NU 352 Puberty

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1

What is puberty? What does this entail for the girl going through puberty? How does puberty affect the female A&P?

  • Breasts: tender when developing; buds appear; small firm, one side may grow faster; areola diameter increases; nipples more erect
  • Vagina: vagina lengthens, epithelial layers thicken; secretions become acidic
  • Uterus: musculature and vasculature increase; lining thickens
  • Ovaries: increase in size & weight; menarche occurs between 8 & 16 years; ovulation occurs monthly
  • Labia majora: Becomes more prominent, hair develops
  • Labia minora: Becomes more vascular
  • Uterine fallopian tubes: Increase in size, cilia in tube starts functioning

Puberty is the entire transition btwn childhood and sexual maturity.

The menarche is the first menstrual period. Only one of the changes of puberty in girls. Age of menarche is about 13 in girls in the US.

Estrogen is a powerful growth steroid. Every cell of the body has estrogen.

Progesterone is a very powerful maturation steroid.

Girls guard their chest at this time bc their breasts are tender.

Through most childhood and adolescent ages, the vaginal secretions are more alkaline. In teenagers going through puberty, they might get more infections bc they haven’t developed the acidic environment yet. The acidic environment protects against infections.

2

What are the Tanner stages for breast development in pubescent girls? What should a nurse teach for each stage?

Stage I: Prepuberty = Elevation of papilla

Stage II: Breast buds develop = Elevation of breast & nipple; areola increases in diameter. Where tenderness starts and we recognize they're going through puberty.

Stage III: Areola deepens in color & enlarges = Glandular tissue begins to develop beneath areola. Time to get a good, comfortable bra for them.

Stage IV: Areola appears as a mound = breast appears as a mound. Some girls don't have mounding.

Stage V: Mature breast = Areola recesses to general contour of breast; nipple projects forward.

Breasts are not fully mature until the first birth of a child takes them into lactation.

Pubescent girls worry over this a lot. Perry 1012 is where these are.

Important thing to teach girls is that breast growth is a process.

3

What are the Tanner stages for pubic hair changes?

  • Stage I: Prepuberty = None whatsoever
  • Stage II: A few darker hairs along labia, hair is very sparse
  • Stage III: Curly pigmented hairs across pubes, hairs are more at the top
  • Stage IV: Small adult configuration, later adolescence, hair but not a big bush
  • Stage V: Adult pubic hair distribution
4

Definitions of thelarche, adrenarche, estrogen, progesterone, lobes, lobules, alveoli, colostrum, myoepithelium, Cooper's ligaments, nipple, areola, montgomery tubercles, and tail of spence?

Thelarche: Changes in the nipple and areola, breast development, Tanner stage II and III. 4 out of 5 girls, the earliest, most visible sign that puberty is about to happen. Average age is 11. Range is from 8 to 13 ½. There should be no dimpling and no retractions on the breast tissue, should be smooth.

Adrenarche: The appearance of pubic hair. Usually follows breast development by 2-6 months. In some girls, pubic hair may precede breast development.

Estrogen stimulates the growth of breasts, which introduces fat in the breast, the ductal system is developed, the vascularity is increased.

Progesterone: helps mature the breast tissue, involved with developing the lobes or lobules of the breast tissue. Full development of the breast is not achieved until after the first pregnancy into lactation.

Lobes: The breasts themselves

Lobules: Individual breast tissue cells

Alveoli are epithelial lines cells that secrete colostrum and milk that line the lobules.

Colostrum: Beginning excretory substance from breast tissue after childbirth. Contains proteins, carbohydrates, fats, vitamins, minerals, and proteins (antibodies) that fight disease-causing agents such as bacteria and viruses.

Myoepithelium: Basement membrane beneath the glandular tissue of the breast, does the squeezing action to get milk out.

Cooper's ligaments: Connective tissue in the breast that helps maintain structural integrity. The ligament suspends the breast from the clavicle and the underlying deep fascia of the upper chest. This supports the breast in its normal position, and maintains its normal shape. Without the internal support of this ligament, the breast tissue (which is heavier than the surrounding fat) sags under its own weight, losing its normal shape and contour.

Areola: Pigmented area surrounding the nipple. Has a lot of erectile tissue, makes it easier to latch for baby. Will contract to squeeze milk out.

Nipple: Medical term is "papilla." Delivers milk to children.

Montgomery tubercles: In the areola surrounding the nipple. The glands make oily secretions (lipoid fluid) to keep the areola and the nipple lubricated and protected, keeps from cracking during lactation. Girls might think something's wrong with them. Important to educate that they're normal, don't squeeze them like pimples.

