Reproductive Function & Disorders Mandy Vichas RN, BSN, NPS Male Anatomy • Testes • Penis • Prostate Gland • Scrotum • Epididymis & Vas Deferns • Seminal Vescicles & Ejaculatory Ducts MALE ANATOMY • Scrotum – Testes are encased in the scrotum – major purpose to provide proper environment for testes – Temperature – Physical activity • Penis – Consists of the glans penis, the body and the root – Erectile tissue is in the body – Nerve supply is autonomic Male Anatomy • Testes • Dual Function • Spermatogenesis – The scrotum maintains a temperature slightly lower than the rest of the body to facilitate Spermatogenesis • Secretion of testosterone Male Anatomy • Epididymis – A hoodlike structure lying on the testes containing ducts that lead to the Vas Deferens • Vas Deferns – tube from end of epididymis to ejaculatory duct • Seminal Vesicles – An outpouching of the Vas Deferens which acts as a reservoir for testicular secretions • Ejaculatory Ducts – The tract that passes through the prostate gland and urethra • Prostate Gland – Surrounds the urethra – Produces secretions suitable for the passage of sperm Male Reproductive Hormones • GONADOTROPIN RELEASING HORMONE (GnRH) – released by the hypothalamus, tells the pituitary to release LH and FSH – ultimately controls sperm production and testosterone levels • FOLLICLE STIMULATING HORMONE (FSH): – released by the anterior pituitary, stimulates the production of sperm in the seminiferous tubules of the testes • LUTEINIZING HORMONE (LH): – Also called ICSH or interstitial cell stimulating hormone – released by the anterior pituitary, stimulates testosterone production by the interstitial cells of the testes Male Reproductive Hormones • ANDOSTERONE – less abundant and less effective than testosterone, made by interstitial cell in the testes • TESTOSTERONE – made in the interstitial cells – stimulates secondary sex characteristics in males – helps stimulate spermatogenesis in the testes (with FSH) – associated with sex drive • INHIBIN – released by sertoli cells when they are low on nutrients to feed developing sperm cells – acts as a negative feedback, goes to brain to slow the release of FSH and GnRH Sperm Production • Maturation takes 74 days • Sperm spend their first 50 days in the testicles and the last 22 to 24 days in the epididymis. • In the epididymis sperm mature and gain motility • During sexual activity, motile sperm are ejaculated into the female reproductive tract • Each ejaculate contains 75,000,000400,000,000 Prostate-Specific Antigen • • • • PSA levels increase with prostate cancer Normal is 0.2-4.0ng/mL Should be done annually in men >50 Some other conditions that may elevate PSA – – – – BPH TURP Acute prostatitis Urinary retention Digital Rectal Exam • Screening of the prostate gland • Should be done with regular check-ups for men >40yrs • Size, shape and consistency of the prostate are evaluated Ultrasound • A condom covered probe rectal probe is inserted to detect abnormalities in those with elevated PSA • Assists with guidance for prostate biopsies Prostatitis • Inflammation of the prostate gland • Type I (acute bacterial) • Type II (chronic bacterial) • Type III (chronic prostatitis/chronic pelvic pain syndrome) • Type IV (asymptomatic inflammatory chronic prostatitis) Prostatitis • Symptoms • Acute – sudden fever & chills – Perineal, rectal or low back pain – Dysuria, frequency, urgency & nocturia • Chronic – – – – perineal discomfort burning, urgency & frequency pain with ejaculation prostatodynia (pain in prostate with voiding) Prostatitis • Complications – – – – – Enlarged prostate Urinary retention Epididymitis Bacteremia Pyelonephritis – – – – – – possible hospitalization for IV antibiotics Analgesics Antispasmodics & bladder sedatives Stool softeners Bedrest Sitz baths (a warm water bath that covers only the hips and buttocks) • Treatment Benign Prostatic Hypertrophy • Progressive enlargement associated with aging • Results in obstructive urinary disorder • Most common neoplastic growth in men >50 • Virtually ALL men >50 show some increase in size Benign Prostatic Hypertrophy • Early Symptoms – Hesitancy initiating urine stream – Decreased force – Frequency – Nocturia • Bladder muscles hypertrophy & may temporarily reduce symptoms Benign Prostatic Hypertrophy • Late Changes – When hypertrophy is no longer effective, muscles decompensate & bladder wall becomes noncompliant & hypotonic – post void residuals lead to increased infections & hydronephrosis Benign Prostatic Hypertrophy • Medication • Flomax (alpha-adrenergic blocker) • Proscar & Avodart (antiandrogen agents) • Saw palmetto – As effective as Proscar – Shouldn’t be used with Proscar, Avodart or estrogen Benign Prostatic Hypertrophy • Transurethral Incision of the Prostate (TUIP) used to treat slightly enlarged prostate – laser incisions in prostate to decrease resistance to urinary flow (outpt procedure) • Transurethral needle ablation – use of localized heat to destroy prostate tissue which body reabsorbs • Microwave thermotherapy – Via transurethral probe – Tissue is sloughed Prostate Cancer • Most common cancer in men • Regular exams for all men >50 yrs. • May be a familial predisposition • Often asymptomatic • Late symptoms – Urinary obstruction – Painful ejaculation – Hematuria Prostate Cancer • Professional exam (DRE) annually >50 • Transrectal ultrasound (TRUS) – Elevated PSA – Abnormal DRE findings • PSA – Recommended annually for men>50 – Normal is 0.2 – 4 ng/ml • Perineal or transrectal needle biopsy Gleason score • System used to grade prostate cancer • Gleason Grades 1 and 2: – Closely resemble normal prostate. – Seldom occur – Prognostic benefit which is only slightly better than grade 3 • Gleason Grade 3: – Most common – Considered well differentiated (like grades 1 and 2). Gleason score • Gleason Grade 4: – Fairly common and because of the fact that if a lot of it is present, patient prognosis is usually (but not always) worsened by a considerable degree • Gleason Grade 5: – Less common than grade 4, and it is seldom seen in men whose prostate cancer is diagnosed early in its development. Gleason score • The lowest possible Gleason score is 2 (1 + 1) – both the primary and secondary patterns have a Gleason grade of 1 and when added together their combined sum is 2. • Very typical Gleason scores might be 5 (2 + 3) – the primary pattern has a Gleason grade of 2 and the secondary pattern has a grade of 3 • The highest possible Gleason score is 10 (5 + 5) – When the primary and secondary patterns both have Gleason grades of 5. Gleason Score • What does the Gleason score mean? • Valuable to doctors in helping them to understand how a • • • particular case of prostate cancer can be treated. In general, the time for which a patient is likely to survive following a diagnosis of prostate cancer is related to the Gleason score. The lower the Gleason score, the better the patient is likely to do General principles do not always apply to individual patients. Prostate Cancer • ProstaScint • Antibody attracted to prostate-specific membrane antigen found on prostate cells • Capable of detecting recurrent prostate cancer with low serum PSA level Prosatectomy • Radical Prosatectomy – Includes removal of prostate, seminal vesicles, lips of vas deferens, and often surrounding fat, nerves & blood vessels • Suprapubic Prostatectomy – not common r/t incontinence, impotence, rectal injury • Retropubic Prostatectomy – better control of blood loss but higher risk of infection • Laparoscopic/robotic radical prostatectomy – better visualization of surgical & surrounding tissue – less bleeding & pain – reduced likelihood of impotence & incontinence Transurethral Prostate Resection (TURP) • Performed thru endoscopy, gland is removed in • • • • small chips with an electrical cutting loop Used for glands of varying size or poor surgical risk Newer technology eliminates risk of TUR syndrome (hyponatremia, hypovolemia) rare but potential complication Repeated procedures may be necessary if residual prostatic tissue grows back Rarely causes erectile dysfunctions