JPTS INSTITUTE OF

SCIENCE, MANAGEMENT & TECHNOLOGY

Reproductive Health

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 Chapter One: Reproductive Health

Introduction

Reproductive health is defined as” A state of complete physical, mental, and social well being and not
merely the absence of disease or infirmity, in all matters related to the reproductive system and to its
functions and process”. This definition is taken and modified from the WHO definition of health.
Reproductive health refers to complete physical, mental and social well-being. It doesn’t only mean the
absence of disease or fertility but instead refers to a broader term, wherein a person is happy and leads a
satisfying personal life. It is used to enhance the quality of life and increase awareness in the population.
It includes real-life approaches involving both women and men that affect them from their teens to old
age. Reproductive health does not only mean any abnormality related to the reproductive system.
Reproductive health includes sexual health, the purpose of which is the enhancement of personal
relations and awareness. It does not merely refer to counselling and care for sexually transmitted diseases
and reproduction.

Reproductive Health addresses the human sexuality and reproductive processes, functions and system at
all stages of life and implies that people are able to have “a responsible, satisfying and safe sex life and
that they have the capability to reproduce and the freedom to decide if, when and how often to do so.”

Components of Reproductive Health

• Quality family planning services

• Promoting safe motherhood: prenatal, safe delivery and post natal care, including breast feeding;

• Prevention and treatment of infertility

• Prevention and management of complications of unsafe abortion;

• Safe abortion services, where not against the law;

• Treatment of reproductive tract infections, including sexually transmitted infections;

• Information and counselling on human sexuality, responsible parenthood and sexual and reproductive
health;

• Active discouragement of harmful practices, such as female genital mutilation and violence related to
sexuality and reproduction;

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• Functional and accessible referral

There are three essential components of sexual and reproductive health care-

1. Family planning – It has a significant impact on the well-being of families and especially women.
With better family planning and the use of contraceptives, one can avoid unwanted pregnancies and
space births and also protect themselves from STDs.
2. Sexual health – It refers to a respectful and positive approach towards sexual relationships. It is a
very important prerequisite for good reproductive health.
3. Maternal health – It refers to the maintenance of a woman’s health during pregnancy and after
childbirth.

Reproductive rights

Reproductive rights are part of human rights which are already acknowledged in domestic laws,
international documents on human rights, and other related documents. These rights are basic right of all
couples and individuals to decide freely and responsibly the number, spacing and timing of their children
and to have the information and means to do so, and the right to attain the highest standard of sexual and
reproductive health. In addition, it also includes their right to make decisions concerning reproduction
free of discrimination, coercion and violence, as expressed in human rights documents. The rights to use
appropriate health care services so that women can enjoy safe pregnancy and delivery and couples can
have the best opportunities to have healthy children are also included.

Three rights in particular were identified:

• The right of couples and individuals to decide freely and responsibly the number and spacing of
children and to have the information and means to do so;

• The right to attain the highest standard of sexual and reproductive health; and,

• The right to make decisions free of discrimination, coercion or violence.

Importance of Reproductive Health

 It is very important for an adult and adolescents to be aware of sexual health, reproduction,
contraceptives, and STDs.
 This will help in maintaining good reproductive health, physically as well as mentally.

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 People can protect themselves from sexually transmitted infections and disease only if they are well
informed about the same.
 Women should be aware of their fitness for pregnancy. They must have access to proper medical
services when they are pregnant, have a safe delivery and deliver a healthy baby.

Factors Affecting the Reproductive Health Needs of Young Adults

 Age.
 Marital status.
 Gender norms.
 Sexual activity.
 School status.
 Childbearing status.
 Economic/social status.
 Rural/urban.
Reproductive Health situation in Nigeria
Nigeria has a population of 140 million people, and adolescents constitute about 20%, or one fifth, of
the total population. This has important reproductive implications because it means a large
proportion of the future adult population needs to have the correct information about reproductive
health. Adolescents have special needs as regards reproductive issues because they are often ill informed,
exploited, and prone to various complications. About two fifths of teenage pregnancies in Nigeria are
believed to end in induced abortions, with the majority being carried out by untrained personnel and in
unsafe environments. They thus constitute the majority of cases of abortion-related complications
admitted in Nigerian hospitals. In most cultures it is rare or even a taboo for parents to discuss
reproductive issues with their adolescent children, leaving adolescents to obtain such information by
themselves. Such information is then obtained from friends, the media, older siblings, and any other
available informants. Most of these sources are wrong and often misleading. The need to establish the
frequency of sexual practices, including intercourse and related issues, among secondary school students.

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 Chapter two: Reproductive system

Introduction

The reproductive system is a collection of internal and external organs in both males and females that
work together for the purpose of procreating. Due to its vital role in the survival of the species, many
scientists feel that the reproductive system is among the most important systems in the entire body. Of
the body’s major systems, the reproductive system is the one that differs most between sexes, and the
only system that does not function until puberty. The male reproductive system is responsible for
delivering sperm to the female reproductive system

Female Reproductive System

The female reproductive system consists of internal and external organs. It creates hormones and is
responsible for fertility, menstruation and sexual activity.

The female reproductive system is the body parts that help women or people assigned female at birth
(AFAB):

 Have sexual intercourse.

 Reproduce.
 Menstruate.

Parts of the female reproductive system

The female reproductive anatomy includes both external and internal parts.

External parts

The function of the external genitals is to protect the internal parts from infection and allow sperm to
enter the vagina. The vulva is the collective name for all the external genitals. A lot of people mistakenly
use the term “vagina” to describe all female reproductive parts. However, the vagina is its own structure
located inside your body.

The main parts of the vulva or external genitals are:

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 Labia majora: The labia majora (“large lips”) enclose and protect the other external
reproductive organs. During puberty, hair growth occurs on the skin of the labia majora, which also
contain sweat and oil-secreting glands.
 Labia minora: The labia minora (“small lips”) can have a variety of sizes and shapes. They
lie just inside the labia majora, and surround the opening to the vagina (the canal that joins the lower part
of your uterus to the outside of the body) and urethra (the tube that carries pee from the bladder to the
outside of the body). This skin is very delicate and can become easily irritated and swollen.
 Clitoris: Your two labia minora meet at your clitoris, a small, sensitive protrusion that’s
comparable to a penis in men or people assigned male at birth (AMAB). Your clitoris is covered by a
fold of skin called the prepuce and is very sensitive to stimulation.
 Vaginal opening: Your vaginal opening allows menstrual blood and babies to exit your
body. Tampons, fingers, sex toys or penises can go inside your vagina through your vaginal opening.
 Hymen: Your hymen is a piece of tissue covering or surrounding part of your vaginal
opening. It’s formed during development and present during birth.
 Opening to your urethra: The opening to your urethra is the hole you pee from.

Internal parts

 Vagina: Your vagina is a muscular canal that joins the cervix (the lower part of uterus) to
the outside of the body. It can widen to accommodate a baby during delivery and then shrink back to
hold something narrow like a tampon. It’s lined with mucous membranes that help keep it moist.
 Cervix: Your cervix is the lowest part of your uterus. A hole in the middle allows sperm to
enter and menstrual blood to exit. Your cervix opens (dilates) to allow a baby to come out during
a vaginal childbirth. Your cervix is what prevents things like tampons from getting lost inside your body.
 Uterus: Your uterus is a hollow, pear-shaped organ that holds a fetus during pregnancy.
Your uterus is divided into two parts: the cervix and the corpus. Your corpus is the larger part of your
uterus that expands during pregnancy.
 Ovaries: Ovaries are small, oval-shaped glands that are located on either side of your uterus.
Your ovaries produce eggs and hormones.
 Fallopian tubes: These are narrow tubes that are attached to the upper part of your uterus
and serve as pathways for your egg (ovum) to travel from your ovaries to your uterus. Fertilization of an
egg by sperm normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it
implants into your uterine lining.

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Functions of the female reproductive system

The female reproductive system provides several functions. In addition to allowing a person to have
sexual intercourse, it also helps a person reproduce.

The vagina has three core functions:

 It carries menstrual flow outside the body

 It receives the male penis during sexual intercourse
 It serves as a birth canal during labour.

Your ovaries produce eggs. These eggs are then transported to your fallopian tube
during ovulation where fertilization by a sperm may occur. The fertilized egg then moves to your uterus,
where the uterine lining has thickened in response to the normal hormones of your menstrual cycle (also
called your reproductive cycle). Once in your uterus, the fertilized egg can implant into the thickened
uterine lining and continue to develop. If implantation doesn’t take place, the uterine lining is shed as
your menstrual period. In addition, the female reproductive system produces sex hormones that maintain
your menstrual cycle. During menopause, the female reproductive system gradually stops making the
female hormones necessary for the menstrual cycle to work. At this point, menstrual cycles can
become irregular and eventually stop. You’re considered to be menopausal when you’ve gone an entire
year without a menstrual period.

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Male Reproductive System

The male reproductive system is responsible for delivering sperm to the female reproductive system

• Overall function is to produce offspring

• Testes produce sperm and male sex hormones

• Ovaries produce eggs and female sex hormones

• Mammary glands produce milk

In males, the reproductive organs include the penis, the testes, a number of storage and transport ducts,
and some supporting structures. The two oval-shaped testes (also called testicles) lie outside the body in

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a pouch of skin called the scrotum, where they can maintain the optimum temperature for sperm
production – approximately 5° F, lower than body temperature. Testes are oval-shaped glands
responsible for the manufacture of sperm and the sex hormone testosterone. From each testis, sperm pass
into a coiled tube – the epididymis – for the final stages of maturation.

Inside the Scrotum

The scrotum contains two testes (testicles) where sperm are manufactured within tubes called
seminiferous tubules, and the two epididymides where sperm are stored. Unlike female egg maturation,
which occurs in cycles and ceases at menopause, sperm production is continuous, reducing gradually

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with age. Each epididymis is a tube about 20 feet long, which is tightly coiled and bunched into a length
of just 2 inches.

Making Sperm

Each testis is a mass of more than 800 tightly looped and folded vessels known as seminiferous tubules.
Inside each tubule, sperm begin as blob-like cells called spermatogonia lining the inner wall. These pass
through a larger stage, as primary spermatocytes, then become smaller as secondary spermatocytes, and
begin to develop tails as spermatids. As all of this happens, they move steadily towards the middle of the
tubule. The spermatids finally develop into ripe sperm with long tails. Thousands of sperm are produced
every second, each taking about two months to mature.

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Difference in Semen and Sperm

Semen, also known as seminal fluid, is much more than just sperm. Sperm is only about 5 to 10% of any
given male single ejaculation and the rest is fructose (aka sugar), fatty acids, and proteins to nourish the
sperm during their journey.

Sperm Count

A man will produce roughly 525 billion sperm during his whole lifetime and close to 1 billion per month.
There are around 200 to 500 million sperm in an average in a single human ejaculation.

Sperm cell - A sperm is about 1/500 inch long, but most of this is a tail.

The sperm head is only 1/5000 inch, about the same size as a red blood cell.

Spermatogenesis and Oogenesis

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An organism undergoes a series of changes throughout its life cycle.
Gametogenesis (spermatogenesis and oogenesis), plays a crucial role in humans to support the
continuance of generations.
Gametogenesis is the process of division of diploid cells to produce new haploid cells. In humans, two
different types of gametes are present. Male gametes are called sperm and female gametes are called the
ovum.

 Spermatogenesis: Sperm formation

 Oogenesis: Ovum formation

Spermatogenesis

In the male, immature germ cells are produced in the testes. At puberty, in males, these immature germ
cells or spermatogonia are converted into sperms by the process of spermatogenesis. Spermatogonia are
diploid cells that undergo mitotic division and their number increases. Primary spermatocytes undergo
meiosis and produce haploid cells- secondary spermatocytes. These secondary spermatocytes undergo
the second meiotic division to produce immature sperms or spermatids. These spermatids undergo
spermiogenesis to transform into sperms. Various hormones like GnRH, LH, FSH and androgens are
involved in stimulating spermatogenesis.

