NCM7 21L: CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS) LEC
LESSON 2: Reproductive and Sexual Health
PRELIMS | 2023
NURS 2-1
CONCEPT OF UNITIVE AND REPRODUCTIVE HEALTH
FOR PROMOTION OF REPRODUCTIVE AND SEXUAL HEALTH
ASSESSMENT
• Problems of sexuality or reproductive health may not be
evident on first meeting clients because it may be difficult
for people to bring up the topic until they feel more
secure with your relationship. This makes good follow-
through and planning important, because even if people
find the courage to discuss a problem once, they may
be unable to do so again. If the problem is ignored or
forgotten through a change in caregivers, the problem
can go unsolved.
• Any change in physical appearance (such as occurs
with puberty or with pregnancy) can intensify or create a
sexual or reproductive concern. The person with a
sexually transmitted infection (STI); excessive weight loss
or gain; a disfiguring scar from surgery or an unintentional
injury; hair loss such as occurs with chemotherapy;
surgery, inflammation, or infection of reproductive
organs; chronic fatigue or pain; spinal cord injury; or the
presence of a retention catheter needs to be assessed
for problems regarding sexual role as well as other
important areas of reproductive functioning.
NURSING DIAGNOSIS
Common nursing diagnoses used with regard to reproductive
health include:
• Health-seeking behaviors related to reproductive
functioning
• Anxiety related to inability to conceive after 6 months
without contraception
• Pain related to uterine cramping from menstruation
• Disturbance in body image related to early development
of secondary sex characteristics
• Risk for infection related to high-risk sexual behaviors
Diagnoses relevant to sexuality may include:
• Sexual dysfunction related to as yet unknown cause
• Altered sexuality patterns related to chronic illness
• Self-esteem disturbance related to recent reproductive
tract surgery
• Altered sexuality patterns related to fear of harming a
fetus
• Anxiety related to fear of contracting an STI
• Health-seeking behavior related to learning responsible
sexual practices
OUTCOME IDENTIFICATION AND PLANNING
• A major part of nursing care in this area is to empower
clients to feel control over their bodies.
• Plan health teaching to provide clients with knowledge
about their reproductive system and specific information
about ways to alleviate discomfort or prevent
reproductive disease. It may also be important to plan
individualized interventions to strengthen the person’s
gender identity or gender role.
• It is essential to design care that demonstrates
acceptance of all gender-related lifestyles equally.
IMPLEMENTATION
• A primary nursing role concerning reproductive anatomy
and physiology is education, because both female and
male clients may feel more comfortable asking questions
of nurses rather than other health care providers.
• Men who have sex with men (MWM), women who have
sex with women (WWW), or others with alternative
lifestyles usually reveal their sexual orientation to health
care providers because they want to be certain their
lifestyle is not adding to a health concern.
• They may also need help or suggestions on dealing with
friends or family who are having difficulty accepting their
gender identity.
• In addition to support, providing health education that
addresses potential concerns of clients of all lifestyles will
enhance their sexual health.
• For example, include a discussion about anal or oral–
genital sex practices when presenting information on
safer sex.
OUTCOME EVALUATION
The evaluation in the area of reproductive health must be
ongoing, because health education needs to change with
circumstances and increased maturity. For example, the needs of
a woman at the beginning of a pregnancy may be different from
her needs at the end.
How people feel about themselves sexually also changes
throughout life. Their concept of themselves may have a great
deal to do with how quickly they recover from an illness, how
quickly they are ready to begin self-care after childbirth, or even
how motivated they are as an adolescent to accomplish activities
in life phases that depend on being sure of their sexuality or gender
role.
Examples of expected outcomes include:
✓ Client states he is taking precautions to prevent
contracting an STI.
✓ Client states she is better able to manage symptoms of
premenstrual dysphoric syndrome.
✓ Couple states they have achieved a mutually satisfying
sexual relationship.
✓ Client states he is ready to tell family about MWM gender
identity.
ASSESSING AND MEETING REPRODUCTIVE CONCERNS
To help clients better understand reproductive functioning and
sexual health throughout their life, specific teaching might include:
• Encouraging women over 40 years of age to have
mammograms
• Explaining to a school-aged boy that nocturnal emissions
are normal
• Teaching an early adolescent about normal anatomy
and physiology and the process of reproduction
• Teaching a young adolescent safer sex practices
• Explaining reproductive physiology to a couple who wish
to become pregnant
INTERVIEWING FOR A SEXUAL HISTORY
Specific Questions to Include in a Sexual History:
• Are you sexually active?
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 • Is your sexual partner of the same or different gender?
• How many sexual partners have you had in the past 6
months?
• Are you satisfied with your sex life? If not, why not?
• Do you have any concerns about your sex life? If so, what
are they? What would you like to change?
• Do you practice “safer sex”?
• Have you ever contracted a sexually transmitted
infection or are you worried you have one now?
• Have you ever experienced a problem such as
maintaining an erection, erectile dysfunction, failure to
achieve orgasm, or pain during intercourse?
• If you’re sexually active, are you using a method to
prevent pregnancy or sexually transmitted diseases?
• Are you satisfied with your current reproductive planning
method, or do you have any questions about it?
• For adolescents: Are you vaccinated against human
papillomavirus (HPV)?
REPRODUCTIVE DEVELOPMENT
Reproductive development begins at the moment of conception
and continues through life.
INTRAUTERINE DEVELOPMENT
➢ The sex of an individual is determined at the moment of
conception by the chromosome information supplied by
the particular ovum and sperm that join to create the
new life.
➢ A gonad is a body organ that produces the cells
necessary for reproduction (the ovary in females, the
testis in males).
➢ At approximately week 5 of intrauterine life, mesonephric
(wolffian) and paramesonephric (müllerian) ducts, the
tissue that will become ovaries and testes, have already
formed.
➢ By week 7 or 8, in chromosomal males, this early gonadal
tissue begins formation of testosterone.
➢ Under the influence of testosterone, the mesonephric
duct develops into male reproductive organs and the
