Transcript Care of Women with Reproductive Disorders

CARE OF WOMEN WITH
REPRODUCTIVE DISORDERS
CHAPTER 39
Mrs. Frascella MSN Ed,RN
EXTERNAL STRUCTURES
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Vulva-name given to the external female
genitalia.
The vulva is composed of the following
structures:

Mons pubis -rounded mound of fatty tissue that
protects the symphysis pubis. Covered with
hair.

Labia majora -2 elongated , raised folds of skin
that enclose the vulvular cleft.
EXTERNAL STRUCTURES
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Labia minora- soft folds of skin within the labia
majora.
Clitoris-located at the top of the vulvular cleft,
made of erectile tissue,highly sensitive to touch.
Urethral meatus- external opening of the urethra
of the urinary bladder.
Perineum-flat muscular surface between the
vagina and the anus.
INTERNAL STRUCTURES
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Vagina -muscular tube lined with membranous
tissue with ridges called rugae. Normal acidic pH
prevents infection.
Uterus -(womb) is a hollow pear-shaped organ
with a thick muscular wall. Capable of
expanding to accommodate a growing fetus.
Lower opening is the cervix which dilates during
labor to allow for delivery of infant.
INTERNAL STRUCTURES
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2 fallopian tubes that branch outward at the top
of the uterus, pathway for the ovum (egg), from
the ovary to the uterus.
2 ovaries, one located near the end of each
fallopian tube. Almond shaped glands, excrete
estrogen and progesterone into the bloodstream.
Bony pelvis -located at the base of the hips,
supports pelvic organs.
INTERNAL STRUCTURES
ACCESSORY ORGANS
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Breasts or mammary glands, located on the upper
chest.
Composed of fibrous, adipose, and glandular
tissue and are responsible for lactation (milk
production).
Pain to breast occur at mid cycle of ovulation.
FEMALE REPRODUCTIVE CYCLE

Ovarian Cycle: (2 phases)
1.Follicular Phase -first 14 days of a 28 day
cycle.
Follicle-stimulating hormone (FSH) &
Luteinizing hormone (LH) stimulate the
maturing of the immature ova in preparation
for fertilization.
Ovulation takes place when estrogen peaks about
14 days before the next cycle.
OVARIAN CYCLE
2.
Luteal phase -15th to 28th days of the cycle.
LH and progesterone are the primary
hormones in this phase.
Blood supply to the uterus increases in
preparation for possible implantation of a
fertilized ovum. ( PMS)
If fertilization and implantation do not occur,
the lining of the uterus will degrade and be shed
during menstruation, and the cycle begins
again.
SEXUAL MATURATION
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Puberty -the period of sexual maturation, usually
occurs between the ages of 9 and 17.
Involves a period of accelerated growth, hips
begin to widen, breasts begin to develop and
axillary and pubic hair appears.
Puberty is completed by the onset of the menstrual
cycle.
Menarche menstruation - the first menstrual
cycle.
CHANGES THAT OCCUR WITH AGING
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Menopause -occurs when menses completely
ceases for 12 months.
After menopause:
 Female organs atrophy
 Loss of elasticity
 Dryness of vaginal membranes
 Reduction in bone mass
 Internal organs may sag, or prolapse into the
vagina
MENSTRUATION
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May be abnormal for the first year.
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Regular cycle is usually every 28 days.
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Menstrual blood consists of shed endometrial
tissue, blood mucous, and vaginal and cervical
cells.
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Amount of actually blood loss is only 40 -80 ml.
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Flow may be heavy at first but gradually reduces.
MENSTRUATION
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Mild cramping may occur.
Mood swings may be associated with hormonal
changes.
Mittelschmerz -sharp pain in the right lower
quadrant, sometimes felt midcycle around the
time of ovulation.
NORMAL VAGINAL DISCHARGE
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Vagina is moist, warm, & dark, good medium for
microorganisms.
Normal vaginal discharge has an off-white color
and is without odor.
If vaginal discharge develops an odor or change
in consistency, or causes irritation or burning, a
healthcare provider should be consulted.
CONTRACEPTION AND FERTILITY
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Many women start sexual relationships and risk
pregnancy before they are ready to have children.
Some women give birth and do not want to have
more children.
Many sexually active women of childbearing age
are concerned about regulating, planning, or
preventing pregnancy.
CONTRACEPTIVE OPTIONS
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Women should make an informed decision
concerning methods of reliable birth control.
Nurses are responsible for providing
comprehensive education concerning the
advantages, limitations, and side effects of
various contraceptive devices.
ORAL CONTRACEPTIVES
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Most popular method of reversible hormonal
contraception.
Effective if used properly.
Offer relief from breast tenderness, bloating, and PMS
symptoms.
Abstinence is the only 100% effective method of birth
control.
ORAL CONTRACEPTIVES
The “Pill”
Combination of synthetic estrogen
and progestin, hormones prevent
ovulation and thicken cervical
mucus, making it difficult for
sperm to travel upward.
Based on a 28 day cycle with 7
hormone free days that result in
monthly menstruation.
Oral Contraceptives
ORAL CONTRACEPTIVES
Prescription required.
 Must be taken faithfully.
 Decreases breast tenderness.
 Not recommended for women older than 35 who
smoke.
 Contraindicated for women with a history of
heart or liver disease, breast or uterine cancer, or
blood clots.
 Seasonale –reduces menstrual periods to 4x a
year
 Lybrel- taken 365 days a year, suspends
menstruation indefinitely

