CHAPTER 33
DYSMENORRHEA SECONDARY DYSMENORRHEA ; begins well after the menstrual cycle has been established and is typically caused by some organic or structural causes ; ; Symptoms begin earlier in cycle and last longer ETIOLOGY/RISK FACTORS Menstrual-related pain that accompanies another medical or physical condition such as endometriosis, chronic PID, or uterine fibroids Later onset, most commonly age 30-40 SIGNS/SYMPTOMS Pain unilateral Pain more constant and lasts longer than in primary. Recurrent, crampy, suprapubic pain Depending on cause, may also experience painful intercourse, painful BM's, or irregular bleeding other than menstruation ; It may be related to IUDs, congenital anomalies, ovarian cysts, or benign or malignant tumors ;There is also a change in bowel habits, rectal pressure, and painful defecation due to the influence production of prostaglandins. DIAGNOSTICS Menstrual and gynecologic history Pelvic exam (pelvic abnormality) TREATMENT/NURSING IMPLICATIONS Depends on the cause (possible surgical interventions or additional drug therapy.
ABNORMAL UTERINE BLEEDING (AUB): Bleeding that deviates from a usual menstrual cycle. ; This includes bleeding between periods, postmenopausal bleeding, postcoital bleeding, bleeding heavier than usual or for greater length of time, or bleeding between menstrual cycles Diagnosed by exclusion: all other causes for the bleeding (including trauma, tumors, or diseases) have been ruled out as the cause of the bleeding. AUB tends to occur either when girls begin to menstruate or when women approach menopause, but it can occur at any time during a woman's reproductive life. ABNORMAL BLEEDING PATTERNS: Any change in a normal menstrual cycle is referred to as abnormal uterine bleeding (AUB) (Twiss, 2013). Bleeding that occurs at regular intervals but is in excessive amounts and/or duration is known as menorrhagia or heavy menstrual bleeding (HB). "Excessive menstrual blood loss is that which interferes with the woman's physical, emotional, social, and material QOL and can occur alone or in combination with other symptoms" (ACOG, 2013). Unpredictable bleeding patterns are considered to be anovulatory bleeding
HEALTH PERCEPTION- HEALTH MGM PATTERN ;Examination practices & screenings (Mammograms, Pap tests, BSE) ;Family History of cancer, DM, hypothyroidism, hyperthyroidism, stroke angina, MI, endocrine disorders, anemia ; Lifestyle choices (smoke? drink? drug use?) NUTRITIONAL METABOLIC PATTERN Diet Assess for presence of eating disorder Estimate calcium & folic acid intake ELIMINATION PATTERN •Stress or urge incontinence •Recurrent UTI's
ACTIVITY EXERCISE PATTERN Amount, type, and intensity of activity & exercise SLEEP-REST PATTERN •Sleep interruption due to hot flashes and sweating •Insomnia •Daytime fatigue COGNITIVE-PERCEPTUAL PATTERN •Ability to read and write •Pain? Location? •Dyspareunia SELF-PERCEPTION- SELF CONCEPT PATTERN •Age-related body changes (pendulous breasts, vaginal dryness)
ROLE RELATIONSHIP PATTERN •Family Structure; family conflict •Occupation; work-related relationships SEXUALITY-REPRODUCTIVE PATTERN •Obtain menstrual history •first day of last menstrual period, description of menstrual flow, age of menarche, and age at menopause •Changes in menstrual pattern •Obtain obstetric history •Number of pregnancies, full-term births, preterm births, live births, ectopic pregnancies; abortions; problems during pregnancy •Sexual activity, beliefs, & practices •Sexual preference (heterosexual, homosexual, bisexual) •Patient's knowledge of safe-sex practices •Changes in sexual satisfaction & performance COPING-STRESS TOLERANCE PATTERN •Patient's support people •Ways to manage stress VALUE-BELIEF PATTERN •Cultural, religious, moral & ethical values
AGE-RELATED CHANGES Physical Changes related to: Altered estrogen production Increase in androgens Sexual Changes related to: Decreased vaginal lubrication Difficulty in maintaining arousal Decreased libido and interest in sex Psychological effects of physical changes SEE IMAGE ON POWERPOINT
BREAST ANATOMY Each breast has 15 to 20 sections, called lobes. Each lobe has many smaller lobules, which end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Fat fills the spaces between lobules and ducts. There are no muscles in the breast, but muscles lie under each breast and cover the ribs. Each breast also contains blood vessels and vessels that carry lymph. The lymph vessels lead to small bean-shaped organs called lymph nodes, clusters of which are found under the arm, above the collarbone, and in the chest, as well as in many other parts of the body.
BENIGH BREAST DISORDERS Mastalgia- breast pain ; Cyclical breast pain - most common type of breast pain. ; It is usually related to hormonal fluctuations during the luteal phase of the menstrual cycle that stimulate the proliferation of normal glandular tissue and subsequently cause pain. May last 2-3 days or most of the month Pain related to hormonal sensitivity Symptoms often decrease with menopause ; Occurs in both breasts ; reassured that breast pain is rarely indicative of cancer ; seek attention for persistent pain ; Elimination of methylxanthines, including caffeine, theophylline, and theobromine may alleviate breast pain ; Coffee, tea, chocolate, and cola beverages ; nonsteroidal anti-inflammatory drugs (NSAIDs) Symptoms: Diffuse breast tenderness/heaviness Treatments to provide relief: Reduce caffeine and dietary fat; wear support bra; Vitamins A, E, and B-complex; compresses; ice; analgesics.
