprotected sexual intercourse, condom rupture, missed pills, or sexual assault.
 It should be regarded as an emergency measure and not as a routine contraceptive method. EC does not terminate pregnancy. It encompasses hormonal, anti-progestin, and other methods.
Types
  1. Emergency Contraceptive Pills (ECP)
  2. Progesterone-Only Pills Regimen
When to Start?
EC should be initiated within 3 -5 days or 72 -120 hours, with earlier administration being more effective, following unprotected sexual intercourse. Intrauterine contraceptive devices (IUCDs) with copper introduction, within a maximum period of 5 days, can prevent conception after accidental unprotected sexual exposure.
Mechanism of Action
  • Prevents implantation
  • Failure rate is about 1%
  • Effectiveness is over 99% in preventing pregnancy
NOTE:
  • Post-coital contraception is solely for emergency use and is not effective if used regularly, except for copper IUCDs.
  • Women seeking emergency contraception should also be counselled about regular contraceptive options, promoting consistent and correct usage. 
  • Referral to relevant services, such as HIV counselling, testing, post-exposure prophylaxis (PEP), and treatment for sexually transmitted infections (STIs), is essential. 
  • Specialized services for sexual and gender-based violence should also be considered.
Basic Steps of Client Care for ECP
  1. Greet and introduce yourself.
  2. Maintain a respectful attitude.
  3. Ensure confidentiality of the discussion.
  4. Explain different ECP options, including usage, side effects, and the need for referral or follow-up.
  5. Encourage questions from the client.
  6. Discuss regular contraception options.
  7. Conduct counselling with active client involvement, reassurance of confidentiality, and in a private and supportive environment.
Examples of ECP:
  • Ethinyl estradiol 2.5mg b.d X 5/7
  • Conjugated oestrogen 15mg b.d X 5/7
  • Levonorgestrel 0.75mg stat and after 12 hours.
  • Mifepristone 600 mg stat – single dose.
  • Copper IUDs inserted within 5 days.
  • Others: Postinor, Microgynon, Eugynon.
Indications
  • Unprotected sexual intercourse
  • Rape survivors
  • Contraceptive method failure
  • Missed contraceptive pills or injections
  • Delay in taking pills
  • Sexual assault or first-time intercourse
Contraindications
  • Pregnancy
  • After 120 hours or 5 days of unprotected sex

Emergency Contraceptive

Dosage

Mechanism of Action

Lofemenal/Microgynon 4BD for 1 day (Low Dose COC)

4 tablets once

Inhibits ovulation, thickens cervical mucus

Eugynon (High Dose COC) 2BD for 1 day

2 tablets twice

Inhibits ovulation, thickens cervical mucus

Regular POP (Ovrette/Microval) at Recommended Dose

As recommended

Alters cervical mucus, inhibits sperm function

Levonorgestrel 2 stat

2 tablets at once

Delays ovulation, inhibits fertilization

Postinar 2 BD for 1 day

2 tablets twice

Alters cervical mucus, inhibits sperm function

Vikela/Levonelle-2/Norlevo Plan B

As recommended

Delays ovulation, inhibits fertilization

NON HORMONAL METHODS click here

Hormonal Contraceptive Methods Read More »

family planning

Family Planning

FAMILY PLANNING

Family planning is defined as the practice of having children by choice and not by chance.

Family planning is defined as a process through which individuals, couples make an informed choice on how many children to have, when to have and how often to have so that each child born is expected and properly catered for in all ways.

Family planning policy does not discriminate against men; they also have great roles to play for the success of care.

 

Unplanned pregnancies constitute major public health problems .The United Nations International Children’s Emergency Fund (UNICEF) estimates that over 800,000 women worldwide die each year as a result of pregnancy and pregnancy-related causes and an additional 15 million women are severely disabled by pregnancy. Countries in which women utilize contraception have lower birth rates and the lowest rates of maternal mortality. Every method of birth control prescribed is safer than pregnancy.

Benefits/Importances of Family Planning

Benefits/Importances of Family Planning

To the Mother

  1. Physical and Mental Recovery: Allows the mother to recover physically and mentally from the effects of previous pregnancies.
  2. Participation in Productive Activities: Offers ample time for a woman to actively participate in productive activities like farming and business.
  3. Enhanced Social Bondage: Increases social bondage between the mother and her baby.
  4. Reduced Maternal Mortality and Morbidity: Helps to reduce maternal mortality and morbidity due to pregnancy-related complications.
  5. Promotion of Marital Happiness: Promotes a happy marital life and enjoyment between the couples without fear of unwanted pregnancy.
  6. Preparation for Pregnancies: Family planning enables sexually active couples to prepare for pregnancies, optimizing fetal and maternal outcomes.
  7. Avoidance of Unwanted Pregnancies: Family planning helps avoid unwanted pregnancies, reducing complications associated with childbirth.
  8. Reduction of Maternal Complications: Reduces incidences of complications such as anaemia, poor maternal health, caesarean section, and maternal-child deaths.

