Você está na página 1de 252

GYNECOLOGIC

NURSING
Anatomy Recall
Common Gynecological Complaints
 Vaginal discharge
 Vaginal/ Vulvar pruritus
 Genital ulceration
 Inguinal lymphadenopathy
 Pelvic mass
 Dyspareunia
 Pelvic pain
 Vaginal bleeding
 Amenorrhea
COMMON GYNECOLOGIC
PROBLEM
 VULVOVAGINITIS
 SALPHINGITIS
 PREMENSTRUAL SYNDROME
 PRIMARY DYSMENORRHEA
 SECONDARY DYSMENORRHEA
 ENDOMETRIOSIS
Gynecological Infections
Lower genital tract Sexually Transmitted
 Vulvitis Diseases/ Infections
 Vaginitis (STD/ STI)
 cervicitis  Bacterial
 Viral
Upper genital tract  Others
 Endometritis
 Pelvic inflammatory disease
(PID)
Diagnostic Tests
 Bloodwork  Genital tract biopsy
- CBC - vulvar
- HCG - vaginal
- LH, FSH, TSH, PRL - endometrial

 Imaging
 Vaginal/ endocervical
culture
- Ultasound  VDRL
- Hysterosalpingography  Papanicolau Smear
- Sonohystography  Colposcopy
 Laparoscopy
VULVOVAGINITIS
 Infectious diseases and other inflammatory
conditions affecting the vaginal mucosa and
involving vagina
 CAUSES
 Bacteria- gardnerella vaginalis
 Protozoa – trichomonas vaginalis
 Candida
 Human papilloma virus (HPV)
Causes ( irritation)
 Frequent douching
 Deodorant spray
 Laundry soap and fabric softener
 Bath water additives
 Tight non-porous, non-absorbent underclothing
 Poor hygiene
 Coital lubricant
 Latex in diaphragm or condom
VULVOVAGINITIS
 Manifestation
 Vaginal discharge
 Candida – thick, cheesy discharge
 Bacterial vaginosis – The fishy smell is stronger after sexual
intercourse , thin, milky white discharge that clings to the
walls of the vagina
 Trichomonas – painful urination, painful sexual intercourse,
and a yellow-green to gray, foul smelling, sometimes frothy,
vaginal discharge.
 Vulvar irritation
 Pruritus
 Burning pain
Management
 Complete physical examination & history
 Note the discharge ( color, consistency, presence
of odor, duration and symptoms )
 Vulva is examined for redness, edema and
excoriation and abnormal lesion
 sample of the vaginal discharge for tests and
microscopic analysis.
 Vaginal culture
 Pap smear
 Treatment
 Specific causes of discharge require specific
therapy
 Candida – miconazole 2% or clotrimazole 1%
cream, vaginal tablet or suppositories x3-7days
 Trichomonas – metronidazole 500mg BID p.o x
5days or 250 mg tid. Sexual partner also treated.
douche

Nursing care
 Patient Education
 Vaginal infections may be prevented by following
these suggestions:
 Over-the-counter yeast infection treatments should not be
taken unless the woman had been diagnosed with
candidiasis before and recognizes the symptoms.
 Douching should be avoided because it may disturb the
balance of organisms in the vagina and may spread them
higher into the reproductive system.
 A vaginal douche is a process of rinsing or cleaning the
vagina by forcing water or another solution into the vaginal
cavity to flush away vaginal discharge or other contents.
Nursing care
 Thoroughly dry oneself after bathing and remove a
wet bathing suit promptly.
 Avoid wearing tight clothing and wear cotton
underwear.
 Clean diaphragms, cervical caps, and spermicide
applicators after use. Use condoms to avoid
sexually transmitted disease.
 After a bowel movement, wipe from front to back
to avoid spreading intestinal bacteria to the
vagina.
 Antioxidant vitamins, including A, C, and E,
as well as B complex vitamins, and vitamin
D, are recommended.
 Foods to avoid include cheese, alcohol,
chocolate, soy sauce, sugar, fruits, and any
fermented foods.
 Wearing cotton underwear and loose fitting
clothes and avoiding panty hose can help
keep the vagina cool and dry, thus helping
to prevent some forms of vulvovaginitis.
CANDIDA VAGINITIS

 vulvovaginitis candidiasis/ yeast vaginitis/ yeast or fungus/


Moniliasis

 second most common cause of abnormal vaginal discharge


 common cause:
Candida albicans
Predisposing factors
 Repeated courses of systemic or topical antibiotics
 Diabetes especially when uncontrolled
 Pregnancy
 Obesity
 Use of corticosteroids and exogenous hormones
 Local allergic or hypersensitivity reaction
Signs and Symptoms
 Thick, curd-like/ cheeselike, white discharge that has no
odor
 Vaginal erythema, edema and tenderness
 Itchiness of the vulva
 Dryness
 Painful urination especially when urine flows in the
vulva
 Dyspareunia
Diagnosis
 Vaginal pH is normal (if > 4.5 suspect trichomoniasis or
bacterial vaginosis)
 KOH wet smear- pseudohyphae

Treament
 Oral agent: Fluconazole 150 mg (single dose)
 Vaginal agents: antifungal preparation (fungicidal azole
creams: Clotrimazole, Miconazole) for 3 to 7 days
 Nystatin –vaginal suppository twice a day for 7 to 14
days or
 Clotrimazole vaginal suppository at bedtime for 7 days
or
 Miconazole nitrate vaginal cream applied nightly for 7
days
Nursing interventions
Client teaching:
 not wearing underwear to bed
 wearing cotton-crotched underwear
 completing full course of treatment even during menstruation
 avoiding feminine sprays, deodorants, scented pads
(allergies and irritation)
 Vitamin C, live culture yogurt - increase vaginal acidity
 Local application of anti fungal agents (eg, Nystatin)
 Inform the patient that the disease can be transmitted to the
newborn leading to the development of ORAL THRUSH
Home Remedies:
 Vaginal douche of two teaspoons ordinary baking

powder dissolved in one quart of warm water


 Application of gentian violet to the vagina &

perineum. Use sanitary pad to prevent staining of


undergarments.
BARTHOLIN’S CYST
 occlusion of a duct with mucus retention resulting in a
nontender mass approx. 1-4cm in size

Causes
 if the duct becomes
blocked for any reason:
infection,
injury or chronic
inflammation
 Very rarely, caused by
cancer
 Unknown (many cases)
BARTHOLIN’S CYST
Causative organisms: Staphylococcus aureus
(others: S. fecalis, E. coli, N. gonorrhea, C. thromatis)

Symptoms:
 Bartholin’s Cyst (asymptomatic)
 Bartholin’s Abscess - pain or tenderness, dyspareunia

Diagnosis
 clinical

Management
 incision and drainage
 marsupialization – entire abscess is incised and sewn open
 Word catheter for 2 – 4 weeks
 broad spectrum antibiotic
BARTHOLIN’S CYST
Nursing interventions
 Teach the importance of completing the course of
antibiotic
 Teach the importance of good hygiene
 Sitz bath – for both pain relief and to decrease healing
time
SALPHINGITIS

 Acute salpingitis is a gynecologic condition


consisting of infection and inflammation of
the oviducts.
 the terms acute salpingitis and pelvic
inflammatory disease (PID) are used
synonymously to describe acute infection of
the female upper genital tract.
 Infection of the fallopian tubes
SALPHINGITIS

 AT RISK
 Occur predominantly in women under 35 yrs old
 Sexually active
 Child birth ( peurperal fever)
 Abortion
 IUDs
SALPHINGITIS

