Transcript Reproductive Function & Disorders

Reproductive Function &
Disorders
Mandy Vichas RN, BSN, NPS
Male Anatomy
• Testes
• Penis
• Prostate Gland
• Scrotum
• Epididymis & Vas Deferns
• Seminal Vescicles & Ejaculatory Ducts
MALE ANATOMY
• Scrotum
– Testes are encased in the scrotum
– major purpose to provide proper environment for
testes
– Temperature
– Physical activity
• Penis
– Consists of the glans penis, the body and the root
– Erectile tissue is in the body
– Nerve supply is autonomic
Male Anatomy
• Testes
• Dual Function
• Spermatogenesis
– The scrotum maintains a temperature slightly
lower than the rest of the body to facilitate
Spermatogenesis
• Secretion of testosterone
Male Anatomy
• Epididymis
– A hoodlike structure lying on the testes containing ducts that
lead to the Vas Deferens
• Vas Deferns
– tube from end of epididymis to ejaculatory duct
• Seminal Vesicles
– An outpouching of the Vas Deferens which acts as a reservoir for
testicular secretions
• Ejaculatory Ducts
– The tract that passes through the prostate gland and urethra
• Prostate Gland
– Surrounds the urethra
– Produces secretions suitable for the passage of sperm
Male Reproductive Hormones
• GONADOTROPIN RELEASING HORMONE (GnRH)
– released by the hypothalamus, tells the pituitary to release LH
and FSH
– ultimately controls sperm production and testosterone levels
• FOLLICLE STIMULATING HORMONE (FSH):
– released by the anterior pituitary, stimulates the production of
sperm in the seminiferous tubules of the testes
• LUTEINIZING HORMONE (LH):
– Also called ICSH or interstitial cell stimulating hormone
– released by the anterior pituitary, stimulates testosterone
production by the interstitial cells of the testes
Male Reproductive Hormones
• ANDOSTERONE
– less abundant and less effective than testosterone, made by
interstitial cell in the testes
• TESTOSTERONE
– made in the interstitial cells
– stimulates secondary sex characteristics in males
– helps stimulate spermatogenesis in the testes (with FSH)
– associated with sex drive
• INHIBIN
– released by sertoli cells when they are low on nutrients to feed
developing sperm cells
– acts as a negative feedback, goes to brain to slow the release of
FSH and GnRH
Sperm Production
• Maturation takes 74 days
• Sperm spend their first 50 days in the
testicles and the last 22 to 24 days in the
epididymis.
• In the epididymis sperm mature and gain
motility
• During sexual activity, motile sperm are
ejaculated into the female reproductive
tract
• Each ejaculate contains 75,000,000400,000,000
Prostate-Specific Antigen
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PSA levels increase with prostate cancer
Normal is 0.2-4.0ng/mL
Should be done annually in men >50
Some other conditions that may elevate PSA
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BPH
TURP
Acute prostatitis
Urinary retention
Digital Rectal Exam
• Screening of the prostate gland
• Should be done with regular check-ups
for men >40yrs
• Size, shape and consistency of the
prostate are evaluated
Ultrasound
• A condom covered probe rectal probe is
inserted to detect abnormalities in those
with elevated PSA
• Assists with guidance for prostate biopsies
Prostatitis
• Inflammation of the prostate gland
• Type I (acute bacterial)
• Type II (chronic bacterial)
• Type III (chronic prostatitis/chronic pelvic
pain syndrome)
• Type IV (asymptomatic inflammatory
chronic prostatitis)
Prostatitis
• Symptoms
• Acute
– sudden fever & chills
– Perineal, rectal or low back pain
– Dysuria, frequency, urgency & nocturia
• Chronic
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perineal discomfort
burning, urgency & frequency