paramesonephric duct regresses.
➢ If testosterone is not present by week 10, the
paramesonephric duct becomes dominant and
develops into female reproductive organs. When ovaries
form, all of the oocytes (cells that will develop into eggs
throughout the woman’s mature years) are already
present (Edmonds, 2012).
➢ At about week 12 of intrauterine life, the external genitals
begin to develop. In males, penile tissue elongates and
the ventral surface of the penis closes to form a urethra.
➢ In females, with no testosterone present, the uterus, labia
minora, and labia majora form. If, for some reason,
testosterone secretion is halted in utero, a chromosomal
male could be born with female-appearing genitalia
(ambiguous genitalia).
➢ If a pregnant woman should be prescribed a form of
testosterone or, because of a metabolic abnormality,
she produce a high level of testosterone, a chromosomal
female could be born with male-appearing genitalia
(Kumar, 2012).
PUBERTAL DEVELOPMENT
➢ Puberty is the stage of life at which secondary sex
changes begin.
➢ These changes in girls are stimulated when the
hypothalamus synthesizes and releases gonadotropin-
releasing hormone (GnRH), which then triggers the
anterior pituitary to release follicle-stimulating hormone
(FSH) and luteinizing hormone (LH).
➢ FSH and LH are termed gonadotropin (gonad “ovary”;
tropin “growth”) hormones not only because they begin
the production of androgen and estrogen, which in turn
initiate secondary sex characteristics, but also because
they continue to cause the production of eggs and infl
uence menstrual cycles throughout women’s lives
(Christensen, Bentley, Cabrera, et al., 2012).
➢ Although the mechanism that initiates this pubertal
change is not well understood, the hypothalamus
apparently serves as a gonadostat or regulation
mechanism to “turn on” gonad functioning.
➢ Although it is not proven, the general consensus is a girl
must reach a critical weight of approximately 95 lb (43
kg) or develop a critical mass of body fat before the
hypothalamus is triggered to send initial stimulation to the
anterior pituitary gland to begin the formation of FSH and
LH.
➢ Probably because of the combination of better nutrition
and increased obesity, girls are beginning puberty at
earlier ages than ever before (9 to 12 years of age)
(Cheng, Buyken, Shi, et al., 2012).
➢ Studies of female athletes and girls with anorexia nervosa
demonstrate that delays or halts in menstruation are
related to the lack of body fat or energy expenditure
(Doyle-Lucas, Akers, & Davy, 2010). The phenomenon of
what triggers puberty is even less understood in boys but
is probably also related to body weight.
THE ROLE OF ANDROGEN
• Hormones responsible for muscular development,
physical growth, and the increase in sebaceous gland
secretions that cause typical acne in both boys and girls
during adolescence.
• In male, androgenic hormones are produced by the
adrenal cortex and the testes
• In female, by the adrenal cortex and the ovaries.
• The level of the primary androgenic hormone,
testosterone is low in males until puberty (between 12 to
14 years) when it rises to influence pubertal changes in:
✓ Testes
✓ Scrotum
✓ Penis
✓ Prostate
✓ Seminal vesicles
✓ Appearance of male pubic
✓ Axillary
✓ Facial hair
✓ Laryngeal enlargement with its accompanying
voice change
✓ Maturation of spermatozoa
✓ Closure of growth plates in long bones (termed
adrenarche)
• In girls, testosterone influences enlargement of the:
✓ Labia majora
✓ Clitoris
✓ Formation of axillary and pubic hair
THE ROLE OF ESTROGEN
• When triggered at puberty by FSH, ovarian follicles in
females begin to excrete a high level of the hormone
estrogen.
• This increase influences the development of the:
✓ Uterus
✓ fallopian tubes
✓ vagina
✓ typical female fat distribution
✓ hair patterns
✓ breast development
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 • It also closes the epiphyses of long bones in girls the same
way testosterone closes the growth plate in boys.
• The beginning of breast development is termed
thelarche, which usually starts 1 to 2 years before
menstruation.
• Beginning of the menstruation termed menarched.
SECONDARY SEX CHARACTERISTICS
• In girls, pubertal changes typically occur as:
✓ Growth spurt
✓ Increase in the transverse diameter of the pelvis
✓ Breast development
✓ Growth of pubic hair
✓ Onset of menstruation
✓ Growth of axillary hair
✓ Vaginal secretions
• The average age at which menarche occurs is 12.4 years
of age. It may occur as early as 9 years of age or as late
as age 17 years.
• Irregular menstrual periods are the rule rather the
exception for the first year or two.
• Menstrual periods do not become regular until ovulation
occurs consistently and this does not tend to happen until
1 to 2 years after menarche.
• In boys, production of spermatozoa does not begin in
intrauterine life as does the production of ova in girls nor
are spermatozoa produced in a cyclic pattern as are
ova; rather, they are produced in a continuous process.
• The production of ova stops at menopause.
• The sperm production continues from puberty throughout
the male’s life.
• Secondary sex characteristics of boys usually occur in the
order of:
✓ Increase in weight
✓ Growth of testes
✓ Growth of face, axillary, and pubic hair
✓ Voice changes
✓ Penile growth
✓ Increase in height
✓ Spermatogenesis (production of sperm)
FEMALE / MALE REPRODUCTIVE SYSTEM
THE MALE REPRODUCTIVE SYSTEM
MALE EXTERNAL STRUCTURES
SCROTUM
➢ Rugated, skin-covered, muscular pouch suspended from
perineum.
➢ FUNCTIONS:
✓ Support the testes and help regulate the
temperature of sperm.
✓ In very cold weather, the scrotal muscle
contracts to bring the testes closer to the body.
✓ In very hot weather, or in the presence of fever,
the muscle relaxes, allowing the testes to fall
away from the body. In this way, the
temperature of the testes can remain as even
as possible to promote the production and
viability of sperm.
TESTES
➢ Two ovoid glands, 2 to 3 cm wide, that rest in the scrotum.
➢ Each testis is encased by a protective white fibrous
capsule and is composed of a number of lobules.
➢ Each lobule contains interstitial cells (Leydig cells) that
produce testosterone and a seminiferous tubule that
produces spermatozoa.
➢ Testes in a fetus first form in the pelvic cavity then
descend late in intrauterine life (about the 34th to 38th
week of pregnancy) into the scrotal sac. Because this
descent occurs so late in pregnancy, many male infants
born preterm still have undescended testes.
➢ These infants need to be monitored closely to be certain
their testes do descend at what would have been the
34th to 38th week of gestational age because testicular
descent does not occur as readily in extrauterine life as it
does in utero.
➢ Testes that remain in the pelvic cavity (cryptorchidism)
may not produce viable sperm and have a four to seven
times increased rate of testicular cancer (Ellsworth, 2012).