Tail of Spence: Extension of breast tissue that extends into axillae.

5

What does a nurse need to know about breast functions?

  • Lactation = Biological function. What breasts do best.
  • Sexual Arousal = Psychosocial with Biological basis – oxytocin & prolactin release, resulting in ‘let down’ of breast milk. When sexually aroused, erectile tissue in the breast stimulates the hypothalamus to produce oxytocin & when released oxytocin will result in milk letdown (milk ejection reflex – MER)
  • When someone is breastfeeding, milk will probably come out when they're having sex. Educate.
  • Sex will stimulate labor.
6

What should a nurse educate about a self breast exam?

Important to educate little girls how to give a self-breast exam early.

Finger tips close together, gently probe each breast in either a circular motion going outward, up and down across the breast, or in each direction going from out to in towards the nipple.

Breasts get very tender and nodular right before your period. Not a good time to do a self-exam. Do one 5-7 days after the period is over. It’s the least stimulated. For women with irregular cycles, just pick one day, and do it then.

7

What should a nurse teach a woman about the glands of the external genitalia and vaginal exams?

  • On either side of the urethra, Skeen’s glands produce secretion, can get enlarged during pregnancy.
  • Bartholin glands can become clogged during sexual activity or can be clogged up with STIs. Requires that the woman have it lanced and drained. Cleanliness after sex is important, just generally keeping the area clean, wiping front to back after using the bathroom.
  • Important to teach to do a vaginal inspection once a month. Need a healthcare provider inspection every year especially if sexually active and over 18. Need a pelvic exam every 3 years. Need a pap smear every year until they have a negative screen 3 times, then every 3 years is good.
  • The cervical canal is covered in columnar epithelium. The cervix itself is covered with squamous epithelium. Where the two tissues meet is called the squamo-collumnar junction. That’s where cervical cancer develops. A pap smear scrapes some of the cells from the junction and tests them.
  • Early in puberty, girls could have a normal discharge called physiologic leucorrhea. It’s white and normal. It means that the girl is getting ready for puberty.
  • The uterine tubes (fallopian tubes) have 4 difference sections. Cilia in the fallopian tube push toward the uterus.
8

What should a nurse teach about menarche?

  • Menarche defined as the first menstrual period
  • Occurs ~ 2 years after appearance of breast buds
  • Menarche is related to % body fat. For menarche to develop, the girl has to have 17% body fat. To maintain it, there has to be 22% body fat. Going to cause a lot of body image problems and dieting that might not be healthy.
  • Dieting leads to Anorexia/bulimia
  • Pubertal Delay - no period no breast development by age 13, or menarche has not occurred within 4 years of onset of breast development.
9

What is menstruation and the how does the cycle work?

Periodic uterine bleeding beginning ~ 14 days after ovulation –controlled by feedback system of 3 cycles: Endometrial, hypothalamic-pituitary, & ovarian.

Btwn ages 8-11, girls have a remarkable increase in estrogen production.

  • Avg length of menstrual cycle is 28 days – varies
  • 1st day of bleeding is day 1 of cycle
  • Avg duration of flow = 5 days (3-6 range)
  • Avg blood loss = 50 ml (range 20 – 80 ml) varies
10

What are the phases of the endometrial cycle?

  • 1. Menstrual phase: bleeding phase
  • 2. Proliferation phase: Endometrial lining grows under the influence of estrogen.
  • 3. Secretory phase: Progesterone is the primary steroid at this time. Endometrial lining is getting ready to nest an egg. Very vascular, very spongy.
  • 4. Ischemic phase occurs when there’s been no fertilization of the ovum. The arterioles and venioles spasm, causing ischemia and tissue death which causes bleeding.
  • The base layer of epithelial tissue is always there. This is the functional layer, that means it’ll nest an egg so a baby will grow.
11

What is the process of the hypothalamic-pituitary cycle?

1.Follicular Phase begins: Estrogen & Progesterone blood levels drop

  • Hypothalamus secretes GnRH
  • Stimulates ant pit to secrete FSH
  • Stimulates development of ovarian follicles, they produce estrogen (Follicular Phase ends [first half of the ovarian cycle]) - More variant phase.

2. Luteal Phase begins: Estrogen levels begin to diminish, hypothalamic GnRH stimulates ant pit to release LH.

  • LH surge (& small estrogen peak) ~ day 12 stimulates maturation of one follicle
  • Release of ovum from mature follicle in ~ 24 – 36 hours after LH surge (Luteal Phase ends [last half of ovarian cycle] Progesterone) - more stationary phase.
12

How does the ovarian cycle operate?

