Hysterectomy/Reproductive Disorders Flashcards
Uterine Disorders
- Endometriosis
- Leiomyomas, or fibroids
- Cancer
Endometriosis
- Is endometrial tissue that plants itself outside the uterine cavity
- 2 layers - endometrium & myometrium
> Myometrium - muscle layer (myomectomy = removal of muscle layer)
> Endometrium - what sheds monthly during menses
- Most common implantation sites are pelvis, ovaries, & posterior rectal vaginal wall
- Widespread dz
! Major concern is scarring, inflammation, & adhesion (affected organs stick together)
Relevant Cues: Clinical Manifestations
- Pain (peaks right before onset of menstrual flow)
- Infertility (esp if it affects the fallopian tubes or ovaries)
- Dyspareunia
- Menstrual irregularities
- GI disturbances (like nausea, diarrhea, some pelvic tenderness)
Diagnostic
- Health hx, pelvic exam
- Laparoscope
- US (transvaginal; to rule out masses)
Take Action: Treatment
- NSAIDs (i.e., ibuprofen, naproxen)
- OCP’s (i.e., low dose estrogen, progesterone [to shrink endometrial tissue])
- regulate flow
- decrease endometrium
- help w/pain
- Lupron/Synarel
> can medically induce menopause & thereby suppress ovarian function
- Calcium, magnesium supplements
- Relaxation techniques
- yoga, massage, biofeedback
- Heat
- Surgery
- laparoscopically to remove endometrial tissue from areas outside uterine cavity
! decrease the pain; restore sexual or fertility function; alleviate anxiety; educate pts
?
Are uterine tumors that arise from the myometrium
Are benign, slow growing, solid tumors of the uterine myometrium, the muscle layer of the uterus
- 20-30% women
- vary in size; if you have 1, probably have >1
- are probably stimulated by estrogen & progesterone; get bigger during pregnancy & shrink >menopause
- nulligravidas are @ higher risk but unsure why
Leiomyomas, or fibroids
Relevant Cues: Clinical Manifestations
- May be totally asymptomatic or very severe; depends on size of fibroid, location, & how many
- Bleeding
- Anemia
- Dysmenorrhea
- Pelvic pressure/back pain
- Urinary retention/frequency
- Infertility
- Spontaneous abortions, miscarriages
Diagnosis
- Health history; pelvic exam
- U/S (transvag)
- Laparoscopic exam
- CBC (to check for anemia d/t bleeding)
Take Action: Treatment
- Hormone Therapy (HT)
- Laser surgery
- Myomectomy
- Uterine artery embolization
- Hysterectomy
What’s the woman’s desire for future fertility?
! Complications incl perforation, bleeding, & infection
All can be done outpt except for hysterectomy
Which 2 procedures help preserve fertility?
laser surgery; myomectomy
Ovarian Disorders
Cancer
* Leading cause of death from female reproductive cancers
* 5th most common cancer in women
* Sx’s are vague & benign
> Survival rates are very low b/c we don’t detect it until late stage
Cysts
* Usually benign
* Lupron
- Rare >menopause
Ovarian Cancer Risk Factors
↠ Nulliparity
↠ H/o infertility
↠ Family hx
↠ Age (>40)
↠ Fertility rx’s (ovulation-stimulating rx’s)
↠ Use of baby talc
Relevant Cues: Clinical Manifestations
- Persistent GI/GU disturbances (tumor enlarging & causing pressure against GI system & bladder)
- Abd distention w/ascites
- Inc abd girth
- Urinary freq/urgency/pain/pressure
- Malnutrition w/wt loss
- Pain
Take Action: Treatment
↠ Surgery
- remove tumor & ovaries; a hysterectomy may or may not be done
- surgery to dec estrogen
- will be putting the woman into a surgical menopause
↠ Chemotherapy
↠ Radiation
↠ Supportive therapies
Uterine (Endometrial) Cancer
