Female Reproductive System & Well Woman Care

Female Reproductive System

  • The female reproductive system includes:

    • External structures (vulva) visible from the pubis to the perineum.

    • Internal structures located in the pelvic cavity.

  • Development and maturation of these structures are influenced by estrogen and progesterone, starting in fetal life, continuing through puberty, and during childbearing years.

  • Reproductive structures atrophy with age or decreased ovarian hormone production.

External Structures (Vulva)

  • Visible externally from the pubis to the perineum.

  • Includes:

    • Mons pubis

    • Labia majora

    • Labia minora

    • Clitoris

    • Vestibular glands

    • Vaginal vestibule

    • Vaginal orifice

    • Urethral opening

  • Appearance varies among women due to heredity, age, race, and parity.
    *FIG. 3.1External Female Genitalia. An illustration of external female genitalia. The labelling from top to bottom are as follows: Mons pubis, prepuce, Clitoris, Labia minora, the orifice of urethra, labia majora, hymen, orifice of the vagina, vestibule, opening of Bartholin's gland, fourchette, perineal body, and anus.

  • Mons Pubis:

    • Fatty pad over the anterior surface of the symphysis pubis.

    • Covered with coarse, curly hair after puberty.

  • Labia Majora:

    • Two rounded folds of fatty tissue covered with skin.

    • Extend downward and backward from the mons pubis.

    • Highly vascular; develop hair on the outer surfaces after puberty.

    • Protect inner vulvar structures.

  • Labia Minora:

    • Two flat, reddish folds of tissue visible when the labia majora are separated.

    • No hair follicles but many sebaceous follicles and few sweat glands are present.

    • Composed of connective tissue and smooth muscle with sensitive nerve endings.

    • Fuse anteriorly to form the prepuce (hood of the clitoris) and the frenulum (fold under the clitoris).

    • Join to form the fourchette (thin, flat tissue) underneath the vaginal opening at midline.

  • Clitoris:

    • Located underneath the prepuce.

    • Small structure composed of erectile tissue with numerous sensory nerve endings.

    • Increases in size during sexual arousal.

  • Vaginal Vestibule:

    • Almond-shaped area enclosed by the labia minora.

    • Contains openings to the:

      • Urethra

      • Skene glands

      • Vagina

      • Bartholin glands

  • Urethra:

    • Not a reproductive organ but located about 2.5 cm below the clitoris.

    • Skene Glands:

      • Located on each side of the urethra.

      • Produce mucus for vaginal lubrication.

    • Vaginal Opening:

      • Located in the lower portion of the vestibule; varies in shape and size.

      • Hymen:

        • Connective tissue membrane surrounding the vaginal opening.

        • Can be perforated by exercise, tampons, masturbation, or intercourse.

    • Bartholin Glands:

      • Lie under the constrictor muscles of the vagina, located posteriorly on the sides of the vaginal opening.

      • Secrete clear mucus to lubricate the vaginal introitus during sexual arousal.

  • Perineum:

    • Area between the fourchette and the anus.

    • Skin-covered muscular area covering pelvic structures.

    • Forms the base of the perineal body, a wedge-shaped mass anchoring pelvic muscles, fascia, and ligaments.

    • Muscles and ligaments support pelvic organs.

Internal Structures

  • Include:

    • Vagina

    • Uterus

    • Uterine tubes (fallopian tubes)

    • Ovaries

  • Vagina:

    • Fibromuscular, collapsible, tubular structure between the bladder and rectum, extending from the vulva to the uterus.

    • Rugae (transverse folds) in the mucosal lining during reproductive years allow for expansion during birth.

    • Estrogen deprivation (after birth, during lactation, or at menopause) causes dryness and thinning of vaginal walls and smoothing of the rugae.

    • Lower segment has few sensory nerve endings.

    • Vaginal secretions are slightly acidic (pH 4 to 5) to limit susceptibility to infections.

    • Functions:

      • Passageway for menstrual flow

      • Female organ of copulation

      • Part of the birth canal for vaginal birth

  • Uterine Cervix:

    • Projects into a blind vault at the upper end of the vagina.

    • Fornices (anterior, posterior, and lateral pockets) surround the cervix.

    • Internal pelvic organs can be palpated through the thin walls of the fornices.

  • Uterus:

    • Muscular organ shaped like an upside-down pear, midline in the pelvic cavity between the bladder and rectum, above the vagina.