FSH stimulates follicles to mature each cycle; increase estrogen levels

LH surge in pre-ovulatory phase causes 1 follicle to reach maturity (time in this phase = variable)

Ovulation occurs

Empty follicle becomes corpus luteum

Luteal phase begins /p ovulation & ends /w menses –timing stable in this phase

Corpus luteum ~8 days past ovulation reaches peak secretion of estrogen & progesterone (maintains pregnancy until placenta can develop).

No fertilization/implantation= corpus luteum regresses after 8 days.

13

What is the order of hormone production in the ovarian cycle?

GnRH is 1st.

FH 2nd. Causes a primary follicle to release estrogen

3rd. As estrogen increases, there’s a dip in estrogen which stimulates LH

4th. That causes (in congruence with FH) an egg to be released. After this, the corpus luteum produces progesterone

5th. Then, if no fertilization, progesterone is stopped, ischemia occurs, endometrium dies, period occurs.

14

What other cyclic changes happen during the ovarian cycle?

Right before ovulation, basal body temp increases.

Spinnbarkheit: cervical mucus increases around ovulation. It becomes stretchy, thin, watery. Makes it easy for sperm to get through. Good traveling medium. If you take a little of cervical mucus and look at it under the microscope, it looks like a fern. Can look at the ferning of mucus as a fertility test.

Mittelschmerz: Sharp pain in the ovary as the egg is released

Prostaglandins are hormones that are necessary for the egg to be released from the follicle at the time of LH surge. We think that prostaglandins are necessary for the muscle movement for the uterus that encourage sperm to travel upward into the uterus. They are also necessary for labor to begin.

15

What are the characteristics of PMS?

Cyclic symptoms occur in luteal phase

All age groups affected - 20s – 30s most frequent symptoms

Ovarian function is necessary for occurrence

Definition of PMS difficult to establish

2 different syndromes recognized:

  • PMS
  • PDD / PMDD - focus more on psychological/emotional s/s
16

What are the s/s of PMS & PMDD?

Usually a period of time in the FP where there are no s/s at all. But sometimes as early as a week before the period, they get these s/s. There’s a problem with how progesterone is managed in the body. PMDD is a serious psychological condition with severe symptoms. When progesterone is the dominant hormone, the brain is kind of clouded. Concentration goes out the window.

Fluid retention

  • abdominal bloating
  • pelvic fullness
  • edema, lower extremities
  • breast tenderness
  • weight gain

Other Physical SX: Headache, fatigue, backache

Premenstrual cravings: Food cravings for sweets and salts, increased appetite

B ehavioral / emotional:

  • depression
  • crying spells
  • irritability
  • panic attacks
  • impaired concentration
17

How do we diagnose PMS? How is stress involved w/ PMS?

AWHONN & ACOG criteria (Perry, p. 79 [in text, not a box]):

  • Sx occur in luteal phase & resolve /w menses
  • Sx-free period occurs in follicular phase
  • Sx recurrent
  • Sx have negative impact on some aspect of woman’s life
  • Other dx that better explain Sx are excluded

Women, as Arlie Hochschild says, have 2nd & 3rd shifts: work/ family / volunteer & church / they have no time for self health, to restore reserves and recover from stressful lives.

Tied with the menstrual cycle with a stress overlay. Biology is interrupted or met with stress from life. PMS is how stress comes out unhealthily.

18

How do we diagnose PMDD?

National Institute of Mental Health Criteria:

  • > 5 affective and physical sx present during the week before menses & absent in follicular phase of menstrual cycle
  • At least one sx is irritability, depressed mood, anxiety, or emotional liability/crying
  • Sx interfere markedly with work or interpersonal relations.
  • Sx not due to an exacerbation of another condition/disorder
  • Criteria confirmed by daily ratings for at least 2 menstrual cycles

Classified as a major depressive disorder

19

What are important nursing management concepts for history and keeping a daily log for PMS?

Detailed Hx: A careful, detailed history and daily log of sx & mood fluctuations spanning several cycles may give direction to mgt plan

Daily Log of Symptoms -Have woman keep a symptom diary. Any change that assists a woman /w PMS to exert control over her life has a positive impact. Education is an important component of the management of PMS

20

What tips for health promotion should a nurse teach to the client experiencing PMS?

Diet: limit consumption of refined sugar (less than 5 tbsp/ day),

limit salt (less than 2 g/ day),

limit red meat (up to 3 oz/day),

limit alcohol (less than 1 oz/day),

limit caffeinated beverages, caffeine is a powerful xanthene that increases blood sugar dramatically, which causes a dramatic drop in blood sugar, exacerbating the symptoms.