Oogenesis

In females, the oogonia are converted to the mature ovum. This process is called oogenesis. In the female
ovary, millions of oogonia or mother cells are formed during fetal development. These mother cells
undergo the meiotic cell division, the meiotic division rests at the prophase-I and lead to the production
of primary oocytes. Primary oocytes are embedded within the primary follicles on the outer layer.
Primary follicles get surrounded by more granulosa cell layer and forms secondary follicles. Secondary
follicles then turn into the tertiary follicle. At the stage of female puberty, the primary oocytes present in
the tertiary follicles complete meiosis and form secondary oocytes (haploid) and the polar body by
unequal division. The tertiary follicle undergoes some structural and functional changes and produces
mature Graafian follicle. Secondary oocyte undergoes second meiotic division to form an ovum. Ovum
is released from the Graafian follicle during the menstrual cycle. The release of an ovum from the
Graafian follicle is called ovulation. Ovulation is controlled by the female reproductive hormone which
is stimulated by the pituitary gland.

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 Chapter three: Physiology of Menstrual Cycle

Introduction

Women or people AFAB of reproductive age (beginning anywhere from 11 to 16 years of age)
experience cycles of hormonal activity that repeat at about one-month intervals. With every cycle, your
body prepares for a potential pregnancy, whether or not that’s your intention. The term menstruation
refers to the periodic shedding of your uterine lining when pregnancy doesn’t occur that cycle. Many
people call the days that they notice vaginal bleeding their “period.”

The average menstrual cycle takes about 28 days and occurs in phases. These phases include:

 The follicular phase (the egg develops).

 The ovulatory phase (release of the egg).
 The luteal phase (hormone levels decrease if the egg doesn’t implant).

There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs)
involved in the menstrual cycle. These hormones include:

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 Follicle-stimulating hormone.
 Luteinizing hormone.
 Estrogen.
 Progesterone.

Follicular phase

This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the
following events occur:

 Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are
released from your brain and travel in your blood to your ovaries.
 The hormones stimulate the growth of about 15 to 20 eggs in your ovaries, each in its own
“shell,” called a follicle.
 These hormones (FSH and LH) also trigger an increase in the production of the hormone
estrogen.
 As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating
hormone. This careful balance of hormones allows the body to limit the number of follicles that will
prepare eggs to be released.
 As the follicular phase progresses, one follicle in one ovary becomes dominant and continues
to mature. This dominant follicle suppresses all of the other follicles in the group. As a result, they stop
growing and die. The dominant follicle continues to produce estrogen.

Ovulatory phase

The ovulatory phase (ovulation) usually starts about 14 days after the follicular phase started (the exact
timing varies). The ovulatory phase is the second phase of your menstrual cycle. Most people will have a
menstrual period 10 to 16 days after ovulation. During this phase, the following events occur:

 The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing
hormone (LH) that your brain produces.
 This causes the dominant follicle to release its egg from the ovary.
 As the egg is released (a process called ovulation) it’s captured by finger-like projections on
the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the fallopian tube.

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 For one to five days prior to ovulation, many women or people AFAB will notice an increase
in egg white cervical mucus. This mucus is the vaginal discharge that helps to capture and nourish a
sperm on its way to meet the egg for fertilization.

Luteal phase

The luteal phase begins right after ovulation and involves the following processes:

 Once it releases its egg, the empty ovarian follicle develops into a new structure called the
corpus luteum.
 The corpus luteum secretes the hormones estrogen and progesterone. Progesterone prepares
your uterus for a fertilized egg to implant.
 If intercourse has taken place and sperm has fertilized the egg (conception), the fertilized egg
(embryo) will travel through your fallopian tube to implant in your uterus. This is how pregnancy begins.
 If the egg isn’t fertilized, it dissolves in your uterus. Not needed to support a pregnancy, the
lining of your uterus breaks down and sheds. This is when your period begins.

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Normal Menstruation

When the hormone levels decrease, the endometrium layer, as it has been changed throughout the
menstrual cycle, is not able to be maintained. This is called menses, considered day 0 to day 5 of the next
menstrual cycle. The duration of menses is variable. Menstrual blood is chiefly arterial, with only 25%
of the blood being venous blood. It contains prostaglandins, tissue debris, and relatively large amounts of
fibrinolysis from endometrial tissue. The fibrinolysis lyses the clot so that menstrual blood does not
contain clots typically unless the flow is heavy. The usual duration of the menstrual flow is 3-5 days, but
flows as shorts as 1 day and as long as 8 days can occur in a normal female. The amount of blood loss
can range from slight spotting to 80 mL and the average being 30 mL. Loss of more than 80 mL of the
blood is considered abnormal. Various factors can affect the amount of blood flow, including
medications, the thickness of the endometrium, blood disorders, and disorders of blood clotting, etc.

Anovulatory Cycles

In some cases, ovulation fails to occur during the menstrual cycle. Such cycles are called anovulatory
cycles, and they are common for the first 12-18 months after menarche (The occurrence of the first
menstrual period) and again before the onset of menopause. When ovulation does not occur, usually no
corpus luteum is found, and the effect of progesterone on the endometrium is absent. Estrogen continues
to cause the growth of the endometrium, however, and the proliferative endometrium becomes thick
enough to break down and begin to slough. The time it takes for the bleeding to occur is fluctuating, but
it generally occurs in less than 28 days from the previous menstrual period. The flow is also inconsistent
and ranges from scanty to relatively profuse.

Abnormalities of the Menstrual Cycle (Menstrual Disorder)

Menustration is ongoing process throughout half of a woman’s life, it affects her self-image significantly.
An irregularity such as a painful cycle can exert a major influence on daily activities and should never be
taken carelessly; it is a health concern requiring as much time and attention as that given to other
concerns.

Menustral Disorders generally fall into:

- Menorrhgia

- Metrorehgia

- Polymenorrhea

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- Oligomenorrihea

- Ammenorrhea

Dysmenorrhea

Definition

-Dysmenorrhea is painful menustration. Currently it is recognized that the pain is due to the release of
prostaglandins (primarily PF2) in response to tissue destruction, during the ischemic phase of the
menustral cycle. PF2 causes smooth muscle contraction in the uterus. Dysmenorrhea is primary if it
occurs in the absence of organic disease; it is secondary if it occurs as a result of organic disease.

Therapeutic management:

- Generally controlled by a common analgesic such as acetylsalicylic acid (asprin) and ibuprofen.

Menorrhagia

Definition-Menorrhagia is an abnormally heavy and prolonged menustral flow. Usually accompanied by

clots. It may occur in girls close to puberty and in woman nearing menopause because of unovulatory
cycles.

Symptom: - It is difficult to determine when a flow is abnormally heavy. If a pad or tampon is saturated
in less than an hour it indicates a heavy flow.

Metrorrhagia

Definition

- Metrorrhagia is bleeding between menstrual periods. It is normal in some adolescents who have
spotting at the time of ovulation (“mittelstaining”).

- May also occur in women on hormonal contraceptives (break through bleeding) for the 1st 3 or 4
months.

- Vaginal irritation from infection might lead to mid-cycle spotting. If metrorrhagia occurs for more than
one menustral cycle and the client is not on hormonal contraceptives, she should be referred to physician
for examination, because vaginal bleeding is also an early sign of uterine carcinoma or ovarian cysts.

Amenorrhea

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Definition-The absence of menstrual flow for at least three cycles in a woman having a regular cycle of
menustration. It could be primary or secondary. Primary amenorrhea is the absence of menustration for a
girl or woman who has reached the age of menustration (who never menustruated) Secondary
amenorrhea is the absence of menustration for a period for a woman who has menustrated preveiously. It
may result from tension, anxiety (stress), fatigue, chronic illness, sudden weight gain or loss or strenuous
exercise. In the reproductive age group pregnancy should be always ruled out.

Oligomenorrhea- Infrequent menustation and is usually defined as occurring when the duration of the
cycle exceeds that of normal for the individual.

Polymonorrhea – Excessive bleeding and the length of the cycle is reduced.

Chapter four: Role of a Reproductive Nurse

Reproductive Nurses (also known as Fertility Nurses) care for individuals, couples, and families who
seek treatment options related to reproductive health. These nurses work with women experiencing
infertility, couples having difficulty with conception, or women going through menopause.

Reproductive Nurses
The role of a Reproductive Nurse is exciting! Reproductive medicine is a constantly developing field and
requires nurses to stay abreast of, and trained in, the latest industry advances and techniques. The
constant and rapid advances make this a stimulating field to work in.

Requirements performed by a Reproductive Nurse, include but are not limited to,

• Educating a patient about their reproductive cycle, treatment protocol and outcomes
• Teaching a patient or her partner how to take their injectable medications
• Assisting a physician during egg retrieval or embryo transfer procedures
• Counselling a patient as she or he copes with a negative pregnancy test, miscarriage or poor treatment
outcome
• Provide ongoing emotional support
• Learning about the latest evidence-based best practice in reproductive technology.
• Participating in team meetings about ethical issues
• Helping patients navigate their options for third-party reproduction, including sperm donors, egg
donors, and surrogates.

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Triumphs and Challenges
Being able to share news that a patient is pregnant is incredibly fulfilling. It is an amazing feeling to
know they played a part in their patients’ journey in welcoming their miracle baby. Reproductive Nurses
are overjoyed to see their patients become parents. They create a close bond with their patients and often
receive newborn photos and updates on the families. On the other hand, there are many challenging
aspects of becoming a Reproductive Nurse. Patients are often emotionally exhausted by the time they
reach a fertility clinic, and the nurses play an important role in providing compassionate care to their
patients and empathize with their unique situations.

Delivering news that a pregnancy test was negative or the cycle has to be cancelled is difficult to convey
because so much time, emotions, and finances are invested in hope of a positive outcome. They
recognize how incredibly tough the journey can be for our patients and they are here for them every step
of the way.

Chapter five: Breast Anatomy

The Female Breasts

The female breasts, also known as the mammary glands, are accessory organs of reproduction.

Situation One breast is situated on each side of the sternum and extends between the levels of the second
and sixth rib. The breasts lie in the superficial fascia of the chest wall over the pectoralis major muscle,
and are stabilized by suspensory ligaments.

Shape Each breast is a hemispherical swelling and has a tail of tissue extending towards the axilla (the
axillary tail of spence).

Size The size varies with each individual and with the stage of development as well as with age. It is not
uncommon for one breast to be little or larger than the other.

Gross structure The axillary tail is the breast tissue extending towards the axilla.

The areoa is a circular area of loose, pigmented skin about 2.5 cm in diameter the centre of each breast.
It is a pale pink colour in a fair- skinned woman, darker in a brunett, the colour deepening with
pregnancy. Within the area of the areola lie approximately 20 sebaceous glands. In pregnancy these
enlarge and are known as montgeomery’s tubercles.

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The nipple lies in the centre of the areola at the level of the fourth rib. Aprotuberance about 6mm in
length, composed of pigmented erectile tissue. The surface of the nipple is perforarted by small orifices
which are the openings of the lactiferous ducts. It is covered with epithelium.

Microscopic structure

The breast is composed largely of glandular tissue, but also of some fatty tissue, and is covered with skin.
This glandular tissue is divided into about 18 lobes which are completely separated by bands of fibrous
tissue. The internal structure is said to be resemble as the segments of a halved grape fruit or orgnge.
Each lobe is a self-contained working unit and is composed of the following structures

Alveoli: Containing the milk- secreting cells. Each alveolus is lined by millk-secreting cells, the acini,
which extract from the mammary blood supply the factors essential for milk formation. Around each
alveolus lie myoepithelial cells, sometimes called ‘basket’ or ‘spider’s cells. When these cells are
stimulated by oxytocin they contract releasing milk into the lactifierous duct.

Lactifierous tubules: small ducts which connect the alveoli.

Lactifierous duct: a central duct into which the tubules run.

Amplulla: the widened-out portion of the duct where milk is stored. The ampullae lie under the areola.

Blood supply Blood is supplied to the breast by the internal mammary, the external mammary and the
upper intercostals arteries.Venous drainage is through corresponding vessles into the internal mammary
and axillary veins.