    • Supported by four pairs of ligaments: cardinal, uterosacral, round, and broad; single anterior and posterior ligaments also support it.

    • Cul-de-sac of Douglas: deep pouch posterior to the cervix formed by the posterior ligament.

    • Divided into two major parts:

      • Corpus (upper triangular portion)

      • Cervix (lower cylindric portion)

    • Fundus: dome-shaped top of the uterus where uterine tubes enter.

    • Isthmus (lower uterine segment): short, constricted portion separating the corpus from the cervix.

  • Uterus Functions:

    • Reception

    • Implantation

    • Retention

    • Nutrition of the fertilized ovum and later of the fetus during pregnancy

    • Expulsion of the fetus during birth

    • Cyclic menstruation

  • Uterine Wall:

    • Three layers:

      • Endometrium (highly vascular lining with outer two layers shed during menstruation)

      • Myometrium (layers of smooth muscles in longitudinal, transverse, and oblique directions)

      • Peritoneum
        *FIG. 3.3Schematic Arrangement of Directions of Muscle Fibers. Note that uterine muscle fibers are continuous with supportive ligaments of the uterus. Schematic arrangement of directions of uterine muscle fibers. The labels from top to bottom are as follows: uterine tube, ovarian ligament, round ligament, uterosacral ligament, cardinal ligament, and anterior ligament.

  • Myometrium:

    • Longitudinal fibers in the outer layer (mostly in the fundus) assist in expelling the fetus during birth.

    • Middle layer contains fibers from all three directions, forming a figure-eight pattern encircling large blood vessels, which assists in ligating blood vessels after birth and controlling blood loss.

    • Circular fibers of the inner layer (mostly around where uterine tubes enter and around the internal cervical os) help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation.

  • Cervix:

    • Made up of mostly fibrous connective tissue and elastic tissue for stretching during vaginal birth.

    • Internal Os: opening between the uterine cavity and the endocervical canal.

    • External Os: narrowed opening between the endocervix and the vagina; small circular opening in women who have never been pregnant.

    • Feels firm (like the end of a nose) with a dimple in the center marking the external os.

    • Outer portion covered with squamous epithelium.

    • Mucosa of the cervical canal covered with columnar epithelium, containing numerous glands secreting mucus in response to ovarian hormones.

    • Squamo-columnar junction (transformation zone) is the most common site for neoplastic changes; cells from this site are scraped for the Papanicolaou (Pap) test.

  • Uterine Tubes (Fallopian Tubes):

    • Attach to the uterine fundus.

    • Supported by the broad ligaments, ranging from 8 to 14 cm in length.

    • Four sections:

      • Interstitial (closest to the uterus)

      • Isthmus (middle portion)

      • Ampulla (middle portion)

      • Infundibulum (closest to the ovary)

    • Infundibulum has fimbriated (fringed) ends pulling the ovum into the tube.

    • Provide a passage between the ovaries and the uterus for the movement of the ovum.

    • Ovum is pushed along by rhythmic contractions and cilia movement.

    • Fertilization by sperm usually occurs in the ampulla.

  • Ovaries:

    • Almond-shaped organs on each side of the uterus below and behind the uterine tubes.

    • During reproductive years: Approximately 3 cm long, 2 cm wide, and 1 cm thick; diminish in size after menopause.

    • Before menarche: Smooth surface; after menarche: nodular due to repeated ruptures of follicles at ovulation.

    • Two functions:

      • Ovulation

      • Hormone Production (estrogen, progesterone, and androgen)

Bony Pelvis

  • Three primary purposes:

    • Protection of the pelvic structures

    • Accommodation of the growing fetus during pregnancy

    • Anchorage of the pelvic support structures

  • Four bones: two innominate (hip) bones (ilium, ischium, and pubis), the sacrum, and the coccyx.
    *FIG. 3.4Adult Female Bony Pelvis. (A) Anterior view. (B) External view of innominate bone (fused). An illustration of the adult bony pelvis. Part A shows the anterior view. The labelling from top to bottom are as follows: Iliac crest, sacroiliac crust, Ileum, sacral promontory, sacrum, acetabulum, coccyx, pubis, obturator foramen, ischium, and subpubic arch under symphysis pubis. Part B shows the external view of the fused innominate bone. The labels from top to bottom are as follows: sacrosciatic notch, Iliac spines, acetabulum, ischial spine, ischial tuberosity, and obturator foramen.