 CAUSES:
 Chlamydia trachomatis 15-75 %
 Neisseria gonorrhea
 Other associated organisms include Ureaplasma
urealyticum, Mycoplasma genitalium,
Trichomonas vaginalis, Gardnerella vaginalis,
and mixed anaerobic and aerobic bacteria
SALPHINGITIS

 SYMPTOMS
 Onset usually shortly after menses
 Lower abdominal pain progressive
 With guarding
 Rebound tenderness
 Discomfort increases with cervical motion
 Vomiting
 Bowel normal initially  paralytic ileus
 Copious purulent cervical discharge
 High fever
SALPHINGITIS

 Complication
 Abscess may develop in
 Tubes
 Ovaries
 pelvis
DIAGNOSIS
 History of:
 recent coitus
 Insertion of IUD
 Childbirth
 Abortion
 Temperature elevation
 CBC
 Wbc elevated
 Culture & smear for Gram stain
 Culdocentesis – examination of fluid
 Laparoscopy
SALPHINGITIS

 TREATMENT:
 Stop infection to prevent infertility
 Antibiotic-PO antibiotics for a full 2-week course
 NURSING CARE
 Examination & treatment of sexual contact
 Treat all sex partners that the patient has had within the 60
days prior to symptom onset.
 Patient education
 Women should remain abstinent from sexual activity until
they are cured of symptoms and they have completed their
full regimen of antibiotics
Patient education
 Primary prevention involves avoiding either
exposure to STDs or acquisition of infection
following exposure.
 Counsel patients regarding safe sex practices in
a manner appropriate to both the patient's
understanding of sexual issues and stage of
development.
 Advise patients to avoid high-risk sex partners
and limit their number of sex partners.
 Patients who present for STD evaluation should
be given hepatitis B vaccination.
SEXUALLY
TRANSMITTED
INFECTION
SEXUALLY TRANSMITTED
DISEASES/INFECTION ( STD/STI)
 Trichomoniasis
 Chlamydia
 Gonorrhea
 Syphilis
 Herpes simplex
 Condylomata acuminatum
TRICHOMONIASIS

 protozoan infection: Trichomonas vaginalis

Signs and Symptoms


 Frothy yellow-green malodorous vaginal discharge
 “strawberry” cervix
 Vaginal irritation & inflammation
 Dyspareunia
 Dysuria
 Vulvar itching

Among males: usually asymptomatic


TRICHOMONIASIS

Diagnosis
 microscopic exam of vaginal discharge

-positive motile flagellated protozoa in a saline wet mount


 elevated vaginal pH 5.5+ (alkaline)

Management
 Sexual partner should receive oral treatment.
 Metronidazole (Flagyl) 500 mg BID for 7 days or a single 2 g
dose (contraindicated during pregnancy)
Home Remedy
 Acidic vaginal douche : 1 tablespoon vinegar with 1 liter
water to counteract the alkaline environment of the vagina
that favors the growth of Trichomonas vaginalis

A vaginal douche is a process of rinsing or cleaning


the vagina by forcing water or another solution into the
vaginal cavity to flush away vaginal discharge or other
contents

Nursing interventions
 Include sexual partner in treatment.
 Advise use of condom during intercourse
 Nursing alerts:
- Concurrent alcohol ingestion with Metronidazole causes
severe GI symptoms (Antabuse-like reaction)
- Metronidazole is associated with preterm labor,
premature rupture of membranes and postcesarean
infection
CHLAMYDIA

 most common cause of mucopurulent cervicitis


 most common bacterial STD in women
 caused by gram (-) bacterium Chlamydia trachomatis
 Vertical transmission to newborns may result in conjunctivitis and
otitis media
 Tends to coincide with gonorrheal infection

IP: 2-10 days

Risk Factors
 Sexual activity < 20 years
 Multiple sexual partners
 Lower socioeconomic status
 (+) others STDs
Signs and symptoms
 May be asymptomatic
 Gray white/ yellowish vaginal discharge
 Burning and itchiness
 Bleeding between periods
 Mucopurulent cervicitis
 Painful and frequent urination

Diagnosis
 (+) culture/ antigen detection test on cervical smear
 Polymerase chain reaction (PCR)
Management
 Doxycycline 100 mg PO BID for 7 days
(causes fetal long bone deformity if used in pregnancy)
 Azithromycin (Zithromax) 1 g PO in a single dose
 Erythromycin 500 mg QID for pregnant patient
 Patient may also be treated for gonorrhea with a single IM shot of
Ceftriaxone 250 mg
 Infant treated with Erythromycin ophthalmic ointment

Nursing interventions
Client teaching:
 Teach the importance of completing the course of antibiotic
 Use condom during sex
 Sexual partner should receive treatment
Complications
 Pelvic inflammatory disease (PID)
 Ectopic pregnancy
 Fetus transmittal (vaginal birth);
 may cause conjunctivitis
(also associated with premature rupture of membranes,
preterm labor and endometriosis, low birth weight and
perinatal mortality due to placental transmission)
GONORRHEA

 Morning drop, Clap


 Sexually transmitted disease caused by gram (-) Neisseria
gonorrhea, which causes inflammation of the mucus membrane
of the genito urinary tract

IP: 3-7 days

Signs and Symptoms


 Females: may be asymptomatic; may have purulent vaginal
discharge, pelvic pain and fever; dyspareunia
Males: Painful urination; purulent yellow penile discharge; urethritis
(decreased sperm count)
 Newborn: yellow discharge, both eyes
Diagnosis
 gram stain and culture of
cervical secretions on
Thayer Martin medium

Complications
 PID
 ectopic pregnancy
 infertility
 Chorioamnionitis
 ophthalmia neonatorum
in newborns (associated
with severe eye infection
and blindness)
 preterm delivery
 sterility & pelvic
inflammatory disease
Management (single dose only)
 Ceftriaxone (Rocephin) 125 mg IM (drug of choice for
pregnant women)
 Ofloxacin (Floxin) 400 mg orally
 Treat concurrently with Doxycycline or Azithromycin
for 50% infected w/ Chlamydia
 Ophthalmic ointment is routinely given as Crede’s
prophylaxis to prevent opthalmia neonatorum
(0.5% Erythromycin or 1% Tetracycline ointment for
newborn babies)
Nursing interventions

Health Teachings:
 Avoid sexual intercourse until cured of the
infection or use condom to prevent
transmitting the infection.
 Examination and treatment of sexual
partner to prevent reinfection is necessary.
 Return to clinic for check-up in 4 to 7 days
after completion of treatment.
 Monitor treatment
SYPHILIS

 caused by motile anaerobic spirochete Treponema pallidum


 “ beautiful” fast moving but delicate spiral thread
 can cross the placental barrier

IP: 10-90 DAYS

 can cause 100% fetal infection if primary and secondary


infection is untreated, and 6-14% fetal infection in latent
syphilis
• 2nd trimester infections cause spontaneous abortion, preterm
labor, stillbirth and congenital anomalies
• 3rd trimester infection causes enlarged liver, spleen, skin
rash and jaundice in a newborn
Signs and Symptoms

 Primary Stage - painless chancre on genitalia, anus or


mouth; most infectious stage

 Secondary Stage - about 2 months after primary


syphilis resolves; generalized maculopapular skin rash
including palms and soles
- painless condylomata lata on vulva
- hepato/ splenomegaly
- headache; anorexia; fever

 Latent syphilis – asymptomatic

 Tertiary Stage –most destructive stage;


neurosyphilis/permanent damage (insanity); gumma
(necrotic granulomatous lesions), aortic aneurysm
Primary – painless chancre Secondary – generalized
rash