can trigger retrograde ejaculation (seminal fluid flows backward into bladder instead of forward thru urethra) Cryosurgery • Ablation of prostate cancer in those who cannot tolerate surgery or with recurrent cancer • Transperineal probes inserted into prostate with ultrasound guidance to freeze tissue • May need to be repeated to keep urethral passage patent Post-Operative Care • VS • Monitor for hemorrhage (most likely to occur immediately pop & 8• • • • • • • • • • • 10 days later) Monitor urinary catheter for clots Irrigation of catheter NO rectal temps, NOTHING in rectum to prevent fistulas Monitor dressing I & O (should be light pink-clear in 24 hrs) Hydration Monitor for distention Monitor for infection Stool softeners (no straining) Antispasmodics and analgesics Sit with firm, even pressure, NO donuts Radiation Therapy • Teletherapy – External beam radiation daily for 6 – 7 wks • Intensity-modulated radiation therapy (IMRT) – Improved version of teletherapy that offers set dose for target volume and restricts dose to adjacent structures • Brachytherapy – Implantation of radioactive seeds via ultrasound guidance – Exposure to others is minimal but should avoid close contact with pregnant women and infants – Use condoms and strain urine for 2 weeks after implantation • Side effects for RT are usually transitory – Inflammation of rectum, bowel & bladder – Possible pain with urination & ejaculation Hormonal Therapy • Orchiectomy (removal of testes) – Decreases plasma testosterone levels, removing testicular stimulus for prostatic growth • Casodex (nonsteroidal antiandrogen) • Eulexen (antiandrogen agents) • DES (estrogen therapy) – Inhibits gonadotropins responsible for testicular androgenic activity • Lupron and Zoladex (lutenizing hormone releasing hormone agonists) – Suppresses testicular androgen Chemotherapy • For hormone refractory prostate cancers • High dose ketanzole (lowers testosterone) • Taxol & taxotere are used for nonandrogen dependent prostate cancers – Peripheral neuropathy – Hypersensitivity reactions Cryptorchidism • Undescended testicle • Treatment – Hormone therapy – Surgery • 3 suture lines = inguinal, scrotal & thigh • teste placed in “traction” in scrotum by attaching suture to thigh; leg can move, but no undue pressure Orchitis • Inflammation of the testes • Signs & Symptoms – fever – pain – swollen testes • Treatment – – – – – Elevate scrotum Strict bedrest Ice bag under scrotum with padding between skin NO heat r/t sperm damage Medications are aimed at treating the causative factor Epididymitis • Infection descends from prostate or urinary tract • to the epididymis Symptoms – – – – – – Unilateral pain & soreness in inguinal canal pain & swelling in scrotum & groin Pus and bacteria in urine Fever & chills Urinary frequency, urgency or dysuria Nausea Epididymitis • Antibiotics • Risk for abscess formation • If becomes chronic may need to excise epididymis from • • • • testes in order to avoid sperm passage obstruction Bedrest Elevate scrotum with scrotal bridge or folded towel Intermittent cold compresses or ice; later Sitz baths or local heat Avoid straining, lifting & sex until infection controlled; may take 4 wks Torsion of Spermatic Cord • Symptoms – sharp, severe pain of testes • Treatment – Surgical emergency Hydrocele • Fluid in the space between teste & tunica vaginalis • Treatment usually not required • Surgery needed if hydrocele becomes tense and compromises testicular circulation or if scrotal mass becomes large, uncomfortable or embarrassing Varicocele • Abnormal dilation of the veins of the scrotum • Infertility or symptomatic concern is the only reason for treatment Testicular Cancer • • • • • Most common cancer in men 15 – 40 Usually curable TSE very important Classified as Seminomas (90%) or Nonseminomas Risk Factors – – – – – Cryptorchidism Family history Cancer of one testicle Caucasians Occupational exposure to chemicals in mining, oil & gas production, leather production – Exposure to prenatal DES Testicular Cancer • Symptoms • • • • • • – – – – Hard, non-tender nodule c/o heaviness in scrotum Back or abdominal pain, weight loss, general weakness (mets) Elevated HCG & AFP levels Treatment Orchiectomy with insertion of gel implant Possible retroperitoneal lymph node dissection Chemo Radiation Sperm Banking VASECTOMY • • • • Ligation of vas deferens Remain fertile for several weeks Need repeated sperm counts to assure infertility Post-operative care – wear athletic supporter – ice packs – analgesics • Vas. Reversal • 45-70% have sperm return but only 25% lead to pregnancy FEMALE ANATOMY • Ovaries • Uterus • Vagina • Cervix • Vulva • Breasts Ovaries • 2 small (2” x 1”), almond-shaped structures • Contain the eggs • The ovaries and fallopian tubes are known as the adnexa Uterus • • • • • • • • • • • • • small, pear-shaped, 3” long, 2” diameter normal position bends anterior 3 sections body = superior Isthmus = constricted portion cervix = inferior, projects short distance into vagina external orifice (cervical os) uterine cavity cervical canal = connected to uterine cavity via internal orifice (internal os) 3 layers serosal= peritoneum covering myometrium = muscular = smooth muscle with many elastic connective tissue fibers; thickens during pregnancy • endometrium = mucosal layer Vagina • 7.5-10 cm. long • Extends from the vulva to the cervix • Angled back & up • • • • • • • • • • • • • Breasts accessory organs glandular epithelium & ducts suspended by Cooper’s ligaments lymphatic drainage thru axillary nodes & some to substernal & diaphragmatic nodes Structures nipple = smooth muscle with erectile properties aerola = 1.5-2.5 cm. diameter with sebaceous glands underneath = rough appearance lactiferous ducts = under aerola are 15-20 which drain milk from milk glands breasts divided into 15-20 lobes with 20-40 lobules 10-100 alveoli = milk-secreting epithelial cells, surrounded by dense capillary network milk production r/t increased estrogen & progesterone levels in pregnancy also need prolactin, prolactin-inhibiting factor, oxytocin growth hormone, ACTH, placental lactogen, thyroxin & thyrotropic releasing hormone Estrogens • Secreted by developing follicle, corpus luteum & placenta • Responsible for secondary sex characteristics • Repairs uterine lining after menstruation • Opposite effect of progesterone • Increases bone matrix formation & retains Na & H2O in kidneys Progesterone • Principle hormone from corpus luteum • Secreted by placenta • Prepares uterus for implantation by inhibiting contractility & changing endometrium to secretory phase • Opposes action of estrogen • Produces increase in breast tissue • Inhibits prolactin Hormones • Androgens – Produce male sex characteristics – female ovary produces androstenedione, a weak compound similar to testosterone – adrenal hormones are also androgens • FSH & LH = produced by pituitary – FSH = ovarian follicle growth, essential to production of estrogen – LH = induces ovulation & stimulates corpus luteum & progesterone production • Prolactin stimulates milk production Hormones • Ovarian Cycle = provides ovum with endometrial • cycle to furnish suitable environment for fertilization of ovum Menstrual Cycle – Menarche onset at 10-14 yrs. – day of menstruation onset is day 1 – cycle ends last day before flow starts again (22-35 days, average 28) – premenstrual phase is 2-3 days before flow Pre-Menstrual Syndrome (PMS) • Discomfort prior to menses (5 days) which disappear 4 – 5 days after onset • Cause unknown but most current theory r/t serotonin regulation • Symptoms – – – – – – Low back pain Tender breasts, Crying Irritability Mood swings Binge eating, • Symptoms vary widely between women • Severe form is called premenstual dysphoric disorder Pre-Menstrual Syndrome (PMS) • Treatment – Exercise – SSRIs – GnRH agonists – prostaglandin inhibitors – diuretics – antianxiety agents – Ca supplements Dysmenorrhea • painful, abnormal menstruation • primary form has no pathology • secondary form caused by endometriosis or PID • Treatment – prostaglandin inhibitors – low dose