NSG210 Durham Ch. 18: Well Women’s Health

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 18, pp. 595-613 (textbooks/DURHAM_OB_CH18.pdf, also in textbooks/exam03/). Week 10 reading; on Exam 3. Lecture slides: raw/nsg210_wk10_OBLecture4.md (Menopause section). Gynecologic disorders are in nsg210-durham-ch19-alterations-womens-health; osteoporosis in med-surg is in nsg210-hinkle-ch36-musculoskeletal-disorders.

Learning Outcomes

1. Identify factors that put women at risk for adverse health conditions.
2. Discuss preventive screenings across the life span.
3. Describe how diet, exercise and smoking affect women’s health.
4. Discuss the effects of obesity.
5. Discuss physical and emotional changes of perimenopause and menopause.
6. Discuss screening for intimate partner violence.
7. Describe the health care needs of LGBTQ women and their barriers to care.
8. Develop a health promotion plan for an older adult based on normal aging.

Nursing diagnoses: risk for adverse health conditions (knowledge deficit about health promotion); knowledge deficit about menopause; risk for disturbed sleep (night sweats); risk for falls (impaired balance).

I. Health Promotion and Risk Reduction

• Health promotion (WHO): “the process of enabling people to increase control over, and to improve, their health”
• Leading causes of death in US women: heart disease, cancer, unintentional injuries, chronic lower respiratory disease, stroke, Alzheimer disease, diabetes, kidney disease, influenza and pneumonia, suicide
• Ages 15 to 19: accidents, suicide and homicide lead; heart disease and cancer dominate in older groups (Table 18-1)

Critical Component, warning signs in women:

• Heart attack (often different from men): unusually heavy chest pressure; sharp upper body pain in the neck, back and jaw; severe shortness of breath; cold sweats (not menopausal hot flashes); unusual fatigue; unfamiliar dizziness; unexplained nausea or vomiting
• Stroke: sudden numbness or weakness of face, arm or leg (especially one side); sudden vision trouble; sudden trouble walking, dizziness, loss of balance; severe headache with no known cause

Risk reduction actions:

• Diet rich in vegetables, fruits, whole grains, fiber, low-fat dairy and fish; low in saturated fat and sodium (MyPlate); 3 servings of calcium-rich foods (yogurt, milk, cheese, broccoli, kale, Chinese cabbage) or a supplement
• At least 150 minutes a week of moderate activity (brisk walking, swimming, biking, dancing); weight-bearing exercise slows bone loss and improves strength and balance; lowers risk of heart disease, falls, depression, type 2 diabetes, colon and breast cancer
• Immunizations (age 19 and older): influenza yearly; COVID-19; PPSV23 at 65 or older; PCV13 if immunocompromised, CSF leak or cochlear implant; zoster (shingles) at 50 or older; Tdap if not received as a teen, then Td every 10 years; MMR 1 dose for ages 19 to 59 (not over 60); varicella 2 doses 4 to 8 weeks apart if not immune; HPV for ages 19 to 26
• Healthy weight (obesity: 40.3% of women 20 to 39, 46.4% at 40 to 59, 42.2% at 60 and older)
• Limit UV exposure: protective clothing, hat, sunglasses, SPF 15 or greater, avoid sun 10 a.m. to 2 p.m. (skin cancer, liver spots, actinic keratoses, premature aging)
• No smoking or secondhand smoke (leading cause of heart disease and cancer; lung cancer is a leading cancer killer; in pregnancy: preterm birth, LBW, miscarriage, fetal lung and brain damage); avoid e-cigarettes (THC vapes linked to lung injury)
• Alcohol: moderation for women is ONE drink a day. In pregnancy: preterm birth, fetal alcohol spectrum disorder, birth defects, LBW, miscarriage, stillbirth. Excess raises risk of infertility, liver disease, diabetes, memory loss, several cancers including breast, heart damage; binge drinking (12% of women) raises risk of sexual assault
• Injury prevention: seat belts, speed limits, no drinking and driving; falls are the leading cause of injury death and disability at 65 and older (strength and balance exercise, home modification, shoes, medication review for dizziness)
• Sexual health (WHO): physical, emotional, mental and social well-being related to sexuality, free of coercion and violence; discuss concerns (low desire, IPV, dyspareunia) with providers; prevent STIs and unintended pregnancy; communicate with partner

Critical Component, HPV: the most common sexually transmitted virus in the US; main cause of cervical cancer and genital warts; also vulvar, vaginal, penile, anal and oropharyngeal cancers.