BREAST CANCER ETIOLOGY & RISK FACTORS Female Age 50 and over Strong genetic predisposition(first-degree relative; BRCA gene mutation) Personal history of breast cancer, colon cancer, endometrial cancer, ovarian cancer Breast cancer occurs when cells in the breast change and grow out of control ; Some breast cancers are in situ, meaning confined within the walls of the ducts of the breast, but the majority are invasive or infiltrating. Hormones (specifically exposure to high estrogen levels) Early menarche (before age 12) Late menopause (after age 55) Delay of 1st pregnancy (first full-term pregnancy after age 30) Modifiable risk factors: Smoking; alcohol intake; obesity
BREAST CANCER CLINICAL MANIFESTATIONS If palpable, lump is hard, irregular shaped, poorly delineated, nonmobile, and nontender Possible nipple discharge; unilateral; may be clear or bloody ; upper outer quadrant, where the most breast tissue is located Nipple retraction may occur Peau d'orange may occur due to the plugging of the dermal lymphatics Large cancers; changes in breast contour (infiltration, induration, dimpling)
FIBROCYSTIC BREAST CONDITIONS PATIENT EDUCATION Reassure the patient that the cysts will not develop into cancer Reinforce importance of BSE to self-monitor changes Instruct patient on self-management of fibrocystic changes Decrease caffeine intake and salt intake; hot/cold compresses; wear supportive bra; anti-inflammatory medications PRN; mild analgesics PRN
BREAST INFECTIONS MASTITIS Inflammatory condition of the breast; organisms enter breast through cracked nipple Occurs most frequently in lactating women Tends to affect only one breast, not both Manifests as a localized area that is red, tender, and painful Fever Continue breast feeding unless an abscess is forming or there is purulent drainage Treatment: Antibiotics LACTATIONAL BREAST ABSCESS Lactational mastitis that persists after several days of antibiotic therapy Ultrasound guided drainage or surgical incision and drainage Culture of drainage to identify organism and appropriate antibiotics Breastfeeding can continue during abscess treatment
Tx./Nursing Implications •Prevention: Regular Pap Tests & HPV vaccine •Treatment determined by stage of tumor, patients age, & general health When involves more than surface & has begun to spread: •Radical hysterectomy- IB or IIA/ removal of the uterus and upper one third of the vagina, including the cervix, but sparing the ovaries. •Chemotherapy; Radiation ; The HPV vaccines are a series of three vaccines administered at 2 and 6 months after the initial injection. It is important to receive the entire series of three vaccinations. ; It is recommended that patients remain in the office for at least 15 minutes after administration of the vaccine to ensure there is no reaction.
CANCER OF THE UTERUS Etiology/Pathophysiology Most common gynecologic malignancy Low mortality rate due to early diagnosis Usually develops after menopause Grows slowly, metastasizes late, & is curable with therapy if diagnosed early. RISK FACTOR: early menarche & late menopause, nulliparity, taking estrogen without progestin after menopause, diabetes, obesity, hypertension, unopposed estrogen use ; PCOS; tamoxifen ; prior pelvic radiation ; Personal or family history of breast, uterine, ovarian, or colon cancer Previous history of atypical hyperplasia Signs &Symptoms Early : 1st sign is abnormal uterine bleeding, usually in postmenopausal Late: Pain Other symptoms arise when cancer metastasizes to other organs.
NURSING MANAGEMENT POST-OPERATIVE CARE Drain Management If patient has had an axillary lymph node dissection or a mastectomy, patients are discharged home with the drains. Provide patient education for home drain managements Restoring arm function on the affected side Semi-Fowler's position with the arm on the affected side elevated on a pillow Flexing and extending of fingers Gradual arm and shoulder exercises. Pain Management Pain affected by extent of lymph node dissection performed Administer prn analgesics prior to beginning exercises Should not life anything greater than 10 lbs FOLLOW-UPS Professional examinations every 6 months for 2 years, then annually. Stress importance of monthly BSE on both breasts, or remaining breast and surgical site
Complications for the Surgical Patient Lymphedema. Caused by the removal of or damage to lymph nodes as a part of cancer treatment. Results from a blockage in the lymphatic system. The blockage prevents lymph fluid from draining well, and the fluid buildup leads to swelling, fibrosis of the soft tissues, neurologic complications such as pain and paresthesias, and infection PREVENTION Prevent or reduce lymphedema after axillary lymph node dissection Affected arm should not be dependent, even during sleep Avoid use of elastic bandages in the early postoperative period Blood pressure readings, venipunctures, and injections should not be done on affected side because they inhibit collateral lymph drainage Instruct woman to protect the arm on the operative side Explain to patient that she is at risk of developing lymphedema for the rest of her life
BENIGN DISORDERS UTERINE FIBROIDS (LEIOMYOMA) ETIOLOGY & PATHOPHYSIOLOGY •LEIO (smooth) MY (muscle) OMA (tumor) •Cause unknown •Estrogen & progesterone causes growth •Shrink after menopause RISK FACTORS include being African American or being overweight SIGNS/SYMPTOMS Usually asymptomatic; until fibroid has enlarged & impeding on organs Symptoms caused by leiomyomas •Abnormal uterine bleeding •Pelvic pressure and pain •Reproductive dysfunction heavy menstrual bleeding, dyspareunia disabling pelvic pain rectal pressure infertility
DIAGNOSIS Pelvic exam: confirms the presence, size and location. Enlarged uterus / nodular masses Abdominal ultrasound; transvaginal ultrasound It is important to rule out pregnancy with a woman who is experiencing these signs and symptoms. There is a risk for miscarriage as the fibroid distorts the uterus impacting on fetal growth. It is estimated that approximately one third of fibroids grow during pregnancy
PROTECTIVE FACTORS Maximize their overall health by maintaining a normal weight, particularly after menopause, engaging in regular physical activity, and avoiding or limiting alcohol consumption. Women who breastfeed for an extended period of time (for a year or longer) may have some added protection. Women at high risk for breast cancer may be candidates for chemoprevention and opt to take medications such as tamoxifen, raloxifene, or exemestane to reduce their risk The nurse should educate the patient on the importance of regular screening mammography, immediate pursuit of attention upon discovery of any palpable abnormality, and the availability of comfort options, such as disposable foam pads to ease discomfort during compression.
DIAGNOSTIC TESTING Ultrasound used in conjunction with mammogram may be used to differentiate a solid mass from a cystic mass. A definitive diagnosis is made by examination of biopsied tissue Fine-needle aspiration (FNA) biopsy - needle removes sample of cells or fluid ; may or may not have local anesthetic ; Stereotactic core biopsy - Mammogram used to locate lesion . Small incision is made and several core samples are sent for biopsy. Min invasive; X-ray guidance ; prone ; Ultrasound core biopsy - Ultrasound used to locate lesion. Small incision is made and several core samples are sent for biopsy. Open surgical biopsy - small cut to remove part or all of the lump.
POLYMENORRHEA- cycles occurring in less than 21 days are METRORRHAGIA - Breakthrough Bleeding ; ; Bleeding that occurs frequently but irregularly ; Uterine bleeding outside the usual menstrual periods ("spotting") May be a sign of an underlying disorder, such as hormone imbalance, endometriosis, uterine fibroids MENOMETRORRHAGIA - Heavy & Prolonged Bleeding at Irregular Intervals Excessive or prolonged uterine bleeding, at the usual time of menstrual periods and also at other irregular intervals. ; lead to iron-deficiency anemia if left undiagnosed and untreated.