- Endometrial cancer is a reproductive cancer, of which adenocarcinoma is the most common type
> is very curable if caught early; 80% of all cases of uterine ca - The main sx is bleeding:
premenopausal heavy or irregular bleeding
postmenopausal bleeding
- Diagnostic assessment incl
> CA-125 tumor marker
> Cxr
Endometrial Cancer Risk Factors
↠ Early onset of menarche
↠ Late menopause (are exposed to estrogen for a longer period of time)
↠ Obesity
↠ Nulliparity
↠ Reproductive cancers (i.e., if you have had ovarian ca)
↠ Tamoxifen use (for breast ca)
↠ Fhx
↠ DM
↠ HTN
! Common sites for metastasis are liver, lungs, & brain
Endometrial Ca
- Stages 1-4
Stage ___
Cancer has spread beyond the uterus but remains confined to the pelvis, such as in bladder or rectum
3
Stage ___
Tumor is confined to the uterine corpus
1
Stage ___
Highest lvl of invasiveness b/c ca has spread beyond the pelvis, causing metastatic dz & large masses, like in the liver or lungs
4
Stage ___
In addition to the uterine corpus, ca has invaded the cervix
2
Relevant Cues: Clinical Manifestations
- Bleeding (AUB, esp in postmenopausal women)
- Pelvic pressure
- Pain
↠ Dx = endometrial biopsy
Types of Hysterectomies
↠ Total hysterectomy
↠ Partial hysterectomy
↠ Panhysterectomy aka TAH-BSO
↠ BSO
↠ Radical hysterectomy
?
Is the removal of the uterus & cervix; may be either vaginal or abdominal, w/ or w/o a laparoscope
Total hysterectomy
?
The uterus is removed but the ovaries are retained esp if the woman is young to prevent menopause
- Cervix can be removed or retained
- Pt should receive ed to know what kinds of gyn exams will need yearly
> no pap smear but ovary palpation will be done
Partial (or subtotal) hysterectomy
?
Is a total abdominal hysterectomy plus BSO (bilateral salpingo-oophorectomy
> fallopian tubes & ovaries
Panhysterectomy aka TAH-BSO
?
Is a total hysterectomy; the uterus & ligaments (tissue fibers) that hold it in place
- cervix & an inch or 2 of the vagina around the cervix are also removed
- may or may not incl a BSO
Radical hysterectomy
Potential Complications
DVT
> Prevent it w/early ambulation
May be wearing pneumatic boots & stockings to help w/circulation
Leg exercises; SC heparin or Lovenox
Hemorrhage
> Assess vaginal bleeding postop
saturates >1 pad/hr ?
if a vaginal hysterectomy may not see a lot of bleeding d/t a lot of packing in place
! overly distended abd; tender to touch
! unstable VS; HTN; tachycardia
Infection
> Look @ abd or lap sites for S/S
- vaginal packing in place for 24 hrs
> Look for infection from urinary catheter
- monitor I&O, temp
- encourage fluids
- check for UTI’s; is bladder emptying completely?
- look for hematuria; inability to void; infections appear ~48-72 hrs in
Bladder dysfunction
- any trauma or dysfunction?
- inability to void; incomplete emptying of bladder; hematuria
- Foley cath in for 24 hrs >surgery; urine color
Sexual dysfunction
- d/t scarring, removal of uterus & cervix & poss part of vagina
Constipation
- d/t bowel manipulation
- monitor bowel sounds, bowel function, & abd distention
- inc warm fluids to inc peristalsis
- early ambulation & Colace will help
Grief response
- grief over the loss of a female reproductive organ; loss of womanhood
Cervical Cancer
- Preinvasive or invasive
- Carcinoma in situ
- is slow growing; if found early, prognosis is very good
___ cancer
Has spread to other pelvic structures
- cervical ca is the 13th most common ca in women in the US
invasive
___ cancer
Is ca just limited to the cervix
preinvasive
?