pain with ejaculation
prostatodynia (pain in prostate with voiding)
Prostatitis
• Complications
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Enlarged prostate
Urinary retention
Epididymitis
Bacteremia
Pyelonephritis
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possible hospitalization for IV antibiotics
Analgesics
Antispasmodics & bladder sedatives
Stool softeners
Bedrest
Sitz baths (a warm water bath that covers only the
hips and buttocks)
• Treatment
Benign Prostatic Hypertrophy
• Progressive enlargement associated with
aging
• Results in obstructive urinary disorder
• Most common neoplastic growth in men
>50
• Virtually ALL men >50 show some
increase in size
Benign Prostatic Hypertrophy
• Early Symptoms
– Hesitancy initiating urine stream
– Decreased force
– Frequency
– Nocturia
• Bladder muscles hypertrophy & may
temporarily reduce symptoms
Benign Prostatic Hypertrophy
• Late Changes
– When hypertrophy is no longer effective,
muscles decompensate & bladder wall
becomes noncompliant & hypotonic
– post void residuals lead to increased
infections & hydronephrosis
Benign Prostatic Hypertrophy
• Medication
• Flomax (alpha-adrenergic blocker)
• Proscar & Avodart (antiandrogen agents)
• Saw palmetto
– As effective as Proscar
– Shouldn’t be used with Proscar, Avodart or
estrogen
Benign Prostatic Hypertrophy
• Transurethral Incision of the Prostate (TUIP)
used to treat slightly enlarged prostate
– laser incisions in prostate to decrease resistance to
urinary flow (outpt procedure)
• Transurethral needle ablation
– use of localized heat to destroy prostate tissue which
body reabsorbs
• Microwave thermotherapy
– Via transurethral probe
– Tissue is sloughed
Prostate Cancer
• Most common cancer in men
• Regular exams for all men >50 yrs.
• May be a familial predisposition
• Often asymptomatic
• Late symptoms
– Urinary obstruction
– Painful ejaculation
– Hematuria
Prostate Cancer
• Professional exam (DRE) annually >50
• Transrectal ultrasound (TRUS)
– Elevated PSA
– Abnormal DRE findings
• PSA
– Recommended annually for men>50
– Normal is 0.2 – 4 ng/ml
• Perineal or transrectal needle biopsy
Gleason score
• System used to grade prostate cancer
• Gleason Grades 1 and 2:
– Closely resemble normal prostate.
– Seldom occur
– Prognostic benefit which is only slightly better than
grade 3
• Gleason Grade 3:
– Most common
– Considered well differentiated (like grades 1 and 2).
Gleason score
• Gleason Grade 4:
– Fairly common and because of the fact that if
a lot of it is present, patient prognosis is
usually (but not always) worsened by a
considerable degree
• Gleason Grade 5:
– Less common than grade 4, and it is seldom
seen in men whose prostate cancer is
diagnosed early in its development.
Gleason score
• The lowest possible Gleason score is 2 (1 + 1)
– both the primary and secondary patterns have a
Gleason grade of 1 and when added together their
combined sum is 2.
• Very typical Gleason scores might be 5 (2 + 3)
– the primary pattern has a Gleason grade of 2 and the
secondary pattern has a grade of 3
• The highest possible Gleason score is 10 (5 + 5)
– When the primary and secondary patterns both have
Gleason grades of 5.
Gleason Score
• What does the Gleason score mean?
• Valuable to doctors in helping them to understand how a
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particular case of prostate cancer can be treated.
In general, the time for which a patient is likely to
survive following a diagnosis of prostate cancer is
related to the Gleason score.
The lower the Gleason score, the better the patient is
likely to do
General principles do not always apply to individual
patients.
