Women's Health: Common Gynecological Issues

Healthy People 2030 Goals

decreased breast/cervical CA deaths

increased % healthy weight

increased cervical CA and colorectal screenings

decreased hip fractures

decreased STDs

decreased CHD deaths

decreased stroke deaths

Well Woman Exam

can start young (ex. if 12-13 yrs get painful periods)

health history

physical exam

menstrual history (short? long? LMP?)

OB history

breast exam (feel for lumps/masses)

pelvic exam

reproductive tract

Immunizations

Lab/Diagnostic Screenings

STDs & HIV

TB skin test: not routine

Cholesterol and other lipids

glucose testing/HgB A1C

urinalysis

thyroid function (T3 and T4)

pap test

Mammography, BRCA1, BRACA2 genes, CA-125 protein- all associated w/breast cancer

ultrasound of pelvis: pelvic issues/not routine

fecal occult blood/colonoscopy; colon cancer

bone density: osteoporosis risk for 40-50yrs

Menstruation: Changes in Female Biology

Paleolithic era: 7-13 yrs

Classical/Medieval times: 14 yrs

Industrial Revolution: 15-16 yrs

20/21st centuries: 9-13yrs

Menstruation: Influencing Factors

genetics

nutrition-poor nutrition

body fat: 17% BMI

environment and lifestyle: may delay or accelerate

socioeconomic status: lower status, younger age

Menstruation: Follicular Phase

estradiol rises a bit

LH and FSH low

growing follicle

Menstruation: Ovulation Phase

estrogen drops

LH and FSH increase

egg gets released

Menstruation: Luteal Phase

after ovulation

LH and FSH drops

Progesterone spikes

estrogen increases

corpus luteum forms

Menstruation Phase

after luteal phase if egg fails to implant

progetsetrone and estrpgen drops

corpus albicans forms from corpus luteum

Abnormal Bleeding Causes

anovulation: does not ovulate

pregnancy

infection

neoplasm: cancer

trauma

systemic disease

iatrogenic: surgical procedures/med SEs

Amenorrhea

absence of menses

Normal for prepubescent, pregnant, postpartum and postmenopausal females

It is a symptom, not a diagnosis

Usually indicates dysfunction in the hypothalamic-pituitary-ovarian-uterine axis

Primary vs Secondary

Primary Amenorrhea

failure to reach menarche in females of reproductive age

concerning, esp if 16 and hasn’t got it yet

never had a period

Causes of Primary Amenorrhea

Congenital abnormalities (missing uterus/closed uterus)

Turner syndrome

Physiologic delay

Stress

Excessive exercise

Disordered eating

PCOS- high androgen

Hypothyroidism

Imperforate hymen: no hole for blood to go through

Chronic illness

Pregnancy

Ovarian/Adrenal tumors

Secondary Amenorrhea

Absence of regular menses for 3 cycles or irregular menses for 6 months in those who have previously menstruated regularly and are not pregnant, breastfeeding, or menopausal

had periods, but stopped

Causes of Secondary Amenorrhea

Pregnancy

Intrauterine adhesions

GnRH deficiency

Systemic diseases (type 1 diabetes, celiac disease)

Pituitary/ovarian/adrenal tumors

Hypothyroid conditions

PCOS

Ovarian insufficiency

Nursing Assessment and Interventions for Amenorrhea

Health history and physical exam: Tanner Stages

Lab/diagnostic Testing: Karyotype, Pelvic/vaginal u/s, hCG, Thyroid function, Prolactin, FSH, LH

education and counseling

Dysmenorrhea

painful menstruation

primary and secondary

Symptom and NOT a diagnosis

Impacts quality of life and daily activities

Primary Dysmenorrhea

occurring in healthy women without any underlying medical condition

Release of prostaglandins causing the uterus to contract

ibuprofen can be used for this

Secondary Dysmenorrhea

results from an underlying medical condition

Endometriosis, fibroids, pelvic inflammatory disease (PID)

Endometriosis

Affects 10% of all adult women globally

Pelvic pain and lesions, adhesions

An estrogen-dominant chronic inflammatory process

Endometrial tissue implants outside of the uterus and responds to the hormones released

during the menstrual cycle: Swelling, Bleeding, S&S– nonexistent to incapacitation

uterine cells go into abd cavity/bladder/intestines

cells act like they are bleeding

look like chocolate cysts

Fibroids

large growths in uterus

causes more bleeding

pelvic inflammatory disease (PID)

associated w/STIs (chlamydia, gonorrhea)

can cause scarring in fallopian tube

Nursing Assessment of Dysmenorrhea: Lab/Diagnostic Tests

Health history, physical assessment

CBC, r/o anemia

UA, r/o UTI

hCG

ESR, detect inflammatory process

Stool guaiac, r/o GI disorders

Pelvic/vaginal u/s

Diagnostic laparoscopy

Management of Dysmenorrhea: Education

Normal cycle

Etiology of pain

Predisposing factors

Med therapy: NSAIDs, naproxen, hormonal contraceptives (keeps progesterone high)

