Chapter_047

Chapter 47 : 

Chapter 47 Female Reproductive Disorders

Anatomy and Physiology of the Female Reproductive System : 

Anatomy and Physiology of the Female Reproductive System External genitalia Mons pubis Labia majora Labia minora Clitoris Pudendum Bartholin’s glands Skene’s glands

Anatomy and Physiology of the Female Reproductive System : 

Anatomy and Physiology of the Female Reproductive System Internal genitalia Vagina Uterus Fallopian tubes Ovaries Breasts

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Figure 47-1

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Figure 47-2

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Figure 47-3

Anatomy and Physiology of the Female Reproductive System : 

Anatomy and Physiology of the Female Reproductive System Menstrual cycle Consists of ovarian cycle and uterine cycle Menstruation: passage through the vagina of a mixture of blood and other fluids and tissue formed in the lining of the uterus to receive the fertilized ovum The length of the menstrual cycle averages 28 to 30 days, but it may be 21 to 40 days; affected by stress, physical activity, and illness

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Figure 47-4

Health History : 

Health History Chief complaint and history of present illness If existing problem, include related signs and symptoms and onset, frequency, and effect on normal functioning Past medical history: menstrual history Age when menstruation began, date of onset of last period, usual number of days between, amount of flow, number of days of flow per period, use of tampons Menopause: age when menstruation ceased as well as whether menopause occurred naturally or resulted from surgery, chemotherapy, or radiation therapy

Health History : 

Health History Past medical history: obstetric-gynecologic Term and preterm births, living children, abortions Blood type, Rh factor, rubella or rubella immunization Infections and sexually transmitted infections, cysts and tumors, structural and functional abnormalities, infertility, and stress incontinence Family history Diabetes mellitus, cancer, complications of pregnancy, multiple pregnancies, genetic disorders, or congenital anomalies

Health History : 

Health History Review of systems Symptoms and prescribed or self-selected treatments Commonly reported symptoms are pain, itching, burning, vaginal bleeding between periods or after menopause, heavy or prolonged bleeding with periods, vaginal discharge, urinary frequency/urgency Functional assessment Includes a diet history, use of dietary supplements including calcium and iron, exercise pattern, sexual history, occupational exposure to potential teratogens, and effects of symptoms on usual activities

Physical Examination : 

Physical Examination Measure vital signs, height, and weight Skin color, texture, and moisture noted. Breasts should be examined for dimpling and abnormal skin texture Abdomen inspected for distention and palpated for tenderness. The legs are inspected for swelling and palpated for tenderness Assesses the external genitalia for lesions, lumps, swelling, and discharge Vagina and uterine cervix are inspected for lesions, growths, discharge, and redness Vagina, abdomen, and rectum palpated for abnormalities

Diagnostic Tests and Procedures : 

Diagnostic Tests and Procedures Pelvic examination Smears and cultures Endometrial and cervical biopsies Culdoscopy Laparoscopy Dilation and curettage Mammography Breast self-examination Breast biopsy

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Figure 47-5A-C

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Figure 47-6

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Figure 47-5D

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Figure 47-7

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Figure 47-8

Therapeutic Measures : 

Therapeutic Measures Douching Cauterization Application of heat Topical medications Surgical procedures Abdominal Vaginal Laparoscopic

Disorders of the Female Reproductive System : 

Disorders of the Female Reproductive System

Uterine Bleeding Disorders : 

Uterine Bleeding Disorders Pathophysiology Metrorrhagia Bleeding or spotting between menstrual periods Menorrhagia Menstrual periods with profuse or prolonged bleeding Amenorrhea The absence of menses

Uterine Bleeding Disorders : 

Uterine Bleeding Disorders Etiology and risk factors Symptoms of underlying factors, rather than being specific definable conditions in themselves Causes: hormonal dysfunction, benign and malignant tumors, coagulation disorders, systemic diseases, use of some contraceptives, endometrial hyperplasia, inflammatory processes, and systemic diseases Causes of amenorrhea include pregnancy; excessive weight loss, physical activity, or stress; pituitary, hypothalamic, thyroid, or adrenal disorders; ovarian failure; and uterine abnormalities

Uterine Bleeding Disorders : 