BCP’s Amenorrhea • Primary: delayed menarche if hasn’t occurred by age 16 • Secondary: absence of menses for 3 cycles or 6 months • may be r/t emotions, eating disorders, athleticism Dysfunctional Uterine Bleeding • Menorrhagia: excessive bleeding • Metorrhagia: bleeding between ovulation time; abnormal & should be reported • Postmenopausal Perimenopause • Period extending from first symptoms of menopause to • • • • • beyond complete cessation of menses (1 yr) Occurs approximately 40 yrs. after menarche or surgery Decreased ovarian activity Uterus, vagina & vulva decrease in size Decreased estrogen & progesterone Symptoms – – – – – – insomnia hot flashes r/t vasomotor disturbances headaches fatigue menstrual irregularity mood changes Perimenopause • Treatment • HT (formerly HRT) – May increase some health problems (stroke, MI, DVT, breats Ca) – Does reduce risk for osteoporosis & hot flashes – Low doses may be OK if used for shortest time possible • Effexor, Paxil, Neurontin, & Catapres reduce hot • flashes Herbal: black cohosh, ginseng, & soy product research doesn’t support Pap Smear • Cells scraped from cervical endothelium with small • • • • spatula Done yearly on all women >18 Can be done every other year on women >30 with a history 2 or more consecutive normal PAPs Pt not to douche, insert vaginal meds, or have sexual intercourse prior to exam History taking – – – – need date of LMP & last Pap period frequency, duration & flow amount type of contraception presence of itching or discharge Pap Smear • Results – LSIL: low grade squamous intraeptihelial lesion equivalent to CIN grade I and to mild changes r/t recent exposure HPV – HgSIL: high grade squamous intraepithelial lesion equivalent to moderate & severe dysplasia, carcinoma in situ (CIS) and CIN grade 2 and 3 – Not always accurate, depending on lab & practitioner; request liquid immersion method • Treat any infection detected & repeat pap post • • treatment if repeat PAP reveals atypical cells with high risk HPV types do colposcopy LSIL paps repeat every 4 – 6 months – perform colposcopy if not resolved • HGSIL & CIS prompt colposcopy Endoscopic Examinations • Hysteroscopy – scope inserted through the cervix – visualization of the uterus – Endometrial ablation can be performed to treat severe bleeding that doesn’t respond to other therapies – Done under general, regional or local anesthesia • Laparoscopy – scope inserted through a small incision, inferior to the umbilicus – insufflation with Carbon dioxide – visualization of all pelvic organs – Facilitates many surgical procedures Colposcopy • Should be done following suspicious pap smear • Portable microscope that allows visualization of the cervix • Acetic acid is applied to the cervix • Abnormal results indicate the need for biopsy Cervical Biopsy • Cone Biopsy – Can be done surgically or with Loop Electrosurgical Excision Procedure (LEEP) – Tissue removed for pathology – Packing needs to be left in place for 24 hr. – The patient needs to avoid coitus, douching, or tampons x 4 - 6 wks. • Excessive bleeding (more than a period) after 7• 10 days & symptoms of infection need to be reported There is a slight future increase in risk of cervical stenosis or preterm deliveries Endometrial Biopsy • Done to evaluate irregular bleeding or irregularities • • • • • • found on pelvic exam Evaluation of infertility Local anesthetic may or may not be used A speculum is inserted into the vagina The cervix is cleansed with an antiseptic solution. a catheter is inserted into the uterus. A smaller tube (internal piston) inside the catheter is withdrawn to create suction. Cramping may occur. Dilation & Curettage • D & C may be diagnostic or therapeutic • The cervical canal is dilated • The endometrium is scraped with a curette • Generally done under anesthesia • The perineum is NOT shaved • Observe for post-operative bleeding • Patient must wait 2 weeks to use tampons or have intercourse Mammography • Two x-ray views are taken of each breast • New mammogram is compared to previous films • May