97% to 99.9% effective.
OTHER OC
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Minipill- small dose of progesterone and no
estrogen
Depro-Prevera- synthetic timed release
progesterone injected q 12 weeks to prevent
ovulation
INTRAUTERINE DEVICE (IUD)
IUD
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Small, sterile, flexible plastic
device inserted into the uterus by
a physician.
Can be a copper device or a
device containing the hormone
levonorgesterel (minera). Can
provide protection up to 5 yrs.
Can be used as an emergency
contraceptive measure if inserted
within a maximum of 7 days after
unprotected sex to prevent
implantation of zygote
Examples of IUD’s
IUD’S
Side Effects/Precautions:
May increase menstrual flow or cause cramping
or low back pain
 Increased incidence of PID with multiple sex
partners.
 Patient must check placement by feeling for
string once each month.
 Must be removed by health care provider.
 Up to 99% effective.
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MALE CONDOM
Condom
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A sheath commonly made
of latex that is placed over
the erect penis before
intercourse.
Oil-based lubricants such
as petroleum jelly can
cause latex to break down
and reduce effectiveness.
Assorted Condoms
MALE CONDOM
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Precautions:
 Leave space at the tip for seman to collect
rather than being forced upward out of the
condom.
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Store in a cool, dry place and do not keep
excessively long to avoid breakage.
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Handle carefully to avoid spilling semen and
possibly introducing it into the vagina.
MALE CONDOM
Effectiveness:
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88% -98% if used properly.
Use of spermicide increases effectiveness to 98%99%.
DIAPHRAGM
How diaphragm works
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A rubber dome-shaped cup
that fits snugly over the
cervix.
Spermacide is applied to
the cervical side of the
diaphragm and it is
inserted into the vagina so
that the fitted ring holds it
securely in place.
Diaphragms
DIAPHRAGM
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Precautions:
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Diaphragm must be fitted professionally and
should be refitted annually.
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Should be refitted with a gain or loss of 7-10
lbs. and after pregnancy.
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Effectiveness is 82%-94%.
INJECTABLE CONTRACEPTIVES
(Depo-Provera)
 Synthetic timed-release progesterone is
injected q 12 weeks to prevent ovulation.
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Injections must be given in clinic or office.
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Must be repeated q12 weeks to remain
effectiveness.
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99.7% effective
EMERGENCY CONTRACEPTION
How Method Works
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Taken orally the day
following intercourse, it
induces menses and
prevents implantation in
the uterus.
Should not be used as a
routine for of
contraception.
97%-99.9% effective
“Morning-after” pill
LEGAL AND ETHICAL CONSIDERATION
Note :
Although the “morning after” contraceptive pill can
be sold over the counter in most states, there has
been considerable unwillingness by certain
pharmacists to provide it.
The pharmacists’ claim that dispensing the pill is
against their religious principles. It may not be
ethical for pharmacists’ to withhold the
medication from a woman because of the
pharmacists’ personal belief.
INFERTILITY
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Primary infertility- the inability of the couple to conceive a
child after at least 1 year of active, unprotected sexual
relations without contraceptives.
Secondary infertility- the inability to conceive after having
once conceived, or the inability to maintain a pregnancy
long enough to deliver a viable infant.
FACTORS CONTRIBUTING TO INFERTILITY
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Problems with ovulation
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An abnormal pathway between the cervix and
the fallopian tube
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Abnormality in the endometrium or the uterus
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Tumors in the reproductive tract
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Vaginal or cervical environment that is
inhospitable
DIAGNOSIS OF INFERTILITY
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Obtain a detailed health history
Serum prolactin levels and endocrine
evaluations, semen analysis & chromosome
analysis
Tests for tubal patency or other possible
abnormalities
EMOTIONAL IMPACT
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The emotional impact of infertility is intense.