Lymphatic drainage

This is largely into the axillary glands, with some dranage in to the portal fissure of the liver and
mediastinal glands. The lymphatic vessels of each breast communicate with one another. Nerve supply

The function of the breast is largely controlled by hormone activity but the skin is supplied by breanches
of the thoracic nerves. There is also some sympathetic nerve supply, especially around the areola and
nipple.

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Structure of Mammary Gland

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Disorder of the Breast

Breasts are usually affected by three conditions. They are infections, benign and malignant tumours.

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Benign

A. Fibrocystic breast disease

It is a common benign breast disease in women of all ages. It can occur as early as puberty when
oestrogen level rises to adult levels, but is found most commonly in women between the age of 20 and
45 years.

Sign and Symptom

- Freely movable, well - delineated breast lamp on palpation

- Visible lamp on the surface of breast

- Often occur on upper outer quadrant of the breast

- Consistency- firm and hard to soft and flexible

- Painful (may) and tender

- Round and fluid filled cyst.

Diagnosis

- Careful palpation

- Mammography

- Biopsy

Management

- Analgesia

- Avoidance of substances contain caffene, theophylline and theobromine

- Avoid smoking

- Aspiration of cysts under local anesthesia

B. Fibro adenoma

Fibro adenoma are tumors consisting of both fibrotic and glandular components that occur in response to
estrogen stimulation. They tend to occur in young women and are rarely seen after menoupuse and are

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non malignant. The tumors may increase in size during adolescence, pregnancy and lactation or when a
woman takes an oestrogen source such as oral contraceptive.

Sign and symptom

- No pain (pain less) and freely movable

- Round and well delineated tumors

- Feel firmer and more rubbery

- Occasionally calcify and feel extremely hard

- Not cause skin retraction

Management:

- Surgical excision

Carcinoma of breast

The carcinoma of the reast commonly occurs from 30 to 60 years of age.

Sign and Symptoms

- Lump and hard fixed mass

- Pain in the breast

- Blood stained discharge (late stage)

- Retracted nipple ,of cancer has spread to the lymph

- Orange like colour of the skin

Clinical and histological staging of breast cancer Clinical stage (American Joint Committee)

Stage I

Tumor less than 2 cm in diameter Nodes, if palpable, not felt to contain metastases Without distant
metastases

Stage II Tumor less than 5 cm in diameter Modes, if palpable, not fixed Stage

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III Tumor less than 5 cm or Tumor of any size with invasion of skin or attached to chest wall Nodes in
supra clavicular area without distant metastases

Stage IV With distant metastases

Management

- Surgery

- Radiation

- Hormonal therapy

- Cytotoxic agent

The woman should be thought to do self examination of breast to detect report and be diagnosed early.

Menopause

It is the stopping of menstrual period permanently and ends of a woman’s reproductive life. It is said to
have stabilized after two years of absence. It is characterized by the gradual cessation of menstruation,
the period first becoming irregular and then ceasing altogether. The usual age for the menopause is
between 45 and 50 years.

Symptoms

- Hot flushes due to sudden release of blood vessels

- Emotional changes

- Excessive / tendency to / gain weight

- Insomnia

- Appearance of signs of aging –

Softening of long bones

Cause:

Hormonal changes due to aging of the ovaries takes place during this period and Climacteric changes
(hormones) also occurs during this time.

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Treatment

- Oestrogen

- Progesterone

- Tranquilizers

Post menopausal bleeding must be investigated for cancer. Artificial menopause may be brought about
by hystrectomy, trauma to ovaries by irradiation or deep X- ray exposure of the pelvis.

Duties of nurse

- Support the patient by proper explanation about menopause

- If symptoms are severe advice to see the doctor

- Advice about the diet to be low in carbohydrate and have adequate sleep during the night. Self
examination of the breast

- Ninety percent of breast cancers are found by the woman or her partner. For this reason it is important
that women understand the importance of examining the breast on a monthly basis. - During pregnancy
there is no special time of the month that is best to reform the examination.

- In non pregnant women, 5 days after cessation of menstruation, it is the optimum time to detect
changes.

Inspection in the Shower

- It is easier to examine breast when hands are soapy.

- With your right hand behind your head, examine your right breast with your left hand using a grid or
circular motion reverse the procedure to examine the other breast.

Inspection in a mirror Stand in front of a mirror for further inspection

A. With arms at sides looks for

• Changes in size and shape of breasts

• Changes in skin dimpling, puckering, scaling, redness, swelling

• Changes in nipple inversion, scaling, discharge from nipples pointing in different directions.

27
B. Holding arms over the head, inspect closely in the mirror for masses, breast symmetry, puckering.

C. Press hands firmly on hips, below slightly forward. Inspect in mirror for lumps or pulling of the skin.

D. Each breast should be a mirror image of the other. If you think you detect a lump in breast, check the
other side to see if it feels the same. If so this is undoubtedly normal tissue. Examine using the circular or
grid motion as in the shower.

E. Gently squeeze the nipple of each breast between your thumb and index finger to check for signs of
discharge or bleeding. Inspection on Lying Down Lying flat on your back, with your right hand under
your head and a pillow or towel under your right shoulder, use your left hand to gently feel your right
breast, using concentric circles to cover the entire breast and nipple. Repeat on your left breast.

Breast self examination

New growths

Pelvic tumors

A. Fibroids (fibromyoma)

These are firm tumors of muscular and fibrous tissue, ranging from the very small to the very large. They
are most frequently found in woman at the older & end of the child bearing age range.

Types:

- They are named according to their position.

a. Sub mucous- when it is situated immediately beneath the surface of the endometrium (decidua)

b. Subserous - When it is beneath the serous coat of the uterus

28
c. Intramural – a fibroid confined to the myometrium.

d. Pedunculated - occasionally when submucous and subserous fibroids develop stalks.

Effect on pregnancy, labour & puerperium

Depends on the site of the uterus whether it is in the lower or upper segment and layers of uterus they
occupy.

- Subfertility

- Abortion

- PPH

- Malpresentation

- Obstructed labour

- Poor uterine contraction

- Subinvolution and prolonged red lochea.

Symptoms

- Painless abdominal swelling

- Menorrhagea

- Rarely pressure on bladder or bowel

Complication

- Menorrhagia

- Torsion of pedanculated fibroid

- Malignancy

Ovarian tumors can be primary and secondary and can be benign or malignant. Secondary tumors are
always malignant.

Management

29
- Myomectomy or removal of fibroid

- Hystrectomy if the women is older

Ovarian cyst

Types: - depending on constitution of the cyst it has 4 types

- Serous cysts- contains serum

- Mucinoid cyst- contains mucin

- Endometrial cysts / chocolate cyst. Its colour looks chocolate

- Dermoid cyst - This is a type of cyst containing hair, teeth or bone. These cysts are said to be
originated from the material derived from the ectoderm, endoderm and mesoderm. These are congenital.

Effects on pregnancy and labour

- It occupies pelvic cavity and causes obstruction

- Possibility of infection in the puerperium

- Haemorrhage into the cyst.

- Pressure symptom

Management

- Removal of the cyst (ovarian cystectomy)

- Biopsy- if malignant total hysterectomy

Complication of ovarian cyst

a. Torsion or twist - of the cyst is pedunculated it may twist. - Sever abdominal pain, tenderness, shock

b. Rupture of the cyst

c. Sepsis - the cyst may become infected (pain tenderness & fever)

d. Malignancy

Uterine Polyp

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Polyps are small bright red, fleshy, pedunculated, benign growths which may cause bleeding usually
originated in the cervical canal and are multiple. The bigger ones can protrude from the cervix into the
vagina.

Diagnosis - Speculum examination

Treatment: - It is usually removed by curettage off the uterus

Cancer of the Cervix

It occurs most commonly between 30 and 45 years of age.

Cause:

- unknown Risk factors

- Early age at first intercourse

- Early child bearing

- Multiple partners

-Chronic cervical infections

Signs and Symptoms

- Metrorrhagia

- Spotting of blood

- Bleeding after intercourse or douching or defecation

- Pain in the back and legs

Diagnosis

- Evaluation of sign and symptoms

- Biopsy

- Colposcopy

- Dilatation and Curettage

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Stages of cervical cancer

Stage 0 - is called cancer in situ. It is limited to the epithelial layer.

Stage I - Confirmed to the cervix

Stage II - It has extended to the vagina

Stage III - It has extended up to the vagina & has extended to one or both pelvic walls. Treatment:

1. Surgery

- Total hystrectomy, Radical hystrectomy (wertherin), removal of uterus, adenexia, proximal vaginal and
bilateral lymph nodes, Radical vaginal hystrectomy

2. Radeim treatment (radiation)

3. Cytotoxic drugs

Vulval Growths

- The growth in the vulva may be benign or malignant

- Benign tumors may be fibromas, adenomas, lipomas fibro adenomas, moles, and elephantionsis.

- Malignant tumors are squamous cell carcinoma and basal cell carcinoma

Treatment-Benign tumors can be treated by surgical removal of lesion.

- Malignant tumors are treated by vulvectomy

Vulval Cysts

Bartholin’s cyst- It arises on the Bartholin’s gland at the posterior end of labia minora. It may be
asymptomatic. Infection may be due to the gonococal organisms, escherichia coli or staphylococcus
auereus can cause an abscess.

Treatment: - Incision and drainage, Antibiotics

Inclusion cyst of the preclitoral area- It develops following circumcision in infancy. Sebaceous cyst

- It can occur in the anterior part of labia meniora.

Management -Incision and drainage

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Infertility

Infertility is defined as the inability to conceive and carry a pregnancy to viability after at least 1 year of
regular sexual intercourse without contraception.

Primary infertility- is an inability to conceive and carry a pregnancy to viability with no previous
history of pregnancy carried to alive birth.

Secondary infertility- is an inability to conceive and carry a pregnancy to alive birth following one or
more successful pregnancies. Although often used interchangeably the term infertility and sterility are
not synonymous.

Sterility denotes a total and irreversible inability to conceive. Broadly defined infertility includes the
inability to carry a pregnancy to viability.

Causes of infertility

Female

- Vaginal abnormalities

• infectious

• highly acidic vaginal PH

- Cervical

- Hostile environment (insufficient oestrogen or infection)

• Incompetent cervix

- Uterine - Abnormalities

• Hostile environmental for implantation and survival of blastocyst

- Tubal

• Adhesions

• Scar tissue due to PID

33
• Endometriosis

- Ovarian - an ovulation

• Irregular or infrequent ovulation

• Secretary dysfunction

• Inadequate luteal phase

Male

- Anatomical abnormalities / congenital factor

- Inadequate sperm production / Maturation

- Varicose –

Testicular inflammation

- Heat exposure

- Sexually transmitted disease

- Radiation exposure

- Stress

- Certain drugs

- Inadequate motility of sperm

- Blockage of sperm in male reproductive tract

Diagnosis

- History and physical examination

- Semen analysis

- The postcoital test

- Basal body temperature recording

- Serum progesterone test

34
- Endometrial Biopsy

- Hysterosalpingogram

- Laparoscopy and culdoscopy

Treatment- On a diagnosis of the cause of the infertility, it has been made to involve the male partner,
the female partner, or both may be initiated.

Chapter Six: Human Sexuality

Human Development

Human development involves the interrelationship between physical, emotional, social, and intellectual
growth. This component includes:

Reproductive Physiology and Anatomy: The parts of the body that form the reproductive and sexual
systems and their functions. Although the whole body is involved in human sexuality, these systems are
central to sexuality and to understanding puberty, menstruation, erections, wet dreams, reproduction, and
sexual pleasure.

Growth and Development: Includes the following key processes related to sexuality:

• Puberty: The physical and emotional changes that occur when the body matures during adolescence,
including the development of secondary sex characteristics (such as broad hips and facial hair) and the
maturing of the reproductive system. Puberty results in the ability to reproduce.

• Reproduction: The process of conception, pregnancy, and birth—the beginning of human

development.

