Chapter 74: Care of Patients with Gynecologic Problems Flashcards
Primary dysmenorrhea
Painful menstrual flow that occurs after ovulation begins, usually six months or more after menarche. Painful uterine cramping with spasmodic lower abdominal pain begins with the onset of flow and lasts 12 to 72 hours. Extensive prostaglandins released cause spasms in the myometrium which result in constricted blood flow to the uterus resulting in ischemia and pain. Secondary dysmenorrhea can because by endometriosis, adhesions, pelvic inflammatory disease, ovarian cysts or tumors, leimyomas/fibroids.
Treatment includes NSAIDS inhibit prostaglandin release and relieve pain, Tylenol, oral contraceptives, IUDs. Heat, CAM, low fat diet, thiamine, calcium, magnesium, vitamin E, fish oil may help.
PMS Premenstrual syndrome
A collection of symptoms that occur in the two weeks before menstruation and are followed by relief with menses and a symptom-free phase. Symptoms may include emotional, physical, and cognitive manifestations such as irritability, breast tenderness, short-term memory problems, depression, anxiety, edema, headache, bloating, cravings, insomnia, fatigue, decrease libido,
Severe disorder of PMS is PMDD premenstrual dysphoric disorder. It occurs most often with mental health disorders.
Risk factors include smoking, substance abuse, obesity, and stress.
Exercise at least 30 minutes 3xweek to increase endorphins, stress management, eat healthy. Eat 6 small meals a day; limit sugar, redmeat, and alcohol ^ bloating; avoid caffeine and alcohol which ^ irritability; limit sodium which may ^edema; calcium and magnesium may help;
CAM: monks pepper AKA Natures way may help, but use contraception while on it.
Homone therapy: oral contraceptives; gnRH may cause flashes, irritability and vaginal dryness, long term decreased bone density, and low libido; antidepressants SSRIs for PMDD, and used for 10-14 days before menses begins
Endometriosis
Endometrial tissue implantation outside uterine. Usually on the ovaries and other pelvic organs. Monthly bleeding occurs at the ectopic/out of place site of implantation which irritates and scars the tissue. Scarring may lead to adhesions and cause in fertility.
Manifestations include pain, despair in reunion, painful defecation, lobectomy, infertility, nausea, diarrhea.
Treatment is similar to dysmenorrhea with world contraceptives, decreasing prostaglandins with NSAID, use GnRH agonist. Heat packs, relaxation techniques, calcium, and magnesium may relieve symptoms. Surgical management includes laparoscopic removal of adhesions. Severing pelvic nerve may relieve intractable pain. IUD may help avoid reoccurence. If children are not wanted, uterus and ovaries may be removed.
Dysfunctional uterine bleeding DUB
Bleeding that is excessive in amount of more than 80 mL per cycle or frequency more than every 21 days. It is made after ruling out other conditions. Occurs most often at the end of the reproductive years. It is from a hormonal imbalance in usually when the ovaries fill ovulate. This decreases progesterone which is needed to mature the uterine lining. It is associated with conditions such as endocrine disturbances diabetes and thyroid, polycystic ovary disease, stress, Obesity or underweight, long-term drug use such as oral contraceptives or tamoxifen, anatomic abnormalities.
Hormone therapy with estrogen, progestin, IUD, NSAIDs may be helpful. For surgical management a D&C used to be used, but now endometrial ablation using a laser, rollerball, or balloon is used. Laparoscopic surgery may be needed. Hysterectomy is performed in other treatments have failed.
Menopause
Normal events caused by the cessation of. For 12 months. It is the depletion of estradiol, and estrogen produced by the ovaries. Symptoms include decreased libido
Women going through menopause at a younger age are at risk for osteoporosis, fracture, cardiovascular disease. Factors that affect the timing a include autoimmune disease, chromosomal abnormalities, genetic, early menarche, hysterectomy, smoking, Cancer treatment. Perimenopause is the change of life is the gradual transition. It is confirmed by hormone levels. Symptoms include hot flashes and night sweats, disturb sleep pattern which affects concentration and memory, vaginal dryness, dispareunia, urogenital atrophy, stress incontinence, menstrual irregularity,
Treatment includes formal replacement therapy. It can cause increased risk for coronary heart disease and breast cancer. Estrogen alone can cause endometrial cancer, gallbladder disease, thromboembolus conditions and stroke. If the patient has atrophic vaginitis should use vaginal estrogen therapy. Hot flashes maybe relieved with gabapentin And low-dose antidepressants. Many women are on prophylactic osteoporosis medications. Exercise can decrease bone loss and prevent hypertension and diabetes, increased mood. Proper nutrition, calcium and vitamin D can help prevent osteoporosis. Black cohosh and soy are popular to use.
Lab studies to confirm menopause
Estradiol Norm 20-750; menopause <20
FSH 1.09-17.2; 19.3-100.6
LH 0.61-56.6; 14.2-52.3
Vulvovaginitis
Vaginal discharge and itching from the inflammation of the lower genital tract and a disturbance of the balance of hormones and normal flora. Have a change in discharge, odor, and lesions. Causes can be fungal infections, bacterial, STDs such as trichomonas, menopausal atrophy, changes in normal flora or pH from douching, chemicals, foreign body, antibiotics, immunosuppression from pregnancy diabetes or HIV.