➢ Normal testes feel fi rm and smooth, and are egg
shaped. Beginning in early adolescence, boys need to
learn testicular self-examination so they can detect
tenderness or any abnormal growth in testes
PENIS
➢ Composed of three cylindrical masses of erectile tissue in
the penis shaft.
➢ With sexual excitement, nitric oxide is released from the
endothelium of blood vessels. This causes dilation and an
increase in blood flow to the arteries of the penis
(engorgement).
➢ The ischiocavernosus muscle at the base of the penis,
under stimulation of the parasympathetic nervous
system, then contracts, trapping both venous and arterial
blood in the three sections of erectile tissue. THIS LEADS
TO DISTENTION (and erection) OF THE PENIS.
➢ GLANS – the distal end of the organ, it is bulging, sensitive
ridge of tissue.
MALE INTERNAL STRUCTURES
EPIDIDYMIS
➢ The seminiferous tubule of each testis leads to a tightly
coild tube, the epididymis.
➢ Responsible for conducting sperm from the tubule to the
vas deferens, the next step in the passage to the outside.
➢ It is actually over 20 ft. long.
➢ Some sperm are stored in the epididymis, and a part of
the alkaline fluid (semen, or seminal fluid that contains a
basic sugar and protein) that will surround sperm at
maturity is produced by the cells lining the epididymis.
➢ Sperm are immobile and incapable of fertilization as they
pass through or are stored at the epididymis level.
➢ It takes at least 12 to 20 days for them to travel the length
of the tube, and a total of 65 to 75 days for them to reach
full maturity. This is one reason aspermia (absence of
sperm) and oligospermia (fewer than 20 million sperm per
milliliter) are problems that do not appear to respond
immediately to therapy, but do respond after 2 months
of treatment.
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VAS DEFERENS (DUCTUS DEFERENS)
➢ hollow tube surrounded by arteries and veins and
protected by a thick fi brous coating, which, altogether,
are referred to as the spermatic cord .
➢ It carries sperm from the epididymis through the inguinal
canal into the abdominal cavity, where it ends at the
seminal vesicles and the ejaculatory ducts below the
bladder.
SEMINAL VESICLES
➢ two convoluted pouches that lie along the lower portion
of the bladder and empty into the urethra by ejaculatory
ducts.
➢ These glands secrete a viscous alkaline liquid with a high
sugar, protein, and prostaglandin content.
➢ Sperm become increasingly motile because this added
fluid surrounds them with a more favorable pH
environment.
PROSTATE GLAND
➢ A chestnut-sized gland that lies just below the bladder
and allows the urethra to pass through the center of it,
like the hole in a doughnut.
➢ The purpose is to secrete a thin, alkaline fluid, which,
when added to the secretion from the seminal vesicles,
further protects sperm by increasing the naturally low pH
level of the urethra.
BULBOURETHRAL GLANDS
➢ Two bulbourethral, or Cowper’s, glands lie beside the
prostate gland and empty by short ducts into the urethra.
➢ They supply one more source of alkaline fluid to help
ensure the safe passage of spermatozoa.
➢ Semen, therefore, is derived from the prostate gland
(60%), the seminal vesicles (30%), the epididymis (5%),
and the bulbourethral glands (5%).
URETHRA
➢ a hollow tube leading from the base of the bladder,
which, after passing through the prostate gland,
continues to the outside through the shaft and glans of
the penis.
➢ It is about 8 in. (18 to 20 cm) long. Like other urinary tract
structures, it is lined with mucous membrane.
THE FEMALE REPRODUCTIVE SYSTEM
FEMALE EXTERNAL STRUCTURES
MONS VENERIS
➢ a pad of adipose tissue located over the symphysis pubis,
the pubic bone joint.
➢ Covered by a triangle of coarse, curly hairs, the purpose
of the mons veneris is to protect the junction of the pubic
bone from trauma.
LABIA MINORA
➢ posterior to the mons veneris spread two hairless folds of
connective tissue, the labia minora. Before menarche,
these folds are fairly thin; by childbearing age, they have
become firm and full; and after menopause, they
atrophy and again become much smaller.
➢ Normally, the folds of the labia minora are pink in color;
the internal surface is covered with mucous membrane,
and the external surface is covered with skin.
➢ The area is abundant with sebaceous glands, so
localized sebaceous cysts may occur here. Women who
perform monthly vulvar examinations are able to detect
infection or other abnormalities of the vulva such as
sebaceous cysts or herpes lesions.
LABIA MAJORA
➢ Two folds of tissue, fused anteriorly but separated
posteriorly, which are positioned lateral to the labia
minora and composed of loose connective tissue
covered by epithelium and pubic hair.
➢ Serve as protection for the external genitalia; they shield
the outlets to the urethra and vagina.
➢ Trauma to the area, such as occurs from childbirth or
rape, can lead to extensive edema formation because
of the looseness of the connective tissue base.
OTHER EXTERNAL ORGANS
Vestibule – flattened, smooth surface inside the labia. The
openings to the bladder (the urethra) and the uterus (the vagina)
both arise from this space.
Clitoris – a small (approx. 1 – 2 cm), rounded organ of erectile tissue
at the forward junction of the labia minora. It’s covered by a fold
skin, the prepuce; is sensitive to touch and temperature; and is the
center of sexual arousal and orgasm in a woman. Arterial blood
supply for the clitoris is plentiful. When the ischiocavernosus muscle
surrounding it contracts with sexual arousal, the venous outflow for
the clitoris is blocked and this leads to clitoral erection.
Two Skene Glands (Paraurethral Glands) – located on each side of
the urinary meatus; their ducts open into the urethra.
Bartholin Glands (Vulvovaginal Glands) – located on each side of
the vaginal opening with ducts that open into the proximal vagina
near the labia minora and hymen.
- Secretions from both of these glands help to lubricate the
external genitalia during coitus.
- The alkaline pH of their secretions also helps to improve
sperm survival in the vagina.
- If these glands are infected, they swell, feel tender, and
produce a serous discharge.
Fourchette – the ridge of tissue formed by the posterior joining of
the labia minora and the labia majora. This is the structure that
sometimes tears (laceration) or is cut (episiotomy) during childbirth
to enlarge the vaginal opening.
Posterior to the fourchette – is the perineal muscle (often called the
perineal body). Because this is a muscular area, it stretches during
childbirth to allow enlargement of the vagina and passage of the
fetal head.
Exercises suggested:
✓ Kegel exercises
✓ Squatting
✓ Tailor sitting
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Hymen – tough but elastic semicircle of tissue that covers the
opening to the vagina during childhood. It is often torn during the
time of first sexual intercourse.