Uterine Bleeding Disorders Medical diagnosis and treatment Colposcopy, biopsy, and cauterization as well as laboratory analyses of blood components, hormone levels, and tissue specimens or smears provide diagnostic information Interventions Deficient Knowledge Anxiety

Vulvitis and Vaginitis : 

Vulvitis and Vaginitis Pathophysiology Vulvitis Inflammation of the vulva Vaginitis Local inflammatory response to various factors Etiology and risk factors Two most common causes: Candida albicans (fungus, or yeast infection) and Trichomonas vaginalis (protozoal infection) Signs and symptoms Include local swelling, redness, and itching

Vulvitis and Vaginitis : 

Vulvitis and Vaginitis Complications Ascending infection Medical diagnosis Based on symptoms and on inspection of the vulva and vagina

Vulvitis and Vaginitis : 

Vulvitis and Vaginitis Medical treatment Specific to the causative agent Topical antifungal creams, oral antiprotozoals or antibiotics, vaginal suppositories to reestablish normal vaginal flora, topical/systemic estrogen replacement therapy, improved diabetes control, and avoidance of offending chemical agents Symptoms managed with frequent cleansing with neutral agents; wearing cotton panties, cotton-crotched pantyhose, and nonconstricting clothing; and heat in the form of sitz baths and perineal irrigations

Bartholin’s Gland Abscess (Bartholinitis) : 

Bartholin’s Gland Abscess (Bartholinitis) Pathophysiology Edema and pus formation due to infectious microorganisms occlude the duct of the affected gland and form an abscess Etiology and risk factors Commonly cultured organisms include normal intestinal bacterial flora, Staphylococcus aureus, Streptococcus pneumoniae, Trichomonas vaginalis, Neisseria gonorrhoeae, and Mycoplasma hominis

Bartholin’s Gland Abscess (Bartholinitis) : 

Bartholin’s Gland Abscess (Bartholinitis) Signs and symptoms Perineal pain, fever, labial edema, chills, malaise, and purulent discharge Complications Systemic infection Medical diagnosis Visual inspection; culture and sensitivity

Bartholin’s Gland Abscess (Bartholinitis) : 

Bartholin’s Gland Abscess (Bartholinitis) Medical treatment Oral analgesics and moist heat in the form of frequent sitz baths or hot wet packs Surgical incision and drainage of the abscess Broad-spectrum antibiotics Nursing care Instruction to help patient comply with treatment Tactful instruction in basic perineal hygiene principles is in order if the evidence indicates that inappropriate or inadequate practices are being followed

Cervicitis : 

Cervicitis Pathophysiology Inflammation of the cervix Etiology and risk factors Infectious organisms, scraping of cells for diagnostic tests, cryosurgery, use of vaginal tampons or medications, childbirth, decreased estrogen levels after menopause, and use of oral contraceptives Signs and symptoms Usually asymptomatic, although it may cause pain, visible vaginal discharge, bleeding, or dysuria Complications Pelvic inflammatory disease

Cervicitis : 

Cervicitis Medical diagnosis and treatment Based on pelvic examination or results of Pap smear Treated with systemic or topical antimicrobial agents If related to menopause, topical or oral estrogen Nursing care Assisting with assessment procedures, patient support, and teaching the patient to carry out the prescribed treatment and posttreatment procedures

Mastitis : 

Mastitis Pathophysiology Infection-induced inflammation of breast tissue in the lactating woman Etiology and risk factors Staphylococcus aureus; Escherichia coli, streptococci Signs and symptoms Usually confined to one breast; may be asymptomatic except for tenderness and low-grade (and often unsuspected) fever Symptomatic mastitis: localized pain, fever, tachycardia, general malaise, and headache

Mastitis : 

Mastitis Complications Abscess formation Medical diagnosis and treatment Diagnosis based on presenting symptoms Culture and sensitivity Treatment based on symptoms alone and consists primarily of immediate and aggressive antibiotic therapy Symptoms managed by frequent emptying of the breast, heat, rest, and analgesics

Mastitis : 

Mastitis Interventions Risk for Injury Deficient Knowledge

Fibrocystic Changes : 