To prevent it wear cotton underwear, avoid tight clothing, wipe from front to back, cleanse with water and not soap, do not have intercourse if partner is infected, increased risk if you are pregnant have diabetes or takes oral contraception, practice monthly self exam.
Toxic shock syndrome
Abrupt onset of a high fever, headache, flu symptoms, severe hypotension with fainting, sunburn like rash, broken capillaries in the eye. Remove the infected source such as a tampon, restore electrolytes, manage hypotension, IV antibiotics, transfusion, and corticosteroids.
Uterine prolapse
It can also include the bladder, rectum, small intestine. A cystocele is the protrusion of the bladder through the vaginal wall and can lead to incontinence and UTI. A rectocele is a protrusion of the rectum through a weakened vaginal wall.
Manifestations include feeling like something is falling out, painful intercourse, backache, heaviness pressure in the pelvis.
Pelvic floor muscle exercises or kegel exercises are taught. Space filling device such as pessary or sphere may be warn. Bladder training maybe necessary. Management of a rectocele focuses on bowel elimination.
Surgery may be recommended for severe symptoms. Anterior colporrhaphy tightens the pelvic muscles for better bladder support. Vaginal approach is used. Care is similar to hysterectomy. Avoid lifting over 5 pounds, strenuous exercises and sexual intercourse for six weeks. Use a heating pad on the lower abdomen and a hot bath. Sutures do not need removed.
Posterior colporrhaphy reduces rectal bulging. Care is similar to any rectal surgery. A low residue diet is prescribed to decrease bowel movements and allow time for incision heal. Avoid strain. May need pain medicine before a bowel movement. Sitz bath.
Hysterectomy may be indicated.
cystocele
Difficulty emptying the bladder, urinary frequency and urgency, urinary tract infection, stress incontinence. A large bulge when the woman is asked to bear down. Cystography, measurement of residual urine with ultrasound, urine culture, x-ray
Rectocele
Constipation, hemorrhoids, fecal impaction, feelings of rectal or vaginal fullness. There may be a bulge of the posterior vaginal wall when a woman is asked to bear down.
Fistulas
Abnormal openings between two adjacent organs or structures. Thy occur between the vagina and the urethra, the vagina and the bladder, or the vagina in the rectum. Tramatic childbirth is the main cause, but can be from complications from surgery cancer or radiation. Manifestations include leakage of urine, flatus, or feces into the vagina. Irritation and excoriation of vaginal tissue, odor. Surgery is not recommended if there is an infection or inflammation. Care includes frequent perineal hygeine, sitz bath, low-pressure douching, commercial deodorizing. Wear sanitary napkins or disposable underwear if leakage. Bladder and bowel training. A&D ointment. Surgical repair similar to cystocele.
Ovarian cyst
CT, MRI, or laparoscopic biopsy may rule out cancer. Some disappear over time and other cause discomfort.
Uterine leiomyoma-fibroids
Benign, slow-growing solid tumors of the uterine myometrium. Intramural are contained in the uterine wall. Submucosal protrude into the cavity of the uterus and cause bleeding and disrupt pregnancy. Subserosal protrude to the outer surface and may extend into the broad ligament pushing into other organs. They are related to the stimulation by estrogen, progesterone, and growth hormone. They are higher in africans and women who have never been pregnant are at risk. They may have extra bleeding or bleeding in between periods. Don’t usually have pain. They may have increased pressure, constipation, urinary frequency or retention. Abdomen increase in size. Painful intercourse or infertility.
There is a potential for hemorrhage. Asymptomatic do not need treated. If children are not wanted, uterine artery embolization (injection of alcohol into artery and blocks circulation to tumor) or hysterectomy are choices.
UAE may have severe cramping for 2-4 days from decreased blood flow. Return to work in week
Myomectomy removal of fibroids is done during early phase of menstrual cycle. Future deliveries will need to by cesarean.
Hysterectomy
Fibroids most common cause for a hysterectomy. The uterus and cervix can be removed. It can be done vaginally or may need to be open or laproscopic.
Postoperatively there should be less than one saturated pad in four hours. Assess abdominal bleeding at the incision site and intactness of the incision. Monitor urine output with a catheter. Limit stair climbing for several weeks. Do not drive for 2 to 6 weeks. No lifting over 5 pounds. Gradually increase walking. Avoid sitting for a long period of time. Avoid aerobic exercise for six weeks. Eat extra protein and vitamin C. Drink at least 3 quarts of water. No sex for 4 to 6 weeks. Take your temperature twice a day for two weeks.
Complications include intestinal obstruction, thromboembolism, atelectasis, pneumonia, wound dehiscense, urinary retention. For a vaginal include hemorrhage, urinary tract complications such as infection or retention, wound infection.