Tertiary - gumma
PRIMARY
SECONDARY
TERTIARY
Diagnosis
 VDRL (venereal disease research laboratory test) or RPR
(rapid plasmin reagin) – nonspecific tests
- for screening and to follow treatment course (decrease
fourfold in 3-6 months)
 Fluorescent Treponemal Antibody AbsorptionTest
(FTA-ABS) or Microhemagglutination Assay for Antibodies to
TP (MHA-TP)– specific tests for syphilis
 Dark-field microscopic examination of lesion- 1st and 2nd
stage
Management
 Primary and secondary and early latent disease - Pen
G (Benzathine Penicillin G 2.4 M U IM)

- Alternatives: Tetracycline 500 mg orally QID or


Doxycycline 100 mg orally BID
 Tertiary - IV Pen G
 Erythromycin & Cefriaxone are the drugs of choice for
pregnant women

Complications
 Congenital syphilis in newborn if untreated in late
pregnancy
 Late abortion
 Stillbirth
Health Teachings :
 Educate women to recognize signs of syphilis.
 Educate women to seek immediate treatment if known
exposure occurs.
 Encourage women to wear cotton underwear.
 Use condom during intercourse.
Sexual partners must also be treated to prevent re-
infection.
 No sexual intercourse until lesions disappear
 After completion of treatment, the woman is treated
monthly & the sexual partner at 3 months, 6 mos & 12
mos.

 Fetus will not be affected if the mother is treated before


the 5th month. Emphasize the importance of screening
for syphilis during the first prenatal visit for early
detection & treatment.

 Inform patients treated with penicillin about Jarish


Herxheimer reaction, a reaction to penicillin
characterized by: fever, chills, malaise, headache,
nausea, & tachycardia. This is a normal reaction that
subsides within 24 hours.
HERPES GENITALIS
 Sexually transmitted disease caused by the Herpes
Simplex Virus 2 (HSV 2)

Signs and Symptoms


 Flulike symptoms (malaise, myalgia, nausea, fever)
 Vulvar burning and pruritus
 Painful vesicles (cervix, vagina, perineum, glans penis) 2
- 20 days after exposure
 Painful genital ulcer
 Recurrent episodes 1-6x a year (during stress, fever,
menstruation)
 Dyspareunia

Diagnosis
 Viral culture
 Pap smear (shows cellular changes)
 Tzanck smear (scraping of ulcer for staining) –
multinucleated giant cells
Management
 Antiviral agents – Acyclovir
200 mg PO q 4 hrs for 5
days
 Sitz bath
 Analgesics
Health teachings
Complications:
• NO sexual activity in the
 Meningitis
presence of lesions and 10-14
 Neonatal infection (vaginal days after lesions subsided
birth) • Keep vulva clean and dry in
 Trigeminal herpes zoster the presence of lesions
(facial muscle paralysis) (wearing of cotton underwear)
• Sitz bath

• use foley catheter if retention


persists
• Povidone- iodine douche and
acyclovir NOT used during
pregnancy
CONDYLOMA ACUMINATUM

 Genital warts
 Genital or venereal warts caused by Human Papilloma Virus
(HPV)
 May be a precursor to cervical cancer

 HPV types 6 & 11 – condyloma acuminatum


 HPV types 16, 18 and 31 – cervical cancer

Signs and Symptoms: Single or multiple dry soft, fleshy painless


(wartlike) growths on the vulva, vagina, cervix, urethra, or anal
area; penis
 Can evolve into larger cauliflower-like growths
 Vaginal bleeding, discharge, odor and dyspareunia
Diagnosis
 Clinical
 Pap smear-shows cellular
changes (koilocytosis)
Acetic acid swabbing (will
whiten lesion)

Management
 Small lesions – treated
topically with podophyllin or
trichloroacetic acid
 Larger lesions – ablated with
cryotherapy, laser
Complications vaporization or surgical
•Neoplasia excision.
•Neonatal laryngeal  Recurrence rate : 20%
papillomatosis
(vaginal birth)
Health Teachings
 Inform the patient that infection with the virus increases
the incidence of CERVICAL CANCER
 Therefore: Annual PAP smear is indicated
Pelvic Inflammatory Disease
 Caused by microorganisms colonizing
endocervix ascending to endometrium and
fallopian tubes
 Due to sexually transmitted microorganisms
ie Neisseria, Chlamydia, Haemophilus
influenza, streptococci
Risk Factors
 Multiple sexual partners
 History of PID
 Early onset sexual activity
 Recent gyne procedure
 IUD
Manifestations
 pelvic pain – sharp and cramping
 Fever
 Excessive vaginal discharge
 Menorrhagia
 Metrorrhagia
 Urinary symptoms
 Cervical uterine tenderness with movement
Diagnostics
 History and PE
 CBC
 Vaginal and endocervical culture
 VDRL
 Endometrial biopsy - endometritis
 Sonography – tubo-ovarian abscess
 Laparoscopy - salpingitis
Management
 Antibiotics
 IV fluids/increase oral fluid
 Pain medications
 Remove IUD
 Evaluation of sexual partners
Toxic Shock syndrome
 Reproductive age, near menses or postpartum period
 D/t S. Aureus
 R/t use of tampons, cervical cap or diaphragm

Manifestations: fever, rash on trunk, desquammation of skin,


hypotension, dizziness, vomiting, diarrhea, myalgia, inflamed
mucous membranes
Diagnostics:
Elev BUN, Crea
Elev AST, ALT, total bilirubin
Dec platelets

Management:
IV fluids
Antibiotics
renal dialysis
Client education – change tampons 3-6 hours, avoid
tampons 6-8 wks after childbirth, do not leave
diaphragms>48 hours
PMS
PREMENSTRUAL SYNDROME
(PMS)
 it has such a wide variety of signs and
symptoms.
 Mood swings, tender breasts, food cravings,
fatigue, bloatedness, irritability and depression
are among the most common symptoms of PMS.
 Occurs during the 7-10 days before menstruation
and disappear few hours after the onset of
menstrual flow
PREMENSTRUAL
SYNDROME (PMS)
CAUSES
Unknown
Fluctuation in estrogen and
progesteron
PMS
Treatment
Symptomatic relief
Tranquilizer as prescribed
Dietary changes : increasing protein,
decreasing sugar + vitamin B complex
counseling
DYSMENORRHEA
Dysmenorrhea

 Is a menstrual condition characterized by


severe and frequent menstrual cramps and
pain associated with menstruation.
 Dysmenorrhea may be classified as
primary or secondary.
 Primary dysmenorrhea (Functional)- cyclic pain
associated with menses during ovulatory cycles
but without demonstrable lesions affecting the
reproductive structure
 Secondary dysmenorrhea ( Acquired) - due to
some physical cause and usually of later onset;
painful menstrual periods caused by another
medical condition present in the body (i.e., pelvic
inflammatory disease, endometriosis).
What causes dysmenorrhea?

 The cause of dysmenorrhea depends on


whether the condition is primary or
secondary.
 primary dysmenorrhea experience
abnormal uterine contractions as a result of
a chemical imbalance in the body
(particularly prostaglandin and arachidonic
acid - both chemicals which control the
contractions of the uterus).
What causes dysmenorrhea?