detect a breast tumor before it is palpable • • • (1cm) ACS recommends a mammogram yearly beginning at 40 See chart 48-1 for guidelines of women at increased risk Digital mammography is now becoming more common Other Breast Diagnostics • Galactography—Injection of contrast prior to mammography – Evaluates breast ducts • Ultrasonography—Helps distinguish fluid cyst form solid lesions – Done in conjunction with mammography • MRI with contrast – Done for women with breast cancer or high risk populations Percutaneous Breast Biopsy • Fine needle aspiration – A small gauge needle is used to make multiple passes through the mass • Core needle aspiration – Uses a larger gauge needle and local anesthetic – Tissue cores are removed via a spring-loaded device • stereotactic core biopsy – Performed on nonpalpable lesions seen on mammogram – Breast suspended through openings in table & compressed between 2 x-ray plates, local anesthetic, small nick, core needle often several passes made – Clips may be placed to facilitate treatment • ultrasound or MRI core biopsy Surgical Breast Biopsy • Excisional biopsy – Standard for pathological assessment – The entire mass and margins are removed – Also referred to as lumpectomy • Incisional biopsy – removes a portion of a mass to confirm diagnosis or for special studies (ER/PR, Her-2/neu) • Wire needle localization – Radiologist inserts a wire through a needle to identify non-palpable mass location before surgery. – The wire is left in place for surgery Endometriosis • Leading cause of infertility • Chronic disease where benign lesions grow in • • • the pelvic cavity outside the uterus Familial predisposition Typically diagnosed at 25 – 35 yrs. Symptoms are r/t tissue bleeding with menses – Dysmenorrhea – > 7days flow – <27 day cycle Endometriosis • Caused by misplaced endometrial tissue – backflow of menses – transplantation of tissue during surgery – spread of tissue via lymphatic or venous channels • Treatment – – – – Menopause Laparoscopic surgery Laparoscopic laser therapy Total abdominal hysterectomy • Medications – analgesics & prostaglandin inhibitors – Oral contraceptives – Danazol—Synthetic androgen causes atrophy of the endometrium – Lupron (GnRH antagonist)—induces artificial menopause Uterine Fibroids • Benign tumors that arise from the muscle tissue of the • • • uterus Menometorrhagia (irregular bleeding) is the most common symptom May interfere with fertility Treatment – – – – – hysteroscopic resections of myomas laparoscopic myomectomy laparoscopic myolysis with use of laser or electrical needles laparoscopic cryhomyolysis use of electric current to coagulate uterine artery embolization (UAE)—polyvinyl alcohol or gelatin particles injected into blood vessels that supply fibroid via femoral artery; percutaneous image guided therapy • May cause pain, infection, amenorrhea, necrosis & • bleeding; rarely death & ovarian failure Usually used in women who have completed childbearing Ovarian Cysts • Dermoid Cysts – Consist of undifferentiated embryonal cells, sometimes have hair teeth, bone & other tissues – Larger cysts may place pressure on adjacent organs • Polycystic Ovary Syndrome (PCOS) – complex disorder of endocrine system involving hypothalamus, pituitary & ovarian network results in anovulaiton & androgen excess • Symptoms irregular periods, infertility, obesity & • • hirsutism Cysts form in ovaries because regular ovulation is not occurring Treatment – Surgery – Oral contraceptives • Increased risk for diabetes & cardiac disorders Cervical Cancer • Usually slow-growing • Most are squamous cell and remainder are • • • • adenocarcinomas, (which often are r/t HPV) or can be a mix Symptoms Rarely there may be a thin, watery discharge noticed after sex or douching Symptoms such as discharge, irregular bleeding or pain often means advanced disease Treatment – – – – – Cryotherapy LEEP hysterectomy if childbearing completed Radiation Chemotherapy Endometrial/Uterine Cancer • Major risk is cumulative exposure to estrogen – – – – – HT early menarche