ch 45
Following a visit to her campus medical clinic motivated by persistent abdominal pain and dyspareunia, a 20-year-old female college student has been referred for a diagnostic workup to rule out pelvic inflammatory disease. Her elevated white cell and C-reactive protein levels lead her care provider to suspect pelvic inflammatory disease (PID). What follow-up question is most likely to help with the differential diagnosis?
"How many sexual partners have you had?"
A patient who is still breast-feeding her infant has arrived at the clinic complaining of sore breasts. The physician has diagnosed mastitis. Which of the following statements made by the patient will require correction by the nurse?
"I need to stop breast-feeding until all my antibiotics have been taken."
The nurse is teaching a 30-year-old female client to perform breast self-evaluation. Which statement by the client indicates correct understanding?
"I will palpate my breast for lumps a few days after my period"
A female client reports that her mother-in-law was just diagnosed with cervical cancer and asked the nurse about her own risk. Which response by the nurse is correct?
"If you had the HPV vaccine, your risk is greatly reduced"
Staff at a women's health center are being briefed by their supervisor on the latest recommendations for breast cancer screening. Which of the following guidelines should staff pass on to their clients?
"Screening mammography and clinical exams are the cornerstones of breast cancer screening."
A 57-year-old woman has been diagnosed with atrophic vaginitis and has expressed surprise to her care provider, citing a lifetime largely free of gynecological health problems. She has asked what may have contributed to her problem. How can the care provider best respond?
"The lower levels of estrogen since you've begun menopause make your vagina prone to infection."
A client asked the healthcare provider to "explain brachytherapy, which is recommended for my cervical cancer" which response by the nurse is most accurate?
"They will insert a radioactive device into your vagina and position it next to the cervix, so that curative levels of radiation are directly on the cancer site"
A 60-year-old woman who is 11 years menopausal has presented to the emergency department stating, "I haven't had my period in years, but lately I've been bleeding again, and quite heavily in the last few days." The care team needs to rule out endometrial cancer. How should they best explain the most accurate plan for confirming or ruling out the diagnosis?
"We're going to have to open your cervix with a speculum and take scrapings from the wall of your uterus."
While taking a history of a female client with vague symptoms But who has a strong feeling that "something is wrong with my body" which comments make the healthcare provider think of ovarian cancer? Select all that apply
"for some reason, I have bloating. My pants are tighter than normal" "I am losing weight. I just feel full after just a few bites of food" "I have to go to the bathroom to urinate frequently. I just can't hold it very long" "I think I must have an infection. I have a heaviness in my groin region"
risk factors for ovarian cancer
- + associated with ovulatory age (length of time of women's life that she has periods- so for those who have not had any period suppression such as hormone therapy and pregnancy) - + family hx in 1st or 2nd degree relatives - Using talc powder in genital area - High fat diet
how does progesterone affect menstrual cycles?
- A lack of progesterone can cause abnormal menstrual bleeding; in its absence, estrogen induces development of a much thicker endometrial layer with a richer blood supply - the absence of progesterone results from the failure of any of the developing ovarian follicles to mature to the point of ovulation, with the subsequent formation of the corpus luteum and production and secretion of progesterone
s/sx of PCOS
- Anovulatory cycles - Irregular infrequent periods (oligomenorrhea) - Hyperandrogenism (elevated testosterone levels, hirsuitism, acne) - Numerous small cysts on ovaries (polycystic) o Increased LH and decreased FSH
treatment of bartholin cyst
- Antibiotics, moist heat, and I&D - Word Cather may be inserted to continue to drain the cyst - If cysts reoccur- surgical intervention may be required
prevention of cervical cancer
- Avoiding risky sexual behaviors; barrier protection - Vaccination with HPV vaccine (Gardasil 9) · protects against HPV strains 16 & 18 that cause 70% of cervical cancer · also protects against strains 6 & 11 that cause 90% of genital warts and other strains (31, 33, 45, 52, and 58)
Primary dysmenorrhea
- Menstrual pain that is not associated with a physical abnormalities or pathologic process - Usually occurs with ovulatory menstruation beginning 6 months to 2 years after menarche - Symptoms may begin 1-2 days before menses, peak on the first day of flow, and subside within several hours to several days - May be associated with systemic symptoms such as headache, nausea, vomiting, diarrhea, fatigue, irritability, dizziness and syncope - Pain is described as dull, lower abdominal aching or cramping, spasmodic or colicky in nature, often radiating to the lower back, labia majora, or upper thighs - Pain can help with dx d/t pain occurs within 1-2 hours before menses - Tx: symptom control
Diagnosis of cervical cancer
- Cervical cancer screening can detect preinvasive disease and help reduce the risk of cervical cancer. - Screening involves: · Cytology (Pap) testing (to identify precancerous lesions or cancerous cells on the cervix) and/or · Human papillomavirus (HPV) testing (to identify the presence of high-risk subtypes of the HPV virus) - Recommendations whether to do Pap testing alone OR with HPV co-testing (Pap and HPV testing performed together) in average-risk women are as following. · Pap testing alone is recommended every 3 years for women ages 21-65 years. · HPV co-testing every 5 years is recommended for women ages 30-65 years as an alternative to Pap testing alone every 3 years. HPV co-testing is not recommended in women younger than age 30 years. · Screening should stop in women older than age 65 years if they have had three consecutive negative Pap tests or two consecutive negative HPV co-tests within 10 years, with the most recent test performed within 5 years. · Average-risk women of any age should not be screened for cervical cancer if they have had a hysterectomy with removal of the cervix.