 Secondary dysmenorrhea
 most often endometriosis
 pelvic inflammatory disease (PID)
 uterine fibroids
 abnormal pregnancy (i.e., miscarriage, ectopic)
 infection, tumors, or polyps in the pelvic cavity
Who is at risk for dysmenorrhea?

 any female can develop dysmenorrhea


 increased risk for the condition:
 females who smoke
 females who drink alcohol during menses
(alcohol tends to prolong menstrual pain)
 females who are overweight
 females who started menstruating before the age
of 11
symptoms of dysmenorrhea
Each adolescent may experience symptoms differently.

 cramping in the lower abdomen


 pain in the lower abdomen
 low back pain
 pain radiating down the legs
 nausea
 vomiting
 diarrhea
 fatigue
 weakness
 fainting
 headaches
 Start before or with menses and Peak 24Hrs and subsides after 2
days
Diagnosis
 Medical history and a complete physical examination
 Pelvic examination.
 ultrasound (Also called sonography.) –
 magnetic resonance imaging (MRI) –
 laparoscopy - a minor surgical procedure in which a
laparoscope, a thin tube with a lens and a light, is inserted
into an incision in the abdominal wall. Using the laparoscope
to see into the pelvic and abdomen area.
 hysteroscopy - a visual examination of the canal of the cervix
and the interior of the uterus using a viewing instrument
(hysteroscope) inserted through the vagina.
Nursing care
 Patient education
 Primary dysmenorrhea
 Assurance that her reproductive organ are normal will
give a physiologic support
 prostaglandin inhibitors (i.e., nonsteroidal anti-
inflammatory medications, or NSAIDs, such as aspirin,
ibuprofen) - to reduce pain – given 24-48H before mense
& continued through 1-2 days of the cycle
 acetaminophen
 oral contraceptives (ovulation inhibitors)
 progesterone (hormone treatment)
 dietary modifications (to increase protein
and decrease sugar and caffeine intake)
 vitamin supplements
 regular exercise
 heating pad across the abdomen
 hot bath or shower
 abdominal massage
 Secondary dysmenorrhea
 Relieved symptomatically or by correction of
underlying abnormality
 Counseling regarding symptoms may increase
understanding and lead to activities for stress
management.
Endometriosis

 Endometrial tissue outside the uterine cavity.


 when cells from the uterus, called endometrial cells, are
found outside the uterus. The cells attach to other organs.

 Pelvis most common location


 Bleeding results to inflammation, scarring of
peritoneum and adhesions
 Cause unknown
 Common in 20-45 yrs old
Endometriosis
Common Sites 0f Endometriosis Formation
Risk Factors:

 Retrograde menstrual flow of endometrium


 Physiologic disruption after gyne surgery or
cesarean birth
 Hereditary
 Possible immunologic effect
Manifestations:

 Pelvic pain – dull/cramping, r/t menstruation


 Dyspareunia
 Abnormal uterine bleeding
 Fixed tender retroverted uterus
 Palpable nodules in the cul de sac

 Diagnostics:
 laparoscopy
Management:

 OCP-combination contraceptives to induce amenorrhea


 Analgesics
 NSAIDS
 Danazol – antiprogesterone; suppresses GnRH, low estrogen
and high androgens to suppress ovulation, promote
amenorrhea and decrease endometrial support
 GnRH agonists ie leuprolide suppress the menstrual cycle
through estrogen antagonism
 Progestins ie Medroxyprogesterone – antiendometrial effect
AMENORRHEA

 Amenorrhea — the absence of menstruation —


can happen during puberty or later in life.
 2 types
 Primary amenorrhea describes a condition in which you
haven't had any menstrual periods by age 16.
 Secondary amenorrhea occurs when you were previously
menstruating, but then stopped having periods.
 Pregnancy – most common
Symptoms

 No menstrual period
 Primary amenorrhea. You have no menstrual
period by age 16.
 Secondary amenorrhea. You have no periods for
three to six months or longer.
 Depending on the cause of amenorrhea,
 milky nipple discharge
 headache
 vision changes
 excessive hair growth on your face and torso (hirsutism).
Causes
Primary amenorrhea
 Affects less than 1 percent of adolescent girls
 The most common causes of primary
amenorrhea include:
1. Chromosomal abnormalities.
2. Problems with the hypothalamus.
 Functional hypothalamic amenorrhea is a disorder of the
hypothalamus — an area at the base of the brain that acts
as a control center for the body and regulates the menstrual
cycle.
 Excessive exercise, eating disorders, such as anorexia, and
physical or psychological stress can all contribute to a
disruption in the normal function of the hypothalamus.
 Less commonly, a tumor may prevent your hypothalamus
from functioning normally.
Causes
Primary amenorrhea

3.Pituitary disease. The pituitary is another gland in the brain


that's involved in regulating the menstrual cycle. A tumor or
other invasive growth may disrupt the pituitary gland's ability
to perform this function.
4.Lack of reproductive organs. Sometimes problems arise
during fetal development that lead to a baby girl being born
without some major part of her reproductive system, such as
her uterus, cervix or vagina. Because her reproductive
system didn't develop normally, she won't have menstrual
cycles.
5.Structural abnormality of the vagina. An obstruction of the
vagina may prevent visible menstrual bleeding. A membrane
or wall may be present in the vagina that blocks the outflow
of blood from the uterus and cervix.
Causes : Secondary amenorrhea

 Secondary amenorrhea is much more common


than primary amenorrhea.
 Many possible causes of secondary amenorrhea
exist:
 Pregnancy-most common cause of amenorrhea.
 Contraceptives. Some women who take birth control pills
may not have periods. When oral contraceptives are
stopped, it may take three to six months to resume regular
ovulation and menstruation.
Causes : Secondary amenorrhea

.
 Breast-feeding. Mothers who breast-feed often
experience amenorrhea. Although ovulation may
occur, menstruation may not. Pregnancy can
result despite the lack of menstruation.
 Stress. Mental stress can temporarily alter the
functioning of your hypothalamus —Ovulation and
menstruation may stop as a result. Regular
menstrual periods usually resume after your
stress decreases.
Causes : Secondary amenorrhea
.
 Medication. antidepressants, antipsychotics, some
chemotherapy drugs and oral corticosteroids

 Illness. Chronic illness may postpone menstrual periods.


As you recover, menstruation typically resumes.

 Hormonal imbalance. A common cause of amenorrhea


or irregular periods is polycystic ovary syndrome
(PCOS).
 This condition causes relatively high and sustained levels of
estrogen and androgen, a male hormone, rather than the
fluctuating levels seen in the normal menstrual cycle. This results in
a decrease in the pituitary hormones that lead to ovulation and
menstruation.
 PCOS is associated with obesity; amenorrhea or abnormal heavy
uterine bleeding; acne and sometimes excess facial hair.
Causes : Secondary amenorrhea
 Low body weight.
 interrupts many hormonal functions in your body, potentially
halting ovulation. Women who have an eating disorder, such as
anorexia or bulimia,
 Excessive exercise. Women who participate in sports that
require rigorous training, such as ballet, long-distance running
or gymnastics, may find their menstrual cycle interrupted.
 Several factors combine to contribute to the loss of periods in
athletes, including low body fat, stress and high energy
expenditure.
 Thyroid malfunction.
 hypothyroidism commonly causes menstrual irregularities,
including amenorrhea.
 Thyroid disorders can also cause an increase or decrease in
the production of prolactin — a reproductive hormone
generated by the pituitary gland.
 An altered prolactin level can affect the hypothalamus and
disrupt the menstrual cycle.
Causes : Secondary amenorrhea