Fibrocystic Changes Pathophysiology An exaggerated response to hormonal influences Excess fibrous tissue develops accompanied by overgrowth of the lining of the mammary ducts, proliferation of mammary ducts, and the formation of cysts

Fibrocystic Changes : 

Fibrocystic Changes Etiology and risk factors Common among women who have never given birth, have had a spontaneous abortion, and early menarche and late menopause Signs and symptoms Smooth round lumps that are freely movable may be felt; sometimes milky yellow or green discharge from the nipple

Fibrocystic Changes : 

Fibrocystic Changes Medical diagnosis and treatment Diagnosis based on the physical exam and health history. A mammogram or ultrasound may be used No specific cure for fibrocystic changes. Danazol reduces symptoms; decreases estrogen production Nursing care Instruct the patient in self-examination and to encourage scheduled professional

Pelvic Inflammatory Disease : 

Pelvic Inflammatory Disease Pathophysiology Infection that may affect any or all structures in pelvic portion of reproductive tract and peritoneal cavity Etiology and risk factors Most PID cases from sexually transmitted organisms N. gonorrhoeae, Chlamydia trachomatis, and M. hominis Non-STI organisms also causative agents Staphylococcal, streptococcal, and other organisms

Pelvic Inflammatory Disease : 

Pelvic Inflammatory Disease Signs and symptoms May be a silent infection with no symptoms Symptomatic PID: with either the gradual onset of dull, steady, low abdominal pain or the sudden onset of severe abdominal pain, chills, and fever Other symptoms: dysuria, irregular bleeding, a foul-smelling vaginal discharge that may cause inflammation and skin breakdown of the vulva, dyspareunia (pain during intercourse)

Pelvic Inflammatory Disease : 

Pelvic Inflammatory Disease Complications Ectopic pregnancy, infertility, and chronic abdominal discomfort Infection of the entire peritoneal cavity (peritonitis) and systemic septic shock also are potential complications

Pelvic Inflammatory Disease : 

Pelvic Inflammatory Disease Medical diagnosis Culture of the causative organism or organisms; sonography, laparoscopy, and culdocentesis Medical treatment Rest; application of heat via warm compresses, a heating pad, or sitz baths; and a regimen of analgesics and broad-spectrum antibiotics Interventions Acute Pain Impaired Skin Integrity Deficient Knowledge

Endometriosis : 

Endometriosis Pathophysiology Endometrial cells deposited in the pelvic cavity implant on structures within the cavity They continue to respond to menstrual cycle hormonal stimulation Result is the periodically painful and potentially destructive condition

Endometriosis : 

Endometriosis Etiology and risk factors Believed to occur in 10% of all women of reproductive age Incidence and severity are greatest in women with relatives who have endometriosis Signs and symptoms Dysmenorrhea; pain with defecation, dyspareunia, and abnormal bleeding

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Figure 47-9

Endometriosis : 

Endometriosis Complications Constriction of pelvic structures by endometriosis-related adhesions Medical diagnosis Visualization and excision of endometrial implants; ultrasonography Medical treatment Nonsteroidal anti-inflammatory agents Gonadotropin-releasing hormone (GnRH) agonists or a synthetic androgenic steroid Surgical management

Endometriosis : 

Endometriosis Nursing care The most significant nursing interventions are validating that the pain is real and providing information about pain relief measures Patient teaching based on treatment method selected and includes anticipatory guidance and treatment-specific instructions

Cysts : 

Cysts A closed saclike structure that is lined with epithelium and that contains fluid, semisolid, or solid material Classified as neoplasms and may be benign or malignant; majority are benign See Table 47-3, p. 1054

Fibroid Tumors : 

Fibroid Tumors Pathophysiology Benign and common Fibroid tumors grow slowly during reproductive years but atrophy after onset of menopause Etiology and risk factors Exact cause unknown; widely thought that fibroids form and grow in response to stimulation by estrogen, primarily estradiol

Fibroid Tumors : 

Fibroid Tumors Signs and symptoms May be asymptomatic, but the most common symptoms are menstrual irregularities—menorrhagia and dysmenorrhea Complications Infertility, crowding and malpositioning of the fetus during pregnancy, degenerative changes from interruption of blood supply