HPV vaccine (Gardasil, Gardasil 9): prevents those cancers and genital warts; IM; injection site reaction. Started before age 15: 2 doses (second at 6 to 12 months). Started at 15 or older: 3 doses (at 0, 1 to 2, and 6 months). Teach: complete the series; still need routine cervical screening; does NOT prevent other STIs.

Critical Component, obesity: Class 1 BMI 30 to 35; Class 2 BMI 35 to 40; Class 3 BMI over 40. Risks: hypertension, coronary heart disease, type 2 diabetes, stroke, cholecystitis, sleep apnea, cancers (endometrial, breast, colon, kidney, gallbladder, liver), osteoarthritis of knee, hip and back, abnormal menses and infertility, high-risk pregnancy, miscarriage, macrosomia.

II. Routine Screening (Table 18-2)

All pregnant women are tested for various STIs.

Breast cancer screening:

• Mammograms for average risk (no personal or family history, no BRCA1 or BRCA2 mutation); MRI PLUS mammogram for high risk (BRCA mutation or lifetime risk of 20% or more, calculated with the cancer.gov tool)
• Monthly breast self-exam is NO LONGER recommended, but women should know and report breast changes (Fig. 18-3): lump, skin dimpling, skin color or texture change, nipple retraction, clear or bloody nipple discharge

Critical Component, screening mammogram: low-dose x-ray with the breast compressed between plates (feels squeezed or pinched); compared with prior films for lumps, abscesses, calcifications; abnormal results need diagnostic mammogram, ultrasound, MRI or biopsy. Tell the facility about implants. NO deodorant, perfume, lotion or powder under the arms or on the breasts that day (they cast shadows).

Cervical cancer screening (American Cancer Society): stop after 65 if no precancer in the previous 10 years; stop after total hysterectomy unless done for cervical precancer or cancer; HPV-vaccinated women still follow screening guidelines.

III. Intimate Partner Violence (IPV)

• Abuse or aggression in a romantic relationship: physical, sexual, psychological aggression, stalking; 1 in 4 women in her lifetime; all races, ages, income levels, religions, heterosexual and same-sex couples
• Use a VALIDATED screening tool
• Screen in PRIVATE at annual exams, the first prenatal visit, EACH TRIMESTER and the postpartum checkup
• Ask whether she feels safe at home and in her relationship
• Know your state’s mandatory reporting laws and available resources
• Prevention: teach healthy relationship skills in adolescence

Clinical Judgment, trauma-informed care:

• More than half of women experience at least one traumatic event (IPV, sexual assault, military sexual trauma, violence based on race or orientation, childhood neglect, combat, disasters, community violence, refugee status, family separation); higher in families with substance use, poverty, homelessness and military families
• Trauma can cause powerlessness, fear, hopelessness, shame, guilt, rage and isolation, and affects attitudes toward care
• The four Rs: REALIZE the widespread effect of trauma; RECOGNIZE signs in patients and families; RESPOND by integrating trauma knowledge into care; RESIST RE-TRAUMATIZATION
• Strategies: safe physical and emotional environment; compassionate, nonjudgmental interactions; ask permission before touching; describe before and during exams; let her shift rather than remove clothing; stop the exam whenever she asks

IV. Reproductive Changes

Puberty:

• Usually starts between ages 8 and 13 with a growth spurt (feet first, face last)
• Hypothalamic GnRH stimulates anterior pituitary gonadotropins, which stimulate ovarian ESTROGEN
• Estrogen drives secondary sex characteristics: breast development (ducts, nipple erection), axillary and pubic hair, wider hips
• Menarche 2 to 2.5 years after puberty begins; puberty is complete when cycles are regular

Menopause:

• Permanent cessation of menses, usually between 40 and 58
• PERIMENOPAUSE: usually in the forties, symptoms for 4 to 8 years, irregular cycles; she CAN still get pregnant
• MENOPAUSE: 12 MONTHS after the last menstrual period; average age 51 in the US (range 45 to 55)
• Postmenopause: the time after menopause
• Ova decline in quality and number from the late thirties, lowering estrogen and progesterone; symptoms range from none to severe

Signs and symptoms:

• Irregular periods (longer or shorter cycles, heavier or lighter flow); anovulatory cycles; no longer fertile after menopause
• HOT FLASHES (most common): vasomotor dilation of skin vessels; sudden warmth spreading over upper body and face, red neck and face, sweating, irritability, exhaustion. Triggers: warm rooms, alcohol, hot or spicy foods, caffeine, stress
• NIGHT SWEATS (hot flashes during sleep; soaked bed linens)
• Sleep disturbance
• Sexual dysfunction: decreased desire and arousal; VAGINAL ATROPHY (thinner, drier tissue); dyspareunia
• Psychological: mood swings, irritability, anxiety, lethargy, low energy, panic attacks, forgetfulness, trouble coping, depression
• Thinning hair, food cravings, dry skin and loss of elasticity, weight gain at waist and hips, palpitations

Critical Component, menopause and sexual well-being: declining estrogen thins vaginal tissue and reduces secretions, causing dryness and dyspareunia; sleep loss, hot flashes and mood changes also affect sexual well-being.

