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