  • Cartilage and ligaments form the symphysis pubis, sacrococcygeal joint, and two sacroiliac joints.

  • Two parts:

    • False pelvis (upper portion above the pelvic brim or inlet)

    • True pelvis (lower, curved, bony canal, includes the inlet, cavity, and outlet through which the fetus passes during vaginal birth)
      *FIG. 3.5Female Pelvis. (A) Cavity of false pelvis is shallow. (B) Cavity of true pelvis is irregularly curved canal (blue arrows). A diagrammatic representation of false pelvis and true pelvis. Part A shows that the false pelvis is present above the inlet that has a shallow cavity while the true pelvis is present below it. Part B shows that the cavity of the true pelvis, which is an irregular curved canal.

  • Upper portion of the outlet is at the level of the ischial spines; the lower portion is at the level of the ischial tuberosities and the pubic arch.

  • Variations in size and shape are related to age, race, and sex.

  • Pelvic ossification is complete at about 20 years of age.

Breasts

  • Paired mammary glands located between the second and sixth ribs.

  • Two-thirds overlie the pectoralis muscle, between the sternum and midaxillary line, with an extension to the tail of Spence.

  • One-third overlies the serratus anterior muscle.

  • Attached to the muscles by connective tissue or fascia.

  • Functions: lactation and organs for sexual arousal in the mature adult female.
    *FIG. 3.6Anatomy of the Breast Showing Position and Major Structures. Cross-section of the breast. The labelling from top to bottom are as follows: clavicle, intercostal muscle, pectoralis major muscle, alveolus, ductule, duct, lactiferous duct, nipple pore, and Cooper's ligaments.

  • Approximately equal in size and shape but often not absolutely symmetric.

  • Size and shape vary with age, heredity, and nutrition.

  • Contour should be smooth without retractions, dimpling, or masses.

  • Estrogen stimulates growth by:

    • inducing fat deposition

    • development of stromal tissue

    • growth of the ductile system

    • increases vascularity.

  • Progesterone causes maturation of mammary gland tissue, specifically the lobules and acinar structures.

  • Full development not achieved until after the end of the first pregnancy or in the early period of lactation.

  • Mammary Gland Composition:

    • Multiple lobes divided into lobules.

    • Lobules are clusters of acini.

    • Acinus: saclike terminal part of a compound gland emptying through a narrow lumen or duct.

    • Acini are lined with epithelial cells that secrete colostrum and milk.

    • Myoepithelium (muscle) contracts to expel milk from the acini.

    • Mammary glands are modified sweat glands.

  • Ducts:

    • Ducts from the clusters of acini merge to form larger ducts draining the lobes.

    • Ducts from the lobes converge in a single nipple (mammary papilla) surrounded by an areola.

    • Anatomy of the ducts varies among women.

  • Protective fatty tissue surrounds the glandular structures and ducts.

  • Cooper’s ligaments (fibrous suspensory ligaments) separate and support the glandular structures and ducts, permitting mobility on the chest wall.

  • Nipple:

    • Round and slightly elevated above the breast.

    • Projects slightly upward and laterally; contains multiple openings from the milk ducts.

    • Surrounded by fibromuscular tissue and covered by wrinkled skin (the areola).

    • Usually no discharge except during pregnancy and lactation.

    • Nipple and areola are more deeply pigmented than the skin of the breast.

  • Areola:

    • Rough appearance caused by sebaceous glands (Montgomery tubercles).

    • Montgomery tubercles secrete a fatty substance thought to lubricate the nipple.

    • Smooth muscle fibers contract to cause the nipple to become erect for breastfeeding.

  • Vascular Supply:

    • Abundant; no obvious vascular pattern in the skin in the nonpregnant state.

    • The skin contains an extensive superficial lymphatic network continuous with the superficial lymphatics of the neck and abdomen.

    • Lymphatics form a rich network in the deeper portions, draining laterally toward the axillae.

  • Breast Changes During the Ovarian Cycle:

    • Breasts change in size and nodularity in response to cyclic ovarian changes.

    • Increasing estrogen and progesterone levels increase vascularity, induce enlargement of the ducts and acini, and promote water retention.

    • Epithelial cells lining the ducts proliferate, ducts dilate, and lobules distend.