To the Child

  1. Emotional and Social Support: The child receives adequate emotional and social support, contributing to emotional maturity and stability.
  2. Healthy Nutrition: Allows adequate nutrition for the baby in the womb, resulting in a healthy newborn.
  3. Reduced Malnutrition: Reduces malnutrition by preventing early weaning and ensuring enough food for the child.
  4. Fewer Infections: The child experiences fewer infections due to a strengthened immune system.
  5. Love and Care for the Child: Enables families to concentrate on other income-generating activities, ensuring love and care for the child.
  6. Ensuring Breastfeeding: Ensures adequate breastfeeding for the child, promoting child health.

To the Father

  1. Reduced Domestic Violence: Family planning reduces domestic violence in a home.
  2. Meeting Basic Needs: Enables the father to meet basic needs like food, medical care, etc.
  3. Cost of Living Reduction: Reduces the cost of living in a home, allowing the father to invest in productive activities.
  4. Preparation for Children: Assists couples in preparing for their children, ensuring they can provide love, care, and adequate support.
  5. Protection Against STIs: Some family planning methods are protective against HIV and other sexually transmitted infections (STIs).

To the Community

  1. Healthy and Productive Population: Family planning contributes to a healthy and productive population, enhancing community stability and harmony.
  2. Reduced Overcrowding: Reduces overcrowding, maximizing available land for productivity.
  3. Increased Socio-economic Development: Leads to increased socio-economic development within the community.
  4. Prevention of Negative Behaviours: Reduces the presence of negative characters in the community, as parents have adequate time to provide for their children.
  5. Improvement in Standards of Living: Family planning contributes to the improvement of standards of living within communities.

To the Nation

  1. Control of Population Growth: Reduces the rapid population growth rate at a national level.
  2. Reduced Dependence on Foreign Aids: Reduces the country’s dependence on foreign aids.
  3. Improved Government Services: Enables the government to provide better social services and infrastructures like roads and health facilities.
  4. Effective Resource Allocation: Facilitates easy budgeting for the people, as the number of resources to the population is manageable.
  5. Population Growth Prediction: Helps predict population growth, allowing for better planning and resource allocation.

Components of Family Planning Services

  1. Counselling: Counselling is an important need for the initiation and continuation of a family planning method. Service providers must undergo training to provide comprehensive counselling about all available family planning methods. Importantly, there should be no incentives or coercion to adopt family planning or a specific contraceptive method.
  2. Provision of Contraceptives: Contraceptives should be provided to clients based on approved method-specific guidelines. Service providers delivering these methods must undergo training to ensure competency in their provision. This ensures that clients receive family planning services that align with their needs and preferences.
  3. Follow-Up and Referral System: Clients choosing a family planning method should be informed about appropriate follow-up requirements. They should be encouraged to return to the service provider if they have any concerns or issues. The established referral system should be followed by service providers when making client referrals for further assistance.
  4. Record Keeping: Family planning service providers are required to maintain comprehensive records. These records help identify each client, specify the type of contraception provided, and note any special circumstances associated with its provision. Effective record-keeping contributes to the overall management and evaluation of family planning programs.
  5. Supervision: Supervision is an essential component of program evaluation. It ensures that client needs are met, and service delivery guidelines are adhered to. Supervisors act as team members who promote staff motivation, assist in problem-solving, and ensure the rights of both service providers and clients are observed throughout the delivery of family planning services.
  6. Logistics: Maintenance of an effective organization and supply system is crucial to prevent both understocking and overstocking of family planning commodities. Staff at service delivery points must adhere to proper procedures for the storage and handling of contraceptives and other supplies to maintain the quality of services provided. This ensures that family planning services are consistently available and accessible to those in need.

Characteristics of an Ideal Family Planning Method

  1. Effectiveness: A good family planning method should demonstrate high efficacy in preventing unintended pregnancies.
  2. Minimal Side Effects: The method should have minimal or no adverse effects on the health and well-being of the individual using it.
  3. Independence from Sexual Intercourse: The effectiveness of the method should not be relying on specific timing related to sexual activity.
  4. User Autonomy: The method should empower individuals to manage their reproductive health without requiring constant supervision or intervention from health professionals.
  5. Accessibility: It should be widely available, ensuring that individuals, regardless of geographic location or socioeconomic status, can access and utilize the method.
  6. Ease of Distribution: The method should have a distribution system that allows for easy accessibility, ensuring convenience for users.
  7. Affordability: Cost-effectiveness is crucial. A good family planning method should be affordable to a broad range of individuals, regardless of income.
  8. Cultural and Religious Acceptance: The method should be culturally and religiously sensitive, respecting diverse beliefs and practices.
  9. Reversibility: Individuals should have the option to discontinue the use of the method easily, with a quick return to fertility if desired.
  10. Educational Support: The method should come with educational resources to ensure users are well-informed about its proper use, benefits, and any potential risks.
  11. Long-Lasting: Ideally, the method should offer a duration of protection that aligns with the user’s family planning goals, whether short-term or long-term.
  12. Compatibility with Health: The method should not compromise overall health, and individuals with specific health conditions should have suitable alternatives available.
  13. Privacy and Confidentiality: The use of the method should be discreet, respecting the user’s privacy and maintaining confidentiality.
  14. Community and Partner Support: It should encourage open communication and support from partners, families, and communities.
  15. Research-Backed: The method’s safety and efficacy should be supported by scientific research and continuous monitoring.
  16. Inclusivity: The method should be inclusive, addressing the diverse needs of different populations, including adolescents, women, and men.

