Female
Reproductive
Disorders
Megan McClintock, MS, RN
Fall 2011
Infertility
 Can’t conceive after 1 year of regular, unprotected
intercourse
 Risk factors
 Tobacco/illicit drug use
 Abnormal BMI (obesity or too thin)
 Age > 35 (in women)
Infertility
 Diagnostic Studies
 Detailed history and general physical exam
 Basal body temperature record (upon awakening, before
any activity, decreased temp prior to ovulation, rise in
temp with ovulation)
 Ovulation prediction kits (measure LH in urine, ovulation
occurs 28-36 hrs after the first rise of LH)
 Hysterosalpingogram to look at tubal factors
 Postcoital cervical mucus exam
Infertility Treatment
 Depends on the cause

Ovarian problems – supplemental hormone therapy

Cervicitis – antibiotics

Inadequate estrogen stimulation - Estrogen

Intrauterine insemination

Assisted reproductive technologies (ART)
 Nursing care

Education

Emotional support

Encourage participation in support groups
Abortion


Spontaneous (occurring naturally)

Natural loss of pregnancy before 20 weeks

s/s – uterine cramping with vaginal bleeding

Tx – bed rest, no vaginal intercourse, D&C may be needed,
emotional/grief support
Induced (occurring due to mechanical or medical intervention)

Intentional or elective termination of a pregnancy

Technique depends on gestational age, women’s condition

Care – give support/acceptance, prepare the pt, no intercourse
or vaginal insertions for 2 weeks, can start contraception
immediately

Cx – abnormal vaginal bleeding, severe abdominal cramping,
fever, foul drainage
Menstrual Problems

PMS

Dysmenorrhea (pain)

Abnormal bleeding

Oligomenorrhea (long intervals between menses)

Amenorrhea (no menstruation)

Metrorraghia (spotting, breakthrough bleeding)

Menorrhagia (excessive bleeding)

Ectopic pregnancy

Perimenopause

Postmenopause
Premenstrual Syndrome
(PMS)
PMS
 Always occurs cyclically before the onset of
menstruation, not present at other times of the month
 s/s – extremely variable even from one cycle to
another, breast tenderness, edema, bloating, binge
eating, headache, dizziness, mood swings
 Dx – must rule out other possible causes, no definitive
test, need to do a symptom diary for 2-3 months
PMS Treatment

No single treatment

Drugs (diuretics, prostaglandin inhibitors, SSRIs, combination
BCPs)

Diet changes (no caffeine, reduce refined carbs, increase complex
carbs with high fiber, vit B6, dairy, poultry, limit salt intake)

Reassure that symptoms are real

Stress management

Exercise

Adequate rest
Dysmenorrhea
 Primary – no pathology, begins within first few years of
menses

s/s – starts 12-24 hrs before menses, rarely lasts more than 2
days, lower abd pain radiating to lower back/upper thighs,
nausea, diarrhea, fatigue, headache

Tx – heat, exercise, NSAIDs, BCPs
 Secondary – usu. caused by pelvic disease, begins age 30-40
after previous pain-free menses

s/s – unilateral, constant pain that lasts longer than 2 days,
can have painful intercourse, painful defecation, or irregular
bleeding