Fibroid Tumors : 

Fibroid Tumors Medical diagnosis On examination, uterus is enlarged and distorted Medical treatment Many need no treatment; tumors atrophy after menopause Myomectomy may be performed Nursing care Assist physician or nurse practitioner with diagnostic procedures and provide support to the patient

Cystocele and Rectocele : 

Cystocele and Rectocele Pathophysiology Vaginal disorders caused by weakness of supportive structures between the vagina and bladder (cystocele) or the vagina and rectum (rectocele) Etiology and risk factors During pregnancy and childbirth, the muscles that support the pelvic floor may be weakened

Cystocele and Rectocele : 

Cystocele and Rectocele Signs and symptoms Dyspareunia, lower back and pelvic discomfort, and recurrent bladder infections Medical diagnosis and treatment Diagnosis based on inspection and palpation Treatment may include pelvic floor (Kegel) exercises; pessary; anterior colporrhaphy and posterior colporrhaphy

Cystocele and Rectocele : 

Cystocele and Rectocele Assessment Problems related to urinary and bowel function If surgery planned, assess patient’s understanding of the procedure, the pre- and postoperative care, and the patient’s concerns

Cystocele and Rectocele : 

Cystocele and Rectocele Interventions Stress Incontinence Constipation Sexual Dysfunction Risk for Infection Acute Pain Risk for Injury Deficient Knowledge

Uterine Prolapse : 

Uterine Prolapse Uterus descends into the vagina from its usual position in the pelvis First degree: cervix is above vaginal introitus Second degree: cervix protrudes from the introitus Third degree: vagina is inverted and both the cervix and the body of the uterus protrude from the introitus

Uterine Prolapse : 

Uterine Prolapse Etiology and risk factors The supporting ligaments may be congenitally weak or become stretched during pregnancy or injured during childbirth, resulting in weakening of support Signs and symptoms Dyspareunia, backache, and a feeling of pelvic heaviness and pressure

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Figure 47-10

Uterine Prolapse : 

Uterine Prolapse Complications In second- and third-degree prolapse, protruding uterine portion subject to trauma and may become eroded and necrotic Medical diagnosis First-degree: diagnosed by pelvic examination Second- and third-degree prolapse: readily detected by visual inspection

Uterine Prolapse : 

Uterine Prolapse Medical treatment Vaginal hysterectomy with anterior and posterior colporrhaphy Pessaries may be used for women who are poor surgical risks or who refuse surgical treatment Interventions When a pessary is the treatment, explain importance of frequent examinations by a physician or nurse practitioner, the need to report pessary-related discomfort to the health care provider, and the need for pessary care

Retroversion and Retroflexion, Anteversion and Anteflexion : 

Retroversion and Retroflexion, Anteversion and Anteflexion Uterus normally at 45-degree angle anterior to the vagina; cervix points downward toward the posterior vaginal wall Retroversion: backward tilt, with the cervix pointed downward toward the anterior vaginal wall Retroflexion: body of uterus bends back on itself Anteversion: entire uterus tilts forward at a sharper angle to the vagina Anteflexion: uterus bends forward, folding on itself

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Figure 47-11

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Figure 47-12

Retroversion and Retroflexion, Anteversion and Anteflexion : 

Retroversion and Retroflexion, Anteversion and Anteflexion Etiology and risk factors Weakening and stretching of the round, broad, and uterosacral ligaments and weakened pelvic floor musculature related to childbearing the most common causes Signs and symptoms Most uterine displacement is asymptomatic, although dyspareunia and low back pain may occur with retroversion

Retroversion and Retroflexion, Anteversion and Anteflexion : 

Retroversion and Retroflexion, Anteversion and Anteflexion Complications Difficulty with conception Nursing care If pessary is inserted, provide instructions similar to those described for uterine prolapse

Vaginal Fistulas : 

Vaginal Fistulas Abnormal passageways between the vagina and other pelvic organs Vesicovaginal fistula Between the vagina and the urinary bladder Urethrovaginal fistula Between the urethra and the vagina Rectovaginal fistula Located between the vagina and the rectum Surgical correction is often needed, although some small fistulas close spontaneously

Breast Cancer : 

