Post on 17-Dec-2015
Female Reproductive
DisordersMegan McClintock, MS, RN
Fall 2011
Infertility Can’t conceive after 1 year of regular,
unprotected intercourse
Risk factors Tobacco/illicit drug use
Abnormal BMI (obesity or too thin)
Age > 35 (in women)
Infertility Diagnostic Studies
Detailed history and general physical exam
Basal body temperature record (upon awakening, before any activity, decreased temp prior to ovulation, rise in temp with ovulation)
Ovulation prediction kits (measure LH in urine, ovulation occurs 28-36 hrs after the first rise of LH)
Hysterosalpingogram to look at tubal factors
Postcoital cervical mucus exam
Infertility Treatment Depends on the cause
Ovarian problems – supplemental hormone therapy
Cervicitis – antibiotics
Inadequate estrogen stimulation - Estrogen
Intrauterine insemination
Assisted reproductive technologies (ART)
Nursing care Education
Emotional support
Encourage participation in support groups
Abortion Spontaneous (occurring naturally)
Natural loss of pregnancy before 20 weeks
s/s – uterine cramping with vaginal bleeding
Tx – bed rest, no vaginal intercourse, D&C may be needed, emotional/grief support
Induced (occurring due to mechanical or medical intervention) Intentional or elective termination of a pregnancy
Technique depends on gestational age, women’s condition
Care – give support/acceptance, prepare the pt, no intercourse or vaginal insertions for 2 weeks, can start contraception immediately
Cx – abnormal vaginal bleeding, severe abdominal cramping, fever, foul drainage
Menstrual Problems PMS
Dysmenorrhea (pain)
Abnormal bleeding Oligomenorrhea (long intervals between menses)
Amenorrhea (no menstruation)
Metrorraghia (spotting, breakthrough bleeding)
Menorrhagia (excessive bleeding)
Ectopic pregnancy
Perimenopause
Postmenopause
Premenstrual Syndrome (PMS)
PMS Always occurs cyclically before the onset of
menstruation, not present at other times of the month
s/s – extremely variable even from one cycle to another, breast tenderness, edema, bloating, binge eating, headache, dizziness, mood swings
Dx – must rule out other possible causes, no definitive test, need to do a symptom diary for 2-3 months
PMS Treatment No single treatment
Drugs (diuretics, prostaglandin inhibitors, SSRIs, combination BCPs)
Diet changes (no caffeine, reduce refined carbs, increase complex carbs with high fiber, vit B6, dairy, poultry, limit salt intake)
Reassure that symptoms are real
Stress management
Exercise
Adequate rest
Dysmenorrhea Primary – no pathology, begins within first few years
of menses s/s – starts 12-24 hrs before menses, rarely lasts more
than 2 days, lower abd pain radiating to lower back/upper thighs, nausea, diarrhea, fatigue, headache
Tx – heat, exercise, NSAIDs, BCPs
Secondary – usu. caused by pelvic disease, begins age 30-40 after previous pain-free menses s/s – unilateral, constant pain that lasts longer than 2
days, can have painful intercourse, painful defecation, or irregular bleeding
Tx – depends on the cause
Abnormal Bleeding Age of the woman helps determine the cause
Young – spontaneous abortion, ectopic pregnancy, clotting disorders
30s/40s – leiomyomas (fibroids), endometrial polyps
Old – endometrial cancer
Amenorrhea Primary – no menses by age 16
Secondary – had periods but they stopped
Need to shed the endometrial lining 4-6 times/year
Bleeding Treatment Depends on the cause, degree of threat to pt’s health,
desire for children in the future
Health history and physical exam first
Combined oral contraceptives, fertility drugs, or progesterone
Balloon thermotherapy
Endometrial ablation
Hysterectomy or myomectomy if due to uterine fibroids
D&C is rarely done
Nursing Care with Abnormal Bleeding
Bathing and hair washing are safe
Can swim, exercise, have intercourse
Need to change tampons or pads frequently
Be aware of TSS (s/s – high fever, vomiting, diarrhea,, weakness, myalgia, sunburn-like rash)
With excessive bleeding, record the number and size of pads/tampons used and degree of saturation
Check fatigue level, BP, and pulse
Ectopic Pregnancy
Life-threatening emergency!
