Hysterectomy/Reproductive Disorders

Question 1

Uterine Disorders

• Endometriosis
• Leiomyomas, or fibroids
• Cancer

Question 2

Endometriosis

• Is endometrial tissue that plants itself outside the uterine cavity
• 2 layers - endometrium & myometrium
  > Myometrium - muscle layer (myomectomy = removal of muscle layer)
  > Endometrium - what sheds monthly during menses

Answer 2

• Most common implantation sites are pelvis, ovaries, & posterior rectal vaginal wall
• Widespread dz
  ! Major concern is scarring, inflammation, & adhesion (affected organs stick together)

Question 3

Relevant Cues: Clinical Manifestations

• Pain (peaks right before onset of menstrual flow)
• Infertility (esp if it affects the fallopian tubes or ovaries)
• Dyspareunia
• Menstrual irregularities
• GI disturbances (like nausea, diarrhea, some pelvic tenderness)

Answer 3

Diagnostic

• Health hx, pelvic exam
• Laparoscope
• US (transvaginal; to rule out masses)

Question 4

Take Action: Treatment

• NSAIDs (i.e., ibuprofen, naproxen)
• OCP’s (i.e., low dose estrogen, progesterone [to shrink endometrial tissue])
• regulate flow
• decrease endometrium
• help w/pain
• Lupron/Synarel
  > can medically induce menopause & thereby suppress ovarian function

Answer 4

• Calcium, magnesium supplements
• Relaxation techniques
• yoga, massage, biofeedback
• Heat
• Surgery
• laparoscopically to remove endometrial tissue from areas outside uterine cavity

! decrease the pain; restore sexual or fertility function; alleviate anxiety; educate pts

Question 5

?

Are uterine tumors that arise from the myometrium

Are benign, slow growing, solid tumors of the uterine myometrium, the muscle layer of the uterus
- 20-30% women
- vary in size; if you have 1, probably have >1
- are probably stimulated by estrogen & progesterone; get bigger during pregnancy & shrink >menopause
- nulligravidas are @ higher risk but unsure why

Answer 5

Leiomyomas, or fibroids

Question 6

Relevant Cues: Clinical Manifestations

• May be totally asymptomatic or very severe; depends on size of fibroid, location, & how many
• Bleeding
• Anemia
• Dysmenorrhea

Answer 6

• Pelvic pressure/back pain
• Urinary retention/frequency
• Infertility
• Spontaneous abortions, miscarriages

Question 7

Diagnosis

• Health history; pelvic exam
• U/S (transvag)
• Laparoscopic exam
• CBC (to check for anemia d/t bleeding)

Answer 7

Take Action: Treatment

• Hormone Therapy (HT)
• Laser surgery
• Myomectomy
• Uterine artery embolization
• Hysterectomy

What’s the woman’s desire for future fertility?

! Complications incl perforation, bleeding, & infection
All can be done outpt except for hysterectomy

Question 8

Which 2 procedures help preserve fertility?

Answer 8

laser surgery; myomectomy

Question 9

Ovarian Disorders

Cancer
* Leading cause of death from female reproductive cancers
* 5th most common cancer in women
* Sx’s are vague & benign
> Survival rates are very low b/c we don’t detect it until late stage

Answer 9

Cysts
* Usually benign
* Lupron
- Rare >menopause

Question 10

Ovarian Cancer Risk Factors

↠ Nulliparity
↠ H/o infertility
↠ Family hx
↠ Age (>40)
↠ Fertility rx’s (ovulation-stimulating rx’s)
↠ Use of baby talc

Answer 10

Relevant Cues: Clinical Manifestations

• Persistent GI/GU disturbances (tumor enlarging & causing pressure against GI system & bladder)
• Abd distention w/ascites
• Inc abd girth
• Urinary freq/urgency/pain/pressure
• Malnutrition w/wt loss
• Pain

Question 11

Take Action: Treatment

↠ Surgery
- remove tumor & ovaries; a hysterectomy may or may not be done
- surgery to dec estrogen
- will be putting the woman into a surgical menopause

Answer 11

↠ Chemotherapy
↠ Radiation
↠ Supportive therapies

Question 12

Uterine (Endometrial) Cancer

• Endometrial cancer is a reproductive cancer, of which adenocarcinoma is the most common type
  > is very curable if caught early; 80% of all cases of uterine ca
• The main sx is bleeding:
  premenopausal heavy or irregular bleeding
  postmenopausal bleeding

