Gynaecological assessments and menstrual issues (benign + cancer)

Question 1

List the benign issues (3) and how to test?

Answer 1

Benign issues (3):
-Vaginitis: test by culture and sensitivity (high?) vaginal swab

• Pelvic inflammatory disease (PID):
  Test by:
• Pregnancy Test
• Full Blood Count, C-Reactive Protein
• Screening for STIs including HIV
  *Culture & Sensitivity Swab, pelvic examination, ultrasound, laparoscopy
  Used as diagnostic here but can be therpeutic in other cases

-Uterine prolapse: test by physical assesment (palpate)

laprascopy same as lapraotomy BUT only keyholes and has camera (‘scope’).

Question 2

List 4 types of cancer and how to test?

Answer 2

1 Breast
Diagnostic Test by:
- Mammography
- Biopsy
- Monitor by: Biopsy, Breast MRI (Magnetic Resonance Imaging), Breast Physical
Exam, BSE, CT scan, Chest X-Rays, Thermography, Ultrasound, Mammograms.

2 Cervical
Test by:
- Pelvic examination
- Pap smear –cells obtained from ectocervix, endocervix and transformation zone of the cervix using cervix brush
- HPV typing
- Schiller’s test: Iodine is applied to the cervix. The iodine colors healthy cells brown; abnormal cells remain unstained, usually appearing white or yellow.
- Cervical biopsy examination
- Colposcopy
- MRI, CT, Laparoscopy

3 Endometrial
- Dilation and Curettage (D & C) –performed in Operating Theatre
- Endometrial tissue biopsy examination using Pipelle

4 Ovarian
- Blood test: CA125 antigen level, AFP, CEA
- Pap smear: abnormal in 30% of patients
- Ultrasound: transabdominal or transvaginal
- Biopsy: through laparotomy
- Laparoscopy: to determine definite diagnosis and remove early ovarian cancer.
- CT scans, MRI scans, chest X-rays, colonoscopy: to detect metastases to other organs

Question 3

Describe postoperative care for uterine prolapse surgery (8)

Answer 3

1. Maintain stable vital signs (respiratory and cardiovascular status)
2. Relieve pain and anxiety
3. Relieve post-op gastro-intestinal disturbances (nausea and vomiting)
4. Administer indwelling urinary catheter care
5. Observe wound dressing (if any)
6. Observe for vaginal haemorrhage and discharge (perineal care)
7. Observe for urine retention, burning, frequency, or urgency to void (the U of BUBBLEHE)
8. Provide patient teaching on discharge
   ➢Heavy lifting, prolonged standing, walking, and sitting are contraindicated
   ➢Sexual intercourse should be avoided until approved by physician

*if not surgical, then usually conservative eg lifestyle change and pelvic floor training

Question 4

Define the following conditions:
1. vaginitis: inflammation of vagina caused by _, _, _ or muscle _

2. Pelvic inflammatory disease (other -itis besides 1): _ (direction) infection from endo__ (location)
3. uterine prolapse: _ displacement of uterus towards __

Answer 4

1. vaginitis: inflammation of vagina caused by bacteria, fungus, parasites or muscle atrophy
2. Pelvic inflammatory disease (other -itis besides 1): Ascending infection from endocervix
   (Uterus -> fallopian tube)
3. uterine prolapse: Downward displacement of the uterus into the vagina

Question 5

Symptoms of following conditions:
1. vaginitis
2. Pelvic inflammatory disease (other -itis besides 1)
3. uterine prolapse

1. vaginitis: vulvovaginal symptoms such as _, _, burning, and abnormal discharge
2. PID:
   * Bilateral __ pain, radiating to the __ (1st indication) -> sudden and severe or gradually increasing
   * __vaginal discharge, _ discharge at cervix
   * Dysuria
   * Fever (T > 38 Celsius), general malaise, anorexia, nausea, __
   * __ during pelvic exams
3. Uterine prolapse:
   ➢ pressure and urinary problems (__ or retention) from displacement of the bladder
   ➢ Aggravated when a woman _, _, or stands for a long time. Normal activities, even walking up stairs, may aggravate the symptoms.