Tx – depends on the cause
Abnormal Bleeding
 Age of the woman helps determine the cause
 Young – spontaneous abortion, ectopic pregnancy,
clotting disorders
 30s/40s – leiomyomas (fibroids), endometrial polyps
 Old – endometrial cancer
 Amenorrhea
 Primary – no menses by age 16
 Secondary – had periods but they stopped
 Need to shed the endometrial lining 4-6 times/year
Bleeding Treatment
 Depends on the cause, degree of threat to pt’s health, desire
for children in the future
 Health history and physical exam first
 Combined oral contraceptives, fertility drugs, or
progesterone
 Balloon thermotherapy
 Endometrial ablation
 Hysterectomy or myomectomy if due to uterine fibroids
 D&C is rarely done
Nursing Care with
Abnormal Bleeding
 Bathing and hair washing are safe
 Can swim, exercise, have intercourse
 Need to change tampons or pads frequently
 Be aware of TSS (s/s – high fever, vomiting, diarrhea,,
weakness, myalgia, sunburn-like rash)
 With excessive bleeding, record the number and size
of pads/tampons used and degree of saturation
 Check fatigue level, BP, and pulse
Ectopic Pregnancy
 Life-threatening emergency!
 Implantation of a fertilized ovum anywhere outside
the uterus
 Risk factors – PID, prior ectopic, progestin-releasing
IUD, progestin-only birth control pills, prior pelvic or
tubal surgery, infertility treatments
 s/s – abd/pelvic pain, missed period, irregular vaginal
bleeding (spotting), if ruptured - pain will be severe
and may be referred to the shoulder
Ectopic Pregnanct
 Dx – difficult b/c it’s similar to other disorders, but
has to be considered first!
 Serum pregnancy test
 Then serial beta-hCG levels
 Vaginal ultrasound
 CBC
 Tx – immediate surgery, may need blood transfusion
Menopause
 Perimenopause – begins with first changes in menses and
ends after cessation of menses
 Menopause – cessation of menses associated with declining
ovary function, complete after 1 year of no periods
 Usu. occurs around age 51, naturally affected only by
genetic factors, autoimmune conditions, cigarette smoking,
racial/ethnic factors
 Increase in FSH, decrease in estrogen
 Remember culture
 Remember vaginal bleeding after menopause is a sign of
possible endometrial cancer
Perimenopause
 s/s – *irregular vaginal bleeding, *vasomotor
instability (hot flashes), redistribution of fat, gain
weight more easily, muscle/joint pain, loss of skin
elasticity, change in hair amount/distribution, atrophy
of external genitalia/breast tissue, dysparenunia,
bladder changes
 Critical changes – increased risk for CAD and
osteoporosis, higher risk for HIV transmission if
exposed
Perimenopause

Diagnosis should only be made after ruling out other things

Tx – hormone replacement therapy (HRT)

Must weigh the risks and benefits

Use lowest effective dose

Estrogen side effects – nausea, fluid retention, headache, breast
swelling

Progesterone side effects – increased hunger, weight gain,
irritability, depression, spotting, breast tenderness
 Depoprovera can cause sudden loss of vision, chest pain, calf pain

Vaginal creams helpful with urogenital symptoms

Transdermal estrogen bypasses the liver but causes skin irritation
HRT
 Take only for short-term (4-5 years) relief of severe
symptoms
 Estrogen alone can cause stroke, blood clots, breast
changes but protects against osteoporosis, colorectal
cancer, heart disease
 Estrogen & progesterone together can cause heart
disease, breast cancer, stroke, blood clots, breast
changes
 Do not take if you have a history of breast cancer,
heart disease, or blood clots
Non Hormonal
Treatments

Cool environment

Vitamin E

Limit caffeine and alcohol

Adequate exercise and sleep

Relaxation techniques

Adequate calcium and
vitamin D

Increase air circulation


Avoid bedding that traps
heat
Diet high in complex carbs
and B6, soy, tofu, sunflower
seeds

Loose fitting clothes

Black cohosh

Kegel exercises

Moisturizing soaps, lotion

Vaginal lubrication
Vulvar, Vaginal, Cervical
Conditions
 Typically infection and inflammation related
to sexual intercourse
 Risks – contaminated hands, clothing,
douche equipment, intercourse, surgery,
childbirth; BCPs, antibiotics, corticosteroids
 s/s – abnormal vaginal discharge, red lesions;
yeast – thick, white, curd-like discharge,
itching, dysuria; bacterial vaginosis – fishy
odor; cervicitis – spotting after intercourse;
lichen sclerosis – white lesions with “tissue
paper” appearance
Treatment

Sexual history is important

Microscopy and cultures

Antibiotics and/or antifungals (must take full course)

