Transcript cancer

NUR 210: Pathophysiology
Female Reproductive Problems
Wanda Lovitz, ARNP
Female Reproductive Problems:
Objectives
 State the major risk factors and
• Compare the age distribution and
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risk factors for cervical and
endometrial cancer.
Characterize the development of
cervical cancer from the
appearance of dysplastic cells to
the development of invasive
cervical cancer.
Explain how the PAP test has
impacted cervical cancer.
Compare the pathology and
manifestations of endometriosis.
Cite the major risk factors and
early symptoms of endometrial
cancer.
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symptoms of ovarian cancer.
Discuss the reason that ovarian
cancer is lethal
Describe the common causes
and symptoms of pelvic
inflammatory disease (PID).
Describe the manifestations of
fibrocystic disease.
Cite the risk factors for breast
cancer, the importance of breast
self-examination, and
recommendations for
mammography.
State the warning signs of breast
cancer.
NORMAL FEMALE PELVIC
ANATOMY
Endometrium is the inner lining of the uterus
Female Reproductive Disorders
Terms:
Ectopic pregnancy- ovum
fertilized in fallopian tube
Leiomyomas (fibroids) – benign
neoplasms of smooth muscle
• Endometriosis – uterine
tissue growing outside
uterus
• Endometritis – infection of
the endometrium
• Cervicitis – infection of the
cervix
• Vulvititis – inflammation and
pruritus of the vulva
Review of the menstrual cycle
There is a CYCLIC release of
hormones.
Note estrogen dominates
during the first half of
the cycle. Progesterone
is dominate in the last
half.
If no pregnancy occurs
progesterone , and menses
occurs.
Vaginal Bleeding…What’s Normal?
 Cycle length: 21-35 days
 Menstrual flow: 20-80 cc. per menses
 Average flow: 35 cc.
 Flow up to 7 days
Ectopic Pregnancy
Fertilized egg implants in the
fallopian tube instead of the uterine
lining.
Ectopic pregnancy
Uterine fibroids: leiomyomas
Leiomyomas (fibroids) are benign
neoplasms of smooth muscle origin.
Can cause menorrhagia (heavy menses)
and cramps.
Disorder of the Cervix
(Cancer of the cervix)
• Cancer of the cervix is one of the most curable cancers among
females
• Peak incidence in early 30’s
• There is a very strong link between genital warts (HPV) and
cervical cancer
• Risk Factors:
• Human papillomavirus (HPV)  genital warts
• If infected during teenage years= especially high risk. Possibly r/t high
rate of cell division that occurs in cervix during those years
Prevention: a new vaccine has been approved by the FDA (2010)
 Gardisil
Cervical Cancer: Prevention
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Girls
HPV Vaccine-Gardisil
should receive vaccine before first
sexual intercourse: recommended for
females ages 9-26
Three
dose vaccine (3 injections over 6 months)
Long
Has
term SE unknown
only been tested in ages 9-26. Safety in
older women unknown
The best protection
• Abstain from sex
• Condoms
Risky Behaviors in Kentucky
• 50.3% of Kentucky 9-12th graders have had sexual intercourse.
(45.9% average in U.S.) Ky ranks 11th
• 7.8% had intercourse before age 13
• 14.4% had four or more sex partners
• 59% of Kentucky sexually active teens did not use a condom at
last sexual encounter
• 14.9% of Kentucky teens experienced dating violence
2007 Youth Risk Behavior Survey
Cancer incidence in women
• 1. lung cancer –
most common cancer in women
• 2. breast cancer – most
common reproductive cancer
• 3. ovarian cancer – most
deadly cancer
• 4. endometrial cancer –most
• 5. cervical cancer –most
common inherited GYN cancer
curable cancer
• Kentucky has the highest cervical cancer rate in the
nation!!
Cancer of the cervix
Cervical metaplasia
Cancer in situ = precancerous
lesions
Ectocervix = visible portion.
Lined with squamous epithelium
Endocervical canal is lined with columnar
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epithelium. Transformation zone is the area where the
squamous and columnar epithelium meet. It is this area
that is sampled with the PAP smear.
