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Female sexual/reproductive dysfunction

Reviewed by Gabrielle Metelli 2009

UANE&S 2009 1

Breast Cancer Breast Conserving


• Several types Surgery
• Removing tumour including
• Majority adenocarcinomas diametrical breast tissue
– arising from ducts
• Known as lumpectomy or breast
• Lobular carcinoma conservation

• Ductal carcinoma • Aims to completely remove tumour


– not invasive & usually treated while preserving look, shape & feel
conservatively unless affecting large of breast
area
Mastectomy
• Total Mastectomy
– some lymph nodes removed
• Radical Mastectomy
– all lymph nodes removed
• Aim of Surgery
– Eradicate the tumour so it cannot spread

UANE&S 2009

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Modified Radical
Mastectomy
• Radical surgery
– Entire breast removed
• Highlighted area indicates tissue
removed
• B - axillary lymph nodes: levels I
• C - axillary lymph nodes: levels II
• No muscles are removed
• Who usually gets a modified
radical mastectomy?
– Most people who are diagnosed
with invasive cancer

http://www.breastcancer.org/treatment/surgery/mastectomy/what_is.jsp

UANE&S 2009

Breast Reconstruction
• Skin, muscle & fat are
transferred to reconstruct the
breast

• Transverse Rectus Abdominis


Muscle (TRAM)

• TRAM is not for everyone and


is not a good choice for
– thin women who don't have
enough abdominal tissue
– women who smoke and
therefore have blood vessels
that are narrow and less
flexible
– women who have multiple
surgical scars on the abdomen
(normal Cesarean-section scars
are not usually a problem)
http://www.breastcancer.org/treatment/surgery/mastectomy/what_is.jsp

UANE&S 2009

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Breast Reconstruction (cont’d)
• Involves prostheses or tissue from other parts of body to re-build
breast

• May directly follow mastectomy or later

• Method depends on nature of problem & or patient’s choice

Complications of Surgery
• Breast pain
• Chest wall pain
• Swelling
• Lymphoedema
• Infection
• Altered perception of body image & appearance

UANE&S 2009

Lymphedema – Client Education Strategies for Reducing


Infection Post Mastectomy
• NO blood pressure cuffs on
affected arm • No cannulas or injections
in affected arm

• Loose clothing & jewellery


• No gardening without
gloves & long sleeves
• Hands submerged in water – wear
gloves
• Shave armpit with electric
razor to avoid minor
• Keep arm skin moist with creams lacerations

• Do not carry heavy items

UANE&S 2009

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Premenstrual (PMS) Dysmenorrhoea – Primary &
Secondary
Cyclic occurrence of physical,
behavioural and psychologic
Clinical manifestations:
symptoms during the luteal • Primary – lower abdominal
phase of the menstrual cycle
(Stevinson & Ernst, 2001) and back pain, nausea, fatigue,
• Breast discomfort light headedness
• Peripheral oedema
• Abdominal bloating • Secondary – dyspareunia,
• Binge eating painful defecation, irregular
• Autonomic nervous system bleeding
arousal
• Emotional symptoms (Hickey & Balen, 2003; McEvoy, Chang & Coupey, 2004)

(Brown & Edwards, 2005; Stevinson & Ernst, 2001)

UANE&S 2009 7

Abnormal Uterine Peri & postmenopausal


Bleeding bleeding
Clinical Manifestations: Clinical manifestations:
• Menorrhagia • Irregular menses

• Metrorrhagia • Hot flushes & sweats


• Mood changes
• Oligomenorrhoea
• Cessation of menses,
• Amenorrhoea
• Atrophy of genitourinary tissue
• Peri & post menopausal
• Stress & urge incontinence
• Post surgery
(Bradley, 2005)
• Vasomotor symptoms
(Brown & Edwards, 2005).

