Female Reproductive Problems Flashcards
Abnormal Vaginal Bleeding
aka uterine bleeding, common gynecological concern
Types of irregularities:
Oligomenorrhea:
-Refers to long intervals between menses, generally >35 days
-dt anovulation is common for women at the beginning and end of menstruation
Amenorrhea:
-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
-Aside from pregnancy, the most common cause for missing menses ⇒ anovulation
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:
-spotting, or breakthrough bleeding, is bleeding between menstrual periods
- ♀ of reproductive age- spontaneous abortion or ectopic pregnancy must be considered
-♀ who are postmenopausal- endometrial cancer must be considered whenever spotting is experienced
Nursing management:
-Teach them about characteristics of menstrual cycle
If menstrual cycle does not fall within the normal range, seek health care provider
-teach about risk of Toxic Shock Syndrome (TSS)
-TSS is an acute condition caused by Staphylococcus aureus
-avoid using prolonged use of superabsorbent tampons & pads
S/s: 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:
-indicated depending on underlying cause of abnormal vaginal bleeding
-D & C
-Hysterectomy
-Myomectomy, via
Laparotomy
Laparoscopy
Hysteroscopy
Ectopic pregnancy
def: Implantation of the fertilized ovum anywhere outside uterine cavity
Cause:
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, F tube ruptures ⇒ peritoneal symptoms
Is a life-threatening condition
A ♀ suspected of ectopic pregnancy should always
be treated as an emergency.
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Risk factors:
-prior ectopic pregnancy
-history of PID (pelvic inflammatory disease),
-progestin-releasing IUD (intrauterine device),
-progestin-only birth control failure,
-prior pelvic or tubal sx
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Clinical manifestations:
-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
-can be challenging due to similarities to other pelvic and abdominal disorders
-A serum (radioimmunoassay) pregnancy test ⇨ would be positive
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
> 1000-2000 Gestational sac present Normal pregnancy
>
- Gestational sac absent Ectopic pregnancy likely
Management:
-sx remains the primary approach, and should be performed immediately
-However, for hemodynamically stable pt and with a size of gestation < 3cm = tx of IM injection of methotrexate is being used with increasing success
-This drug stops cells from growing, which ends the pregnancy. The pregnancy then is absorbed by the body over 4–6 weeks. This does not require the removal of the fallopian tube.
Sx:
-Laparoscopy is preferable to laparotomy
less blood loss, ↓ LOS
-Often, no time to fully prepare pt for surgery
-Ectopic tissue needs to be removed
2 types:
- Salpingotomy
The ectopic pregnancy is removed; F tube is left to heal on its own - Salpingectomy
Both ectopic pregnancy & the F tube are removed
The choice of procedure depends on:
Pt’s age
Tube condition
serum βhCG levels
Pt’s future fertility desire
Endometriosis
def: 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 released during menstruation is reabsorbed into blood stream → causes inflammation → scarring & adhesions
Typically in those who have never had a full-term pregnancy
A common cause of infertility, ↑ risk for ovarian cancer
Etiology poorly understood
S/s and pain vary considerably, and does not correlate with extent of endometriosis
S/s:
dysmenorrhea
pelvic pain,
infertility
dyspareunia (painful intercourse)
and irregular bleeding
Diagnosis ⇨ laparoscopy for a definitive diagnosis
Treatment influenced by pt’s age, desire for pregnancy, symptom severity, and the extent and location of disease
The only cure is surgical removal of all the endometrial implants
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
Definitive surgery: removal of uterus, fallopian tubes, ovaries, and as many endometrial implants as possible
- post-op care similar as abdominal hysterectomy
Surgical Procedures for Female Reproductive System
Abdominal Hysterectomy
Vaginal Hysterectomy
Laparoscopic Hysterectomy
Robot-Assisted Surgery
Vulvectomy
Vaginectomy
Pelvic Exenteration
Hysterectomy
Hysterectomy
Indications:
-Gynecological cancer
-Fibroids
-Endometriosis
-Uterine prolapse
-Abnormal vaginal bleeding
-Chronic pelvic pain
3 approaches
-Abdominal
-Vaginal
-Laparoscopic
Types:
-Subtotal hysterectomy
-Total hysterectomy
-Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
-Wertheim’s hysterectomy (take out lymph nodes)
3 approaches
-Abdominal
-Vaginal
-Laparoscopic
Abdominal
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)
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Vaginal
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
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Laparoscopic
Uterus is usually removed through vagina, but sometimes through incisions for laparoscope if uterus is not too large
Types:
-Subtotal hysterectomy
-Total hysterectomy
-Total hysterectomy with bilateral or unilateral salpingo-oophorectomy
-Wertheim’s hysterectomy (take out lymph nodes)
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
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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
ABC
IV infusion 24-48 hrs
(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 PT
By post-op day 2, should be able to ambulate to BR
With return of BS, start clear water/full fluids
With start of oral fluids, IV rate may needs to be adjusted (e.g., ↓ )
Prevent constipation (e.g., Lactulose or supp)
Encourage to empty bladder fully
Strict I & O
With horizontal wound (bikini line) – stitches removed usually 5th day
vertical wound - 7 or 10th day
Splint abdomen (or hold a towel in place if had a vaginal hysterectomy) when coughing
Common to feel ‘blue’ on post-op Day 3 or 4 → reassure this is a normal reaction, that it will pass
Discharge Teaching
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
Housework:
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 others 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
Most common cancer in women (other than skin)
88% 5-year survival rate
Risk factors:
-Female Gender
-age
-Genetic Factors -
-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 ca.
