Chapter 66

Chapter Overview

  • Title: Care of Patients with Gynecologic Problems

  • Reference: Saunders, an imprint of Elsevier Inc.

Key Concepts

  • Priority Concepts:

    • Sexuality

    • Comfort

    • Pain

  • Interrelated Concepts:

    • Elimination

    • Reproduction

Learning Outcomes

  1. Collaborate with healthcare team for gynecologic cancer care.

  2. Educate patients on community resources for gynecologic cancers.

  3. Identify risk factors associated with gynecologic cancers.

  4. Teach health promotion for preventing or early-detecting gynecologic cancers.

  5. Identify interventions for adapting to changes due to gynecologic issues and treatment.

  6. Develop teaching plans for managing vaginal infections.

  7. Prioritize postoperative care for anterior/posterior repair, focusing on comfort and elimination.

  8. Create evidence-based care plans for hysterectomy patients.

  9. Plan education for self-management of radiation therapy for gynecologic cancers.

Common Gynecologic Concerns

  • Pain/impaired comfort

  • Vaginal discharge

  • Abnormal bleeding

  • Urinary elimination issues

Uterine Leiomyoma (Fibroids or myomas)

Overview

  • Excessive local growth of smooth muscle tissue.

  • Types based on position:

    • Intramural contained in the uterine wall within the myometrium ( in muscle)

    • Submucosal protrude into the cavity of the uterus and can cause bleeding and disrupt pregnancy

    • Subserosal protrudes through the outer surface of the uterine wall and may extend to the broad ligament pressing other organs.

    • The pedunculated stalk (with stalk attachment) is the outside of the uterus and occasionally breaks off and attaches to other tissues (parasitic fibroids)

sexuality concept exemplar: uterine leiomyoma

  • pedunculated stalk

  • develop from excessive local growth of smooth muscle cells

    • stimulated by estrogen, progesterone, and growth hormones

  • symptomatic vs asymptomatic

Etiology and Risk Factors

  • Not completely understood. Common risk factors include:

    • Higher incidence in Black women than white women.

    • Vitamin D deficiency.

    • Reproductive tract infections.

    • Early menarche ( period at a younger age)

    • Diet high in red meat and alcohol.

    • Hypertension.

Incidence and Prevalence

  • Uterine leiomyomas are the most commonly diagnosed pelvic tumors and more prevalent in Black women.

Assessment

  • Key Symptoms:

    • Heavy vaginal bleeding (ask about daily pad/tampon use).

    • Intermenstrual or prolonged bleeding for more than 5 to 6 days.

    • Pain (varies between individuals). dyspareunia, which is painful intercourse

  • Examination Methods:

    • Abdominal, vaginal, and rectal examination by healthcare provider.

    • assess the abdomen for distention or enlargement

Psychosocial Assessment

  • Consider quality of life and fears regarding loss of uterus for the patient and partner.

Diagnostic Assessment

  • Common tests include:

    • CBC (Hematocrit) for the heavy bleeding

    • TSH ( thyroid stimulating hormone) to rule out hypothyroidism

    • A pregnancy test to determine whether the cause of the uterine enlargement

    • Transvaginal ultrasound

    • Laparoscopy

    • Hysteroscopy

    • MRI

Problem Analysis

  • Priority Problem:

    • Potential for prolonged or heavy bleeding due to abnormal growth.

Planning and Implementation

goal is to manage bleeding

Nonsurgical Management

  • Monitor fibroids without immediate intervention.

  • Hormone Replacement Therapy (HRT) be careful for cancer

  • Oral contraceptives. progesterone is what we want to be higher

  • Myolysis is the laparoscopic thermal, radiofrequency, or cryoablation of leiomyoma tissue

  • uterine fibroid embolization (UFE) may report severe cramping within the 1st 24 hrs does not preserve fertility

  • Surgical Management

  • Options include:

    • Uterus-sparing management (e.g., myomectomy, TCER) if the woman desires to have kids

    • Transcervical endometrial resection.

    • Hysterectomy (vaginal/abdominal).

    • Abdominal usually has incision wounds and it’s done 16 weeks pregnancy

      • total hysterectomy is the entire removal of the uterus including the cervix

      • supracervical (subtotal or partial) is the removal of the upper part of the uterus

      • salpingo-oophorectomy (BSO)

        • the fallopian tubes and ovaries are removed

        • removal of just the fallopian is a salpingectomy

        • removal of just the ovaries is an oophorectomy

        • radical the uterus, cervix, adjacent lymph nodes, upper third of the vagina, and surrounding tissues (parametrium) are removed.

  • Preoperative Care:

    • Discuss the procedure, provide prophylactic antibiotics, and provide patient education about the surgery.

    • Assess psychological readiness.

  • operative procedure

    • TAH (total aBD. hysterectomy) vs TVH (total vaginal hysterectomy)

Postoperative Care

  • Similar to care for any patient post-laparoscopic or open abdominal surgery:

    • Monitor vital signs, manage dressing changes, encourage cough/deep breathing, and ensure fluid intake.