DIAGNOSTIC TESTING (What is causing the bleed?) Pelvic Exam; Pap Smear Testing for STD's CBC (check for anemia, infection) Pituitary and thyroid levels US of pelvis Endometrial biopsy - identify abnormal cells, Hysteroscopy- views lining of uterus; able to remove uterine polyps & fibroid tumors. TREATMENT (Control or stop the bleeding) Minimize blood loss Bed rest for heavy bleeding Oral estrogen and progesterone (if result of anovulatory cycle) Tranexamic acid: antifibrinolytic agent (risk of developing DVT) Balloon thermotherapy : ablation of uterine lining;. decreases likelihood of pregnancy, but possible. contraception or sterilization required. Treat underlying problem If related to fibroid: uterine artery embolization, myomectomy, hysterectomy) TREAT SYMPTOMS Manage anemia with iron supplements
CERVICAL CANCER EtiologyPathophysiology/Risk Factors •Develops in cervix (lower part of uterus) •Assoc. with low economic status •Early sexual activity (before age 17) •Multiple sex partners; •Usually results from infection with HPV •Immunosuppression (cancer, AIDS, corticosteroids) •Smoking STIs High parity (multiple births) intercourse w/ uncircumcised male Signs &Symptoms Early: (Precancerous changes) usually asymptomatic unless they have condyloma. Symptoms may not occur until cancer has enlarged or spread •Abnormal bleeding (initially spotting. Becomes heavier & more frequent as the tumor enlarges. •painful intercourse •increased vaginal discharge (thin & watery but becomes dark and foul smelling as the cancer spreads, indicating infection) Late symptom: Pain, weight loss, anemia, & cachexia
Diagnostic Testing •Papanicolaou (Pap) test: Dysplasia •Cryosurgery •Biopsy;- taken in areas of visible abnormal vascular patterns. ; Conization •Loop Electrosurgery Excision Procedure (LEEP) •HPV DNA test Cytologic screening test Colposcopy-high-powered magnification of the cervix, which has had an acetic acid solution applied to it to help differentiate the cervical cell STAGES - Stage 0 is known as carcinoma in situ (CIS). Stage IVB is consistent with distant metastasis when the disease has spread to the remainder of the reproductive organs, bladder, rectum, liver, and/or lungs
BENIGH BREAST DISORDERS NONCYCLIC MASTALGIA No relationship to menstrual cycle May continue after menopause Constant or intermittent pain throughout the month May occur in only one breast May be due to trauma, fat necrosis, duct ectasia, or arthritic pain Symptoms: Burning, aching, soreness in breast Treatment: Determine and treat the cause to relieve pain. Mammogram completed to rule out Breast Cancer and determine cause of mastalgia FIBROCYSTIC BREAST CONDITIONS ETIOLOGY/PATHOPHYSIOLOGY Benign condition ; transient breast mass. Women 35-50 years of age Changes in breast tissue include: Development of excess fibrous tissue Hyperplasia of the epithelial lining of the mammary ducts Proliferation of mammary ducts Cyst formation
FIBROCYSTIC BREAST CONDITIONS SIGNS/SYMPTOMS: One or more palpable lumps (usually round, well delineated, and freely movable within the breast) Nipple discharge is often milky, yellow, or green ; Nudularity ; Discomfort ranging from tenderness to pain = often a normal response to hormonal changes during the menstrual cycle, Pathologists also may use the term "fibrocystic" in reference to microscopic findings, such as fibrosis, adenosis, papillomatosis, ductal epithelial hyperplasia, and cysts Cyclic (may become larger and more painful before menstruation)
BOX 33-9 Patient Education Performing Kegel (Pelvic Muscle) Exercises Purposes: To strengthen and maintain the tone of the pubococcygeal muscle, which supports the pelvic organs; to reduce or prevent stress incontinence and uterine prolapse; to enhance sensation during sexual intercourse; and to hasten postpartum healing: Become aware of pelvic muscle function by "drawing in" the perivaginal muscles and anal sphincter as if to control urine or defecation, but not contracting the abdominal, buttock, or inner thigh muscles. Sustain contraction of the muscles for up to 10 seconds, followed by at least 10 seconds of relaxation. Perform these exercises 30-80 times a day.
FISTULAS An abnormal opening between organs or between an organ and exterior of the body. Causes: congenital anomalies, trauma, postpartum infections and perineal tears, gastrointestinal disease, neoplasm of rectum or vagina and radiation therapy Vesciovaginal Fistula (vesico = bladder) beween bladder & vagina Urinary incontinence, leaks into vagina ; occur as a result of congenital anomalies, trauma due to childbirth or surgery, radiation therapy, Crohn disease, diverticular diseases, or neoplasm of the rectum or vagina. ; Postpartum infections also may result in fistula formation due to third- and fourth-degree perineal tears or tissue breakdown ; severe pain; risk for urosepsis due to recurrent UTI Rectovaginal Fistula between rectum & vagina flatus & fecal incontinence, leaks into vagina ; develops as a result of anal abscess and may be an indication of some other disorder such as lymphogranuloma venereum (a sexually transmitted systemic disease that affects the lymph nodes and rectal area, as well as the genitals), rectal tuberculosis, or neoplasm
Complications for the Surgical Patient Lymphedema. TREATMENT Decongestive therapy Massage-like technique (mobilizes subcutaneous fluid accumulation) Compression bandaging (controls swelling) Intermittent pneumatic compression sleeve (helps lymph drainage toward heart) Elevation of the arm to level of heart (reduces fluid volume in the arm) Diuretics (reduces fluid volume in the arm) Isometric exercises (reduces fluid volume in the arm) Fitted elastic pressure gradient sleeve (maintains maximum volume reduction while awake)
NURSING ALERT To prevent lymphedema or lymphangitis (infection of the lymph vessels), nurses should place a sign above the bed of a patient following mastectomy or node dissection not to perform blood pressures, blood draws, injections, or IV insertions on the side where the operation was performed. Lymphatic drainage is altered due to node dissection, causing the potential for fluid to accumulate in the affected extremity. Complications of infiltration, phlebitis, or trauma can result if the affected extremity is used. Some patients will obtain a medical alert bracelet with this warning.
SCREENING Breast self-examination (BSE) monthly starting at age 20 Clinical breast examination (CBE) at least every 3 years for women age 20-30, and yearly beginning at age 40 Mammograms yearly, starting at age 40 Women at increased risk (family history, genetics, past breast cancer) may benefit from more frequent examinations, earlier mammograms or additional tests. ;Any breast mass or abnormality should be evaluated in men, and male BRCA mutation carriers, due to their increased risk of developing breast cancer, are followed with increased breast cancer surveillance. BREAST SELF-EXAMINE Goal is early detection of small tumors and earlier detection of breast cancer. Begin by the age of 20 and continue the practice throughout life - even during pregnancy and after menopause. Regular BSE provides self-awareness Women who routinely practice BSE will be prepared to ask questions and have their concerns addressed during the clinical evaluation.