    • Acini become enlarged and secretory, and lipid (fat) is deposited within their epithelial cell lining.

    • Common symptoms: Breast swelling, tenderness, and discomfort just before the onset of menstruation.

    • After menstruation:

      • Cellular proliferation begins to regress, acini begin to decrease in size, and retained water is lost.

      • Physiologic alterations in breast size and activity reach their minimum level about 5 to 7 days after menstruation stops.

      • Small, persistent areas of nodulations may develop after repeated hormonal stimulation.

  • Breast Self-Examination (BSE):

    • Systematic palpation of breasts to detect signs of breast cancer or other changes.

    • Best carried out 5 to 7 days after menstruation stops.

    • The new terminology that includes breast self-exam is “breast awareness”.

    • All women should be familiar with how their breasts normally appear and feel, and report any changes to a health care provider immediately.

Menstruation and Menopause

  • Menarche: First menstruation, typically occurs around age 13 in North America.

  • Puberty: Transitional stage between childhood and sexual maturity.

  • Menstrual periods are initially irregular, unpredictable, painless, and anovulatory.

  • After 1 or more years, a hypothalamic-pituitary rhythm develops, leading to regular, ovulatory periods.

  • Estrogen dominates the first half of the cycle; progesterone dominates the second half.

  • Pregnancy can occur at any time after the onset of menses.

Menstrual Cycle

  • Periodic uterine bleeding that begins approximately 14 days after ovulation.

  • Controlled by a feedback system of three cycles: endometrial, hypothalamic-pituitary, and ovarian.

  • Average length: 28 days (variations are normal).

  • First day of bleeding is designated as day 1 of the menstrual cycle (menses).

  • Average duration of menstrual flow: 5 days (range 3 to 6 days).

  • Average blood loss: 50 mL (range 20 to 80 mL).
    *FIG. 3.7Menstrual Cycle: Hypothalamic-pituitary, Ovarian, and Endometrial. GnRH, Gonadotropin-releasing hormone. Events of the menstrual cycle displayed through a chart.

  • Menstrual blood usually does not clot due to liquefaction of clots before discharge.

  • Uterine discharge includes mucus and epithelial cells in addition to blood.

  • Regulated by interactions among the endometrium, hypothalamus, pituitary gland, and ovaries.

  • Prepares the uterus for pregnancy; menstruation follows if pregnancy does not occur.

  • Influenced by a woman’s age, physical and emotional status, and environment.

Endometrial Cycle

  • Four phases:

    • Menstrual phase

    • Proliferative phase

    • Secretory phase

    • Ischemic phase

  • Menstrual Phase:

    • Shedding of the functional two-thirds of the endometrium (compact and spongy layers), initiated by vasoconstriction.

    • The basal layer is retained and regeneration begins.

  • Proliferative Phase:

    • Rapid growth from about the fifth day to the time of ovulation.

    • The endometrial surface is completely restored in approximately 4 days.

    • Depends on estrogen stimulation from ovarian follicles, thickening occurs.

  • Secretory Phase:

    • Extends from the day of ovulation to about 3 days before the next menstrual period.

    • Large amounts of progesterone are produced.

    • An edematous, vascular endometrium develops (a protective and nutritive bed for a fertilized ovum).

    • Implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation.

  • Ischemic Phase:

    • Blood supply to the functional endometrium is blocked and necrosis develops.

    • The functional layer separates from the basal layer, and menstrual bleeding begins.

Hypothalamic-Pituitary Cycle

  • The hypothalamus and anterior pituitary glands regulate the production of FSHFSH and LHLH.

  • Feedback mechanism between hormone secretion from the ovaries, the hypothalamus, and the anterior pituitary gland aids in control.

  • Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone decrease.

  • Low blood levels stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRHGnRH ).

  • GnRHGnRH stimulates anterior pituitary secretion of follicle-stimulating hormone (FSHFSH).

  • FSHFSH stimulates development of ovarian graafian follicles and their production of estrogen.

  • Estrogen levels begin to decrease, and hypothalamic GnRHGnRH triggers the anterior pituitary gland to release luteinizing hormone (LHLH).

  • A surge of LHLH and a smaller peak of estrogen precedes the expulsion of the ovum from the graafian follicle by about 24 to 36 hours.

  • LHLH peaks at about day 13 or 14 of a 28-day cycle.