Prostate Cancer
• ProstaScint
• Antibody attracted to prostate-specific
membrane antigen found on prostate cells
• Capable of detecting recurrent prostate
cancer with low serum PSA level
Prosatectomy
• Radical Prosatectomy
– Includes removal of prostate, seminal vesicles, lips of vas
deferens, and often surrounding fat, nerves & blood vessels
• Suprapubic Prostatectomy
– not common r/t incontinence, impotence, rectal injury
• Retropubic Prostatectomy
– better control of blood loss but higher risk of infection
• Laparoscopic/robotic radical prostatectomy
– better visualization of surgical & surrounding tissue
– less bleeding & pain
– reduced likelihood of impotence & incontinence
Transurethral Prostate Resection
(TURP)
• Performed thru endoscopy, gland is removed in
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small chips with an electrical cutting loop
Used for glands of varying size or poor surgical
risk
Newer technology eliminates risk of TUR
syndrome (hyponatremia, hypovolemia) rare but
potential complication
Repeated procedures may be necessary if
residual prostatic tissue grows back
Rarely causes erectile dysfunctions can trigger
retrograde ejaculation (seminal fluid flows
backward into bladder instead of forward thru
urethra)
Cryosurgery
• Ablation of prostate cancer in those who
cannot tolerate surgery or with recurrent
cancer
• Transperineal probes inserted into
prostate with ultrasound guidance to
freeze tissue
• May need to be repeated to keep urethral
passage patent
Post-Operative Care
• VS
• Monitor for hemorrhage (most likely to occur immediately pop & 8•
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10 days later)
Monitor urinary catheter for clots
Irrigation of catheter
NO rectal temps, NOTHING in rectum to prevent fistulas
Monitor dressing
I & O (should be light pink-clear in 24 hrs)
Hydration
Monitor for distention
Monitor for infection
Stool softeners (no straining)
Antispasmodics and analgesics
Sit with firm, even pressure, NO donuts
Radiation Therapy
• Teletherapy
– External beam radiation daily for 6 – 7 wks
• Intensity-modulated radiation therapy (IMRT)
– Improved version of teletherapy that offers set dose for target
volume and restricts dose to adjacent structures
• Brachytherapy
– Implantation of radioactive seeds via ultrasound guidance
– Exposure to others is minimal but should avoid close contact
with pregnant women and infants
– Use condoms and strain urine for 2 weeks after implantation
• Side effects for RT are usually transitory
– Inflammation of rectum, bowel & bladder
– Possible pain with urination & ejaculation
Hormonal Therapy
• Orchiectomy (removal of testes)
– Decreases plasma testosterone levels, removing testicular
stimulus for prostatic growth
• Casodex (nonsteroidal antiandrogen)
• Eulexen (antiandrogen agents)
• DES (estrogen therapy)
– Inhibits gonadotropins responsible for testicular androgenic
activity
• Lupron and Zoladex (lutenizing hormone releasing
hormone agonists)
– Suppresses testicular androgen
Chemotherapy
• For hormone refractory prostate cancers
• High dose ketanzole (lowers testosterone)
• Taxol & taxotere are used for nonandrogen dependent prostate cancers
– Peripheral neuropathy
– Hypersensitivity reactions
Cryptorchidism
• Undescended testicle
• Treatment
– Hormone therapy
– Surgery
• 3 suture lines = inguinal, scrotal & thigh
• teste placed in “traction” in scrotum by
attaching suture to thigh; leg can move,
but no undue pressure
Orchitis
• Inflammation of the testes
• Signs & Symptoms
– fever
– pain
– swollen testes
• Treatment
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Elevate scrotum
Strict bedrest
Ice bag under scrotum with padding between skin
NO heat r/t sperm damage
Medications are aimed at treating the causative factor
Epididymitis
• Infection descends from prostate or urinary tract
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to the epididymis
Symptoms
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Unilateral pain & soreness in inguinal canal
pain & swelling in scrotum & groin
Pus and bacteria in urine
Fever & chills
Urinary frequency, urgency or dysuria
Nausea
Epididymitis
• Antibiotics
• Risk for abscess formation
• If becomes chronic may need to excise epididymis from
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testes in order to avoid sperm passage obstruction
Bedrest
Elevate scrotum with scrotal bridge or folded towel
