Transcript Care of Women with Reproductive Disorders

Care of Women with
Reproductive Disorders
Mrs. Frascella MSN,Ed,RN
External Structures
• Vulva-name given to the external female genitalia.
• The vulva is composed of the following structures:
– Mons pubis -rounded mound of fatty tissue that protects the
symphysis pubis. Covered with hair.
– Labia majora -2 elongated , raised folds of skin that enclose the
vulvular cleft.
External Structures
• Labia minora-soft folds of skin within the labia majora.
• Clitoris-located at the top of the vulvular cleft, made of
erectile tissue,highly sensitive to touch.
• Urethral meatus- external opening of the urethra of the
urinary bladder.
• Perineum-flat muscular surface between the vagina and the
anus.
Female External Structures
Internal Structures
• Vagina -muscular tube lined with membranous tissue with
ridges called rugae. Normal acidic pH prevents infection.
• Uterus -(womb) is a hollow pear-shaped organ with a thick
muscular wall. Capable of expanding to accommodate a
growing fetus. Lower opening is the cervix which dilates
during labor to allow for delivery of infant.
Internal Structures
• 2 fallopian tubes that branch outward at the top of the
uterus, pathway for the ovum (egg), from the ovary to the
uterus.
• 2 ovaries, one located near the end of each fallopian tube.
Almond shaped glands, excrete estrogen and progesterone
into the bloodstream.
• Bony pelvis -located at the base of the hips, supports pelvic
organs.
Internal Structures
Accessory Organs
• Breasts or mammary glands, located on the upper chest.
• Composed of fibrous, adipose, and glandular tissue and
are responsible for lactation (milk production).
• Pain to breast occur at mid cycle of ovulation.
Female Reproductive Cycle
• Ovarian Cycle: (2 phases)
1.Follicular Phase -first 14 days of a 28 day cycle.
Follicle-stimulating hormone (FSH) & Luteinizing
hormone (LH) stimulate the maturing of the immature ova
in preparation for fertilization.
Ovulation takes place when estrogen peaks about 14 days
before the next cycle.
Ovarian Cycle
2.
Luteal phase -15th to 28th days of the cycle. LH and
progesterone are the primary hormones in this phase.
Blood supply to the uterus increases in preparation for
possible implantation of a fertilized ovum. ( PMS)
If fertilization and implantation do not occur, the lining of the
uterus will degrade and be shed during menstruation, and
the cycle begins again.
Sexual Maturation
• Puberty -the period of sexual maturation, usually occurs
between the ages of 9 and 17.
• Involves a period of accelerated growth, hips begin to
widen, breasts begin to develop and axillary and pubic hair
appears.
• Puberty is completed by the onset of the menstrual cycle.
• Menarche menstruation - the first menstrual cycle.
Changes That Occur with Aging
• Menopause -occurs when menses completely ceases for
12 months.
• After menopause:
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Female organs atrophy
Loss of elasticity
Dryness of vaginal membranes
Reduction in bone mass
Internal organs may sag, or prolapse into the vagina
Menstruation
• May be abnormal for the first year.
• Regular cycle is usually every 28 days.
• Menstrual blood consists of shed endometrial tissue, blood
mucous, and vaginal and cervical cells.
• Amount of actually blood loss is only 40 -80 ml.
• Flow may be heavy at first but gradually reduces.
Menstruation
• Mild cramping may occur.
• Mood swings may be associated with hormonal changes.
• Mittelschmerz -sharp pain in the right lower quadrant,
sometimes felt midcycle around the time of ovulation.
Normal Vaginal Discharge
• Vagina is moist, warm, & dark, good medium for
microorganisms.
• Normal vaginal discharge has an off-white color and is
without odor.
• If vaginal discharge develops an odor or change in
consistency, or causes irritation or burning, a healthcare
provider should be consulted.
Contraception and Fertility
• Many women start sexual relationships and risk pregnancy
before they are ready to have children.
• Some women give birth and do not want to have more
children.
• Many sexually active women of childbearing age are
concerned about regulating, planning, or preventing
pregnancy.
Contraceptive Options
• Women should make an informed decision concerning
methods of reliable birth control.