VULVAR BLOOD SUPPLY

➢ Blood supply of female external genitalia is mainly from

the pudendal artery and a portion is from the inferior
rectus artery.
➢ Pressure on this vein by the fetal head during pregnancy
can cause extensive back pressure and development of
varicosities (distended veins) in the labia majora and in
the legs.

VULVAR NERVE SUPPLY

➢ The anterior portion of the vulva derives its nerve supply

from the ilioinguinal and genitofemoral nerves (L1 level).
➢ The posterior portions of the vulva and vagina are
➢ Although a fallopian tube is a smooth, hollow tunnel, it is
supplied by the pudendal nerve (S3 level).
anatomically divided into four separate parts:
FEMALE INTERNAL STRUCTURES • The most proximal division, the interstitial
portion, is the part of the tube that lies within the
OVARIES uterine wall. This portion is only about 1 cm in
length; its lumen is only 1 mm in diameter.
➢ Approx. 3 cm long by 2 cm diameter and 1.5 cm thick, or • The next distal portion is the isthmus. This is about
the size and shape of almonds. 2 cm in length and like the interstitial tube,
➢ Grayish-white and appear pitted, with minute remains extremely narrow. This is the portion of
indentations on the surface. the tube that is cut or sealed in a tubal ligation,
➢ Located close to and on both sides of the uterus in the or tubal sterilization procedure.
lower abdomen. They lie so low they cannot be located • The ampulla is the third and also the longest
by abdominal palpation. portion of the tube. It is about 5 cm in length
➢ Function is to produce, mature, and discharge ova (the and is the portion of the tube where fertilization
egg cells). of an ovum usually occurs.
• The infundibular portion is the most distal
segment of the tube. It is about 2 cm long,
funnel shaped, and covered by fi mbria (small
hairs) that help to guide the ovum into the
fallopian tube.
➢ The lining of the fallopian tubes is composed of a mucous
membrane, which contains both mucus-secreting and
ciliated (hair-covered) cells. Beneath this mucous lining
are connective tissue and a circular muscle layer. The
muscle layer is important because it is able to produce
peristaltic motions that help conduct the ovum the
length of the tube (probably also aided by the action of
the ciliated lining and the mucus, which acts as a
lubricant).

UTERUS

➢ Hollow, muscular, pear-shaped organ located in the

The Division of Reproductive Cells (Gametes) – at birth, each ovary lower pelvis, posterior to the bladder and anterior to the
contains approx. 2 million immature ova (oocytes), which were rectum.
formed during the first 5 months of intrauterine life. ➢ During childhood, it is about the size of an olive, the cervix
is the largest portion and the uterine body is the smallest
The Maturation of Oocytes – between 5 and 7 million ova form in part.
utero. Most never develop beyond a primitive state and then ➢ When a girl reaches about 8 years of age, an increase in
atrophy, so by birth only about 2 million are still present. By age 7 the size of the organ begins. This growth is so slow,
years, only about 500,000 are present in each ovary; by 22 years however, the young woman closer to 17 years old before
of age, the count is down to 300, 000; and by menopause, or the the uterus reaches its adult size and changes its
end of the fertile period in females, none are left. proportions so the body cavity, not the cervix, is its largest
portion.
FALLOPIAN TUBES
Uterine and Cervical Coats (consists of three separate coats or
➢ Arise from each upper corner of the uterine body and
layers of tissue)
extend outward and backward until each opens at its
distal end, next to an ovary. - Endometrium – an inner layer of mucous membrane
- Myometrium – middle layer of muscle fibers
- Perimetrium – outer layer of connective tissue

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 VAGINA

➢ a hollow, musculomembranous canal located posterior

to the bladder and anterior to the rectum.
➢ It extends from the cervix of the uterus to the external
vulva. Its function is to act as the organ of intercourse and
to convey sperm to the cervix. With childbirth, it expands
to serve as the birth canal.