 Pituitary tumor.
 A noncancerous (benign) tumor in the pituitary gland
(adenoma or prolactinoma) can cause an overproduction
of prolactin. Excess prolactin can interfere with the
regulation of menstruation. This type of tumor is treatable
with medication, but it sometimes requires surgery.
 Uterine scarring.
 Asherman's syndrome, a condition in which scar tissue
builds up in the lining of the uterus,
 occur after uterine procedures, such as a dilation and
curettage (D and C)
 Caesarean section or treatment for uterine fibroids.
 Uterine scarring prevents the normal buildup and
shedding of the uterine lining, which can result in very
light menstrual bleeding or no periods at all.
Causes : Secondary amenorrhea

 Premature menopause.
 Menopause usually occurs between ages 45
and 55.
 If menopause before age 40,  premature.
 The lack of ovarian function associated with
menopause decreases the amount of circulating
estrogen in the body, which in turn thins the
uterine lining (endometrium) and brings an end to
the menstrual periods.
 Premature menopause may result from genetic
factors or autoimmune disease, but often no
cause can be found.
Nursing care
 Patient education
 For primary or secondary amenorrhea, consult :
 never had a menstrual period, and you're age 16
or older
 previously menstruated, but have missed three or
more periods in a row
Tests and diagnosis

 Not life threatening


 Finding the underlying cause and may require
more than one kind of testing.
 History and physical assessment
 pregnancy test.
 perform a pelvic exam
 In young women, check for signs and symptoms
of changes that are normal to puberty.
Tests and diagnosis

 Blood tests
 hormone levels,
 thyroid function test or evaluation of prolactin level.
 A progestin challenge test — in which they take a hormonal
medication (progesteron) for seven to 10 days to trigger bleeding
 Imaging tests
 computerized tomography
 magnetic resonance imaging
 ultrasound, can reveal pituitary tumors or structural
abnormalities in your reproductive organs.
 laparoscopy or hysteroscopy — minimally invasive surgical
techniques to view the internal organs — may sometimes be
recommended.
Nursing care
 if any — depends on what's causing the
amenorrhea.
 suggest that they make changes to their lifestyle
depending on their weight, physical activity or
stress level.
 If with PCOS or athletic amenorrhea, may
prescribe oral contraceptives to treat the
problem.
 Amenorrhea caused by thyroid or pituitary
disorders may be treated with medications.
DYSFUNCTIONAL UTERINE
BLEEDING ( DUB)
 is the most common cause of abnormal
vaginal bleeding during a woman's
reproductive years.
 The diagnosis of DUB should be used only
when other organic and structural causes
for abnormal vaginal bleeding have been
ruled out.
 AUB- diagnosis referring to any uterine
bleeding that is irregular in amount,
duration, or timing
 DUB- most common type of AUB and is
frequently defined as irregular uterine bleeding
unrelated to organic pathology, medication,
pregnancy related disorders, systemic condition,
 causes of AUB:
1. pregnancy-ectopic, spontaneos abortion
2.endocrine problem- cushing
syndrome,diabetes
3.medication-
amphetamines,anticoagulants,steroids,INH,SS
RIs
4. systemic dse.- thyroid
dysfunction,leukemia,ITP
 Types:
 1.anovulatory DUB- due to lack of progesterone in
the luteal phase of anovulatory cycles leads to
unstable ,excessively vascular endometrium, often lead
to abnormal cycle interval, or abnormal amount of
bleeding
 2. ovulatory DUB- are regular and tend to be
cyclic,although the bleeding pattern are often
abnormal,menorrhagia is commonly observed and is
commonly associated with pelvic pathology
 Causes of anovulation:
 Physiologic:
 Pregnancy
 Lactation
 Perimenarche
 Perimenopause
 Pathologic causes:
 Hyperandrogenic disorder
 Hyperprolactinemia
 Extreme stress
 s/sx: uterine bleeding
 Physical Examination:
 1. pelvic examination
 2.Speculum examination
 3. bimanual examination
 Management:Goal:1. normalize the
bleeding
2. correct any anemia
3. restore quality of life
4.prevent cancer
1. medication – oral contraceptives
2. surgery- D and C, Hysterectomy
Management
 pelvic ultrasonography.
 Transvaginal ultrasonography (TVUS): if the
patient may be pregnant or may have anatomic
problems or polycystic ovarian syndrome.

 D & C- can be both therapeutic and diagnostic. It


may be the treatment of choice when bleeding is
severe, and it allows more extensive sampling of
the uterine cavity and also has a higher sensitivity
than endometrial biopsy.
 Hysteroscopy can be used in place of D&C and
allows direct visualization of the endometrial
cavity with directed biopsy.
 Pelvic examination
 Before instituting therapy,
 perform an endometrial sampling or endometrial biopsy to
diagnose intrauterine pathology and to exclude endometrial
malignancy.
 Perform endometrial biopsy for the following patients:
 All patients older than 35 years
 Obese patients
 Patients with diabetes mellitus
 Patients with hypertension
 Patients with suspected polycystic ovarian disease

 D&C is indicated in the following situations:
 Consider D&C in patients at high risk for endometrial
hyperplasia and carcinoma.
 Consider D&C rather than endometrial biopsy if suspected
diagnosis is endometritis, atypical hyperplasia, or
carcinoma.
 Perform in patients having heavy, uncontrolled bleeding.
 Perform if histologic examination is required but biopsy is
contraindicated.
 Perform if medical curettage fails.
 Medical management
 Estrogen therapy
 Conjugated estrogen ( 10 mg/day) controls most acute
bleeding in 24hrs
 Progestin Therapy ( Provera)
 Both hormones is continued 7-10 days
 For acute profuse DUB
 Parenteral estrogen- bleeding stop in 12Hrs
 Progestin must be started at the same time
 Oral contraceptive for 3 months to prevent
recurrence
Nursing care
 Physical assessment & history
 Monitor vital sign
 Monitor bleeding
 Monitor I & O
 Administer IVF as prescribed
 Nursing priority : Bleeding
 Informed consent for the procedure
 Emotional support
Disturbance in sexuality
to women
Dyspareunia
Vaginismus
What is Dyspareunia?
 Vaginal pain after sexual intercourse.
 Painful sexual intercourse.
TYPES Dyspareunia
1. Superficial dyspareunia: Pain or
dysfunction felt upon initial penetration
2. Deep dyspareunia: Pain or dysfunction
felt deep within the pelvis during
intercourse
CAUSES Dyspareunia
 Poor vaginal lubrication
 Reduced libido
 Reduced estrogen
 Vaginal dryness
 Inadequate foreplay
 Menopause
 Perimenopause
 Lactation - causes vaginal dryness
Dyspareunia
 Post-childbirth
 Episiotomy - if performed for childbirth
 Vaginal infection
 Cystitis
 Urethritis
 Vaginal infection
 Vulva infection
 Atrophic vaginitis
 Vaginal changes from childbirth
CAUSES Dyspareunia