• Nurses are responsible for providing comprehensive
education concerning the advantages, limitations, and side
effects of various contraceptive devices.
Oral Contraceptives
• Most popular method of reversible hormonal contraception.
• Effective if used properly.
• Offer relief from breast tenderness, bloating, and PMS
symptoms.
• Abstinence is the only 100% effective method of birth
control.
Oral Contraceptives
The “Pill”
Combination of synthetic estrogen and
progestin, hormones prevent
ovulation and thicken cervical
mucus, making it difficult for sperm
to travel upward.
Based on a 28 day cycle with 7
hormone free days that result in
monthly menstruation.
Oral Contraceptives
Oral Contraceptives
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Prescription required.
Must be taken faithfully.
Decreases breast tenderness.
Not recommended for women older than 35 who smoke.
Contraindicated for women with a history of heart or liver
disease, breast or uterine cancer, or blood clots.
• 97% to 99.9% effective.
Intrauterine Device (IUD)
IUD
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Small, sterile, flexible plastic device
inserted into the uterus by a
physician.
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Can be a copper device or a device
containing the hormone
levonorgesterel (minera). Can
provide protection up to 5 yrs.
Can be used as an emergency
contraceptive measure if inserted
within a maximum of 7 days after
unprotected sex to prevent
implantation of zygote
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Examples of IUD’s
IUD’s
Side Effects/Precautions:
• May increase menstrual flow or cause cramping or low
back pain
• Increased incidence of PID with multiple sex partners.
• Patient must check placement by feeling for string once
each month.
• Must be removed by health care provider.
• Up to 99% effective.
Male Condom
Condom
• A sheath commonly made of
latex that is placed over the
erect penis before
intercourse.
• Oil-based lubricants such as
petroleum jelly can cause
latex to break down and
reduce effectiveness.
Assorted Condoms
Male Condom
• Precautions:
• Leave space at the tip for seman to collect rather than
being forced upward out of the condom.
• Store in a cool, dry place and do not keep excessively long
to avoid breakage.
• Handle carefully to avoid spilling semen and possibly
introducing it into the vagina.
Male Condom
Effectiveness:
• 88% -98% if used properly.
• Use of spermicide increases effectiveness to 98%-99%.
Diaphragm
How diaphragm works
• A rubber dome-shaped cup
that fits snugly over the
cervix.
• Spermacide is applied to the
cervical side of the
diaphragm and it is inserted
into the vagina so that the
fitted ring holds it securely
in place.
Diaphragms
Diaphragm
• Precautions:
• Diaphragm must be fitted professionally and should be
refitted annually.
• Should be refitted with a gain or loss of 7-10 lbs. and after
pregnancy.
• Effectiveness is 82%-94%.
Injectable Contraceptives
(Depo-Provera)
• Synthetic timed-release progesterone is injected q 12
weeks to prevent ovulation.
• Injections must be given in clinic or office.
• Must be repeated q12 weeks to remain effectiveness.
• 99.7% effective
Emergency Contraception
How Method Works
• Taken orally the day
following intercourse, it
induces menses and
prevents implantation in the
uterus.
• Should not be used as a
routine for of contraception.
• 97%-99.9% effective
“Morning-after” pill
Legal and Ethical Consideration
Note :
Although the “morning after” contraceptive pill can be sold
over the counter in most states, there has been
considerable unwillingness by certain pharmacists to
provide it.
The pharmacists’ claim that dispensing the pill is against their
religious principles. It may not be ethical for pharmacists’
to withhold the medication from a woman because of the
pharmacists’ personal belief.
Infertility
• Primary infertility-the inability of the couple to conceive a
child after at least 1 year of active, unprotected sexual
relations without contraceptives.
• Secondary infertility-the inability to conceive after having
once conceived, or the inability to maintain a pregnancy
long enough to deliver a viable infant.
Factors contributing to infertility
• Problems with ovulation
• An abnormal pathway between the cervix and the fallopian
tube
• Abnormality in the endometrium or the uterus
• Tumors in the reproductive tract
• Vaginal or cervical environment that is inhospitable
Diagnosis of Infertility
• Obtain a detailed health history
• Serum prolactin levels and endocrine evaluations, semen
analysis & chromosome analysis
• Tests for tubal patency or other possible abnormalities
Emotional Impact
• The emotional impact of infertility is intense.