Treatment approaches:

• Lifestyle: 8 hours of sleep, balanced diet, weight loss if needed, exercise, avoid caffeine, alcohol and smoking
• Alternative: herbal supplements, acupuncture, biofeedback, hypnosis
• Menopausal hormone therapy (MHT): research is conflicting, so she should discuss risks and benefits with her provider
  • ESTROGEN ALONE if she has NO UTERUS (oral, transdermal, vaginal)
  • ESTROGEN PLUS PROGESTERONE if she HAS A UTERUS (progesterone reduces the risk of ENDOMETRIAL CANCER); oral, transdermal, or progesterone IUD
  • Start low and increase as needed; transdermal preferred; lowest effective dose; reevaluate yearly
  • Estrogen CONTRAINDICATIONS: unexplained vaginal bleeding, liver disease, gallbladder disease, clotting disorders, pulmonary embolism, untreated hypertension, uterine cancer, breast cancer

Specific discomforts:

• Hot flashes: avoid triggers (alcohol, hot drinks, spicy food, warm rooms, smoking); dress in layers; avoid wool and synthetics; fans. Low-dose antidepressants (fluoxetine), gabapentin and clonidine reduce hot flashes
• Night sweats: cotton nightwear and linens, cool room, fan, cool shower before bed
• Sleep: regular bedtime routine, no TV or computer in bed, dark quiet cool room, loose breathable clothing, phone in another room, early dinner, no alcohol or caffeine near bedtime
• Vaginal dryness: WATER-BASED lubricants, vaginal moisturizers, estrogen vaginal cream; soy flour and flaxseed may help
• Psychological: daily exercise, limit alcohol, natural light or light box for seasonal affective disorder; MHT; psychotherapy and antidepressants or anxiolytics if needed

Nursing: patient education. Menopause is a natural phase; review her symptoms and relief methods; discuss sexual well-being; teach lifestyle, medication and alternative options.

V. Osteoporosis

• Bone resorbed faster than it is formed; bone mass decreases after 35 and loss ACCELERATES in the first 2 to 3 years after menopause; 80% of Americans with osteoporosis are women; vertebral and hip fractures
• DXA scan (hip, spine, forearm) gives a T score compared with peak density for sex and race:
  • T score of -2.5 or below: OSTEOPOROSIS
  • T score -1 to -2.5: OSTEOPENIA (at risk)
• Signs: back pain from fractured or collapsed vertebrae, loss of height, stooped posture, fractures
• Risk factors: White women; thin, small-boned; family history of hip fracture; smoking; inactivity; low calcium and vitamin D (vitamin D aids absorption); 3 or more drinks a day; corticosteroids more than 3 months, aromatase inhibitors, proton pump inhibitors; BMI 20 or less (under 127 lb); eating disorders; weight loss surgery

Risk reduction:

• Calcium: 1,300 mg/day ages 9 to 18; 1,000 mg/day ages 19 to 50; 1,200 mg/day at 51 and older. Vitamin D 600 to 1,000 IU/day at 50 and older. Start building bone matrix around age 9
• Calcium-rich foods: canned sardines (3 oz) 325 mg; plain low-fat yogurt (4 oz) 310 mg; cheddar (1.5 oz) 307 mg; fortified orange juice, 2% milk, or almond, rice or soy milk (8 oz) 300 mg; salmon (3 oz) 181 mg; frozen kale (8 oz) 180 mg
• Weight-bearing exercise (walking, jogging, dancing, weight lifting) 3 to 4 times a week
• No smoking or secondhand smoke; limit alcohol (heavy drinking lowers bone density)

ACOG recommends drug therapy for: a fragility (low-impact) fracture; T score -2.5 or lower; or risk factors with T score below -1.5.

