Female Reproductive Problems Flashcards
Abnormal vaginal bleeding
aka uterine bleeding, common gynecological concern
Types of irregularities
a) Oligomenorrhea
b) Amenorrhea
c) Menorrhagia
d) Metrorrhagia
Cause may vary ⇨ from anovulatory menstrual cycles to more serious causes such as ectopic pregnancy or endometrial cancer
Menorrhagia
Excessive bleeding characterized as an increased duration (> 7days), increased amount (> 80ml), or both
The most common cause ⇒ anovulatory uterine bleeding
For young ♀ with excessive bleeding, clotting disorders must be considered
Metrorrhagia
Also referred to as spotting, or breakthrough bleeding, is bleeding between menstrual periods
For ♀ of reproductive age, spontaneous abortion or ectopic pregnancy must be considered
For ♀ who are postmenopausal, endometrial cancer must be considered whenever spotting is experienced
Amenorrhea
Aside from pregnancy,
The most common cause for missing menses –> anovulation
Primary amenorrhea → failure of menstrual cycles to begin by 16 yrs (or 14yrs with secondary sex characteristics)
Second amenorrhea → cessation of menstrual cycle once established
Oligomenorrhea
Refers to long intervals between menses, generally >35 days
Oligomenorrhea owing to anovulation is common for women at the beginning and end of menstruation
Nursing Management of abnormal vaginal bleeding
Teach them about characteristics of menstrual cycle
- will assist to identify normal variations
- If menstrual cycle does not fall within the normal range, seek health care provider
↓ risk of Toxic Shock Syndrome (TSS)
- TSS is acute condition caused by Staphylococcus aureus
- avoid using prolonged use of superabsorbent tampons & pads
- initially, flu-like symptoms – high fever, N/V, diarrhea, dizziness, fainting, and disorientation
Excessive amount of vaginal bleeding should be assessed accurately
Anemia & hypovolemia may be present – assess variations in BP, HR
Surgical therapy for abnormal vaginal bleeding
Surgery is indicated depending on underlying cause of abnormal vaginal bleeding
- D & C (dilation and curettage)
- Hysterectomy
- Myomectomy, via
Laparotomy
Laparoscopy
Hysteroscopy
Ectopic pregnancy
Implantation of the fertilized ovum anywhere outside uterine cavity
Result of fibrosis or damage to cilia in the tube following infection or inflammation of the Fallopian tube
3% of all pregnancies; 98% occur in fallopian tube
Eventually tube ruptures ⇒ peritoneal symptoms
Is a life-threatening condition
A ♀ suspected of ectopic pregnancy should always
be treated as an emergency.
Risk factors of ectopic pregnancy
history of PID (pelvic inflammatory disease), prior ectopic pregnancy, progestin-releasing IUD (intrauterine device), progestin-only birth control failure, and prior pelvic or tubal surgery
Clinical manifestations of ectopic pregnancy
Abdominal or pelvic pain
Almost always present ⇨ due to distention of the fallopian tube
Missed menses
Irregular vaginal bleeding
If tubal ruptures, pain is intense ⇨ risk for hemorrhage & hypovolemic shock
Suspected rupture is treated as an emergency
Dx of ectopic pregnancy
Diagnosis can be challenging due to similarities to other pelvic and abdominal disorders
A serum (radioimmunoassay) pregnancy test ⇨ would be pos. If test is negative ⇨ likely, not ectopic pregnancy
Dx can be confirmed by using a serum βhCG (Beta-Human Chorionic Gonadotropin)
- Key ⇒ presence or absence of an intrauterine gestational sac correlated with serum βhCG levels
- Suspect ectopic pregnancy if transvaginal U/S shows no intrauterine gestational sac when the βhCG level is > 1,500 IU/L
Symptoms vary depending on the site of implantation (although most occur in fallopian tube
Management of ectopic preg
Surgery remains the primary approach, and should be performed immediately
However, for hemodynamically stable pt and with the size of gestation < 3cm, tx of IM injection of methotrexate is being used with increasing success
Laparoscopy is preferable to laparotomy
less blood loss, ↓ LOS (length of stay)
Laparoscopy for ectopic pregnancy
Often, no time to fully prepare pt for surgery
Fertilized egg cannot develop normally outside uterus. Ectopic tissue needs to be removed
Laparoscopic types
1) Salpingotomy
The ectopic pregnancy is removed; tube is left to heal on its own
2) Salpingectomy
Both ectopic pregnancy & the tube are removed
What does the choice of laparoscopic procedures depend on?