MAMMOGRAPHY Mammograms are used to visualize the internal structure of the breast using x-rays. May give false-positive results in younger women due to greater density of breast tissue. used to assist in interventional breast procedures, such as stereotactic breast biopsy and needle localization. Screening Mammograms: Check for breast cancer in women who have no signs or symptoms. Can also find tiny deposits of calcium that may indicate the presence of cancer.; ROUTINE ; Diagnostic Mammograms: Check for breast cancer after a lump or other sign or symptom has been found. Can be used to evaluate changes found during a screening mammogram. Diagnostic mammography takes longer than screening mammography because more x-rays are needed to obtain views of the breast from several angles. The technician may magnify a suspicious area to produce a detailed picture that can help the doctor make an accurate diagnosis.
CAUSES Coagulation disorders, such as thrombocytopenia (low platelet count) or Von Willebrand disease (most common inherited bleeding disorder in humans, refer to Chapter 20), are causes of AUB and should be ruled out as an underlying factor. ;unopposed estrogen are likely to develop AUB, ; liver diseases ; Certain endocrine disorders, including Cushing syndrome, Addison disease, thyroid disorders, and PCOS; extreme fluctuations in weight; or excessive exercise can cause irregular uterine bleeding. ; Other causes include pelvic infections caused by sexually transmitted infections (STIs; gonorrhea, Chlamydia, trichomonas), weight loss or weight gain, recent systemic infections, endometriosis, trauma, benign tumors, or lesions Once any pathology has been ruled out, it is appropriate for the patient to be treated with hormonal contraception that will regulate the menstrual cycle, decrease bleeding and cramping associated with heavy bleeding, and decrease any incidence of anemia associated with excessive blood loss
MEDICAL AND NURSING MANAGEMENT Vital signs, including orthostatic blood pressures, pulse rate to evaluate for tachycardia or arrhythmias, and a BMI Menstrual pad counts assist the health care provider in determining the approximate amount of blood loss through the description of the saturation of sanitary pads or tampons on an hourly basis. ; Characteristics of the flow ; Physical examination of the genitalia and a Pap smear are performed. ; ; Pelvic ultrasound ; endocrine test ; CBC with differential, TSH, prothrombin time (PT), and partial prothrombin time (PTT) are indicated in the workup for AUB; ; iron panel ; An endometrial biopsy is considered the first-line diagnostic test to rule out endometrial hyperplasia or malignancy in women over 35 years of age or in those under 35 years of age who are morbidly obese or who have chronic anovulation or PCOS
CLINICAL MANIFESTATIONS AND ASSESSMENT Obstetric or surgical complication = fistulas may not be apparent for up to 30 days after the initial injury or may be discovered incidentally during the 6-week postpartum follow-up visit ; Fecal discharge through the vagina produces a malodorous discharge and may be mistaken for a vaginal infection. ; palpable on DRE or Vaginal Exam ;A sigmoidoscopy, colonoscopy, small bowel imaging, cystoscopy, or intravenous pyelography will aid in definitive diagnosis. ; There is a high rate of recurrence of fistulas in spite of surgical repair Risk for infections related to excoriation & irritation of the vaginal & vulvar tissues Medical and Nursing Management: Small fistulas may heal spontaneously Surgery: fistulectomy; may result in ileal conduit or temporary colostomy. Skin assessment, sitz baths and peripad changes Patient education: s/sxs of infection and fistula recurrence
Medical and Nursing Management: Nurses play an important role in helping the patient to understand the importance of cleanliness and hygiene and to understand the signs and symptoms of recurrent infection or surgical failure to repair the fistula. Regular sitz baths and changing of perineal pads help prevent infection. It is important for the nurse to inspect the patient's skin for any signs of erythema or breakdown. Many patients suffer from physical and social distress as well as sexual dysfunction as a result of urinary and fecal incontinence due to fistulas (Ma et al., 2015). Assessing the patient's support system as well as appropriate referrals to pain management and surgeons familiar with this type of surgery is imperative.
UTERINE PROLAPSE Uterus falls into vagina Symptoms vary with degree of prolapse Feels like "something coming down" Dyspareunia heavy feeling in pelvis Stress incontinence ; pessary device CYSTOCELE Bladder drops into vagina Support between vagina & bladder is weakened Difficulty emptying bladder Bladder infections RECTOCELE Rectum bulges into vagina Support between vagina & rectum is weakened Difficulty defecating
Medical and Nursing Management: Treatment depends on severity and degree of prolapse.; urodynamic testing= evaluates bladder function. Patient Education: Weight loss, smoking cessation, avoid heavy lifting, straining, constipation; Pessary device: proper insertion, removal and cleaning = help avoid vaginal infections ; Pessaries are removable devices made of silicone, latex, plastic, or rubber that are inserted into the vagina to provide support. ;Pelvic floor muscle training (PFMT) and Kegel exercises Reconstructive Pelvic Surgery: Cystocele: colporrhaphy ("bladder tack") repair anterior wall of vagina, post op indwelling urinary catheter; ; Sacrospinous fixation, also referred to as an anterior-posterior repair, utilizes the surrounding ligaments to tighten and attach lax musculature onto the bony pelvis Rectocele: colporrhaphy repair posterior wall of the vagina, post op stool softener; low residue diet ; The extrusion of the rectum into the posterior vagina
Women May develop postembolization syndrome: fever, pain, and leukocytosis due to the degenerating fibroid. This is a normal response to treatment, but patients must be monitored for worsening symptoms PATIENT EDUCATION Seek medical attention when symptoms develop Importance of regular pelvic exams NURSING MANAGEMENT Nurses can reassure patients of the benign nature of fibroids and the potential side effects of medications and surgical procedures. ;The use of GnRH agonists induces temporary menopause and vasomotor symptoms associated with menopause. The patient may experience hot flashes, sleep disruption, and vaginal dryness as a result of loss of estrogen. [reversible once the medication has been discontinued.]
NURSING MANAGEMENT Due to the high level of bleeding associated with any myomectomy or surgical procedure, all aspirin and aspirin-containing products should be discontinued 3 to 4 weeks before the procedure is performed PAIN MANAGAMENT ; Instructing patients on the patient-controlled analgesia (PCA) pumps and regular administration of NSAIDs and antiemetics will ensure adequate pain control. ; Patients are coping not only with the physical loss but also the psychological loss of fertility if the patient is not undergoing fertility-sparing surgery so nurses need to address those concerns and offer referrals to therapists if needed.