Answer 5

1. vaginitis: vulvovaginal symptoms such as itching, irritation, burning, and abnormal discharge
2. PID:
   * Bilateral lower abdominal pain, radiating to the legs (1st indication) -> sudden and severe or gradually increasing
   * Foul smelling vaginal discharge, purulent discharge at cervix
   * Dysuria
   * Fever (T > 38 Celsius), general malaise, anorexia, nausea, headache
   * Tenderness during pelvic exams
3. Uterine prolapse:
   ➢ pressure and urinary problems (incontinence or retention) from displacement of the bladder
   ➢ Aggravated when a woman coughs, lifts a heavy object, or stands for a long time. Normal activities, even walking up stairs, may aggravate the symptoms.

Question 6

What is the nursing care and mangement for:
1. vaginitis
2. PID?

1. Vaginitis:
   * Diagnosis through vaginal swab – _
   * Treatment – oral anti-fungal, may or may not be used to treat the partner
2. PID:
   * Attitude: non-judgmental, accepting
   * _ to abdominal area if ordered: to improve circulation and provide comfort
   *_ pain relief

Patient education:
* self
* Recognize whether her sexual partner is infected with_
* Compliance to treatment: Completing the treatment regimen and follow-up visits.
* Safe sex guidelines (use of condom)

Answer 6

1. Vaginitis:
   * Diagnosis through vaginal swab – Culture & Sensitivity
   * Treatment – oral anti-fungal, may or may not be used to treat the partner
2. PID:
   * Attitude: non-judgmental, accepting
   * Heat application to abdominal area if ordered: to improve circulation and provide comfort
   *Analgesics for pain relief

Patient education:
* Basic Hygiene
* Perineal hygiene: wipe from front to back
* Recognize whether her sexual partner is infected with gonococcus: discharge from
penis of whitish fluid with painful urination (not all males are symptomatic) .
* Compliance to treatment: Completing the treatment regimen and follow-up visits.
* Safe sex guidelines (use of condom)

Question 7

Types of AUB

Answer 7

metrorrhagia: intermenstrual bleed
menorrhagia: heavy bleed
oligomenorrhea: infrequent periods
postmenopausal bleeding

Question 8

Discuss treatment of PMS

First Line:
-Exercise, diet, stress reduction
-Cognitive behavioural therapy, vitamin B6 dose (110mg om)
-Combined ___ pill
-Continuous or ___ phase (day 15-28) lose dose ___

Second Line:
-____ patches (100mcg) with progestogens day 17-28
-Higher dose ___ continuously or in luteal phase

Third Line:
- GnRH analogues with add back ___ (continuous combined oestrogen and
progesterone of tibolone) (if used for > than 6 months)

Fourth Line:
-Hysterectomy and bilateral oophorectomy with add back ___ (including testosterone)

Answer 8

First Line:
-Exercise, diet, stress reduction
-Cognitive behavioural therapy, vitamin B6 dose (110mg om)
-Combined new generation pill
-Continuous or luteal phase (day 15-28) lose dose SSRI

Second Line:
-Oestradiol patches (100mcg) with progestogens day 17-28
-Higher dose SSRI continuously or in luteal phase

Third Line:
- GnRH analogues with add back HRT (continuous combined oestrogen and
progesterone of tibolone) (if used for > than 6 months)

Fourth Line:
-Hysterectomy and bilateral oophorectomy with add back HRT (including testosterone)

Question 9

Discuss treatment of AUB (medical and surgical)
Surgery: Therapeutic ___, Endometrial ____ (Laser surgery), ___ectomy

Answer 9

Medications: Anovulatory/ Ovulatory Abnormal Uterine Bleeding

Surgery: Therapeutic D & C, Endometrial ablation (Laser surgery), Hysterectomy

Question 10

Discuss treatment of primary dysmenorrhea

Answer 10

-Pain management with analgesic such as NSAIDs
- Oral contraceptives
- Local heat application
- Psychotherapy
- Hypnotherapy

Patient Education:
- Avoidance of fatigue and overexertion
- Ingest oral analgesia as prescribed

Question 11

Discuss treatment of secondary dysmenorrhea (medical and surgical)