Breast Cancer Etiology and risk factors White non-Hispanic women have highest incidence of breast cancer African-American women most likely to die from it Family history important; risk rises if one or more first-degree family members has had breast cancer and if that cancer was premenopausal and bilateral

Breast Cancer : 

Breast Cancer Prognosis When cancer is confined to the breast, the 5-year relative survival rate is 96.8%; cancer spread to surrounding tissue, 5-year rate is 75.9%; disease has metastasized, the rate is 20.6% Signs and symptoms Painless breast tissue thickening or lump Late symptoms include dimpling of the skin, nipple discharge, nipple or skin retraction, edema, dilated blood vessels, ulceration, and hemorrhage

Breast Cancer : 

Breast Cancer Complications Infiltration of adjacent breast and axillary tissue and metastasis to distant sites Medical diagnosis Clinical breast examination; mammogram; breast ultrasound, digital mammography, or MRI

Breast Cancer : 

Breast Cancer Medical treatment Lumpectomy, simple mastectomy, and radical mastectomy (see Figure 47-14, p. 1065) Staging: the tumor-node-metastasis classification Critical factor determined—whether the cancer cells are estrogen receptors or nonreceptors Tamoxifen: selective estrogen receptor modulator (SERM) prescribed for the estrogen receptors Chemotherapy, hormone therapy, radiation therapy, biologic therapy, or a combination of these may be employed before, during, or after surgery

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Figure 47-13

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Figure 47-14

Breast Cancer : 

Breast Cancer Interventions Disturbed Body Image Risk for Injury Impaired Physical Mobility Deficient Knowledge

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Figure 47-15

Cervical Cancer : 

Cervical Cancer Etiology and risk factors Research indicates that the risk for cervical cancer is increased in women who have been infected with the human papillomavirus or HIV Additional factors: cigarette smoking, initial sexual intercourse in early adolescence, multiple sexual partners, dietary deficiencies in folic acid and in vitamins A and C

Cervical Cancer : 

Cervical Cancer Signs and symptoms Early cervical cancer is asymptomatic Advanced cancer also may be asymptomatic or may be associated with blood-tinged or frank bloody vaginal discharge, menstrual irregularities, or bleeding after intercourse

Cervical Cancer : 

Cervical Cancer Complications Invasion of cervical cancer into adjacent structures Medical diagnosis Tissue specimens obtained by multiple punch biopsy, endocervical curettage, or conization Medical treatment Mild dysplasia: with loop electrosurgical excision Localized carcinoma (in situ): with laser destruction, cryosurgery, or conization alone; total hysterectomy may be performed if childbearing is not desired Invasive cancer: radiation, surgery, or both

Ovarian Cancer : 

Ovarian Cancer Etiology and risk factors Family or personal history of ovarian cancer; a personal history of ovarian dysfunction or of breast, endometrial, or colorectal cancer; high-fat diet; nulliparity; early menarche and late menopause Signs and symptoms Asymptomatic in its early stage Advanced: abdominal pain and bloating, GI symptoms such as flatulence and urinary tract complaints Complications Spread to the peritoneum, omentum, and bowel surface via direct invasion, peritoneal fluid, and the lymphatic and venous systems

Ovarian Cancer : 

Ovarian Cancer Medical diagnosis Pelvic and rectal examinations; abdominal and vaginal ultrasound; exploratory laparotomy or laparoscopy Medical treatment Depends on the staging of the tumor Options include surgery (usually total abdominal hysterectomy and bilateral salpingo-oophorectomy), systemic or intraperitoneal chemotherapy, intraperitoneal radioisotope instillation, and external radiation therapy

Vulvar Cancer : 

Vulvar Cancer Etiology and risk factors Cause unknown, but it may be related to STIs, particularly human papillomavirus Other factors: diabetes mellitus, hypertension Signs and symptoms Commonly reported symptom is pruritus Also pain and bleeding

Vulvar Cancer : 

Vulvar Cancer Complications Invades adjacent structures or metastasizes via the lymphatic system Medical diagnosis Localized lesions: conservative removal of the malignant tissue by laser surgery; topical chemotherapy For wider, deeper, or invasive lesions, radical surgical removal through hemivulvectomy or vulvectomy and bilateral dissection of groin lymph nodes or through pelvic exenteration

