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Med-Surg Ch 49

Female Reproductive Disorders

Ovaries produce what hormones Estrogen, Progesterone, and Androgens
Estrogen estrone, estradiol, and estriol. Development and maintain of 2ndary sex organs. Decreases rate of bone reabsorption. Helps keep cholesterol low. Promotes retention of sodium and water.
Progesterone Develops breast tissue. Helps reduce uterine contrations during pregnancy.
Androgens Hair development. Metabolic effects.
Menstrual Cycle Menstrual phase (3-5 days). Proliferative phase: Maturing follicle begins to produce estrogen (day 6-14). Secretory phase: Days 14-28, homones fall, spasm of the spiral arteries causes hypoxia of the endometrial cells, degenerate, and slough off.
Women’s Genetic Considerations Family hx: ovarian, endometrial, colon or breast cancer. Genetic testing for breast cancer carrier. Turner Syndrome: Short stature, lack of sexual development at puberty, webbed neck, heart defects, and kidney abnormalities.
Age-Related Changes Breast Atrophy/Sagging. Labia flattens. Loss of pubic hair. Vagina < lubricated and Shortens. Cervix Becomes smaller. Uterus shrinks. Fallopian Tubes Shorter, shrink. Ovaries are smaller. Pelvic floor muscles Weaken and Involuntary or stress incontinence.
Health Assessment Questions Bleeding after sex? Itching/burning? Vaginal infection s/s? Last period? Other systemic diseases (diabetes, endocrine)? Breast implants (type/kind)? Sexual concerns? Partners? Contraceptions? Smoking? Painful intercourse? Sexual trauma? Dissatisfied sex?
Tips for Health Assessment Questions Non-threatening, matter of fact manner. Use understandable, not embarrassing or offensive words. Ask about menstruation and childbirth before STI’s. Include psychological, social, and cultural factors that affect sexuality and sexual activity.
Disorders of Female Sexual Function Dyspareunia: Painful intercourse. Vaginismus: Involuntary spasms of vagina and constriction of surrounding muscles so tight that nothing can enter. Anorgasmia: Lack of orgasm.
Perimenopausal period first s/s to the end. Reproductive function gradually ceases. Lasts several years. Permanent loss of ovarian function. no menstruation: exceeds one year after final menstrual cycle, then the woman is considered: Postmenopausal (No period for over a year)
Menopause Manifestations Hot flashes, Mood swings, Even depression, Irritability, Night sweats, Age related changes begin, Difficulty concentrating, Vaginal pH changes.
Different types of Menopause Natural menopause: Permanent cessation of menses. Surgical menopause: Hystorectomy. Chemical menopause: Chemotherapy.
Long term changes from Menopause Osteoporosis. Risk for CVD (Cholesterol). Risk for Breast Cancer.
Hormone Replacement Medications (HRT) Helps with menopause s/s, but increased risk of cancer, stroke, heart attack. Premarin and Estradiol.
Selective estrogen receptor modulators (SERMs) Raloxifene (Evista) and Triphenylethylene (Tamoxifen). Alternative to HRT for prevention of osteoporosis. Reduces risk of breast cancer in menopausal women.
Other Menopause meds Antidepressants: Paxil, Prozac.
Premenstrual Syndrome (PMS) Estrogen/progesterone imbalance. Increased aldosterone: Preserves sodium, Fluid retention. Decreased monamine in the brain, depression. Decreased serotonin, mood swings.
PMS Manifestations Peaks in women in mid 30s. Food cravings. Acne. Weight gain.
Premenstrual dysphoric disorder (PMDD) When PMS becomes a disabling condition.
PMS Medications Suppression of ovulation. Progesterone and NSAIDs: Pamprin, Midol, Advil. Diuretics. Selective serotonin reuptake inhibitors (SSRI): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil).
Alternative and Complementary PMS therapies Heat. Chocolate. Pinrose oil.
Women with Dysmenorrhea Pain or discomfort associated with menstruation. Primary = No physiological reason. Secondary = Tumor or Polycystic ovarian syndrome.
Dysmenorrhea Manifestations Abd. Pain 12-48 hours with menses. Lower back, thigh pain. Headache. N/V. Diarrhea. Fatigue. Breast Tenderness.