Intermittent cold compresses or ice; later Sitz baths or
local heat
Avoid straining, lifting & sex until infection controlled;
may take 4 wks
Torsion of Spermatic Cord
• Symptoms
– sharp, severe pain of testes
• Treatment
– Surgical emergency
Hydrocele
• Fluid in the space between teste & tunica
vaginalis
• Treatment usually not required
• Surgery needed if hydrocele becomes
tense and compromises testicular
circulation or if scrotal mass becomes
large, uncomfortable or embarrassing
Varicocele
• Abnormal dilation of the veins of the
scrotum
• Infertility or symptomatic concern is the
only reason for treatment
Testicular Cancer
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Most common cancer in men 15 – 40
Usually curable
TSE very important
Classified as Seminomas (90%) or Nonseminomas
Risk Factors
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Cryptorchidism
Family history
Cancer of one testicle
Caucasians
Occupational exposure to chemicals in mining, oil & gas
production, leather production
– Exposure to prenatal DES
Testicular Cancer
• Symptoms
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Hard, non-tender nodule
c/o heaviness in scrotum
Back or abdominal pain, weight loss, general weakness (mets)
Elevated HCG & AFP levels
Treatment
Orchiectomy with insertion of gel implant
Possible retroperitoneal lymph node dissection
Chemo
Radiation
Sperm Banking
VASECTOMY
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Ligation of vas deferens
Remain fertile for several weeks
Need repeated sperm counts to assure infertility
Post-operative care
– wear athletic supporter
– ice packs
– analgesics
• Vas. Reversal
• 45-70% have sperm return but only 25% lead to
pregnancy
FEMALE ANATOMY
• Ovaries
• Uterus
• Vagina
• Cervix
• Vulva
• Breasts
Ovaries
• 2 small (2” x 1”), almond-shaped
structures
• Contain the eggs
• The ovaries and fallopian tubes are known
as the adnexa
Uterus
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small, pear-shaped, 3” long, 2” diameter
normal position bends anterior
3 sections
body = superior
Isthmus = constricted portion
cervix = inferior, projects short distance into vagina
external orifice (cervical os)
uterine cavity
cervical canal = connected to uterine cavity via
internal orifice (internal os)
3 layers
serosal= peritoneum covering
myometrium = muscular = smooth muscle with many elastic
connective tissue fibers; thickens during pregnancy
• endometrium = mucosal layer
Vagina
• 7.5-10 cm. long
• Extends from the vulva to the cervix
• Angled back & up
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Breasts
accessory organs
glandular epithelium & ducts
suspended by Cooper’s ligaments
lymphatic drainage thru axillary nodes & some to substernal &
diaphragmatic nodes
Structures
nipple = smooth muscle with erectile properties
aerola = 1.5-2.5 cm. diameter with sebaceous glands underneath =
rough appearance
lactiferous ducts = under aerola are 15-20 which drain milk from
milk glands
breasts divided into 15-20 lobes with 20-40 lobules
10-100 alveoli = milk-secreting epithelial cells, surrounded by dense
capillary network
milk production
r/t increased estrogen & progesterone levels in pregnancy
also need prolactin, prolactin-inhibiting factor, oxytocin growth
hormone, ACTH, placental lactogen, thyroxin & thyrotropic releasing
hormone
Estrogens
• Secreted by developing follicle, corpus
luteum & placenta
• Responsible for secondary sex
characteristics
• Repairs uterine lining after menstruation
• Opposite effect of progesterone
• Increases bone matrix formation & retains
Na & H2O in kidneys
Progesterone
• Principle hormone from corpus luteum
• Secreted by placenta
• Prepares uterus for implantation by
inhibiting contractility & changing
endometrium to secretory phase
• Opposes action of estrogen
• Produces increase in breast tissue
• Inhibits prolactin
Hormones
• Androgens
– Produce male sex characteristics
– female ovary produces androstenedione, a weak
compound similar to testosterone
– adrenal hormones are also androgens
• FSH & LH = produced by pituitary
– FSH = ovarian follicle growth, essential to production
of estrogen
– LH = induces ovulation & stimulates corpus luteum &
progesterone production
• Prolactin stimulates milk production
Hormones
• Ovarian Cycle = provides ovum with endometrial
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cycle to furnish suitable environment for
fertilization of ovum
Menstrual Cycle
– Menarche onset at 10-14 yrs.