Medical
– __ management
–__ suppression of endometrial tissues using oral contraceptives or progesterone to induce pseudo-pregnancy (amenorrhea)

Surgical
- Surgical _ and _ of endometriosis (laparoscopic/ open)
- For cysts > 5cm in diameter (unlikely to respond to conservative therapy (choco cysts in endometriosis)
- _ ectomy (uterus removal) to prevent recurrence
- _ for frozen pelvis associated with intractable chronic pelvic pain

Answer 11

Medical
–Pain management
–Hormonal suppression of endometrial tissues using oral contraceptives or progesterone to induce pseudo-pregnancy (amenorrhea)

Surgical
- Surgical ablation and excision of endometriosis (laparoscopic/ open)
- For cysts > 5cm in diameter (unlikely to respond to conservative therapy (choco cysts in endometriosis)
- Hysterectomy (uterus removal) to prevent recurrence
- Pelvic clearance for frozen pelvis associated with intractable chronic pelvic pain

Question 12

How to treat climacteric and menopause?

Answer 12

hormone replacement therapy

Question 13

S&S of Breast cancer (initial and advanced)

Answer 13

Initial sign: single, hard, non-tender nodule,
freely movable

Advanced signs:
- Fixed nodule
- Skin dimpling, pulling
- Nipple discharge, retraction or elevation
- Change in breast contour
- Enlarged axillary nodes

Question 14

How frequent should do breast cancer screening? (for normal risk)

Answer 14

Screening (mammography):
50-69 Normal Risk: every 2 years
40-49 NR: annual
under 40: no need

Question 15

S&S of Cervical cancer (subjective + objective has only 1)

Answer 15

Subjective
Asymptomatic in early stage, “silent killer”
Menstrual disturbances
Postmenopausal bleeding
Bleeding after intercourse
Watery discharge

Objective:
Suspicious Pap smear result

Question 16

S&S of Endometrial cancer (subjective and objective)

Answer 16

Subjective:
* Postmenopausal bleeding
* Bleeding between cycles
* Bleeding after intercourse
* Watery vaginal discharge

Objective:
* Uterine enlargement
* Suspicious Pap smear results

Question 17

S&S of Ovarian cancer

Answer 17

Mainly presented as digestive and bladder issues
- Pressure or pain in the abdomen, pelvis, back, legs
- A swollen or bloated abdomen
- Nausea, indigestion, gas
- Constipation, or diarrhoea
- Feeling very tired all the time
- Shortness of breath
- Feeling the need to urinate often
- Unusual vaginal bleeding (heavy periods, or bleeding after menopause)

Question 18

Diagnostic tests for menstual problems
Secondary Dysmenorrhea: 2

AUB:2

Climacteric, PMS, amenhorrhea:

Answer 18

Secondary Dysmenorrhea:
Investigation –pelvic sonography, laparoscopy

AUB:
- Blood tests: CBC, Pituitary and Adrenal function test, Thyroid function studies, progesterone test
- Pap smear, Pelvic ultrasound, Hysteroscopy, Endometrial biopsy

Climacteric, PMS, amenhorrhea: Hx and PA

Question 19

Nursing care (and treatment) for breast cancer?

Answer 19

-Breast:
pre-op:
- Emotional support: acceptance, reassurance, and encouragement in illness adjustment; psychosocial intervention
- Providing education & preparation about surgical treatments
- Reducing fear and anxiety and improving coping ability
- Promoting decision-making ability

post-op:
Immediate postoperative care:
* Promote comfort and maintain optimum fluid and electrolytebalance
* Managing postoperative sensations

Subsequent Care:
(Monitoring and managing potential complications –lymphedema/ haematoma’ seroma formation))
* Affected arm care (Promote neurovascular function):
 Assess circulatory status of affected arm
 Elevate affected arm above level of right atrium to prevent edema
 Measure upper arm and forearm twice daily to monitor oedema
 Encourage exercises of the affected arm when approved by a physician; avoid abduction;
 Avoid drawing blood or administering parenteral fluids or taking blood pressure on affected arm.
* Wound care:
 Monitor dressing for haemorrhage
 Empty Haemovac drainage tube and measure drainage
* Mobility care: Assist with gradual ambulation
* Respiratory care: Encourage deep breathing exercise (minimize pain by administrating oral analgesia

Question 20

cervical, ovarian and endometrial cancer treatments (besides radiation and chemo)?