 Narrow vaginal
 Hymen
 Psychological disorders
 Anxiety
 Vaginismus
 Endometriosis
 Hemorrhoids
CAUSES Dyspareunia
 Pelvic infection
 Pelvic inflammatory disease
 Genital tract tumor
 Vaginal tumors
 Vaginal surgery
 Pelvic disorders
 Sexual organ disorders
 Some causes of deep penetration intercourse pain in women
include:
 Pelvic inflammatory disease
 Pelvic tumor
 Irritable bowel syndrome
MANAGEMENT Dyspareunia
 History and physical examination with pelvic and rectal
exams
–Timing: Onset (e.g., upon entry, after intercourse), duration,
persistence after intercourse, prior occurrence(s)
–Associations: Symptoms may occur with all vaginal or vulvar
contact, with intercourse only, with exams only, with
masturbation, or with memories or recollections of prior
occurrences or traumatic experiences
–Alleviating and aggregating factors during intercourse
–Qualifiers: Burning, sharp, dull, aching, throbbing, stabbing
–Include complete psychiatric history and exam
Dyspareunia
 Routine studies include a CBC, sedimentation
rate, urinalysis, urine culture and sensitivity, and
vaginal smear and culture.
 A Pap smear should also be done.
 If pregnancy is suspected, a pregnancy test
should be done.
 If there is a pelvic mass, pelvic ultrasound may be
helpful.
MANAGEMENT Dyspareunia
 Imaging studies
 pelvic and/or abdominal ultrasound and/or CT
scan
 Management of psychiatric causes is
particularly challenging and requires
specific and specialized therapy
 Consider gynecology and/or psychiatry
consult
TREATMENT Dyspareunia
 Treatment varies depending on
etiology
 Psychological causes may require counseling
with behavioral feedback and/or pharmacological
treatment
 Symptoms refractory to initial treatment of proper
duration require prompt reconsideration and
further workup
 Referral may be necessary for specialized cases
or cases with psychiatric components
Vaginismus:
 Vaginal entrance muscle spasms triggered
by sex
 Involuntary contraction of muscle at the
outlet of the vagina when coitus is
attempted prohibiting penile penetration.
CAUSES
1. Fear of sex
2. Unpleasant sexual experience
3. Negative attitude to sex
TREATMENT
PSYCHOLOGICAL COUNSELLING
Prognosis of Vaginismus
Most women recover to normal sex
life and motherhood with treatment.
SEXUAL
DYSFUNCTION IN
MALE
Erectile dysfunction
impotence
Erectile dysfunction ( impotence)
 Inability of the man to produce or maintain
erection , long enough for vaginal
penetration or partner satisfaction.
 Formerly called impotence
Causes:
Erectile dysfunction ( impotence)
 Physical cause
 Common causes of erectile dysfunction
include:
 Heart disease
 Clogged blood vessels (atherosclerosis)
 High blood pressure
 Diabetes
 Obesity
 Metabolic syndrome
Causes:
Erectile dysfunction ( impotence)
 Other causes of erectile dysfunction include:
 Certain prescription medications -antidepressants,
antihistamines and medications to treat high blood
pressure, pain and prostate cancer
 Tobacco use
 Alcoholism and other forms of drug abuse
 Treatments for prostate cancer
 Parkinson's disease
 Multiple sclerosis
 Hormonal disorders such as low testosterone
(hypogonadism)
 Surgeries or injuries that affect the pelvic area or spinal
cord
 Psychological causes of erectile
dysfunction

 Depression
 Anxiety
 Stress
 Fatigue
 Poor communication or conflict with your partner
 Ultrasound. This test can check blood flow to your penis.
 Neurological evaluation.
 Dynamic infusion cavernosometry and cavernosography
(DICC).
 This procedure involves injecting a dye into penile blood
vessels to permit view any possible abnormalities in blood
pressure and flow into and out of your penis. It's generally done
with local anesthesia by a urologist who specializes in erectile
dysfunction.
 Nocturnal tumescence test.
 A simple test that involves wrapping a special perforated tape
around the penis before going to sleep can confirm whether you
have erections while you're sleeping. If the tape is separated in
the morning, your penis was erect at some time during the
night. Tests of this type confirm that there is not a physical
abnormality causing erectile dysfunction, and that the cause is
likely psychological.
 Oral medications
Oral medications available to treat ED include:
 Sildenafil (Viagra)
 Tadalafil (Cialis)
 Vardenafil (Levitra)
 ACTION :
 Chemically known as phosphodiesterase inhibitors, these
drugs enhance the effects of nitric oxide, a chemical that
relaxes muscles in the penis. This increases the amount
of blood flow and allows a natural sequence to occur —
an erection in response to sexual stimulation.
 Hormone replacement therapy
For the small number of men who have testosterone deficiency,
testosterone replacement therapy may be an option.
 Penis pumps
 This treatment involves the use of a hollow tube with a hand-powered or
battery-powered pump. The tube is placed over the penis, pump is used to
suck out the air. This creates a vacuum that pulls blood into the penis.
 Once you achieve an adequate erection, slip a tension ring around the
base of the penis to maintain the erection. then remove the vacuum device.
The erection typically lasts long enough for a couple to have sex. remove
the tension ring after intercourse.
 Vascular surgery
This treatment is usually reserved for men whose blood flow has
been blocked by an injury to the penis or pelvic area.
 The goal of this treatment is to correct a blockage of blood flow to the penis
so that erections can occur naturally. But the long-term success of this
surgery is unclear.
 Penile pump

Penis pump
 Penile implants
The inflatable device allows to control when and how long
you have an erection, These implants consist of either an
inflatable device or semirigid rods made from silicone or
polyurethane. This treatment is often expensive and is
usually not recommended until other methods have been
considered or tried first. As with any surgery, there is a small
risk of complications such as infection.
 Psychological counseling and sex therapy

 Stress, anxiety or depression is the cause of erectile


dysfunction
 Counseling can help, especially when your partner participates.
Penile implant
Nursing care
 Patient education
 Limit or avoid the use of alcohol.
 Avoid illegal drugs such as marijuana.
 Stop smoking.
 Exercise regularly.
 Reduce stress.
 Get enough sleep.
 Get help for anxiety or depression.
 advised regular checkups and medical screening tests.
 Communicate with patient and partner openly
ANOMALIES &
MALFORMATION OF THE
REPRODUCTIVE ORGANS
Imperforate hymen
Congenital absence of vagina
Septate vagina
Uterine malformation
Imperforate hymen:
 Lack of opening in the vaginal hymen
 occurring in 0.1% of infant girls.
 No menstrual bleeding
 Enlarged uterus
S/S
 Amenorrhoea
 Cryptomenorrhea -A condition where menstrual
products are prevented from exiting the body by a partial
or complete obstruction.
 Dyspareunia
 Female infertility
 Haematocolpos- An accumulation of menstrual blood
in the vagina
 Haematometra -An accumulation of blood in the uterus
 Hematosalpinx
 Hydrometrocolpos -accumulation of secretions in the
vagina and uterus
 Physical exam

 Laboratory studies are not necessary in the


evaluation and treatment of imperforate
hymen.

 Abdominal and pelvic ultrasonography and


MRI
TREATMENT
 Medical therapy has no role in the
management of imperforate hymen

 SURGICAL MANAGEMENT
 Hymen incision
CONGENITAL ABSENCE
OF THE VAGINA
CONGENITAL ABSENCE OF THE
VAGINA

 The usual lesion consists:


 absence of the middle and upper vagina,
 total absence or a rudiment in the location of the uterus,
 an absence or one or both Fallopian tubes.
 The vagina may be totally absent, or represented
by a rudimentary pouch of up to one half to three
quarters of an inch deep.
Vaginal agenesis
CONGENITAL ABSENCE OF THE
VAGINA
 is a rare anomaly, 1: 5000 birth
 Known also as aplasia or dysplasia of the
Müllerian (paramesonephric) ducts.
 Referred to as ROKITANSKY-KUSTER-HAUSER
SYNDROME
 The external genitalia and vestibule, deriving from
the urogenital sinus, are normal.
 The sex chromatin pattern is female.
 endocrine system is not affected.
 Ovarian function is normal
CONGENITAL ABSENCE OF THE
VAGINA
 Cause :
 UNKNOWN
 no known gene is linked to this condition.
Diagnostic:

 Imaging studies
 UTZ
 MRI
 Laparoscopy provides only indirect assessment of uterine
cavitation.
 Laparoscopy is the preferred procedure when uterine
remnants or endometriosis cause cyclic pelvic pain
requiring excision.
 Pyelography: Perform intravenous pyelography to assess
renal structure.
 Radiography: Perform spinal radiography to exclude
vertebral anomalies
Management
 Treatment : Surgical
 Vaginal reconstruction
 modified McIndoe vaginoplasty
 Prognosis:
 The patient may have normal sexual functioning
after surgical reconstruction.
 Surgical reconstruction does not establish the
ability to conceive through natural means.
modified McIndoe vaginoplasty
DOUBLE / SEPTATE
VAGINA
vaginal septum is a congenital
partition within the vagina; such a
septum could be either longitudinal
or transverse.
Treatment

 Manual dilatation or surgical excision


 require a surgical procedure to resect the fibrous
septal tissue
 Complication:
 stenosis or scarring of the vagina in the area of
the transverse vaginal septum which can create
an "hour-glass" effect in the vagina.
Nursing care:
 Informed consent of procedure
 Patient Education
 Teach patient that after resection of the transverse vaginal
septum, she is required to use a vaginal dilator in order to
avoid this "hour-glass" effect of the healing process.
 Once the transverse vaginal septum has been surgically
corrected, tell her that she can be able to have normal
sexual relations and should also have no long-term effects
on reproductive function and the ability to have a child.
 Emotional support
UTERUS
 Approximately 0.1-3.2 % of women
have a uterine abnormality.
Many women will have an abnormality
without ever knowing anything about it,
because it has no effect on their fertility
or on their ability to give birth.
Uterine malformation Types
classification:

 Class I: Mullerian agenesis (absent uterus).

 Class II: Unicornuate uterus (a one-sided uterus).

 Class III: Uterus didelphys, (double uterus).

 Class IV: Bicornuate uterus (uterus with two horns).


 Class V: Septated uterus (uterine septum
or partition).
 Class VI: DES uterus.
 The uterine cavity has a "T-shape" as a result of
fetal exposure to diethylstilbestrol.
unicornuate uterus
 (a womb with one 'horn') happens when the
tissue that forms the womb does not
develop properly.
 very rare condition.
 A unicornuate uterus is just half the size of
a normal UTERUS and the woman has only
one fallopian tube. However, she usually
has two ovaries
Unicornuate uterus
 is smaller than a typical uterus and usually
has only one functioning fallopian tube. The
other side of the uterus may have what is
called a rudimentary horn.
 a second smaller hemi-uterus which is
obstructed
 If the rudimentary horn is obstructed,
 S/s
 an enlarging pelvic mass.
 painful menses/perimenstrual pain
 obstructed uterus does not have a means for the blood
to Regress or leave the body. This can result in pain.

 If the contralateral healthy horn is almost fully


developed, a full-term pregnancy is believed to
be possible
Unicornuate uterus
Most of the time it does not cause
any gynecologic or obstetric problem
Unicornuate uterus
DIAGNOSTIC
 Imaging studies
 Hysterosalpingography (HSG), performed under
fluoroscopy, allows evaluation of the uterine
cavity and tubal patency
 Hysteroscopy
 three-dimensional ultrasound
 laparoscopy might also be used to confirm the
diagnosis.
RISK
 PRETERM LABOR-is thought to be because of space
restrictions; because a unicornuate uterus is smaller than a
typical uterus, the growth of the baby might trigger early
labor.

 MISCARRIAGE-due to abnormalities in the blood supply of


the unicornuate uterus that might interfere with the
functioning of the placenta

 ECTOPIC PREGNANCY

 miscarriage in 37%
 preterm birth in 16%,
 term birth in only 45%.
MANAGEMENT

 The resection of the obstructed hemi-uterus


can be performed laparoscopically.
 Nursing management:
 Informed consent
 Explain the procedure
 Monitor vital sign
 Emotional support
BICORNUATE
UTERUS
a type of congenital uterine malformation
(müllerian duct abnormality).
uterus is heart-shaped with two joined
cavities whereas a typical uterus has a
single cavity.
Cause
 This can happen to women whose mothers
took a medication called DES during
pregnancy,
 it can happen for unknown reasons.
Diagnosing Bicornuate

 hysterosalpingogram (HSG)
 hysteroscopy
 but diagnosis should be confirmed with a
three-dimensional ultrasound or
laparoscopy.
Risk
 preterm labor
 cervical insufficiency
 many women with bicornuate uteri carry
pregnancies to full term without any
problems, so the risk may vary for each
woman.
Management
 reconstructive laparoscopic
 cervical cerclage, a stitch placed in the
cervix to stop premature dilation
Double uterus
 Definition
 In a female fetus, the uterus starts out as
two small tubes. As the fetus develops, the
tubes normally join to create one larger,
hollow organ the uterus. Sometimes,
however, the tubes don't join completely.
Instead, each one develops into a separate
cavity. This condition is called double
uterus (uterus didelphys).
Double uterus
 Each cavity in a double uterus often leads to its own cervix.
Some women with a double uterus also have a duplicate or
divided vagina.
 Double uterus is rare — and sometimes not even diagnosed.
 occurs in 2 %t to 4 % of women who have normal
pregnancies.
 The percentage may be higher in women with a history of
miscarriage or premature birth.
 Treatment is needed only if a double uterus causes
symptoms or complications, such as pelvic pain or repeated
miscarriages.
Symptoms

 Some women have a double uterus and never


realize it — even during pregnancy and childbirth.
 Possible signs and symptoms may include:
 A mass in the pelvis
 Unusual pain before or during a menstrual period
 Abnormal bleeding during a period, such as blood flow
despite the use of a tampon
Causes

 Unknown .
 The condition is associated with kidney
abnormalities, which suggests that
something may influence the development
of these related tubes before birth.
Tests and diagnosis

 routine pelvic exam  observes a double


cervix or an unusually shaped uterus.
 Magnetic resonance imaging (MRI).
 Ultrasound.
 Hysterosalpingography. a special dye is
injected into the uterus through the cervix.
Then X-rays are taken to determine the
shape and size of the uterus.
 Hysteroscopy. inserts a tiny tube with a light into
the vagina and through the cervix. This allows to
examine the inside of the uterus.
 Laparoscopy. With this surgical procedure, a
small incision beneath the navel and inserts a
laparoscope — an illuminated, fiber-optic device
— into the abdomen to examine the uterus.
Laparoscopy requires general anesthesia.
Complications

 Many women with a double uterus have


normal sex lives, pregnancies and
deliveries.
 sometimes a double uterus leads to
infertility or miscarriage.
 A double uterus may also cause premature
birth or unusual positions of the baby in the
uterus, such as breech presentation.
Nursing Care
 Patient Education
 If you have a double uterus but no signs or
symptoms, treatment is rarely needed.
 Surgery to unite a double uterus is rarely done —
although other surgical procedures may help
partial division within the uterus.
 Advised importance of prenatal care to prevent
Preterm labor or miscarriage.
 Emotional / psychological support
BICORNUATE UTERUS
BICORNUATE UTERUS
ANOMALIES WITH
PROLAPSE
CYSTOCELE
RECTOCELE
ENTEROCELE
 Cystocele – protrusion of the bladder
through the vaginal wall
 Assessment – interference with voiding
and stress incontinence
 Management includes Kegel’s
exercises; surgery (anterior
colporrhaphy) to surgically shorten the
muscles that support the bladder
 Rectocele – protrusion of the rectum
through the vaginal wall characterized by
rectal pressure, heaviness, and
hemorrhoids
Enterocele
 Prolapse of the small bowel into the wall of the vagina,
usually caused by past damage to the pelvic floor
muscle.
 Herniation near the apex of the vagina between the
major supporting uterosacral ligaments
 Symptoms
 Abdominal pain
 Constipation
 Diarrhea
 Bowel obstruction
 Pelvic discomfort in presence of enterocoele due to
downward traction of viscera
Causes of Enterocoele

 unknown although there seems to be an


increased incidence associated with any
other problems
 trauma during parturition.
 congenital inadequacy of endopelvic
connective tissue.
 chronic constipation.
Treatment