Classification of family planning methods  

 There are 2 broad types of family planning:

  • Natural or Traditional or Non-hormonal methods.
  • Artificial or Hormonal methods.
Natural/Traditional Methods

Method

Description

Calendar/Rhythm

Tracking menstrual cycles for fertility awareness. This is the only method approved in the Roman Catholic Church

Basal Body Temperature

Monitoring temperature variations during the menstrual cycle

Cervical Mucus Method

Observing changes in cervical mucus for fertility awareness

Lactation Amenorrhea Methods

Reliance on breastfeeding as a natural contraceptive during postpartum period

Abstinence

Refraining from sexual activity

Withdrawal/Coitus Interruptus

Withdrawing the penis before ejaculation

Artificial Methods
a) Barrier Methods:

Method

Description

Spermicides

Chemical substances that kill sperm

Condoms

Barrier devices worn over the penis or inserted into the vagina to prevent sperm from reaching the egg

Intrauterine Contraceptive Devices (IUCDs)

Devices placed inside the uterus to prevent pregnancy

Diaphragm

Shallow, dome-shaped cup placed over the cervix with spermicide

b) Hormonal Methods:

i. Oral Pills:

Method

Description

Combined Oral Contraceptives

Pills containing both oestrogen and progestin hormones

Progesterone-Only Pills

Pills containing only progestin hormone

Emergency Contraceptive Pills

Pills taken after unprotected sex to prevent pregnancy

ii. Implants:

Method

Description

Implanon (1 Rod Capsule)

Subdermal contraceptive rod

Jadelle (2 Rod Capsules)

Subdermal contraceptive rods

Norplant (6 Rod Capsules)

Subdermal contraceptive rods

iii. Injectable Contraceptives:

Method

Description

Depo Provera

Injectable contraceptive administered every three months

Injector Plan

Injectable contraceptive

Sayana Press

Injectable contraceptive

Noristrate

Injectable contraceptive

c) Permanent Methods:

Method

Description

Tubal Ligation (Tubectomy) for Women

Surgical procedure to block or cut the fallopian tubes

Vasectomy for Men

Surgical procedure to block the vas deferens in the male reproductive system

NON-HORMONAL FAMILY PLANNING METHODS

They are so-called because they are not manufactured with hormone basis. 

NATURAL NON-HORMONAL

These include:

Fertility awareness methods of family planning which involve identification of the fertile days of the menstrual cycle (when pregnancy is most likely to occur) and avoiding sexual intercourse (or using barrier methods ) during these days. The fertile days of the menstrual cycle can be determined by one of the following methods:

  • Calendar/Rhythm or Standard Days method, including cycle beads.
  • Basal Body Temperature
  • Cervical Mucus Method
  • Symptom- thermal ( a combination of cervical mucus and BBT methods).

Other Non Hormonal/traditional include;

  • Lactation Amenorrhea Methods
  • Periodic abstinence, abstaining from sexual intercourse during a woman’s fertile time.
  • Withdrawal/Coitus Interruptus

These methods, also known as fertility awareness methods, are based on understanding key physiological conditions related to reproduction, Such as;

Lifespan of Sperm and Ovum:

  • The lifespan of a sperm is approximately 3 – 5 days in the female reproductive tract.
  • The lifespan of an ovum (egg) is around 12- 24 hours.
  • Menstrual cycles can range between 23 to 35 days, but usually 28 days.
General Advantages:
  1. Safety and Lack of Side Effects: FAMs are generally considered safe with minimal or no side effects.
  2. Cost-Effectiveness: They are affordable, requiring no ongoing financial commitment.
  3. Acceptability Across Groups: Often acceptable to individuals and religious groups opposing modern contraceptive methods.
  4. Educational Benefits: These methods empower women with knowledge about their menstrual cycles and fertility.
  5. Couples’ Control: Couples have direct involvement and control over the method, promoting shared responsibility.
  6. Facilitates Pregnancy Planning: FAMs can be used for both family planning and to facilitate pregnancy when desired.
  7. Non-Invasive: FAMs do not involve invasive procedures or the use of synthetic substances.
  8. No Hormonal Interference: They do not interfere with hormonal balances, making them suitable for those sensitive to hormonal contraceptives.
  9. Long-Term Relevance: Useful throughout a woman’s reproductive life, fostering awareness and informed decision-making.
General Disadvantages:
  1. Learning Curve: Some methods require substantial education and learning before effective use.
  2. Record Keeping: Users must maintain accurate records over several menstrual cycles for proper reference.
  3. Challenges with Irregular Periods: Effectiveness diminishes when menstrual cycles are irregular.
  4. Behavioural Adjustments: Requires adjustments to sexual behaviors during fertile periods.
  5. Dependency on Partner Cooperation: Success depends on the level of cooperation between partners, which can be challenging.
  6. Risk of Error: Inconsistencies in recording or misinterpretation may lead to unintentional pregnancies.
  7. Limited Protection from STIs: FAMs provide no protection against sexually transmitted infections (STIs), including HIV/AIDS.
  8. Intensive Monitoring: The method demands continuous and intensive monitoring, which may be burdensome for some users.
Indications:

Fertility awareness methods are suitable for any woman or couple who is willing and committed to observing, recording, and interpreting fertility signs on a daily basis. This includes:

  • Women who find other contraceptive methods unacceptable due to reasons such as religious beliefs.
  • Women who cannot use certain contraceptive methods for health reasons.
  • Couples who are open to abstaining from sexual intercourse (or using condoms) for more extended periods during each menstrual cycle.
Contraindications:

While there are no medical conditions that worsen with the use of fertility awareness methods, some conditions may make their application more challenging. In the presence of these conditions, the method may either be postponed or require specialized counselling to ensure correct utilization. These conditions include:

  • Breastfeeding, especially until the return of menstruation.
  • Less than three postpartum menstrual cycles.
  • Irregular vaginal bleeding.
  • Abnormal vaginal discharge.
  • Diseases that influence body temperature.
barrier methods of family planning

Barrier methods

Barrier methods work by preventing the passage of sperm into the female genital tract. 

Female barrier methods include the diaphragm, cervical cap, FemCap, and the condom to both females and males  and Spermicides 

Condoms

A condom is a latex sheath put on an erect penis before coitus and worn during coitus.

Indications for Condom Use:
  1. Men Engaging in Family Planning: Condoms are an excellent choice for men who wish to actively participate in family planning.
  2. Sexually Active Adolescents: Adolescents engaging in sexual activity can benefit from the use of condoms as a reliable contraceptive and STI prevention method.
  3. Infrequent Sexual Intercourse: Couples who engage in sexual intercourse infrequently may find condoms to be a practical and effective choice.
  4. Casual Sexual Relationships: Individuals in casual sexual relationships where pregnancy is not desired can use condoms to prevent both unwanted pregnancies and sexually transmitted infections (STIs).
  5. Back-Up Contraception: Couples waiting for another contraceptive method to become effective can use condoms as a reliable back-up method.
  6. Temporary Contraception: Couples awaiting the initiation of another contraceptive method can use condoms as a temporary solution to prevent unintended pregnancies.
Mechanism of action of condom
  • Acts as a barrier, preventing sperm from entering the female genital tract.
  •  For condoms that are coated with spermicide, the spermicide immobilizes and kills sperm.
 Advantages of male and female condom
  • Effectiveness: When used correctly, condoms provide a high level of effectiveness (95 – 97%) in preventing pregnancy.
  • STI and HIV Prevention: Condoms are crucial in preventing the spread of sexually transmitted infections (STIs), including HIV.
  • Accessibility: Condoms are easy to obtain and can be distributed widely by Community Based Health Workers and the commercial sector.
  • Dual Purpose: They serve a dual purpose of family planning and STI/HIV prevention.
  • Potential Cervical Cancer Protection: There is a probable protective effect for women against the development of Intra-epithelial Neoplasm, i.e., cervical cancer.
  • Ease of Use: Condoms are easy to use, usually inexpensive, safe, effective, and portable.
  • Sexual Enhancement: They can help some men with premature ejaculation maintain an erection.
  • Convenient Short-Term Contraception: Condoms are convenient when short-term contraception is required.
  • Safety and Lack of Side Effects: Condoms are considered safe with minimal side effects.
Disadvantages:
  1. Allergic Reactions: Some individuals may experience allergic reactions to latex or other materials used in condoms.
  2. Sexual Enjoyment: Condoms may reduce the quality of sex for some individuals.
  3. Male Partner Cooperation: Requires cooperation from the male partner for effective use.
  4. Vulnerability to Damage: Can be damaged by exposure to oil-based lubricants, heat, humidity, or light.
  5. Decreased Sensitivity: May decrease sensitivity for men, impacting the enjoyment of intercourse.
  6. Slipping or Tearing: There is a small possibility of slipping or tearing during sexual intercourse.
  7. Storage Requirements: Condoms can deteriorate if not properly stored, e.g., in too much heat, sunlight, or humidity.
  8. Erection Challenges: Some men may struggle to maintain an erection with a condom on.

 

Spermicides

Vaginal spermicides come in the form of foam, cream, jelly, tablet or suppository and are inserted into the vagina just before sexual intercourse to prevent pregnancy.