• Psychological intervention may be necessary.
• Couples may not be able to focus, increased tension,
blaming each other.
Assisted Reproduction
• Reproductive therapy associated with many legal and
ethical issues.
• Ex. Risk of having multifetal pregnancy, freezing embryos
for later use, surrogate mother.
Menopause
• Defined by the World Health Organization as the cessation
of menses for 12 consecutive months due to a decrease in
estrogen production.
• The perimenopausal period is the time around the actual
cessation of the menstrual cycle.
• S/S include: hot flashes, night sweats, low estrogen levels.
Risks of Menopause
• Osteoporosis due to decrease in estrogen slows bone
growth.
• Increased risk for cardiovascular disease due to change in
lipid metabolism.
• Treatment may be hormone replacement therapy.
Health Screening
• Primary prevention is designed to decrease the probability
of becoming ill.
• Secondary prevention is designed to focus on detection of
specific at-risk diseases so that early treatment may be
given.
• Tertiary prevention minimizes the impact of alreadydiagnosed conditions.
Breast Self-Examination
• Should be done monthly, about 1 week after menstruation
begins, or on a specific date each month.
• See figure 39-5 for self breast exam.
• https://www.youtube.com/watch?v=E5SKi-mALbY
Common Gynecologic Tests
• Pelvic exam-visual inspection of the external genitalia,
vagina, and the cervix to obtain specimens such as a Pap
smear.
• Process- Inspection via the vaginal speculum; manual
palpation through abdominal wall, vaginally, and rectally of
internal organs.
Common Gynecologic Tests
• Pap Smear-to obtain samples of cells and fluids for
pathology/ cytology studies.
• Process-exudate, mucous, and cells are obtained from
surface with sterile swab or scraping tool and placed on a
laboratory slide or into a preservative solution for pathology
evaluation.
Common Gynecologic tests
• Dilation & Evacuation (D &E)-to detect cause of
excessive bleeding; to remove hypertrophied uterine lining,
retained placenta, or tissue from an incomplete abortion.
Done in the OR.
• Process-the cervix is dilated and the interior of the uterus
is cleansed by scraping, suction, or both.
Common Gynecologic Tests
• Mammography-to screen breasts for abnormal growths,
particularly cancer.
• Process-a full-field digital mammography machine records
images on a computer screen and can computer-enhance
images for increased accuracy.
Surgical Procedures
• Hysterectomy-removal of entire uterus, vaginally or
abdominally.
• Panhysterectomy-removal of entire uterus, fallopian
tubes, and ovaries.
• Radical hysterectomy-removal of uterus, tubes, ovaries,
upper third of the vagina, and lymph nodes.
Surgical Procedures
• Salpingectomy-removal of the fallopian tubes
• Oophorectomy-removal of an ovary.
• Vulvectomy-surgical excision of the labia, clitoris, perineal
structures, femoral and inguinal lymphatic tissues.
Menstrual Dysfunctions
Premenstrual Syndrome- (PMS)
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AKA ovarian cycle syndrome.
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Presence of physical, psychological, or behavioral
symptoms that occur regularly within the luteal phase of the
menstrual cycle and disappear during the remainder of the
cycle.
Menstrual Dysfunctions
Signs & symptoms:
• Weight gain, bloating
• Irritability, changes in eating patterns
• Fatigue, mood swings
Management:
• Lifestyle modifications
• Diet high in B vitamins
• Exercise, stress management
• Avoidance of fatigue
Dysmenorrhea
• Painful menstruation, 2 types:
1. Primary Dysmenorrhea
2. Secondary Dysmenorrhea
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Primary dysmenorrhea-occurs 6-12 months after
menarche.
Caused by the release of high levels of prostaglandins in
the first 2 days of menstruation, causing uterine
contractions that result in abdominal cramps.
It is at this stage at young females may have negative
attitude toward own sexuality.