• Climacteric and Menopause: The physiological and psychological changes in our sexual and
reproductive functioning that occur in midlife in both women and men, including the period leading up
to menopause for women. Menopause occurs when menstruation stops.

Body Image: Attitudes and feelings about one’s own body, appearance, and attractiveness that affect
one’s mental well-being, comfort with, and expression of one’s sexuality.

Sexual Orientation: The direction of one’s romantic and sexual attraction—to either the opposite, the
same, or both sexes. Includes heterosexual, homosexual, and bisexual orientations.

35
Gender Identity and Roles: Gender identity is one’s internal sense of being either male or female,
usually but not always the same as one’s biological sex. Gender roles are the set of socially prescribed
behaviours and characteristics expected of females and males.

Relationships and Emotions

All people need to have relationships with others in which they experience emotional close- ness. This
component includes:

Families: The primary social unit to which most people belong and which includes people who are
related by blood, marriage, or affection.

Friendships: Relationships between people based on liking, caring, and sharing; these relationships can
differ in emotional depth, but usually do not include a sexual relationship.

Loving, Liking, and Caring: Feelings that are the basis of emotional bonds and positive connections
and relationships between people.

Attraction and Desire: Emotional and physical feelings that draw someone to another person; these
feelings may include emotional and sexual longing and passion.

Flirting: Playful romantic or sexual interactions that communicate attraction. Flirting can cross the line
and become harassment if the recipient perceives it to be unwelcome or offensive.

Dating and Courtship: Meeting, spending time together, and going out as a part of the process of
getting to know and love someone, sometimes with the purpose of deciding whether or not to marry.

Intimacy: Emotional closeness to others characterized by feelings of connectedness, openness, sharing,

and reciprocity.

Marriage and Lifetime Commitments: The union, usually legal, of two people who make a
commitment to love and care for each other and share their lives and family responsibilities over the long
term.

Raising Children: Bringing up, providing for, and nurturing children, usually as a part of a family.

Sexual Behaviour

Sexuality is a natural and healthy part of life from birth to death, which individuals express through a
variety of behaviours. This component includes:

36
Masturbation: Giving oneself sexual pleasure, usually by touching or rubbing one’s own genitals.

Shared Sexual Behavior: Includes, but is not limited to:

• Kissing: Touching and caressing someone with one’s lips to express affection and love

• Caressing and Touching: Stroking gently to express affection and love; being in physical contact with
someone

• Sexual Intercourse: Vaginal, oral, or anal intercourse

Abstinence: Not having sexual intercourse. Abstinence may include other types of sexual touching.

Pleasure and Human Sexual Response: The enjoyable response of the body to sexual touching, which
may or may not include orgasm, a highly pleasurable release of built-up sexual tension.

Fantasy: Sexual or erotic thoughts, dreams, and imaginings that are sexually arousing but are not
necessarily acted on or even desired in reality.

Sexual Health

Sexual health includes having the knowledge and attitudes and taking the actions necessary to actively
maintain the health of one’s reproductive system and to avoid unwanted consequences of sexual
behaviour. This component includes:

Contraception: The use of various methods to intentionally prevent pregnancy; these methods include
devices, agents, drugs, sexual practices, and surgical procedures.

Abortion: Induced termination of pregnancy.

Reproductive Tract Infections, Sexually Transmitted Infections (STIs), and HIV/AIDS: A range of
infections that occur in the reproductive tract (such as yeast infections or vaginitis), or that can be
acquired through sexual intercourse or intimate sexual contact (such as gonorrhea, chlamydia, herpes,
and HIV/AIDS). Many can be transmitted in other ways as well, such as during childbirth.

Reproductive Health: Includes:

• Genital Care and Hygiene: Caring for and keeping one’s genitals clean, healthy and free from injury.

• Breast Self-Exam: A simple self-help technique in which women feel their breast tissue in a prescribed
manner every month to check for changes or lumps that may indicate a problem.

37
• Testicular Self-Exam: A simple self-help technique in which men feel their testicles in a pre- scribed
manner every month to check for changes or lumps that may indicate a problem.

• Prevention of HIV/STIs and Unwanted Pregnancy: Decisions and actions taken to reduce the risk of
infection with an STI or HIV and the risk of an unwanted pregnancy; includes abstinence, seeking advice
and preventive care, open and honest communication between sexual partners, and the use of condoms
and contraception.

• Prenatal Care: Regular check-ups with a trained health care provider during pregnancy to monitor the
health of the woman and the fetus and to help to identify any problems early.

• Infertility: The continuing inability to bear a child.

Sexual Dysfunction: A psychological or physical problem that interferes with a person’s ability to
express or enjoy his or her sexuality to the fullest degree. Includes lack of desire, inadequate lubrication,
and difficulties maintaining erections or achieving orgasm.

Sexual Violence Sexual violence is any violence (that is, abusive or unjust use of power) that has a
sexual aspect or element. It includes the use of sexuality to influence, control, or manipulate others. This
element includes:

Sexual Abuse: Any sexual contact or interaction between an older or more powerful person and a child
or minor; this may or may not involve touch. The abuser is usually someone known to the child

. Incest: Asexual relationship between two people who are too closely related to get married by law or
custom.

Rape: Forced or non-consensual sexual intercourse or other intimate sexual contact. The force may be
physical or psychological (that is, through threats or coercion). Sexual intercourse constitutes rape if one
of the parties is not capable of giving consent for whatever reason.

Sexual Manipulation: Using sex to indirectly influence, control, coerce, or exploit someone to one’s
own advantage.

Sexual Harassment: Persistent unwelcome verbal or physical sexual advances or conduct of a sexual
nature, or demand for sexual activity in exchange for benefits, for example in a school or work setting.

Partner or Domestic Violence: Physical or sexual violence against a partner with whom one is in a
romantic and/or marital relationship.

38
Gender Discrimination: Showing preference or prejudice or denying equal treatment to someone based
solely on his or her gender.

Harmful Practices: A range of practices, whether traditional or modern, that decreases a person’s sexual
well-being or ability to experience his or her sexuality safely and pleasurably.

Chapter Seven: Reproductive Tract Infections

Introduction

Reproductive tract infections (RTIs) are infections of the genital tract of women and men. There are
three types of RTIs:

1. Sexually transmitted infections (STIs) { Infections caused by organisms that are passed through
sexual activity with an infected partner. More than 40 have been identified, including Chlamydia,
gonorrhea, hepatitis B and C, herpes, HPV, syphilis, trichomoniasis, and HIV.

2. Endogenous infections

– Infections that result from an overgrowth of organisms normally present in the vagina.

– These infections are not usually sexually transmitted, and include bacterial vaginosis and candidiasis.

3. Iatrogenic infections

– Infections introduced into the reproductive tract by a medical procedure such as menstrual regulation,
induced abortion, IUD insertion, or childbirth.

– This can happen if surgical instruments used in the procedure are not properly sterilized, or if an
infection already present in the lower reproductive tract is pushed through the cervix into the upper
reproductive tract.

These three types of RTIs overlap and should be considered together. For example, some STIs, like
gonorrhea or Chlamydia, can be spread in the reproductive tract if not treated prior to a procedure. In
addition, some non-sexual infections, such as candidiasis, can be passed on through sexual activity. Not
all STIs are RTIs; and not all RTIs are sexually transmitted; STI refers to the way of transmission
whereas RTI refers to the site where the infections develop.

Main STI Pathogens

39
More than 30 pathogens are transmissible through sexual intercourse-oral, anal, or vaginal. The main
sexually transmitted bacteria are:

Neisseria gonorrhoeae (causes gonorrhoea)

Chlamydia trachomatis (chlamydial infections)

Treponema pallidum (causes syphilis)

Haemophilus ducreyi (causes chancroid)

The main sexually transmitted viruses are:

– Human immunodeficiency virus (causes AIDS)

– Herpes simplex virus (causes genital herpes)

– Human papilloma virus (causes genital warts)

– Hepatitis B virus

– Cytomegalovirus

• The main parasitic organisms are:

– Trichomonas vaginalis (causes vaginal trichomoniasis)

Public Health Significance of STIs

Over 340 million curable, and many more incurable, STIs occur each year. Among women, non-
sexually- transmitted RTIs are usually even more common. In developing countries, STIs and their
complications rank in the top five disease categories for which adults seek health care. In women (15-49
years), STIs, even excluding HIV, are second only to maternal factors as causes of disease, death and
healthy life lost.

Women: cervical cancer, pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy and
infertility.

• Men: sub-fertility

• Newborn: blindness and lung damage

40
• Syphilis can result in congenital syphilis for the baby and fatal cardiac, neurological and other
complications in adults

• Genital warts can lead to ano-genital cancers

Untreated gonococcal and chlamydial infections in women will result in pelvic inflammatory disease in
up to 40% of cases. One in four of these will result in infertility. In pregnancy, untreated early syphilis
will result in a stillbirth rate of 25% and be responsible for 14% of neonatal deaths – an overall perinatal
mortality of about 40%. Syphilis prevalence in pregnant women in Africa,

Classification of STIs

1. Diseases characterized by genital ulcer

• Chancroid, Genital herpes simplex virus, Granuloma inguinale (Donovanosis), Lymphogranuloma

Venarum, Syphilis

2. Diseases characterized by urethritis and cervicitis

• Chlamydial infection, Gonorrhea

3. Diseases characterized by vaginal discharge

• Bacterial vaginosis, trichomoniasis, Vulvo- vaginal candidiasis

4. Pelvic Inflammatory Disease (PID)

5. Epididymitis

6. Human papilomavirus infection (Genital wart)

7. Vaccine preventable STDs

• Hepatitis A, Hepatitis B

8. Proctitis, Proctocolitis and enteritis

9. Ectoparasitic Infections

• Pediculosis Pubis, Scabies

Prognostic classification of STDs

41
Curable (mostly bacterial)

Gonorrhea Syphilis

Chlamydia Trichomoniasis

Incurable (virus)

• HIV/AIDS

• Hepatitis

• Herpes

• Human papilloma virus

Traditional Approaches to STI Diagnosis

1. Etiologic diagnosis: using laboratory tests to identify the causative agent

2. Clinical diagnosis: using clinical experience to identify the symptoms typical for a specific STI.

• Even in a well-structured health system, etiological and clinical diagnoses are problematic because they
are low in sensitivity.

• Etiological diagnosis is expensive and time-consuming; it requires special resources and delays
treatment.

• With clinical diagnosis, it is easy to diagnose some STIs incorrectly and also to miss mixed infections.

The STI Syndromes and the Syndromic Approach to Case Management

Many different agents cause STIs, however, some of these agents give rise to similar or overlapping
clinical manifestations.

Aim of Syndromic management of STIs:

• Prompt and effective detection and treatment of STDs

• Decrease STD incidence and prevalence by reducing period of infectiousness

The main STI syndromes are:

 Urethral discharge

42
 Genital ulcer o Inguinal bubo o Scrotal swelling o Vaginal discharge o Lower abdominal pain o
Neonatal conjunctivitis

Main Features of Syndromic Management

• Periodic laboratory-based classification of the main causal pathogens by the clinical syndromes they
produce

• Use of flow charts derived from this classification to manage a particular syndrome • Treatment for all
important causes of the syndrome

• Education and counseling of the patient on how to prevent re-infection

• Notification and treatment of self

Principles in the Syndromic management

• Many STIs can be identified and treated on the basis symptoms and signs.

• Treatment covers several possible infections responsible for the syndrome

• Syndromic management will reduce the cost of laboratory work up and extra visits to the clinic and
treatment delay.

Advantages and Limitations of Syndromic Management

Advantages of Syndromic management:

• Immediate treatment: Clients receive diagnosis and treatment within a single visit.

• Effectiveness: Clients are treated for a potential mixed infection. The use of flowcharts with
appropriate treatment recommendations reduces the chance of ineffective treatment. This approach helps
to prevent incorrect diagnoses in settings where clinical diagnosis is common.

• Ease of use: It is easy to teach and learn. So, all levels of health care providers and facilities can use it.
It requires good training, but not specialized knowledge about STIs/RTIs.

• Low costs: There are cost savings since expensive lab tests are not used.

