NSG210 Durham Ch. 19: Alterations in Women’s Health

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 19, pp. 615-641 (textbooks/DURHAM_OB_CH19.pdf, also in textbooks/exam03/). Week 10 reading; on Exam 3. Lecture slides: raw/nsg210_wk10_OBLecture4.md (Menstrual Disorders, Symptoms and Treatment of Prolapse, Infertility). Screening, menopause and osteoporosis are in nsg210-durham-ch18-well-womens-health. Breast, cervical and ovarian cancer in med-surg are in Hinkle Ch. 51 and 52 (not assigned).

Learning Outcomes

1. Discuss causes of abnormal uterine bleeding (AUB).
2. Describe common alterations in women’s health, with medical management and nursing actions.
3. Describe complications related to childbirth trauma.
4. Describe hysterectomy procedures and related nursing care.

Nursing diagnoses: deficient knowledge about chronic pelvic pain; anxiety about a breast cancer diagnosis.

I. Menstrual Disorders

Normal menstrual parameters:

• Frequency: every 24 to 38 days
• Duration: 8 days or less
• Regularity: shortest-to-longest cycle variation 7 to 9 days or less
• Volume: judged by the woman (normal, light, heavy)

Regulation: hypothalamus secretes GnRH, which stimulates the anterior pituitary to release FSH and LH; FSH drives follicles to make estrogen; LH triggers ovulation and progesterone secretion.

Table 19-1:

II. Chronic Pelvic Pain (CPP)

• Pelvic pain lasting 6 MONTHS or longer causing functional or psychological disability; cramping, sharp, steady or intermittent pain, deep pelvic pressure, dyspareunia, painful bowel movements
• Causes: reproductive (PID, fibroids, adhesions, endometriosis, IUD), urologic (bladder tumor, chronic UTI, stones), musculoskeletal (compression fracture, posture, fibromyalgia), GI (Crohn, celiac, colitis, IBS, colon cancer), neurologic (shingles, degenerative joint disease, herniated disc), psychological (personality disorders, depression, sleep disorders), sexual or physical abuse
• Treatment depends on the cause and may take weeks to months: physical therapy; NSAIDs, acetaminophen, opioids, tricyclic antidepressants, gabapentin, muscle relaxants (Flexeril); hormones; antibiotics; steroids; laparoscopic release of adhesions; anti-inflammatory diet; psychotherapy; alternative medicine
• Nursing: assess location, character, frequency and quality; evaluate interventions; assess knowledge and teach; explain tests and surgery; relaxation, guided imagery, heat, massage; take pain-control measures BEFORE pain becomes severe

III. Polycystic Ovary Syndrome (PCOS)

• Hyperandrogenic disorder, probably neuroendocrine (hypothalamic-pituitary abnormality causing excess ovarian and adrenal androgens)
• Diagnosis requires 2 of 3: clinical or biochemical androgen excess; oligo- or anovulation; polycystic ovaries on ultrasound
• Signs: infertility (anovulation), AUB, HIRSUTISM (face, chest, stomach, back), ovarian cysts, obesity, oily skin and acne, pelvic pain, alopecia
• Higher risk of: type 2 diabetes (insulin resistance, hyperinsulinemia), cardiovascular disease, hypertension, endometrial, ovarian and breast cancer (continuous estrogen), dyslipidemia (high LDL, low HDL), infertility (high androgens and LH, low FSH), miscarriage, gestational diabetes, preeclampsia, cesarean, sleep apnea, metabolic syndrome (about one-third), depression, anxiety, binge eating

Clinical Judgment, metabolic syndrome (3 or more): waist 35 inches or more in women; triglycerides 150 mg/dL or more; HDL below 50 mg/dL; BP over 130 systolic or 85 diastolic; fasting glucose 110 mg/dL or more.

Management:

• DIET, EXERCISE and WEIGHT LOSS (first-line): lowers androgens and diabetes and CVD risk, improves ovulation and fertility, lowers lipids and BP
• Low-dose hormonal contraceptives if not seeking pregnancy (inhibit LH, lower testosterone, reduce acne and hirsutism)
• Anti-androgens (reduce hair loss, hirsutism, acne; NOT in pregnancy or when trying to conceive)
• Fertility therapy: ovulation induction (Clomid); IVF if no response
• Antidiabetic drugs: lower glucose and testosterone; may regulate cycles and help fertility
• Hirsutism: laser hair removal; eflornithine cream. Acne and alopecia: dermatology

Eflornithine (Vaniqa): reduces unwanted facial hair; inhibits ornithine decarboxylase; thin layer twice daily at least 8 hours apart; do NOT wash for 4 hours after; burning, rash, stinging, tingling.