THE PHYSIOLOGY OF MENSTRUATION

Four body structures are involved in the physiology of the menstrual

cycle to be complete:

- Hypothalamus
- Pituitary Gland
- Ovaries
- Uterus

CHARACTERISTICS OF NORMAL MENSTRUAL CYCLES

Ordinarily, the body of the uterus tips slightly forward. Positional

deviations of the uterus that are commonly seen include:

• Anteversion: the entire uterus tips far forward

• Retroversion: the entire uterus tips far back
• Anteflexion: the body of the uterus is bent sharply forward
at the junction with the cervix
• Retroflexion: the body of the uterus is bent sharply back
just above the cervix

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HYPOTHALAMUS
- The release of GnRH (also called luteinizing hormone-
releasing hormone [LHRH]) from the hypothalamus
initiates the menstrual cycle.
- GnRH then stimulates the pituitary gland to send
gonadotropic hormone to the ovaries to produce
estrogen. When the level of estrogen rises, release of
GnRH is repressed and no further menstrual cycles will
occur (the principle that birth control pills use to eliminate
menstrual flows). Excessive levels of pituitary hormones
can also inhibit release.
- During childhood, the hypothalamus is apparently so
sensitive to the small amount of estrogen produced by
the adrenal glands, release of GnRH is suppressed.
- Beginning with puberty, the hypothalamus becomes less
sensitive to estrogen feedback, so every month in
females, the hormone is released in a cyclic pattern.
- Diseases of the hypothalamus, which cause deficiency
of this releasing factor, can result in delayed puberty.
Likewise, a disease that causes early activation of GnRH
can lead to abnormally early sexual development or
precocious puberty.
PITUITARY GLAND
- Under the influence of GnRH, the anterior lobe of the
pituitary gland (the adenohypophysis) produces two
hormones:
✓ FSH, a hormone active early in the cycle that is
responsible for maturation of the ovum.
✓ LH, a hormone that becomes most active at the
midpoint of the cycle and is responsible for
ovulation, or release of the mature egg cell
from the ovary. It also stimulates growth of the
uterine lining during the second half of the
menstrual cycle.
OVARIES
- FSH and LH are called gonadotropic hormones because
they cause growth (trophy) in the gonads (ovaries). Every
month during the fertile period of a woman’s life (from
menarche to menopause), one of the ovary’s oocytes is
activated by FSH to begin to grow and mature. As the
oocyte grows, its cells produce a clear fluid (follicular
fluid) that contains a high degree of estrogen and some
progesterone. As the follicle surrounding the oocyte
grows, it is propelled toward the surface of the ovary. At
full maturity, the follicle is visible on the surface of the
ovary as a clear water blister approximately 0.25 to 0.5 in.
across. At this stage of maturation, the small ovum
(barely visible to the naked eye, about the size of a
printed period) with its surrounding follicular membrane
and fluid is termed a graafian follicle.
UTERUS
The First Phase of the Menstrual Cycle (Proliferative). Immediately
after a menstrual flow (which occurs during the first 4 or 5 days of
a cycle), the endometrium, or lining of the uterus, is very thin,
approximately one cell layer in depth. As the ovary begins to
produce estrogen (in the follicular fluid, under the direction of the
pituitary FSH), the endometrium begins to proliferate so rapidly the
thickness of the endometrium increases as much as eightfold from
day 5 to day 14. This first half of a menstrual cycle is
interchangeably termed the proliferative, estrogenic, follicular, or
postmenstrual phase.
The Second Phase of the Menstrual Cycle (Secretory). After
ovulation, the formation of progesterone in the corpus luteum
(under the direction of LH) causes the glands of the uterine
endometrium to become corkscrew or twisted in appearance and
dilated with quantities of glycogen (an elementary sugar) and
mucin (a protein). It takes on the appearance of rich, spongy
velvet. This second phase of the menstrual cycle is termed the
progestational, luteal, premenstrual, or secretory phase. The Third
Phase of the Menstrual Cycle (Ischemic). If fertilization does not
occur, so the corpus luteum in the ovary begins to regress after 8
to 10 days, the production of progesterone decreases. With the
withdrawal of progesterone, the endometrium of the uterus begins
to degenerate (at about day 24 or day 25 of the cycle). The
capillaries rupture, with minute hemorrhages, and the
endometrium sloughs off.
The Fourth Phase of the Menstrual Cycle (Menses). Menses, or a
menstrual fl ow, is composed of a mixture of blood from the
ruptured capillaries; mucin; fragments of endometrial tissue; and
the microscopic, atrophied, and unfertilized ovum. Menses is
actually the end of an arbitrarily defined menstrual cycle. Because
it is the only external marker of the cycle, however, the first day of
menstrual flow is used to mark the beginning day of a new
menstrual cycle. Contrary to common belief, a menstrual flow
contains only 30 to 80 ml of blood; if it seems to be more, it is
because of the accompanying mucus and endometrial shreds.
The iron loss in a typical menstrual flow is approximately 11 mg. This
is enough loss that many women need to take a daily iron
supplement to prevent iron depletion during their menstruating
years (Coad & Conlon, 2011).
HUMAN SEXUALITY
SEXUALITY
➢ A multidimensional phenomenon that includes feelings,
attitudes, and actions.
➢ It has both biologic and cultural diversity components. It
encompasses and gives direction to a person’s physical,
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 emotional, social, and intellectual responses throughout
life.
BIOLOGIC GENDER
➢ The term used to denote a person’s chromosomal sex:
male (XY) or female (XX).
GENDER IDENTITY
➢ Or sexual identity is the inner sense a person has of being
male or female, which may be the same as or different
from biologic gender.
GENDER ROLE
➢ The male or female behavior a person exhibits, which,
again, may or may not be the same as biologic gender
or gender identity.
THE HUMAN SEXUAL RESPONSE
➢ Sexuality has always been a part of human life, but only
in the past few decades has it been studied scientifically.
One common finding of researchers has been that
feelings and attitudes about sex vary widely across
cultures and individuals (Box 5.5). Although the sexual
experience is unique to each individual, sexual
physiology (how the body responds to sexual arousal)
has common features (Kimmel & Rogers, 2011).
THE SEXUAL RESPONSE CYCLE
• Excitement
✓ Occurs with physical and psychological
stimulation (sight, sound, emotion, or thought)
that causes parasympathetic nerve stimulation.
✓ Leads to arterial dilation and venous
constriction in the genital area.
✓ In women, this vasocongestion causes the
clitoris to increase in size and mucoid fluid to
appear on vaginal walls for lubrication. The
vagina widens in diameter and increases in
length. Breast nipples become erect.
✓ In men, penile erection occurs, as well as scrotal
thickening and elevation of the testes.
• Plateau
✓ In the woman, the clitoris is drawn forward and
retracts under the clitoral prepuce; the lower
part of the vagina becomes extremely
congested (formation of the orgasmic
platform), and there is increased breast nipple
elevation.
✓ In men, vasocongestion leads to distention of
the penis. Heart rate increases to 100 to 175
beats/min and respiratory rate to about 40
breaths/min.
• Orgasm
✓ Occurs when stimulation proceeds through the
plateau stage to a point at which a vigorous
contraction of muscles in the pelvic area expels
or dissipates blood and fluid from the area of
congestion.
✓ The average number of contractions for the
woman is 8 to 15 contractions at intervals of 1
every 0.8 seconds.
✓ In men, muscle contractions surrounding the
seminal vessels and prostate project semen into
the proximal urethra.
✓ These contractions are followed immediately
by three to seven propulsive ejaculatory
contractions, occurring at the same time
interval as in the woman, which force semen
from the penis.
• Resolution
✓ a 30-minute period during which the external
and internal genital organs return to an
unaroused state. For the male, a refractory