Pt’s age
Tube condition
serum βhCG levels
Pt’s future fertility desire
Endometriosis
Presence of endometrial epithelial tissue (usually lines uterus) found outside the uterine cavity
Most frequent sites : near ovaries, broad ligament, uterosacral ligaments, bowel, bladder
Endometrial tissues undergoes a mini-menstrual cycle
Blood collects in cystlike nodules blue/black in color cause inflammation scarring and adhesions
Typically in those who has never had a full-term pregnancy
A common cause of infertility, ↑ risk for ovarian cancer
Symptoms of endometriosis
Symptoms and pain vary considerably, and does not correlate with extent of endometriosis
Most common manifestations: dysmenorrhea, infertility, pelvic pain, dyspareunia, and irregular bleeding
Dx of endometriosis
Diagnosis ⇨ laparoscopy for a definitive diagnosis
Tx of endometriosis
Treatment influenced by pt’s age, desire for pregnancy, symptom severity, and the extent and location of disease
Sx for endometriosis
The only cure is surgical removal of all the endometrial implants
2 types of endometriosis
1) Conservative surgery: to confirm diagnosis or to remove implants lysing or excision of adhesion by laparoscopic laser surgery or laparotomy
- for women wishing to get pregnant
2) Definitive surgery: removal of uterus, fallopian tubes, ovaries, and as many endometrial implants as possible
- post-op care similar as abdominal hysterectomy
Sx procedures for female reproductive system
Abdominal Hysterectomy
Vaginal Hysterectomy
Laparoscopic Hysterectomy
Robot-Assisted Surgery
Vulvectomy
Vaginectomy
Pelvic Exenteration
Indications for hysterectomy
Gynecological cancer
Fibroids
Endometriosis
Uterine prolapse
Abnormal vaginal bleeding
Chronic pelvic pain
3 approaches of hysterectomy
Abdominal
Vaginal
Laparoscopic
Types of hysterectomies
Subtotal hysterectomy
Total hysterectomy
Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
Wertheim’s hysterectomy
Abdominal approach to hysterectomy
In the presence of large tumors
when pelvic cavity needs to be explored
When tubes and ovaries are to be removed
Very large uterus b/c fibroids (vaginal approach is impossible)
Vaginal approach to hysterectomy
When vaginal repair is done in addition to removal of the uterus
Fewest complications, shorter hospital stay & fastest recovery
Usually in older women where there is prolapse of uterus
For treatment of early stage of cervical and uterine cancers
Laparoscopic approach to hysterectomy
Uterus is usually removed through vagina, but sometimes through incisions for laparoscope if uterus is not too large
Types of hysterecomy
Subtotal hysterectomy
Total hysterectomy
Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
Wertheim’s/Radical hysterectomy
Subtotal hysterectomy
Uterus is removed, leaving cervix in place
Rarely performed today
Less disruption to pelvic floor, less damage to urinary tract, and fewer infections
Total hysterectomy
Both uterus and cervix are removed
Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
Body of uterus, cervix, fallopian tube(s), and ovary(ies) are removed
Usually done at the same time as total abdominal hysterectomy
Removal of ovaries brings on a sudden menopause d/t loss of ovarian hormones
Prevents recurrence of ovarian ca
Wertheim’s/Radical hysterectomy
Removal of uterus, ovaries, Fallopian tubes, adjacent pelvic tissue, lymph ducts, and upper 1/3 of vagina
Necessary in case of advanced cervical and endometrial cancer
Treatment of choice for low risk Stage 1 disease
Post op care for hysterectomy
ABC
IV infusion for 24-48 hours (possible blood transfusion depending on blood loss)
Hemovac drain (drain blood from operation site) – to prevent hematoma
Foley cath – accurate u/o
Maybe a suprapubic catheter via abdomen ⇒ to ↓ post-op UTI
Unless heavy oozing from wound, a light dry dressing to cover wound x 48 hrs
Women with vaginal hysterectomy ⇒ will have ‘vaginal pack’ (with ribbon gauze) inserted into vagina to stop bleeding from suture point
Analgesia: epidural or PCA
Control nausea: e.g., Ondansetron, Metoclopramide
Early mobilization
Sit up on a bedside chair, work with physiotherapist
With return of BS, start clear water/full fluids
With start of oral fluids, IV rate may needs to be adjusted (e.g., ↓ )
Strict I & O
Encourage to empty bladder fully
By post-op day 2, should be able to ambulate to BR
Splint abdomen (or hold a towel in place if had a vaginal hysterectomy) when coughing
With horizontal wound (bikini line) – stitches removed usually 5th day vertical wound - 7 or 10th day
Prevent constipation (e.g., Lactulose or supp)
Common to feel ‘blue’ on post-op Day 3 or 4 → reassure this is a normal reaction, that it will pass