A 31-year-old woman and her husband have presented to their family physician due to their inability to conceive a child after trying for the last 18 months. Which of the following will the nurse practitioner want to specifically rule out as potential contributing factors? Select all that apply.
- Cryptorchidism in the husband - Slow maturation of the endothelial lining after ovulation - Low levels of LH and FSH in the wife - Sexually transmitted diseases like gonorrhea or chlamydial infection.
risk factors for cervical cancer
- Early age at first intercourse - Multiple sexual partners - History of STDs - Women who have sex with women may have a higher incidence of abnormal pap smears as they often delay screening - Smoking: Nicotine is a potential carcinogen. Concentrated in cervical tissue of women who smoke. 2x greater risk of cervical cancer in smokers. - immunosuppression (e.g., HIV infection, transplant recipients) - low socioeconomic status, poor nutrition - Human papillomavirus (HPV) is the most important etiologic factor (strains 16 & 18)
treatment of breast cancer
- Includes surgery, chemo, radiation, and hormonal manipulation - Radical mastectomy (removal of entire breast) rarely is used today unless breast cancer is advanced at time of diagnosis - Hormone therapy is used to block the effects of estrogen on the growth of cancer cells
Lichen sclerosus
- Inflammatory disease of the vulva characterized by plaque like areas that may progress to parchment-thin epithelium with focal areas of ecchymosis and superficial ulceration secondary to scratching - If this condition becomes chronic; atrophy and contracture of the vulvar tissues with eventual stenosis are common - Also seen with autoimmune disorders such as thyroiditis and vitiligo - Tx: topical steroids
Cancer of the vulva
- Initial lesion of squamous cell vulvar carcinoma may appear as an inconspicuous thickening of the skin, a small raised area or lump, or an ulceration that fails to heal; may be single or multiple and vary in color from white to velvety red or black; lesions may resemble eczema or dermatitis o Can be divided into 2 general groups - HPV associated usual vulvar intraepithelial neoplasm · Commonly found in younger women · 1/3-1/2 appear to be caused by the cancer promoting potential of certain strains of HPV such as 16 and 18 - HPV independent VIN · More commonly occurs in postmenopausal women with a history of lichen sclerosus or lichen simplex chronicus
Generalized Vulvodynia
- Involves severe, constant, widespread pain or burning that interferes with daily activities - No abnormalities are found on exam, but there is diffuse and variable hypersensitivity and altered sensation to light tough which is similar to that of other neuropathic pain disorders
clinical manifestations of PID
- Low abdominal pain during menstrual period or within one week following - Abnormal vaginal discharge (55%) - Adnexal tenderness, purulent cervical discharge - + "Chandelier's sign" (Cervical Motion tenderness) when move cervix - Postcoital bleeding, dyspareunia - Intermenstrual spotting - Elevated ESR, WBC, C-reactive protein levels - Fever (> 101 degree Fahrenheit) & chills (40%) - Dysuria - Minimal criteria for diagnosis-low abdominal pain, adnexal tenderness, and CMT
clinical manifestations of ectopic pregnancy
- Lower abdominal discomfort- diffuse or localized to one side that progresses to severe pain caused by rupture - Spotting - Syncope (blood loss, hemodynamically unstable) - Pain referred to tip of L shoulder (worse with laying down) from bleeding into abdominal cavity that causes peritoneal irritation and impedes diaphragm movement when lying down (+ Kehr's sign). - Amenorrhea - Physical exam usually reveals: adnexal tenderness
Prior to performing a laparoscopy, a patient exhibiting which of the following clinical manifestations would be treated with oral antibiotic therapy for suspected pelvic inflammatory disease (PID)? Select all that apply.