Mechanism of action of spermicide
  • Inactivates and kills sperm;
  • Blocks the path of sperm to the uterus.
Effectiveness of spermicides
  • Fairly effective, depending on the user (79-97%);
  • If used with condom, effectiveness is 99%;
  • Effectiveness lasts only 30 to 40 minutes after insertion.
Advantages of spermicides 
  • Over-the-Counter Availability: Spermicides can be obtained without a prescription, making them easily accessible.
  • Immediate Protection: Spermicides can be kept available for immediate use whenever needed, providing on-the-spot protection.
  • Additional Lubrication: Spermicides can offer additional lubrication during intercourse, enhancing comfort.
  • Enhanced Effectiveness with Condoms: When used in conjunction with condoms, spermicides can increase their overall effectiveness in preventing pregnancy.
  • Back-Up Option for Contraceptive Delays: Spermicides serve as a simple back-up option for women waiting to start oral contraceptives or have an IUD inserted. They are also useful for women who forget multiple contraceptive pills or run out of pills.
  • Emergency Use: In cases of a condom breakage, spermicides can be applied quickly as an emergency measure.
Disadvantages and Side Effects:
  1. Sexual Interruption: Some forms of spermicides, such as suppositories or foaming tablets, may require a waiting period of 10 minutes for dissolving before becoming effective, potentially interrupting sexual intercourse.
  2. Application Before Each Act: Spermicides must be used before each act of sexual intercourse, requiring consistent and timely application.
  3. Post-Intercourse Wetness: Spermicides may cause increased vaginal wetness for several hours after intercourse.
  4. Sensitivity or Allergic Reactions: A few women may be sensitive or allergic to spermicides, leading to irritation and discomfort, especially with frequent use.
  5. Lower Effectiveness Rates: Spermicides are generally less effective in preventing pregnancy compared to more modern methods such as IUDs and hormonal contraceptives.
  6. Risk of Candida Vaginitis: Some women may develop Candida Vaginitis as a side effect of using spermicides.
  7. Increased Infections: Spermicides can potentially increase the risk of urinary and yeast tract infections in women.
  8. Messiness and Discomfort: Spermicides can be messy and may cause mild discomfort or minor allergic reactions in some individuals.
Vaginal Diaphragm 

Diaphragm is a mechanical barrier placed between the vagina and cervical canal .They are designed to fit in the cul-de-sac and cover the cervix.

The contraceptive jelly or creams should be placed on the cervical side of the diaphragm before insertion because the device itself is ineffective. Again, this medication serves as lubricant for insertion of a device.

The device is inserted 6 hours prior to intercourse and should be left in place 6-24 hours after intercourse 

Advantages
  • Easy to use
  • It offers some protection against STDs 
  • Well used, it protects from conception with the failure rate as low as 6% of women per year of exposure.
Disadvantages
  • It require fitting by a well trained medical professional
  • Fitting may loose during intercourse
  • It cannot be effective in women with significant pelvic relaxation,a sharply retroverted or anteverted uterus or shortened vagina.
Side effects
  • Vagina irritation
  • Increased risk of urinary tract infection due to pressure of the rim against the urethra and alterations in the composition of vaginal normal flora.

cervical cap

Cervical Cap (CAP)

Cervical caps are small cuplike diaphragms placed over the cervix that are held in place by suction.

To provide a successful barrier against the sperms, they must be tightly fit over the cervix therefore, individualization is essential because of variability in cervical size.

It has few advantages because;

  • Unpleasant odour often develops after approximately 1 day of use 
  • Dislodgment (as in diaphragm) 
  • The cup should remain in place 1 or 2 days before intercourse and should be left in place for 8 -48 hours after intercourse.
Intrauterine Contraceptive Devices (IUCDs):

Intrauterine Contraceptive Devices (IUCDs):

Intrauterine Contraceptive Devices, or IUCDs, are flexible plastic devices inserted into a woman’s uterus to prevent pregnancy, usually renewed every 3-5 years. These devices are often made of copper impregnated with gold, silver, and stainless steel.

Various Design Types:

Copper T 380A:

Intrauterine Contraceptive Devices, Copper T Model Tcu 380a | Mother's Garage

  • T-shaped device with copper on the stem and arms of the T.
  • Duration of effectiveness: 10 years.
  • Shelf life: 7 years.

Multiload 375:

  • Lasts for 5 years.
Mechanism of Action:
  • Renders the endometrium unsuitable for the implantation of a fertilized ovum.
  • Copper emits metal ions with spermicidal properties.
Advantages:
  1. Very Effective: Provides high efficacy, ranging from 99-99.5%.
  2. Immediate Effectiveness: Works instantly upon insertion.
  3. Long-Term Method: Offers a long duration of effectiveness.
  4. No Interference with Intercourse: Does not interfere with sexual activity.
  5. Quick Return to Fertility: Fertility returns immediately upon removal.
  6. Few Side Effects: Mild side effects compared to other methods.
  7. No Client Supplies Needed: Does not require additional supplies by the client.
Disadvantages and Side Effects:
  1. Mild Cramps: May experience mild cramps in the first 3-5 days post-insertion.
  2. Menstrual Changes: Longer and heavier menstrual blood loss in the initial 3 months.
  3. Increased Cramping Pain: Increased cramping pain during menstruation.
  4. Provider-Dependent: Insertion and removal depend on a healthcare provider.
  5. String Checks: Need to check for strings after menstruation.
  6. Increased Bleeding: May experience increased bleeding in the first few months.
  7. Spontaneous Expulsion: There is a possibility of spontaneous expulsion, especially in the first 6 months.
  8. Uterine Perforation: Very rare, occurring in 1 out of 1000 cases.
  9. Pelvic Inflammatory Diseases (PID): May increase the risk of PID.
  10. Pain and Discomfort: Pain, especially with larger devices.
  11. Menstrual Changes: Increased menstrual loss; intermenstrual spotting may occur.
  12. Expulsion Risk: Higher risk of expulsion during the first 6 months, especially during menses.
  13. Translocation Risk: Possibility of translocation to the peritoneal cavity or broad ligament.
  14. Pregnancy Risks: May increase the risk of pregnancy and ectopic pregnancy.
  15. No Protection Against STIs/HIV or Cancers: Does not provide protection against STIs, HIV, ovarian, endometrial, or cervical cancers.

IUCDs users who develop PID should be treated with the IUCD in place if they want to continue using it. If no improvement within 72 hours, remove it.

When to Insert an IUCD:
  • During or immediately after menstruation.
  • At a postnatal examination.
  • Immediately following delivery or any time within 46 hours after childbirth.
  • After termination of a pregnancy.
  • During the caesarean section.
iucd reminder
Insertion of an Intrauterine Contraceptive Device (IUD): Procedure
Insertion of an Intrauterine Contraceptive Device (IUD): Procedure
  1. Aseptic Technique: Implement aseptic techniques, including hand washing and wearing sterile gloves.
  2. Device Preparation: Place the IUD in an introducer and plunger.
  3. Straightening: The device straightens inside the introducer.
  4. Visualization of Cervix: Insert a Cusco’s vaginal speculum to clearly visualize the cervix.
  5. Cleaning: Clean the cervix and vaginal vault with sterile swabs.
  6. Uterine Measurement: Measure the length of the uterus with a uterine sounder.
  7. Introducer Insertion: Insert the introducer into the uterus through the cervix.
  8. Plunger Action: Gently push the plunger to force the device out of the introducer into the uterus.
  9. Device Lodging: In the uterus, the device resumes its original shape and lodges against the uterine walls.
  10. String Placement: The two small strings attached to the device hang down through the cervical opening.
  11. String Cutting: Cut the string with scissors to reduce the size, leaving approximately 3cm hanging out of the cervix.
  12. Post-Insertion: After insertion, the client rests and can remain on the procedure table until ready to get dressed.
  13. String Check: The woman can feel the strings in the vagina to ensure the device is in position.
Post-Insertion Instructions:
  1. Backup Use: Use backup contraception for a minimum of 3 days.
  2. Mild Pain: Slight pain may occur but usually does not require medication.
  3. String Check: Check the string during menstruation to ensure it is in place; return if removed or dislodged.
  4. Immediate Return for Discomfort: Return to the facility immediately in case of any discomfort.
Removing the IUDs:
  1. Discussion with Client: Discuss side effects with the client and weigh the option of managing the problem or immediate removal.
  2. Timing for Removal: Removal is simple and can be done any time of the month, with monthly bleeding making it easier.
Removal Procedure:
  • Explain the removal procedure to the client.
  • Ensure privacy and confidentiality.
  • Visualize cervix and UID strings with a vaginal speculum.
  • Clean cervix and vagina with antiseptic solution.
  • Instruct the client to relax and take slow breaths.
  • Gently pull the IUD strings until it comes completely out of the cervix.
  • Show the removed IUD to the client for assurance.
  • Thank the client for cooperating throughout the procedure.
Reasons for Missed Threads in IUDs:
  1. Coiled thread inside.
  2. Thread torn through.
  3. Device expelled outside unnoticed by the client.
  4. Device perforated the uterine wall and is lying in the peritoneal cavity.
  5. Device pulled by the growing uterus in pregnancy.
Methods of Identification:
  • History taking (exclude pregnancy).
  • Ultrasonography.
  • Hysterectomy.
  • Hysteroscopy.
  • Straight x-ray.
Contraindications:
  • Pregnant women or those suspected to be.
  • Women with menorrhagia or abnormal bleeding.
  • Women with PID, current, or in the past 3 months.
  • Purulent per vaginal discharge, gonococcal, or chlamydial infection.
  • Malignant trophoblastic disease.
  • Pelvic tuberculosis.
  • Women with genital tract cancer.

Surgical methods

Male Vasectomy

Male vasectomy  is a permanent operation in the male where a segment of vas deferens of both sides are resected and the cut ends are ligated.

Vasectomy is a voluntary surgical procedure for permanently terminating fertility in men.

Mode of Action

Blocking the vas deferens (ejaculatory duct) to prevent sperm presence in the ejaculate.

Indications

Men certain about achieving their desired family size, seeking a highly effective permanent contraceptive method, or whose partners face unacceptable pregnancy risks.