– day of menstruation onset is day 1
– cycle ends last day before flow starts again (22-35
days, average 28)
– premenstrual phase is 2-3 days before flow
Pre-Menstrual Syndrome (PMS)
• Discomfort prior to menses (5 days) which disappear 4 –
5 days after onset
• Cause unknown but most current theory r/t serotonin
regulation
• Symptoms
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Low back pain
Tender breasts,
Crying
Irritability
Mood swings
Binge eating,
• Symptoms vary widely between women
• Severe form is called premenstual dysphoric disorder
Pre-Menstrual Syndrome (PMS)
• Treatment
– Exercise
– SSRIs
– GnRH agonists
– prostaglandin inhibitors
– diuretics
– antianxiety agents
– Ca supplements
Dysmenorrhea
• painful, abnormal menstruation
• primary form has no pathology
• secondary form caused by endometriosis
or PID
• Treatment
– prostaglandin inhibitors
– low dose BCP’s
Amenorrhea
• Primary: delayed menarche if hasn’t
occurred by age 16
• Secondary: absence of menses for 3
cycles or 6 months
• may be r/t emotions, eating disorders,
athleticism
Dysfunctional Uterine Bleeding
• Menorrhagia: excessive bleeding
• Metorrhagia: bleeding between ovulation
time; abnormal & should be reported
• Postmenopausal
Perimenopause
• Period extending from first symptoms of menopause to
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beyond complete cessation of menses (1 yr)
Occurs approximately 40 yrs. after menarche or surgery
Decreased ovarian activity
Uterus, vagina & vulva decrease in size
Decreased estrogen & progesterone
Symptoms
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insomnia
hot flashes r/t vasomotor disturbances
headaches
fatigue
menstrual irregularity
mood changes
Perimenopause
• Treatment
• HT (formerly HRT)
– May increase some health problems (stroke, MI, DVT,
breats Ca)
– Does reduce risk for osteoporosis & hot flashes
– Low doses may be OK if used for shortest time
possible
• Effexor, Paxil, Neurontin, & Catapres reduce hot
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flashes
Herbal: black cohosh, ginseng, & soy product
research doesn’t support
Pap Smear
• Cells scraped from cervical endothelium with small
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spatula
Done yearly on all women >18
Can be done every other year on women >30 with a
history 2 or more consecutive normal PAPs
Pt not to douche, insert vaginal meds, or have sexual
intercourse prior to exam
History taking
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need date of LMP & last Pap
period frequency, duration & flow amount
type of contraception
presence of itching or discharge
Pap Smear
• Results
– LSIL: low grade squamous intraeptihelial lesion equivalent to
CIN grade I and to mild changes r/t recent exposure HPV
– HgSIL: high grade squamous intraepithelial lesion equivalent to
moderate & severe dysplasia, carcinoma in situ (CIS) and CIN
grade 2 and 3
– Not always accurate, depending on lab & practitioner; request
liquid immersion method
• Treat any infection detected & repeat pap post
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treatment
if repeat PAP reveals atypical cells with high risk HPV
types do colposcopy
LSIL paps repeat every 4 – 6 months
– perform colposcopy if not resolved
• HGSIL & CIS prompt colposcopy
Endoscopic Examinations
• Hysteroscopy
– scope inserted through the cervix
– visualization of the uterus
– Endometrial ablation can be performed to treat
severe bleeding that doesn’t respond to other
therapies
– Done under general, regional or local anesthesia
• Laparoscopy
– scope inserted through a small incision, inferior to the
umbilicus
– insufflation with Carbon dioxide
– visualization of all pelvic organs
– Facilitates many surgical procedures
Colposcopy
• Should be done following suspicious pap
smear
• Portable microscope that allows
visualization of the cervix
• Acetic acid is applied to the cervix
• Abnormal results indicate the need for
biopsy
Cervical Biopsy
• Cone Biopsy
– Can be done surgically or with Loop Electrosurgical
Excision Procedure (LEEP)
– Tissue removed for pathology
– Packing needs to be left in place for 24 hr.
– The patient needs to avoid coitus, douching, or
tampons x 4 - 6 wks.
• Excessive bleeding (more than a period) after 7•
10 days & symptoms of infection need to be
reported
There is a slight future increase in risk of
cervical stenosis or preterm deliveries
Endometrial Biopsy
• Done to evaluate irregular bleeding or irregularities
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found on pelvic exam
Evaluation of infertility
Local anesthetic may or may not be used
A speculum is inserted into the vagina
The cervix is cleansed with an antiseptic solution.
a catheter is inserted into the uterus. A smaller tube
(internal piston) inside the catheter is withdrawn to
create suction.
Cramping may occur.