- Lower abdominal pain. - Tenderness when cervix is touched during bimanual exam. - Purulent cervical drainage noted on tissue after voiding. - Elevated white cell count.
detection of breast cancer
- May manifest as a mass, a puckering, nipple retraction, or unusual discharge - Many cancers are found by women themselves - American cancer society advises all women do breast self-examination · Premenopausal should perform this right after menses - Postmenopausal and women who have had a hysterectomy should perform this any day of the month - Mammography is the only effective screening technique - A generally slow-growing form of cancer, may have been present for 2-9 years before it reaches 1 cm, the smallest mass normally detected by palpation - Mammography can disclose lesions as small as 1 mm and has a sensitivity of 80-90% · Even if mammogram is negative- a palpable mass requires further evaluation
Secondary dysmenorrhea
- Menstrual pain caused by specific organic conditions such as endometriosis, uterine fibroids, adenomyosis, pelvic adhesions, IUDs, or PID - pain starts 1-2 days before menses and lasts longer than primary - Tx: depends on identifying the cause of the problem; medical or surgical interventions may be needed
factors that predispose women to PID
- Menstruation—blood good medium for bacterial growth - Unmarried status - Age of 16-24 - Nulliparity (never having completed pregnancy past 20 weeks) - History of multiple sexual partners - Previous history of PID - IUDs only increase the risk in women who also have multiple sexual partners
Lactobacilli
- Metabolize glycogen, in the process produce lactic acid to maintain the normal healthy vaginal pH at 3.8 to 4.2 during reproductive years - Disruptions in the normal ecology predispose to infection (e.g., antibiotic use, douches) · Allows overgrowth of candida species
diagnosis of breast cancer
- Physical examination, mammography, ultrasound, percutaneous needle aspiration, stereotactic needle biopsy, and excisional biopsy - Often manifests as a solitary, painless, firm, fixed lesion with poorly defined borders - Can be fund anywhere in the breast must most common in the upper outer quadrant
Pathogenesis of cervical cancer
- Precancerous lesions can be detected and treated before cancer develops - Pap smears may note atypical cells - Atypical cells differ from normal cervical squamous epithelium - There are changes in the nuclear and cytoplasmic parts of the cell and more variation in cell size and shape (dysplasia) - These precancerous changes represent a continuum of morphologic changes with indistinct boundaries that may gradually progress to cancer in situ and then to invasive cancer, or they may spontaneously regress - A system of grading is used in the Histopathological findings of dysplastic changes of the cancer precursors and uses the term cervical intraepithelial neoplasia (CIN)
Lichen simplex
- Presents as thickened, gray-white plaques with an irregular surface - Response of the genital skin to a type of irritant and diagnosis can only be made if HPV, fungal infections, or other known causative conditions have been ruled out - Common presenting complaint: valvular pruritus - Tx: aimed at reducing itching and preventing further irritation
risk factors for breast cancer
- Sex, increasing age, personal or family history, history of benign breast disease (primary hyperplasia), and hormonal influences that promote breast maturation and may increase the chance of cell mutation (early menarche, late menopause no term pregnancies or first child after 30 years of age, and no breastfeeding) - Modifiable: obesity (especially after menopause), physical inactivity, and alcohol intake greater than one drink per day
lichen planus
- Thought to have an autoimmune component and is more rarely seen - 3 types · erosive-most common · papulosquamous · hypertrophic - tx: mild topical steroid
clinical manifestations of endometriosis
- Usually becomes apparent in the reproductive years when ovarian hormones stimulate the lesions in the same way as normal endometrium - The lesions then become proliferative, then secretory, and finally undergo menstrual breakdown - Bleeding into the surrounding structures can cause pain and the development of significant pelvic adhesions - Sx tend to be strongest premenstrually, subsiding after cessation of menstruation - Pelvic pain is the most common sx but other sx include: back pain, dyspareunia, and pain on defecation and micturition - Associated with infertility because of adhesions that distort the pelvic anatomy and cause impaired ovum release and transport
how does estrogen affect the menstrual cycle?