Contraindications

Vasectomy should be delayed in the case of local or systemic infections.

Benefits

  • Highly effective
  • Permanent
  • Simple surgery under local anesthesia
  • No further expense or concerns about conception
  • No long-term side effects
  • Does not interfere with sexual intercourse

Side Effects

  • Wound infection
  • Scrotal hematoma
  • Granuloma
  • Excessive swelling
  • Pain at incision sites

Explain to Clients

  • When to come back for follow-up visits
  • Common side effects of the method
  • What to do if there are changes in menstrual periods
  • How soon the method is effective
  • How to protect against STIs
  • How to care for the wound postoperatively

General Instructions to Clients Using Permanent Methods

  • Inform about follow-up visit schedules
  • Explain common side effects in simple language
  • Share warning signs or possible problems requiring medical attention
  • Guide regarding changes in menstrual periods
  • Emphasize the method’s lack of protection against HIV/AIDS and STIs, advocating for backup methods like condoms
  • Provide instructions on wound care postoperatively

 

Female -Tubal ligation

Female Tubal Ligation  is the interruption of continuity of fallopian tubes. 

Tubal ligation is a voluntary surgical procedure for permanently terminating fertility in women. It can be done by a mini-operation (laparatomy/laparoscopy).

Mode of Action

Blocking fallopian tubes by cutting, cautery, rings, or clips, preventing sperms from reaching the ovum.

Indications

Women certain about achieving desired family size, seeking a highly effective permanent contraceptive method, or facing unacceptable pregnancy risks. Family planning should be delayed in specific cases, such as pregnancy, postpartum complications, or certain health conditions.

Timing of the Tubal Ligation

  • Immediately after childbirth or within the first seven days (if chosen in advance)
  • Six weeks or more after childbirth
  • Immediately after abortion (if chosen in advance)
  • Any time, provided pregnancy is ruled out (between seven days and six weeks postpartum)
  • During cesarean section

Benefits

  • Highly effective
  • Immediate effectiveness
  • Permanent
  • Simple surgery under local anesthesia
  • No contraception-related concerns
  • No long-term side effects
  • Does not interfere with sexual intercourse

Disadvantage

  • Does not protect against STIs/AIDS
  • Irreversible

Side Effects

  • Wound infection
  • Post-operative fever
  • Rare bladder and intestinal injuries
  • Hematoma
  • Pain at the incision site
  • Superficial bleeding

Challenges associated with Tubal Ligation

  • Desire for more children after the operation
  • Excessive desire for reversal
  • Disagreement to sign the informed consent form
  • External pressures
  • Depression
  • Marital problems

General Complications

  • Obesity
  • Psychological upset
  • Chronic pelvic pain
  • Congestive dysmenorrhea
  • Menstrual abnormalities
General Advantages 
  • Simple Surgical Procedure: The procedure is straightforward and uncomplicated.
  • Out-Patient Procedure: It can be performed as an outpatient procedure, avoiding the need for a hospital stay.
  • Few Complications: The surgery has a low incidence of complications.
  • Reversal Anastomosis: Reversal procedures, known as anastomosis, have a 50% chance of success.
  • Highly Effective: The failure rate is minimal, at 0.15%.
  • No Interference with Sexual Life: Vasectomy does not interfere with the sexual life of the individual.
  • Performed Under Anesthesia: The operation is conducted under anaesthesia, ensuring a painless experience.
General Disadvantages
  • Lack of Protection Against HIV and STDs: Vasectomy does not provide protection against HIV and sexually transmitted diseases (STDs).
  • Costly Reversal: Reversal procedures can be expensive.
  • Consent Requirements: Obtaining consent may involve important family members in decision-making.
  • Risk of Injury to Internal Organs: There is a potential risk of injury to internal organs during the procedure.
  • Anaesthesia Risks: The use of anaesthesia carries inherent risks.
  • Post-Surgical Complications: Possible complications include infection and bleeding.
  • Additional Contraception Required: Additional contraception is needed for about 2-3 months until semen becomes free of sperm.
  • Potential for Impotency: There is a rare risk of impotence.
  • Frigidity: Frigidity, especially sexual unresponsiveness in women and an inability to achieve orgasm during intercourse, may occur.
  • Stigma: Societal stigma may be associated with the decision to undergo vasectomy.

Important points to think about before the use of a permanent contraception

Because male and female sterilization are permanent methods of contraception, thorough counselling procedures must be followed to ensure that the client fully understands his or her choice and to minimize chances of regret. 

  • Counselling: Thorough counselling sessions to ensure informed decision-making.
  • Reasons for Choosing Permanent Methods: Understand and evaluate the motivating factors behind the choice of permanent contraception.
  • Screening for Risk Indicators for Regret: Identify potential risk indicators such as:
  1. Young age
  2. Low parity
  3. Single-parent status
  4. Marital instability
  • Completion of Informed Consent Process: Ensure the individual fully comprehends the implications and consequences of the procedure.
  • Details of the Procedure: Provide comprehensive information about the surgical process involved in permanent contraception.
  • Possibility of Failure: Acknowledge the rare but existing possibility of the procedure not being 100% effective.
  • Positive Pregnancy Test Result: In case of a positive pregnancy test post-tubal ligation, rule out ectopic pregnancy.
  • Condom Use for STD Protection: Emphasize the continued need for condom use to safeguard against sexually transmitted diseases.