Abstain from intercourse for at least 1 week

Douching should be avoided

May need to treat sexual partners

Vaginal creams should be inserted before going to bed

Clean carefully after urination and bowel movements

Use a non-judgmental attitude

Pelvic Inflammatory
Disease
(PID)
Infection of pelvic cavity (fallopian tubes, ovaries, pelvic
peritoneum), often the result of untreated cervicitis
 Chlamydia and gonorrhea are most common organisms,
but is not always from STDs
 Can cause infertility and chronic pelvic pain
 s/s – lower abdominal pain that starts gradually and
becomes constant, movement increases the pain, spotting
after intercourse, may have fever, chills
 Will have adnexal tenderness and positive cervical motion
tenderness with bimanual pelvic exam (diagnostic), can
also do a vaginal ultrasound
PID Complications
 Septic shock
 Fitz-Hugh-Curtis syndrome (perihepatitis)
 Peritonitis
 Thrombophlebitis of the pelvic veins
 Adhesions of the fallopian tubes
 Ectopic pregnancy
PID Treatment

Antibiotics

No intercourse for 3 weeks

Sexual partner(s) must be treated

Physical rest

Lots of oral fluids

Must be reevaluated in 48-72 hours to ensure they are improving

If hospitalized:

Corticosteroids

Heat to abdomen or sitz baths

Semi-Fowler’s position to promote drainage by gravity

Analgesics, IV fluids

May require surgery
Endometriosis

Normal endometrial tissue located in
sites outside of the endometrial cavity

Not life-threatening, but causes lots of
pain

Increases the risk of ovarian cancer

Typical pt – late 20s or early 30s, white,
never had a full-term pregnancy

s/s – dysmenorrhea after year of painfree periods, infertility, pelvic pain, pain
with intercourse, irregular bleeding,
backache

Cx – bowel obstruction, painful urination
Endometriosis Treatment
 Definitive diagnosis – laparoscopy
 Tx determined by age, desire for pregnancy, symptom
severity, extent/location of disease
 Drugs – NSAIDs, Depo-Provera or Lupron to imitate
a state of pregnancy or menopause (is only controlled,
not cured by this), lots of side effects, will take for 9
months to shrink the endometrial tissue
 Surgery – only cure
Leiomyomas
 Uterine fibroids, benign smooth-muscle tumors
 Seem to depend on ovarian hormones b/c they grown
slowly during reproductive years and atrophy after
menopause
 s/s – generally none, but may have abnormal uterine
bleeding, pain, pelvic pressure
 Tx – depends on symptoms, age of pt, desire to bear
children, location/size of tumors; lots of bleeding or large
tumors mean surgery (hysterectomy, myomectomy, uterine
artery embolization, or cryosurgery)
Cervical Polyps
 Benign lesion on a stalk, seen through the cervical os
during a speculum exam (bright cherry-red, soft,
fragile, small (< 3 cm))
 s/s – none usually, might have spotting, bleeding after
BM straining, bleeding after sex, infection
 Tx – outpatient excision or polypectomy (send for
biopsy to ensure no malignancy)