- estorgen deprivation causes retrogression of a previously built-up endometrium and bleeding; such bleeding often is irregular in amount and duration, with the flow varying with the time and degree of estrogen stimulation and with the degree of estrogen withdrawal - periodic bleeding episodes alternating with amenorrhea are caused by variations in the number of functioning ovarian follicles present; if sufficient follicles are present and active and if new follicles assume functional capacity, high levels of estrogen develop, causing the endometrium to proliferate for weeks or even months - in time, estrogen withdrawal and bleeding develop and this can occur for two reasons: · an absolute estrogen deficiency- may develop when several follicles simultaneously degenerate · relative deficiency- may develop as the needs of the enlarged endometrial tissue mass exceed the capabilities of the existing follicles, even though estrogen levels remain constant
Estrogen Levels
- maintain a thick, protective squamous epithelium that contains glycogen - Lactobacillus bacteria (normally found in Vaginal Flora) breaks down glycogen and produce lactic acid, which helps maintain acidic PH in vagina. Acidic PH is bacteriostatic. - Decreased estrogen in menopause causes atrophic vaginitis, lack of regenerative growth of vaginal epithelium, pH increases to > 6.0, predisposing to infections.
risk factors for PCOS
- obesity (50%) - insulin resistance and hyperinsulinemia are associated with hyperandrogenism
Following a workup that included endocrine studies (FSH/LH, prolactin, testosterone, DHEAS levels), a 22-year-old college student complaining of abnormal bleeding has been diagnosed with dysmenorrhea due to alterations in her hormone levels. The nurse should anticipate that she will likely be prescribed: Select all that apply.
- oral contraceptives. - prostaglandin synthetase inhibitors.
While educating a mother about the benefits of giving her child the human papilloma virus (HPV) vaccine, gardisil, which of the following statements will the nurse need to clarify for the parent? Select all that apply. The vaccine is
-100% effective against development of cervical cancer for her life span. -only recommended for females between the ages of 9 and 26.
Which of the following women is most likely to have a sexually transmitted infection as a contributing factor to her health problem?
A 41-year-old with a diagnosis of mucopurulent cervicitis
A nurse who works in a fertility clinic is conducting a program option for various fertility issues. The nurse judges the participants' understanding of the education when they identify that donor eggs are the best option for which one of the following women?
A 42-year-old
Which of the following sexually active women most likely faces the highest risk of developing an ectopic pregnancy?
A 42-year-old who has decided to try to have one more child and has had her tubal ligation reversed.
After a long and frustrating course of constant vaginal pain, a 38-year-old woman has diagnosed with generalized vulvodynia by her gynecologist. What treatment plan is her physician most likely to propose?
Antidepressant and antiepileptic medications
A client who has a history of untreated cervicitis tells the nurse that she is concerned about the risk of experiencing problems with fertility. The nurse explains that problems may result from
Ascending infection of the fallopian tubes
A 29-year-old client had a Pap smear performed during her recent visit to her primary care provider. This diagnostic procedure aims to identify
Atypical cervix cellular changes
Which symptoms are believed to have a strong association with ovarian cancer? Select all that apply
Bloating, abdominal pelvic pain, difficulty eating
Which condition with the nurse expect a female client with HPV to exhibit?
Cervical intraepithelial neoplasia
Localized Vulvodynia
Characterized by often stinging, burning, or cutting pain at onset of intercourse, localized point tenderness near the vaginal opening, and sensitivity to tampon placement
In assessing a client with fibroadenoma of the breast, what will the nurse find?
Firm, rubbery masses
A nurse is conducting a healthy living workshop for a group of women in their 20s. Which screening recommendation should the nurse provide to the participants of this age group?
Clinical breast examination every three years until age 40
Polycystic Ovarian Syndrome
Common endocrine disorder affects up to 6-15% of women of reproductive age
The vulva area is especially prone skin infections. The nurse knows that this occurs because of
Constant exposure to secretion and moisture
45-year-old client reports "needing to bear down with urination", frequency, and occasional loss of year and when coughing. Based on the symptoms, which diagnosis is most appropriate for this client?
Cystocele
A 45-year-old client reports "needing to bear down with urination", frequency, and occasional loss of urine when coughing. Based on symptoms, which diagnosis is most appropriate for this client?
Cystocele
What is the term for the condition that involves dyspareunia, and widespread vaginal burning in the absence of bacterial presence?
Generalized vulvodynia
A nurse monitors for side effects in a female patient receiving endometriosis treatment with a gonadotropin releasing hormone against leuprolode (Lupron)Which of the following adverse effects would because to limit duration of treatment?
Decreased bone density
A female client is being evaluated for abdominal pain and unusual menstrual bleeding. What factors in their history will the nurse identify as increasing the risk for endometrial cancer? Select all that apply
Diabetes, estrogen therapy, obesity, polycystic ovarian syndrome
A female client reports a grayish green nipple discharge in one breast. Which additional manifestation corresponds with the diagnosis of ductal ectasia?