PAP Smear
Sample taken from the transformation zone. A change seen on the Pap
Smear must be further evaluated by either repeat Pap and/or colposcopy.
Current recommendation: Every 3 years for women ages 21-65
What is Colposcopy?
Human Papilloma Virus (HPV): the
primary risk factor for cervical cancer
Almost 100% of
women with cervical
cancer have HPV
Transmission can occur
from skin to skin contact
There are over 32 serotypes of HPV.
Also known as condolyomas
Incidence of HPV
Cervical Cancer:Pathogenesis
Pre-malignant changes in
cervix (cervical dysplasia)
usually precedes CA by
many years
• Detection via Pap stain
slide test – microscopic
examination of cells
• 1945 American Cancer
Dyplastic changes
identified and staged during
cytological studies of a
cervical smear  PAP
Dysplasia = disordered
growth/atypical cells
Society endorses Pap
Smear as screening test
Invasive Cervical Cancer
 Involves invasion and spread to adjacent pelvic areas or to
distant sites through lymphatic system
 Job of Pap is to  rate of invasive cervical cancer- is a
screening test only
 A change in the Pap must be further evaluated by colposcopy
 ONLY 1% OF LESIONS PROGRESS TO INVASIVE CANCER
 There has been a 70% reduction in US cervical cancer mortality
over last 30 years!
Cervical cancer
Cervical Cancer
• Prognosis
• Preinvasive cancer
very curable (75-90%).
There is a very long latent
period.
• Only the epithelium is
(not the entire gland)
affected in preinvasive
• Average age of dx is
30’s
• Worse prognosis with
adenocarcinoma
(glandular involvement) =
endometrial/uterine
cancer
Cervical Cancer: Descriptive
Diagnosis
Epithelial cell abnormalities
- (normal PAP)
-Atypical glandular cells of undetermined
significance: ASCUS
-low grade SIL -1/4 tissue (squamous epithelial lesion)
-high grade SIL – 2/4 tissue
-invasive cancer
Cervical Cancer
• Clinical
Manifestations
• Preinvasive: no sx
• Invasive
characterized:
• Diagnostic Tools
• Direct cytological
sampling = punch biopsy
or COLPOSCOPY
• Sample of tissue taken
for cytology studies
• Unusual vaginal
bleeding or discharge
• Postcoital pain or
bleeding
Cancer cells
Cervical Cancer Death Rates
Cervical Cancer
Incidence Rates* by State, 2008
Note dramatic 
in cervical cancer
deaths over last
30 years
Kentucky ranked #31 8.2 in incidence.
Incidence in US is 7.8
Cervical Cancer Death Rates
2009 Cervical Cancer Rates per 100,000
women
Kentucky ranks 50
in mortality
Only Arkansas has
higher rate
Disorders of the Uterus
 Endometriosis
 The presence of uterine endometrial cells and tissue
outside of the uterus, anywhere in pelvic or abdominal
cavity
 Endometrial cells respond to estrogen and
progesterone with:
 Proliferation, secretion, and bleeding during menstrual cycle
 Results in severe inflammation  pain
 Continued inflammation scarring of pelvic or abdominal organs
Endometriosis
Endometrial tissue
outside of the uterus
Endometriosis: Cause
• Evidence suggests:
retrograde
menstruation
• Menstrual discharge
moves up the
fallopian tubes into
peritoneal cavity
• Who develops it?
• Genetic tendency and
depressed immune
system may predispose
• Early adolescence or
perimenopause
• Exposure to
environmental toxins
may contribute
Endometriosis: Clinical
Manifestations
• Pain
• Ranging from mild to severe
• Before and during menstruation
• Pain intensity is not proportional to amount of endometrial tissue in
various extauterine sites
• Dyspareunia (pain during intercourse)
• Pain on defecation – if rectal tissue involved
Endometriosis: Clinical
Manifestations (cont)
 Dysmenorrhea
 Pelvic pain
 Infertility
 Irregular bleeding
 Backache
 May have adhesions
 These may cause
bowel obstructions
Endometriosis: Diagnosis
• Diagnostic Tools
• Laproscopy – exam of PERITONEUM with a laproscope
• The abdomen Isinflated with CO2 and laprascope passed thru a
small incision in the abdomen
• Laparoscopy can DIAGNOSE disease and assign a stage
• Laproscopic surgery can also be used to TREAT some gyn
conditions.