UANE&S 2009 8
Disorders of the female reproductive system
• Ovarian cysts
• Polycystic ovarian syndrome (PCOS)
• Ovarian cancer
• Uterine fibroids
• Cervical polyps
• Uterine prolapse
• Endometriosis
• Endometrial cancer
• Pelvic inflammatory disease (PID)
• Salpingitis

UANE&S 2009 9

Ovarian Cysts

• Functional cysts Signs and symptoms


– Follicle
– Corpus luteum •Usually asymptomatic until large
•Constipation
• Endometrial cysts •Menstrual irregularity
•Urinary frequency
• Neoplastic cysts
– Cystadenomas •Abdominal distention
– Dermoid •Anorexia
•Painful intercourse
(Brown & Edwards, 2005; HWHW, 1999;
Pregler & DeCherney, 2002) •Pelvic pain

(Brown & Edwards, 2005; HWHW, 1999; Pregler


& DeCherney, 2002)

UANE&S 2009 10
Diagnosis and Management
Uterus

•Ultrasound

•Pelvic examination
Ovarian Cyst
•Laboratory tests

•<8cm = re-exam in 3 weeks

•>8cm or solid = Laparoscopic


Surgery / Laparotomy
•Immediate surgery for ovarian
torsion

•Hysterectomy if malignant

(Courtesy of Brown & Edwards, 2005 p1423 Fig 52-8)


UANE&S 2009 11

Polycystic Ovarian Syndrome


• Numerous follicular cysts
• Caused by > production of LH
& < FSH
• Imbalance results in
anovulation
• Irregular menstrual cycles
• Dysfunctional uterine bleeding
• Infertility
• Hirsutism
• Obesity
• Acne (Lane, 2006; Markle, 2001)
Diagnosis and treatment
•Pelvic & TV ultrasound
•Oral contraceptives
•Weight management
•Regular check ups

(Brown & Edwards, 2005; Lane, 2006; Markle, www.advancedfertility.com/pco.htm


2001)
UANE&S 2009 12
• Usually asymptomatic Ovarian Cancer
• Abdominal discomfort
• Pelvic heaviness
• Loss of appetite
• Change in bowel habits
• Abnormal PV bleeding
Stage I = limited to ovaries
Stage II = limited to true pelvis
Stage III = Limited to abdo Cavity
Stage IV = distant metastatic disease
Screening, prevention & treatment
• History (family)
• CA - 125
• Bimanual pelvic examination
• Salpingo-oophorectomy
• Chemotherapy / Radiation
http://www.gynoncology.com/common_files/Leiomyoma%20
• Surgical excision and%20Ovarian%20Cancer.htm

• Counseling
• Palliative care UANE&S 2009 13
(Brown & Edwards, 2005; Chen & Bethan Powell, 2006)

Uterine fibroids - (Leiomyomas/Myomas)


• Benign smooth muscle uterine
tumour
• Affecting 25-40% women in
reproductive years
• Usually asymptomatic
• Abnormal bleeding
• Pain
• Pelvic pressure (Walker & Stewart, 2005)
Treatment/Management
• Pelvic examination
• Treat symptoms
• Consider family planning
• Hysterectomy
• Myomectomy
• Hysteroscope / Laser
• Embolisation / Cryosurgery www2.mc.duke.edu/depts/ obgyn/ivf/fibroid.htm
• Heavy menstruation = anaemia UANE&S 2009 14
 Surgery (Brown & Edwards, 2005).
Cervical polyps

• Benign, pedunculated lesion protrudes through cervix


• Soft, cherry red
• Generally asymptomatic
• Metrorrhagia & bleeding
• Speculum examination
• Prone to infection
• Polypectomy
• Pathological review

(Brown & Edwards, 2005; Pregler &


DeCherney, 2002) http://www.nlm.nih.gov/medlineplus/ency/imagepages/17036.htm

UANE&S 2009 15

Pelvic organ
prolapse
• Present in 50% of
parous women
• Recognised risk
factors
– Pregnancy
– Vaginal childbirth
– Menopause
– Chronic rise in IAP
(eg. Obesity, cough)
– Pelvic floor muscle
weakness