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Psychological intervention may be necessary.
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Couples may not be able to focus, increased
tension, blaming each other.
ASSISTED REPRODUCTION
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Reproductive therapy associated with many legal
and ethical issues.
Ex. Risk of having multifetal pregnancy, freezing
embryos for later use, surrogate mother.
MENOPAUSE
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Defined by the World Health Organization as the
cessation of menses for 12 consecutive months
due to a decrease in estrogen production.
The perimenopausal period is the time around
the actual cessation of the menstrual cycle.
S/S include: hot flashes, night sweats, low
estrogen levels.
RISKS OF MENOPAUSE
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Osteoporosis due to decrease in estrogen slows
bone growth.
Increased risk for cardiovascular disease due to
change in lipid metabolism.
Treatment may be hormone replacement
therapy.
HEALTH SCREENING
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Primary prevention is designed to decrease the
probability of becoming ill.
Secondary prevention is designed to focus on
detection of specific at-risk diseases so that early
treatment may be given.
Tertiary prevention minimizes the impact of
already-diagnosed conditions.
BREAST SELF-EXAMINATION
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Should be done monthly, about 1 week after
menstruation begins, or on a specific date each
month.
See figure 39-5 for self breast exam.
https://www.youtube.com/watch?v=E5SKimALbY
BREAST EXAMINATION
COMMON GYNECOLOGIC TESTS
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Pelvic exam-visual inspection of the external genitalia,
vagina, and the cervix to obtain specimens such as a Pap
smear.
Process- Inspection via the vaginal speculum; manual
palpation through abdominal wall, vaginally, and rectally of
internal organs.
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Provide privacy and good lightening
Gloves and supplies
Orient to equipment and purpose of exam
Void prior to test
Position – lithotomy, side-lying, or knee chest
Stay with woman for encouragement and comfort
COMMON GYNECOLOGIC TESTS
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Pap Smear-to obtain samples of cells and fluids
for pathology/ cytology studies.
Process-exudate, mucous, and cells are obtained
from surface with sterile swab or scraping tool
and placed on a laboratory slide or into a
preservative solution for pathology evaluation.
Cause some mild bleeding and cramping
COMMON GYNECOLOGIC TESTS
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Dilation & Evacuation (D &E)-to detect cause
of excessive bleeding; to remove hypertrophied
uterine lining, retained placenta, or tissue from
an incomplete abortion. Done in the OR.
Process-the cervix is dilated and the interior of
the uterus is cleansed by scraping, suction, or
both.
Mild cramping and bleeding for 1 week, next
period may be early or late
COMMON GYNECOLOGIC TESTS
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Coloscopy-examination of vagina and cervix to
evaluate abnormal cells and lesion
 Done after a positive Pap smear
Process – area visualized through scope, with
photos and possible biopsies of lesions requiring
further study
No tampons until healing
COMMON GYNECOLOGIC TESTS
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Mammography-to screen breasts for abnormal
growths, particularly cancer.
Process-a full-field digital mammography
machine records images on a computer screen
and can computer-enhance images for increased
accuracy.
Mild breast discomfort, bruising
 No deodorant or lotion to upper body
 Clothing that can be easily removed
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SURGICAL PROCEDURES
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Hysterectomy-removal of entire uterus,
vaginally or abdominally.
Panhysterectomy-removal of entire uterus,
fallopian tubes, and ovaries.
Radical hysterectomy-removal of uterus,
tubes, ovaries, upper third of the vagina, and
lymph nodes.
SURGICAL PROCEDURES
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Salpingectomy-removal of the fallopian tubes
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Oophorectomy-removal of an ovary.
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Vulvectomy-surgical excision of the labia,
clitoris, perineal structures, femoral and inguinal
lymphatic tissues.
MENSTRUAL DYSFUNCTIONS
Premenstrual Syndrome- (PMS)
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AKA ovarian cycle syndrome.
Presence of physical, psychological, or behavioral
symptoms that occur regularly within the luteal
phase of the menstrual cycle and disappear
during the remainder of the cycle.
MENSTRUAL DYSFUNCTIONS