Is the most advanced, pre-malignant stage
carcinoma in situ
The earlier cervical dysplasia has no recognizable sx’s & is sometimes not visible even to trained providers
Most common sx 1st seen is vaginal bleeding in invasive cervical ca
Cervical Cancer Risk Factors
- HPV (leading cause)
> Gardasil (3 inj series over 6 mos) - Multiple sexual partners
- Early sexual intercourse
- H/o STD’s
- Smoking
- Immunosuppression
- Low socioeconomic status
- Poor access to health care
Relevant Cues: Manifestations
- Often asymptomatic
- Classic sx - painless vaginal bleeding
- Watery, blood-tinged vaginal d/c that may become dark & foul-smelling as the dz progresses
- Unexplained wt loss, pelvic pain, dysuria, hematuria, rectal bleeding, CP, & cough
- Leg/flank pain
> leg pain is followed along the sciatic nerve & involves swelling of 1 leg; ca is growing & pressing on the sciatic nerve
> flank pain is a late sign; is a sx of hydronephrosis, indicating that the ca has adv & is pressing on ureters, backing up urine into the kidneys
Diagnostic Assessment
- Pap smear
- Colposcopy
- Endocervical curettage
?
Is the gold standard
- Done annually for all women during their reproductive yrs
- Should begin within 3 yrs >1st intercourse OR by age 21 & then annually
- Refrain from sex <
- No douching, tampons, or vaginal creams 48 hrs prior
- Not usually done during a menstrual flow; isn’t unusual to see sm amts of vag bleeding the 1st 24 hrs after
Pap smear
?
The physician applies a thick acid solution to the cervix & then visualizes it w/magnification & a bright light to examine the cervical cells
> may take 1 or more bx’s @ this time
> might expect some dark vag bleeding or d/c 1-2 wks >
Colposcopy
?
This is a scraping of the endocervical wall for biopsies
Endocervical curettage
Treatment
- Local Cervical Ablation (3 types)
> LEEP
> Cryosurgery
> Laser - Cone biopsy
- Hysterectomy
- Radiation/chemotherapy
LEEP
Loop electrical or electrocautery procedure
> newest & most common
> performed to excise cervical areas in question; under local anesthesia
> lesions totally removed by low voltage cautery
> rapid healing & less tissue damage
Cryosurgery
> uses freezing on affected surgical tissue
minimal s/e but can have vaginal d/c for 2-4wks following
Laser
> Uses heat over cold
A laser beam is directed into the area to ablate ca cells
Care after a cervical ablation
- no intercourse, tampons, douching, hot tubs for 2-3 wks after
- avoid heavy lifting & report foul-smelling d/c, fever, or pain (d/c that lasts longer than a couple of wks might signify infections)
Cone biopsy
- a cone-shaped segment is removed
- used to preserve reproductive ability
- can be both diagnostic & treatment
Hysterectomy
> If the woman doesn’t desire fertility & it’s in adv stage
Radiation/chemotherapy
> For adv stage; can be done in combo
?
Occurs when the pelvic organs relax & descend into the vagina
- involves the urethra, bladder, uterus, bowel, & rectum
- seen in older women
- women that’ve had mult childbirths w/extra large macrosomia infants or had prolonged pushing during childbirth
- different grades (1-3) described by degree of descent of uterus
Urogenital displacement/prolapse; uterine prolapse
Sx’s
Backache, pressure in pelvis, bowel, or bladder problems all common
Grade ___
Uterus bulges farther into the vagina, & then the cervix protrudes through the entrance of the vagina
2
Grade ___
Uterus bulges into the vagina, but the cervix doesn’t protrude through the entrance of the vagina
1
Grade ___
Body of the uterus & cervix protrudes through the entrance of the vagina. Vagina actually turns inside out & it’s not uncommon in older women
3
Cystocele [bladder] / Rectocele [rectum]
- difficulty emptying bladder
- urinary freq/urgency
- UTIs
- stress urinary incontinence
> laughing, sneezing, peeing; women who laugh too hard, cough, sneeze loose a little urine, dribble a little urine
- The elderly become dehydrated b/c they don’t drink. Don’t drink b/c they don’t want to pee
?
Occurs where the rectum is displaced, causing bulging of the posterior vaginal wall
> constipation & hemorrhoids; fecal impaction
> feeling of rectal or vaginal fullness
Rectocele
Treatment
- Pessary
- Kegel exercises
- Surgery (anterior posterior repair)