Polycystic Ovary
Syndrome
(PCOS)
Many benign cysts on both ovaries,
usu. occurs in women < age 30, causes
infertility
 s/s –irregular menses, infertility,
hirsutism, obesity, acne, can even
develop CV disease and type 2
diabetes
 Tx – BCPs, aldactone (for hirsutism),
Lupron, Metform, may use fertility
drugs (Clomid) to cause ovulation,
may ultimately need hysterectomy
with salpingectomy and oopherectomy
 Needs weight management and
exercise
Cervical Cancer
 Risk factors – low socioeconomic status, early sexual
activity (< age 17), multiple sexual partners, HPV infection,
immunosuppression, smoking
 Higher incidence in white women, but higher mortality in
African American women (avg age-50)
 Best tx is prevention with regular Pap screens
 Cause – repeated injuries to the cervix
 s/s – early cancer is asymptomatic, thin/watery vaginal
discharge becoming dark and foul-smelling, spotting that
becomes heavier and more frequent, pain is a late symptom
as is weight loss, anemia, muscle wasting
Cervical Cancer
 Diagnostic studies
 *Pap testing – begin 3 years after
first intercourse but no later than
age 21
 Not 100% accurate so very impt to
follow up after abnormal Pap tests
 Minor changes in Pap – repeat Pap
in 4-6 months for 2 years
 Prominent changes in Pap –
colposcopy and biopsy, may have
punch biopsy or conization
(outpatient procedures with mild
analgesics or sedation)
Cervical Cancer
 Treatment
 Prevention with Gardasil vaccine for females age 9-26
 Guided by tumor stage, pt’s age, general state of health
(see pg 1364, Table 54-11)
 Can sometimes preserve fertility
 Invasive cancer is treated with surgery, radiation (4-6
weeks external, 1-2 internal implants), and chemo
Endometrial Cancer
 Most common gynecologic cancer, grows slowly,
metastasizes late, curable if diagnosed early
 Risk factors – estrogen, increasing age, no pregnancy, late
menopause, obesity, smoking, diabetes, history of
colorectal cancer
 s/s – *first sign is abnormal uterine bleeding in
postmenopausal women, pain occurs late
 Tx - *endometrial biopsy, total hysterectomy/bilateral
salpingo-oophorectomy with lymph node biopsy, may need
radiation; may also need progesterone hormonal therapy
(Megace) or Tamoxifen and chemo
Ovarian Cancer
 Most have advanced disease at time of diagnosis
 Risk factors – family history of ovarian cancer, breast
cancer, colon cancer, no pregnancies, increasing age, highfat diet, early menses or late menopause, HRT, use of
infertility drugs
 Reduced risk – use of BCPs, breastfeeding, multiple
pregnancies, early age at first pregnancy
 s/s – vague in early stages, abdominal enlargement, daily
symptoms for at least 3 weeks (pelvic/abdominal pain,
bloating, urinary urgency/frequency, difficulty eating or
feeling full quickly), pain is a late symptom, vaginal
bleeding is not a usual symptom
Ovarian Cancer
 Diagnostics
 No screening tests other than a yearly bimanual pelvic
exam (if postmenopausal should not have palpable
ovaries)
 OVAI – can help detect whether a pelvic mass is benign
or malignant
 If at high risk, can test for CA-125 (tumor marker) and
use ultrasound with the yearly pelvic exam
Ovarian Cancer
 Treatment
 If at high risk, prophylactic oophorectomy, BCPs
 Staging guides treatment decision
 Stage I – total abdominal hysterectomy/bilateral salpingo-
oophorectomy and chemo
 Stage II – external irradiation and/or chemo
 Stage III – chemo and surgical debulking
 Metastasis often causes pleural effusion and shortness
of breath
Vaginal and Vulvar
Cancer
 Both are relatively rare
 Treatment may be with surgery and radiation
 Vulvar surgery has a high risk of morbidity due to
scarring and wound breakdown
Surgeries
 Hysterectomy – removal of the uterus, may (total) or
may not (subtotal) remove the cervix, removal of
fallopian tubes (salpingectomy), removal of ovaries
(oophorectomy); if all TAH-BSO
 Can be done vaginally or abdominally
 In both, the ligaments that support the uterus are
attached to the vaginal cuff to maintain the normal
depth of the vagina
Care after Hysterectomy

Abdominal dressing or sterile perineal pad (vaginal approach)

Observe closely for bleeding for first 8 hours

Watch for urinary retention (may have catheter for 1-2 days )

Report backache or decreased urine output to surgeon

Watch for paralytic ileus

Prevent DVTs – turn, no high-Fowler’s, no pressure under the knee

Assist with grief over loss of fertility

May need HRTs

Discharge – no intercourse for 4-6 weeks, may be temporary loss of vaginal
sensation, no heavy lifting for 2 months, avoid pelvic congestion for several
months (ie. Dancing, walking swiftly), wear a girdle

