Nursing Management Female Reproductive Problems

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Anatomy

Abnormal Vaginal Bleeding

- common gyne concern; problem r/t menstruation

- cause varies from anovulation to more serious causes such as ectopic pregnancy or endometrial ca

- age helps identify cause (hormonal phase; prepubescent, pubescent, menopausal)

types

Problems r/t menstruation: Uterine bleeding

- Amenorrhea

- Oligomenorrhea

- Menorrhagia

- Metrorrhagia

amenorrhea

Types of Irregular Bleeding:

- the absence of menstruation

primary, secondary amenorrhea

Types of Irregular Bleeding:

- ________ _______: failure of menstrual cycles to begin by 16 yrs (or 14yrs with secondary sex characteristics of early puberty)

- _________ _______: cessation of menstrual cycle once established

amenorrhea etiology

- pregnancy *most common

- anovulation *2nd most common

anovulation

- corpus luteum that produces progesterone does not form → no shedding

- result = unopposed estrogen + excessive endometrium → increases risk of endometrial ca

- reduce risk via hormonal tx or oral contraceptives → ensure endometrium shedding 4-6x / yr

oligomenorrhea

Types of Irregular Bleeding:

- Refers to long intervals between menses

- generally >35 days

- light, irregular periods

oligomenorrhea etiology

Types of Irregular Bleeding:

- ovulation erratic for several years following menarche + before menopause

- d/t anovulation for women at beginning + end of menstruation (puberty, menopause)

menorrhagia

Excessive or Prolonged bleeding r/t

- increased duration (> 7days)

- increased amount (> 80ml)

menorrhagia etiology

Types of Irregular Bleeding:

- most common → anovulatory uterine bleeding

- young women → consider clotting dx + antifibrinolytic tx

- older women → fibroids, polyps, cancer

anovulatory bleeding

In anovulation...

- corpus luteum & progestrogen not produced → unopposed estrogen + excess endometrium buildup

- eventually becomes unstable → excess vaginal bleeding

metrorrhagia

Types of Irregular Bleeding:

- spotting, or breakthrough

- bleeding between menstrual periods

metrorrhagia etiology

Types of Irregular Bleeding:

- reproductive age: pregnancy comp (ie. spontaneous abortion, ectopic) (other: ca, polyps, infection, hormones)

- postmenopausal: endometrial/cervical ca

Interprofessional Care

- Based on underlying cause, degree of threat to pts health, desire to preserve fertility

- Amenorrhea/Oligomenorrhea

- Menorrhagia

- Surgery

amenorrhea/oligomenorrhea

Interprofessional Care: Uterine Bleeding

- If r/t anovulation

- contraceptives for normal shedding (min 4-6x yearly) + normal hormonal balance

menorrhagia

Interprofessional Care: Uterine Bleeding

- Severe → hospitalization

*most common indication for surgery*

- evaluate for secondary anemia + hypovolemia

- Treat underlying cause + minimize further blood loss

- Antifibrinolytic, Contraceptive, Ablation

contraceptives

Menorrhagia: Tx of Underlying Cause

- for pts who want to prevent pregnancy

- tx of anovulatory bleeding d/t unopposed estrogen accumulation → causes normal shedding of endometrium lining

clotting disorder

Menorrhagia: Tx of Underlying Cause

- antifibrinolytic (tranexamic acid)

- use caution w/ concurrent contraceptive use (increases risk of blood clots + stroke)

ablation

Menorrhagia: Tx of Underlying Cause

- using thermal source; endometrium destroyed; uterine lining sloughs off in 7-10 days

- contraindicated: maintain fertility, query endometrial ca, hx non–lower segment C- Section, myomectomy

surgery

Indicated for tx of underlying cause :

- Dilation and curettage (D&C)

- Ablation

- Hysterectomy

- Myomectomy (laparotomy, laparascopy, hysteroscopy)

dilation and curettage (D&C)

Surgery: uterine bleeding

- in cases of acute excess bleeding

- cervix dilated + uterine lining scraped to remove any abnormal tissue

Endometrial Ablation

Surgery: uterine bleeding

- tx of acute excess bleeding (menorrhagia)

- for pts who do not want to maintain fertility

hysterectomy

Surgery: uterine bleeding

- removal of the uterus

- indications; r/t uterine fibroids or ca

myomectomy

Surgery: uterine bleeding

- removal of a fibroid without removing the uterus

- indications; r/t uterine fibroids + uterine preservation desired

- approaches: laparotomy/laparoscopy, hysteroscopy

hysteroscopy

- scope is used to look at inside of cervix

- can take biopsies, remove polyps, fibroids, tumors

Nursing Management

Uterine Bleeding:

- Health Promotion

- Acute Interventions

health promotion

Nursing Management Uterine Bleeding:

- education r/t menstrual cycle → help identify normal variations

- If abnormal variations → seek health care provider

- ↓ risk of Toxic Shock Syndrome (TSS)

toxic shock syndrome (TSS)

Nursing Management Uterine Bleeding: Acute Interventions

- acute condition; staphylococcus aureus

- initial, flu-like sx → high fever, N/V, diarrhea → dizziness, fainting, disorientation → sepsis

- avoid prolonged use of tampons & pads + wearing them in bodies of water

acute interventions

Nursing Management Uterine Bleeding:

- Excess vaginal bleeding assessed accurately

- Assess + Manage secondary anemia + hypovolemia

- Periop Care if surgery indicated

Ectopic pregnancy

- Implantation of fertilized ovum anywhere outside uterine cavity

- 3% of all pregnancies; 98% occur in fallopian tube

*remaining 2-3% may be ovarian, abdominal, cervical

etiology/patho

Ectopic pregnancy

- r/t fibrosis/damage to fallopian tube d/t infection or inflammation

- blockage/reduction of tubal peristalsis → impedes/delays zygote transport to uterus → implantation outside uterus

- growth of gestational sac expands tubal wall → eventually ruptures

...

Ectopic pregnancy in fallopian tube

tubal rupture

Ectopic pregnancy

- life-threatening condition → hemorrhage + hypovolemic shock

- suspected = emergency

- acute peritoneal symptoms (peritonitis)

risk factors

Ectopic Pregnancy:

- history of PID (pelvic inflammatory disease) (caused by STIs)

- prior ectopic pregnancy

- progestin-releasing IUD (intrauterine device)

- progestin-only birth control failure

- prior pelvic or tubal surgery

6-8

Ectopic Pregnancy:

- less acute sx: ______wks → after the last menstrual period

- weeks before gestational sac expansion → rupture

- vary depending on site of implantation

- hallmark: abdo/pelvic pain + spotting (6-8wk after last menses)

*98% = fallopian tube, 2-3% = abdominal, cervical, ovarian*

manifestations

Ectopic Pregnancy:

- Missed menses (amennorhea)

- abdominal/pelvic pain (almost always) (post-6-8wk last menses)

- Irregular bleeding (spotting/metorrhagia) (post-6-8wk last menses)

rupture

Ectopic Pregnancy:

- sudden severe pain

- shoulder tip pain when lying down

- vaginal bleeding

- pallor + sx of shock/hemorrhage

- distended/rigid abdomen

ectopic pregnancy diagnosis

Challenging d/t similarities w/ other pelvic & abdo dx (40% misdiagnosed)

- Serum (radioimmunoassay) pregnancy test

- Serum BhCG levels

- Transvaginal U/S

serum (radioimmunoassay) pregnancy test

ectopic pregnancy diagnostics:

- (+) indicative of ectopic pregnancy

- (-) likely, not ectopic pregnancy

Transvaginal ultrasound

- used to diagnose ectopic pregnancy in a stable pt

- transducer inserted into vagina + visualization of uterus, cervix, ovary, fallopian tubes

- presence or absence of an intrauterine gestational sac

transvaginal u/s

ectopic pregnancy diagnostics:

- presence or absence of an intrauterine gestational sac correlated w/ BhCG levels

- suspect when no intrauterine gestational sac when the βhCG level is > 1,500 IU/L

Beta-Human Chorionic Gonadotropin levels

ectopic pregnancy diagnostics:

- > 1,500 IU/L

- decrease in spontaneous abortion (thus measured more than once)

- measured w/ transvaginal U/S to confirm dx

ectopic pregnancy management

- Surgery

- IM methotrexate

IM methotrexate

ectopic pregnancy management:

- hemodynamically stable pt + size of gestation < 3cm

- stops cell growth + dissolves existing cells

- being used with increasing success

surgery

ectopic pregnancy management:

- primary approach → performed immediately

- fertilized egg cannot develop normally outside uterus → ectopic tissue needs to be removed

- Laparoscopy preferred over Laparotomy (↓ blood loss + LOS)

laparoscopic surgery

- preferred over laparotomy d/t ↓ blood loss + LOS

- 2 types: Salpingotomy, Salpingectomy

- choice depends on: pts age + future fertility desire + tube condition

Salpingotomy

- ectopic pregnancy removed; tube left to heal on its own (conservative)