Implantation of a fertilized ovum anywhere outside the uterus
Risk factors – PID, prior ectopic, progestin-releasing IUD, progestin-only birth control pills, prior pelvic or tubal surgery, infertility treatments
s/s – abd/pelvic pain, missed period, irregular vaginal bleeding (spotting), if ruptured - pain will be severe and may be referred to the shoulder
Ectopic Pregnanct Dx – difficult b/c it’s similar to other
disorders, but has to be considered first! Serum pregnancy test
Then serial beta-hCG levels
Vaginal ultrasound
CBC
Tx – immediate surgery, may need blood transfusion
Menopause Perimenopause – begins with first changes in menses and
ends after cessation of menses
Menopause – cessation of menses associated with declining ovary function, complete after 1 year of no periods
Usu. occurs around age 51, naturally affected only by genetic factors, autoimmune conditions, cigarette smoking, racial/ethnic factors
Increase in FSH, decrease in estrogen
Remember culture
Remember vaginal bleeding after menopause is a sign of possible endometrial cancer
Perimenopause s/s – *irregular vaginal bleeding, *vasomotor
instability (hot flashes), redistribution of fat, gain weight more easily, muscle/joint pain, loss of skin elasticity, change in hair amount/distribution, atrophy of external genitalia/breast tissue, dysparenunia, bladder changes
Critical changes – increased risk for CAD and osteoporosis, higher risk for HIV transmission if exposed
Perimenopause Diagnosis should only be made after ruling out other things
Tx – hormone replacement therapy (HRT) Must weigh the risks and benefits
Use lowest effective dose
Estrogen side effects – nausea, fluid retention, headache, breast swelling
Progesterone side effects – increased hunger, weight gain, irritability, depression, spotting, breast tenderness
Depoprovera can cause sudden loss of vision, chest pain, calf pain
Vaginal creams helpful with urogenital symptoms
Transdermal estrogen bypasses the liver but causes skin irritation
HRT Take only for short-term (4-5 years) relief of
severe symptoms
Estrogen alone can cause stroke, blood clots, breast changes but protects against osteoporosis, colorectal cancer, heart disease
Estrogen & progesterone together can cause heart disease, breast cancer, stroke, blood clots, breast changes
Do not take if you have a history of breast cancer, heart disease, or blood clots
Non Hormonal Treatments
Cool environment
Limit caffeine and alcohol
Relaxation techniques
Increase air circulation
Avoid bedding that traps heat
Loose fitting clothes
Kegel exercises
Vaginal lubrication
Vitamin E
Adequate exercise and sleep
Adequate calcium and vitamin D
Diet high in complex carbs and B6, soy, tofu, sunflower seeds
Black cohosh
Moisturizing soaps, lotion
Vulvar, Vaginal, Cervical Conditions
Typically infection and inflammation related to sexual intercourse
Risks – contaminated hands, clothing, douche equipment, intercourse, surgery, childbirth; BCPs, antibiotics, corticosteroids
s/s – abnormal vaginal discharge, red lesions; yeast – thick, white, curd-like discharge, itching, dysuria; bacterial vaginosis – fishy odor; cervicitis – spotting after intercourse; lichen sclerosis – white lesions with “tissue paper” appearance
Treatment Sexual history is important
Microscopy and cultures
Antibiotics and/or antifungals (must take full course)
Abstain from intercourse for at least 1 week
Douching should be avoided
May need to treat sexual partners
Vaginal creams should be inserted before going to bed
Clean carefully after urination and bowel movements
Use a non-judgmental attitude
Pelvic Inflammatory Disease (PID)
Infection of pelvic cavity (fallopian tubes, ovaries, pelvic peritoneum), often the result of untreated cervicitis
Chlamydia and gonorrhea are most common organisms, but is not always from STDs
Can cause infertility and chronic pelvic pain
s/s – lower abdominal pain that starts gradually and becomes constant, movement increases the pain, spotting after intercourse, may have fever, chills
Will have adnexal tenderness and positive cervical motion tenderness with bimanual pelvic exam (diagnostic), can also do a vaginal ultrasound
PID Complications Septic shock
Fitz-Hugh-Curtis syndrome (perihepatitis)
Peritonitis
Thrombophlebitis of the pelvic veins
Adhesions of the fallopian tubes
Ectopic pregnancy
PID Treatment Antibiotics
No intercourse for 3 weeks
Sexual partner(s) must be treated
Physical rest
Lots of oral fluids
Must be reevaluated in 48-72 hours to ensure they are improving
If hospitalized: Corticosteroids
Heat to abdomen or sitz baths
Semi-Fowler’s position to promote drainage by gravity
Analgesics, IV fluids
May require surgery
Endometriosis Normal endometrial tissue located in
sites outside of the endometrial cavity
Not life-threatening, but causes lots of pain
Increases the risk of ovarian cancer
Typical pt – late 20s or early 30s, white, never had a full-term pregnancy