Limitations and concerns:

43
• Limitations in diagnosing vaginal discharge: Vaginal discharge poses a particular challenge since the
syndrome might not be related to an STI. Because of the potential for negative reactions from clients and
partners when the infection may not even be caused by an STI, it is important to consider each case on
an individual basis. Women who do not have STIs, but who have non-sexually transmitted RTIs that
cause vaginal discharge may be told that they should have their partners come for treatment; this can
lead to relationship problems, including violence.

• Potential for over treatment: Clients are treated for multiple infections, although some will have no
infection or only one. This is costly in terms of unnecessary drug use, waste of drugs that could be used
to treat other clients, and the potential for microorganisms to develop resistance to antimicrobial drugs.

• Ineffectiveness against asymptomatic infections: This approach cannot be used with clients who are
infected, but show no signs and symptoms.

• Need for data: Algorithms, risk assessment tools, and treatment protocols should be based on
information that is difficult to collect in many settings, including: disease surveillance data, studies of
risk factors, and microbial resistance tracking in the geographic location where the Syndromic approach
is being used.

Why Invest in STI Prevention and Control Now?

To reduce STI-related morbidity and mortality

• To prevent HIV infection because:

– Genital ulcer diseases have been estimated to increase the risk of transmission of HIV 50–300-fold per
episode of unprotected sexual intercourse

– Improved syndromic management of STIs reduced HIV incidence by 38% in a community intervention
trial in Mwanza, Tanzania

• To prevent serious complication in women

– STIs are main preventable cause of infertility

– PID, ectopic pregnancy and cervical cancer

• To prevent adverse pregnancy outcome

– Perinatal deaths

44
– Spontaneous abortions

– Preterm deliveries

– Ophthalmia neonatorum

STI Control Strategies

1. Prevention by promoting safer sexual behaviours;

What is safer sex? It is any sexual activity that reduces the risk of passing STI and HIV from one person
to another.

Some safer sex practices:

 Consistent use of condom every time individual is having sex

 Reducing the number of sex partners-sex with uninfected monogamous is safe
 Massaging, rubbing touching, dry kissing, hugging or masturbation instead of intercourse
 To be away from unsafe sexual practices, like “dry sex”
 Not to have intercourse with partner having genital sore or discharge

2. General access to quality condoms at affordable prices;

3. Promotion of early recourse to health services by people suffering from STIs and by their partners;

4. Inclusion of STI treatment in basic health services;

5. Specific services for populations with frequent or unplanned high-risk sexual behaviours 6. Proper
treatment of STIs, i.e. use of correct and effective medicines; treatment of sexual partners; education and
advice; reliable supply of condoms;

7. Screening of clinically asymptomatic patients;

8. Provision for counseling and voluntary testing for HIV infection;

9. Prevention and care of congenital syphilis and neonatal conjunctivitis;

10. Involvement of all relevant stakeholders, including the private sector and the community, in
prevention of STIs and prompt contact with health services for those requiring care.

Many people with an STI/RTI do not seek treatment since they are asymptomatic or have mild
symptoms and do not realize that anything is wrong. Others who have symptoms may prefer to treat

45
themselves or seek treatment at pharmacies or from traditional healers. Even those who come to a clinic
may not be properly diagnosed and treated. In the end, only a small proportion of people with an
STI/RTI may be cured and avoid re-infection. In order to address these challenges, health providers
should:

• Raise awareness in the community about STIs/RTIs and how they can be prevented

• Promote early use of clinic services.

• Promote safer sexual practices when counseling clients.

• Detect infections that are not obvious.

• Prevent iatrogenic infection

• Manage symptomatic STI/RTI effectively

• Counsel patients on staying uninfected after treatment.

Obstacles to Provision of Services for STI Control

 Decline in interest and resources for STIs prevention and control globally
 Lack of integration of prevention and care activities for STIs (including HIV) into sexual and
reproductive health services. Problem with Syndromic management of women with vaginal discharge,
especially in low prevalence areas
 Intervention efforts to prevent STIs have failed to take into consideration the full range of the
underlying determinants
 Inability to ensure consistent supplies of STI medicines and condoms
 Counselling on risk reduction is also usually lacking
 Inadequate participation of partners, especially communities

Diagnostic problem: either asymptomatic or do not seek care

46
 Chapter Eight: HIV/AIDS and Reproductive Health

Introduction

AIDS (acquired immune deficiency syndrome) is a human tragedy. Since the epidemic began in the early
1980s, AIDS has caused more than 30 million deaths and orphaned more than 14 million children
worldwide. With no cure in sight, the AIDS-causing virus, human immunodeficiency virus (HIV),
continues to spread around the world, causing more than 13,000 new infections each day. By the end of
2007, 33.2 million people were living with HIV, including 2.5 million children under 15 years old. Over
95 percent of these HIV cases occurred in the developing countries of sub-Saharan

HIV/AIDS exacts a heavy toll on its victims. People living with HIV/AIDS face tremendous health risks
from opportunistic illnesses (such as tuberculosis) that compromise their way of life and dramatically
increase their risk of death. In sub-Saharan Africa, average life expectancy has dropped to 47 years, 15
years less than it would have been without AIDS. In addition to health risks, people living with
HIV/AIDS face social and cultural barriers, including stigmatization, discrimination, and rejection from
health-service providers, friends, and relatives. These barriers, often worsened by the concurrence of the
HIV and tuberculosis epidemics, can affect their access to health and medical services, the quality of
services they receive, and their daily livelihoods.

The consequences of HIV/AIDS extend beyond its immediate victims, also affecting surviving family
members, communities, and societies. It is estimated that for each woman who dies of AIDS in Africa,
two children will be orphaned. More than 90 percent of children orphaned by AIDS live in sub-Saharan
Africa, and the numbers are increasing daily.

47
Modes of Transmission

Modes of Transmission of HIV Several large studies have confirmed that there is no risk of transmission
through casual contacts with household members, such as sharing meals, sleeping together (without
sexual contact), handshaking, hugging, or holding a baby. There have been no reports of transmission in
out-of-home childcare settings or in schools.

The primary modes of transmission of HIV are: sexual transmission, transfusion, or exposure to, infected
blood products, or exposure to contaminated needles and other equipment; and MTCT. Each mode of
transmission is associated with a different risk of acquiring HIV infection. The greatest risk of
transmission of HIV infection follows an HIV-contaminated blood transfusion. Ninety percent of
individuals who receive a transfusion of HIV-contaminated blood acquire infection. In many developing
countries, screening of blood products before transfusion is inadequate or nonexistent.

Contaminated blood products continue to be a significant source of new HIV infections. Re-use of
needles or syringes in the health care setting has led to many infections in infants and children. If
equipment must be re-used, strict adherence to proper decontamination and sterilization procedures is
essential. Intravenous drug abuse carries a risk of approximately 0.5 to 1% per exposure if needles or
injection equipment used by an HIV-infected person are shared. When visible blood or other body fluids
are present, (for example, on bandages) there may be a small risk of HIV transmission through an intact
skin. Therefore, in such situations, gloves should be worn. Hands should be washed immediately with
soap and water, if contact with blood or other bodily fluids occurs.

Sexual Transmission of HIV

Heterosexual transmission is the primary mode of acquiring HIV in developing countries. Women,
especially young girls, are more likely than men to become infected following heterosexual intercourse.
Cases of HIV infection resulting from sexual abuse of children, and even infants, have been reported.
Adolescents are increasingly at risk from unprotected sexual intercourse or the use of contaminated
needles.

Disturbing gender differences in rates of HIV infection have been reported in developing countries,
especially in sub-Saharan Africa, where several countries report that the number of teenage girls infected
with HIV is up to six times greater than the number of teenage boys who are infected. Studies suggest
that girls are more susceptible than mature women to HIV infection per sexual act.

48
Many girls are exposed to older HIV-infected men who seek sexual partners less likely to be HIV
infected, or to men who request sexual favours in exchange for economic support. Worldwide, sexual
abuse and trafficking of children increases the risk of HIV infection in very young children. Some
studies place the number of children in forced prostitution as high as 10 million. The fairly widespread
(and false) myth that having sex with a virgin can cure HIV infection has resulted in HIV infected men
seeking younger sexual partners. Young girls, who are viewed as less likely to be HIV infected, may
command a premium as prostitutes, placing them at high risk for acquiring HIV.

Mother to child transmission (MTCT) of HIV

Children can become infected with HIV through the same modes as those by which adults are infected
(exposure to contaminated blood or other body fluids, eg, through transfusions of infected blood
products, through contact with needles or other instruments contaminated with infected blood or other
body fluids, and through sexual abuse), and also through MTCT.

Perinatal transmission encompasses MTCT before delivery (antepartum), during delivery (intrapartum),
or following delivery through breast-feeding in the first few days of life (postnatal). In medical literature,
the term "perinatal" is used synonymously with "vertical" to describe MTCT, but generally does not
include transmission by breast-feeding after the first few days of life. In resource-rich countries, where
safe alternatives to breast-feeding are available perinatal (intrauterine and intrapartal), HIV transmission
accounts for virtually all new cases of HIV infection in children. A small proportion of children may be
infected as the result of sexual abuse.

Rates of MTCT

The majority of children born to HIV-infected mothers are uninfected. Without interventions to prevent
MTCT of HIV, rates of MTCT is 40% in Africa.

Timing of MTCT

MTCT of HIV occurs during three different time periods: antepartum, intrapartum, and postnatally
through breast- feeding. With the advent of highly sensitive techniques for detecting virus in the
peripheral circulation of the infant, it is possible to estimate the timing of MTCT more accurately. In the
absence of breast-feeding, an estimated 50 to 70% of transmissions occur around the time of delivery.
Therefore, without breast-feeding, most MTCT is presumed to be a result of exposure to HIV during late
pregnancy, during parturition via the placenta, or during passage of the infant through the vagina.

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Intrapartum transmission is presumed to occur across the infant's mucous membranes, principally in the
oropharynx and possibly in the esophagus and stomach.

Risk Factors for MTCT

Several factors put a woman at a higher risk of transmitting HIV to her child.

Maternal Factors

• High maternal viral load

• Low CD4 count

• Advanced maternal disease

• Viral or parasitic placental infections during pregnancy, labour and childbirth

• Maternal malnutrition ( including iron and folate, vitamin A, and zinc deficiencies)

• Nipple fissures, cracks, mastitis and breast abscess

Infant factors

• First infant in multiple births

• Preterm low birth weight

• Duration of breastfeeding

• Mixed feeding

• Oral diseases in child

Obstetric and Delivery Practices

• Rupture of membrane for more than four hours

• Injuries to birth canal during child birth (vaginal and cervical tears)

• Ante partum procedures e.g. amniocentesis, external cephalic version

• Invasive childbirth procedures (e.g. episiotomy, fetal scalp monitoring)

• Vaginal delivery

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• Delayed infant cleaning and eye care

• Routine infant airway suctioning

Breast-Feeding Transmission

Breast-feeding is associated with increased transmission overall. A randomized clinical trial comparing
breast-feeding with formula feeding demonstrated the efficacy of complete avoidance of breast-feeding
for the prevention of MTCT. In resource-poor settings, breast-feeding offers the best opportunity for
inexpensive, readily available, and safe infant nutrition. In most communities, breast-feeding is naturally
viewed as a caring and nurturing response of a mother toward her infant.

HIV/AIDS prevention and control

The steady growth of HIV prevalence throughout the world stems not from the deficiencies of available
prevention strategies and tools, but rather from the failure to use them. At present, there are more HIV
infections every year than AIDS-related deaths. The trends in increasing infections pose a major threat to
the global response to AIDS.

Effective HIV prevention programming focuses on the critical relationships between the epidemiology of
HIV infection, the risk behaviours that transmit HIV, and the cultural, institutional and structural factors
that drive risk behaviours. Risk behaviours are enmeshed in complex webs of economic, legal, political,
cultural and psychosocial determinants that must be analyzed and addressed by policies that are also
effectively implemented and through scaled-up programming.