Dysmenorrhea Diagnostic Tests Pelvic examination: Pap smear, cervical and vaginal cultures. FSH and LH levels. Progesterone and estradiol levels. Thyroid function tests (T3 and T4). Vaginal or pelvic ultrasonography. Possible laparoscope and/or D&C.
Dysmenorrhea Medications Analgesics, NSAIDs, Oral contraceptives.
Dysfunctional Uterine Bleeding (DUB) Manifestations Vaginal bleeding that is usually painless. Abnormal amount, duration, or time of occurrence.
Amenorrhea no period, Anorexia, Excessive athletic training, Hypothyroidism, Pregnancy.
Oligomenorrhea Scant menses.
Menorrhagia Excessive or prolonged menstruation, Endometriosis, PID, thyroid disorders.
Metrorrhagia Bleeding between menstrual periods, IUDs, PID, polyps, cancer. Post menopausal bleeding: Cervical polyps, endometrial hyperplasia, cancer.
Dysfunctional Uterine Bleeding (DUB) Diagnostic Tests CBC. Thyroid function tests: T3, T4, TSH. Endocrine studies to evaluate pituitary and adrenal function. Serum progesterone levels. Pap smear. Pelvic ultrasound. Hysteroscopy to detect abnormalities of uterine cavity. Endometrial biopsy.
Dysfunctional Uterine Bleeding Medications Hormonal agents & oral iron supplements.
Dysfunctional Uterine Bleeding Surgeries D&C (dilation and carterization): watch circulation and leg sensation, No tampons/sex/heavy lifting 2 weeks, Next period delayed. Endometrial ablation: Laser, thermal balloon, electrocautery, after D&C fail, Major pregnancy issues. Hysterectomy.
Hysterectomy Removal of Uterus. Premenopausal Women Ovaries are generally left in place. Postmenopausal Women Complete hysterectomy.
Abdominal Hysterectomy Preexisting abdominal scar is present. Adhesions are thought to be present. Large operating field is necessary. Surgical incision: Longitudinal, Pfannenstiel (bikini cut).
Vaginal Hysterectomy Uterus has descended into the vagina. Urinary bladder or rectum prolapsed into vagina. No visible abdominal scar.
Hysterectomy Pre-op Clean, enema, void, consent ,medications.
Hysterectomy Post-op Assessment, TCDB, restricted activity 4-6 wk. Count peripads to monitor for hemorrhage. No lifting, climbing stairs, tub baths, or anything into the vagina to prevent hemorrhage. Will need to continue to have female exams. Pap smear if cervix remains.
Uterine Displacement Retroversion, backward tilting. Retroflexion, backward bending. Anteversion, forward tilting. Anteflexion, forward bending. Prolapse.
Prolapse Degrees and kinds Degrees: 1-half way, 2-contained in vagina, but almost out, 3-out of vagina/inversion of the vagina. Cystocele, Herniation of bladder into the vagina. Rectocele, Herniation of rectum into the vagina.
What could cause uterine displacement? Child birth. Multiple pregnancies. Pelvic floor weakness.
What would be some complaints for suspension of uterine displacement? Infection. Backaches. Infertility. Sexual dissatisfaction. Urinary incontinence. Painful menses.
Uterine Displacement Teaching Kegals. Peripads, pericare. Pessary. Reduce caffeine, increase fiber/fluid.
Uterine Displacement Surgery Anterior colporrhapy, repair cystocele, repair pelvic floor muscles. Marshall-Marchetti-Krantz, tacking the bladder back to anatomical location. Posterior colporrhaphy, repair rectocele, make pelvic floor muscles tighter. Hysterectomy.
Uterine Displacement Pessary Temporary support of uterine/bladder. Can stay in for 6 weeks, clean, then back in. Ring shape.
Vaginal Fistula Abnormal opening or passage between 2 organs or spaces. Great risk for infection.
Vesicovaginal fistula bladder
Rectovaginal fistula rectum
Vaginal Fistula Causative Factors complication of childbirth. Surgery. radiation therapy for gynecological cancer.
Cysts Fluid/pus filled. Ovary cysts: Can be painful and cause menstrual irregularities. Vulva (bartholin’s cyst): Pain, redness, perineal mass. Endometrial cysts: Old blood- “chocolate cysts”, Bleeding between periods, Associated with endometriosis.