period occurs during which further orgasm is
impossible. Women do not go through this
refractory period, so it is possible for women
who are interested and properly stimulated to
have additional orgasms immediately after the
first.
CONTROVERSIES ABOUT FEMALE ORGASM
The female orgasm has been a topic of much controversy over the
years, beginning with Freud, who deducted there were two types
of female orgasms: clitoral and vaginal. He believed clitoral
orgasms (originating from masturbation or other noncoital acts)
represented sexual immaturity and only vaginal orgasms were the
authentic, mature form of sexual behavior in women. Accordingly,
he considered women to be neurotic if they did not achieve
orgasm through coitus.
Masters et al. (1998) revealed that women report a difference in
intensity and character between orgasms achieved through
coitus and through direct stimulation of the clitoris and some prefer
one to the other, but there is no physiologic difference between
the two. For most women, adequate time for foreplay is essential
for them to be orgasmic.
In recent years, a subject of controversy regarding female
sexuality has arisen regarding the existence of a “G spot.” First
described in 1950 by the German physician Gräfenberg, the G
spot, presumably located on the inner portion of the vaginal wall
halfway between the pubic bone and the cervix, has been
promoted as an area of heightened erotic sensitivity ( Kimmel &
Rogers, 2011). Several studies carried out in the past 10 years have
not been able to verify the existence of this particular anatomic
site, although some women claim to possess such an erotic trigger
(Kilchevsky, Vardi, Lowenstein, et al., 2012).
THE INFLUENCE OF THE MENSTRUAL CYCLE ON SEXUAL RESPONSE
During the second half of the menstrual cycle—the luteal phase—
there is increased fluid retention and vasocongestion in the
woman’s lower pelvis. Because some vasocongestion is already
present at the beginning of the excitement stage of the sexual
response, women appear to reach the plateau stage more quickly
and achieve orgasm more readily during this time. Women also
may be more interested in initiating sexual relations during this
time.
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THE INFLUENCE OF PREGNANCY ON SEXUAL RESPONSE
Pregnancy is another time in life when there is vasocongestion of
the lower pelvis because of the blood supply needed by a rapidly
growing fetus. This causes some women to experience their first
orgasm during their first pregnancy.
Following a pregnancy, many women continue to experience
increased sexual interest because the new growth of blood vessels
during pregnancy lasts for some time and continues to facilitate
pelvic vasocongestion. These differences in response are why
discussing sexual relationships is an important part of health
teaching during pregnancy.
At a time when a woman may want sexual contact very much,
she needs to be free of myths and misconceptions, such as the
notion that orgasm will cause a spontaneous miscarriage.
Although the level of oxytocin, the hormone that rises with labor,
does appear to rise in women after orgasm, this rise is not enough
that women should worry that sexual relations will lead to
premature labor in the average woman.
For some women, the increased breast engorgement that
accompanies pregnancy results in extreme breast sensitivity
during coitus. Foreplay that includes sucking or massaging of the
breasts may also cause release of oxytocin, but it is not
contraindicated unless the woman has a history of premature
labor. Box 5.6 shows an interprofessional care map illustrating both
nursing and team planning for reproductive and sexual health.
TYPES OF SEXUAL ORIENTATION
HETEROSEXUALITY
• a person who finds sexual fulfillment with a member of
the opposite gender.
HOMOSEXUALITY
• a person who finds sexual fulfillment with a member of his
or her own sex.
BISEXUALITY
• if they achieve sexual satisfaction from both homosexual
and heterosexual relationships.
TRANSSEXUALITY / TRANSGENDER
• an individual who, although of one biologic gender, feels
as if he or she is of the opposite gender.
TYPES OF SEXUAL EXPRESSION
SEXUAL ABSTINENCE / CELIBACY
• Separation from sexual activity. It is the avowed state of
certain religious orders. It is also a way of life for many
adults and one that is becoming fashionable among a
growing number of young adults.
MASTURBATION
• a self-stimulation for erotic pleasure; it can also be a
mutually enjoyable activity for sexual partners. It offers
sexual release, which may be interpreted by the person
as overall tension or anxiety relief.
EROTIC STIMULATION
• the use of visual materials such as magazines or
photographs for sexual arousal. Although this is thought
to be mostly a male phenomenon, there is increasing
interest in erotic literature, DVDs, and centerfold
photographs in magazines marketed primarily to
women.
FETISHISM
• Paraphilia is sexual arousal to objects, situations, or
individuals. The most common form of this is fetishism, the
sexual arousal from the use of certain objects perceived
to have erotic qualities such as leather, rubber, shoes, or
feet.
TRANSVESTISM
• transvestite is a form of fetishism in which an individual
dresses in the clothes of the opposite sex. Transvestites
can be heterosexual, homosexual, or bisexual. Many are
married. Some transvestites, particularly married
heterosexuals, may be under a great deal of strain to
keep their lifestyle a secret from friends and neighbors.
VOYEURISM
• obtaining sexual arousal by looking at another person’s
body. Almost all children and adolescents pass through
a stage when voyeurism is appealing, but this passes with
more active sexual expressions.
SADOMASOCHISM
• involves inflicting pain (sadism) or receiving pain
(masochism) to achieve sexual satisfaction (Wright,
2010). It is a practice generally considered to be within
the limits of normal sexual expression as long as the pain
involved is minimal and the experience is consensual and
satisfying to both sexual partners.
ADDITIONAL TYPES OF SEXUAL EXPRESSION
Exhibitionism – revealing one’s genitals in public.
Bestiality – sexual relations with animals.
Pedophiles – individuals who are interested in sexual encounters
with children. They are registered as sex offenders. When they
move into a new community, families are notified of the move
according to Megan’s Law, a national law designed to alert
citizens to the presence of a sex offender in a community. Ways to
keep children safe from sex offenders are discussed in Chapter 31,
along with other aspects of community safety for young children.
SEXUAL HARASSMENT
➢ unwanted, repeated sexual advances, remarks, or
behavior toward another that is offensive to the recipient
or interferes with job or school performance. It can
involve actions as obvious as a job superior demanding
sexual favors from an employee, or it could be a man or
woman sending sexist jokes by e-mail to another person
in the department. In school, it can refer to bullying.
➢ TWO TYPES EXIST:
✓ Quid Pro Quo (an equal exchange) – which an
employer asks for something in return for sexual
favors, such as hiring or promotion preference.
09 / 01 / 23 PRELIMS| 9
 ✓ Hostile Work Environment – which an employer
creates an environment in which an employee
feels uncomfortable and exploited (such as
being addressed as “honey” or “babe”, asked
to wear revealing clothing, or working where
walls are decorated with sexist posters).
DISORDERS OF SEXUAL FUNCTIONING
FAILURE TO ACHIEVE ORGASM
• Can be a result of poor sexual technique, concentrating
too hard on achievement, or negative attitudes toward
sexual relationships.
ERECTILE DYSFUNCTION
THE INDIVIDUAL WITH A HYPOACTIVE SEXUAL DESIRE
- Decreased sexual desire can also be a side effect of
many medicines.
- Chronic diseases, such as peptic ulcers or chronic
pulmonary disorders that cause frequent pain or
discomfort, may interfere with a man’s or a woman’s
overall well-being and interest in sexual activity.
- Obese men and women may not feel as much
satisfaction from sexual relations as others because they
have difficulty achieving deep penetration due to the
bulk of their abdomens.
- An individual with an STI such as genital herpes may
choose to forgo sexual relations rather than inform a
partner of the disease.