-Increased risk if family member has had ovarian cancer, was premenopausal at diagnosis, had bilateral breast cancer and is a first degree relative.
-Hormone therapy
-Weight gain
-Sedentary lifestyle
-Smoking
-Obesity
-Alcohol intake
Patho:
noninvasive breast cancer -“ductal carcinoma insitu” DCIS
-can’t spread outside the breast
Invasive (infiltrating) ductal carcinoma- IDC
-starts in the milk ducts of the breast and moves into nearby tissue.
-In time, IDC may spread (metastasize) through the lymph nodes or bloodstream to other areas of the body.
Invasive (infiltrating) lobular carcinoma -ILC
-begins in the milk-producing glands (lobules) of the breast, metastatic
Inflammatory:
-a rare type of breast cancer that develops rapidly, making the affected breast red, swollen and tender. Inflammatory breast cancer occurs when cancer cells block the lymphatic vessels in skin covering the breast, causing the characteristic red, swollen appearance of the breast.
Paget’s disease of the nipple:
- a rare condition associated with breast cancer. It causes eczema-like changes to the skin of the nipple and the area of darker skin surrounding the nipple (areola). It’s usually a sign of breast cancer in the tissue behind the nipple.
Triple-negative:
-most aggressive
-characterized by 3 negative biomarkers:
cancer cells don’t have estrogen receptors (ER), progesterone receptors ( PR) and also don’t make any or too much of the protein called HER2
- a faulty BRCA1 gene
Clinical manifestations:
-lump. hard, irregularly shaped, nonmobile, non-tender, poorly delineated
-upper outer quadrant of breast
-nipple retraction
-nipple discharge clear or bloody
-peau d’orange caused by plugging of lymphatic vessels
-infiltration, induration, and dimpling of the skin in large cancers
Complications:
-reoccurrence
-metastases because of lymph spread
Dx
Axillary lymph node dissection
lymph drainage and Sentinel lymph node biopsy
TNM and Stage
Estrogen and progesterone status
HER2
Interprofessional care:
-Depends on the clinical stage and biology of the cancer
TNM and Stage
Surgical Therapy. - primary tx
-Axillary lymph node dissection (ALND)
-ALND is usually done at the same time as a mastectomy or breast-conserving surgery (BCS), but it can be done in a second operation.
Modified radical mastectomy:
-removes the entire breast — including the breast tissue, skin, areola and nipple — and most of the underarm (axillary) lymph nodes.
-The underlying chest muscles will be left in the place, unlike a traditional radical mastectomy.
Adjuvant Therapy:
-radiation
-palliative radiation
-chemo
-High-dose brachytherapy
-estrogen receptor blockers
-Aromatase inhibitors
Acute intervention Mastectomy:
-Post-Op Complications
Acute intervention Mastectomy:
-pain correlates with extent of lymph node dissection
-pts discharge with a drain
-restore arm function w/ arm and shoulder exercises
-prevent/reduce lymphedema
Post-Op Complications
1) Lymphedema
-accumulation of lymph in soft tissue dt excision/radiation of nodes
-causes heaviness, pain, numbness, impaired motor function, paresthesia of fingers
-can cause cellulitis and progressive fibrosis
-affected arm should never be dependent even in sleep
-elastic bandages should not be used early post op as they inhibit lymph drainage
-protect from trauma, sunburn
-decongestive therapy
-do not take BP, do venipuncture, infections. on affected arm
2) Post-mastectomy pain syndrome
-chest and upper arm pain
-tingling down arm
-numbness
-shooting/pricking pain
-unbearable itching >3 month normal healing time
-possible dt nerve injury
-TX: NSAIDs, antidepressants, topical lidocaine, gabapentin local anesthetic