Vaginal Cancer : 

Vaginal Cancer Etiology and risk factors No definite cause has been identified Risk factors: STIs, previous diagnosis of cervical/vulvar cancer, previous radiation therapy, and intrauterine exposure to diethylstilbestrol Signs and symptoms In early and most treatable form, usually is asymptomatic Later symptoms: burning sensation, discharge that may have a foul odor, dyspareunia, spotting after intercourse, and bleeding Complications Invasion of adjacent structures and metastasis

Vaginal Cancer : 

Vaginal Cancer Medical diagnosis and treatment Most cases detected during inspection of vagina and from Pap smears Definitive diagnosis made via colposcopy and biopsy of suspicious areas followed by tissue studies Treatment In situ (localized) cancer: treated relatively simple with local laser surgery or cryosurgery More radical treatment indicated if cancer is more invasive Possible treatments either alone or in combination include topical chemotherapy, internal or external radiotherapy, partial or total vaginectomy, and pelvic exenteration

Care of the Patient with Cancer of the Cervix, Ovaries, Vulva, or Vagina : 

Care of the Patient with Cancer of the Cervix, Ovaries, Vulva, or Vagina Assessment Signs and symptoms and possible risk factors When reviewing the systems, related changes or problems: fatigue, pain, bowel or bladder dysfunction Effects of the symptoms on normal functioning Patient may react to the diagnosis with anxiety, fear, depression, anger, or withdrawal A complete physical examination should be done Physician/nurse practitioner performs a pelvic examination that may reveal lesions, masses, and lymph node enlargement

Care of the Patient with Cancer of the Cervix, Ovaries, Vulva, or Vagina : 

Care of the Patient with Cancer of the Cervix, Ovaries, Vulva, or Vagina Interventions Anxiety and Fear Disturbed Body Image Ineffective Sexuality Pattern Ineffective Family Coping Risk for Injury

Infertility : 

Infertility Etiology and risk factors Conception depends on a number of factors Timing and techniques used for sexual intercourse Production and release of a healthy ovum and numerous (200 million/ejaculate) healthy sperm Anatomically and physiologically correct female and male reproductive systems Biochemical compatibility between female vaginal-cervical-fallopian environment and male ejaculate

Infertility : 

Infertility Medical diagnosis Based on data obtained from exhaustive psychosocial and physical health and sexual health histories of both partners

Infertility : 

Infertility Medical treatment See Table 47-5 Interventions Situational Low Self-Esteem Ineffective Sexuality Pattern Ineffective Coping Deficient Knowledge

Menopause : 

Menopause Cessation of menstruation; end of reproductive capacity Natural menopause part of normal aging; surgical menopause from removal of the ovaries May begin as early as age 35 but more commonly occurs between ages 40 and 55 Process from earliest signs to complete cessation of menstruation usually is 2 years or less A woman is said to be menopausal when she has not had a menstrual period for 1 year

Menopause : 

Menopause Signs and symptoms Hot flashes typically accompanied by perspiration and sometimes faintness Also vaginal dryness, insomnia, joint pain, headache, and nausea Without estrogen, the uterus becomes smaller, vagina shortens, and vaginal tissues become drier Breast tissue may lose its firmness, and pubic and axillary hair becomes sparse Supporting pelvic structures relax, causing stress incontinence Emotional instability, irritability, and depression

Menopause : 

Menopause Medical treatment Estrogen therapy Drugs used to control hot flashes include clonidine patches, Bellergal-S, venlafaxine, and paroxetine

Menopause : 

Menopause Nursing diagnosis, goal, and outcome criterion Nursing diagnosis: Ineffective Management of Therapeutic Regimen related to lack of understanding of the effects and treatment of menopause Goal of nursing care is effective management of prescribed therapy and decreased signs and symptoms of menopause Outcome criterion is reduced symptoms

Menopause : 

Menopause Interventions Patient’s understanding of menopause and how she feels about it May need reassurance that her symptoms and responses are normal If drug therapy, instruct regarding self-medication Women who wish to prevent “menopausal” pregnancy should use a reliable form of contraception for at least 1 year following cessation of menses