Endometriosis: complications
• Complications of endometriosis
• Ruptured cysts
• Peritonitis
• Infertility: 30-40%
• Results from chronic inflammation and scarring of fallopian tubes
• Hormonal disturbances may occur
Endometriosis: chocolate cyst
A ruptured chocolate cyst can
cause *peritonititis
*Peritonitis is inflammation of
the serous membrane which
lines the abdominal cavity
Cysts formed from bleeding
endometrial tissue= chocolate cysts
What is Peritonitis?
 Peritionitis is an inflammation of the lining of the
abdominal cavity
 It can occur from trauma or infection
 Usually represents a surgical emergency!
 Examples of conditions which may cause peritonitis
 ruptured chocolate cysts, appendicitis, diverticulitis, PID,
abdominal trauma
What are the clinical signs of
peritonitis?
• 1. Abdominal pain
• Rigid abdomen “washboard abdomen”
• 2. Abdominal tenderness
• 3. Abdominal “guarding” ( pain with movement)
• Rebound tenderness – pain is greater after the hand is removed
when palpating the abdomen
Endometrial Cancer
• Role of estrogen in endometrial cancer
1. Estrogen is synthesized in body fat
2. Estrogen use without progesterone (unopposed) is
CONTRAINDICATED
3. Estrogen causes proliferation of the endometrial cells.
they grow and increase in number
4. Progesterone causes the endometrial cells to mature and
withdrawal of progesterone leads to endometrial sloughing
5. Life long exposure to estrogen increases in women who are
 obese
 have never been pregnant
 experienced early menarche or late menopause
So, who gets endometrial
cancer?
• Postmenopausal women
• Users of unopposed
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estrogen
Increased age
Family history
Obesity
Nulliparity
HTN/DM
Most common pelvic
cancer
White women (70% more
common)
Endometrial Hyperplasia
 Caused by the formation and growth of new normal
cells.
 THE ENDOMETRIAL LINING THICKENS
 Can lead to dysplasia
 A major risk factor for the development of
endometrial cancer
Endometrial Cancer
• Major Symptom:
abnormal, painless vaginal bleeding
• Diagnosed with endometrial biopsy, transvaginal
ultrasound or d & c
• 5 year survival rate for those dx early is greater than 90%
Endometrial Biopsy
Ovarian Cancer
• Ovarian Cancer
• The most LETHAL female reproductive cancers!
• Difficult to diagnose =  60 % have metastatic disease at the time
of dx
• Major Risk factors
• Ovulatory age
• GREATEST INCIDENCE BETWEEN 65-84
• Incidence is much lower in countries where women have numerous
children
•  risk with use of powders containing talc (talcum powder)
• Genetic link – 2 or more first or 2nd degree relatives with ovarian
cancers have a 50% risk for developing
Ovarian Cancer
• Multiple forms with
epithelial tumors the
most common
• Clinical
The longer the exposure to estrogen;
the higher the risk
manifestations
None usually!