Dilation & Curettage
• D & C may be diagnostic or therapeutic
• The cervical canal is dilated
• The endometrium is scraped with a
curette
• Generally done under anesthesia
• The perineum is NOT shaved
• Observe for post-operative bleeding
• Patient must wait 2 weeks to use tampons
or have intercourse
Mammography
• Two x-ray views are taken of each breast
• New mammogram is compared to previous films
• May detect a breast tumor before it is palpable
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(1cm)
ACS recommends a mammogram yearly
beginning at 40
See chart 48-1 for guidelines of women at
increased risk
Digital mammography is now becoming more
common
Other Breast Diagnostics
• Galactography—Injection of contrast prior to
mammography
– Evaluates breast ducts
• Ultrasonography—Helps distinguish fluid cyst
form solid lesions
– Done in conjunction with mammography
• MRI with contrast
– Done for women with breast cancer or high risk
populations
Percutaneous Breast Biopsy
• Fine needle aspiration
– A small gauge needle is used to make multiple passes through
the mass
• Core needle aspiration
– Uses a larger gauge needle and local anesthetic
– Tissue cores are removed via a spring-loaded device
• stereotactic core biopsy
– Performed on nonpalpable lesions seen on mammogram
– Breast suspended through openings in table & compressed
between 2 x-ray plates, local anesthetic, small nick, core needle
often several passes made
– Clips may be placed to facilitate treatment
• ultrasound or MRI core biopsy
Surgical Breast Biopsy
• Excisional biopsy
– Standard for pathological assessment
– The entire mass and margins are removed
– Also referred to as lumpectomy
• Incisional biopsy
– removes a portion of a mass to confirm diagnosis or
for special studies (ER/PR, Her-2/neu)
• Wire needle localization
– Radiologist inserts a wire through a needle to identify
non-palpable mass location before surgery.
– The wire is left in place for surgery
Endometriosis
• Leading cause of infertility
• Chronic disease where benign lesions grow in
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the pelvic cavity outside the uterus
Familial predisposition
Typically diagnosed at 25 – 35 yrs.
Symptoms are r/t tissue bleeding with menses
– Dysmenorrhea
– > 7days flow
– <27 day cycle
Endometriosis
• Caused by misplaced endometrial tissue
– backflow of menses
– transplantation of tissue during surgery
– spread of tissue via lymphatic or venous channels
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Menopause
Laparoscopic surgery
Laparoscopic laser therapy
Total abdominal hysterectomy
• Medications
– analgesics & prostaglandin inhibitors
– Oral contraceptives
– Danazol—Synthetic androgen causes atrophy of the
endometrium
– Lupron (GnRH antagonist)—induces artificial menopause
Uterine Fibroids
• Benign tumors that arise from the muscle tissue of the
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uterus
Menometorrhagia (irregular bleeding) is the most
common symptom
May interfere with fertility
Treatment
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hysteroscopic resections of myomas
laparoscopic myomectomy
laparoscopic myolysis with use of laser or electrical needles
laparoscopic cryhomyolysis use of electric current to coagulate
uterine artery embolization (UAE)—polyvinyl alcohol or gelatin
particles injected into blood vessels that supply fibroid via
femoral artery; percutaneous image guided therapy
• May cause pain, infection, amenorrhea, necrosis &
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bleeding; rarely death & ovarian failure
Usually used in women who have completed childbearing
Ovarian Cysts
• Dermoid Cysts
– Consist of undifferentiated embryonal cells, sometimes have hair
teeth, bone & other tissues
– Larger cysts may place pressure on adjacent organs
• Polycystic Ovary Syndrome (PCOS)
– complex disorder of endocrine system involving hypothalamus,
pituitary & ovarian network results in anovulaiton & androgen
excess
• Symptoms irregular periods, infertility, obesity &
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hirsutism
Cysts form in ovaries because regular ovulation is not
occurring
Treatment
– Surgery
– Oral contraceptives
• Increased risk for diabetes & cardiac disorders
Cervical Cancer
• Usually slow-growing
• Most are squamous cell and remainder are
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adenocarcinomas, (which often are r/t HPV) or can be a
mix
Symptoms
Rarely there may be a thin, watery discharge noticed
after sex or douching
Symptoms such as discharge, irregular bleeding or pain
often means advanced disease
Treatment