Nursing: address body image; teach risk factors, benefits of weight loss, healthy diet, hirsutism and acne options, infertility, and coping with depression and anxiety. Care plan topics: infertility, type 2 diabetes risk, CVD risk (30 minutes of exercise 3 days a week, low-carbohydrate low-fat diet), chronic pain (pain diary, medication at the start of pain), body image, PCOS support groups.

IV. Endometriosis

• Chronic inflammatory disease: endometrial-like tissue (lesions) OUTSIDE the uterus, usually on pelvic peritoneum, ovaries, tubes, bladder, bowel; estrogen-dependent; reproductive years
• Lesions build up, break down and BLEED each cycle like the endometrium, causing pain, inflammation, scarring, fibrosis and adhesions
• Cause unknown; main theory is RETROGRADE MENSTRUATION through the tubes; also genetic, immune and hormonal factors
• One-third are asymptomatic; symptom severity does NOT match lesion size
• Signs: pelvic pain and dysmenorrhea beginning a few days before menses and ending with menstruation; low back pain; sharp pelvic pain and pressure; DYSPAREUNIA; INFERTILITY; AUB; bowel lesions cause diarrhea, painful defecation, constipation; bladder lesions cause hematuria and dysuria; fixed retroverted uterus; enlarged tender ovaries
• Emotional effects: anger and grief over infertility; pain limits social life; dyspareunia strains relationships
• Treatment:
  • NSAIDs
  • Hormones to suppress menstruation and lesion growth: oral contraceptives; GnRH agonists such as nafarelin (Synarel) (the text also lists allopurinol, which is not a GnRH agonist); progestins; danazol (Danocrine; harms a fetus, not for women trying to conceive). Symptoms usually return 1 to 5 years after stopping
  • Laparoscopic excision and laser for severe symptoms with infertility and desire for pregnancy (may recur)
  • Hysterectomy with bilateral salpingo-oophorectomy for severe symptoms without desire for pregnancy
  • Ovulation induction with IUI or IVF
• Nafarelin (Synarel): synthetic GnRH analogue; prolonged use lowers estrogens and androgens; INTRANASAL 1 spray (200 mcg) in one nostril in the morning and 1 in the other at night, max 800 mcg/day; side effects emotional lability, headache, vaginal dryness, acne, amenorrhea, impaired fertility, low libido, HOT FLASHES
• Nursing: teach about the disease and pain management (NSAIDs, heat, biofeedback, relaxation); emotional support; teach medications and surgery

V. Infections of the Reproductive System

Three types: sexually transmitted infections, endogenous (bacterial vaginosis), iatrogenic (UTI from poor technique). Prevention and early treatment reduce cancer, chronic pain, systemic infection and infertility.

A. Sexually transmitted infections

• Chlamydia and gonorrhea are the top two reported STIs, highest in adolescent girls
• Women are often asymptomatic but still infect partners; TREAT THE PARTNER too

Critical Component, untreated STIs cause: cervical cancer, PID, infertility and ectopic pregnancy (blocked tubes), CPP. Lesbian and bisexual women have the same STI risk depending on partners and practices and need the same screening. Woman-to-woman transmission: oral-genital (herpes, syphilis, gonorrhea); digital-vaginal (HPV, BV, trichomonas, chlamydia, gonorrhea); oral-anal (syphilis, herpes, hepatitis A); genital-genital (HPV, herpes); shared sex toys (trichomonas, gonorrhea, herpes, HPV).

Table 19-2:

Nursing (prevention teaching): monogamy with a screened uninfected partner; condoms or DENTAL DAMS every time; discuss STIs and protection before sex; tell providers and partners about current or past STIs; follow guidelines for pelvic exams, Pap and HPV testing.

B. Vaginitis

Normal flora is dominated by LACTOBACILLI, which inhibit yeast and bacteria. Vaginitis: discharge (possibly malodorous), burning, irritation, itching.