MEDICAL MANAGEMENT Menstrual cycle diaries (2-3 cycles) ; presence or absence of symptoms is noted daily ; = trends ; encourage lifestyle changes = exercise, avoidance of caffeine , sodium-enriched foods; decreased alcohol intake ; smoking cessation ; 1,200 to 1,600 mg of calcium daily, vitamin B6 from 50 to 500 mg/day ; oral magnesium, vitamin E supplements, and evening primrose oil ; oral contraceptives ( 3 months are longer) ;
NURSING MANAGEMENT Accurate and detailed health and nutritional histories and screen for symptoms of anxiety and/or depression as well as assess for current or past suicidal and homicidal ideation. ; encourage the patient to seek evaluation by an appropriate health care provider. if needed. ; Nurses also may help patients with stress reduction and management techniques, compliance with medication, and therapeutic lifestyle changes (such as smoking cessation, regular exercise, and eating a low-fat, low-cholesterol, low-sodium diet). Pain management is similar to that discussed under dysmenorrhea (NSAIDs, PPIs, and heat pad use).
NURSING MANAGEMENT Post Op Pain management Psychosocial support: Grieving, Coping ; IS , Vaginal Peripads Assessments and vital signs Assess for bleeding Assess vaginal discharge Monitor urine output vaginal discharge consisting of blood and mucus for several weeks postoperatively Abdominal Abdominal dressing Assess bowel sounds (return on BM) Monitor urine output/catheter Ambulate in 24 hrs Sutures/Staples/Steri-strips Possible hemovac Not permitted to drive for 4 to 6 wks Avoid any heavy lifting, pushing, or pulling (such as vacuum cleaning) until their surgeon clears them to resume Vaginal bleeding is normal for a week Laparoscopic May be outpatient Frequent ambulation Monitor lap sites
NURSING MANAGEMENT Discharge Teaching: Pelvic rest 4-6 weeks Signs/symptoms of infection wound care Report unusual pain, SOB, leg edema, foul vaginal discharge (reg. discharge = normal) Avoid heavy lifting, pulling, pushing and driving until clearance from HCP If there is evidence of unilateral swelling of the lower extremities, shortness of breath, or any discharge or redness around their incision sites, patients should contact their health care provider. Possible Complications Atelectasis Urinary retention, UTI Ileus (FROM return of BM) Nerve injury Infection Accidental ligation of a ureter DVT/PE Hemorrhage Hematoma Loss of uterus, fertility Cancer diagnosis wound infection bowel function
HYSTERECTOMY Abdominal -Uterus is removed through the abdomen via a surgical incision. -Incision may be horizontal or vertical, depending on the reason of hysterectomy and size of the area being treated. -Allows the entire abdomen and pelvis to be examined. -Most commonly used with large uterine fibroids, cancer of the ovaries, uterus, and endometriosis. -Fallopian tubes and ovaries can be removed at the same time (TAH-BSO) -Greater risk for postoperative complications -Requires longer hospital stay
NURSING MANAGEMENT PRE OP Perineal or abdominal prep Vaginal douche Enema Empty bladder/Catheter Antibiotics Begin post-op teaching: What to expect after surgery Wound care Vaginal bleeding or mucus Ambulation Incentive spirometer Pain management DVT prophylaxis Hormone replacement Elicit feelings and concerns about surgery
Surgeries/Treatments Surgical procedures involving the reproductive system Total Hysterectomy? Oophorectomy? Salpingectomy? Mastectomy? Cryosurgery? Tubal sterilization? Cystocele? Rectosele? OBJECTIVE DATA PHYSICAL EXAMINATION Breasts: Breast Examination Pelvic Inspection: External Genitalia Pelvic Examination: Internal Genitalia URINE STUDIES Pregnancy Testing Hormone Studies
OBJECTIVE DATA BLOOD STUDIES Hormone Studies Tumor Markers Serology Tests for Syphilis Cultures & Smears STD Test Cytologic Studies Pap Test Nipple Discharge Test Radiologic Studies Mammography Ultrasound Pelvic Computed Tomography and Magnetic Resonance Imaging
FEMALE REPRODUCTIVE DISORDERS AMENORRHEA - Absence of Menstruation Primary: absence of menstruation by age 16 years in the presence of normal pubertal development ; CAUSED BY- hypothyroidism, Turner syndrome, pituitary disorders, hyperandrogenism, disorders of sexual development, pregnancy, anatomic abnormalities or in utero exposure to DES (diethylstilbestrol) ; Turner syndrome = one normal "X" chromosome and have absence of breast or ` Secondary: Cessation of menstrual cycles once they have been established. (Periods stop for at least 3 months) [book says 6 months]. ex: breastfeeding CAUSED BY: eating disorders, pregnancy, excessive weight loss, low body mass index (BMI) of less than 22% of average, excessive exercise, endocrine dysfunction such as polycystic ovarian syndrome (PCOS), hypothalamic or pituitary dysfunction, medications, or anatomical deviations such as cervical stenosis or imperforate hymen COMMON: Athletes, rapid weight loss due to bariatric surgery or starvation dieting, hormonal contraceptives, such as oral contraception, Depo-Provera, implanted long-term progesterone contraception, or the presence of a progesterone-only intrauterine device (IUD).
OLIGOMENORRHEA - Light or Infrequent Menstruation Long intervals between menses, usually > 35 days Women with diabetes, thyroid problems, or elevated prolactin levels; young women who participate in sports or engage in heavy exercise; may also be caused by eating disorderfs such as anorexia nervosa and bulimia MENORRHAGIA -- Heavy Bleeding Excessive or prolonged menstrual vaginal bleeding that occurs at the normal time of the menstrual cycle. CAUSED BY hormonal imbalances, uterine fibroids, uterine polyps, endometriosis, anticoagulants, oral contraceptives, cancer, infection, pregnancy, cirrhosis, or thyroid disorders.