 Prevention
 pelvic floor exercises
 avoid chronic constipation and straining
 estrogen therapy
 Conservative
 pessaries (ring)
 replace prolapse to reduce edema and cure ulceration
 Surgical measures
 Vaginal
 Vaginal hysterectomy + Pelvic Floor Repair
 Manchester [Fothergill] Repair + Pelvic Floor Repair
 Le Fort’s operation
 Abdominal: Total abdominal hysterectomy & repair of
enterocoele [usually will also require vaginal repair].
Enterocoele
 Nursing care
 well- ordered hygienic mode of living
 a nutritious and bland diet
 adequate mental and physical rest
 daily exercise , agreeable, occupation, fresh air
 regular hours of eating and sleeping
 regulation of the bowels and wholesome
companionship with others.
Nabothian cyst
 Common findings
 is a mucus-filled cyst on the surface of the uterine cervix.
 appear most often as firm bumps on the cervix's surface. A
woman may notice the cyst when inserting a diaphragm or
cervical cap, or when doing the cervix check as part of fertility
awareness
 Cause is unknown
 Diagnosis is made clinically
 There are no symptoms
 are not considered problematic unless they grow very large
and present secondary symptoms
 Treatment: no treatment
Cervical polyps
 Are a result of benign hyperplasia of the glandular tissue
arising from the mucosa
 Causes: unknown
 most often occur in women older than 20 who have had
several pregnancies
 Symptoms : abnormal vaginal bleeding
 Between menstrual periods.
 After menopause.
 After sexual intercourse.
 After douching.

 Treatment: removal of polyps


Uterine fibroids
 are noncancerous growths of the uterus that often
appear during your childbearing years.
 Also called fibromyomas, leiomyomas or myomas.
 Types: subserosal( external surface of the
uterus
intramural (within the myometrium)
submucosal (with in the
endometrial layer)
symptoms
 Heavy menstrual bleeding
 Prolonged menstrual periods or bleeding
between periods
 Pelvic pressure or pain
 Urinary incontinence or frequent urination
 Constipation
 Backache or leg pains
CAUSE
 Genetic alterations. Many fibroids contain
alterations in genes that code for uterine muscle
cells.
 Hormones. Estrogen and progesterone, two
hormones that stimulate development of the
uterine lining in preparation for pregnancy, appear
to promote the growth of fibroids. Fibroids contain
more estrogen and estrogen receptors than do
normal uterine muscle cells.
 Other chemicals. Substances that help the body
maintain tissues, such as insulin-like growth
factor, may affect fibroid growth.
DIAGNOSIS
 Pelvic examination
 UTZ
Treatment
 Watchful waiting
 Medications
They don't eliminate fibroids, but may shrink
them. Medications include:
 Gonadotropin-releasing hormone (Gn-RH) agonists.
 Androgens :Danazol,
 Oral contraceptives or progestins can help control
menstrual bleeding, but they don't reduce fibroid size
 Hysterectomy

 myomectomy
Benign Ovarian masses
 Ovarian cysts – physiologic variations in
menstrual cycle
 Dermoid cysts - (cystic teratomas) –
cartilage, bone, teeth, skin or hair can be
observed
 Endometriomas (chocolate cysts)
Manifestations
Benign Ovarian masses
 Sensation of fullness, cramping, dyspareunia,
irregular bleeding

Diagnostics:
USG
Management:
OCP to suppress ovarian function
surgery
Leiomyoma
 Fibroid tumors
 40 yrs old
 Potential for cancer is minimal
 Smooth muscle cells present in whorls and
arise from uterine muscle
Manifestations
 Frequently asymptomatic
 Lower abdominal pain
 Fullness or pressure
 Menorrhagia
 Metrorhaggia
 dysmenorrhea
Diagnostics: USG

Management:
Routine pelvic exam every 3-6 months
surgery
Vaginal Cancer
 Upper 1/3 most common site
 S/S: painless vaginal bleeding and discharge,
urinary retention, bladder spasm, hematuria,
frequency of urination, tenesmus, constipation,
blood in the stool
 Dx: pap smear, biopsy
 Mx: radiation, surgery
Cervical Ca

 Preventable

Risk Factors:
coitus at an early age
Multiple sexual partners
Sex partner w/ a hx of numerous sexual partners
Exposure to STD
HPV infections
Chemotherapy
Contraceptive use>5 yrs
Smoking
Antenatal exposure to DES
History of dysplasia
Diagnostics:
Pap smear
Colposcopy
Endocervical curettage

Management:
surgery
Colposcopy is performed with
the woman lying on her back,
legs in stirrups, and buttocks
at the lower edge of the table
(a position known as the
dorsal lithotomy position).
A speculum is
placed in the vagina after the
vulva is examined for any
suspicious lesions .
Three percent acetic acid is applied to
the cervix using cotton swabs
Areas of the cervix which turn white
after the application of acetic acid or
have an abnormal vascular pattern are
often considered for biopsy. If no
lesions are visible, an iodine solution
may be applied to the cervix to help
highlight areas of abnormality
Endometrial Ca
 Postmenopausal
Risk Factors:
1. Obesity
2. Multiparity
3. DM
4. HPN
5. Use of unopposed estrogen
6. High fat diet
7. Early menarche and late menopause
8. Use of Tamoxifen- is an orally active selective estrogen
receptor modulator (SERM). decreases DNA synthesis
and inhibits estrogen effects. it acts as partial agonist
on the endometrium
Manifestations:
 Unusual bleeding, spotting, or other discharge
 abnormal vaginal bleeding such as bleeding between
periods or after menopause
 In about 10% of cases, the discharge associated with
endometrial cancer is not bloody
 Pelvic pain and/or mass and weight loss

Diagnosis:
Pap smear
Endometrial biopsy
USG

Management:
TAHBSO
counseling
Stage Characteristics

IA Limited to the endometrium

Invasion of less than one half of


Stage I (grade 1, 2, or 3)* IB the myometrium
Invasion of one half or more than
IC one half of the myometrium
Endocervical glandular
IIA involvement only
Stage II (grade 1, 2, or 3)
IIB Cervical stromal invasion

Invades serosa and/or adnexa


IIIA and/or positive peritoneal
cytology
Stage III (grade 1, 2, or
3) IIIB Vaginal metastases

Metastases to pelvic and/or


IIIC para-aortic lymph nodes
Invasion of bladder and/or bowel
IVA mucosa
Stage IV (grade 1, 2, or
Distant metastases, including
3)
IVB intra-abdominal metastases
and/or inguinal lymph nodes
Ovarian Ca
Risk Factors:
Increased age (mean age 59 yrs old)
Fertility drugs
Early menarche or late menopause
Asbestos and talc exposure

S/sx: abdominal swelling or inc abdominal girth, bloating,


pelvic pressure, mild constipation

Management: surgery
-End -
You better live your best and act your
best and think your best today,
For today, is the sure preparation for
tomorrows that follow
-Matineau-

Você também pode gostar