s/s – dysmenorrhea after year of pain-free periods, infertility, pelvic pain, pain with intercourse, irregular bleeding, backache
Cx – bowel obstruction, painful urination
Endometriosis Treatment
Definitive diagnosis – laparoscopy
Tx determined by age, desire for pregnancy, symptom severity, extent/location of disease
Drugs – NSAIDs, Depo-Provera or Lupron to imitate a state of pregnancy or menopause (is only controlled, not cured by this), lots of side effects, will take for 9 months to shrink the endometrial tissue
Surgery – only cure
Leiomyomas Uterine fibroids, benign smooth-muscle tumors
Seem to depend on ovarian hormones b/c they grown slowly during reproductive years and atrophy after menopause
s/s – generally none, but may have abnormal uterine bleeding, pain, pelvic pressure
Tx – depends on symptoms, age of pt, desire to bear children, location/size of tumors; lots of bleeding or large tumors mean surgery (hysterectomy, myomectomy, uterine artery embolization, or cryosurgery)
Cervical Polyps Benign lesion on a stalk, seen through the
cervical os during a speculum exam (bright cherry-red, soft, fragile, small (< 3 cm))
s/s – none usually, might have spotting, bleeding after BM straining, bleeding after sex, infection
Tx – outpatient excision or polypectomy (send for biopsy to ensure no malignancy)
Polycystic Ovary Syndrome (PCOS)
Many benign cysts on both ovaries, usu. occurs in women < age 30, causes infertility
s/s –irregular menses, infertility, hirsutism, obesity, acne, can even develop CV disease and type 2 diabetes
Tx – BCPs, aldactone (for hirsutism), Lupron, Metform, may use fertility drugs (Clomid) to cause ovulation, may ultimately need hysterectomy with salpingectomy and oopherectomy
Needs weight management and exercise
Cervical Cancer Risk factors – low socioeconomic status, early sexual
activity (< age 17), multiple sexual partners, HPV infection, immunosuppression, smoking
Higher incidence in white women, but higher mortality in African American women (avg age-50)
Best tx is prevention with regular Pap screens
Cause – repeated injuries to the cervix
s/s – early cancer is asymptomatic, thin/watery vaginal discharge becoming dark and foul-smelling, spotting that becomes heavier and more frequent, pain is a late symptom as is weight loss, anemia, muscle wasting
Cervical Cancer Diagnostic studies
*Pap testing – begin 3 years after first intercourse but no later than age 21
Not 100% accurate so very impt to follow up after abnormal Pap tests
Minor changes in Pap – repeat Pap in 4-6 months for 2 years
Prominent changes in Pap – colposcopy and biopsy, may have punch biopsy or conization (outpatient procedures with mild analgesics or sedation)
Cervical Cancer Treatment
Prevention with Gardasil vaccine for females age 9-26
Guided by tumor stage, pt’s age, general state of health (see pg 1364, Table 54-11)
Can sometimes preserve fertility
Invasive cancer is treated with surgery, radiation (4-6 weeks external, 1-2 internal implants), and chemo
Endometrial Cancer Most common gynecologic cancer, grows slowly,
metastasizes late, curable if diagnosed early
Risk factors – estrogen, increasing age, no pregnancy, late menopause, obesity, smoking, diabetes, history of colorectal cancer
s/s – *first sign is abnormal uterine bleeding in postmenopausal women, pain occurs late
Tx - *endometrial biopsy, total hysterectomy/bilateral salpingo-oophorectomy with lymph node biopsy, may need radiation; may also need progesterone hormonal therapy (Megace) or Tamoxifen and chemo
Ovarian Cancer Most have advanced disease at time of diagnosis
Risk factors – family history of ovarian cancer, breast cancer, colon cancer, no pregnancies, increasing age, high-fat diet, early menses or late menopause, HRT, use of infertility drugs
Reduced risk – use of BCPs, breastfeeding, multiple pregnancies, early age at first pregnancy
s/s – vague in early stages, abdominal enlargement, daily symptoms for at least 3 weeks (pelvic/abdominal pain, bloating, urinary urgency/frequency, difficulty eating or feeling full quickly), pain is a late symptom, vaginal bleeding is not a usual symptom
Ovarian Cancer Diagnostics
No screening tests other than a yearly bimanual pelvic exam (if postmenopausal should not have palpable ovaries)
OVAI – can help detect whether a pelvic mass is benign or malignant
If at high risk, can test for CA-125 (tumor marker) and use ultrasound with the yearly pelvic exam
Ovarian Cancer Treatment
If at high risk, prophylactic oophorectomy, BCPs
Staging guides treatment decision
Stage I – total abdominal hysterectomy/bilateral salpingo-oophorectomy and chemo
Stage II – external irradiation and/or chemo
Stage III – chemo and surgical debulking
Metastasis often causes pleural effusion and shortness of breath
Vaginal and Vulvar Cancer
Both are relatively rare
Treatment may be with surgery and radiation
Vulvar surgery has a high risk of morbidity due to scarring and wound breakdown
Surgeries Hysterectomy – removal of the uterus, may