CERVICAL POLYPS. ETIOLOGY & PATHOPHYSIOLOGY •Cause unknown •Usually occur in women who have had several pregnancies •Occasionally undergo malignant changes SIGNS/SYMPTOMS Usually asymptomatic; •Possible metrorrhagia and bleeding after straining for a bowel movement and coitus. •May become inflamed causing yellow or white mucus vaginal discharge DIAGNOSIS Pelvic exam: Protruding smooth, red, finger-shaped growths seen protruding through the cervix. TREATMENT/SURGERY •When polyp is small, can be removed in outpatient procedure. •Possible Polypectomy •All tissue removed sent for pathological review. PATIENT EDUCATION Importance of annual Pap test and regular pelvic exams
OVARIAN CYSTS. (POLYCYSTIC OVARIAN SYNDROME) ETIOLOGY & PATHOPHYSIOLOGY OF PCOS ; multiple cysts due to chronic anovulatory cycles and hyperandrogenism •chronic disorder •benign cysts form on the ovaries •ovaries produce estrogen and excess testosterone but not progesterone •Affects both ovaries Androgen excess —>insulin resistance, and an imbalance in the ratios of luteinizing hormone and FSH, causing anovulation (lack of ovulation). SIGNS/SYMPTOMS •Irregular menstrual cycles •Amenorrhea or oligomenorrhea •Dysfunctional uterine bleeding; •Infertility, hirsutism, obesity, acne ;history of irregular menstrual cycles (can be over 35 days per cycle or fewer than eight menses annually). ; heavy flow ; increased abdominal cramping ; large cloths ; hirsute on face and chest or btwn breast MALES: baldness or alopecia Acanthosis nigricans is a hyperpigmentation of the skin around the neck but also may be noted in the axilla, groin, or the dorsal aspect of hands, and the patient also may have an excessive number of skin tags around the neck, under the arms and breasts, or in the groin = ass. w/insulin resistance.
PREMENSTRUAL SYNDROME (PMS) Usually occurs during the luteal phase, 7-10 days prior to menses and may continue into the first week of menstrual cycle. Uncertain Etiology Possible Causes: Imbalance of estrogen and progesterone Nutritional deficiencies Serotonin imbalance Genetic predisposition Signs & Symptoms Breast tenderness or swelling Ankle Swelling Peripheral edema Abdominal bloating Sensation of weight gain Binge eating/ food cravings Headaches, fatigue, sleep disturbance Emotional symptoms- anxiety, depression, irritability, hostility, agitation, mood swings ; may be misdiagnosed as menopause, anxiety, bipolar disorder, metabolic disorders (such as diabetes), chronic fatigue syndrome, or rheumatologic diseases.
PREMENSTRUAL SYNDROME (PMS) Other S/S Physical: • Constipation or diarrhea • Acne • Heart palpitations Behavioral: • Irritability • Depression • Mood swings • Insomnia • Crying spells Cognitive: • Decreased concentration • Paranoia • Indecision • Sensitivity to rejection • Suicidal ideation Diagnostic Studies No definitive diagnostic test; only diagnosed when other possible causes have been ruled out Symptom diary Treatment Stress management Nutritional Therapy Exercise Drug Therapy (such as oral contraceptives, NSAIDS, or antidepressants)
SURGICAL MANAGEMENT; AXILLARY NODE DISSECTION Removes breast cancer that may have spread to axilla Stages cancer; prognostic information May be performed during lumpectomy or mastectomy Complication: Lymphedema BOX 33-3 Patient Education Hand and Arm Care After Axillary Lymph Node Dissection (ALND) • Avoid blood pressures, injections, and blood draws in the affected extremity. • Use sunscreen (at least 15 SPF) for extended exposure to sun. • Apply insect repellent to avoid insect bites. • Wear gloves for gardening. • Use a cooking mitt for removing objects from the oven.
Patient Education Hand and Arm Care After Axillary Lymph Node Dissection (ALND) • Avoid cutting the cuticles; push them back during manicures. • Use an electric razor for shaving the armpit. • Avoid lifting objects greater than 5-10 lb. Patients should avoid too much increased pressure on the arm (e.g., heavy purse). • Avoid tight jewelry, clothing, or elastic bandages on the affected arm. • Avoid chemical hair removers under the affected arm, and avoid nicks and cuts if removing underarm hair. • If a trauma or break in the skin occurs, wash the area with soap and water, and apply an OTC antibacterial ointment (Bacitracin or Neosporin). • Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the surgeon or nurse.
FEMALE REPRODUCTIVE SYSTEM Essential (Primary) Organs "Gonads" Ovaries One Pair- located on either side of the uterus Function Ovulation Secretion of estrogen and progesterone Accessory (Secondary) Organs Fallopian Tubes Fertilization of an ovum by a sperm occurs here. Fimbrae Fingerlike projections at distal end of the tubes Help release the fertilized ovum Uterus Consists of a fundus, body, & cervix Three layers Vagina Contains fluid that protect against infection External Genitalia Mons pubis Labia majora and labia minor Clitoris Urethral meatus
Role of Estrogen on powerpoint ;SEE IMAGE ON POWERPOINT Key Points Non-judgmental in manner Provide reassurance Ensure the environment promotes respect, privacy, and confidentiality of information Ask open-ended questions Begin with least sensitive questions first As the interviewer, you must first be comfortable in your own sexuality to prevent displaying any discomfort in your questioning PAST MEDICAL HISTORY Major illnesses, hospitalizations, immunizations & surgeries Rubella vaccination? Obstetric & gynecologic history? Other health problems? Endocrine related problems? Medications All prescription & OTC medications Herbal products? Dietary supplements? Diuretics? Psychotropics? Drug use? (alcohol, marijuana, etc.) Oral contraceptives? Hormone replacements?
MENOPAUSE SIGNS/SYMPTOMS Perimenopause -- Irregular menses, hot flashes, mood changes, weight gain, stress & urge incontinence (ovaries gradually make less estrogen) Menopause - Cessation of menses associated with declining ovarian function. Considered complete after 1 year of amenorrhea. (ovaries have stopped making estrogen) Postmenopause - The years after menopause. no menses; hot flashes, night sweats, stress & urge incontinence. Health risk related to the loss of estrogen rise as the woman ages. DIAGNOSIS Only made after other conditions ruled out (thyroid dysfunction, anemia, anxiety) SUPPORTIVE TREATMENT Drug Therapy Hormone replacement therapy (HRT) Estrogen: No uterus; Estrogen & Progesterone: Uterus Antidepressants (SSRI's): paroxetine, fluoxetine, venlafaxine Bisphosphonates Selective estrogen receptor modulators (SERMS)
SUPPORTIVE TREATMENT Non-Hormonal Therapy (cool environment, adequate exercise & sleep, limit caffeine & alcohol) Nutritional Therapy (calcium, vitamin D, complex carbohydrates,vitamin B complex, phytoestrogens) Breast Self-Examination (BSE) Patient Education Have patient demonstrate BSE technique Discuss abnormal findings during BSE: Asymmetry Discharge (other than breast milk) Swelling of the breast or development of a lump Skin irritation, abnormal pigmentation or dimpling Nipple abnormalities (pain, redness, scaling, turning inward) Stress the importance of reporting breast changes ASAP to healthcare provider for evaluation. Allow time for the patient to ask questions
SURGICAL MANAGEMENT; LUMPECTOMY Removal of the entire tumor (cancerous tissue) along with a margin of normal surrounding tissue. Breast-Conserving; same as patients who chose mastectomy. Following lumpectomy, radiation therapy is delivered to the entire breast. ; 5 to 7 weeks If high risk for reoccurrence, chemotherapy may be given prior to radiation. ; A woman who undergoes lumpectomy also may have regional lymph nodes removed to determine if the cancer has spread beyond the breast. Contraindications: Breast size too small in relation to tumor masses or calcifications in more than one quadrant. Central location of tumor near nipple. Patient with active lupus would not be able to receive radiation, so they would need mastectomy.