Signs & symptoms:
 Weight gain, bloating
 Irritability, changes in eating patterns
 Fatigue, mood swings
Management:
 Lifestyle modifications
 Diet high in B vitamins
 Exercise, stress management
 Avoidance of fatigue
DYSMENORRHEA
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2.
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Painful menstruation
Primary Dysmenorrhea
Secondary Dysmenorrhea
Primary dysmenorrhea-occurs 6-12 months
after menarche.
Caused by the release of high levels of
prostaglandins in the first 2 days of
menstruation, causing uterine contractions that
result in abdominal cramps.
It is at this stage at young females may have
negative attitude toward own sexuality.
DYSMENORRHEA
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S/S-backache, weakness, decreased appetite,
dizziness, headache, and poor concentration.
Symptoms subside when prostaglandin levels
decrease.
Treatment-heating pad, back message,
nonsteroidal anti-inflammatories, oral
contraceptives.
DYSMENORRHEA
 Secondary
Dysmenorrhea-usually
occurs after the age of 25 and is caused by
endometriosis, pelvic inflammatory
disease, uterine polyps, or fibroids.
 Pain
is usually a dull, lower abdominal
pain that radiates to the back or thighs.
 Treatment
is the same as for primary
dysmenorrhea.
PELVIC RELAXATION SYNDROME
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Occurs when the muscles, ligaments, and fascia
that support the pelvic floor weaken, the pelvic
organs may descend toward the vaginal orifice.
Lack of estrogen results in weakening of tissue
structure.
May occur at any age.
PELVIC RELAXATION SYNDROME
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The descent of the pelvic organs may cause:
Cystocele-bladder protrudes through the vaginal
wall.
Rectocele-rectum protrudes through the vaginal
wall.
Enterocele-uterus protrudes through the vaginal
wall.
PELVIC RELAXATION SYNDROME
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S/S-relate to the specific organ involved.
 Eg.with a cystocele, the patient may exhibit
urinary incontinence.
Nonsurgical treatment-lifestyle changes, avoid
heavy lifting.
 A pessary can be fitted in the vagina to support
the pelvic muscles. (Hard plastic ring)
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PELVIC RELAXATION SYNDROME
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Surgical treatment:
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Anteroposterior repair (colporrhaphy) is the
procedure to repair a cystocele or rectocele.
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Hysterectomy-removal of the uterus.
POLYCYSTIC OVARIAN SYNDROME
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Congenital condition in which many cysts develop in one or
both ovaries.
Excess estrogen is produced, along with high levels of
testosterone, and LH. Low levels of FSH occur.
S/S -irregular menstruation, infertility, hyperinsulinemia,
and glucose tolerance problems, and excessive hair on the
body, (hirsutism).
Treatment is usually with oral contraceptives.
DYSFUNCTIONAL UTERINE BLEEDING
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Oligomenorrhea-decreased menstruation
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Amenorrhea-absence of menstruation.
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Metorrhagia-bleeding between menstrual
periods.
Menorrhagia-excessive menstrual bleeding.
LEIOMYOMA
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Also known as fibroids, benign tumors of the
uterine muscle.
Common in women taking birth control pills.
Spontaneously shrink during and after
menopause.
S/S -backache,sense of lower abdominal
pressure,constipation, urinary frequency or
incontinence, and abnormal uterine bleeding.
LEIOMYOMA
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Treatment-depends on the size and location of
the fibroids.
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Nonsteroidal anti-inflammatories and oral
contraceptives may be prescribed.
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Uterine artery embolization- injection of
special pellets into selected blood vessels that
supply the fibroid
ENDOMETRIOSIS
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Endometrial tissue is found outside uterus, particularly in
ovaries, in the rectovaginal septum, and in pelvis and
abdomen
Excessive menstrual flow, bleeding between periods,
painful bowel movements, and painful coitus
Continuous hormonal contraceptive therapy 3-6 months
Surgery- laparoscopy to remove adhesions or laser for
uterine tissue
Choice- if woman does not want children- complete
hysterectomy and removal of all endometrial lesion
Treat- menopausal symptoms
ROBOTIC GYNECOLOGIC SURGERY
Performed by a surgeon’s medical manipulation
of robotic hands and electric monitors
 Benefits:
 Shorter operative time
 Shorter hospitalization
 Sophisticated surgery
 Limitations:
 Increased hospital costs