Vulvectomy,
Vaginectomy
Vulvectomy – removal of vulva and wide margin of skin,
Vaginectomy – removal of vagina
 Post-op care

Perineal wound extending to the groin that may be covered
or left exposed, usu. has a drain

Meticulous wound care – clean with NS twice daily

Use heat lamp or hair dryer to dry the area

Prevent stool straining

Be very careful not to dislodge urinary catheter

Lots of discomfort due to heavy, taut sutures

Ambulation on 2nd post op day

Easy to get discouraged due to mutilation of perineum and
slow healing
Pelvic Exenteration
 Radical hysterectomy, total
vaginectomy, removal of bladder
with urinary diversion, resection
of bowel with colostomy
(anterior – no bowel resection,
posterior – no bladder removal
 Post-op care - similar to care
after radical hysterectomy, abd
perineal resection and ileostomy
and/or colostomy; lots of
physical, emotional, and social
adjustments
Radiation Therapy
(Brachytherapy)

In the OR, places radiation near or into the tumor causing
less damage to surrounding normal tissue, delivered using
wires, capsules, needles, tubes, seeds; left in for 24-72 hrs

Preparation – cleansing enema to prevent stool straining,
indwelling catheter to prevent distended bladder

Care – lead-lined private room, absolute bed rest (can be
turned from side to side), analgesics for uterine contractions,
deodorizer, cluster care, nurses can spend no more than 30
minutes/day in room, stay at foot of bed or entrance to
room, visitors must stay 6 feet from bed and stay less than 3
hours/day, discharge to home after radioactive material and
catheter are removed

Common to have foul-smelling vaginal discharge from
destruction of cells, may also have n/v, diarrhea, malaise

Cx – fistulas, cystitis, phlebitis, hemorrhage, fibrosis
Problems with Pelvic
Support
Uterine Prolapse
Displacement of uterus into the vaginal canal
 First degree – cervix in lower part of vagina
 Second degree – cervix at vaginal opening
 Third degree – uterus protrudes through vaginal
opening
 s/s – feeling of “something coming down”, pain with
sex, backache, stress incontinence
 Tx – Kegel exercises, pessary, vaginal hysterectomy
Cystocele and Rectocele
 Cystocele – weakening between vagina and bladder
 Rectocele – weakening between vagina and rectum
 Common and asymptomatic
 Tx – Kegel exercises, pessary, surgery to tighten the vaginal
wall, colporrhaphy (post-op care includes catheter to
prevent suture strain)
Fistula
 Abnormal opening between internal organs or between an
organ and the exterior of the body
 Causes – gyneocologic procedures, injury during childbirth,
cancer
 s/s – excoriation, irritation, severe infections, wetness,
odors
 Tx – if small may heal on own, can’t do surgery until
inflammation and edema is resolved
 Care – perineal hygiene every 4 hours, warm sitz baths 3
times/day, good fluid intake, post-op – catheter for 7-10
days, delay the first post-op stool to prevent wound
contamination
Sexual Assault
 Forcible perpetration of a sexual act on a person without
their consent
 s/s – may have no signs of physical trauma, may have
bruising and/or lacerations, STDs, pregnancy; may have a
range of psychologic symptoms; may have post-traumatic
stress disorder weeks to months to years after assault (rapetrauma syndrome)
 Tx - *highest priority is ensuring emotional and physical
safety, SANE RN provides care while ensuring evidence is
safeguarded (obtain consent, collect and label data, have as
few people handle the data as possible, gynecologic/sexual
history, account of the assault, lab tests looking for sperm
and pregnancy), need follow-up physical and psychological
care (return weekly for the first month)
Sexual Assault

Nursing care

Encourage all women to learn self-defense

Quiet, private area for exam

Never leave the patient alone

Maintain a non-judgmental attitude

Let the patient talk, listen carefully

Be supportive during the pelvic exam

Provide a change of clothing

Offer the “morning after pill”

Explain about application for financial compensation

Never send them home alone

Let them know about the crisis center