Ductal inflammation with thickening
The nurse is caring for a client with lichen Symplex chronicus. What assessment finding does the nurse expect?
Gray white plaques with an irrregular surface
A client who has been diagnosed with premenstrual syndrome asked if there's anything to help alleviate the symptoms. The best response would be
Eat a diet low in simple sugars and high in protein
The nurse is caring for a patient in the emergency room with lower abdominal pain that is greater on the right side and who is having light vaginal spotting. When the patients human chorionic gonadroptropin (hCG) level is lower than normal, the nurse plans care for a patient with which of the following?
Ectopic pregnancy
Which clinical manifestations will the nurse expect to observe in a female with pelvic inflammatory disease? Select all that apply
Elevated CRP, purulent cervical discharge, lower abdominal pain
The nurse working in a fertility clinic is assessing a clients risk for Fallopian tube obstruction. Which disorder place is the woman at greatest risk her fallopian tube obstruction?
Endometriosis
The nurse working in a fertility clinic is assessing a patient at risk for fallopian tube obstruction. Which one of the following places the woman at greatest risk?
Endometriosis
The school nurse is providing an informational session about the prevention of cervical cancer in young girls and women. The most important information for the nurse to present would be
HPV vaccine before becoming sexually active
A 38-year-old woman with proliferative breast changes of papilloma asked the nurse about her risk for breast cancer. Which statement of risk is correct?
Higher because of your papilloma
risk factors for infertility in men
History of mumps, cryptorchidism (undescended testes), testicular torsion, hypospadias, previous urologic surgery, and history of STDs
The nurse is teaching a client about risk factors for cervical cancer. What will be included in the plan of care? Select all that apply
History of sexually transmitted infections, smoking, first intercourse at an early age, multiple sexual partners
The nurse performs a complete physical assessment on a client with polycystic ovarian syndrome. Which assessment finding support this diagnosis? Select all that apply
Increased dark facial hair, obesity, elevated blood glucose
What risk factors for breast cancer should a healthcare provider teach his or her clients? Select all that apply
Increasing age, family history, obesity
A client is experiencing oligomenorrhea. The nurse interprets this as
Infrequent menstruation with periods more than 35 days apart
The parents of a nine-year-old child asked the nurse for information about Gardasil. Which of the following instructions are appropriate for the nurse to provide? Select all that apply
It should be given before the child is sexually active, it prevents a common cause of cervical cancer, it can be given to boys and girls
What lab findings would one suspect in a patient with polycystic ovarian syndrome?
LH levels are higher in proportion to FSH
The healthcare provider suspects a diagnosis of endometriosis. Which procedure provides a definitive diagnosis?
Laparoscopy
A 23-year-old woman has been referred to a fertility clinic after 1 year of attempting to become pregnant. Her diagnostic workup has resulted in a diagnosis of polycystic ovary syndrome (PCOS). What will the first line of treatment most likely consist of?
Lifestyle modifications to include weight loss by lowering calories and fat consumption
A 28-year-old female has been told she has atypical glandular cells following Pap smear. The physician will likely recommend which procedure that can be performed in his office to remove the abnormal zone and provide a specimen for further histological evaluation?
Loop electrosurgical excision procedure (LEEP)
A client has been diagnosed with acute cervicitis caused by chlamydia. Which clinical manifestations correlates to this diagnosis?
Mucopurulent drainage
A 31-year-old patient with breast cancer is concerned about being prescribed a hormonal medication to help block the effects of estrogen on the growth of breast cancer cells. The nurse should provide education about which of the following likely medications?
Nolvadex (Tamoxifen), a nonsteroidal antiestrogen
The nurse is assessing a 24-year-old client who states that she has infrequent menstrual periods at approximately 40 to 42 days apart. She also states "my periods are really light. It's almost like I hardly even need to use a pad sometimes" the nurse should document which medical terms associated with this client's menstruation? Select all that apply
Oligomenorrhea, hypomenorrhea
causes for bleeding
P= polyps A= adenomyosis L= leiomyomas M= malignancy and hyperplasia C= coagulopathy O= ovulatory dysfunction E= endometrial I= iatrogenic causes N= not yet classified
A 15-year-old female has presented to her family physician complaining of frequent discomfort around the time of her period. She has subsequently been diagnosed with primary dysmenorrhea. Which of the following treatments is most likely to be effective?