  • Clients encouraged to include whole grains, legumes, seeds, nuts, vegetables, fruits, and vegetable oils in their diet
  • Eat 3 small-to-moderate-sized meals & 3 small snacks a day that are rich in complex carbohydrates and fiber,
  • Use natural diuretics (like water) to reduce fluid retention,
  • Nutritional supplements may assist in symptom relief
  • Calcium (1000-1200 mg daily); Vitamin D3 (600 – 1000 IU)
  • Magnesium (300-400mg daily); Vitamin B6 (100-150 mg daily)

Exercise:

  • Regular exercise (aerobic exercise 3 - 4 X / wk, 30 min), especially in the luteal phase, recommended for relief of PMS sx.
  • 10,000 steps a day is good exercise
  • Women who exercise regularly have less premenstrual anxiety than do non-athletic women
  • Aerobic exercise increases B-endorphin levels causes fewer symptoms of depression & elevates mood

Education:

  • Relationship exists between estrogen fluctuation and changes in serotonin levels.
  • Serotonin is a brain chemical that assists in coping with normal life stresses.
  • Different mgt strategies recommended to help maintain serotonin levels: Counseling, support groups or individual or couple counseling, Stress reduction techniques, Adequate Sleep
21

What should a nurse teach to a PMS pt regarding medications?

Medications (added in addition to lifestyle changes):

  • If no significant sx relief in 1 to 2 months, meds often begun.
  • Medications often used in the treatment of PMS include diuretics, prostaglandin inhibitors (e.g., NSAIDs). Long-term use causes cardiac problems in women.
  • Fluoxetine (Sarafem or Prozac, 20 mg a day): a selective serotonin reuptake inhibitor (SSRI), is the only Food and Drug Administration (FDA)-approved agent for PMS. Results in decrease in emotional sx, esp depression. Many times only take the SSRI during luteal phase to deal w/ symptoms.
22

What is dysmenorrhea? What are the characteristics of dysmenorrhea?

  • Defined = pain during or immediately before menstruation
  • Young women ages 17 to 24 years are most likely to report, but can occur in all age groups
  • Improves in most women after full term pregnancy
  • More common in women who smoke & are obese
  • Severe dysmenorrhea assoc /w early menarche, nulliparity, stress
  • Differentiated as primary or secondary
23

What are the s/s of dysmenorrhea?

Sx begin /w menstruation, although some women have discomfort several hrs before onset of flow

Painis usually located in suprapubic area or lower abdomen

Pain described as either sharp, cramping, gripping or as a steady dull ache

Pain may radiate to lower back or upper thighs

Range and severity of sx are different from woman to woman and from cycle to cycle in the same woman

Sx of dysmenorrhea may last several hours or several days

24

What is primary dysmenorrhea? What characterizes it?

Physiologic alteration in some women. No pathology. Just made that way. Excessive release of prostaglandin F2a. After the first 48 hours of their period, the pain lessens. Women who do not ovulate, including those who are older and those who’ve just started their periods, do not have this problem.

Incidence declines with age

—Most common in late teens & early twenties

—It is d/t the occurrence of a physiologic alteration in some women

—It is not caused by underlying pathology

Excessive release of PGF 2a leads to uterine contrax, vasospasm of uterine arterioles à ischemia & cyclic low abd cramps

Sx d/t PGF 2a : PAIN =

  • —Backache, weakness, sweating,
  • —GI (anorexia, nausea, vomiting, and diarrhea), &
  • —CNS sx (dizziness, syncope, headache, and poor concentration)
25

What are nursing management strategies for primary dysmenorrhea?

Information and support

Heat

Massage

Effleurage - series of massaging strokes to the uterus

Guided imagery, progressive relaxation, yoga, and meditation

Exercise

Good nutrition

26

What are some specific dietary changes used to manage primary dysmenorrhea?

Decreased salt and refined sugar intake 7 to 10 days before expected menses may reduce fluid retention

Increasing water intake = a natural diuretic

Other natural diuretics: asparagus, cranberry juice, peaches, parsley, and watermelon may help reduce edema

Decreasing red meat intake also may help minimize sx

Switch from a high-fat to a low-fat diet. Make fats vegetable fats. Olive oil, avocados.

Ginger a natural anti-inflammatory = good in salads

Decrease caffeine – Xanthine drug family

27

What are some meds used for primary dysmenorrhea?

NSAIDS = prostaglandin inhibitors. Effective if begun 2 to 3 days before menses or with the first sign of bleeding. (Table 4-1, p 77)

Oral Contraceptive Pills = decrease prostaglandin production

Herbal / Folk medicines – important that you take a hx of herbals. Ginger tea is used for cramps.

28

What is secondary dysmenorrhea? S/s? How is it diagnosed? How is it treated?

Menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25 (Usually around 30 – 40 years)

Associated with pelvic pathology, such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids)

SX = irregular flow (metrorrhagia) [bleeding betwn periods], heavy flow (menorrhagia), pain, dyspareunia (pain during intercourse), painful defecation

DX = assisted by US, D&C, endometrial bx, or laparoscopy.

TX = removal of the underlying pathology.

29

What is amenorrhea? What are the characteristics of amenorrhea?

Definition: the absence of menstrual flow

Evaluate:

—(1) the absence of both menarche and secondary sexual characteristics by age 14 years;

—(2) absence of menses by age 16 years, regardless of presence of normal growth and development (primary amenorrhea);

—(3) a 3- to 6-month absence of menses after a period of menstruation (secondary amenorrhea)

Amenorrhea is not a disease, but rather a sign of one

Amenorrhea is most commonly a result of pregnancy - anybody who presents w/amenorrhea gets a pregnancy test.

—Amenorrhea always results in loss of calcium from bones:Dental exam before they get pregnant.

—Preg women need lots of calcium – diet almost always inadequate during pregnancy

30

What are the characteristics of Hypogonadotropic amenorrhea? How is it diagnosed? What are two common causes?

Etiology = hypothalamic suppression d/t stress, sudden wt loss, eating disorder, strenuous exercise, mental illness

Reflects a problem in the central hypothalamic-pituitary axis

DX = Rule out preg /w hCG pregnancy test

—Dx tests used = FSH level, TSH & prolactin levels; x-rays, CT scan, or MRI of the sella turcica, & progesterone challenge test

  • The progesterone challenge test is where the woman takes progesterone for 5 days. If she has a period, she has passed the progesterone challenge test. If she doesn’t have a period, she likely has a brain tumor.

2 disorders that frequently are of this type:

—anorexia nervosa: amenorrhea is classic sign

—female athlete triad: amenorrhea, eating disorder, osteoporosis

FAT is associated with body composition where height/weight and fat percentage is out of whack. Have to have 22% body fat to maintain menses. Competitive women sometimes get this disorder.

31

What are the characteristics of exercise-associated hypogonadotropic amneorrhea?

Assoc /w body composition (ht, wt, & % body fat)

Type, intensity, & frequency of exercise

Nutritional status

Presence of emotional or physical stressors

Women engaged in sports emphasizing low bodyweight, contour-revealing clothing worn for competition, & wt categories for participation are at greatest risk

Dance, gymnastics, figure skating, distance running, cycling, swimming, diving, volleyball, rowing, martial arts.

Have to change exercise routine, osteoporosis will occur w/o periods.

32

What are nursing management options for amenorrhea?

Potentially reversible

Counseling and education are primary interventions

—D/c meds known to affect menstruation, correct weight loss, deal more effectively /w psychological stress, address emotional distress, & alter exercise routine

—Work /w the woman to help her identify, cope /w, & resolve sources of stress

—Deep-breathing exercises & relaxation techniques are simple, effective stress reduction measures

—Referral for biofeedback or massage therapy

—Decrease intensity or duration of training

—Teach about consequences of osteoporosis

—Increase daily Ca+ intake (1200 – 1500 mg/day)

—Vitamin D 400 – 800 IU

—K+ 60 – 90 mg

—If placed on OCPs (so @ least 4-6 periods /yr) -important to teach how to take & what SE to report

33

What is toxic shock syndrome? What are the s/s? Who does it affect?

Definition: acute female condition r/t menses & tampon use

Etiology: toxin from Staphylococcus aureus

Pathophysiology: unclear

Signs/Symptoms: high fever, vomiting, diarrhea, weakness, myalgia, & sunburn-like rash-peeling soles & palms, hypotension

Epidemiology: young women < 30 y/o

History

Not a huge deal bc of better tampons in the modern era

34

What are the methods of prevention and treatment of toxic shock syndrome?

Prevention:

  • Abolish use of antibiotics in food sources for animals that we eat. Bacteria become resistant to those antibiotics. We eat the meat. We become resistant to antibiotics.
  • Use combination of tampons and pads
  • Instruct in safe tampon use

Treatment:

  • Fluid replacement to correct dehydration & electrolyte imbalance with D5LR or LR
  • IV antibiotics : Nafacillin & cephalosporins
  • Narcan for hypotension
  • Transfusion to reverse low platelet counts
  • Corticosteroids to tx skin changes
  • Monitor: client’s fatigue level, B/P, pulse, anemia & hypovolemia may be present
35

What causes the menstrual phase of the cycle?

Decreased amounts of progesterone and estrogen