Polyps > risk for cancer. Endometrial polyps: Intrauterine overgrowhts, usually have a stalk. Cervical polyps: Over age 40, Multi-gravida, hx of oral contraceptive use, Vaginal end of cervix, stem, highly vascular, Bleeding after intercourse or between periods.
Polycystic Ovary Syndrome (POS) Endocrine disorder, characterized by numerous follicular cysts.
Polycystic Ovary Syndrome Manifestations Elevated estrogen, androgen, and LH levels. Anovulation. Hirsuitism, obesity, acne, HTN, and infertility.
Polycystic Ovary Syndrome Increased risk for Breast and endometrial cancer. DM2. Heart disease.
Leiomyoma (fibroid tumors) Benign tumors of the uterus.
Kinds of Leiomyoma Subserous: beneath serous lining, outer edge of uterus. Intramural: within uterine wall. Submucous: beneath endometrial lining, inner edge of uterus.
Leiomyoma Manifestations Pelvic pressure. Pain. Dysmenorrhea. Menorrhagia and fatigue. Urinary urgency and frequency. Constipation.
Leiomyoma Treatment Size. Location. Severity of manifestations. Age. Childbearing status.
Leiomyoma Medications Leuprolide acetate (Lupron). Chemical menopause. Also used to children who have started puberty way too early.
Leiomyoma Surgery Myomectomy, removal of tumor. Laproscopic laser. Hysterectomy.
Endometriosis Implantation of endometrial tissue in areas other than the endometrium. Cause is unclear. Ovarian hormone stimulation. Scarring, inflammation, and adhesions = possible infertility.
Endometriosis Risk factors Early menarche. Cycles less than 27 days. Menses lasting more than 7 days. Heavy, throbbing menses. Close family history.
Endometriosis Manifestations Hx of dysmenorrhea, dyspareunia. Rectal pressure/discomfort with BM. Dysfunctional bleeding. Leg pain.
Endometriosis Diagnostics Ultrasound and laparoscope. CBC.
Endometriosis Treatment Analgesics. NSAIDS. Hormone therapy. Progestin (Depo-Provera). Danazol (Danocrine). Laparosope with ablation. Hysterectomy.
Endometrial Cancer Risk Factors Prolonged estrogen stimulation. Obesity. Anovulatory menstrual cycles. Increased numbers of menstrual cycles. High fat diet. Hx of breast/ovarian cancer. Menopause. Medical conditions: DM, HTN, Polycystic ovary. Family history.
Endometrial Cancer Manifestations Early: Abnormal painless vaginal bleeding. Later: pelvic cramping, bleeding after intercourse, lower abdominal pressure. Late: lymph node enlargement, abdominal masses, ascites.
Endometrial Cancer Diagnostics Endometrial biopsy or D&C for definitive diagnosis. Xray, MRI, bone scan to determine extent of metastasis.
Endometrial Cancer Medications Progesterone therapy: Provera, Megestrol acetate (Megace). Gonadotropin-releasing hormones: Lupron. Chemotherapy. Radiation.
What to teach about Endometrial Cancer prevention and early recognition of symptoms? Control DM and HTN to decrease risks. Annual pelvic exams. Report unexpected bleeding/spotting. High risk – biopsies Q2yrs >35.
Cervical Cancer Risk Factors HPV. Smoking. Sex prior to 16. Multiple partners. Prolonged use of birth control. Poor nutritional status. Obesity.
Cervical Cancer Manifestations Asymptomatic. vaginal bleeding after intercourse-hematuria, blood in stools, anemia, weight loss.
Cervical Cancer Diagnostic Tests Pap smear. Colposcopy. Cervical biopsy. MRI. CT.
Cervical Cancer Treatment Loop Diathermy-LEEP: Office, Wire, cut on cervix, electrical incision. Laser Surgery With Colposcopy. Cryosurgery. Conization: Anesthetic, Remove cone shape of cervix, removal of cells. Hysterectomy or Radical Hysterectomy. Pelvic Exenteration.
2 Types of Pelvic Exenteration Anterior exenteration: Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra, and lymphatic system. Posterior exenteration: Removal of uterus, ovaries, fallopian tubes, bowel, and rectum.
Health Promotion Cervical Cancer Screening for cervical cancer: After three consecutive normal Pap tests, Every 2-3 years. 70+ can stop. 3 or more normal Pap smears in 10 years = May choose to stop cervical cancer screening. Even with hysterectomy if cervix remains.