Dysmenorrhea
• S/S-backache, weakness, decreased appetite, dizziness,
headache, and poor concentration.
• Symptoms subside when prostaglandin levels decrease.
• Treatment-heating pad, back message, nonsteroidal antiinflammatories, oral contraceptives.
Dysmenorrhea
• Secondary Dysmenorrhea-usually occurs after the age of
25 and is caused by endometriosis, pelvic inflammatory
disease, uterine polyps, or fibroids.
• Pain is usually a dull, lower abdominal pain that radiates to
the back or thighs.
• Treatment is the same as for primary dysmenorrhea.
Pelvic Relaxation Syndrome
• Occurs when the muscles, ligaments, and fascia that
support the pelvic floor weaken, the pelvic organs may
descend toward the vaginal orifice.
• Lack of estrogen results in weakening of tissue structure.
• May occur at any age.
Pelvic Relaxation Syndrome
• The descent of the pelvic organs may cause:
• Cystocele-bladder protrudes through the vaginal wall.
• Rectocele-rectum protrudes through the vaginal wall.
• Enterocele-uterus protrudes through the vaginal wall.
Pelvic Relaxation Syndrome
• S/S-relate to the specific organ involved. Eg.with a
cystocele, the patient may exhibit urinary incontinence.
• Nonsurgical treatment-lifestyle changes, avoid heavy
lifting. A pessary can be fitted in the vagina to support the
pelvic muscles. (Hard plastic ring)
Pelvic Relaxation Syndrome
• Surgical treatment:
• Anteroposterior repair (colporrhaphy) is the procedure to
repair a cystocele or rectocele.
• Hysterectomy-removal of the uterus.
Polycystic Ovarian Syndrome
• Congenital condition in which many cysts develop in one or
both ovaries.
• Excess estrogen is produced, along with high levels of
testosterone, and LH. Low levels of FSH occur.
• S/S -irregular menstruation, infertility, hyperinsulinemia,
and glucose tolerance problems, and excessive hair on the
body, (hirsutism).
• Treatment is usually with oral contraceptives.
Dysfunctional Uterine Bleeding
• Oligomenorrhea-decreased menstruation
• Amenorrhea-absence of menstruation.
• Metorrhagia-bleeding between menstrual periods.
• Menorrhagia-excessive menstrual bleeding.
Leiomyoma
• Also known as fibroids, benign tumors of the uterine
muscle.
• Common in women taking birth control pills.
• Spontaneously shrink during and after menopause.
• S/S -backache,sense of lower abdominal
pressure,constipation, urinary frequency or incontinence,
and abnormal uterine bleeding.
Leiomyoma
• Treatment-depends on the size and location of the fibroids.
• Nonsteroidal anti-inflammatories and oral contraceptives
may be prescribed.
Endometriosis
• Endometrial tissue is found outside uterus, particularly in
ovaries, in the rectovaginal septum, and in pelvis and
abdomen
• Continuous hormonal contraceptive therapy
Toxic Shock Syndrome
• Risk factors- prolonged use of high0absorbency tampons,
cervical caps, or diaphrams
• Symptoms
– Sudden spiking fever, flu-like symptoms, hypotension,
generalized rash resembling a sunburn, and peeling
skin on palms or soles
• Treatment: IV antimicrobial, good hand hygiene with
insertion of tampon, change tampon q 4hrs,diaphrams and
cervical caps should not be in for long time and not used
during menstruation
Cancer of the Repro Tract
• Vulvar Cancer-growth of abnormal tissue on the vulva.
• Occurs most commonly in elderly women.
• S/S -red, brown, or white patches on the skin of the vulva.
• Treatment includes surgical removal of the pathologic
tissue.
• Vulvar cancer is rare, may be associated with the HPV
virus.
Cancer of the Cervix
• Second leading cause of death in women 20 to 29 years of
age.
• Risk factors: multiple sex partners, sexual intercourse
with uncircumcised males, starting intercourse at a young
age, multiple pregnancies, obesity, hx of HPV, or STI.
Cancer of the Cervix
• Treatment-may include cryosurgery,electrosurgical
incision, or surgical conization.