Management of Dysmenorrhea: Non-Med Therapies

Exercise

Decrease stress

Warm packs

Massage/yoga/acupuncture

Abnormal Uterine Bleeding (AUB)

Deviation from normal menstruation

Change in volume, regularity or timing that has presented for 6 months or longer

Painless endometrial bleeding that is prolonged, excessive, and irregular and is not attributed to an underlying structural or systemic condition, occurring when the patient is not pregnant.

Underrecognized, underreported, and undertreated

DUB-dysfunctional uterine bleeding- old term being phased out

Specific type of AUB, underlying hormonal imbalance after r/o of other causes of bleeding

AUB Management: Goals and treatment

Depends on the cause of the bleeding, age and health status of patient, desire for future fertility

Normalize bleeding

Correct anemia

Prevent or diagnose early cancer

Restore quality of life

Treatment may include: Pharmacotherapy, Surgical intervention-D&C, ablation, hysterectomy

AUB Management: Nursing Intervention

Education: Normal cycle and Reasons for abnormal pattern

Coping strategies: Managing treatment, Managing anxiety, fear, Managing loss, Self-care

Premenstrual Disorders

Group of symptoms that occur during the luteal phase of the menstrual cycle (last half) and resolve with the onset of menstruation

Physical, emotional, behavioral

At least one emotional or physical symptom that causes severe distress and interferes w/some aspect of the person’s life either socially, at work, or at home

Likely related to the interaction between the hormonal events of the menstrual cycle and central neurotransmitter function– low serotonin, increased PMS symptoms

No cure, treatment to help manage symptoms

Premenstrual Syndrome (PMS)

Multidimensional, holistic approach

Treatment includes:

Dietary changes (caffeine, water, alcohol intake)

Exercise

Supplements

Pharmacotherapy (NSAIDs, OCs)

PMS Symptoms

acne, bloating, moodniess

not uncommon

Premenstrual Dysphoric Disorder (PMDD)

More severe and debilitating

May require SSRIs or antidepressants in addition

PMDD Symptoms

symptoms of PMS plus:

depression or anxiety

feeling hopeless or suicidal

keeps you from living life

less common (3-8%)

Pelvic Exam: External palpation

Abdominal masses, lymph nodes, liver

Pelvic Exam: Vulvar exam

Erythema or rashes

Pelvic Exam: Speculum exam

Pap smear/STD testing

Vaginal discharge

Pelvic Exam: Bimanual exam

Cervical tenderness, uterine position, adnexa (structures adjacent to the

uterus, ie: ovaries, fallopian tubes, ligaments)

Pelvic Exam: Rectovaginal exam

not commonly done

Uterus or adnexa masses, hemorrhoids, polyps, growths

Pelvic Pain

Appendicitis, IBS

Mittelschmerz- pain that happens when ovulating (egg coming out)

Menstrual cramps

Ectopic pregnancy

STI

Endometriosis

PID

Ovarian cyst

Uterine fibroids

UTI, Kidney stones

Pelvic organ prolapse

Scar tissue/adhesions

Endometriosis Treatments

Pain relief, hormonal suppression, surgery

Uterine Fibroids

Slow growing benign fibroid tumors found in the uterine muscle wall

Growth influenced by: Ovarian hormones, OCs, Pregnancy, HRT

Spontaneously shrink after menopause

Rarely malignant

Symptoms of Uterine Fibroids

Heavy, prolonged periods

Pelvic pain

Back/leg pain

Pain during sex

Bladder pressure

Bowel pressure

Abnormally enlarged abd

Medical Management of Uterine Fibroids

GnRN (Lupron)

NSAIDs

Surgical Management of Uterine Fibroids

Uterine fibroid embolization (burning)

Myomectomy (removal of fibroids)

Ablation (damage lining)

Hysterectomy

Infertility

Inability to conceive a child after 1 year of regular sexual intercourse unprotected by contraception