    • activity tolerance

    • temp and color of skin

    • heart, lung, and bowel sounds

    • urine output

    • incision characteristics ( pain, intactness of incision, presence or absence of bleeding)

self-management education

  • expected physical changes: no longer have periods but may have some vaginal discharge, use condoms, no need for birth control, may experience menopause symptoms

  • no strenuous activities, heavy lifting, limited stair climbing,

  • take temp 2 times each day for the 1st 3 days after surgery 9 ( report fevers of over 100)

  • symptoms to report

    • increased vaginal drainage or change in drainage ( bloodier, thicker, foul smelling)

    • signs of infection

    • temp over a 100

    • pain or burning on urination

    • pain, tenderness, redness, or swelling on yr calves

Pelvic Organ Prolapse (POP)

  • Types:

    • Uterine prolapse can be caused by neuromuscular damage of childbirth; increased intra-abdominal pressure related to pregnancy, obesity, or physical exertion; or weakening of pelvic support caused by decreased estrogen

    • Cystocele (bladder displacement) is a protrusion of the bladder through the vaginal wall, which can lead to UTIs and stress urinary incontinence( loss of control of the bladder)

    • Rectocele (rectum displacement) is the protrusion of the rectum through a weakened vaginal wall

Assessment

  • Symptoms include:

    • uterine prolapse: painful intercourse, backache, pelvic pressure.

    • Cystocele: Difficulty emptying the bladder.

    • Rectocele: Constipation.

  • Diagnostic Testing:

    • Cystography (X-ray of the bladder), bladder ultrasound (scan) , urine culture and sensitivity, radiographic imaging of urinary anatomy

Interventions

Nonsurgical Management

  • Preferred for POD management when possible:

    • Kegel exercises.

    • Use of vaginal pessaries.

    • cystocele bladder training and attention to complete emptying

    • rectocele promoting bowel elimination. high-fiber diet, laxatives, stool softeners

Surgical Management

  • Least invasive methods preferred:

    • MIS-vaginal mesh/tape,

    • anterior colporrhaphy tightens the pelvic muscles for better bladder support

      • activity restriction (6 weeks) lift nothing heavier than 5 lbs

      • urinary catheter after surgery

      • signs and symptoms of infection ( fever, persistent pain, purulent, foul-smelling discharge)

      • warm bath/compress

    • posterior colporrhaphy, which reduces rectal building

      • if both cystocele and rectocele are present, an anterior and posterior colporrhaphy is performed

      • pt may return from surgery with a urinary catheter to keep the surgical area clean and dry

      • low-fiber diet to decrease bowel movement


Endometrial (Uterine) Cancer

  • cancer of the uterine lining

  • Most common gynecologic malignancy (usually slow-growing).

  • Staging:

    • Stage 1: contained in the uterus.

    • Stage 2: extends to the cervix.

    • Stage 3: involves vagina/lymph nodes.

    • Stage 4: metastasizes beyond the pelvis.

Assessment

  • Abnormal bleeding is the main symptom; other symptoms include low back, pelvic pain, or watery discharge.

    • ask pt how many pads/tampons are used each day

    • ask to describe the exact location and intensity of her discomfort

    • A pelvic exam reveals the presence of a palpable uterine mass or uterine polyp. uterus enlarged if the cancer is advanced

  • Diagnostic measures include:

    • CBC anemia due to heavy bleeding

    • CA-125 tests assess for metastasis

    • AFP may be elevated when ovarian cancer is present

    • hCG to rule out pregnancy

    • Transvaginal ultrasound is the gold standard diagnostic test for determining the presence of endometrial thickening and cancer.

  • other diagnostics: CXR, IVP to assess renal function/renal metastasis, abdominal US, CT of the pelvis, MRI of abdomen and pelvis, liver/bone scan to assess for distant metastasis

Surgical Management

  • Stage 1: Total hysterectomy with BSO; peritoneum fluid or washings for cytologic examination.

  • Stage 2: Radical hysterectomy with node dissection, upper 1/3 of vagina

    • same nursing care as simple hysterectomy

    • longer hospital stay and recovery

Nonsurgical Management

  • radiation (stage 2 to 3 cancers)

    • brachytherapy (internal radiation to prevent recurrence)

    • placed for minutes, 2-5 times once or twice a week

    • bedrest during treatment session

    • radiation is emitted only while the implant is in place

    • combined with external beam radiation

  • health teaching for pt having brachytherapy for gynecologic cancer

    • heavy vaginal bleeding

    • urethral burning for more than 24 hrs

    • blood in the urine (hematuria)

    • extreme fatigue

    • severe diarrhea

    • fever over 100

    • abdominal pain

  • external beam radiation therapy

    • used to treat any stages of endometrial can be combined with surgery, brachytherapy, and/or chemo (tissue around the tumor and pelvic wall nodes also treated)

    • 4-6 weeks

    • avoid sunbathing, and watch for skin breakdown, especially in the perineal area

    • avoid washing markings outlining the treatment site

interventions: responding

  • nonsurgical management

    • chemotherapy

      • used as palliative treatment in advanced and recurrent disease when it has spread to distant areas pf the body

      • not always effective

      • Doxorubicin (Adriamycin), cisplatin (Platinol), and paclitaxel (taxol).