Prevention and treatment must be scaled up in a balanced way, to capitalize fully on synergies between
the two. Comprehensive HIV prevention requires a combination of programmatic interventions and
policy actions that promote safer behaviours, reduce biological and social vulnerability to transmission,
encourage use of key prevention technologies, and promote social norms that favour risk reduction.

Essential Policy Actions for HIV Prevention

1. Ensure that human rights are promoted, protected and respected and that measures are taken to
eliminate discrimination and combat stigma.

2. Build and maintain leadership from all sections of society, including governments, affected
communities, nongovernmental organizations, faith- based organizations, the education sector, media,
the private sector and trade unions.

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3. Involve people living with HIV, in the design, implementation and evaluation of prevention strategies,
addressing the distinct prevention needs.

4. Address cultural norms and beliefs, recognizing both the key role they may play in supporting
prevention efforts and the potential they have to fuel HIV transmission.

5. Promote gender equality and address gender norms and relations to reduce the vulnerability of women
and girls, involving men and boys in this effort.

6. Promote widespread knowledge and awareness of how HIV is transmitted and how infection can be
averted.

7. Promote the links between HIV prevention and sexual and reproductive health.

8. Support the mobilization of community-based responses throughout the continuum of prevention, care
and treatment.

9. Promote programmes targeted at HIV prevention needs of key affected groups and populations.

10. Mobilizing and strengthening financial, and human and institutional capacity across all sectors,
particularly in health and education.

11. Review and reform legal frameworks to remove barriers to effective, evidence based HIV prevention,
combat stigma and discrimination and protect the rights of people living with HIV or vulnerable or at
risk to HIV.

12. Ensure that sufficient investments are made in the research and development of, and advocacy for,
new prevention technologies.

HIV prevention strategies

The main strategies proposed by the United Nations AIDS programme are:-

1. Condom use

2. Education

3. HIV prevention for key population

4. HIV post exposure prophylaxis

5. Male circumcision

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6. New HIV prevention technologies

7. Prevention of mother to child transmission

8. Social and behaviour change

Condom use

Conclusive evidence from extensive research shows that correct and consistent condom use significantly
reduces the risk of HIV transmission. The male latex condom is the single, most efficient, available
technology to reduce the sexual transmission of HIV and other sexually transmitted infections. Along
with the female condom, it is a main component of comprehensive strategies to reduce risks of sexual
exposure to HIV.

Education

The education sector is critical to HIV prevention for young people and can also play a vital role in
support for orphans and vulnerable children affected by HIV.

Education in school settings

Simply ensuring young people’s access to school or other educational opportunities is an important
aspect of HIV prevention. Not only are higher levels of education associated with safer sexual
behaviours and delayed sexual debut, but school attendance provides students the benefits of school-
based sexuality education and HIV prevention programming.

HIV prevention among key populations

Although comprehensive HIV prevention programmes must be made available to all, actions must be
taken to ensure that specialized and focused HIV prevention programmes are developed and available for
people most at risk. UNAIDS encourages countries to “know their epidemic and their current response”.
Knowing their epidemic and response enables countries to “match and prioritize the response” by
identifying, selecting and funding those Engaging these key populations within HIV prevention activities
is critical to an effective response, so too is ongoing analysis of what works, the costs and benefits of the
different HIV prevention measures and their feasibility given the available human and financial
resources.

Key populations include:

Children and orphans

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Indigenous people

Injecting drug users

Men who have sex with men

Migrants and mobile workers

Prevention of mother-to-child transmission of HIV

Each day, approximately 1,800 children become infected with HIV, the vast majority of who are
newborns. A pregnant woman who is HIV-positive can pass the virus on to her baby in the womb or
during childbirth, or postnatal, through breastfeeding.

In the absence of any intervention, the risk of mother-to- child-transmission (MTCT) of HIV is around
15-30%, if the mother does not breastfeed the child. But it can rise as high as 30-45% with prolonged
breastfeeding. The risk of transmission can be reduced by up to 50% with the administration of a short
course of antiretroviral drugs to mother and baby around the time of delivery, in conjunction with
replacement feeding. However, less than 8% of pregnant women worldwide are currently offered
services to prevent mother-to-child transmission (MTCT) of HIV.

Prevention of perinatal HIV transmission requires a comprehensive package of services that includes
preventing primary HIV infection in women, preventing unintended pregnancies in women living with
HIV, preventing transmission from pregnant women living with HIV to their infants, and providing care,
treatment and support for women living with HIV and their families. Health systems need to be
strengthened so that interventions to prevent mother to child transmission of HIV infection, including the
use of antiretroviral drugs, can be safely and effectively implemented. Moreover, HIV testing in
pregnancy has a number of benefits in terms of prevention and care for mother and child, although to
avoid or minimize negative consequences testing must be voluntary and confidential and accompanied
by quality counselling. Timely administration of antiretroviral drugs to the HIV- diagnosed pregnant
woman and her newborn significantly reduces the risk of mother-to-child HIV transmission. Positive
mothers should also be provided with access to ART for the protection of their own health.

Chapter Nine: Harmful Traditional Practices

Introduction

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World Health Organization, the United Nations Children's Fund, and the United Nations Population
Fund issued a joint statement that summarized the importance as well as the challenges inherent to
addressing harmful health practices: "Human behaviours and cultural values have meaning and fulfil a
function for those who practice them. People will change their behaviour when they understand the
hazards and indignity of harmful practices and when they realize that it is possible to give up harmful
practices without giving up meaningful aspects of their culture." Health professional’s worldwide
struggle with how to address harmful health practices. In many cases, this division masks more
complicated reasons for defending harmful practices, the victims of which tend to be women and
children and others who are less powerful in their society. These reasons often include power struggles,
local and national politics, and/or lack of understanding about the risks of the practice. Sometimes a
harmful practice is so deeply rooted that it seems impossible to change. But in every country people have
pushed forward positive social changes, and harmful practices have been ended. For example, foot
binding was once the norm in many parts of China. Women without tiny, hobbled feet were considered
unmarriageable. Women were completely dependent on men since they were unable to walk well. Yet,
the practice was eliminated in a short time, in conjunction with major political, social, and economic
changes in that society. In the nineteenth-century Europe, women endured pain and physical damage
from constrictive whalebone corsets which caused their waists to appear slim. This practice was also
recognized as dangerous, and fell out of favour. At the same time, Western medicine is recognizing the
benefits of some traditional health practices, which fall into an overarching category described by some
as "Indigenous Knowledge." Traditional plants are being researched by drug companies, and the health
benefits of non-Western therapies such as Indian yoga, Chinese acupuncture, and African community
support systems are increasingly being recognized. As leaders in Western medicine learn more about
helpful traditional practices, and vice versa, health professionals in all countries can draw from the best
of these worlds in order to help their clients make healthy choices.

Harmful Practices

- Female genital mutilation

- Early marriage:

- Severely restricted weight gain during pregnancy

- Withholding colostrum (initial breast milk with special nutritional value) from newborn

- Low levels of breast feeding:

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- Postpartum nutritional restrictions:

- Vaginal douching:

- "Dry sex" practices (removal of vaginal fluid with absorbent materials):

- Breast and penis implants:

Violence against Women

Globally, at least one in three women has experienced some form of gender-based abuse during her
lifetime. Violence against women is any act of gender-based violence that results in, or is likely to result
in, physical, sexual, psychological harm or suffering to women, including threats of such acts, coercion
or arbitrary deprivations of liberty, whether occurring in public or private life. Abuse of women and girls
is best understood within gender framework because it stems in part from women’s and girls’
subordinate status in the society. In addition to causing injury, violence increases women's long-term risk
of a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse,
and depression. Women with a history of physical or sexual abuse are also at increased risk for
unintended pregnancy, sexually transmitted infections, and adverse pregnancy outcomes. Females of all
ages are victims of violence, in part because of their limited social and economic power compared with
men.

Violence against women (VAW) encompasses, but is not limited to:

 Spousal battering
 Sexual abuse of female children
 Dowry-related violence
 Rape including marital rape
 Traditional practices harmful to women such as FGM
 Non-spousal violence
 Sexual harassment and intimidation at work and in school
 Trafficking in women
 Forced prostitution

Magnitude of the Problem

Violence against women (VAW) is the most pervasive, yet least recognized human rights abuse in the
world. Around the world, at least one woman in every three has been beaten, coerced into sex or

56
otherwise abused in her lifetime. Two of the most common forms of violence against women are abuse
by intimate partner violence (IPV) and coerced sex.

I. Intimate Partner Violence (IPV)

Intimate partner violence occurs in all countries, irrespective of social, economic, religious or cultural
group. Although women can be violent in relationships with men, and violence is also sometimes found
in same-sex partnerships, the overwhelming burden of partner violence is borne by women at the hands
of men

Events Triggering Violence

A wide range of studies have produced a remarkably consistent list of events that are said to trigger
partner violence. These include:

 Not obeying the man

 Arguing back
 Not having food ready on time
 Not caring adequately for the children or home
 Questioning the man about money or girlfriends
 Going somewhere without the man’s permission
 Refusing the man sex
 The man suspecting the woman of infidelity

In many developing countries, women often agree with the idea that men have the right to discipline
their wives, if necessary by force. % of women believed a man is justified in beating his wife at least for
one reason. The most widely accepted reasons for wife-beating are going out without telling the partner
and neglecting the children (about 64 percent).

II. Sexual Coercion

Sexual coercion exists along a continuum, from forcible rape, to non-physical forms of pressure that
compel girls and women to engage in sex against their will. The touchstone of coercion is that a woman
lacks choice and faces severe physical and social consequences if she resists the sexual advances.

Sexual violence includes:

 Rape within marriage or dating relationships

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 Rape by strangers
 Systematic rape during armed conflict
 Sexual harassment
 Sexual abuse of children
 Forced first sex
 FGM
 Forced marriage
 Denial of the right to use contraception

Impact on Health

Physical: injuries, bruises, chronic pain syndromes, disability, fractures, GI disorders, irritable bowel
syndrome, reduced physical functioning

Sexual and reproductive health: gynecological disorders, infertility, PID, pregnancy

complications/miscarriage, sexual dysfunction, STIs including HIV/AIDS, unsafe abortion and unwanted
pregnancy

Psychological and behavioural: alcohol and drug abuse, depression and anxiety, poor self- esteem,
psychosomatic disorders, unsafe sexual behavior, phobias and panic disorder

Fatal health consequences: AIDS-related mortality, maternal mortality, homicide, and suicide

Impact on Reproductive Health

Women who live with violent partners have a difficult time protecting themselves from unwanted
pregnancy or disease.

Violence can lead directly to unwanted pregnancy or STIs, including HIV infection, through coerced sex,
or else indirectly by interfering with a woman’s ability to use contraceptives, including condoms.

One in every four women is physically or sexually abused during pregnancy, usually by a partner.

Violence during pregnancy has been associated with miscarriage, late entry into prenatal care, stillbirth,
premature labour and birth, fatal injury, and low birth weight.

What Can Be Done Against Gender Based Violence (GBV)?

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Initiatives against gender-based violence take many forms, including police and judicial reforms,
legislative initiatives, community mobilization to encourage behaviour change, and the reorientation of
health services.

The most effective approach is integrated and multi-level: in the short term it provides services for
victims and punishes perpetrators, while in the long term it addresses the social and economic
determinants of violence.

Prevention strategies also need to focus on:

 Empowering women and raising their status

 Combating norms of violence, and
 Reducing poverty and alcohol consumption

Health care providers can do:

Health care providers can play a crucial role in addressing violence against women because health care
providers often are well placed to recognize victims of violence and to help them. Since violence
increases the risk of other health problems for women, early help can prevent serious conditions that
follow from abuse.

Health care providers can help solve the problem of violence against women if they learn how to ask
clients about violence, if they become better aware of signs that can identify victims of domestic
violence, and help women protect themselves by developing a personal safety plan.

Health workers can educate themselves about physical, sexual, and emotional abuse, and explore their
own biases, fears and prejudices. They can also provide supportive, non-judgmental care to victims of
violence and ask clients about in a friendly, gentle way.