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Cryotherapy
LEEP
hysterectomy if childbearing completed
Radiation
Chemotherapy
Endometrial/Uterine Cancer
• Major risk is cumulative exposure to estrogen
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HT
early menarche
late menopause,
nuliparity
anovulation
• Other risk factors infertility, diabetes, hypertension,
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gallbladder disease, & obesity
Symptoms
– Pre-menopause = irregular bleeding
– postmenopausal = any bleeding
• Treatment
– Surgery (TAH)
– Radiation
– Chemotherapy
Ovarian Cancer
• Causes more death than any other female
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cancer
Tumors are often difficult to detect & no early
screening mechanisms exist
CA-125 & transvaginal ultrasound may be useful
for screening
Risk Factors
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Risk increases with age
increases breast cancer likelihood 3 – 4 x
Nulliparity
Infertility
BRCA-1, BRCA-2
Ovarian Cancer
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Increased abdominal girth
pelvic pressure
bloating
back pain
constipation
urinary frequency
flatulence
• Treatment
• Surgery TAH & BSO
• Chemotherapy
– Intraperitoneal & traditional site may be done in tandem
• Recurrence is common
Vaginal Cancer
• Rare & slow growing
• DES is a cause of early development
– ask if pt was born or pregnant 1938–1971
• colposcopy is done for those exposed in
utero
• Early treatment consists laser therapy
• Radiation
• Surgery
Vulva Cancer
• Seen Mostly in postmenopausal women 50-70yrs
• Risk factors include smoking, HPV (16,18,31),
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HIV and immunosuppression
Symptoms
– most common long standing pruritis & soreness
– chronic dermatitis
– lump that continues to grow
• Treatment
– Surgery
– Laser ablation
– Chemotherapy creams
Toxic Shock Syndrome (TSS)
• Acute bacterial infection caused by staph aureus
– often r/t tampon use
– high absorbency tampons implicated
– Need to obtain vaginal culture to r/o staph colony
• Symptoms r/t endotoxins enter blood
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Elevated WBC
Elevated BUN & Creatinine
Elevated Bilirubin
sudden high fever (102-105 F)
vomiting & diarrhea
sore throat
headache
profound fatigue
edema & impaired perfusion
rash on soles & palms which sloughs in 1-2 wks.
disorientation
decreased urinary output
Toxic Shock Syndrome (TSS)
• Caution women NOT to use non-
cotton, high absorbency tampons
• Change tampons frequently
• Sanitary napkins at night
• Avoid tampons if skin infection
present
Hysterectomy
• Can be abdominal, laparoscopic & robotic
• Post-operative care
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pain control
Prevent thrombus formation with positioning
I&O
Foley
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dressing √
peri pad √
no clots
serosanguinous
amt = NO more than period
√ every 10-15 min. first few hrs.
spotting for 2 wks.
• Monitor for paralytic ileus
• Monitor for hemorrhage
INFERTILITY
• Inability to conceive after a year or more of regular
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intercourse without contraception
Primary = no pregnancies
Secondary = after successful pregnancy
Infertility Tests
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Hysterosalpingography—x-ray with contrast media
D & C before menses
Semen Analysis
Ovulation Index—urine stick test to determine whether surge in
LH has occurred (this precedes ovulation)
– Serum Progesterone
– Postcoital Immunology
– Endometrial Biopsy
• Laparoscopic exam
Benign Breast Disorders
• Cysts
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Fluid filled sacs that develop as breast ducts dilate
Most commonly occurs in women 30 – 55
Cause is unknown
Usually disappear after menopause
Fluctuate in size usually larger premenstrually
May be painless or become very tender premenstrually
Cysts do NOT increase the risk of breast cancer
• Fibroadenomas
– Firm, round, movable benign tumors
– Occur from puberty to menopause with peak at 30
– Sometime removed for definitive diagnosis
Benign Proliferative Breast Disease
• Atypical Hyperplasia
– An abnormal increase in ductal or lobular cells in the
breast
– usually found incidentally in mammography
abnormalities
– increases risk for breast cancer 4–5x
– 10x if has relative with breast cancer
• Lobular Carcinoma in Situ
– Characterized by a proliferation of cells within the
breast lobules
– Found incidentally on pathologic diagnosis
– Cannot be seen on mammography
– Does not form a palpable lump
– Marker for increased risk 8-10x
Breast Cancer
