Cervical Cancer

Management of Patients With Female
Reproductive Disorders
Pelvic Organ Prolapse
• Weakening of vaginal walls allows the pelvic organs to descend
and protrude into the vaginal canal
– Risk factors: age, parity, delivery of large babies, possible
hormone deficiency
– Cystocele - downward displacement of bladder
– Rectocele - rectum pouches upward and pushes the posterior
vaginal wall forward
– Signs/symptoms: pelvic pressure and urinary problems
(Cysto), rectal pressure and bowel problems (recto),
Pelvic Organ Prolapse
• Medical Management
– Kegel exercises (cysto)
– Pessaries
• Surgical management
– Colporrhaphy - repair of anterior vaginal wall
– Posterior colporrhaphy - repair of rectocele
Pelvic Floor Relaxation
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Complete Prolapse of the Uterus
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Uterine Prolapse
• Structures that support the uterus weaken and the uterus
works its way down the vaginal canal (prolapse) and may
protrude out of the vagina (procidentia)
– May begin to pull the bladder and rectum with it
• Signs/symptoms: pressure and urinary problems aggravated by activity; dyspareunia
• Medical Management
– Pessaries
– Hysterectomy
Uterine Prolapse
• Nursing Management
– Teach Kegel exercises during the postpartum period
– Preoperative teaching
• Expectations of postoperative period
• Effect of surgery on sexual function
– Postoperative care
• Prevention of infection
• Voiding
• Perineal care
• Stool softener
• Pain management
• Teaching
Ovarian Cysts (Benign Ovarian Tumors)
• May be enlargements of ovarian constituents, follicle,
corpus luteum, or normal growth of the epithelium
• 98% occur in women under 30
• > age 50 - only 50% of cysts are benign
• Symptoms - acute or chronic abdominal pain;urinary
frequency; feeling of fullness; ruptured cyst may mimic
an acute abdomen
– Often asymptomatic if small
• Polycystic ovarian syndrome - endocrine condition that
results in anovulation and androgen excess
Ovarian Cysts
• Medical Management
– Many resolve on their own
– Surgical removal if large or suspicious
– Oral contraceptives
– Possible hysterectomy if ovaries are being removed
due to suspicious mass
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Fibroids tumors
• Benign smooth muscle tumors that occur within the
– May occur in the lining of, the muscle wall and
outside surface of the uterus
– Usually develop between 25-40, slow growing
• Clinical manifestations : asymptomatic, abnormal vaginal
bleeding, menorrhagia, pelvic pressure, bloating,
backache, constipation
Fibroids (myomas)
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Fibroid tumors
• Medical management
– Dependent on size, symptoms, location, woman’s
age and reproductive plans
– Observation, tumor removal, hysterectomy, tumor
ablation, medications to shrink the fibroids (induce
menopause like state)
• Presence of normal endometrial tissue in sites outside
the endometrial cavity - grow aberrantly
– Usually in pelvic area, but may include other areas
like the stomach, spleen and lungs
• Major cause of chronic pain and infertility
• Familial predisposition; ages 25-35 most common
• Clinical manifestations: dysmenorrhea, dyspareunia,
pelvic pain, radiation of pain to back or legs
Depression, loss of work, relationship difficulties
Tenderness with pelvic exam
• Medical management
• Pharmacologic
– Hormonal therapy (usually OCP initally)
– Androgen therapy - induce pesudomenopause
– Gonadropin-releasing hormone agonists (GnRH a)
• Surgical
– If conservative measures fail
– Laparoscopy, laser surgery, electrocoagulation,
laparotomy, hysterectomy, oopherectomy
• Nursing management
– History and physical
– Specific symptoms - what, where, how long
– Psychosocial care
• Impaired relationships
• Fertility problems
– Education
• Seek treatment early
• Support group referral
Malignant Disorders of the Female
Reproductive Tract
• Cervical (10,300), uterine (41,000), vaginal (2420),
vulvar (3740), and ovarian cancers (25,000)
– **new cases/yearly in the USA
• Early disease may not have symptoms.
• Signs and symptoms depend upon location and may
include vaginal discharge, pain, bleeding, and systemic
symptoms (weight loss and anemia).
• Prevention, screening, and early detection are vital.
Cervical cancer
• Squamous cell cancer; strongly associated with certain
strains of human papillomavirus
• Less common now - early detection by Pap smear
• Prevention
– Regular pelvic exams and Pap smears to identify
preinvasive lesions
• Begin 3 years after intercourse, by age 21
• Every 2-3 years for average risk; more for high risk
– Preventive counseling -delay first intercourse,
avoidance of HPV, smoking cessation, HPV vaccination
for ages 9-26
Cervical cancer
• Clinical manifestations
– Often asymptomatic
– May include discharge, irregular bleeding, pain after sexual
• If symptoms - usually advanced disease
• Advanced disease should not occur with routine
gynecologic care!