 Vague GI symptoms
(flatulence, bloating, mild
abdominal distress)
  abdominal girth
 Bowel & bladder
dysfunction
 Menstrual irregularities
 Reason for these sx is not
understood
Ovarian Cancer
• Diagnosis
• NO GOOD EARLY
SCREENING TEST
• Serum tumor marker
CA 125 (a cell surface
antigen)
• However marker is NOT
specific to ovarian
cancer
• CA 125 may also be
 with fibroids or
endometriosis
• Transvaginal
ultrasonography
(TVS) – helps
evaluate ovarian
masses
Prognosis: Female
Reproductive Cancers
• Death can occur with any of the reproductive
cancers
• Survival rates:
• HIGHEST (75-95%) with cervical and endometrial cancer
• LOWEST (25-30%) with ovarian cancer
• Early detection can improve survival
• Especially true for cervical cancer
• Important nursing role is with education to
encourage screening tests
Reproductive cancer death rates
Cancer Rates….no REAL
progress
2001-2005 Cases
Deaths
Ovarian
1435
1037
72%
Lung
9042
6676
74%
Breast
16,708
3054
18%
2005-2009 Cases
Deaths
Ovarian
1474
1020
69%
Lung
10,185
7010
69%
Breast
18,022
2956
16%
Prognosis: Female
Reproductive Cancers
• Death can occur with any reproductive cancer
• Survival rates
• Highest: cervical and endometrial cancer (75-95%)
• Lowest: ovarian cancer (25-30%)
• Early detection can improve survival
• Especially true for cervical cancer
• Important nursing role: EDUCATION
• Screening tests
Pelvic Inflammatory Disease
(PID)
• Cause:
most cases d/t STD microorganism
infectious of the pelvic cavity. May affect fallopian
tubes, ovaries, uterus and pelvic peritoneum
• Refers to inflammation of
• Cervix (cervicitis)
1.Uterus (endometritis)
2.Fallopian tube (salpingitis)
3.Ovaries (oophoritis)
4.Peritoneum (peritonitis)
OR
any combination of organs
PID-Symptoms
• Sometimes asymptomatic
• Dysuria
• Fever
• ABD pain- ↑ with movement, intercourse
• Bleeding between periods
• Abnormal vaginal discharge
Prevention of female PID
• Abstinence
• Monogamy
• Protected intercourse
PID-Diagnosis
• Physical Exam
• Pelvic Exam
• CERVIX TENDER to movement on pelvic exam
(CMT)
• Culture of discharge is obtained to ID organism
• Serum WBC and ESR (erythrocyte sedimentation
rate) are elevated
• Possible direct visualization of pelvic organs with
laparoscope
• 25-40% require hospitalization!
PID-Complications
• Scarring and adhesions of uterus and fallopian
tubes→Infertility
• Adhesions also ↑ risk for ectopic pregnancy
• Severe cases of PID have been associated with
peritonitis
• Rarely, death can occur due to septic shock
Disorders of the Breast: benign
vs cancerous
• Fibrocystic Disease –
AKA mammary dysplasia
• Is a benign condition typified by the development
of fibrosis and cystic tissue formation of the
breast
• Is the most common disorder of the breast
• Accounts for 50-75% of surgical procedures on
female breast
• Biopsy done to r/o cancer
Fibrocystic Breast Disease:
the most common breast lesion
• Presentation
• Nodular, granular, painful
breast masses, mobile
masses (little BB’s
under the skin)
• Most common in women
30-50 years
• Diagnosis
•
PE, Biopsy,
Mammography
BREAST CANCER
SIGNIFICANCE/INCIDENCE
Common malignant cancer among women in the nation
One of the leading causes of death by cancer among females (#2)
Especially prevalent between the ages of 45 and 64
Usually does not occur before age 35
Kills three times as many women as ovarian or uterine cancer
Risk that a woman will develop cancer is about 1:8
Men can develop breast cancer although the incidence is very low
2009 Breast Cancer Deaths
Kentucky ranks 37th (rate 23.2 versus US rate 22.2)
Highest – 27.9
Lowest – 16.3
Breast Cancer: Risk Factors
First degree relative (sister or mother) with history of the
disease
Lifetime exposure to estrogen
Women who have experienced early menarche
and late menopause. ( exposure to estrogen)
Fibrocystic breast disease
High fat diet
Excessive alcohol consumption
BRCA gene and breast cancer
risk
Warning signs of breast cancer
- Hard irregular shaped lump in breast
- Changes in size or shape of one breast
- Changes in skin texture
- Discharge from nipple
- in breast skin temp
- Breast pain
“stellate” = star shaped lesion
Breast Cancer
• Exam findings:
• Irregular contours
• Lump is usually fixed (non-mobile) with irregular borders
• Lymph node swelling
• May have nipple discharge and/or retraction
• Dimpling “peau d’orange apperance”
Breast Cancer: Diagnosis
 Diagnostic Tools
 Regular breast self-exam and PE
 Mammography (85% sensitivity)
 Ultrasound
 Biopsy of the suspected lump
Complications

Widespread metastases
THE END