Female Reproductive Problems

Question 1

Abnormal vaginal bleeding

Answer 1

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

Question 2

Menorrhagia

Answer 2

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

Question 3

Metrorrhagia

Answer 3

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

Question 4

Amenorrhea

Answer 4

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

Question 5

Oligomenorrhea

Answer 5

Refers to long intervals between menses, generally >35 days
Oligomenorrhea owing to anovulation is common for women at the beginning and end of menstruation

Question 6

Nursing Management of abnormal vaginal bleeding

Answer 6

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

Question 7

Surgical therapy for abnormal vaginal bleeding

Answer 7

Surgery is indicated depending on underlying cause of abnormal vaginal bleeding
- D & C (dilation and curettage)
- Hysterectomy
- Myomectomy, via
Laparotomy
Laparoscopy
Hysteroscopy

Question 8

Ectopic pregnancy

Answer 8

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.

Question 9

Risk factors of ectopic pregnancy

Answer 9

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

Question 10

Clinical manifestations of ectopic pregnancy

Answer 10

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

Question 11

Dx of ectopic pregnancy

Answer 11

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

Question 11

Management of ectopic preg

Answer 11

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)

Question 12

Laparoscopy for ectopic pregnancy

Answer 12

Often, no time to fully prepare pt for surgery
Fertilized egg cannot develop normally outside uterus. Ectopic tissue needs to be removed

Question 13

Laparoscopic types

Answer 13

1) Salpingotomy
The ectopic pregnancy is removed; tube is left to heal on its own
2) Salpingectomy
Both ectopic pregnancy & the tube are removed

Question 14

What does the choice of laparoscopic procedures depend on?

Answer 14

Pt’s age
Tube condition
serum βhCG levels
Pt’s future fertility desire

Question 15

Endometriosis

Answer 15

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

Question 16

Symptoms of endometriosis

Answer 16

Symptoms and pain vary considerably, and does not correlate with extent of endometriosis
Most common manifestations: dysmenorrhea, infertility, pelvic pain, dyspareunia, and irregular bleeding

Question 17

Dx of endometriosis

Answer 17

Diagnosis ⇨ laparoscopy for a definitive diagnosis

Question 18

Tx of endometriosis

Answer 18

Treatment influenced by pt’s age, desire for pregnancy, symptom severity, and the extent and location of disease

Question 19

Sx for endometriosis

Answer 19

The only cure is surgical removal of all the endometrial implants

Question 20

2 types of endometriosis

Answer 20

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

Question 21

Sx procedures for female reproductive system

Answer 21

Abdominal Hysterectomy
Vaginal Hysterectomy
Laparoscopic Hysterectomy
Robot-Assisted Surgery
Vulvectomy
Vaginectomy
Pelvic Exenteration

Question 22

Indications for hysterectomy

Answer 22

Gynecological cancer
Fibroids
Endometriosis
Uterine prolapse
Abnormal vaginal bleeding
Chronic pelvic pain

Question 23

3 approaches of hysterectomy

Answer 23

Abdominal
Vaginal
Laparoscopic

Question 24

Types of hysterectomies

Answer 24

Subtotal hysterectomy
Total hysterectomy
Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
Wertheim’s hysterectomy

Question 25

Abdominal approach to hysterectomy

Answer 25

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)

Question 26

Vaginal approach to hysterectomy

Answer 26

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

Question 27

Laparoscopic approach to hysterectomy

Answer 27

Uterus is usually removed through vagina, but sometimes through incisions for laparoscope if uterus is not too large

Question 28

Types of hysterecomy

Answer 28

Subtotal hysterectomy
Total hysterectomy
Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
Wertheim’s/Radical hysterectomy

Question 29

Subtotal hysterectomy

Answer 29

Uterus is removed, leaving cervix in place
Rarely performed today
Less disruption to pelvic floor, less damage to urinary tract, and fewer infections

Question 30

Total hysterectomy

Answer 30

Both uterus and cervix are removed

Question 31

Total hysterectomy with bilateral or unilateral salpingo-oophorectomy

Answer 31

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

Question 32

Wertheim’s/Radical hysterectomy

Answer 32

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

Question 33

Post op care for hysterectomy

Answer 33

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

Question 34

Upon discharge for hysterectomy

Answer 34

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

Question 35

Breast cancer risk factors

Answer 35

Female Gender
Advancing age
Hormone therapy
Weight gain
Sedentary lifestyle
Smoking
Obesity
Alcohol intake

Question 36

Genetic factors of breast cancer

Answer 36

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

Question 37

Patho of breast cancer

Answer 37

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

Question 38

Clinical manifestations

Answer 38

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

Question 39

Complications of breast cancers

Answer 39

Most common is recurrence
Metastases

Question 40

Diagnosis of breast cancer

Answer 40

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

Question 41

Sx therapy

Answer 41

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

Question 42

Adjuvant therapy for breast cancer

Answer 42

radiation
high dose brachytherapy (type of radiation that goes down to the source)
Palliative radiation therapy
Estrogen receptor blockers
aromatase inhibitors

Question 43

Acute intervention mastectomy

Answer 43

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

Question 44

Post op complications

Answer 44

Lymphedema
Postmastectomy pain syndrome

Question 45

Lymphedema

Answer 45

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

Question 46

Postmastectomy pain syndrome

Answer 46

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

Question 47

Lymphedema

Answer 47

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