Ovarian Cancer Risk factors Family Hx. Breast cancer. Colorectal Cancer. > age. No children or birth after 35. Early menarche and late menopause. Infertility drugs. Obesity, high fat diet.
Ovarian Cancer Manifestations Early: None-vague, mild complaints, feel full quickly, urinary urgency/frequency, abd bloating, constipation, back pain, pain during sex, menstrual changes prior to menopause, Abnormal vaginal bleeding; pelvic pain. Late: Enlarged abd /c ascites.
Ovarian Cancer Diagnostic Tests Biopsy. Pap smears. CA125. Ultrasonography. CT scan and X-ray to determine areas of metastasis.
Ovarian Cancer Treatment Surgery: treatment of choice. Chemotherapy. Radiation.
Cancer of the Vulva Risk Factors > 50. STIs. HPV. Smoking. HIV. Precancerous lesions.
Cancer of the Vulva Manifestationss Asymptomatic lesions. Pruritis. Wart-like growths. Changes in color, density of vulva. Lymph enlargement.
Cancer of the Vulva Diagnostic Tests Biopsy of lesion.
Cancer of the Vulva Treatment Surgery: preferred treatment. Radiation (if lymph nodes are involved). Chemotherapy: to treat metastasis.
Self Breast Exam Monthly breast self-examination (BSE): beginning at age of 20 (after menstrual period). Clinical breast examination: every 3 years age 20 – 39 years. Clinical breast examination and mammogram: yearly at age 40.
Fibrocystic Breast Disease Physiologic nodes and breast tenderness that fluctuates with menstrual cycle.
Fibrocystic Breast Disease Manifestations Unilateral or bilateral pain and tenderness in upper outer breast quadrant. May feel lumpy prior to menses. Nipple discharge may be present. Multiple mobile cysts form. Blood tinged fluid is suspicious of malignancy.
Intraductal Disorders Intraductal papilloma: Tiny wart-like growth on inside of mammary duct, Nipple discharge (clear/sticky/bloody). Mammary duct ectasia: Palpable lumpiness beneath areola, Sticky/thick discharge, Burn/itch, Nipple retraction, Occurs in perimenopausal women.
Care of Intraductal Disorders Well-fitting bra worn day and night. Eliminating xanthenes: Caffeine, tea, coffee, chocolates. Mild analgesics. Local heat or cold. Vitamin E.
Breast Cancer Risk Factors Genetics/family hx. Age/gender. Past breast cancer. Dense breast tissue. Chest radiation. Menstruation prior to 12. Late menopause. Not breastfeeding. No children or having them after age 30. Hormone replacement for more than 5 years. Alcohol. Obesity.
Breast Cancer Manifestations Non-tender lump. Abnormal nipple: discharge, rash, retraction, change in position. Dimpling of skin. Peau d’ orange: Skin looks like orange pealing, Detection on mammography.
Diagnostic Tests for Breast Cancer Breast examination by trained health professional. Mammogram starting at age 40. Biopsy.
Breast Cancer Medications Tamoxifen (Nolvadex): Oral medication that interferes with estrogen activity. Chemotherapy is standard of care for cases with axillary node involvement. Immunotherapy: Herceptin, stops tumor growth.
Types of Surgical Mastectomy Lumpectomy. Partial: ¼ breast, radiation. Simple: breast only. Modified Radical: breast, some of lymph nodes. Radical: breast, pectoral muscles, lymph nodes (rare). Sentinel node biopsy: inject radioactive material, trace infected nodes.
Nursing care Post Mastectomy Affected side up (arm raised). No BP/injections/venipunctures on side. s/s of edema. Limit arm exercises (24 hrs). Abduction and external rotation after healed. Assess dressing for drainage (COCA). Chemo/Radiation. Psychological concerns.
Types of Breast reconstruction Placement of sub-muscular implant. Use of tissue expander to be followed later by implant. Transposition of muscle and blood supply from abdomen or back.
Postmastectomy exercises Wall climbing. Overhead pulleys. Rope turning. Arm swings.
Breast Cancer Radiation Therapy Used post surgery to destroy any remaining cancer cells. Used preoperatively to shrink large tumor. Commonly used in combination with lumpectomy.
Created by: nimeggs
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