  • If fertilization and implantation have not occurred, the corpus luteum regresses.

  • Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is stimulated to secrete GnRHGnRH again.

Ovarian Cycle

  • Primitive graafian follicles contain immature oocytes (primordial ova).

  • Before ovulation, 1 to 30 follicles begin to mature under FSHFSH and estrogen.

  • The pre-ovulatory surge of LHLH affects a selected follicle.

  • The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum.

  • The follicular phase (pre-ovulatory phase) varies in length from woman to woman, causing variations in ovarian cycle length.

  • Rarely, more than one follicle is selected, and more than one oocyte matures and undergoes ovulation.

  • After ovulation, estrogen levels drop.

  • For 90% of women, only a small amount of withdrawal bleeding occurs, and it goes unnoticed. In 10% of women, there is sufficient bleeding for it to be visible, resulting in what is termed midcycle bleeding.

  • The luteal phase begins immediately after ovulation and ends with the start of menstruation (usually requires 14 days, range 13 to 15 days).

  • The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting the steroids estrogen and progesterone.

  • Coincident with peak luteal functioning, the fertilized ovum is implanted in the endometrium.

  • If no implantation occurs, the corpus luteum regresses, and steroid levels drop.

  • Two weeks after ovulation, if fertilization and implantation do not occur, the functional layer of the uterine endometrium is shed through menstruation.

Other Cyclic Changes

  • When the hypothalamic-pituitary-ovarian axis functions properly, other tissues undergo predictable responses.

  • Basal Body Temperature: often less than 37°C37°C (98.6°F98.6°F) before ovulation; rises after ovulation with increasing progesterone levels.

  • Cervical Mucus:

    • Preovulatory and postovulatory mucus is viscous (thick) to discourage sperm penetration.

    • At the time of ovulation, cervical mucus is thin and clear with spinnbarkeit (stretchable quality).

  • Mittelschmerz: localized lower abdominal pain that coincides with ovulation.

Prostaglandins

  • Oxygenated fatty acids classified as hormones.

  • Different kinds are distinguished by letters (PGEPGE and PGFPGF), numbers (PGE2PGE2), and Greek alphabet letters (PGF2αPGF2α).

  • Produced in most organs of the body, including the uterus; menstrual blood is a potent source.

  • Metabolized quickly by most tissues; biologically active in minute amounts.

  • PGF2αF2α, PGE4E4, and PGE2E2 are most commonly used in reproductive medicine.

  • Affect smooth muscle contractility and modulation of hormonal activity.

  • Role in Ovulation: If PG levels do not rise along with the surge of LHLH, the ovum remains trapped within the graafian follicle.

  • After Ovulation: PGs may influence production of estrogen and progesterone by the corpus luteum.

  • Increase motility of uterine musculature, which may assist the transport of sperm through the uterus and into the oviduct.

  • Cause regression of the corpus luteum and regression and sloughing of the endometrium, resulting in menstruation.

  • Increase myometrial response to oxytocic stimulation, enhance uterine contractions, and cause cervical dilation.

  • PGs may be a factor in the initiation and maintenance of labor.

Climacteric and Menopause

  • Climacteric: Transitional phase during which ovarian function and hormone production decline.

  • Menopause: Refers only to the last menstrual period; can be dated with certainty only 1 year after menstruation ceases.

  • The average age at natural menopause is approximately 51 years.

  • Perimenopause: Preceding menopause; ovarian function declines, ova slowly diminish, and menstrual cycles may be anovulatory, resulting in irregular bleeding.

Sexual Response

  • Females and males achieve physical maturity at approximately 17 years of age; individual development varies greatly.

  • Women and men are more alike than different in their physiologic response to sexual excitement and orgasm.

  • Glans clitoris and the glans penis are embryonic homologs.

  • Physical response is essentially the same whether stimulated by coitus, fantasy, or masturbation.

  • Physiologic Processes:

    • Vasocongestion: Increased circulation to circum-vaginal blood vessels (lubrication in the female), causing engorgement and distention of the genitals; venous congestion also occurs in the breasts and other parts of the body.

    • Myotonia: Increased muscular tension, resulting in voluntary and involuntary rhythmic contractions.