(Kobashi & Leach, 2000; Novara &


Artibani, 2005)

www.merck.com/mmhe/sec22/ch249/ch249a.html
UANE&S 2009 16
Uterine Prolapse

Signs & symptoms


• Downward displacement
of the uterus into the • Sensation
vaginal canal • Dyspareunia
• Backache
1st Degree: Cervix rests in • Bowel & bladder complications
lower part vagina
nd
2 Degree: Cervix at vaginal Management:
opening • Pelvic floor exercises
rd
3 Degree: Uterus protruding • Pessary
through introitus
(Pregler & Cherney 2002; Ringold, Lynm, &
• Surgery / Hysterectomy
Glass, 2005) (Ringold, Lynm, & Glass, 2005)

UANE&S 2009 17

Endometriosis

Signs and symptoms


• Presence of normal endometrial • Dysmenorrhoea
tissue outside endometrial cavity • Pelvic pain
• Dyspareunia
• Tissue responds to hormones of • Irregular Bleeding
ovarian cycle & experiences a • Nodules palpable on
‘mini menstrual cycle’ examination
• Infertility
• Found in 10% of women
(reproductive age)
Treatment
• Laparoscopy (definitive diagnosis)
• Generally white, late 20s to
• Surgery
early 30s & never had full term
pregnancy • Drug therapy
• Education

(Gould, 2003; Huntington & Gilmour, 2005)


(Gould, 2003; Huntington & Gilmour, 2005)
UANE&S 2009 18
Endometrial Cancer

• Generally adenocarcinomas
• Metrorrhagia
• Metastatic symptoms
• Pain (occurs late in disease process)
• Endometrial biopsy

Treatment
• Total hysterectomy
• Progesterone therapy
• Chemotherapy
• Counseling
• Palliative care

UANE&S 2009 19

Pelvic Inflammatory Disease (PID)

• Infectious condition of pelvic Prevention / Education / Health


promotion
cavity. May have:
– Lower abdominal • Bimanual pelvic examination
pain/tenderness
• Out patients / Surgery
– Deep dyspareunia
– Abnormal vaginal/cervical • Broad spectrum antibiotics
discharge • Examination of partner
– Cervical excitation and adnexal • Physical rest, fluids
tenderness motion
– Fever (> 38oC) • Analgesics
• Sitz baths
(Brown & Edwards, 2005; RCOG, 2003)
• Psychosocial care
(Brown & Edwards, 2005; RCOG, 2003)

UANE&S 2009 20
Salpingitis

• Infectious condition
involving fallopian tubes
• Salpingectomy
• Oophorectomy
• Pre & post op care
• Manage same as PID

http://www.macmed.ttuhsc.edu/Graham/gyn2/images/Untitled-50.jpg
UANE&S 2009 21

Disorders of Pregnancy

STI’s are a disorder of


pregnancy together with:

• Spontaneous abortion
(miscarriage)

• Ectopic pregnancy

• Gestational diabetes

• Pregnancy induced
hypertension

UANE&S 2009 22
www.positivenation.co.uk/issue117/pics/foetus
Spontaneous Abortion (Miscarriage)

Defined as: “the loss of a conceptus prior to 20 weeks of gestation”


(Pregler & DeCherney, 2002, p. 809)

Physical management:
– Surgical – D&C
– Medical – Misoprostol, oxytocin
– Expectant care

Possible complications:
– Haemorrhage
– RPOC
– Infection
– Pain
– Anxiety & depression
(Aleman, Althabe, Belizán, & Bergel, 2006, Shelley, Healy, & Grover, 2005; White & Bouvier, 2005)

UANE&S 2009 23

Ectopic Pregnancy
•Zygote implants outside uterine Management:
cavity.
• Serum beta hCG, blood pathology and
•More than 95% in fallopian ultrasound
tubes
• Monitor vital signs / offer emotional support
•Responsible for 9-13% of
maternal mortality in 1st • Administer analgesia as ordered
trimester.
• Report & record PV loss
•Signs & symptoms
•Severe abdomino-pelvic pain • IV fluids & / or blood transfusion as indicated
•Dizziness, nausea & diarrhoea
• Methotrexate if fallopian tube has not ruptured
•+/-Vaginal bleeding & patient haemodynamically stable