Bisphosphonates (inhibit bone resorption; side effects musculoskeletal aches, GI irritation, ESOPHAGEAL ULCERATION):

• Alendronate (Fosamax): prevention 5 mg/day or 35 mg/week; treatment 10 mg/day or 70 mg/week
• Ibandronate (Boniva): 150 mg/month orally, or 3 mg IV every 3 months
• Risedronate (Actonel): 5 mg/day
• Zoledronate (Reclast): IV 5 mg every 2 years (prevention) or yearly (treatment)

Patient Education, alendronate:

• Take in the MORNING on an EMPTY stomach at least 30 MINUTES before breakfast
• With at least 8 OUNCES of PLAIN WATER (not juice, coffee or tea, which reduce absorption)
• Sitting or standing; stay UPRIGHT at least 30 MINUTES (prevents esophageal reflux and ulceration)

Other drugs:

• Denosumab (Prolia): for those who cannot take bisphosphonates (reduced kidney function); 60 mg subcutaneously every 6 MONTHS; reduces vertebral and hip fractures; side effects cystitis, hypocalcemia, hypophosphatemia, high cholesterol, back and limb pain, dyspnea; encourage routine DENTAL care (risk of OSTEONECROSIS OF THE JAW)
• Teriparatide (Forteo): postmenopausal women at high fracture risk or on long-term glucocorticoids; 20 mcg subcutaneously DAILY
• Raloxifene (Evista), a selective estrogen-receptor modulator: estrogen-like effects on bone; 60 mg/day; adverse effects VENOUS THROMBOEMBOLISM, leg cramps, death from stroke
• Hormone therapy: conjugated estrogen plus medroxyprogesterone (Premphase) for women WITH a uterus (0.625 mg estrogen days 1 to 14, then 5 mg medroxyprogesterone days 15 to 28); conjugated estrogen alone (Premarin, 0.3 to 1.25 mg/day) for women WITHOUT a uterus; both contraindicated with estrogen-dependent cancer

Nursing (education): risk factors; FALL PREVENTION (remove throw rugs, clear floors, light stairways, grab bars by shower, tub and toilet, yearly eye exams, limit alcohol, wear shoes inside and out); purpose of DXA; calcium and vitamin D foods; activity; medications; smoking and alcohol.

VI. Specific Populations

A. Adolescents (ages 12 to 19)

• Physical: sexual maturation; grow 2 to 8 inches and gain 15 to 55 lb; skeletal growth completed
• Cognitive: concrete to abstract thinking, logic, planning; concern with moral and social issues
• Psychosocial: identity, values, self-esteem, sexual identity
• Health issues: menstrual disorders, acne, eating disorders (obesity, anorexia, bulimia), STIs (chlamydia and gonorrhea are common), teen pregnancy (16.6 births per 1,000 aged 15 to 19), bullying (20.4% electronic, 23.6% at school), mental health (46.6% of high school girls report persistent sadness or hopelessness; 24.1% seriously considered suicide; 11% attempted). Leading causes of death at 15 to 19: unintentional injury, suicide, homicide
• 2019 Youth Risk Behavior Survey, high school girls: 37.6% ever had sex, 28.4% currently active, 49.6% used a condom last time, 11.4% forced to have intercourse
• School nurses are trusted adults; provide health and risk reduction information and advocate for resources

B. Older adult women

Table 18-4, age-related changes and health promotion:

Other areas:

• Dry, itchy skin (low fluid intake, low humidity, fewer sweat and oil glands, sun, smoking, diabetes, kidney disease): 8 or more glasses of fluid, daily moisturizer, humidifier, mild soap and warm (not hot) water, sun protection
• Nutrition: barriers include living alone, depression, mouth pain, low income, altered taste (drugs, gum disease, dentures, alcohol, smoking); take a detailed dietary history; address problems that affect appetite and chewing
• Mouth care: brush twice daily with fluoride toothpaste, floss daily, dental visits every 6 months, quit smoking
• Medications: more sensitive (slower metabolism and organ function) and more drugs (interactions); keep a complete list of all drugs and supplements and bring it to every visit; keep drug information; dispose of expired drugs at the pharmacy
• Sexual health: older women are sexually active; orgasm capacity is unchanged (intensity may lessen); clitoris stays sensitive; frequency may drop; low estrogen causes dryness, burning, itching, discharge and painful penetration; women in their sixties have half the testosterone of women in their twenties. Promote fitness, local vaginal estrogen, open communication with her partner

Estradiol vaginal cream (Estrace): atrophic vaginitis of menopause; relieves vaginal dryness and soreness, vulvar itching and redness, urinary urgency and dysuria. 0.5 to 1 g vaginally daily for 2 weeks, then twice weekly. Side effects: breast pain or enlargement, genital itching, headache, nausea, stinging, thick white mild-odor discharge. Use at BEDTIME for better absorption; NOT right before intercourse (limits partner exposure); ask about use with latex condoms, diaphragms and caps.