  • Four phases that occur progressively, with no sharp dividing line between any two phases:

    • Excitement

    • Plateau

    • Orgasm

    • Resolution

  • It is still common to describe the classic four phases in which specific body changes take place in sequence, and this description is useful in educating and talking with women who may have concerns about possible sexual dysfunction.

Reasons for Entering the Health Care System

  • Women enter the health care system for varied reasons, including those specifically related to women’s reproductive health, but also for general well-woman care.

  • Women’s health needs and concerns are common reasons for women to enter the health care system.

  • These may include preconception counseling and care, pregnancy, menstrual problems, well and sick care, fertility control and infertility, and termination of unwanted pregnancy.

Barriers to Entering the Health Care System

  • Financial issues.

  • Access to care varies greatly based on system, private versus public programs, provider availability, individual preferences, and insurance coverage.

Social Determinants of Health

  • Healthy People 2020 highlights the importance of addressing the social determinants of health by including “Create social and physical environments that promote good health for all” as one of the four overarching goals for the decade.

  • Social determinants of health affect a wide range of health, functioning, and quality-of-life outcomes and risks.

  • Health care is dependent not only on single interventions, but also on factors apart from any care we can provide.

  • Poverty, education, nutrition, exercise, smoking, drinking, and drug use are potent social determinants of a woman’s health.

  • In the United States, disparity among races and socioeconomic classes affects many facets of life including health.

  • Women use health care services more often than men but are more likely than men to have difficulty in financing them.

Cultural Issues

  • Cultural differences must be addressed with great sensitivity and humility.

  • Some women experience racial discrimination or disrespectful, disillusioning, or discouraging encounters with community service providers.

  • Desired health outcomes are best achieved when the health care provider has knowledge of and understanding about the culture, language, values, priorities, and health beliefs of those in various ethnic groups.

  • Conversely, members of these various cultures should understand the health goals to be achieved and the methods proposed to do so.

  • Nurses can integrate into their own practice various holistic approaches to care, in accordance with Dossey’s (2013) classic Theory of Integral Nursing.

  • It is critically important to be sensitive to cultural differences and at the same time to avoid stereotyping and assuming that a woman has certain beliefs because of her ethnic background.

Gender Identity and Sexual Orientation

  • In order to understand the term gender, it is important to clarify that the term sex refers to biology, specifically chromosomes and genitalia.

  • However, some people are considered to be “intersex,” a condition in which one’s chromosomes and genitalia do not fall into either male or female.

  • Gender is composed of one’s sex assigned at birth, one’s own gender identity, and how one expresses gender identity.

  • Nurses and other health care professionals need to understand the specific health care needs and issues related to sexual orientation, particularly since many lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual (LGBTQIA) individuals feel stigmatized and are reluctant to seek health care.

  • To offset stereotypes, it is necessary for providers to develop an approach that does not assume that all patients are heterosexual.

  • Ellis (2017) presented helpful definitions of terms related to gender that health care providers must understand in order to provide empathic care.

  • A transgender woman is defined as someone born as a male based on physiological sex but identifies herself as female.

  • A transgender man is defined as someone born as a female based on physiological sex but identifies himself as male.

  • A cisgender person is defined as someone whose sex at birth (based on genitalia) coincides with the gender with which the person identified.

Caring for the Well Woman Across the Life Span

  • Essential components of health maintenance are the identification of unrecognized problems and potential risks and the education and health promotion needed to reduce them.

  • A holistic approach to women’s health care goes beyond only reproductive needs and includes a woman’s health needs throughout her lifetime, with attention to physical, mental, emotional, social, and spiritual health.

  • Assessment and screening focusing on a multisystem evaluation that emphasizes the maintenance and enhancement of wellness.

Top 10 Leading Causes of Death in Women in the United States

  • Heart disease

  • Malignant neoplasm (cancer)

  • Chronic lower respiratory disease

  • Stroke

  • Alzheimer disease

  • Unintentional injury

  • Diabetes mellitus

  • Influenza and pneumonia

  • Nephritis

  • Septicemia
    *COVID is now considered the leading cause of death among certain age groups.

Conditions Across the Life Span

  • Adolescents:

    • Should treat the adolescent very carefully, as they often experience stress related to identity, relationships, or career goals.

    • Adolescent enter health care for screening or a problem such as illness or accident.

    • Current guidelines suggest that Pap tests begin at 21 years of age.

    • Gynecologic problems are often associated with menses, vaginitis, STIs, Contraception, or pregnancy.