• Formerly referred to as impotence, is the inability of a RESPONSIBLE PARENTHOOD

man to produce or maintain an erection long enough for REPRODUCTIVE LIFE PLANNING
penetration or partner satisfaction.
• Includes all the decisions an individual or couple make
PREMATURE EJACULATION about whether and when to have children, how many
children to have, and how they are spaced.
• Ejaculation before the sexual partner’s satisfaction has
been achieved. It applies to both same sex and opposite
sex couples. Premature ejaculation can be
unsatisfactory and frustrating for both partners.

PERSISTENT SEXUAL AROUSAL SYNDROME

• Occurs in women and is the excessive and unrelenting

sexual arousal in the absence of desire. It may be
triggered by either medications or psychological factors
and is associated with restless leg syndrome and
overactive bladder.

PAIN DISORDERS

• When pain occurs in response to sexual activities, it can

be acute and severe and can impair a person’s ability to
enjoy this aspect of their life.

VAGINISMUS

• involuntary contraction of the muscles at the outlet of the

vagina when coitus is attempted, which prohibits penile
penetration (Reissing, 2012). Vaginismus may occur in
women who have been raped. Other causes are
unknown, but it could also be the result of early learning
patterns in which sexual relations were viewed as bad or
sinful.

DYSPAREUNIA

• pain during coitus. Dyspareunia can occur because of

endometriosis (abnormal placement of endometrial
tissue), vestibulitis (infl ammation of the vestibule), vaginal
infection, or hormonal changes such as those that occur
with menopause and cause vaginal drying.
INDIVIDUALS WITH UNIQUE NEEDS OR CONCERNS
THE INDIVIDUAL WITH A DISABILITY
- They may, however, have difficulty with sexual identity or
sexual fulfillment because of their disability. Males with
upper spinal cord injury, for example, may have difficulty
with erections and ejaculation because these actions
are governed at the spinal level. Manual stimulation of
the penis or psychological stimulation can, however,
achieve erection in most men with spinal cord lesions,
allowing the man a satisfying sexual relationship with his
partner. Most women with spinal cord injuries cannot
experience orgasm but are able to conceive and have
children.
FOR REPRODUCTIVE LIFE PLANNING
ASSESSMENT
➢ As a result of changing social values and lifestyles, many
people today are able to talk easily about reproductive
life planning. Other people, however, may be
uncomfortable with this topic and may not voice their
interest in the subject independently. For this reason, at
health assessments, ask clients if they want more
information or need any help with reproductive life
planning as part of obtaining a basic health history.
NURSING DIAGNOSIS
➢ Because reproductive life planning touches so many
facets of life, nursing diagnoses can differ greatly
depending on the circumstances and individual
preferences. Examples might include:
✓ Readiness for enhanced knowledge regarding
contraception options related to a desire to
prevent pregnancy.