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Seen with urogynecologic reconstructive
surgery and fistula
ROBOTIC SURGERY
TOXIC SHOCK SYNDROME
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Rare and potentially fatal disorder caused by strains of
Staph
Risk factors- prolonged use of high-absorbency tampons,
cervical caps, or diaphrams
Symptoms
 Sudden spiking fever, flu-like symptoms, hypotension,
generalized rash resembling a sunburn, and peeling
skin on palms or soles
Treatment: IV antimicrobial, good hand hygiene with
insertion of tampon, change tampon q 4hrs,diaphrams and
cervical caps should not be in for long time and not used
during menstruation
CANCER OF THE REPRO TRACT
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Vulvar Cancer-growth of abnormal tissue on the vulva.
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Occurs most commonly in elderly women.
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S/S -red, brown, or white patches on the skin of the vulva.
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Treatment includes surgical removal of the pathologic
tissue.
 Vulvar cancer is rare, may be associated with the HPV
virus.
 Gardasil- HPV vaccine
CANCER OF THE CERVIX
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Second leading cause of death in women 20 to 29 years of
age.
Risk factors: multiple sex partners, sexual intercourse
with uncircumcised males, starting intercourse at a young
age, multiple pregnancies, obesity, hx of HPV, or STI.
Treatment- cryosurgery, electrosurgical incision, or
surgical conization
 Advanced- hysterectomy with salpingo-oophorectomy.
Will need radiation and chemotherapy
CANCER OF THE UTERUS
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The most common malignant tumor of the
reproductive tract is endometrial cancer.
Slow growing, often occurs after menopause.
Treatment of choice- hysterectomy, with
bilateral salpingo-oophorectomy.
Surgery is usually followed by chemo and
radiation.
CANCER OF THE OVARY
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Approximately 70% of ovarian tumors are benign.
Known as the "silent cancer” because the s/s are usually vague
and non- specific.
S/S -abdominal pain, feeling full quickly when eating,
frequent or urgent need to urinate, increased abdominal girth.
IMPORTANT: sister or mother with disease or inheriting
BRCA1 or BRCA2 gene
Diagnosis- routine pelvic examination
Treatment- panhysterectomy, followed by chemo and
radiation.
DISORDERS OF THE BREAST
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Fibroadenoma -commonly found in teenagers
and young adults.
Firm, rubbery, mobile nodules of fibrous and
glandular tissue.
Usually occur in upper outer quandrant of the
breast.
A fine-needle aspiration or biopsy may be
performed to determine the presence of cancerous
cells.
FIBROCYSTIC BREAST CHANGES
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(FBCs)-commonly occurs during the reproductive
years.
Palpable, thickening portions of the breast
associated with pain and tenderness.
More painful during the menstrual cycle.
Treatment is conservative, vitamin E
supplements, limiting caffeine, alcohol, use of
non-steroidal anti-inflammatory drugs.
INTRADUCTAL PAPILLOMA
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Development of small elevations in the
epithelium of the ducts of the breasts under the
areola.
Ducts erode causing a serosanguinous discharge
from the nipple.
Treatment includes excision of the mass and
analysis of the discharge to determine if cancer
cells are present.
BREAST CANCER
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The United States has a high incidence of breast
cancer.
Incidence is higher in white women than rates for
African American or Asian women.
RISK FACTORS FOR BREAST CANCER
Family history of a relative with breast cancer.
 Early menarche, late menopause.
 Late first pregnancy or no children.
 Abnormal cells in previous breast biopsy.
 Obesity
 Environmental exposure to hormone-modulating
chemicals.
 Inherited BRCA1 or BRCA2 gene.
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BREAST CANCER
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Development of breast cancer is thought to be
related to the hormones estrogen and
progesterone.
The genes BRAC1 & BRAC2 were identified as
genes involved in the inherited form of cancer.
80% of women with this gene develop breast
cancer.
BREAST CANCER
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Signs/Symptoms:
 90% of breast lumps are detected by women
during the monthly breast exam.