– Symptoms of advanced disease may also include leg pain,
rectal bleeding, dysuria, extremity edema, back pain
– Survival rate for carcinoma in situ may be up to 100%, but
decreases dramatically for invasive disease
Cervical Cancer
• Diagnosis made on basis of abnormal pap smear and
– Severe dysplasia (CIN III)
– Carcinoma in situ (‘preinvasive cancer’)
– Invasive cervical cancer
• Patient is then staged : TNM staging system
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Cervical Cancer
• Medical management
– Precursor lesions (LGSIL - CIN I or II)
• Monitoring, conservative treatment, possible
cryotherapy, LEEP
• LEEP, conization
– Preinvasive
• Hysterectomy if childbearing is complete
• If not, conization may suffice and close monitoring
Cervical Cancer
• Medical management
– Invasive
• Hysterectomy
• Radiation (treat and prevent recurrence)
• May be delivered by external beam or
brachytherapy: radiation is placed near the
• Chemotherapy
• Close follow-up: risk of recurrence is 35%
Uterine cancer (endometrial)
• Most originate in the lining of the uterus
• Risk factors: *cumulative exposure to estrogen especially unopposed*; also infertility, diabetes,
hypertension, smoking, late menopause, obesity
– Pregnancy and OCP use are protective
• Irregular bleeding, often postmenopausal
• Treatment involves total hysterectomy; adjuvant
radiation, progesterone therapy
• Recurrent cancer or advanced: chemotherapy
Ovarian cancer
• Gynecologic cancer with the highest mortality rate
• Early detection is difficult
– Transvaginal U/S, CA-125 antigen testing
• Risk peaks in 70s
• 3-4 fold increased risk for breast cancer; association with
BRCA genetic mutations
• Risk factors: family history, nullparity, infertility, HRT
– ?genetic testing?
• Breast feeding and oral contraceptives may be protective
Ovarian Cancer
• May arise from germ cells, stromal cells, epithelial cells
– Most epithelial (90%)
• Clinical manifestations
– Nonspecific; may include increased abd girth, pelvic
pressure, bloating, back pain, constipation, urinary
urgency, indigestion, flatulence, leg pain, pelvic pain
– Often considered “silent”
• Diagnosis
– Enlarged ovary must be investigated (U/S, CT, MRI) not always definitive
– By the time of diagnosis, 75% of tumors are
Ovarian cancer
• Medical management
– Surgical removal of tumor
• Total hysterectomy; lymph node dissection,
peritoneal biopsies
– Radiation or chemotherapy
• High rate of recurrence; may become chronic in nature
Hysterectomy (see table 54-13)
• Surgical removal of the uterus to treat cancer,
dysfunctional uterine bleeding, endometriosis,
nonmalignant growths, persistent pain, pelvic relaxation
and prolapse, and previous injury to the uterus.
• Total hysterectomy
• Radical hysterectomy
• Types of approaches
– Laparoscopic -assisted vaginal hysterectomy
– Abdominal
Nursing Process: Care of the Patient
Undergoing a Hysterectomy: Assessment
• History, signs and symptoms
• Physical and pelvic exam
• Psychosocial and emotional responses
• Patient knowledge
Nursing Process: Care of the Patient
Undergoing a Hysterectomy: Diagnosis
• Anxiety
• Disturbed body image
• Acute pain
• Ineffective sexuality pattern
• Deficient knowledge
Collaborative Problems/Potential
• Hemorrhage
– Perineal pad count
– Monitor vital signs and abdominal dressings
– Elastic compression stockings
– Change positions; early ambulation
• Bladder dysfunction
– May require indwelling catheter
• Bowel dysfunction
– Monitor for ileus
Nursing Process: Care of the Patient
Undergoing a Hysterectomy: Planning
• Major goals may include relief of anxiety, acceptance of
loss of the uterus, absence of pain or discomfort,
increased knowledge of self-care requirements, and
absence of complications.
• Preoperative management
– Preoperative cleansing, shaving
– Enema and antiseptic douche before surgery
– Education
• Postoperative management
– Monitor for complications
– Pain management
• Anxiety
– Allow patient to express feelings.
– Explain physical preparations and procedures.
– Provide emotional support.
• Body image
– Listen and address concerns.
– Provide appropriate reassurance.
– Address sexual issues.
– Approach and evaluate each patient individually.
• Usually administered IV
• Patients undergoing chemotherapy need specific care to
address the side effects and complications of the
chemotherapy agent or agents administered. Side effects
may include neutropenia, thromobocytopenia,
nephrotoxicity, neurotoxicity, hair loss, hypersensitivity
reactions, nausea, and vomiting.
• Paclitaxel (Taxol)
• Carboplatin (paraplatin)
Radiation Therapy
• External radiation therapy
• Intraoperative radiation therapy
• Internal (intracavity irradiation)
• Care of the patient undergoing radiation therapy
Placement of Tandem and Ovoids for
Internal Radiation Therapy
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Nursing Considerations Related to
Intracavity Radiation Therapy
• Monitor applicator to ensure it does not become dislodged
– If this occurs, do not touch the applicator and notify
the Radiation Safety Department
• Foley catheter (prevent bladder wall exposure)
• Absolute bed rest, positioning restrictions - HOB up to
15*, move side to side with back support
• Diet: low residue (prevent frequent bowel movements)
• Monitoring of patient (VS, fever!)
• Side effects of therapy (diarrhea, cramping, dysuria)
• Emotional support of patient
• Address potential for isolation.
Intracavitary Radiation Safety
• Minimize time near radioactive source (RN - <30 min/day)
• Maximize distance from radioactive source (RN as far as possible;
visitors 6 feet away)
• Required shielding
• Pregnant personnel prohibited/visitors restricted
• Other instructions
Film badges
Rubber gloves to dispose of soiled matter
Specific housekeeping instructions
Patient is restricted to her room
Discharge survey performed by Radiation Safety Department to
ensure all sources of radiation have been removed