09 / 01 / 23 PRELIMS| 10
 ✓ Deficient knowledge related to use of a NATURAL FAMILY PLANNING
diaphragm.
✓ Spiritual distress related to partner’s preferences ABSTINENCE
for contraception.
• refraining from sexual relations, has a theoretical 0%
✓ Decisional conflict regarding choice of birth
failure rate and is also the most effective way to prevent
control because of health concerns.
STIs.
✓ Decisional conflict related to unintended
pregnancy. LACTATION AMENORRHEA METHOD
✓ Powerlessness related to failure of chosen
contraceptive. • As long as a woman is breastfeeding, there is both
✓ Altered sexuality pattern related to fear of natural suppression of ovulation and the return of menses
pregnancy. ( Baselice & Lawson, 2011).
✓ Risk for ineffective health maintenance related • Lactation amenorrhea method (LAM) is a safe birth
to lack of knowledge about natural family control method (a failure rate of about 1% to 5%) if an
planning methods. infant is:
✓ Under 6 months of age
PLANNING AND IMPLEMENTATION ✓ Being totally breastfed at least every 4 hours
during the day and every 6 hours at night
➢ If a woman has a history of poor compliance with
✓ Receives no supplementary feedings
medication, for instance, it might not be realistic for her
✓ Menses has not returned
to plan on taking an oral contraceptive every day. If she
only desires temporary contraception, tubal ligation or COITUS INTERRUPTUS / WITHDRAWAL
vasectomy for her partner would certainly be
inappropriate. Be certain when counseling to be sensitive • one of the oldest known methods of contraception. The
to a couple’s religious, cultural, and moral beliefs before couple proceeds with coitus until the moment of
suggesting possible methods. It is equally important to ejaculation. Then the man withdraws and spermatozoa
explore your own beliefs and values before counseling. are emitted outside the vagina.
This not only helps develop self-awareness of how these
beliefs affect nursing care but it also allows you to POSTCOITAL DOUCHING
become more sensitive to the beliefs of others.
• Douching following intercourse, no matter what solution
OUTCOME EVALUATION is used, is ineffective as a contraceptive measure as
sperm may be present in cervical mucus as quickly as 90
➢ Evaluation is important in reproductive life planning, seconds after ejaculation, long before douching could
because anything that causes clients to discontinue or be accomplished.
misuse a particular method will leave them at risk of
pregnancy. Reassess early (within 1 to 3 weeks) after a
couple begins a new method of contraception, to
prevent such an occurrence. Evaluate not only whether
a chosen method is effective but also whether the
woman and her partner are satisfied or have further
questions. Examples of expected outcomes include:
✓ Client voices confidence in chosen
contraceptive method by next visit
✓ Client expresses satisfaction with chosen
method at follow-up visit
✓ Client consistently uses chosen method without
pregnancy for 1 year’s time

CONTRACEPTION

09 / 01 / 23 PRELIMS| 11

FERTILITY AWARENESS METHODS
- rely on detecting when a woman will be capable of
impregnation (fertile) so she can use periods of
abstinence during that time.
CALENDAR (RHYTHM) METHOD
• requires a couple to abstain from coitus on the days of a
menstrual cycle when the woman is most likely to
conceive. To plan for this, the woman keeps a diary of
about six menstrual cycles.
• To calculate “safe” days, she subtracts 18 from the
shortest cycle she documented. This number predicts her
first fertile day. She then subtracts 11 from her longest
cycle. This represents her last fertile day. If she had six
menstrual cycles ranging from 25 to 29 days, her fertile
period would be from the 7th day (25 [the shorted cycle]
– 18) to the 18th day (29 [the longest cycle] – 11). To avoid
pregnancy, she would avoid coitus during those days
(Fig. 6.1A).When used conscientiously, the method has a
low failure rate; in typical use, however, this rate rises
substantially because of irregular menstrual cycles,
miscalculation, or disregard for predicted fertile days.
BASAL BODY TEMPERATURE METHOD
• the temperature of her body at rest, falls about 0.5°F. At
the time of ovulation, her BBT rises a full Fahrenheit
degree (0.2°C) because of the rise in progesterone with
ovulation. This pattern serves as the basis for the BBT
method of contraception (Taylor et al., 2012). To use this
method, the woman takes her temperature, either orally
or with a tympanic thermometer, each morning
immediately after waking before she rises from bed or
undertakes any activity; this is her BBT. A woman who
works nights should take her temperature after
awakening from her longest sleep period, no matter
what the time of day.
CERVICAL MUCUS METHOD (BILLING’S METHOD)
• Before ovulation each month, the cervical mucus is thick
and does not stretch when pulled between the thumb
and finger.
• Just before ovulation, mucus secretion increases.
• On the day of ovulation (the peak day), it becomes
copious, thin, watery, and transparent. It feels slippery
(like egg white) and stretches at least 1 inch before the
strand breaks, a property known as spinnbarkeit.
TWO-DAY METHOD
• a woman assesses for vaginal secretions daily. If she feels
secretions for 2 days in a row, she avoids coitus that day
and the day following as the presence of secretions
suggests fertility. The method requires conscientious daily
assessment and results in about 12 days per month in
which she should avoid coitus, the same as a calendar
method.
SYMPTOTHERMAL METHOD
• combines the cervical mucus and BBT methods (Soler &
Barranco Castillo, 2010). The woman takes her
temperature daily, watching for the rise in temperature
that marks ovulation. She also analyzes her cervical
mucus every day and observes for other signs of
ovulation such as mittelschmerz (mid cycle abdominal
pain) or if her cervix feels softer than usual. The couple
then abstains from intercourse until 3 days after the rise in
temperature or the fourth day after the peak of mucus
change.
STANDARD DAYS METHOD: CYCLEBEADS
• designed for women who have menstrual cycles
between 26 and 32 days (Bekele & Fantahun, 2012). A
woman purchases a circle of beads that helps her
predict fertile days.
09 / 01 / 23 PRELIMS| 12
OVULATION DETECTION

• by the use of an over-the-counter ovulation detection kit.

These kits detect the midcycle surge of luteinizing
hormone (LH) that can be detected in urine 12 to 24
hours before ovulation. Such kits are 98% to 100%
accurate in predicting ovulation. Although they are fairly
expensive and not intended to be used as a
contraceptive aid, combining a cervical mucus
assessment and the ovulation detector to mark the peak
fertile day is becoming the method of choice for many
families.

09 / 01 / 23 PRELIMS| 13