Cervical
Surgery:
- Conization, LEEP (___ to remove abnormal cells): for micro-invasive cancer
- Hysterectomy (Stage I and IIA):
- Simple: removal of ____ and ___
- Radical: uterus, cervix, upper vagina, and the tissue around the cervix, and the lymph nodes;
lower colon, rectum or bladder may also be removed if affected.

Radiation: in advance case (Stage IIB and above)
Chemotherapy

Ovarian
Chemotherapy:
- ___ chemotherapy: directly into the abdomen and pelvis through a thin tube.
- Systemic chemotherapy: by mouth or vein.
-Radiotherapy: not common

Endometrial
- Surgical intervention: Pan hysterectomy (Radical hysterectomy), oophorectomy (ovary remove), salpingectomy (fallopian tube remove)
- Chemotherapy
- Radiation

Answer 20

Cervical
Surgery:
- Conization, LEEP (Loop Electrosurgical excision procedure to remove abnormal cells): for micro-invasive cancer
- Hysterectomy (Stage I and IIA):
- Simple: removal of uterus and cervix
- Radical: uterus, cervix, upper vagina, and the tissue around the cervix, and the lymph nodes; lower colon, rectum or bladder may also be removed if affected.

Radiation: in advance case (Stage IIB and above)
Chemotherapy

Ovarian
Chemotherapy:
- Intraperitoneal chemotherapy: directly into the abdomen and pelvis through a thin tube.
- Systemic chemotherapy: by mouth or vein.
-Radiotherapy: not common

Endometrial
- Surgical intervention: Pan hysterectomy (Radical hysterectomy), oophorectomy (ovary remove), salpingectomy (fallopian tube remove)
- Chemotherapy
- Radiation

Question 21

Nursing care for endometrial, ovarian and cervical cancers
- ____: Reassure the patient and family that adjustment illness can be slow.
- Managing ___: radiation or chemotherapy
- Provide general ___ and ____ care: if undergo surgery.

Provide care for those receiving an internal radium implant:
- Provide ____ and limit visiting time.
- Maintain _____ or ____ position
- Diet? high ___, low ____
- Maintain high fluid intake: ____ to ___ ml daily
- ____ to prevent bladder distension

Answer 21

• Emotional support: Reassure the patient and family that adjustment illness can be slow.
• Managing side effects: radiation or chemotherapy
• Provide general pre- and post- operative care: if undergo surgery.

Provide care for those receiving an internal radium implant:
Provide isolation and limit visiting time.
Maintain supine or side-lying position
Diet: high-protein, low residue diet
Maintain high fluid intake: 2000 to 3000 ml daily
Insert Foley catheter to prevent bladder distension

Question 22

risk factor for BC (3)

Answer 22

-Family history: mother or sibling, specific genes
-Menstrual and Obstetric history: Reproductive factors associated with prolonged exposure to endogenous oestrogens, such as long period of regular menstrual cycles (early menarche, late menopause), late age at first childbirth are among the most important risk factors for breast cancer; nulliparity; Never breast fed; Exogenous hormones.

• Medical history: breast cancer, fibrocystic breast disease, previous breast irradiation.
• Personal history: 21% of all breast cancer deaths worldwide are attributable to alcohol use, overweight and obesity, and physical inactivity

Question 23

risk factor for EC (3)

Answer 23

 Increased oestrogen levels (HRT for postmenopausal women for more than
five years.)
 Infertility
 Obesity, diabetes, hypertension increase risk

Question 24

Risk factor for CC (6)

Answer 24

o Multiple sex partners
o Sexual activity at an early age
o Weakened immune system
o Long term consumption of contraceptive pills
o Patient history of STDs
o Cigarette smoking

Question 25

risk factor for OC (6)

Answer 25

-family and personal history of cancer,
-age over 55,
- nulliparity,
-infertility and taking certain fertility drugs
- menopausal hormone therapy,
-using talcum powder, or being obese