Emotional, social, economic impacts

Familial, cultural consequences

Multifactorial, known and unknown causes

Female-factor infertility: 50% of cases

Male-factor infertility: 26% of cases

Combined or unknown: 28% of cases

Factors/Causes of Male Infertility

Abnormal sperm production or function

Problems with delivery of sperm

Environmental toxins

Cancer treatment

Cigarette smoking

Diabetes

Frequent sauna/hot tub use

Anabolic steroids

Factors/Causes of Female Infertility

Over or underweight

Scarred fallopian tubes

Fibroids

Endometriosis

Pelvic adhesions

Eating disorders

Smoking

Chemo exposure

Immune system disorders

Evaluation of Infertility

Preconception counseling

Health history and physical exam

Lab/diagnostic tests:

Semen analysis

Endocrine tests

Ultrasound

Ovulation prediction

Hysterosalpingogram

Hysterosalpingogram (HSG)

dye is injected into uterus to determine if it comes out fallopian tubes

Uterine Malformations

didelphys- double uterus

arcuate- saddle indentation towards top

unicornuate- half a uterus w/1 ovary

bicornuate- looks like heart

septate- septum runs down middle

Treatment for Infertility: Lifestyle Changes

Stop smoking

Avoid alcohol and drugs

Limit caffeine

Exercise moderately

Avoid weight extremes

Treatment for Infertility: Medical

Ovulation induction (Clomid)

Surgical procedures

Therapeutic insemination- take semen and inject into uterus

Egg donation

Surrogate parenting/gestational carrier

ARTs: In Vitro Fertilization (IVF)

embryo transfer to the uterus

done in petri dish

ARTs: Gamete intrafallopian transfer (GIFT)

egg and sperm placed in fallopian tube to fertilize inside

not as common due to chance of ectopic pregnancy

ARTs: Zygote intrafallopian transfer (ZIFT)

egg and sperm fertilized outside, then placed in fallopian tube

not as common due to chance of ectopic pregnancy

ARTs: Intracytoplasmic sperm injection (ICSI)

the sperm is injected into an egg for IVF

ARTs: Intrauterine insemination (IUI)

injecting sperm directly into the uterus

Psychosocial Responses to Infertility

Assumption of fertility

Growing awareness of problem

Reactions during evaluation and treatment

Psychosocial Responses to Infertility: Seeking Help

Importance of having a baby

Sharing intimate info

Financial considerations

Commitment to the process

Psychosocial Responses to Infertility: Influences on Decision Making

Social, cultural, religious values

Difficulty of treatment

Probability of success

Financial concerns

Psychosocial Responses to Infertility: Psychological Reactions

Guilt

Isolation

Depression

Stress on the relationship

Breasts

mammary glands are modified sweat glands laying over the pectoralis muscle of the anterior chest

specialized for milk formation to nourish offspring

Closely linked to societal views of womanhood in American culture

Seen as physical markers for transition from one life stage to another and are often perceived as elements of a person’s physical attractiveness and sexuality

Benign Breast Disorders

non-proliferative epithelial lesions

fibroadenomas

mastitis

non-proliferative epithelial lesions

fibrocystic breast changes

Not associated with increased risk of breast cancer

Fibrocystic changes caused by an overgrowth of fibrous tissues in the connective tissues supporting the breasts

tissues usually accompanied by fluid-filled cysts

Can cause tenderness and pain

most common in patients between 30-50 years of age

Assessment of non-proliferative epithelial lesions

History

Physical exam/breast exam

Mammography/Ultrasound

Needle aspiration

Management of non-proliferative epithelial lesions

Symptom relief

Supportive bra

OCs/Aspirin/Ibuprofen

Dietary changes, restrict alcohol

Vit E, D, thiamine

Aspiration/surgical removal of cysts

Fibroadenomas

Most common benign tumor of the breast

50% of all breast biopsies

Stimulated by hormones and composed of both fibrous and granular tissue

Firm, rubbery, smooth, mobile, and may be tender upon palpation

Watch, cryotherapy, surgical removal if very large

Mastitis

Infection of connective tissue primarily in lactating or engorged females

Lactational or nonlactational

Oral antibiotics, acetaminophen, warm compresses

Assessment of Mastitis

risk factors, flulike symptoms, warm, red, tender swollen breast, cracked or abraded nipple

Management of Mastitis

breastfeeding or continued emptying of the breast, medications, proper infant positioning at the nipple, warm compresses, good hand washing, supportive bra

Malignant Breast Disorders

breast cancer

Breast Cancer

neoplastic disease in which normal body cells mutate and grow out of control to create a malignant mass or tumor

2nd most common cancer in U.S. females and 2nd leading cause of cancer death in U.S. females

1 in every 3 cancer diagnoses is breast cancer

Black females have a disproportionately higher rate of death from breast cancer.