- preferred; limits damage to reproductive system

- if pt wishes to preserve fertility

Salpingectomy

- ectopic pregnancy & tube are removed

- if tube is ruptured; bleeding profusely (conservative approach not possible)

preop

Nursing Management:

- often no time to fully prepare pt (rupture = emergency)

- 2 x Large Bore IVs

- Blood Transfusion + IV resus → tx shock + stabilize pt for safe anesthesia + operation

serum HCG levels

Nursing Management:

- checked post-op to make sure entire ectopic pregnancy removed

Endometriosis

- presence of endometrial epithelial tissue (uterus lining) in sites outside the uterine cavity

- common sites → near ovaries, broad ligament, uterosacral ligaments, bowel/bladder

Endometriosis patho

- endometrial tissue responds to the hormones of the ovarian cycle → undergoes “mini-menstrual cycle”

- blood collects in cystlike nodules (chocolate cysts) → bluish-black + contain thick chocolate colored material

- chocolate cyst rupture (acute pain) → inflammation/irritation → endometrial adhesions

endometrial adhesions

- fix the affected area to another pelvic structure

- severe = bowel obstruction or painful micturition

endometriosis

- late 20s-30s; never had full-term pregnancy

- common cause of infertility

- ↑ risk for ovarian cancer

- causes +++ pain

etiology

Endometrosis:

- poorly understood

- common theory: retrograde menstrual flow passes through Fallopian tubes → carries viable endometrial tissues into pelvis → attaches to various sites

manifestations

Endometriosis

- vary considerably

- severity of sx does not correlate w/ extent of dx

common sx

Endometriosis

- dysmenorrhea (painful menses)

- infertility

- pelvic pain

- dyspareunia (painful intercourse)

- irregular bleeding

laparoscopy

for a definitive diagnosis of endometriosis

treatment

influenced by

- pt's age

- pregnancy desire (conserve uterus)

- sx severity

- extent + location of disease

- risk for ovarian cancer

disruptive

- when sx not _______ = "watch-and-wait" approach

- when identified as probable cause of infertility → tx proceeds more rapidly

meds

For symptomatic mngt:

- NSAIDs → Pain

- Hormonal Tx → prevent mini menstrual cycle (++ adverse effects)

cure

The only ______ is surgical removal of all the endometrial implants

endometriosis surgery

May be

- conservative

- definitive

conservative

Endometriosis surgery:

- to confirm diagnosis or to remove implants

- for women wishing to get pregnant

- removal/destruction of endometrial implants by lysing or removal of adhesion or endometrial tissue (laparoscopy or laparotomy)

- Post-op care similar to laparotomy

definitive

Endometriosis surgery:

- may be last resort

- removal of uterus, fallopian tubes, ovaries and as many endometrial implants as possible hysterectomy

- post-op care similar as abdominal hysterectomy

Hysterectomy

- surgical removal of the uterus

- different types + approaches

indications

Hysterectomy:

- gyne cancer (ie. endometrial)

- fibroids

- endometriosis + chronic pelvic pain

- uterine prolapse

- abnormal vag bleeding

abdominal

Hysterectomy approaches:

- indications: large tumors, tube + ovary removal,exploring pelvic cavity/complex cases (need greater access + visualization)

- most invasive (last choice)

- large abdo incision

- bikini cut/horizontal or vertical (larger + longer healing)

vaginal

Hysterectomy approaches:

- cut inside vagina, at top junction of vaginal wall near cervix; suture site at vaginal cuff (no external incision)

- preferred ↓ complications + LOS + healing time

- indications: uterus prolapse, early stage cervical/uterine ca, vaginal repair w/ removal of uterus, too large for laproscopy

laparoscopic

Hysterectomy approaches:

- indications: cervix left intact (subtotal) or small uterus

- 2nd choice; not as cost effective

- may be inserted into abdomen to assist in open vaginal approach

subtotal

Hysterectomy types:

- Uterus removed + cervix left in place

- rare today

- ↓ disruption to pelvic floor + damage to urinary tract + infections

total

Hysterectomy types:

- both uterus and cervix are removed

total w/ salpingo-oophorectomy (uni/bilateral)

Hysterectomy types:

- uterus + cervix removed *and* uni/bilateral fallopian tube(s) + ovary(ies)

- bilateral removal of ovaries = sudden menopause d/t loss of ovarian hormones

- prevents recurrence of ovarian ca

wetheim's/radical

Hysterectomy types:

- removal of uterus + cervix → also bilateral ovaries + fallopian tubes AND adjacent pelvic tissue, lymph ducts, upper 1/3 of vagina

- Indications: advanced cervical/endometrial ca, tx of low

risk Stage 1 disease

preop

Hysterectomy Nursing Management:

- perineal/abdo skin prep

- vaginal douche/enema

- Empty bladder → indwelling cath

postop

Hysterectomy Nursing Management:

- ABC

- IV infusion

- Wound Care

- GI

- GU

- Analgesia

- Mobilization

- Teaching

IV infusion

Hysterectomy postop care:

- POD 1-2; 24-48 hr

- possible blood transfusion (r/t blood loss)

wound care

Hysterectomy postop care:

- Depends on approach (Abdominal/Vaginal)

- Hemovac

- prevent infection

abdominal incision

Post-Op Wound Care

- risk of dehiscence/evisceration r/t abdo incision

- splint w/ DB&C + prevent straining

- drsg; light dry x 48 hrs (unless heavy oozing)

Stitches removal

- horizontal: POD 5

- vertical: POD 7-10

vaginal incision

Post-Op Wound Care

- incision inside top of vaginal; suture site at vaginal cuff

- sterile/perineal pad

- vaginal pack (w/ ribbon gauze)

- need to be catheterized → surgical site proximity to bladder (prevent stress + infection)

vaginal pack (w/ ribbon gauze)

Vaginal Incision Care:

- inserted into vagina

- to stop bleeding from suture point

hemovac

Post-Op Wound Care

- drains blood from operation site (pelvis/abdomen) → prevent hematoma

- risk of perforation + peritonitis

abdominal

- risk of all approaches d/t anesthesia → ______ approach further increases risk

- paralytic ileus + abd distension

GI

Hysterectomy postop:

- avoid straining = surgical site stress (stool softener, hydration, mobilization, prevent nausea)

- NPO + IV fluids

- return of bowel function → PO clear fluids + SL

- monitor BM regularity

- antiemetic

GU

Hysterectomy postop:

- foley cath (hard to insert d/t swelling, infection++)

- Suprapubic cath → prevent UTI + urinary drainage + reduce strain

- strict I & O

- POD2 → ambulate to BR

- encourage bladder emptying

Ureter Ligation

- serious complication

- snipping of ureter during removal of uterus (ureter passes right behind site of operation)

- sx: backache, decreased UO (Report!)

analgesia

Hysterectomy postop:

- epidural or PCA

Early mobilization

Hysterectomy postop:

- sit up; bedside chair

- work w/ physio

- POD2 → should be able to ambulate to BR

- helps w/ return of BS + prevent DVT (also LMWH)

education

Hysterectomy postop:

- common to feel 'blue' on POD 3-4 → reassure pt

- may be harder for younger pts w/ loss of fertility + desire for children

DC teaching

- Bleeding

- Sufficient rest x 2 wks

- Exercise

- house work

- work

- sexual intercourse

- hormonal effects

bleeding

DC teaching:

- vaginal discharge for up to 4 wks

- change color from red to pale brown

- seek help if discharge becomes heavier, brighter in color, or offensive smell

2

DC teaching:

- common: suddenly feel tired and exhausted

- important to get sufficient rest for first ____weeks

exercise, 6

DC teaching: Hysterectomy:

- start slowly; short walks

- increase gradually in duration

- may resume swimming ___ wks post-op

housework, 2wk, 4wk, 3mo

DC teaching: Hysterectomy:

- fully restricted for __ __ postop → after light chores can done

- Do not lift heavy objects for ___ __ post-op; very heavy objects for at least __ __

work

DC teaching: Hysterectomy:

- varies in individuals

- some feel ready to return in 6-8 wks

- other take longer

sexual intercourse

DC teaching: Hysterectomy:

- approx. 6 wks to feel physically + emotionally ready

- wait until vaginal bleeding stopped → infection risk

- partner gentle + avoid undue trauma to area

hormonal effects

DC teaching:

- decreased sexual response → d/t scar tissue

- bilateral oophoerectomy*

oophorectomy

DC teaching: hormonal effects

- Bilateral = onset of surgical menopause + estrogen deficiency

- loss of menstruation, libido, vaginal atrophy, ↓vaginal lubrication

- sudden severe sx of menopause

Breast Cancer

- most common ca in women

- 2nd leading cause of death in women

- mortality is declining

- 5-year survival = 88%