CHAPTER 19
ALTERATIONS IN
WOMEN’S HEALTH
Copyright © 2014. F.A. Davis Company
OBJECTIVES
The learner will be able to
◦Define keys terms
◦Describe diagnostic procedures
commonly used in women’s health
care
◦Discuss various causes of menstrual
disorders
◦Describe common alterations in
women’s health, including medical
management and nursing actions
COMMON DIAGNOSTIC
PROCEDURES
• Breast biopsy and aspiration:
• Abnormal breast mass/lump
• Colposcopy
• Evaluation of cells from abnormal pap smear
• Dilation and curettage
– Remove uterine tissue/Tx VG BLD
• Endometrial biopsy
• Removal of tissue from uterus (when CA is
suspected)
COMMON DIAGNOSTIC
PROCEDURES
(CONT’D)
• Laparoscopy: Visualize/tx pathology
• Magnetic resonance imaging (MRI)
– To evaluate breast/ovarian CA
• Cervical conization
• Removal of pre/cancerous cervical cells
• Ultrasonography-most commonly used
– Eval abnormal breast mass/pelvic organ
pathology
MENSTRUAL DISORDERS
◦ Primary amenorrhea
• No menses by age 16 w/secondary sex characteristics
◦ Secondary amenorrhea: Most common reason?
• no period x6m after having prior menses
◦ Menorrhagia
• Excessive vaginal bleeding for increasing # of days
◦ Metrorrhagia
• Bleeding in between periods (STD r/o)
◦ Primary dysmenorrhea (common)
• Painful menses w/out pathology (high prostaglandins)
Tx?
◦ Secondary dysmenorrhea
• Painful menses due to pelvic pathology
◦ PMS: psychological & physical sx that go away with menses
The most significant form of
menstrual disorder that warrants
immediate investigation is _______.
A. Primary amenorrhea
CLICKER
B. Menorrhagia
QUESTION
C. Metrorrhagia
D. Secondary dysmenorrhea
ANSWER
◦C
◦Rationale: Menorrhagia
◦Menstrual bleeding that is
excessive in number of days and
amount of blood
CHRONIC PELVIC
PAIN
◦ Definition
◦ Pelvic pain x6m
◦ Signs and symptoms
◦ Sharp, dull, ache (various by Dx)
◦ Causes
◦ Various pelvic/muscle pathology, often unknown
◦ Medical management –Start with U/S
◦ Tx known cause (e.g. PMS), Tx Sx (diet, SSRI, pain rx)
◦ Nursing actions
◦ Teach to use pain rx before pain gets severe
◦ Educ on CAM (hot/cold, massage, etc)
Definition (1/10 woman suffer)
• Hormonal imbalance à menstrual
disorders
Pathophysiology
POLYCYSTIC • Now well known, suspected High “T”
and androgens
OVARY Signs and symptoms
SYNDROME • Irreg periods, hirsutism, infertile, acne
(PCOS) Medical management
• Decrease MS consequences,
preserve fertility
Nursing actions
• COC (yaz), M q3 months,
diet/exercise, metformin
PCOS
Hirsutism
PCOS
Metabolic Syndrome Mgmt strategy Benefits
Which statements are true
regarding PCOS and the benefits
of diet and exercise? Select all that
apply
A. Reduces risk of type 2 diabetes CLICKER
B. Increases the levels of circulating
androgens
QUESTION
C. Improves frequency of ovulation
and menstruation
D. Lowers risk of uterine cancer
ANSWER
◦ A, C, D
A. Reduces risk of type 2 diabetes
C. Improves frequency of ovulation and
menstruation
D. Lowers risk of uterine cancer
ENDOMETRIOSIS
◦ Definition-video
• Endometrial tissue outside uterus
◦ Pathophysiology
• Retrograde menses, risk factor c/s?
◦ Signs and symptoms
• Infertile, dysmenorrhea, dyspareunia
(painful IC)
◦ Medical management
• COC , NSAIDS, IVF, Nafarelin (MP sx)
◦ Nursing actions
• How to use COC/NSAIDS, help w/IVF
information
Endometriosis Video
PID
◦ Definition-Picture
◦ Infection of upper genital tract
◦ Pathophysiology
◦ CT/GC à invade/scar fallopian tubes à infertility
◦ Risk factors
◦ X sex partner, <24 y.o, douching (no longer
recommended)
◦ Signs and symptoms
◦ Pelvic pain, fever, abnormal DC, High ESR (lab result)
◦ Medical management
◦ AntiBX, re-eval pt in 72 hrs, Tx sex partner (why?)
◦ Nursing actions
◦ Tx partner, no sex x7 days, sx of ectopic (why?)
PID
CANDIDIASIS (yeast
infx)
◦ Definition
• Disturbance of vaginal ecosystem
◦ Pathophysiology
• Overgrowth of candida Albicans (fungal-how to Tx???)
◦ Risk factors
• Recent antibx, high sugar diet??
◦ Signs and symptoms
• What are they?