Candida vaginitis (yeast, Candida albicans):

• 3 of 4 women have at least one episode
• Triggers: hormonal changes (before and after menses; high estrogen in pregnancy), depressed cell-mediated immunity (corticosteroids, AIDS), broad-spectrum ANTIBIOTICS (penicillin, tetracycline kill lactobacilli)
• Risk: immunosuppression, antibiotics, steroids, DIABETES, pregnancy, menopause
• Signs: vulvar and vaginal ITCHING and irritation (primary), WHITE CHEESY (cottage cheese) discharge, dyspareunia, burning on urination, vaginal pH below 4.5
• Diagnosis: wet smear
• Treatment: OTC creams or suppositories for 1 to 7 days (miconazole, tioconazole, butoconazole, clotrimazole); fluconazole (Diflucan) 150 mg PO single dose if OTC fails or infection is severe (safety in pregnancy not established; usually compatible with breastfeeding); recurrent: 6 months of fluconazole
• See a provider BEFORE using OTC treatment if: first yeast infection, age 12 or younger, pregnant or breastfeeding, more than 4 infections a year, taking WARFARIN, immunosuppressed. Also call if symptoms last more than a week or return
• Nursing: teach OTC use; report bloody discharge, abdominal pain or fever; cotton underwear. Women may mistake BV for yeast

Bacterial vaginosis (BV):

• The most common vaginal infection: fewer lactobacilli, more organisms such as Mycoplasma, Peptostreptococcus, Gardnerella
• Critical Component: abnormal discharge must be evaluated (looks like chlamydia, gonorrhea, candida, trichomonas); BV in pregnancy raises risk of PRETERM LABOR and endometritis
• Risk: new or multiple partners (male or female), shared uncleaned sex toys, DOUCHING, antibiotics
• Signs: FISHY odor; thin white or gray (milky) discharge
• Treatment: metronidazole (Flagyl) PO or vaginal gel; clindamycin (Cleocin) PO or vaginal; tinidazole (Tindamax) PO. Male partners do NOT need treatment; female partners may
• Nursing: teach medications; metronidazole WITH MEALS and NO ALCOHOL (severe nausea, vomiting, flushing, tachycardia, dyspnea); signs of recurrence; risk factors

C. Urinary tract infection

• More common in women (short urethra near vagina and anus); usually ascending; cystitis usually E. coli; urethritis usually from STIs (chlamydia); untreated can lead to pyelonephritis; diagnosed by symptoms and confirmed by urine culture
• Risk: young girls and menopausal women (low estrogen), immunosuppression, diabetes, obstruction, incomplete or infrequent emptying, pregnancy, urethral irritation during sex, allergies to soaps, creams and bubble baths, recent urinary procedures or catheters, bowel incontinence
• Signs: dysuria, frequency, urgency, bladder fullness, suprapubic tenderness, cloudy foul urine, back and pelvic pain, low-grade fever
• Clinical Judgment, UTI in older women: often NO fever (fever means serious infection); present with CONFUSION or delirium, agitation, hallucinations, poor motor skills or dizziness, falls. Risk from weak immunity, incomplete emptying, low estrogen (E. coli overgrowth)
• Treatment: trimethoprim-sulfamethoxazole (Bactrim, Septra), ciprofloxacin, nitrofurantoin (Macrodantin), fosfomycin (Monurol)
• Bactrim: inhibits bacterial folic acid metabolism; 160 mg TMP/800 mg SMX PO every 12 hours for 10 to 14 days (3 to 5 days also effective); nausea, vomiting, diarrhea, rash
• Nursing: FINISH the antibiotic course; drink to thirst until urine is pale yellow (unless fluid restricted); void every 2 to 4 hours; void BEFORE and AFTER intercourse; wipe FRONT TO BACK; cotton underwear changed daily, no tight clothes; avoid caffeine and alcohol; no douching or feminine sprays; avoid harsh soaps, powders, bubble baths. Cranberry juice has no proven benefit and should be avoided with warfarin (Coumadin)

VI. Leiomyomas (Uterine Fibroids)

• Benign fibrous tumors of the uterine wall; the MOST COMMON tumors in women; estrogen and progesterone sensitive (grow in reproductive years, usually shrink after menopause); usually asymptomatic
• Risk: early menarche, mother or sister with fibroids, BLACK women, obesity
• Signs: pelvic pressure, dysmenorrhea, AUB (can cause severe anemia), pelvic, back or leg pain, urinary frequency and urgency, palpable mass on bimanual exam
• Diagnosis: pelvic ultrasound (also rules out pregnancy)
• Treatment by size, location, symptoms and desire for pregnancy: GnRH agonists for 3 months to control bleeding and shrink the tumor; UTERINE ARTERY EMBOLIZATION (polyvinyl alcohol pellets); laser coagulation (scarring may cause infertility); MYOMECTOMY if she wants pregnancy; HYSTERECTOMY if she does not (fibroids are a main reason for hysterectomy); transfusion for severe anemia