•Postural hypotension with • Prepare for surgery


tachycardia
(Pregler & DeCherney, 2002; Shima, 2002; Waters,
(Brown & Edwards, 2005; Shima, 2002)
Dean & Sullivan, 2006)
UANE&S 2009 24
Pregnancy Induced
Gestational Diabetes
Any degree of glucose intolerance with onset or first Hypertension
recognition during pregnancy
(Porth, 2002)
Gestational hypertension:
- BP midpregnancy
• Assess past history (previously - Normal BP 12 weeks
diabetic, large babies, family history) postpartum
• Close observation of mother &
foetus Preeclampsia – Eclampsia:
• Regular fasting BGL’s – systolic ≥ 140 mmHg or diastolic ≥
90mmHg
• Monitor vital signs, BSL’s and urine
– after 20 weeks pregnancy
glucose levels
– Proteinuria
• Nutritional guidance/insulin therapy
if required Non-pharmacological treatment – ideal
• Encourage exercise/good hygiene
Pharmacological treatment
• Monitor signs & symptoms of hyper - only if necessary & used with caution
& hypoglycaemia - NEVER ACE inhibitors
(Fink, 2006; Scollan-Koliopoulos, Guadagno, & Walker, 2006).

(Porth, 2002; Pregler & DeCherney, 2002; Yankowitz, 2004)

UANE&S 2009 25

References

Bradley, L. (2005). Abnormal uterine bleeding. The Nurse Practitioner, 30(10), 38-49.
Brown. D., & Edwards, H. (2005). Lewis’s medical – surgical nursing: Assessment and
management of clinical problems. Elsevier. Sydney
Chen, L., & Bethan Powell, C. (2006). Combating ovarian cancer with salpingo-
oophorectomy. Contemporary Obstetrics and Gynaecology, 86-92.
Gould, D. (2003). Endometriosis. Nursing Standard,17(27), 47-53.
Hickey, M., & Balen, A. (2003). Menstrual disorders in adolescence: Investigation and
management. Human Reproduction Update, 9(5), 493-504.
Huntington, A., & Gilmour, J. (2005). A life shaped by pain: Women and
endometriosis. Journal of Clinical Nursing, 14, 1124-1132.
HWHW. (1999). Ovarian disorders. Harvard Women’s Health Watch, 6(12), 4-5.
Kobashi, K., & Leach, G. (2000). Pelvic prolapse. The Journal of Urology, 164, 1879-1890.
Lane, D. (2006). Polycystic ovary syndrome and its differential diagnosis. Obstetrical and
Gynecological Survey, 61(2), 125-135.
McEvoy, M., Chang, J., & Coupey, S. (2004). Common menstrual disorders in
adolescence:Nursing interventions. MCN: The American Journal of Maternal Child
Nursing,29, 41-49.

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Markle, M. (2001). Polycystic ovary syndrome: Implications for advanced practice nursing in
primary care. Journal of the American Academy of Nurse Practitioners 13(4), 160-
163.
Novara, G., & Artibani, W. (2005). Surgery for pelvic organ prolapse: Current status and
future perspectives. Current Opinion in Urology 15, 256-262.
Pregler & DeCherney, (2002). Women’s health: Principles and clinical practice. Philadelphia:
B.C. Decker
Ringold, S., Lynm, C., & Glass, R. (2005). Uterine prolapse. The Journal of the American
Medical Association, 293 (16), 2054.
Royal College of Obstetricians and Gynaecologists (2003). Management of acute pelvic
inflammatory disease. Guideline No. 32.
Stevinson, C., & Ernst, E. (2001). Complementary/alternative therapies for premenstrual
syndrome: A systematic review of randomised controlled trials. American Journal of
Obstetrics and Gynaecology, 185(1), 227-235.
Walker, C., & Stewart, E. (2005). Uterine fibroids: The elephant in the room. Science,
308,1589-1592.

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