HORMONAL CONTRACEPTIVES (click here)

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Menstruation Disorders

Menstruation Disorders

MENSTRUATION DISORDERS

Menstrual disorders are abnormalities in menstruation during reproductive life.

Common disorders associated with menstruation are as follows;

  1. Amenorrhoea
  2. Dysmenorrhoea
  3. Menorrhagia
  4. Metrorrhagia
  5. Polymenorrhagia (epimenorrhoea)
  6. Dysfunctional uterine bleeding
  7. Endometriosis

MENSTRUATION

Menstruation is defined as the periodic physiological discharge of blood from the uterus through the vagina.

The normal period of menstruation usually lasts 2-7 days with a total blood loss of

10 – 80 ml is considered normal.

 

The normal menstruation cycle has a length of 21-35 days.

 

THE MENSTRUATION CYCLE 

The menstrual cycle is a sequence of physiological events that occur periodically (on average every 28 days) from puberty until menopause. 

The events occur under the influence of hormones produced by pituitary glands(Follicle Stimulating Hormone – FSH and Luteinizing hormone – LH)  and the ovaries (Progesterone & Oestrogen).

Menstrual Cycle nurses revision uganda

The menstrual cycle is divided into 3 phases namely:

  • Follicular phase
  • Ovulatory phase
  • Luteal phase
Follicular phase (proliferative phase)

This is marked by the beginning of menstruation.

  • Bleeding results from the decrease in the levels of oestrogen and progesterone from the luteal phase.
  • The reduction in oestrogen and progesterone leads to the shedding of the endometrium.
  • During this phase, Follicle stimulating hormone (FSH) from the anterior lobe of the pituitary gland rises to stimulate the growth of several ovarian follicles with each follicle containing an ovum.
  • Later, FSH levels reduce which leads to only one dominant follicle developing.
  • The dominant follicle then produces oestrogen hormone.
The Ovulatory phase

This begins with a sharp rise in the levels of LH and FSH.

  • The luteinizing hormone stimulates ovulation at about the 14th day of the menstrual cycle (between the 7th – 21st day depending on the cycle length).
  • The oestrogen levels reach a peak and progesterone levels begin to rise once the ovum has been released.
  • What is left behind of the dominant follicle after ovum release is referred to as the corpus luteum and it is the one that produces progesterone.
Luteal phase (Secretory phase)

Luteal phase usually occurs after ovulation.

  • During this phase, the endometrium begins to thicken in preparation for nourishment of an embryo in case fertilization takes place.
  • If fertilization doesn’t occur, the increasing levels of oestrogen and progesterone decrease the production of both luteinizing and follicle stimulating hormones.
  • Since the maintenance of corpus luteum depends on the luteinizing hormone, a decrease in its production causes the corpus luteum to atrophy leading to a reduction in the production of oestrogen and progesterone.
  • The thickened uterine lining then begins to slog off and menstruation begins.
  • And the follicular phase begins to complete the menstrual cycle.
Factors that may interfere with menstrual cycle thereby causing menstrual disorders

Factors that may interfere with menstrual cycle thereby causing menstrual disorders

1. Physical conditions such as trauma, tumors, and diseases of the glands, ovaries, and uterus can impact the normal functioning of the reproductive system, potentially causing menstrual irregularities.

2. Debilitating diseases such as tuberculosis (TB) and HIV/AIDS can affect overall health, potentially disrupting the menstrual cycle.

3. Malnutrition can lead to hormonal imbalances, affecting the regularity of menstrual periods.

4. Dysfunctional uterine bleeding, which involves abnormal bleeding patterns, can be a contributing factor to menstrual disorders.

5. Age plays a role, as menstruation can be irregular in young girls after menarche (the first occurrence of menstruation).

6. Pregnancy naturally alters the menstrual cycle, and complications during pregnancy can lead to menstrual irregularities.

7. Certain drugs and exposure to X-rays, especially radiography, can impact hormone levels and disrupt the menstrual cycle.

8. Menopause, with its gradual onset, marks the end of the reproductive years and can cause significant changes in menstrual patterns.

9. The use of intrauterine contraceptives (IUCs) can also affect menstrual regularity in some women.

10. Extreme stress and worries, such as those experienced during times of war or conflict, can disrupt hormonal balance and impact the menstrual cycle.

11. Anxiety and mental health conditions can influence hormone levels, potentially leading to menstrual irregularities.

12. Environmental changes, such as transitioning to a new school or significant shifts in routine, can impact stress levels and, in turn, affect the menstrual cycle.

13. The stage of adolescence is a period of significant hormonal changes, and this transition can lead to menstrual irregularities as the body adjusts to these fluctuations.

AMENORRHOEA

AMENORRHOEA

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