VII. Ovarian Cysts

• Fluid, blood or cell-filled sacs in or on the ovary; most disappear within 8 weeks (reabsorb or rupture)
• Follicular cysts (most common): follicle fails to rupture or degenerate in the first half of the cycle; usually asymptomatic (one-quarter have pelvic ache or heaviness)
• Corpus luteum cysts: corpus luteum seals and fills with fluid or blood in the luteal phase; acute lower abdominal pain, delayed menses, then acute AUB
• Rupture (coitus, exercise, trauma, pelvic exam) can cause intraperitoneal bleeding: sudden severe pain; may need surgery and transfusion
• Diagnosis: symptoms and bimanual exam; ultrasound (rule out pregnancy); CA 125 (elevated in endometriosis, fibroids, PID and ovarian cancer); laparoscopy. Rule out ovarian cancer
• Treatment: watchful waiting if mild; NSAIDs; oral contraceptives to suppress ovulation; surgery if postmenopausal (cancer risk), enlarging, unusual on ultrasound, or severely painful

VIII. Pelvic Organ Prolapse (POP)

• Weakened muscles, ligaments and fascia let pelvic organs descend into or against the vagina; includes uterine prolapse, cystocele, rectocele
• Risk: childbirth trauma (vaginal deliveries, large babies, forceps or vacuum, poor laceration repair), pelvic surgery, heavy lifting, constipation, chronic coughing, obesity, menopause (low estrogen weakens pelvic floor)

Uterine prolapse:

• Uterus descends into the vagina; degrees from slight to third-degree (complete, uterus outside the vagina)
• Signs: protrusion, low backache, pelvic or vaginal heaviness, feeling that the uterus is falling out, dyspareunia
• Treatment: vaginal PESSARY (rubber or silicone ring; for mild prolapse); surgery including hysterectomy

Cystocele (anterior prolapse): bladder bulges into the anterior vaginal wall; fullness or pressure, worse with straining, coughing, bearing down, lifting or prolonged standing; STRESS INCONTINENCE; bladder infections; urine leakage during intercourse; dyspareunia, dryness.

Rectocele (posterior prolapse): rectum bulges into the posterior vaginal wall; worse with straining and standing; vaginal irritation; CONSTIPATION.

Treatment: pessary, estrogen therapy (pelvic muscle tone), surgical repair.

Nursing (education): KEGEL exercises; prevent constipation (fiber, fluids) to avoid straining; avoid heavy lifting; weight reduction; postoperative care after hysterectomy or repair.

IX. Urinary Incontinence

• Loss of bladder control: STRESS incontinence (leakage with coughing, sneezing, laughing, lifting from increased abdominal pressure) or URGE (sudden intense urge followed by uncontrolled voiding); embarrassing and limits activities
• Risk: childbirth, aging (less estrogen, weaker muscles), obesity (risk rises with every 5-unit BMI increase), smoking (chronic cough)
• Treatment: bladder training (wait 5 minutes after the urge and gradually extend); scheduled toileting; limit alcohol and caffeine (bladder stimulants and diuretics); weight loss; KEGEL exercises; tolterodine (Detrol) or mirabegron (Myrbetriq) for overactive bladder; vaginal estrogen cream; pessary; surgery
• Tolterodine (Detrol): anticholinergic that inhibits bladder contractions; 2 mg PO twice daily; DRY MOUTH, headache, dizziness
• Nursing: Kegels; prevent constipation; avoid heavy lifting; weight reduction; keep skin clean and dry; limit caffeine and alcohol; bladder retraining schedule

X. Vaginal Fistulas

• Abnormal connection between vagina and bladder (vesicovaginal), urethra, or rectum (rectovaginal); urine or stool enters the vagina
• Causes: childbirth trauma, surgery, pelvic radiation, weak tissue, violent coitus or sexual abuse
• Signs: leakage of urine or feces from the vagina, foul odor, vaginal irritation
• Small fistulas often heal with rest; larger ones need surgery
• Post-op: VS, perineal bleeding, pain; after rectal fistula repair, high fiber and fluids for soft stools; SITZ BATHS; antibiotics; report fever, bleeding or increased pain

XI. Breast Disorders

Most breast changes are benign but cause fear; all need evaluation (mammogram, ultrasound, MRI).