Pain control with prostaglandin synthetase inhibitors
A college student presents to the nurse's office complaining of premenstrual syndrome. Which the following clinical manifestations would confirm this diagnosis? Select all that apply
Painful edematous breasts, abdominal bloating
A client has been diagnosed with endometriosis. What assessment findings does the nurse expect? Select all that apply
Pelvic pain, back pain, pre-menstrual pain
A 70-year-old woman who delivered four children during her reproductive years has weakened pelvic floor muscles. Which of her following anatomical structures is least susceptible to inappropriate herniation into her vagina?
Peritoneum
A client has been diagnosed with endometriosis. What assessment finding does the nurse expect? Select all that apply
Premenstrual pain, back pain, pelvic pain
A nurse who works on a urology-gynecology ward of a hospital is coming on shift and will be caring for a 34-year-old woman who has been admitted overnight for the treatment of a large endometriosis. What interventions should the nurse most realistically anticipate providing over the course of the shift and the next several days?
Providing pain control; preparing the client for a laparoscopic procedure or hysterectomy.
After a long and frustrating course of constant vaginal pain, 38-year-old woman has been diagnosed with generalized vulvodynia by her gynecologist. What treatment plan is most likely to be prescribed by her healthcare provider?
Tricyclic antidepressants and gabapentin, and antiepileptic medication
Fibrocystic changes in the breast is not uncommon. How is the diagnosis of fibrocystic changes made?
Ultrasound and mammogram
While teaching a class on female cancers, the instructor emphasizes to the nursing students that many patients with ovarian cancer may display
abdominal pain, bloating, feeling full quickly after ingesting food.
menorrhagia
heavy menstrual bleeding; defined as regular menses, lasting a week or more, or bleeding that is greater than 80 mL per cycle
metrorrhagia
intermenstrual bleeding; defined as any bleeding between periods; flow is usually light
Hypomenorrhea
light menstrual bleeding; defined as a regular period but flow is light
A college student has come to the health clinic complaining of heavy bleeding during and between her menstrual periods. The nurse practitioner will document this as
menometrorrhagia
treatment of PCOS
metformin for insulin resistance and can also help women to ovulate if they want to have children; even if they don't want children, the metformin may help with weight loss and make sure they're on birth control because metformin will increase their chances
Cervicitis
o An acute or chronic inflammation of the cervix o Acute cervicitis may result from the direct infection of the cervix or may be secondary to a vaginal or uterine infection o With acute cervicitis, the cervix becomes reddened and edematous o Irritation from the infection results in copious mucopurulent drainage and leucorrhea o Untreated cervicitis may extend to include the development of pelvic cellulitis, dyspareunia, cervical stenosis, and ascending infection of the uterus or fallopian tubes
uterine prolapse
o Bulging of the uterus into the vagina that occurs when the primary supportive ligaments (cardinal ligaments) are stretched o Ranked as first, second, or third degree depending on how far the uterus protrudes through the introitus o Sx: result from irritation of the exposed mucous membranes of the cervix and vagina and the discomfort of the protruding mass; sometimes, the woman has incontinence along with discomfort
Nonneoplastic Epithelial Disorders
o Characterized by white lesions of the vulva accompanied by itching or irritation- usually among older women o Refers to nonmalignant atropic and hyperplastic changes of the vulvar skin and mucosa that can develop at any age and can progress to malignancy o Lesions can be categorized as lichen simplex chronicus, lichen sclerosus, or lichen planus o These precursor lesions can progress differentiated vulvar intraepithelial neoplasia (VIN) or VIN simplex
Adenomyosis
o Condition in which endometrial glands and stroma are found within the myometrium, interspersed between smooth muscle fibers o Typically found in multiparous women o Events associated with repeated pregnancies, deliveries, and uterine involution may cause the endometrium to be displaced throughout the myometrium o No known cause o Frequently coexists with uterine myomas or endometrial hyperplasia o Dx: usually an incidental finding o Common complaints: heavy, painful periods with clots and painful intercourse
Endometriosis
o Condition in which functional endometrial tissue is found in ectopic sites outside the uterus o Estrogen dependent o Lesions become proliferative, secretory, and may bleed, which can cause pelvic pain, adhesions, & infertility o The sites where endometriosis may occur include the ovaries, posterior broad ligaments, uterosacral ligaments, pelvic, vagina, vulva, perineum or intestines
Endometritis