Most breast cancer can be detected by
mammography before it can be clinically
palpated.

A nipple discharge or dimpled skin may be a
sign of breast cancer.
BREAST CANCER
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Prevention:
 Healthy lifestyle
 Foods high in antioxidants
 Regular scheduled mammograms between the
ages of 50 and 74.
 The drug Mifoxen is used to prevent recurrent
breast cancer.
 Women who have the BRCA1 or BRCA2 may
elect to have prophylactic bilateral
mastectomies.
BREAST CANCER

Treatment-based on the type of breast cancer.
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Lumpectomy-removal of the tumor only.

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Partial or segmental mastectomy -removal of
tumor and a portion of the surrounding breast
tissue and axillary lymph nodes.
Simple or total mastectomy -removal of entire
breast and axillary lymph nodes.
BREAST CANCER
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Modified radical mastectomy -removal of breast,
axillary lymph nodes, and lining over chest wall
muscles.
Radical mastectomy - removal of breast, axillary
lymph nodes, and chest muscles under breast.
BREAST CANCER
Bilateral Mastectomy
Breast Reconstruction
BREAST CANCER SURGERY
PREOPERATIVE CARE

Educational programs
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Reach to Recovery

Make sure patient has an understanding of
procedure
POSTOPERATIVE CARE
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Pain Management

Observation for s/s of infection

Support and educational measures

Encourage support groups

Body image issues
COMPLICATIONS

Lymphedema -swelling of the arm due to
damage to the lymphatic tract.
 Post-op Infection.
 Educate patient on providing meticulous skin
care.
 Instruct patient to elevate arm.
 No BP or labs in affected arm.
 Compression garments.
 Post-op exercises.
POSTOP COMPLICATIONS
Lymphedema
Compression Garment