Three most common breast symptoms:

• Pain: usually hormonal (perimenopause) or cysts; fewer than 10% of breast cancers present with pain
• Nipple discharge: elicited, bilateral, milky, non-bloody discharge is normal; SPONTANEOUS, UNILATERAL or BLOODY discharge needs evaluation; discharge is not a common cancer symptom
• Palpable mass: usually benign, but every mass must be evaluated

Fibrocystic breasts (benign breast disease):

• Fibrous tissue and benign cysts in more than 50% of women aged 20 to 50; probably estrogen-progesterone imbalance; cysts are tender and change size with the cycle; CAFFEINE may worsen it
• Signs: cyclic bilateral pain, usually upper outer quadrants; engorgement and density; nodularity; fluctuating cysts
• Management: mammogram and ultrasound to rule out cancer; cyst aspiration; oral contraceptives; NSAIDs or acetaminophen; supportive bra; avoid caffeine, smoking and alcohol; heat; fine-needle aspiration
• Nursing: follow screening guidelines; report changes; heat and supportive bra

Breast cancer:

• Second most common cancer in US women; Black and White women have similar rates but Black women have HIGHER mortality; prognosis improves with early detection
• Risk factors (ACS): increasing age; BRCA1 or BRCA2; family history; dense breasts; hormonal birth control; not breastfeeding; personal history; chest or head radiation; excess weight; long estrogen exposure (early menarche, late menopause, hormone therapy); excess alcohol; DES exposure
• Critical Component, NCI Breast Cancer Risk Assessment Tool: estimates 5-year and lifetime (to age 90) risk using age, family history and prior biopsies
• Diagnosis: diagnostic mammogram; ultrasound (cyst vs solid); MRI (dense breasts, scar tissue, prior lumpectomy; yearly MRI plus mammogram for high risk); BIOPSY distinguishes benign from malignant. Of screening mammograms about 90% are normal and 10% need more evaluation
• Prognostic indicators: STAGE 0 (ductal carcinoma in situ) to IV (distant metastasis); GRADE (how abnormal the cells look; high grade grows and spreads faster); HORMONE RECEPTOR status (estrogen and progesterone fuel growth); HER2/neu

Treatment by stage:

• Lumpectomy (lump plus margin, usually followed by radiation)
• Partial or segmental mastectomy (tumor, surrounding tissue, part of the chest wall lining, some axillary nodes; usually radiation after)
• Simple mastectomy (all breast tissue with nipple and areola)
• Modified radical mastectomy (whole breast plus several axillary nodes; chest wall intact)
• Reconstruction by a plastic surgeon, often at the same time
• Radiation usually starts 3 to 4 weeks after surgery: external (5 days a week for 5 to 6 weeks) or internal (MammoSite: seeds, wires or catheter twice daily for 5 days, 10 sessions)
• Chemotherapy: for advanced disease or to prevent recurrence; usually 2 or more drugs, PO or IV. Critical Component, Oncotype DX: a 21-gene assay on tumor tissue predicting recurrence and benefit from chemotherapy; for stage I or II, ER-positive, node-negative cancer
• Hormone therapy for ER-positive cancer: TAMOXIFEN (blocks estrogen receptors); fulvestrant (Faslodex) for HR-positive metastatic disease in postmenopausal women; AROMATASE INHIBITORS such as anastrozole (Arimidex) in postmenopausal women (block conversion of androgens to estrogen in body tissue)
• Targeted therapy: trastuzumab (Herceptin), a monoclonal antibody against HER2-overproducing tumors

Tamoxifen (Nolvadex D): reduces risk in high-risk women and treats breast cancer; competes with estrogen at breast receptors; 10 to 20 mg PO twice daily or 20 mg daily for 5 years. SERIOUS: pulmonary embolism, stroke, uterine malignancy. Common: vaginal dryness, hot flashes, joint pain, leg cramps, nausea.

Nursing: emotional support for woman and family; current evidence on options; encourage second opinions; manage side effects; nutrition for healing and immunity; complementary methods (imagery, journaling, hypnosis); resources (Look Good Feel Better; ACS Reach to Recovery).