    • The adolescent is also at risk for use of street drugs, for eating disorders, and for stress, depression, and anxiety.

    • Teenage Pregnancy:

      • Effective educational programs about sex and family life are imperative to control the rate of teen pregnancy and STIs.

      • Teenagers usually lack the financial resources to support a pregnancy and may not have the maturity to avoid teratogens or seek prenatal care and instruction or follow-up care.

      • Children of teen mothers may be at risk for abuse or neglect because of the teenager’s inadequate knowledge of growth, development, and parenting.

  • Young and Middle Adulthood:

    • Women 20 to 40 years of age may prefer to use their gynecologic or obstetric provider as their primary care provider.

    • During these years the woman may be “juggling” family, home, and career responsibilities, with resulting increases in stress-related conditions.

    • Health maintenance includes not only pelvic and breast screening but also promotion of a healthy lifestyle.

    • Common conditions requiring well-woman care include vaginitis, urinary tract infections, menstrual variations, obesity, sexual and relationship issues, and pregnancy.

  • Parenthood after 35 years:

    • May have had health status changes as a result of time and the aging process.

    • Increased risk for certain genetic anomalies.

  • Late Reproductive Age:

    • (40 years and older) are often experiencing change and reordering personal priorities.

    • Divorce rates are high and children leaving home may produce an “empty nest syndrome”.

    • Chronic diseases become more apparent.

    • Most problems for the well woman are associated with perimenopause (e.g., bleeding irregularities and vasomotor symptoms).

    • Health maintenance screening continues to be important because some conditions such as breast disease or ovarian cancer occur more often during this stage.

Approaches to Care at Specific Stages

  • Preconception Counseling and Care:

    • Preconception health promotion provides women and their partners with information that is needed to make decisions about their reproductive future.

    • Activities that promote healthy mothers and babies must be initiated before critical fetal organ development begins.

    • Preconception care is important to minimize fetal malformations. For example, the offspring of women who have pre-existing diabetes mellitus have significantly more congenital anomalies than do children of mothers without diabetes.

    • Rate of malformation is greatly reduced when the woman with pre-existing diabetes has excellent blood glucose control at the time she becomes pregnant and maintains euglycemia (normal blood glucose level) throughout the period of organ development in the fetus.

    • The incidence of neural tube defects is decreased with the intake of 400mcg400 mcg of supplemental folic acid.
      *BOX 3.2 Components of Preconception Care:
      *Health promotion: Patient education • Nutrition • Healthy diet, including folic acid • Optimal weight • Exercise and rest • Avoidance of substance abuse (tobacco, alcohol, “recreational” drugs) • Use of risk-reducing sex practices.
      *Pregnancy: Early entry into prenatal care allows for identification of the woman at risk for complications and initiation of measures to prevent problems or treat them if they arise.
      *BOX 3.3 Major Goals of Prenatal Care:

  • Define health status of mother and fetus.

    • Determine the gestational age of the fetus and monitor fetal development.

    • Identify the woman at risk for complications and minimize the risk whenever possible.

    • Provide appropriate education and counseling.

  • Fertility Control and Infertility:

    • Education is the key to encouraging women to make family planning choices based on preference and actual benefit-to-risk ratios.

    • Approximately 6% to 12% of women, ages 15 to 44 in the United States, have some degree of infertility.

    • Infertility can cause emotional pain for many couples.

    • Steps toward prevention of infertility should be undertaken as part of ongoing routine health care, and information about how women may prevent some causes of infertility is especially appropriate in preconception counseling.

  • Menstrual Problems:

    • Irregularities or problems cause them to seek help from the health care system

    • Common menstrual disorders include amenorrhea, dysmenorrhea, premenstrual syndrome, endometriosis, and menorrhagia or metrorrhagia.

  • Perimenopause:

    • Most women seeking health care during the perimenopausal period do so because of irregular bleeding or vasomotor symptoms

    • Women are urged to maintain some method of birth control because pregnancies still can occur.

    • All women need information, the dispelling of myths, a thorough examination, and periodic health screenings thereafter.

Identification of Risk Factors to Women’s Health

  • Differences exist among people from different socioeconomic levels and ethnic groups with respect to risk for illness and distribution of disease and death.

  • Socioeconomic status affects birth outcomes. The rates of perinatal and maternal deaths, preterm births,