SURGICAL MANAGEMENT; MODIFIED RADICAL MASTECTOMY ; Performed to treat invasive breast cancer ; Removal of the entire breast , ALC and axillary lymph nodes, but preserves the chest wall muscles ; Used (rather than lumpectomy) if tumor is too large to remove with good margins and attain a reasonable breast appearance. ; May have breast reconstructive surgery immediately following the mastectomy ; the pectoralis major and pectoralis minor muscles are left intact, unlike in radical mastectomy
CANCER OF THE OVARY Etiology/Pathophysiology Most common gynecologic malignancy Low mortality rate due to early diagnosis Usually develops after menopause high fatality rate due to the aggressiveness of the malignancy. Grows slowly, metastasizes late, & is curable with therapy if diagnosed early. Cancer that "whispers" because its clinical manifestations are not apparent until the tumor has invaded surrounding structures and is causing symptoms. Risk factor: early menarche & late menopause, nulliparity, taking estrogen without progestin after menopause, diabetes, obesity (BMI —>30), hypertension,Northern American or Northern European descent. history of breast, colon, or endometrial cancer, Use of fertility drugs Long-term use of hormone replacement therapy (HRT) Signs &Symptoms Early Stage: vague symptoms Discomfort in the lower abdomen Bloating early satiety / hunger change in bowel/ bladder habits Urinary frequency or urgency Weight loss
Signs &Symptoms Later signs: Ascites Increased abdominal girth Unexplained weight loss or gain Menstrual irregularities Signs &Symptoms Due to the close proximity of the ovaries to the intestines, patients will complain of GI symptoms, and, as a result, this cancer carries a high rate of misdiagnosis, with patients commonly receiving treatment for a variety of disorders, including IBS, gastroesophageal reflux (GERD), menopause, or UTIs. CANCER OF THE OVARY Diagnostic Testing No screening test exists ; bi manual exam Pelvic exam- palpable ovaries in postmenopausal women blood test Abdominal Ultrasound & Transvaginal Ultrasound CA-125 tumor marker (supports diagnosis) Laparotomy(diagnose & staging)
ENDOMETRIOSIS The presence of normal endometrial tissue in sites outside the endometrial cavity ; It does not continue after menopause. ; ; disabling and chronic. A significant number of women are asymptomatic and may have a normal pelvic examination SIGNS/SYMPTOMS Secondary dysmenorrhea, after years of relatively pain-free menses Infertility from adhesions pulling uterus out of position & blockage of fallopian tubes Pelvic pain ; low back pain , dyspareunia, dysuria, dyschesiz (pain w. defecation) dysmenorrhea, and menorrhagia Painful intercourse if supporting ligaments affected by adhesions Irregular bleeding CAUSED BY the retrograde flow during menses of endometrial tissue through the fallopian tubes and into the peritoneal cavity, where this tissue seeds, forming adhesions in the pelvic, bladder, and bowel areas. DIAGNOSIS Definitive diagnosis made by laparoscopy (may also remove growths & scar tissue) ; Any tenderness of the fallopian tubes, ovaries, or uterus on bimanual examination is an indication for further evaluation.
TREATMENT Determined by patient's age, desire for pregnancy, symptom severity, extent & location Watchful waiting; pain relief (NSAIDS) Hormonal treatments Oral Contraceptives (take continuously for 9 months) Progestin Agents: Medroxyprogesterone (IM injection every 3 mos) Gonadotropin-releasing hormone (GnRH) agonists; Leuprolide Surgical therapy (only cure for endometriosis) Laparotomy Total abdominal hysterectomy= remains the definitive therapy for those women who have completed their childbearing and is effective for those women who suffer from debilitating pain and bilateral salpingo-oophorectomy (TAH-BSO) NURSING MANAGEMENT Patient education: comfort measures (NSAIDS, heat, relaxation techniques, exercise, stress mgm, yoga Psychological support (disabling pain, dyspareunia, infertility) COCs decrease Inflammation and pain.
DYSMENORRHEA PRIMARY DYSMENORRHEA Painful menstruation ; primary/secondary ; Primary = occurs at the onset of menarche and the early following years after establishing a cycle and may become more severe over time ; occurs with menarche ETIOLOGY/RISK FACTORS Cramping pain in abdomen caused by menstruation Caused by excess and/or increased sensitivity to prostaglandin Begins the first few years after menarche ; The onset of primary dysmenorrhea typically occurs 6 to 12 months after the menstrual cycle has been established SIGNS/SYMPTOMS: Pain severe on 1st day of menses and usually lasts < 2 days Lower abdominal pain (colicky-like) that radiates to lower back and upper thighs; sharp, intermittent abdominal pain that is accompanied by backache, or constipation, nausea, diarrhea, fatigue, headache, light-headedness DIAGNOSTICS No tests are specific to diagnosis Menstrual and gynecologic history Pelvic exam (unremarkable findings)
TREATMENT/NURSING IMPLICATIONS Heat Exercise Drug therapy ; NSAIDS & hormonal contraceptives = due to antiprostaglandin effect NSAIDs can have a negative impact on the GI system; therefore, care must be taken to avoid long-term use of these medications. ; Combined oral contraceptives (COCs) are very beneficial PATIENT EDUCATION Coping Eliminating stress & fatigue Avoiding constipation Pain relief Exercise Proper nutrition Keep a menstrual diary Take an OTC NSAID 1 to 2 days prior to the onset It is recommended that PPIs be taken on an empty stomach. The patient should eat something 30 to 60 minutes after taking the PPI to allow the medication to start working. Also, taking the NSAID with food will help to minimize stomach upset.