Table 19-3, radiation side effects:

• Diarrhea: 8 to 12 cups of clear liquids (Gatorade, Pedialyte), 5 to 6 small meals, low fiber, low fat, low lactose foods, antidiarrheals, baby wipes, sitz baths
• Fatigue: 8 hours of sleep, rest breaks and naps, fewer activities, 15 to 30 minutes of exercise, adjust work, ask for help
• Sexual and fertility changes: discuss egg preservation; water- or mineral-based lubricant; vaginal dilators for stenosis
• Skin: wash gently without rubbing or scratching; lukewarm water; NO heating pads or ice packs; soft loose clothing; sun protection
• Urinary: 6 to 8 cups of fluid; avoid coffee, black tea, alcohol, spices; report changes

Table 19-4, chemotherapy side effects:

• Anemia: high-protein and iron-rich foods
• Appetite changes: 5 to 6 small meals; milkshakes and soup; new foods; eat with others; PLASTIC utensils and glass pots if food tastes metallic
• Bleeding: soft toothbrush, electric shaver, wear shoes, avoid constipation
• Constipation: high fiber, fluids, exercise 15 to 30 minutes a day
• Mouth and throat: brush teeth and tongue with a soft brush after meals, prescribed rinse, lip balm, soft wet foods

XII. Gynecologic Cancers

ENDOMETRIAL cancer is the most common reproductive cancer, followed by cervical and ovarian.

A. Cervical cancer

• Once the leading cancer killer of women; now 21st thanks to the Pap smear (1950s)
• HPV is the primary cause; most sexually active people get HPV
• Slow-growing; begins as DYSPLASIA (precancerous, 100% treatable); can spread to bladder, intestines, lungs, liver
• Pap and HPV tests are SCREENING tests; abnormal results need COLPOSCOPY with biopsy for diagnosis. Most women diagnosed had no regular Pap testing or did not follow up
• Risk factors: HPV, sex before 16, smoking, weak immunity, multiple partners, in utero DES exposure, oral contraceptives 5 years or more, three or more births
• Early stages are usually asymptomatic. Advanced: watery, pink, brown, bloody or foul discharge; bleeding between periods, after intercourse or after menopause; leaking urine or feces from the vagina; dyspareunia; weight loss; fatigue; pelvic, back or leg pain
• Workup: cone biopsy; CT, MRI, PET, IVP, chest x-ray, cystoscopy, labs
• Stages 0 (abnormal epithelial cells) to IVB (liver, lungs, bone)
• Treatment by stage and desire for pregnancy: conization, cryosurgery, total or radical hysterectomy, internal or external radiation, lymph node removal; chemotherapy for metastatic or recurrent disease; bevacizumab (angiogenesis inhibitor) with chemotherapy for advanced disease
• Nursing: support, nutrition, rest, community services; pre- and postoperative care; radiation skin care (ask about lotions, NO adhesive tape on the treatment area, expose to air); chemotherapy and side-effect teaching
• Critical Component, external radiation for cervical cancer: short term fatigue, nausea and vomiting, diarrhea, cystitis, bruising, anemia, rash; long term vaginal stenosis and dryness, premature menopause, leg swelling (pelvic nodes), weak bones (hip fracture risk)

B. Endometrial (uterine) cancer

• Endometrial carcinoma is the most common uterine cancer; diagnosed by endometrial biopsy
• Risk factors (prolonged estrogen exposure): UNOPPOSED ESTROGEN therapy with a uterus (endometrial hyperplasia); early menarche or menopause after 52; OBESITY (fat makes estrogen); TAMOXIFEN; nulliparity; diabetes
• Signs: POSTMENOPAUSAL BLEEDING or AUB (most common symptom); abnormal discharge; dysuria; dyspareunia; pelvic pain or pressure
• Stages: 0 carcinoma in situ; IA less than halfway into the myometrium; IB more than halfway; II invades cervical stroma; III outside the uterus within the pelvis; IV outside the pelvis, bladder or rectal mucosa, or distant
• Treatment: hysterectomy with bilateral salpingo-oophorectomy and pelvic and para-aortic node dissection; radiation; chemotherapy; progesterone; targeted drugs (lenvatinib and bevacizumab block new vessel growth; pembrolizumab targets PD-1)
• Nursing: support, nutrition, rest, perioperative care, chemotherapy and side effects