      • alopecia pt education

      • complementary and integrative health- encourage her to check with her oncologist and/or pharmacist because some integrative therapies can be harmful or interfere with cancer treatment.

Ovarian Cancer

  • Leading cause of death from female reproductive cancers.

  • Symptoms: abdominal swelling, bloating, urinary frequency, pelvic pain, and difficulty eating fullness.

  • overexposure to estrogen

  • pregnancy/contraceptive protect

  • tubal ligation, oral contraceptives, breast-fed

  • diagnose after menopause

  • family history small percent of causes (BRCA1/BRCA2)

  • Risk factors for ovarian cancer

    • middle to older age

    • BRCA 1 or BRCA 2 gene mutation

    • infertility

    • difficulty getting pregnant

    • nulliparity

    • history of endometriosis

    • history of breast, uterine, or colorectal (colon) cancer (especially Lynch syndrome), hereditary nonpolyposis colorectal cancer

    • of Eastern European or Ashkenazi Jewish background

Assessment

  • “think ovarian” at the onset of vague abdominal and GI symptoms

  • abdominal pain or swelling or have vague GI disturbances such as indigestion and gas

  • ask about urinary frequency or incontinence, unexpected weight loss, or vaginal bleeding

  • advanced metastatic cancer

    • pleural effusion

    • venous thromboembolism (VTE)

    • bowel obstruction

  • Diagnostic procedures include:

    • CA-125 tests, ultrasound, CT scans, CBC, liver profile, transvaginal US, CXR

Interventions: Responding

  • Surgical exploration and possibly staging for diagnosis.

  • abdominal surgery

    • for staging and treatment

  • chemotherapy

    • cisplaton (platinol), carboplatin, taxanes ( IV/intraperitoneally)

  • radiation may be used for more widespread cancer ( but not for ovarian cancer alone)

care coordination transition management for ovarian cancer

  • avoid tampons, douches and intercourse for 6 wks

  • keep follow-up surgical appointment

  • possible hospice referral

  • community health resources; support groups; grief counseling; spiritual leader ( if desired)

Cervical Cancer

  • Causation primarily due to HPV infection.

  • progressive development

  • premalignant changes are classified on a continuum

  • Health promotion involves vaccination with Gardasil or Cervarix ( ages 9-26) before sexual contact)

risk factors for cervical cancer

  • smoking

  • family history

  • infection with Chalamydia

  • HPV infection

  • long-term use of oral contraceptives

  • IUD

  • having 1st full-term pregnancy earlier than 17

  • obesity

health promotion and maintenance

  • HPV vaccine must get an entire series

    • 3 injections over 6 months

    • ideally before 1st intercourse

  • pelvic exam and pap test

    • begins at 21 yrs every 3 yrs until 29

    • 30-65 pap + HPV every 5 yrs


Assessment

  • Often asymptomatic; classic symptom includes painless vaginal bleeding (especially between periods, or after intercourse or douching)

  • unexplained weight loss, dysuria, pelvic pain, hematuria, rectal bleeding, and chest pain may be reported

  • Diagnostic assessments.

    • pap

    • A HPV-typing DNA test of a cervical sample

    • colposcopy application of an acetic acid solution is applied to the cervix

    • cervical biopsy

    • endocervical curettage scraping of the endocervix wall

  • nonsurgical management

    • radiation therapy

    • concurrent chemoradiation combination of both radiation and chemotherapy

Interventions and Management

  • surgery

    • cervical ablation (local treatment)

    • LEEP is both a diagnostic procedure and a treatment because it provides a specimen

    • laser therapy vaporizes abnormal cells

    • cryotherapy involves freezing the cancer-causing subsequent necrosis

    • radical trachelectomy the cervix and upper parts o the vagina are removed leaving the body of the uterus intact.

  • conization

  • total hysterectomy

  • radiation and chemotherapy may be used for late-stage disease (invasive cancer)

Vulvovaginitis

  • Inflammation of the lower genital tract resulting from disturbance o the balance of hormones and flora in the vagina and vulva

  • Symptoms include itching, odor, lesions, and discharge changes.

  • prevention of vulvovaginitis

    • wear cotton underwear

    • avoid wearing tight clothes

    • always wipe front to back

    • use fragrance-free laundry detergent

    • don’t douche or use feminine hygiene sprays

    • no intercourse with infected partners

    • yeast infection take full drug dose

Toxic Shock Syndrome (TSS)

  • Fatal conditions often linked to menstruation and tampon use, gynecologic surgical wound infection, use of internal contraceptives, minor trauma, viral infection

  • develops within 5 days after the onset of instruction

  • fever, rash, myalgias, sore throat, edema, hypotension

  • requires immediate healthcare intervention.

  • treatment focuses on removing the infection source, restoring fluid and electrolyte balance; and medication therapy.

Audience Response System Questions

  • Included for exam preparation and application of knowledge about interventions and patient care in gynecologic oncology.