◦ Medical management
• OTC vaginal anti-fungal (clotromizole) or PO x1 diflucan
◦ Nursing actions
• Cotton underwear, low sugar diet, exercise, eat yogurt
(lactobacillus)
BACTERIAL VAGINOSIS (BV)
◦ Definition
◦ Disruption of vaginal flora
◦ Pathophysiology
◦ Low lactobacillus, overgrowth of
gardnerella
◦ Risk factors
◦ X sex partners, douching, lesbian
◦ Signs and symptoms
◦ What are the symptoms?
◦ Medical management
◦ Tx w/antibiotics (Flagyl 100 mg bid x7 days)
◦ Nursing actions
◦ Avoid ETOH w/Rx, partner need tx?, use
condoms
SEXUALLY TRANSMITTED INFECTIONS
◦ Acquired Immune Deficiency Syndrome (AIDS)
◦ Chlamydia-most commonly reported STI
◦ Genital warts/condylomas
◦ Genital herpes-no cure, prevent outbreaks
◦ Gonorrhea-second most commonly reported STI
◦ Hepatitis B
◦ Syphilis-Needs Tx and f/u
◦ Trichomoniasis-
◦ Nursing Interventions
• If bacterial her partner(s) need Tx Tuskegee Study
• NO sex x7 days, ALWAYS USE CONDOMS
• Retest them, assure it is gone
• Woman often have no sx
CRITICAL COMPONENT – SEXUALLY
TRANSMITTED INFECTIONS (STI)
Untreated STI places a woman at risk for:
◦Cervical cancer (HPV)
◦Pelvic inflammatory disease (two most common?)
◦Infertility due to blocked fallopian tubes
◦Ectopic pregnancy due to blocked fallopian tubes
◦Chronic pelvic pain (adhesions/scar tissue)
◦Transmitting STI: since most woman have no sx, they
often unknowingly transmit STI’s to their partners.
URINARY TRACT INFECTIONS
• Risk factors
• Nursing interventions:
–Urinate b4/after sex
–Increase fluids/urinate PRN
–Wipe front-back
–Do not douche
–Cotton underwear
–Cranberry juice? I prefer ..
CRITICAL COMPONENT – UTI AND OLDER WOMEN
◦ Older women are more susceptible to UTI:
◦ Present atypically: confusion, agitation
◦ Because of presentation, Dx late and
aggressive
◦ Weakened muscles of the bladder that
increases the risk for incomplete emptying of
the bladder
◦ Decreased levels of estrogen which can alter
the normal vaginal flora allowing for growth
of E. coli which can spread to the urinary
track.
LEIOMYOMAs OF THE UTERUS
• Definition AKA fibroids
–Fibrous tumors of uterine wall (95% benign)
• Risk factors
–A.A, obese, low parity
• Signs and symptoms
–Pelvic pressure, polyuria, menorrhagia, or no
sx
• Medical management
–IUD mirena, embolization, myomectomy
• Nursing actions
–Gets better with menopause
–Return for heavy bleeding
Fibroid Types
OVARIAN CYSTS
Pathophysiolo Risk factors Assessment Medical Nursing actions
gy findings management
Collection of Being on fertility U/S, <3 cm, re- COC, most >3 cm Discuss
fluid/cells within drugs (clomid) measure in 3-6 resolve w/out torsion/rupture
ovaries months intervention precautions
•Severe pelvic
pain/vaginal
bleeding
Ovarian Cyst
What’s going to happen?
CYCTOCELE, RECTOCELE AND UTERINE
PROLAPSE
Management for Cystocele/Uterine Prolapse
Pathophysiology
• Uterus descends into vagina (weak
musculature)
DISORDERS Risk factors
OF PELVIC • NVSD, macrosomia, Menopause,
pelvic surgery
SUPPORT: Medical management
UTERINE • Pessary, Surgery
PROLAPSE Nursing actions
• Risk reduction: KEGELS (How and
why?)
• Avoid strain, treat constipation, do
not lift heavy items
◦ Pathophysiology
◦ Cystocele: bladder bulges into
vagina
◦ Rectocele: rectum bulges into
vagina
◦ Risk factors: same as uterine
prolapse
DISORDERS OF PELVIC
◦ Symptoms
SUPPORT: ◦ Cystocele: leaking or urine, pressure,
CYSTOCELES/RECTOCELE painful sex
◦ Rectocele: constipation
◦ Assessment findings: see image
◦ Medical management:
pessary/surgery for rectocele
◦ Nursing actions
◦ Same as for uterine prolapse
Evaluation
Cystocele Rectocele
DISORDERS OF PELVIC
SUPPORT: GENITAL FISTULAS
◦ Pathophysiology
◦ Abnormal connection between vagina,
rectum, bladder
◦ Risk factors
◦ Crohns Dx #1, surgery, childbirth
◦ Assessment findings
◦ Varies: feces in vagina, urine in vagina,
menses in urine
◦ Medical management: Surgical repair
◦ Nursing actions
◦ Post Surgery
◦ Sitz bath, Antibx, high fiber diet
Types of genital fistulas
URINARY
INCONTINENCE: STRESS
INCONTINENCE
◦ Pathophysiology: image
◦ Risk factors
◦ Childbirth, obesity, smoker
◦ Assessment findings
◦ Leak urine when coughing or sneezing
◦ Medical management
◦ Pessary or anticholinergic (i.e.,
oxybutynin)
◦ Nursing actions
◦ Kegels
◦ Limited coffee/ETOH-diuretic in nature
◦ Bladder training (when urge until
strong, hold 5 min, then void)
Stress incontinence
BREAST DISORDERS—
FIBROCYSTIC CHANGES
◦ Overview
◦ Nodular, fibrous/cystic breast-hormonal?