C. Ovarian cancer

• Epithelial, germ cell or stromal; mostly POSTMENOPAUSAL women; only 25% found early (5-year survival 94% when found early); symptoms are VAGUE
• Risk factors: first-degree relative with ovarian cancer or family history of colorectal or breast cancer; personal cancer history; age over 55; obesity; first full-term pregnancy after 35 or never; infertility drugs over 1 year; BRCA1 or BRCA2
• Signs: often silent or vague; abdominal, pelvic, back or leg pressure or pain; swollen or BLOATED abdomen; urinary urgency and frequency
• Tests: CA 125, transvaginal ultrasound, CT, MRI, PET, barium enema; diagnosis by histology, usually at surgery
• Stages: I one or both ovaries; II pelvic spread; III outside the pelvis or regional nodes; IV beyond abdomen and pelvis
• Treatment: total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, node and tissue biopsies (plus chemotherapy for high grade or stage II and III); stage IV debulking then chemotherapy; targeted: bevacizumab, PARP inhibitors, larotrectinib
• Nursing: perioperative care, chemotherapy, side effects, support, malnutrition assessment

Patient Education, nutrition in cancer care:

• Anorexia: small high-protein high-calorie meals every 1 to 2 hours (milkshakes, pudding, yogurt, eggs)
• Taste changes: rinse mouth before eating; pair meats with something sweet; plastic utensils; add spices and sauces
• Nausea: eat before treatments; rinse mouth; bland soft foods; avoid warm rooms and cooking odors
• Diarrhea: broth, soup, bananas, canned fruit; at least 8 cups of fluid plus 1 cup after each loose stool; avoid greasy, high-fiber, milk and sugar-free foods

XIII. Intimate Partner Violence

• CDC: physical violence, sexual violence, stalking and psychological aggression (including coercion) by a current or former partner; 1 in 4 US women in her lifetime; all groups and orientations
• Physical (slapping, shaking, choking, burning, weapons), sexual (forced sex, trading sex for food, money or drugs), psychological (humiliation, control, isolation from family and friends, withholding money)
• Lifelong effects: depression, traumatic brain injury, chronic pain, vaginal infections, dyspareunia, unintended pregnancy
• Risk: low self-esteem, low academic achievement, adolescence or young adulthood, alcohol or drug use, few friends, marital conflict, one partner dominating
• Abuser characteristics: extreme jealousy, possessiveness, controlling, blaming, public or private demeaning, controlling her clothing or behavior

Critical Component, signs of IPV:

• Repeated nonspecific complaints; overuse of health care
• Hesitancy, embarrassment or evasiveness about the injury history
• DELAY between injury and seeking care; untreated serious injuries
• OVERLY SOLICITOUS partner who stays close and answers for her
• Injuries to head, neck, face and areas covered by a one-piece bathing suit; in pregnancy the BREASTS and ABDOMEN are targets
• Bruises at VARIOUS STAGES of healing

Nursing (ANA): UNIVERSAL screening; DOCUMENT abuse; follow mandatory reporting laws. Screening questions: Do you feel safe at home? Has your partner ever hit you? Do arguments leave you feeling bad about yourself? Are you frightened by what your partner says or does? Do you feel safe in your relationship? When she discloses: assess URGENT SAFETY first, help with a plan, give information on IPV and shelters, and help her develop protective strategies.

XIV. Hysterectomy

• Surgical removal of the uterus; one of the most common major surgeries in women. Top reasons: LEIOMYOMAS, ENDOMETRIOSIS, PROLAPSE; also cancer, AUB, chronic pain

Types:

• Supracervical (partial): uterus only, cervix left
• Total (simple): uterus and cervix
• With bilateral salpingo-oophorectomy: uterus, cervix, tubes and ovaries
• Radical: uterus, cervix, tubes, ovaries, upper vagina and lymph nodes (some cancers)

Approaches:

• Abdominal: transverse (Pfannenstiel) or vertical (low midline) incision; preferred for gynecologic cancer; general anesthesia with ETT (plus epidural for postoperative pain in cancer cases)
• Vaginal: lithotomy position, pericervical incision; general, epidural or spinal anesthesia
• Laparoscope-assisted vaginal (LAVH): steep Trendelenburg; started laparoscopically, finished vaginally; higher risk of bladder injury and UTI; general anesthesia (CO2 insufflation raises abdominal pressure, can compromise breathing and venous return, and with Trendelenburg increases aspiration risk)
• Robotic-assisted laparoscopic: steep Trendelenburg, 3 to 4 small incisions near the umbilicus; general anesthesia with full muscle relaxation (surgeon has limited access, patient must not move)
• In steep Trendelenburg, watch for FACIAL and CONJUNCTIVAL EDEMA; extubation may be delayed for laryngeal edema risk

Risks: anesthesia complications, injury to ureters, bladder or bowel, hemorrhage, infection, DVT and VTE.