o Endometrium and myometrium are relatively resistant to infections because the endocervix normally forms a barrier to ascending infections o Endometriosis is inflammation of the endometrium o Acute endometriosis can occur as a result of an abortion or after delivery of a newborn when the cervical barrier is compromised o Chronic inflammation of the endometrium can occur with PID or after instrumentation such as a biopsy or an IUD o Clinical picture is variable but often includes mild to severe uterine tenderness, fever, malaise, and foul smelling discharge
cervix tissues
o Exocervix- visible portion covered with stratified squamous epithelium which also lines the vagina o Endocervix- canal that leads to the endometrial cavity and is lined with columnar epithelium that contains large, branched mucus-secreting glands
Bartholin Gland Cyst and Abscess
o Fluid-filled sac that results from occlusion of the duct system in the Bartholin gland o If the cyst becomes infected, an abscess may develop in the gland and is commonly caused by staphylococcal, chlamydia, and anaerobic infections o Acute symptoms are usually the result of infection and include pain, tenderness, and dyspareunia (pain with intercourse) o These are uncommon in postmenopausal women and therefore a valvular growth in these women should be considered suspicious and evaluated for malignancy
cystocele
o Herniation of the bladder into the vagina o It occurs when the normal muscle support for the bladder is weakened, and the bladder sags below the uterus o Sx: annoying bearing-down sensation, difficulty emptying bladder, frequency and urgency of urination, and cystitis
Rectocele
o Herniation of the rectum into the vagina o Occurs when the posterior vaginal wall and underlying rectum bulge forward, ultimately protruding through the introitus as the pelvic floor and perineal muscles are weakened o Sx: discomfort because of the protrusion of the rectum and difficulty in defecation
Mastitis
o Inflammation of the breast and occurs most frequently during lactation but also may result from other conditions in nonlactating women o In lactating women- inflammation results from an ascending infection that travels from the nipple to the ductile structures (usually staphylococcus and usually originates from the suckling infants' nasopharynx or the mother's hands) o Infection and inflammation cause obstruction of the ductile system and breast becomes hard, inflamed, and tender if not treated early o Without treatment, the area becomes walled off and may abscess o May also occur d/t hormonal fluctuations, tumors, trauma, or skin infection
male factors in infertility
o Man must be able to provide sperm in sufficient quantity, delivered to the upper end of the vagina, with adequate motility to traverse the female reproductive tract o Male contributions can be assessed by a semen analysis o Causes of male infertility: - Varicocele - Ejaculatory dysfunction - Hyperprolactinemia - Hypogonadotropic hypogonadism - Infection - Immunologic problems (antisperm antibodies) - Obstruction - Congenital anomalies
Ductal ectasia
o Manifests in older women as a spontaneous, intermittent, usually unilateral, grayish-green nipple discharge o Palpation of the breasts increases the discharge o Occurs during or after menopause and is symptomatically associated with burning, itching, pain, and a pulling sensation of the nipple and areola o Disease results in inflammation of the ducts and subsequent thickening
Cervical Polyps
o Most common lesion of the cervix and can be found in women of all ages but their incidence is higher during reproductive years o Polyps are soft, velvety, red lesions; they usually are pedunculated and often are found protruding through the cervical os o Usually develop as a result of inflammatory hyperplasia of the endocervical mucosa o Typically asymptomatic but also may be associated with postcoital bleeding o Most are benign but should be evaluated
Vulvodynia
o Multifactorial chronic vulvar pain disorder of at least 3 months' duration o Characterized by vulvar pain in the absence of relevant visible findings or a clinically identifiable disorder o May be primary or secondary as well as localized or generalized o Diagnosis of exclusion after ruling out: genital herpes, lichen, vulvar cancer, or neurologic disorders such as herpes neuralgia or spinal nerve compression o Many proposed triggers: chronic recurrent vaginal infections, chemical irritation or drug effects- especially prolonged use of topical steroid creams, irritating events of elevated urinary levels of calcium oxalate, and immunoglobulin
Pelvic Inflammatory Disease
o Polymicrobial infection of the upper reproductive tract (uterus, fallopian tubes, or varies) o Associated with STDs and other infections o Organisms ascend through the endocervical canal to the endometrial cavity, and then to the tubes and ovaries o Endocervical canal is slightly dilated during menstruation, allowing bacteria to gain entrance to the uterus and other pelvic structures—after entering the upper reproductive tract, the organisms multiply rapidly in the favorable environment of the sloughing endometrium and ascend to the fallopian tube o Inflammation of upper reproductive tract that involves the uterus (endometritis), Fallopian tubes (salpingitis), or ovaries (oophoritis) o Result of ascending organisms: Chlamydia, N. gonorrhea, E. coli, Streptococcus, Mycoplasma, Actinomyces, Gardnerella Vaginalis, H. Influenzae
Cancer of the vagina