◦ 50% woman experience in their 20-30s
◦ C/O bilat breast pain, changes throughout
month
◦ Medical management
◦ COC, NSAIDS, U/S, supportive bra (sports)
◦ Nursing actions
◦ Limit caffeine, smoking
◦ BSE
◦ Reassurance
BREAST CANCER
◦ Risk factors
◦ Age (90% CA >age 40), BRCA gene, Ashkanazi Jew,
+2 relatives w/breast or ovarian CA, 50% have NO
risk factors
Medical management: varies on stage 1-4
◦ Surgical interventions-radical/partial masectomy
◦ Radiation therapy
◦ Chemotherapy
◦ Hormone therapy-tamoxofin (decreases “E”) x5
years
◦ Nursing Interventions
◦Emotional support
◦Schedule
◦Wig selection/make-up
CERVICAL CA
• Overview: 40 years ago #1 killer, now rare
• Risk factors: HPV, smoker, x sex partners
• Risk reduction: Gardasil, monogamous,
condoms
• Signs and symptoms of early cervical
cancer
◦ None, “spotting,” slow progression
• Signs and symptoms of advanced cervical
cancer
◦ Vaginal bleeding, pelvic pain, weight loss
• Medical management
◦ Usually caught pre-cancerous stages
• Nursing actions
◦ Emotional
Critical Component-
Complications of External
◦ Proctitis Radiation
◦ Cystitis
◦ Vaginal scarring and stenosis
◦ Anemia
◦ Bruising
◦ Increase risk for infection
◦ Skin rash
◦ Sexual difficulties
◦ Premature menopause
◦ Vesicovaginal fistulas
ENDOMETRIAL CANCER #4 CA KILLER
◦ Overview
◦ CA of lining of uterus
◦ Risk factors
◦ PCOS, age, HRT, obese, nullip
◦ Signs and symptoms
◦ Abnormal uterine bleeding, bleeding after
menopause
◦ Medical management
◦ Varies, usually chemo/hysterectomy
◦ Nursing actions
◦ Prevention: COC, having a menses q3 months
OVARIAN CA #3 CA KILLER
• Risk factors
◦ Nullip, Caucasian, >40 y.o.
• Signs and symptoms
◦ SO VAUGE…one reason it is found late stage
◦ Bloating, urinary freqency, feeling full quickly
• Stages: 0-4
• Medical management
◦ Radiation/chemo
◦ De-bulking, removal of uterus/ovaries
• Nursing actions
◦ Emotional
Why does ovarian cancer spread so quickly?
GYNECOLOGICAL CANCERS
•Management of radiation side
effects
•Management of chemotherapy side
effects
Look up, pages 527-529
CLICKER QUESTION
Tamoxifen (Nolvadex-D) is used in the
treatment of _____________.
A. Breast cancer
B. Cervical cancer
C. Endometrial cancer
D. Ovarian cancer
ANSWER
Tamoxifen (Nolvadex-D) is used in the
treatment of _____________.
A. Breast cancer
B. Cervical cancer
C. Endometrial cancer
D. Ovarian cancer
INTIMATE PARTNER VIOLENCE
◦ Definition
◦ Physical, emotional, sexual, financial abuse
◦ Overview: DV/Abuse cycle
◦ Nursing actions
◦ Report DV in CA
◦ Make patient feel safe
◦ Make plan to leave
◦ Bag of impt documents
◦ Places she can stay
CRITICAL COMPONENT – SIGNS OF INTIMATE PARTNER
VIOLENCE
Signs of IPV
• Repeated nonspecific complaints
• Overuse of health-care system
• Hesitancy, embarrassment, or evasiveness in
relating history of injury
• Time lag between injury and presentation for
care
• Untreated serious injuries
CRITICAL COMPONENT – SIGNS OF INTIMATE
PARTNER VIOLENCE
◦Overly solicitous partner who stays close
to the woman and attempts to answer
questions directed at her
◦Injuries of head, neck, face, and areas
covered by a one-piece bathing suit;
during pregnancy, the breasts and
abdomen are particular targets of
assault
◦Presence of bruises at various stages of
healing
CASE STUDY
You are assigned a 50-year-old woman
who had a radical hysterectomy and
removal of lymph nodes for stage 2
cervical cancer. Her treatment will
include internal and external radiation
therapy and chemotherapy. She is
concerned about the side effects of
these therapies and asks for advice on
how to cope with the side effects.
CASE STUDY (CONT’D)
◦Develop a teaching plan for
this woman that includes (1)
management of side effects
related to radiation therapy
and (2) management of side
effects related to
chemotherapy.