DIAGNOSIS Pelvic ultrasound: Enlarged ovaries with multiple cysts; Early diagnosis decrease risk of complication] ;Patients with unilateral right lower quadrant pain must be evaluated for the potential of appendicitis. RISK FOR type 2 diabetes, acne, endometrial cancer, hyperlipidemia, obesity, hirsutism, and infertility TREATMENT/SURGERY Oral contraceptives (regulate cycle) ; If pain persists longer than 48 hours, an exploratory laparoscopy may be performed to rule out the presence of ovarian torsion (twisting of the ovary, primarily affecting the right ovary). Spironolactone (hirsutism) Leuprolide (hyperandrogenism) Metformin (improves hyperandrogenism, restore ovulation, reduce hyperinsulemia) Clomiphene (induces ovulation) If treatment unsuccessful: Hysterectomy with bilateral salpingectomy and oophorectomy
TREATMENT/SURGERY Aimed at the primary concerns (acne, infertility, obesity) ; Patients with PCOS require extensive blood work and a transvaginal ultrasound to rule out any other causative factors. ; Labs include FSH, LH, beta human chorionic gonadotropin (β-hCG), SHBG, free testosterone, prolactin, lipid panel, thyroid studies, and a fasting glucose. [ no blood work while pt is on BC] A 2-hour glucose tolerance test is useful in determining glucose intolerance. PATIENT EDUCATION Regular follow up; Weight management and exercise to decrease insulin resistance; low fat diet ; Monitor lipid profile & fasting glucose levels. COCs improves acne, hirsutism, and alopecia;
Diagnostic Endometrial biopsy - PRIMARY DIAGNOSTIC TEST=simple procedure performed in the health care provider's office and does not involve anesthesia. Hysteroscopic-directed biopsy is another alternative that is performed with the insertion of a scope through the cervix and directly into the uterus, allowing for complete visualization of the endometrium. If the biopsy is inconclusive or suggests endometrial cancer, a D&C is the gold standard Nursing Alert A D&C is brief surgical procedure that can be performed in a medical office or outpatient surgical center in which the cervix is dilated and a special instrument called a curette, or by a suction curettage (also called vacuum aspiration for evacuations for terminations or abortions), is used to scrape the uterine lining. An anesthetic is administered (spinal, general, or local anesthetizing of the cervix) and a sample of the uterine contents may be sent for analysis. Pap Test - Not reliable, but can rule out cervical cancer ; Greater than 16 mm is a predictor of abnormal pathology; in postmenopausal women, greater than 5 mm is considered pathologic
Testing Tx./Nursing Implications Total hysterectomy (TAH) and bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries) with lymph node biopsies. Radiation to decrease reoccurrence ; Vaginal brachytherapy consists of the placement of a device containing sealed radioactive material into the vagina postoperatively for 3 to 4 days and then removed ; strict bed rest; isolated ; camera mounted to bed while minimized exposure to caregivers ; a portable lead shield is placed at the bedside behind which all caregivers stand to administer medications, change IV bags, or deliver food trays. Nurses wear film badges or dosimeters to measure the amount of radiation exposure. Progesterone hormonal therapy (megestrol) Chemotherapy Surgical staging is the most precise method to determine metastasis to surrounding tissues and organs; it involves abdominal and pelvic washings and periaortic lymph node evaluation. Nurses caring for patients receiving brachytherapy must take precautions against occupational exposure to radioactive material.
Tx./Nursing Implications ; During surgery, the suspicious tissue that is removed and sent to the laboratory for immediate analysis is known as a frozen section. ; If positive, the surgeon then performs extensive cytoreduction surgery or debulking to obtain clean tissue margins. This includes a TAH with BSO, removal of the omentum, peritoneal washings, and partial colectomy if there is any colon involvement Counseling regarding prophylactic oophorectomy & oral contraceptives (if identified high risk) Treatment based on staging Abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor debullking; radiation, chemotherapy; Palliative chemotherapy & radiation to shrink tumor & relieve pain. Care must be individualized based on the patient's psychological and physical status, stage of illness, and treatment plan.
Tx./Nursing Implications pt need to be monitored for signs and symptoms of infection, ileus, DVT, pulmonary embolus (PE), and bleeding Encouraging the patient in the regular use of incentive spirometry, as well as regular ambulation, will help to decrease the development of DVT and atelectasis. emotional support ;
HYSTERECTOMY Surgical removal of female reproductive organs may be vaginal or abdominal: ;Problems such as dysfunctional uterine bleeding, benign or malignant masses, pelvic organ prolapse, pelvic pain, endometriosis, or trauma ; consist of surgical removal of the uterus and fallopian tubes ;Surgical removal of the ovaries results in immediate cessation of production of both estrogen and androgen, causing surgical menopause ;dependent upon a patient's BMI and other comorbid conditions.
Vaginal Uterus is removed through the vaginal opening Used for conditions such as uterine prolapse, endometrial hyperplasia or cervical hyperplasia. Not used when the uterus is enlarged or when the entire abdomen requires examination. No external incision is made, which means there is no visible scarring Laparoscopic-Assisted Vaginal Hysterectomy (LAVH)- 1 day surgery ; safe alternative for obese than TAH. Modified approach to vaginal hysterectomy (uses laparoscope) Allows the upper abdomen to be examined during surgery Few small incisions Less blood loss, less scarring, less post-operative pain (may have gas-like pain) quicker recovery, shorter hospital stay, few infections, less pain in the abdominal approach.
TREATMENT/SURGERY Depends of symptoms, age of patient, desire to have children, location and size of tumor. ØShrink the fibroid •Luprelide (used alone or prior to surgery) •Uterine artery embolization - uses minimally invasive plastic or gelatin particles that are injected into the uterine arteries to occlude blood flow to the fibroid [used on women who have completed childbearing] •MRI guided focused ultrasound- high-intensity ultrasound with increased temperature to destroy fibroid cells without damaging collateral tissue [only premenopausal women with symptomatic fibroids.] - Return to normal activities the day after treatment.
•Cryosurgery/ radio frequency - provide a reduction in severity of symptoms 12 months after the procedure without concerns of postembolization syndrome commonly found with patients who have undergone UAE Return to normal activities approx. 5 days after. may develop postembolization syndrome: fever, pain, and leukocytosis due to the degenerating fibroid. This is a normal response to treatment, but patients must be monitored for worsening symptoms ØRemove the fibroid •Myomectomy - preserve their fertility ; removes fibroid but leaves uterus intact ØRemove the uterus •Hysterectomy