Leaders of Reproductive Health Programs Can:

Establish policies and procedures to ask women clients about abuse

Establish protocols that clearly indicate appropriate care and referral for victims of violence

Promote access to emergency contraception

Lend facilities to women’s groups seeking to organize support groups and to hold meetings

Why have health care providers been slow to address violence against women?

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Lack of technical competence and resources

Cultural stereotypes and negative social attitudes

Institutional constraints

Women’s reluctance to disclose violence

HCPs can screen women for domestic violence when they come for:

Antenatal and postnatal care

Reproductive health services: Family planning and prevention of STIs

Mental health services

Emergency departments

Supporting Women Who Disclose Abuse

Assess for immediate danger

Provide appropriate care

Document women’s condition

Develop a safety plan

Inform women of their rights

Refer women to community resources

Moving outside the clinic

• Community health promotion

• Communication campaigns

Female genital mutilation (FGM)

It is estimated that at least 2 million girls are at risk of female genital mutilation (FGM) each year. FGM
is practiced in at least 26 of 53 African countries. FGM comprises all procedures involving partial or
total removal of the external female genitalia or other injuries to the female genital organs for cultural or

60
non- therapeutic reasons. In 1995, the World Health Organization developed the following four broad
categories for FGM operations:

Type I: Excision (removal) of the clitoral hood with or without removal of part or the entire clitoris.

Type II: Removal of the clitoris together with part or all of the labia minora.

Type III (infibulation): Removal of part or all of the external genitalia (clitoris, labia minora, and labia
majora) and stitching and/or narrowing of the vaginal opening leaving a small hole for urine and
menstrual flow.

Type IV (unclassified): All other operations on the female genitalia, including pricking, piercing,
stretching, or incision of the clitoris and/or labia; cauterization by burning the clitoris and surrounding
tissues; incisions to the vaginal wall; scraping (angurya cuts) or cutting (gishiri cuts) of the vagina and
surrounding tissues; and introduction of corrosive substances or herbs into the vagina.

These procedures are not reversible, and their effects last a lifetime. Type I and II account for up to 85
percent of FGM operations.

Health consequences of FGM seem to vary according to the type and severity of the procedure.
Complications may range from immediate, such as bleeding and shock, to a wide range of longer-term
problems for women and their newborn children. Psychological effects may be profound and permanent.
Additionally, FGM may increase the risk of HIV or Hepatitis B, due to unclean conditions often
associated with the procedure.

Global efforts to promote alternatives to FGM are increasing

Efforts to promote alternatives to FGM are increasing worldwide. International health organizations and
conventions have uniformly condemned the procedure. The 1994 Programme of Action of the
International Conference on Population and Development (ICPD) included a recommendation to ". . .
urgently take steps to stop the practice of female genital mutilation and to protect women and girls from
all such similar unnecessary and dangerous practices." The 1995 Platform for Action of the Fourth
World Conference on Women urged governments, international organizations, and nongovernmental
groups "to develop policies and programmes to eliminate all forms of discrimination against the girl
child, including female genital mutilation." FGM is recognized as a human rights violation in the U.S.
State Department's annual country reports

Early Marriage (EM):

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It has been a common practice, particularly in much of rural Nigeria to get girls married at an early age
as 10 – 15 years old. The young adolescent or preadolescent girl is not ready physically and
psychologically for intercourse, pregnancy, child bearing and child rearing.

Some of the reasons for early marriage are:

• Parents desire to see the marriage of their daughters and their grandchild before they die

• Strengthen the family or business ties between the two parties to be married

• Avoid the possibility of a daughter not getting married or becoming not eligible for marriage

• Avoid premarital sex or loss of virginity and its consequences

Harmful effects of early marriage include:

• Psychological effect on the girl bride leading to different somatic problems. The small genitalia are
traumatized ending up in tears, bruising, cystitis, and damage to the urethra.

• Preclampsia, prolonged and obstructed labour leading to fistula formation

• Haemorrhage and shock at delivery

• Still born babies

• Loveless marriage often ending in divorce

• Difficulty in managing a household by the young girl

• Deprivation of the girl of her education leading to poor opportunity for employment and gainful
income

Marriage by abduction

Is a gross violation of women’s rights. It has been common in some parts of Nigeria. In some cases the
girl may be willing and ready to proceed with the marriage. In these cases, the consequences are less
grave. However, when the girl objects and fights against the abductors she can be severely hurt and even
get killed.

Reasons for Marriage by Abduction:

• Refusal or anticipated refusal of consent by parents or girl

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• Avoid excessive wedding ceremony expenses

• Ease the economic burdens of the conventional bride price

• Outsmart rivals when the girl has many suitors and/or the inclinations of the girl or her parents are not
predictable

• Difference of ethnic origins or economic status of partners may also be reasons for possible abduction.

Harmful effects of marriage by abduction

• Battering, inflicting bodily harm, suffocation, and severe disabilities and death may ensue.

• Conflict created between families may lead to feuding lasting for generations. There are incidents of
ethnic conflicts due to marriage by abduction

• The outcome may be an unhappy, unstable and loveless marriage

• Psychological stress on the girl. Might end up in suicide.

• There are large expenses related to conflict resettlements as compensation to the family or for court
cases

• Discontinuation of schooling and other opportunities for the girl.

Other harmful traditional practices include Uvulectomy, milk teeth extraction, food prohibitions for
mothers, eye brow incision, and soiling the umbilicus of the new born with cow dung. Each of these
traditional practices have mistakenly perceived advantages.

Uvulectomy is supposed to prevent problems of feeding (swallowing), avoid noisiness and improve
speech. Milk teeth extraction is assumed to prevent diarrhoea and cure various diseases. Eye brow
incision is undertaken to prevent eye diseases and blindness. Certain food items which contain important
nutrients are believed to cause diseases in women and children. These harmful traditional beliefs and
practices might result in serious health outcomes including serious bleeding, acquiring dangerous and
fatal infection and malnutrition.

Suggested intervention strategies to minimize and eliminate harmful traditional practices include:

• Educate the community and the leaders by using acceptable and effective methods

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• Provide legal support against the negative aspects of traditional practices and formulate legislative
measures to eliminate them

• User friendly health facilities to deal with problems related to harmful traditional practices

• Endeavour to educate practitioners of harmful traditional practices about the dangers of such practices

• Imposing punishment on such practitioners if they persist with the practice

• Should a victim be willing to testify or discuss his/her dilemma, on the case to the public as example to
others.

Chapter Ten: Adolescent Reproductive Health

Definition:

World Health Organization defines adolescents as individuals between 10 and 19 years of age. The
broader terms "youth" and “young” encompass the 15 to 24 year-old and 10 to 24 year-old age groups,
respectively. For girls, puberty is a process generally marked by the production of estrogen, the growth
of breasts, the appearance of pubic hair, the growth of external genitals, and the start of menstruation.
For boys, it is marked by the production of testosterone, the enlargement of testes and penis, a deepening
of the voice and a growth spurt.

Why Focus on Young People?

• Young people constitute a large and growing segment of the population.

At the turn of 21st century 1.7 billion people were between the ages of 10 and 24.

– Eighty six percent of these live in less developed countries.

• Certain health problems (like STIs and HIV) are more prevalent in this age group

• Behaviours starting in adolescence frequently lead to health problems, which may emerge in later life,
at immense cost to the individual and their society.

• While young people face many new problems, there are also new opportunities which if combined with
the energy and creativity of young people can bring tremendous dividends and can help them play vital
role in their family and to the society as a whole.

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• Future economic development depends on having increasing proportion of reasonably well educated,
healthy and economically productive population.

Global Youth Today

The current generation of young people is the healthiest, most educated, and most urbanized in history.
However, there still remain some serious concerns:

Education: Despite increasing attention given worldwide to education, 121 million children worldwide
are out of school, with 9 million more girls than boys. Educating girls is essential to reducing child
mortality, HIV/AIDS, and other diseases. Furthermore, educated women will most likely have healthy
children who will complete schooling. Decades of research have shown that educated women have
greater control of their reproductive lives, such as decisions about the number and spacing of their
children.

Sexuality: Globally, most people become sexually active during adolescence. Premarital sexual activity
is common and is on the rise worldwide. Rates are highest in sub Saharan Africa, where more than half
of girls aged 15-19 are sexually experienced. Millions of adolescents are bearing children, in sub-
Saharan Africa, more than half of women give birth before age 20.

Health: Sexual activity puts adolescents at risk of various reproductive health challenges. Each year,
about 15 million adolescents aged 15-19 years give birth, as many as 4 million obtain an abortion, and up
to 100 million become infected with a curable sexually transmitted disease (STI). Globally, 40 percent of
all new human immunodeficiency virus (HIV) infections occur among 15-24 year olds; recent estimates
are that 7,000 are infected each day. These health risks are influenced by many interrelated factors, such
as expectations concerning early marriage and sexual relationships, access to education and employment,
gender inequities, sexual violence, and the influence of mass media and popular culture.

Challenges: Adolescents often lack basic reproductive health information, skills in negotiating sexual
relationships, and access to affordable, confidential reproductive health service. Incompetent providers
further limit access to services where they exist, as do legal barriers to information and services. Many
adolescents lack strong stable relationships with parents or other adults whom they can talk to about their
reproductive health concerns.

Characteristics of the adolescence period

The period is characterized by:

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• The period when the individual progresses from the point of initial appearance of secondary sex
characteristics to sexual maturity.

• It is period when psychological processes and patterns of identification to those of an adult.

• Transition from the state of total socio-economic dependence to relative independence.

• Period of rapid physiological changes and vulnerability to physical, psychological and environmental
influences.

• Period of physical, biological, psychological and social maturity from childhood to adulthood.

Transition from childhood to adulthood involves adjustment encompassing physiological, psychological,

cognitive, social and economic changes. The process is universal, but varies by individual and culture.

. Reproductive Health Risks and consequences for adolescents

Adolescent reproductive health is affected by pregnancy, abortion, STIs, sexual violence, and by the
systems that limit access to information and clinical services. Reproductive health is also affected by
nutrition, psychological well-being, and economic and gender inequities that can make it difficult to
avoid forced, coerced, or commercial sex.

Pregnancy:

In many parts of the world, women marry and begin childbearing during their adolescent years.
Pregnancy and childbirth carry greater risk of morbidity and mortality for adolescents than for women in
their 20s, especially where medical care is scarce. Girls younger than age 18 face two to five times the
risk of maternal mortality as women aged 18-25 due to prolonged and obstructed labour, haemorrhage,
and other factors. Potentially life- threatening pregnancy-related illnesses such as hypertension and
anaemia also are more common among adolescent mothers, especially where malnutrition is endemic.
One in every 10 births worldwide and 1 in 6 births in developing countries is to women aged 15-19 years.

Unsafe abortion: About one in 10 abortions worldwide occurs among women age 15-19 and each year
one million to 4.4 million adolescents in developing countries undergo abortion, and most of these
procedures are performed under unsafe conditions due to:

- Lack of access to safe services.

- Self-induced methods

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 - Unskilled or non-medical providers

- Delay in seeking procedure

Adolescent unwanted pregnancies often end in abortion. Surveys in developing countries show that up to
60 percent of pregnancies to women below age 20 are mistimed or unwanted.

Induced abortion often represents a greater risk for adolescents than for older women. Adolescents tend
to wait longer to get help since they cannot access a provider or because they may not realize that they
are pregnant; this risk is compounded in conditions. In Nigeria, for example 50-70 percent of mothers
hospitalized for complications of induced abortion are younger than 20; 3 of 5 women seeking health
care for unsafe abortion in developing countries are under 20. Some of the complications of abortion are
infection, hemorrhage, and intestinal perforation, injury to reproductive organs and toxic reactions to
drugs. These complications can result in infertility, psychological trauma or death.

Young people tend to be at higher risk of contracting STIs, including HIV/AIDS, for several reasons.
Intercourse often is unplanned or unwanted. Even when she is consensual, adolescents often do not plan
ahead for condom or other contraceptive use, and inexperienced users are more likely to use methods
incorrectly. Furthermore, adolescent girls are at greater risk of infection than older women because of the
immaturity of their reproductive system. Other reasons are little knowledge of STIs, failure to seek
treatment, multiple partners, partners with multiple partners and use of drug and alcohol.