Answer 12

• Diagnostic assessment incl
  > CA-125 tumor marker
  > Cxr

Question 13

Endometrial Cancer Risk Factors

↠ Early onset of menarche
↠ Late menopause (are exposed to estrogen for a longer period of time)
↠ Obesity
↠ Nulliparity

Answer 13

↠ Reproductive cancers (i.e., if you have had ovarian ca)
↠ Tamoxifen use (for breast ca)
↠ Fhx
↠ DM
↠ HTN

! Common sites for metastasis are liver, lungs, & brain

Question 14

Endometrial Ca

• Stages 1-4

Answer 14

Question 15

Stage ___

Cancer has spread beyond the uterus but remains confined to the pelvis, such as in bladder or rectum

Answer 15

3

Question 16

Stage ___

Tumor is confined to the uterine corpus

Answer 16

1

Question 17

Stage ___

Highest lvl of invasiveness b/c ca has spread beyond the pelvis, causing metastatic dz & large masses, like in the liver or lungs

Answer 17

4

Question 18

Stage ___

In addition to the uterine corpus, ca has invaded the cervix

Answer 18

2

Question 19

Relevant Cues: Clinical Manifestations

• Bleeding (AUB, esp in postmenopausal women)
• Pelvic pressure
• Pain

↠ Dx = endometrial biopsy

Answer 19

Types of Hysterectomies

↠ Total hysterectomy
↠ Partial hysterectomy
↠ Panhysterectomy aka TAH-BSO
↠ BSO
↠ Radical hysterectomy

Question 20

?

Is the removal of the uterus & cervix; may be either vaginal or abdominal, w/ or w/o a laparoscope

Answer 20

Total hysterectomy

Question 21

?

The uterus is removed but the ovaries are retained esp if the woman is young to prevent menopause
- Cervix can be removed or retained
- Pt should receive ed to know what kinds of gyn exams will need yearly
> no pap smear but ovary palpation will be done

Answer 21

Partial (or subtotal) hysterectomy

Question 22

?

Is a total abdominal hysterectomy plus BSO (bilateral salpingo-oophorectomy
> fallopian tubes & ovaries

Answer 22

Panhysterectomy aka TAH-BSO

Question 23

?

Is a total hysterectomy; the uterus & ligaments (tissue fibers) that hold it in place
- cervix & an inch or 2 of the vagina around the cervix are also removed
- may or may not incl a BSO

Answer 23

Radical hysterectomy

Question 24

Potential Complications

Answer 24

DVT

> Prevent it w/early ambulation
May be wearing pneumatic boots & stockings to help w/circulation
Leg exercises; SC heparin or Lovenox

Question 25

Hemorrhage > Assess vaginal bleeding postop > saturates >1 pad/hr ? > if a vaginal hysterectomy may not see a lot of bleeding d/t a lot of packing in place ! overly distended abd; tender to touch ! unstable VS; HTN; tachycardia

Answer 25

Infection > Look @ abd or lap sites for S/S - vaginal packing in place for 24 hrs > Look for infection from urinary catheter - monitor I&O, temp - encourage fluids - check for UTI's; is bladder emptying completely? - look for hematuria; inability to void; infections appear ~48-72 hrs in

Question 26

Bladder dysfunction - any trauma or dysfunction? - inability to void; incomplete emptying of bladder; hematuria - Foley cath in for 24 hrs >surgery; urine color

Answer 26

Sexual dysfunction - d/t scarring, removal of uterus & cervix & poss part of vagina

Question 27

Constipation - d/t bowel manipulation - monitor bowel sounds, bowel function, & abd distention - inc warm fluids to inc peristalsis - early ambulation & Colace will help

Answer 27

Grief response - grief over the loss of a female reproductive organ; loss of womanhood

Question 28

Cervical Cancer * Preinvasive or invasive * Carcinoma in situ

Answer 28

- is slow growing; if found early, prognosis is very good

Question 29

___ cancer Has spread to other pelvic structures - cervical ca is the 13th most common ca in women in the US

Answer 29

invasive

Question 30

___ cancer Is ca just limited to the cervix

Answer 30

preinvasive

Question 31

? Is the most advanced, pre-malignant stage

Answer 31

carcinoma in situ

Question 32

The earlier cervical dysplasia has no recognizable sx's & is sometimes not visible even to trained providers