1% of breast cancer diagnoses are in male patients.

Noninvasive (in situ) or invasive (infiltrating)

Most common breast cancer

Invasive ductal carcinoma (IDC)

Non-modifiable Risks for Breast Cancer

sex at birth

aging

genetic mutations

history of ovarian or colon cancer

increased breast density

family or personal history of breast cancer

race

previous abnormal breast biopsy

exposure to chest radiation

previous breast radiation

early menarche or late menopause

Modifiable Risk Factors for Breast Cancer

not having children or childbearing after age 30

postmenopausal use of estrogens and progestins

not breastfeeding for up to a year after pregnancy

alcohol use

smoking

high BMI

high-fat diet

sedentary lifestyle

Diagnostic Tests for Breast Cancer

Diagnostic mammography

Magnetic resonance mammography (MRM)

Fine-needle aspiration

Stereotactic needle-guided biopsy

Sentinel lymph node biopsy

Hormone receptor status

DNA ploidy status

Cell proliferative indices

HER-2/neu genetic marker

Therapeutic Management of Breast Cancer: Surgical

Breast-conserving surgery

Mastectomy: simple, modified radical

Therapeutic Management of Breast Cancer: Adjunct Therapy

Radiation therapy

Chemotherapy

Endocrine therapy

Immunotherapy

Late Signs of Breast Cancer

Continued and persistent changes in the breast

Lump or thickening in one breast

Persistent nipple irritation

Unusual breast swelling or asymmetry

Lump or swelling in the axilla

Changes in skin color or texture

Nipple retraction, tenderness, or discharge

Breast Cancer: Stage 1

early disease

tumor confined to the breast

node neg

Breast Cancer: Stage 2

early disease

tumor spread to moveable ipsilateral axillary node(s)

node positive

spreads a little from breast

Breast Cancer: Stage 3

locally advanced disease tumor spread to the chest wall

involvement of ipsilateral internal mammary lymph nodes

Breast Cancer: Stage 4

advanced (metastatic) disease

metastases preset at distant sites like bone, liver, lungs, and brain and including supraclavicular lymph node involvement

Assessment for Breast cancer

Often asymptomatic; possible changes in breast appearance or contour

Clinical breast examination

Characteristics of mass

Nursing Diagnoses for Breast Cancer

Disturbed body image

Fear

Deficient knowledge

Nursing Interventions for Breast Cancer

education, emotional support, post op care

health promotion and disease prevention strategies

breast cancer screening (self exam, clinical, mammography)

nutrition

Education Topics for Breast Cancer

Prevention

Early detection (Breast self-examination, Clinical breast examination, Mammography)

Screening

Dispelling myths and fears

Self-examination techniques

Patterns using a circular motion

Types of palpation

Changes to Assess During Breast Self Exam

Changes in shape, size, contour, or symmetry

Skin discoloration or dimpling, bumps/lumps

Sores or scaly skin

Discharge or puckering of the nipple

Breast Augmentation Post Cancer

implants

Saline-filled

Location typically is subglandular (over the pectoral muscle) or subpectoral (under the muscle)

Breast implants are not lifetime devices, but most are guaranteed for approximately 10 years

Risks: Capsular contracture, rippling, implant rupture, infection, or hematoma

Perimenopause

the transition from the reproductive phase of life to the final menstrual period

45-55, average age 47 years

Lasts 7-14 years

Menopause

the point in time at which menses and fertility cease; 1 year without a period

Average age 51.4 years

(Peri)menopause can occur with which life transitions?

Children leaving or returning home

Older parents requiring more care or dying

Partners undergoing their own midlife challenges

Physio of Menopause: Ovarian Function Decline

With age, ovarian follicles decline in number and function

Results in reduced production of estrogen, progesterone, and inhibin B (regulates follicle-stimulating hormone)

Physio of Menopause: Hormonal Changes

Estrogen and progesterone levels decrease significantly

Irregular menstrual cycles

FSH rises as ovaries become less responsive to estrogen (body tries to get out egg one last time and this how some end up w/baby at 45/50yrs)

LH rises

Testosterone declines slightly

Impact of Menopause: Brain

hot flashes; sleep, mood, and memory problems

Impact of Menopause: Heart

lower levels of HDL; increased risk of CVD

Impact of Menopause: Bones

bone density loss; increased risk of osteoporosis

Impact of Menopause: Breasts

duct and gland tissue replaced by fat

Impact of Menopause: GU

vaginal dryness, stress incontinence, cystitis

Impact of Menopause: GI

less Ca+ absorbed; increased fractures