• Advanced cervical cancer may require a hysterectomy,
followed by chemotherapy or radiation.
Cancer of the Uterus
• The most common malignant tumor of the reproductive
tract is endometrial cancer.
• Slow growing, often occurs after menopause.
• Treatment of choice is a hysterectomy, with bilateral
salpingo-oophorectomy.
• Surgery is usually followed by chemo and radiation.
Cancer of the Ovary
• Approximately 70% of ovarian tumors are benign.
• Known as the "silent cancer” because the s/s are usually
vague and non- specific.
• S/S -abdominal pain, feeling full quickly when eating,
frequent or urgent need to urinate, increased abdominal
girth.
• Treatment is a panhysterectomy, followed by chemo and
radiation.
Disorders of the Breast
• Fibroadenoma -commonly found in teenagers and young
adults.
• Firm, rubbery, mobile nodules of fibrous and glandular
tissue.
• Usually occur in upper outer quandrant of the breast.
• A fine-needle aspiration or biopsy may be performed to
determine the presence of cancerous cells.
Fibrocystic Breast Changes
• (FBCs)-commonly occurs during the reproductive years.
• Palpable, thickening portions of the breast associated with
pain and tenderness.
• More painful during the menstrual cycle.
• Treatment is conservative, vitamin E supplements, limiting
caffeine, alcohol, use of non-steroidal anti-inflammatory
drugs.
Intraductal Papilloma
• Development of small elevations in the epithelium of the
ducts of the breasts under the areola.
• Ducts erode causing a serosanguinous discharge from the
nipple.
• Treatment includes excision of the mass and analysis of
the discharge to determine if cancer cells are present.
Breast Cancer
• The United States has a high incidence of breast cancer.
• Incidence is higher in white women than rates for African
American or Asian women.
Risk Factors for Breast Cancer
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Family history of a relative with breast cancer.
Early menarche, late menopause.
Late first pregnancy or no children.
Abnormal cells in previous breast biopsy.
Obesity
Environmental exposure to hormone-modulating chemicals.
Inherited BRCA1 or BRCA2 gene.
Breast Cancer
• Development of breast cancer is thought to be related to
the hormones estrogen and progesterone.
• The genes BRAC1 & BRAC2 were identified as genes
involved in the inherited form of cancer.
• 80% of women with this gene develop breast cancer.
Breast Cancer
• Signs/Symptoms:
• 90% of breast lumps are detected by women during the
monthly breast exam.
• Most breast cancer can be detected by mammography
before it can be clinically palpated.
• A nipple discharge or dimpled skin may be a sign of breast
cancer.
Breast Cancer
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Prevention:
Healthy lifestyle
Foods high in antioxidants
Regular scheduled mammograms between the ages of 50
and 74.
• The drug Mifoxen is used to prevent recurrent breast
cancer.
• Women who have the BRCA1 or BRCA2 may elect to have
prophylactic bilateral mastectomies.
Breast Cancer
• Treatment-based on the type of breast cancer.
• Lumpectomy-removal of the tumor only.
• Partial or segmental mastectomy -removal of tumor and a
portion of the surrounding breast tissue and axillary lymph
nodes.
• Simple or total mastectomy -removal of entire breast and
axillary lymph nodes.
Breast Cancer
• Modified radical mastectomy -removal of breast, axillary
lymph nodes, and lining over chest wall muscles.
• Radical mastectomy - removal of breast, axillary lymph
nodes, and chest muscles under breast.
Breast Cancer
Bilateral Mastectomy
Breast Reconstruction
Breast Cancer Surgery
Preoperative Care
• Educational programs
• Reach to Recovery
• Make sure patient has an understanding of procedure
Postoperative Care
• Pain Management
• Observation for s/s of infection
• Support and educational measures
• Encourage support groups
• Body image issues
Complications
• Lymphedema -swelling of the arm due to damage to the
lymphatic tract.
• Post-op Infection.
• Educate patient on providing meticulous skin care.
• Instruct patient to elevate arm.
• No BP or labs in affected arm.
• Compression garments.
• Post-op exercises.
Postop Complications
Lymphedema
Compression Garment