Driving: changes in vision and reflexes; giving up driving threatens independence. Conditions that interfere: dementia, vision and hearing changes, stroke, Parkinson disease, arthritis, diabetes, some drugs. Promote yearly eye exams, no drinking and driving, avoid night and bad-weather driving, limit distractions (radio, talking, phones), avoid sedating drugs, sunglasses.

Critical Component, signs driving is no longer safe: trouble seeing or following signals, signs and markings; stopping at green lights or where there is no stop sign; confusion at signals; running stop signs or red lights; getting lost in familiar places; dents and scrapes on the car, fence, mailbox or garage; slower responses; trouble moving the foot from gas to brake.

Nursing: discuss age-related changes; individualized teaching plan and health promotion.

C. Lesbian health (LGBTQ)

• Disparities come from stigma, discrimination and denial of rights, NOT from being LGBTQ
• Barriers: no insurance, fear of negative reactions, providers’ lack of knowledge; lesbians see providers less often and later
• Higher risks: breast, cervical, endometrial and ovarian cancer (more smoking, alcohol and obesity); obesity and heart disease; polycystic ovary syndrome (menstrual problems, infertility, insulin problems, heart disease); osteoporosis (smoking, alcohol, antidepressants); tobacco, alcohol and substance use; domestic violence (screen all women; few lesbian-specific agencies)
• CULTURAL HUMILITY: ongoing self-reflection on assumptions and biases. Cultural competence implies “I am the expert”; cultural humility implies “You are the expert”
• Education: routine screening and immunizations, exercise, diet and weight, smoking cessation, limiting alcohol, safety planning for domestic violence, osteoporosis risk reduction

High-Yield Numbers

• At least 150 minutes of moderate activity a week; 3 servings of calcium foods a day
• Alcohol: 1 drink a day for women
• Td every 10 years; zoster at 50; PPSV23 at 65; HPV 19 to 26; MMR 19 to 59
• HPV doses: 2 if started before 15, 3 if started at 15 or older
• Obesity classes: 30 to 35, 35 to 40, over 40
• SPF 15 or more; avoid sun 10 a.m. to 2 p.m.
• Pap every 3 years (19 to 29 per Table 18-2); Pap plus HPV every 5 years from 30; stop after 65 if 10 years clear
• High breast cancer risk: BRCA or lifetime risk 20% or more (MRI plus mammogram)
• IPV: 1 in 4 women; screen each trimester and postpartum
• Puberty 8 to 13; menarche 2 to 2.5 years later
• Menopause: 12 months without menses; average age 51; perimenopause 4 to 8 years
• Bone loss fastest 2 to 3 years after menopause; 80% of osteoporosis is in women
• T score -2.5 or below osteoporosis; -1 to -2.5 osteopenia; treat if below -1.5 with risk factors
• Calcium 1,300 (9 to 18), 1,000 (19 to 50), 1,200 (51+) mg/day; vitamin D 600 to 1,000 IU at 50+
• Alendronate: 30 minutes before food, 8 oz water, upright 30 minutes
• Denosumab every 6 months; teriparatide daily; zoledronate yearly (treatment)

Priority Nursing Actions and Red Flags

• Women’s heart attack signs may be atypical (jaw or back pain, fatigue, nausea, dyspnea, cold sweats)
• Screen for IPV privately with a validated tool; use trauma-informed care
• No deodorant or powder before a mammogram
• Estrogen alone only without a uterus; add progestin with a uterus (endometrial cancer)
• Estrogen contraindicated with unexplained bleeding, clots or PE, breast or uterine cancer, liver or gallbladder disease, untreated hypertension
• Alendronate taken wrong causes esophageal ulceration
• Denosumab: dental care for jaw osteonecrosis risk
• Raloxifene: watch for VTE and stroke
• Falls are the leading cause of injury death at 65+; teach home safety
• Older adults: rise slowly (orthostatic hypotension); review all medications

Medications

Related

• nsg210-durham-ch19-alterations-womens-health
• nsg210-durham-ch12-postpartum-care (contraception table)
• nsg210-hinkle-ch36-musculoskeletal-disorders (osteoporosis)
• nsg210-hinkle-ch35-musculoskeletal-assessment (FRAX, DXA)
• INDEX