o Primary cancers of the vagina are extremely rare o Mostly a disease of olden women; most women are >60 years of age or older at the time of diagnosis o May be the result from local extension of cervical cancer, from exposure to HPV, or local irritation such as occurs with prolonged use of pessary (soft, flexible device to tx pelvic organ collapse or incontinence)
Vaginitis
o Represents an inflammation of the vagina that is characterized by vaginal discharge and burning, itching, redness, and swelling of vaginal tissues o Pain often occurs with urination and sexual intercourse o The prevention and treatment of vaginal infections depend on proper health habits and accurate diagnosis and treatment of ongoing infections
female factors in infertility
o Requires production and release of a mature ovum capable of being fertilized, production of cervical mucus that assists in sperm transport and maintains sperm viability in the female reproductive tract, patent fallopian tubes with the motility potential to pick up and transfer the ovum to the uterine cavity, development of an endometrium that is suitable for the Implantation and nourishment of a fertilized ovum, and a uterine cavity that allows for growth and development of a fetus - Diminished ovarian reserve - Ovarian dysfunction - Cervical mucus problem uterine cavity abnormalities - Tubal factors
Galactorrhea
o Secretion of breast milk in a nonlactating breast o May result from vigorous nipple stimulation, exogenous hormones, internal hormonal imbalance, or local chest infection or trauma o A pituitary tumor, such as a prolactinoma, may produce large amounts of prolactin and cause this o Occurs in men and women and is usually benign
enterocele
o The area between the uterosacral ligaments just posterior to the cervix may weakened and form a hernia sac into which the small bowel protrudes when the woman is standing o May extend into the rectovaginal septum o May be congenital or acquired through birth trauma o Can be asymptomatic or cause a dull, dragging sensation, and occasionally low backache
metaplasia
o Transformation zone is a critical area of metaplasia for the development of cervical cancer o During metaplasia, a newly developed squamous epithelial cells are vulnerable to development of dysplasia and genetic change if exposed to cancer-producing agents
Ovarian Cancer
o Types: Serosal epithelium (90%), germ cell layers, or gonadal stroma tissue o Often diagnosed late o Sx often vague: abdominal bloating, feeling full quickly, pelvic or abdominal pain (often mimic GI sx) o Ascites associated with poorer prognosis o No good screening tool: CA 125 serum tumor marker is elevated in 80-90% of women in stages II-IV but is not cancer or tissue specific for ovarian cancer; it is negative in up to 50% of women in stage I
Dysplasia
o disordered growth or development of the cells - this is initially a reversible cell change, but untreated dysplasia can develop into carcinoma
Primary amenorrhea
o no menses and no secondary sexual characteristics by age 14 OR no menses by age 16 with secondary sexual characteristics evident
secondary infertility
occurs after one or more previous pregnancies
Dysmenorrhea
pain or discomfort with menstruation
vulvar non-neoplastic disorders
precancerous lesions and are risk factors for the development of vulvar cancer
primary infertility
refers to situations in which there has been no prior conception
secondary amenorrhea
the women has had menstrual cycles and then no cycle for a period of at least 6 months
CIN I
· (mild dysplasia-atypical changes in cervical epithelium) o Initial one third of epithelial layer involved o Well differentiated lesion
CIN II
· (moderate dysplasia) o Initial two thirds of epithelial layer o Less well-differentiated lesion
transformation zone
· During reproductive years, the cervix exerts or turns outward, exposing the columnar epithelium to the vaginal environment · The mechanical irritation lead to a gradual transformation from columnar to squamous epithelium- a process called metaplasia
infertility
· Inability to conceive a child after 1 year of unprotected intercourse
ectopic pregnancy
· Occurs when a fertilized ovum implants outside the uterine cavity, the most common site being the fallopian tube · Leading cause of maternal mortality in first trimester
supporting ligaments
· The uterus and the pelvic structures are maintained in proper position by the uterosacral ligaments, round ligaments, broad ligament, and cardinal ligaments · The two cardinal ligaments maintain the cervix in its normal position · The uterosacral ligaments hold the uterus in a forward position and the broad ligaments suspect the uterus, fallopian tubes, and ovaries in the pelvis · The muscular floor of the pelvis is a strong, sling like structure that supports the uterus, vagina, urinary bladder, and rectum
cause of ectopic pregnancy
· delayed ovum transport, which may result from decreased tubal motility or distorted tubal anatomy
menometrorrhagia
· heavy irregular bleeding; defined as prolonged or heavy bleeding that occurs at irregular times
oligomenorrhea
· infrequent cycles; refers to cycles that are irregular and occur greater than 35 days apart
CIN III
· severe dysplasia or carcinoma in situ) o Full-thickness involvement o Undifferentiated lesion