late menopause, nuliparity anovulation • Other risk factors infertility, diabetes, hypertension, • gallbladder disease, & obesity Symptoms – Pre-menopause = irregular bleeding – postmenopausal = any bleeding • Treatment – Surgery (TAH) – Radiation – Chemotherapy Ovarian Cancer • Causes more death than any other female • • • cancer Tumors are often difficult to detect & no early screening mechanisms exist CA-125 & transvaginal ultrasound may be useful for screening Risk Factors – – – – – Risk increases with age increases breast cancer likelihood 3 – 4 x Nulliparity Infertility BRCA-1, BRCA-2 Ovarian Cancer • Symptoms – – – – – – – Increased abdominal girth pelvic pressure bloating back pain constipation urinary frequency flatulence • Treatment • Surgery TAH & BSO • Chemotherapy – Intraperitoneal & traditional site may be done in tandem • Recurrence is common Vaginal Cancer • Rare & slow growing • DES is a cause of early development – ask if pt was born or pregnant 1938–1971 • colposcopy is done for those exposed in utero • Early treatment consists laser therapy • Radiation • Surgery Vulva Cancer • Seen Mostly in postmenopausal women 50-70yrs • Risk factors include smoking, HPV (16,18,31), • HIV and immunosuppression Symptoms – most common long standing pruritis & soreness – chronic dermatitis – lump that continues to grow • Treatment – Surgery – Laser ablation – Chemotherapy creams Toxic Shock Syndrome (TSS) • Acute bacterial infection caused by staph aureus – often r/t tampon use – high absorbency tampons implicated – Need to obtain vaginal culture to r/o staph colony • Symptoms r/t endotoxins enter blood – – – – – – – – – – – – Elevated WBC Elevated BUN & Creatinine Elevated Bilirubin sudden high fever (102-105 F) vomiting & diarrhea sore throat headache profound fatigue edema & impaired perfusion rash on soles & palms which sloughs in 1-2 wks. disorientation decreased urinary output Toxic Shock Syndrome (TSS) • Caution women NOT to use non- cotton, high absorbency tampons • Change tampons frequently • Sanitary napkins at night • Avoid tampons if skin infection present Hysterectomy • Can be abdominal, laparoscopic & robotic • Post-operative care – – – – pain control Prevent thrombus formation with positioning I&O Foley – – – – – – – dressing √ peri pad √ no clots serosanguinous amt = NO more than period √ every 10-15 min. first few hrs. spotting for 2 wks. • Monitor for paralytic ileus • Monitor for hemorrhage INFERTILITY • Inability to conceive after a year or more of regular • • • intercourse without contraception Primary = no pregnancies Secondary = after successful pregnancy Infertility Tests – – – – Hysterosalpingography—x-ray with contrast media D & C before menses Semen Analysis Ovulation Index—urine stick test to determine whether surge in LH has occurred (this precedes ovulation) – Serum Progesterone – Postcoital Immunology – Endometrial Biopsy • Laparoscopic exam Benign Breast Disorders • Cysts – – – – – – – Fluid filled sacs that develop as breast ducts dilate Most commonly occurs in women 30 – 55 Cause is unknown Usually disappear after menopause Fluctuate in size usually larger premenstrually May be painless or become very tender premenstrually Cysts do NOT increase the risk of breast cancer • Fibroadenomas – Firm, round, movable benign tumors – Occur from puberty to menopause with peak at 30 – Sometime removed for definitive diagnosis Benign Proliferative Breast Disease • Atypical Hyperplasia – An abnormal increase in ductal or lobular cells in the breast – usually found incidentally in mammography abnormalities – increases risk for breast cancer 4–5x – 10x if has relative with breast cancer • Lobular Carcinoma in Situ – Characterized by a proliferation of cells within the breast lobules – Found incidentally on pathologic diagnosis – Cannot be seen on mammography – Does not form a palpable lump – Marker for increased risk 8-10x Breast Cancer • 1 in 8 lifetime risk for women • Mammography for screening contribute to • • • • decreased mortality rates due to early detection