Female Genital Cutting (FGC)

FGC, the partial or complete removal of external genitalia or other injuries to the female genitalia, is a
deeply rooted traditional practice that has severe reproductive health consequences for girls. In addition
to the psychological trauma at the time of the cutting, FGC can lead to infection, haemorrhage, and
shock. Uncontrolled bleeding or infection can lead to death within hours or days. Some forms of FGC
can lead to Dyspareunia, recurrent pelvic infection, and dystocia. The ICPD Programme of Action calls
FGC a basic human rights violation and urges governments to stop the practice

Commercial Sex

• Sexual exposure is occurring at ages as young as 9-12 years as older men seek young girls as sexual
partners to protect themselves from STD/HIV infection. In some cultures, young men are expected to
have their first sexual encounter with a prostitute.

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• Adolescents, especially young girls, often experience forced sexual intercourse in sub– Saharan Africa,
some girls’ first sexual experience is with a sugar daddy, who provides clothing, school fees, and books
in exchange for sex.

• Millions of children live and work on the streets in developing countries and many are involved in
“survival sex”, where they trade sex for food, money, protection or drugs.

Sexual violence

Sexual abuse occurs worldwide. One-third of teenagers experience abuse, with in heterosexual
relationships, in United States. Rape and involuntary prostitution can result in physical trauma,
unintended pregnancy, STIs, psychological trauma and increased likelihood of high- risk sexual
behaviour.

The health risks of adolescent sexuality is more than older people

1. Maternal death: Girls aged 15-19 are up to twice as likely to die during pregnancy or delivery as
women aged 20-34.

2. Infant and child mortality: children born to adolescents are more likely to die during their first five
years of life than those born to women age 20- 29.

3. Sexually transmitted infections (STIs): each year, 1 in 20 adolescents worldwide contracts STIs
(including HIV/AIDS).

4. Violence/sexual abuse: Adolescent girls may lack the confidence and decision-making skills to refuse
unwanted sex.

Unwanted pregnancy

Every year, approximately 50 million unwanted pregnancies are terminated. Some 20 million of these
abortions are unsafe. About 95 % of unsafe abortions take place in developing countries, causing the
deaths of at least 200 women each day. Many adolescents face unintended births for example in sub-
Saharan Africa about 50 % of last births in women under 20 years were unintended.

Psychological and socio-economic consequences of pregnancy for unmarried adolescents

• Psychological stress, poor self esteem, lack of hope and social stigma

• Disrupted education, poor academic achievement

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• Leaving home and prostitution

• Poor socio-economic future, poor earning capacity: fewer career or job opportunities.

• Unstable marriage

• Unwanted child- mistreated, abandoned

• Their children face psychological, social and economic obstacles

Causes for early unprotected sexual intercourse in adolescents

• Lack of knowledge on physiology of the reproductive system and human sexuality

• Declining age of menarche

• Early marriage

• Urbanization, migration, (western cultural influences)

• Sexual violence and coercion

• Peer influence

• Lack of knowledge on family planning

• Unavailability and inaccessibility (including culturally) of services

• (negative) attitude of the society (including service providers) towards use of family planning services
by the adolescents

• Sense of guilt, fear of discovery, disapproval or rejection

Effects of gender roles

• Expectations of sexual activity of boys and girls

• Views regarding responsibility for contraception

• Social consequences of pregnancy

Factors affecting Reproductive Health (RH) needs of adolescents

 Age

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 Marital status
 Gender norms
 Sexual status
 School status
 Child bearing status
 Rural/urban residence
 Peer pressure
 Cultural/ political conditions

Adolescents’ contraceptive use

Few married adolescents use contraception before first pregnancy. After becoming sexually active,
unmarried adolescents delay use of contraceptives for about a year. Two common reasons for non-use of
contraceptives among youth are:

• Did not expect to have sex

• Lacked knowledge about contraception

Barrier to Contraceptive Use

Adolescents’ contraceptive use is limited due to:

• Do not plan ahead or anticipate consequences

• Think they are not at risk

• Lack of confidence or motive to use

• Embarrassed or not assertive

• Lack power and skill to negotiate use

• Clinics not friendly to adolescent's use

• Providers reluctance to serve unmarried adolescents

• Prohibition by law/policy to serve adolescents

• Adolescent's reluctance to use service for fear of judgment or concerned about having pelvic
examination

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Adolescent Reproductive Health Services

Making clinical services available

Adolescent clinical health services are best staffed by providers trained to deal with specific adolescent
health concerns and to counsel adolescents about sensitive reproductive health issues and contraceptive
use. In all interventions, providers must consider adolescents’ marital status, overall health, and how
much power they have in sexual activity. Adolescents often name the following characteristics as
important to meeting their health needs confidentiality; convenient location and hours; youth friendly
environment; open to men and women; strong counselling component; specially trained providers; and
comprehensive clinical service.

Providing information

Providing appropriate and relevant information about reproductive health is essential to any program.
Clinic- based education and counselling are important to this effort, as are school- based programs.
Obviously, parents are a key source of information, although they may feel ill-informed or embarrassed
to discuss these topics with their children, or simply may disapprove of young people expressing an
interest in sexuality. Youth- friendly approaches such as radio call-in shows, drop-in centres, magazines,
and hotlines also can be effective strategies for reaching adolescents.

Children living in poverty may feel no reason to plan for the future and protect their health. Other factors
that influence adolescent health and behaviour include:

• Gender inequities and sexual exploitation

• Cultural expectations about childbearing.

Open, discussions on sexuality are:

• Difficult topic to discuss openly for both adolescents and adults

• Includes a wide range of issues, such as peer pressure, sexual identity, sexual orientation, sexual
capability, and sexual coercion.

• Helps adolescents understand and express their feelings.

• Promotes responsible sexual behaviour thus helps prevent unintended pregnancy and STDs.

Early sex education

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• Gives adolescents skills to delay sexual activity

• Does not lead to earlier or increased sexual activity

• Can increase contraceptive use

Health clinic Designed for adolescents:

• Separate units for adolescents

• Outreach clinics with specially trained staff

• Mobile clinics

• Special hours

• Convenient and safe locations

• Youth-to-youth promotions

• Low or no-cost services

Providers’ communications skills:

• Sincerity, Honesty, Non-judgmental, Respect, Sense of humour, Confidentiality, very critical

Range of providers are needed to reach adolescents:

• Teachers

• Peer educators

• Health workers

• Community workers

Provider training:

• Technical knowledge

• Knowledge of issues facing adolescents

• Gender awareness

• Counselling skills

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• Skills in training adolescents

Important education information topics for adolescents

1. Risks and consequences of sexuality:

• Contraception and STDs

• Sexual education

• Fertility issues for men and women

• Gender issues

2. Potential sites for information and services for adolescents:

• Home

• Health institutions

• School

• Youth organizations

• Mass media

3. Effective programs for adolescents:

- Identify target group and needs

- Involve adolescents

- Work with community and parents

- Use materials designed by and for adolescents

- Make services accessible based on adolescent's preference

- Incorporate evaluation

Ensuring community support

Programs for adolescents often encounter problems gaining community acceptance since adults fear that
access to education and services will encourage adolescent sexual activity. Program evaluations have

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shown this not to be the case. Some programs have found that explaining objectives to parents, religious
leaders, and community leaders, and inviting them to discussion sessions with adolescents helps reduce
opposition. Adolescent Reproductive life involves government representatives, NGOs, community
groups, young people, and other in a program to increase awareness about reproductive health issues,
encourage advocacy, and provide service.

Community-based outreach programs: Are especially important to groups such as out-of school youth,”
street” youth and girls who have limited freedom to leave their community. These community-based
projects use a variety of formats to reach youth where they gather for “work or play”. After attending
educational sessions, interested members can be made to join a theatre group to perform in public areas
and schools to provide information to their peers.

Components of successful adolescent reproductive health programs

Reproductive health programs for adolescents tend to be most successful when they:

(1) Accurately identify and understand the group to be served;

(2) involve adolescents in the design of the program;

(3) work with community leaders and parents;

(4) remove policy barriers and change providers' prejudices;

(5) help adolescents rehearse the interpersonal skills needed to avoid risks;

(6) Link information and advice to services;

(7) Offer role models that make safer behaviour attractive;

(8) And invest in long-enough time frames and resources

Chapter Eleven: Common Gynaecologic Procedures

Hysterectomy
A hysterectomy is a procedure to remove the uterus. It is a very common type of surgery for women.
Removing your uterus means that you can no longer become pregnant. Different types of hysterectomies
include:

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Total Laparoscopic Hysterectomy (TLH)
TLH is the removal of the uterus and cervix through four small abdominal incisions. Depending on the
patient’s individual case, the ovaries and fallopian tubes may also be removed.

Laparoscopic Supracervical Hysterectomy (LSH)

This procedure involves laparoscopic removal of the uterus and the patient is able to keep her cervix.
The patient can either keep her ovaries or have them removed at the same time.

Laparoscopic Assisted Vaginal Hysterectomy (LAVH)

LAVH is a surgical procedure using a laparoscope to guide the removal of the uterus and/or fallopian
tubes and ovaries through the vagina.

Fibroid Removal
Fibroids are noncancerous tumors in the muscle of the uterus. Treatment approaches for removing
fibroids includes:

Laparoscopic Myomectomy for Fibroids

This surgery involves removing fibroids (noncancerous tumors in the muscle of the uterus) from the wall
of the uterus.

Hysteroscopic Myomectomy
Hysteroscopic myomectomy involves inserting a thin lighted viewing instrument (hysteroscope) through
the vagina and the cervix into the uterus. This instrument then allows the doctor to view the fibroid to
remove it through the vagina.

Ovarian Cyst Removal

An ovarian cyst is a fluid-filled sac that develops on a woman's ovary. Patients who need a cyst removed
may receive the following minimally invasive treatment:

Laparoscopic Ovarian Cystectomy

Laparoscopic Ovarian Cystectomy is surgery to remove a cyst or cysts from one or both of the ovaries
using small incisions and specialized tools.

Treating Adhesions
Adhesions are scars that form within the body, typically after surgery, as part of the healing process.

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Laparoscopic Lysis of Adhesions
This procedure is used to treat abdominal and chronic pelvic pain caused by adhesions.

Diagnostic Hysteroscopy
A diagnostic hysteroscopy is a gynecologic procedure to evaluate the endometrial cavity, the layer of
mucus membranes that line the uterus.

Removing Uterine Polyps

Uterine polyps are noncancerous cells that grow on the inner wall of the uterus and extend to the uterine
cavity

Hysteroscopic Polypectomy
Hysteroscopic polypectomy is a surgery to remove uterine polyps. This allows the uterus to be
preserved.

Hysteroscopic Endometrial Ablation

A thin lighted viewing instrument (hysteroscope) is used to see inside the uterus. Then, to treat abnormal
uterine bleeding, an endometrial ablation procedure is performed and destroys (ablates) the uterine lining.

Hysteroscopic Sterilization (Essure)

Hysteroscopic sterilization is a type of tubal sterilization procedure that uses the body's natural openings
to place small implants into the fallopian tubes. These implants cause tissue growth that blocks the tubes.
No surgical incision is needed.

Robotic-Assisted Surgery
In robotic-assisted surgery, the surgeon uses a computer-controlled device that moves, positions, and
manipulates surgical tools based on his or her movements. He or she sits at the computer console with a
monitor and the camera provides a three-dimensional view of the surgical area that is magnified 10 times
greater than a person's normal vision. The surgeon's hands control the robotic arms to perform the
procedure.

Robotic-assisted surgery is performed to treat pelvic organ prolapsed, fibroids, and gynaecological
cancers in appropriately selected patients.
Patient benefits may include:

 Reduced body trauma and pain

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 Reduced blood loss and/or need for blood transfusions
 Reduced post-operative pain and/or discomfort
 Reduced hospital stay

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