(total) or may not (subtotal) remove the cervix, removal of fallopian tubes (salpingectomy), removal of ovaries (oophorectomy); if all TAH-BSO Can be done vaginally or abdominally
In both, the ligaments that support the uterus are attached to the vaginal cuff to maintain the normal depth of the vagina
Care after Hysterectomy
Abdominal dressing or sterile perineal pad (vaginal approach)
Observe closely for bleeding for first 8 hours
Watch for urinary retention (may have catheter for 1-2 days )
Report backache or decreased urine output to surgeon
Watch for paralytic ileus
Prevent DVTs – turn, no high-Fowler’s, no pressure under the knee
Assist with grief over loss of fertility
May need HRTs
Discharge – no intercourse for 4-6 weeks, may be temporary loss of vaginal sensation, no heavy lifting for 2 months, avoid pelvic congestion for several months (ie. Dancing, walking swiftly), wear a girdle
Vulvectomy, Vaginectomy
Vulvectomy – removal of vulva and wide margin of skin, Vaginectomy – removal of vagina
Post-op care Perineal wound extending to the groin that may be
covered or left exposed, usu. has a drain
Meticulous wound care – clean with NS twice daily
Use heat lamp or hair dryer to dry the area
Prevent stool straining
Be very careful not to dislodge urinary catheter
Lots of discomfort due to heavy, taut sutures
Ambulation on 2nd post op day
Easy to get discouraged due to mutilation of perineum and slow healing
Pelvic Exenteration Radical hysterectomy, total
vaginectomy, removal of bladder with urinary diversion, resection of bowel with colostomy (anterior – no bowel resection, posterior – no bladder removal
Post-op care - similar to care after radical hysterectomy, abd perineal resection and ileostomy and/or colostomy; lots of physical, emotional, and social adjustments
Radiation Therapy (Brachytherapy)
In the OR, places radiation near or into the tumor causing less damage to surrounding normal tissue, delivered using wires, capsules, needles, tubes, seeds; left in for 24-72 hrs
Preparation – cleansing enema to prevent stool straining, indwelling catheter to prevent distended bladder
Care – lead-lined private room, absolute bed rest (can be turned from side to side), analgesics for uterine contractions, deodorizer, cluster care, nurses can spend no more than 30 minutes/day in room, stay at foot of bed or entrance to room, visitors must stay 6 feet from bed and stay less than 3 hours/day, discharge to home after radioactive material and catheter are removed
Common to have foul-smelling vaginal discharge from destruction of cells, may also have n/v, diarrhea, malaise
Cx – fistulas, cystitis, phlebitis, hemorrhage, fibrosis
Problems with Pelvic Support
Uterine ProlapseDisplacement of uterus into the vaginal canal
First degree – cervix in lower part of vagina
Second degree – cervix at vaginal opening
Third degree – uterus protrudes through vaginal opening
s/s – feeling of “something coming down”, pain with sex, backache, stress incontinence
Tx – Kegel exercises, pessary, vaginal hysterectomy
Cystocele and Rectocele
Cystocele – weakening between vagina and bladder
Rectocele – weakening between vagina and rectum
Common and asymptomatic
Tx – Kegel exercises, pessary, surgery to tighten the vaginal wall, colporrhaphy (post-op care includes catheter to prevent suture strain)
Fistula Abnormal opening between internal organs or between
an organ and the exterior of the body
Causes – gyneocologic procedures, injury during childbirth, cancer
s/s – excoriation, irritation, severe infections, wetness, odors
Tx – if small may heal on own, can’t do surgery until inflammation and edema is resolved
Care – perineal hygiene every 4 hours, warm sitz baths 3 times/day, good fluid intake, post-op – catheter for 7-10 days, delay the first post-op stool to prevent wound contamination
Sexual Assault Forcible perpetration of a sexual act on a person
without their consent
s/s – may have no signs of physical trauma, may have bruising and/or lacerations, STDs, pregnancy; may have a range of psychologic symptoms; may have post-traumatic stress disorder weeks to months to years after assault (rape-trauma syndrome)
Tx - *highest priority is ensuring emotional and physical safety, SANE RN provides care while ensuring evidence is safeguarded (obtain consent, collect and label data, have as few people handle the data as possible, gynecologic/sexual history, account of the assault, lab tests looking for sperm and pregnancy), need follow-up physical and psychological care (return weekly for the first month)
Sexual Assault Nursing care
Encourage all women to learn self-defense
Quiet, private area for exam
Never leave the patient alone
Maintain a non-judgmental attitude
Let the patient talk, listen carefully
Be supportive during the pelvic exam
Provide a change of clothing
Offer the “morning after pill”
Explain about application for financial compensation
Never send them home alone
Let them know about the crisis center