• 1 in 8 lifetime risk for women
• Mammography for screening contribute to
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decreased mortality rates due to early detection
of disease
Annual mammograms at 40
CBE annually
BSE monthly
high risk women
– clinical breast exams twice yearly at 25
– mammogram annually at 25
Breast Cancer
• Risk Factors
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gender (99% in women)
Age>50
Family history
Personal History
Nulliparity
1st pregnancy after 30
radiation exposure especially during adolescence & early
adulthood
obesity
Alcohol use
Estrogen exposure
BRCA-1 & BRCA-2 tumor suppressors, if damaged 55 – 85% risk
of cancer
Types of Breast Cancer
• Non-invasive breast cancer
• Ductal Carcinoma in Situ (DCIS)
• Malignant cells within the milk ducts without invasion
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into the surrounding tissue
Considered Stage 0
Mastectomy
Breast conservation (lumpectomy, partial mastectomy)
Radiation
Tamoxifen
Arimidex
Types of Breast Cancer
• Invasive Cancer
– Infiltrating ductal Carcinoma
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• most common (75%)
Infiltrating lobular Carcinoma
Medullary Carcinoma
Mucinous Carcinoma
Tubular ductal CA
Inflammatory Carcinoma
• rare (1-2%),
• Aggressive with unique symptoms
• diffuse edema & brawny erythema; referred to as “peau d’orange
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(orange peel)
malignant cells block lymph channels
can be confused with infection r/t appearance
can spread rapidly
– Paget Disease 1%
– scaly, erythematous, pruritic lesions of the nipple
– Often represents DCIS of the nipple but can be invasive
Paget Disease
Peau D’Orange
Breast Cancer
• Often found in upper outer quadrant where
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most breast tissue located
Nontender, fixed lesion
Hard with irregular border
Advanced symptoms
Skin dimpling
Nipple retraction
Skin ulceration
Breast Cancer
• Staging
– Stage 0 (DCIS, LCIS or Paget no invasion)
– Stage I (tumors <2 cm no node involvement)
– Stages II & III represent wide spectrum so
classification more difficult
– Stage IV (tumors of any size with distant
mets)
• Generally, the smaller the tumor the
better the prognosis
Mastectomy
• Total mastectomy
–removal of breast, nipple areola
complex
• Modified radical mastectomy
–Is done for invasive breast cancer
includes axillary lymph node
dissection (ALND)
• Reconstruction
Post-Operative Care
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Overnight hospitalization
Pain control
Positive body image Reach for Recovery
Managing sensations of numbness, tightness, pulling
twinges & phantom sensations
• Managing lymphedema occurs in 10 – 30% ALND & 0 –
7% SLND
– tends to be chronic; hand & arm care help to prevent
– avoid BP, injections, tourniquet, heavy lifting
• May be discharged with JP drain
– remove when draining <30 ml in 24 hr.)
• assess for hematoma
• compression wrap may be applied
Sentinel Lymph Node Biopsy
• Sentinel lymph node biopsy (SLNB)
• First lymph node(s) in lymphatic basin that
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receive drainage from primary breast tumor
Radioisotope or blue dye injected for surgeon to
locate and excise
Sent for frozen section (note: false negatives
can occur & require subsequent surgery)
If positive an ALND is done during surgery
Radiation Therapy
• External Beam/IMRT
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External beam most common
6 weeks of radiation to entire breast
Boost to tumor site
Skin breakdown
• Brachytherapy
– Internal radiation to lumpectomy site
– Dose administered over 4 – 5 days
• Intraoperative (IORT)
– Single intense dose to surgical site in OR
Adjuvant Chemotherapy
• Delays or prevents recurrence
• Considered for patients that have positive lymph
•
nodes or invasive tumors >1cm
Targeted Therapy
– Herceptin for Her-2/neu positive patients
– Regulates cell growth
• Chemo is often delivered prior to radiation
– Adriamycin + Cytoxan
– Taxol
Hormone Therapy
• For hormone receptor positive tumors
– ER +
– PR +
• Selective Estrogen Receptor Modulator (SERM)
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Compete with estrogen by binding to receptor sites
Pre-menopausal women
Taken for 5 years
Tamoxifen (Nolvadex)
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Block estrogen Production
Post-menopausal women
Anastrozole (Arimidex)
Duration of treatment is still unclear
• Aromatase Inhibitors
BIRTH CONTROL
• Need to have a basic comprehension for
STD unit
• See FDA guide
• Examples
– IUD
– Rhythm Method/Beads
– Condom
– Oral Contraceptives