Upon discharge for hysterectomy
Important to teach pt AND family: what she can and cannot do
Bleeding
- May be vaginal discharge for up to 4 wks – will change color from red to pale brown
- Seek help if discharge becomes heavier, brighter in color, or offensive smell
Important to get sufficient rest first 2 weeks
- Common to suddenly feel tired and exhausted
Exercise
- Advisable to go for short walks, increasing gradually in duration
- May resume swimming by 6 weeks post surgery
House work
- No housework for the first 2 weeks
- Light chores can be undertaken after this period
- Do not lift heavy objects first 4 weeks; very heavy objects for at least 3 months
Work
- Varies in individuals; some feel ready to return 6-8 weeks, while other take longer
Sexual intercourse
- In general, takes approx. 6 weeks to physically and emotionally feel ready to resume sexual intercourse after major gynecological surgery
- Important to wait until any vaginal bleeding has stopped, to prevent risk of infection
- Partner should be gentle and avoid undue trauma to the area
- Hormonal effects of oophorectomy ⇒ loss of libido, vaginal atrophy, ↓vaginal lubrication r/t ↓ estrogen and testosterone
- Some report ↓ sexual response after hysterectomy (may be d/t scar tissue at surgical site)
She may need to be encouraged to focus on other sensations that will help build her sexual response
Breast cancer risk factors
Female Gender
Advancing age
Hormone therapy
Weight gain
Sedentary lifestyle
Smoking
Obesity
Alcohol intake
Genetic factors of breast cancer
Increased risk if family member has had ovarian cancer, was premenopausal at diagnosis, had bilateral breast cancer and is a first degree relative.
First degree relative increases likelihood from 1.5 to 3X depending on age.
Women with the BRAC1 and BRAC2 ( mutations) have a 85% chance of developing breast cancer in their lifetime and are at a high risk for ovarian
Patho of breast cancer
Noninvasive breast cancer (one place)
Invasive (infiltrating) ductal carcinoma (most common) - milk ducts to surround tissues
Invasive (infiltrating) lobular carcinoma - starts in lobs (producing milk)
Inflammatory - develops when cancer cells block lymph vessels, rare and spreads quickly
Paget’s disease - develops on nipple, unilateral, invasive ductal carcinoma with this cancer
Triple negative - no estrogen, progesterone or human epidural growth factor (HER2
Clinical manifestations
Lump or mammographic abnormality
Most often in outer upper quadrant of the breast
If palpable hard, irregularly shaped, poorly delineated, nonmobile and nontender
Nipple d/c in small percentage may be clear or bloody
nipple retraction may occur
Peau d’orange caused by plugging of the lymphatic vessels
infiltration, induration, and dimpling of the skin may occur in large cancers
Complications of breast cancers
Most common is recurrence
Metastases
Diagnosis of breast cancer
Axillary lymph node dissection
lymphatic drainage and sentinel lymph node biopsy
tumor size
estrogen and progesterone status
HER2 (increases cell growth)
Spreads to liver, bones and brain
Sx therapy
Thergical therapy considered the primary tx
breast conserving therapy (non-invasive, lumpectomy)
ALND (removal of all breast tissue, chest muscles left intact)
Modified radical mastectomy
Adjuvant therapy for breast cancer
radiation
high dose brachytherapy (type of radiation that goes down to the source)
Palliative radiation therapy
Estrogen receptor blockers
aromatase inhibitors
Acute intervention mastectomy
pain corelates to extent of lymph node dissection
pts usually d/c home with drains
restoring arm function on side of sx is a key nursing goal
postop arm and shoulders exercises
prevent or reduce lymphedema
psychological care
Post op complications
Lymphedema
Postmastectomy pain syndrome
Lymphedema
An accumulation of lymph in soft tissue as a result of excision or radiation of lymph nodes
Can cause, heaviness, pain, impaired motor function, numbness and paresthesia of fingers in the affected arm. Cellulites and progressive fibrosis
Postmastectomy pain syndrome
chest and upper arm pain, tingling down arm, numbness, shooting or prickling pain, and unbearable itching that persists beyond the normal 3 months healing time. Though to be due to nerve injury
tx - NSAIDs, antidepressants, topical lidocaine, gabapentin, local anesthetic
Lymphedema
affected arm should never be dependent even in sleep
elastic bandages not used in early post op as they inhibit lymphatic drainage
protect arm from trauma and sunburn
if trauma treat and watch closely
decongestive therapy
BP, venipuncture and injection should never be done on the affected arm