Answer 32

Most common sx 1st seen is vaginal bleeding in invasive cervical ca

Question 33

Cervical Cancer Risk Factors * HPV (leading cause) > Gardasil (3 inj series over 6 mos) * Multiple sexual partners * Early sexual intercourse * H/o STD's * Smoking * Immunosuppression * Low socioeconomic status * Poor access to health care

Answer 33

Relevant Cues: Manifestations * Often asymptomatic * Classic sx - painless vaginal bleeding * Watery, blood-tinged vaginal d/c that may become dark & foul-smelling as the dz progresses * Unexplained wt loss, pelvic pain, dysuria, hematuria, rectal bleeding, CP, & cough * Leg/flank pain > leg pain is followed along the sciatic nerve & involves swelling of 1 leg; ca is growing & pressing on the sciatic nerve > flank pain is a late sign; is a sx of hydronephrosis, indicating that the ca has adv & is pressing on ureters, backing up urine into the kidneys

Question 34

Diagnostic Assessment * Pap smear * Colposcopy * Endocervical curettage

Question 35

? Is the gold standard - Done annually for all women during their reproductive yrs - Should begin within 3 yrs >1st intercourse OR by age 21 & then annually - Refrain from sex < - No douching, tampons, or vaginal creams 48 hrs prior - Not usually done during a menstrual flow; isn't unusual to see sm amts of vag bleeding the 1st 24 hrs after

Answer 35

Pap smear

Question 36

? The physician applies a thick acid solution to the cervix & then visualizes it w/magnification & a bright light to examine the cervical cells > may take 1 or more bx's @ this time > might expect some dark vag bleeding or d/c 1-2 wks >

Answer 36

Colposcopy

Question 37

? This is a scraping of the endocervical wall for biopsies

Answer 37

Endocervical curettage

Question 38

Treatment * Local Cervical Ablation (3 types) > LEEP > Cryosurgery > Laser * Cone biopsy * Hysterectomy * Radiation/chemotherapy

Question 39

LEEP Loop electrical or electrocautery procedure > newest & most common > performed to excise cervical areas in question; under local anesthesia > lesions totally removed by low voltage cautery > rapid healing & less tissue damage

Answer 39

Cryosurgery > uses freezing on affected surgical tissue > minimal s/e but can have vaginal d/c for 2-4wks following

Question 40

Laser > Uses heat over cold > A laser beam is directed into the area to ablate ca cells

Answer 40

Care after a cervical ablation - no intercourse, tampons, douching, hot tubs for 2-3 wks after - avoid heavy lifting & report foul-smelling d/c, fever, or pain (d/c that lasts longer than a couple of wks might signify infections)

Question 41

Cone biopsy - a cone-shaped segment is removed - used to preserve reproductive ability - can be both diagnostic & treatment

Answer 41

Hysterectomy > If the woman doesn't desire fertility & it's in adv stage Radiation/chemotherapy > For adv stage; can be done in combo

Question 42

? Occurs when the pelvic organs relax & descend into the vagina - involves the urethra, bladder, uterus, bowel, & rectum - seen in older women - women that've had mult childbirths w/extra large macrosomia infants or had prolonged pushing during childbirth - different grades (1-3) described by degree of descent of uterus

Answer 42

Urogenital displacement/prolapse; uterine prolapse

Question 43

Sx's Backache, pressure in pelvis, bowel, or bladder problems all common

Question 44

Grade ___ Uterus bulges farther into the vagina, & then the cervix protrudes through the entrance of the vagina

Answer 44

2

Question 45

Grade ___ Uterus bulges into the vagina, but the cervix doesn't protrude through the entrance of the vagina

Answer 45

1

Question 46

Grade ___ Body of the uterus & cervix protrudes through the entrance of the vagina. Vagina actually turns inside out & it's not uncommon in older women

Answer 46

3

Question 47

Cystocele [bladder] / Rectocele [rectum] - difficulty emptying bladder - urinary freq/urgency - UTIs - stress urinary incontinence > laughing, sneezing, peeing; women who laugh too hard, cough, sneeze loose a little urine, dribble a little urine

Answer 47

- The elderly become dehydrated b/c they don't drink. Don't drink b/c they don't want to pee

Question 48

? Occurs where the rectum is displaced, causing bulging of the posterior vaginal wall > constipation & hemorrhoids; fecal impaction > feeling of rectal or vaginal fullness

Answer 48

Rectocele

Question 49

Treatment * Pessary * Kegel exercises * Surgery (anterior posterior repair)