of disease Annual mammograms at 40 CBE annually BSE monthly high risk women – clinical breast exams twice yearly at 25 – mammogram annually at 25 Breast Cancer • Risk Factors – – – – – – – – – – – gender (99% in women) Age>50 Family history Personal History Nulliparity 1st pregnancy after 30 radiation exposure especially during adolescence & early adulthood obesity Alcohol use Estrogen exposure BRCA-1 & BRCA-2 tumor suppressors, if damaged 55 – 85% risk of cancer Types of Breast Cancer • Non-invasive breast cancer • Ductal Carcinoma in Situ (DCIS) • Malignant cells within the milk ducts without invasion • • • • • • into the surrounding tissue Considered Stage 0 Mastectomy Breast conservation (lumpectomy, partial mastectomy) Radiation Tamoxifen Arimidex Types of Breast Cancer • Invasive Cancer – Infiltrating ductal Carcinoma – – – – – • most common (75%) Infiltrating lobular Carcinoma Medullary Carcinoma Mucinous Carcinoma Tubular ductal CA Inflammatory Carcinoma • rare (1-2%), • Aggressive with unique symptoms • diffuse edema & brawny erythema; referred to as “peau d’orange • • • (orange peel) malignant cells block lymph channels can be confused with infection r/t appearance can spread rapidly – Paget Disease 1% – scaly, erythematous, pruritic lesions of the nipple – Often represents DCIS of the nipple but can be invasive Paget Disease Peau D’Orange Breast Cancer • Often found in upper outer quadrant where • • • • • • most breast tissue located Nontender, fixed lesion Hard with irregular border Advanced symptoms Skin dimpling Nipple retraction Skin ulceration Breast Cancer • Staging – Stage 0 (DCIS, LCIS or Paget no invasion) – Stage I (tumors <2 cm no node involvement) – Stages II & III represent wide spectrum so classification more difficult – Stage IV (tumors of any size with distant mets) • Generally, the smaller the tumor the better the prognosis Mastectomy • Total mastectomy –removal of breast, nipple areola complex • Modified radical mastectomy –Is done for invasive breast cancer includes axillary lymph node dissection (ALND) • Reconstruction Post-Operative Care • • • • Overnight hospitalization Pain control Positive body image Reach for Recovery Managing sensations of numbness, tightness, pulling twinges & phantom sensations • Managing lymphedema occurs in 10 – 30% ALND & 0 – 7% SLND – tends to be chronic; hand & arm care help to prevent – avoid BP, injections, tourniquet, heavy lifting • May be discharged with JP drain – remove when draining <30 ml in 24 hr.) • assess for hematoma • compression wrap may be applied Sentinel Lymph Node Biopsy • Sentinel lymph node biopsy (SLNB) • First lymph node(s) in lymphatic basin that • • • receive drainage from primary breast tumor Radioisotope or blue dye injected for surgeon to locate and excise Sent for frozen section (note: false negatives can occur & require subsequent surgery) If positive an ALND is done during surgery Radiation Therapy • External Beam/IMRT – – – – External beam most common 6 weeks of radiation to entire breast Boost to tumor site Skin breakdown • Brachytherapy – Internal radiation to lumpectomy site – Dose administered over 4 – 5 days • Intraoperative (IORT) – Single intense dose to surgical site in OR Adjuvant Chemotherapy • Delays or prevents recurrence • Considered for patients that have positive lymph • nodes or invasive tumors >1cm Targeted Therapy – Herceptin for Her-2/neu positive patients – Regulates cell growth • Chemo is often delivered prior to radiation – Adriamycin + Cytoxan – Taxol Hormone Therapy • For hormone receptor positive tumors – ER + – PR + • Selective Estrogen Receptor Modulator (SERM) – – – – Compete with estrogen by binding to receptor sites Pre-menopausal women Taken for 5 years Tamoxifen (Nolvadex) – – – – Block estrogen Production Post-menopausal women Anastrozole (Arimidex) Duration of treatment is still unclear • Aromatase Inhibitors BIRTH CONTROL • Need to have a basic comprehension for STD unit • See FDA guide • Examples – IUD – Rhythm Method/Beads – Condom – Oral Contraceptives