Critical Component, surgical site infection bundles: ACS “Strong for Surgery” preoperative checklist covers nutrition, glycemic control, medication management, smoking cessation, pain management, delirium, prehabilitation, and patient directives.

Preoperative care (abdominal): history and physical; CBC, type and cross-match, UA; ECG; NPO 8 hours; informed consent; antibiotics. Nursing: admission assessment and forms; verify documents and NPO status; surgical checklist (remove jewelry, glasses or contacts, dentures); explain what to expect; IV and antibiotics; void or Foley; support.

Postoperative care (abdominal):

• Medical: IV therapy, analgesia, antibiotics if at risk, hormone replacement if ovaries removed, diet advanced within 12 to 24 hours, Foley for 12 to 24 hours, ambulate once recovered from anesthesia
• Nursing: VS; monitor blood loss on the abdominal dressing and perineal pad (small to moderate vaginal bleeding for several days); consciousness, sensation, anesthesia effects; lung sounds, deep breathing and coughing with a PILLOW SPLINT; anti-embolism therapy; reposition every 2 hours; pain relief; AMBULATE (prevents DVT, restores peristalsis, reduces gas); I&O; discontinue IV and Foley as ordered; bowel sounds and diet; emotional support (hormonal changes, loss of fertility)
• Discharge teaching: keep the incision dry per instructions; walk to rebuild activity; follow limits on activity and LIFTING; light vaginal bleeding for several days; protein, iron and vitamin C; pain management; NOTHING IN THE VAGINA (no douching, tampons or intercourse) until cleared; report increased or unrelieved pain, incision drainage, redness or swelling, heavier vaginal bleeding, calf pain, swelling or redness, fever of 102.2 F (39 C) or as instructed

High-Yield Numbers

• Normal cycle 24 to 38 days, 8 days or less, variation 7 to 9 days or less
• Primary amenorrhea: none by 16 (with secondary sex characteristics) or 13 (without); secondary: none for 3 months
• Chronic AUB: 6 months; CPP: 6 months
• Primary dysmenorrhea: prostaglandin 10 times normal; starts 12 to 24 hours before flow
• PCOS: 2 of 3 criteria; metabolic syndrome in about one-third
• Metabolic syndrome: waist 35 inches, TG 150, HDL under 50, BP 130/85, glucose 110
• Endometriosis: one-third asymptomatic; symptoms return 1 to 5 years after stopping drugs
• Nafarelin max 800 mcg/day
• Chlamydia: 30% have discharge; doxycycline 7 days or azithromycin 1 g once
• Syphilis chancre 10 to 90 days after contact; secondary 6 weeks to 6 months
• Trichomonas 5 to 28 days; no alcohol for 24 hours after metronidazole
• Candida: 3 of 4 women; pH below 4.5; fluconazole 150 mg once
• Bactrim every 12 hours for 10 to 14 days (3 to 5 days effective)
• Void every 2 to 4 hours
• Ovarian cysts resolve within 8 weeks
• Fibrocystic changes in over 50% of women 20 to 50
• Fewer than 10% of breast cancers present with pain
• Radiation after breast surgery starts 3 to 4 weeks later; external 5 days a week for 5 to 6 weeks; internal twice daily for 5 days
• Tamoxifen 5 years
• Ovarian cancer: 25% found early; 94% 5-year survival if early
• Fever 102.2 F (39 C) after hysterectomy: report

Priority Nursing Actions and Red Flags

• Secondary amenorrhea: rule out pregnancy first
• Ibuprofen (prostaglandin inhibitor) is the mainstay for primary dysmenorrhea
• PCOS: weight loss is first-line; screen for diabetes and CVD
• Treat STI partners (except male partners in BV); no alcohol with metronidazole
• Fishy odor with thin gray discharge: BV; cottage-cheese discharge with itching: candida; frothy yellow-green: trichomonas
• Older woman with new confusion or falls: think UTI
• Postmenopausal bleeding: evaluate for endometrial cancer
• Unilateral spontaneous or bloody nipple discharge: needs evaluation
• Tamoxifen: watch for PE, stroke, uterine cancer (report abnormal bleeding)
• IPV: screen privately, assess immediate safety, document
• After hysterectomy: ambulate early, splint to cough, nothing in the vagina until cleared, watch for DVT and bleeding

Medications

Related

• nsg210-durham-ch18-well-womens-health
• nsg210-durham-ch14-high-risk-postpartum (postpartum infections)
• nsg210-hinkle-ch12-oncologic-management (chemotherapy and radiation nursing)
• INDEX