9 Reproductive System 11111111111111111

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9 Reproductive System 11111111111111111 - Presentation Transcript

  1. Chapter 10 Reproductive System Conditions: Introduction
    • Function and structure, female reproductive system (Fig. 10.1):
      • Ovaries
        • Produce hormones, eggs
      • Oviducts (aka, Fallopian tubes, uterine tubes)
        • Fimbriae
        • Site of fertilization
      • Uterus
        • Endometrium
          • Shed with menses
        • Cervix
      • Vagina
  2.  
  3. Chapter 10: Reproductive System Conditions: Introduction, cont.
    • Function and structure, male reproductive system (Fig. 10.2):
      • Testes
        • Manufacture sperm
        • Hormones
      • Epididymis
        • Sperm mature here
      • Vas deferens
        • Carries sperm into abdomen
      • Prostate gland
      • Urethra
        • Shared by the urinary system
  4.  
  5. Cervical Cancer
    • Growth of malignant cells in the lining of the cervix
    • Incidence:
      • 16,000 diagnoses of invasive cervical cancer/year
        • 4× as many with precancerous cellular changes
      • 4,000 deaths/year
      • Average age at diagnosis: 28 years
  6. Cervical Cancer, cont.
    • Related to viral infection with human papilloma virus (HPV)
      • Cervical warts
      • Many types of HPV; not all cause invasive cervical cancer
      • Sexually transmitted disease; not prevented with condom use
  7. Cervical Cancer, cont.
    • Infection with HPV causes changes in cervical lining: dysplasia
      • Can be low-risk or high-risk variety
      • Low-risk problems are self-limiting
      • High-risk problems may develop into cervical cancer
    • Other factors in cervical cancer:
      • Smoking
      • Being a DES daughter
      • Coinfection with genital herpes
      • Having limited access to health care
  8. Cervical Cancer, cont.
    • Signs and symptoms
      • Usually none until cancer is advanced
      • Bleeding or spotting between menses, vaginal discharge, abdominal or pelvic pain
    • Diagnosis:
      • Papanicolaou test (Pap test)
      • Pap test has brought rates of cervical cancer down by 74% since 1955
  9. Cervical Cancer, cont.
    • Treatment:
      • Depends on stage
        • Cryotherapy
        • LEEP ( loop electrosurgical excision procedure )
        • Partial/full hysterectomy
        • Exenteration
        • Radiation, chemotherapy
    • Massage?
      • Fine in the context of treated cervical dysplasia
      • For more advanced forms of cervical cancer, work with health care team for maximum benefit and minimum risk
  10. Dysmenorrhea
    • Painful menstrual periods
    • Incidence:
      • 40% women have painful periods regularly
      • 10% are incapacitated 1–3 days /month
    • Primary vs. secondary:
      • Primary: free-standing problem (usually begins soon after menarche)
      • Secondary: symptom or complication of some other disorder
  11. Dysmenorrhea, cont.
    • Causes of primary dysmenorrhea:
      • Prostaglandins
        • Inflammatory chemicals rise before period starts
      • Pain–spasm cycle
        • Ischemia, pain, reinforce uterine spasm
      • Ligament irritation
        • Uterus pulls on uterine ligament at sacrum, can contribute to low back pain
  12. Dysmenorrhea, cont.
    • Causes of secondary dysmenorrhea:
      • Endometriosis
      • Fibroid tumors
      • Ovarian cysts
      • Pelvic inflammatory disease, STDs
      • Pelvic adhesions, scar from surgery
  13. Dysmenorrhea, cont.
    • Signs and symptoms:
      • Dull ache or sharp pains in abdomen, pelvis, low back
        • Usually happen early in menses; may persist through whole period
        • Headaches, nausea, vomiting, diarrhea, constipation may also occur
    • Diagnosis:
      • Need to consider underlying disorders
        • Laparoscopy, ultrasound, culture for infectious agents
  14. Dysmenorrhea, cont.
    • Treatment:
      • Painkillers to inhibit prostaglandins
      • Nutritional assistance
      • Exercise, stretching
      • Low-dose birth control pills
      • Surgery or medication to deal with underlying causes
    • Massage?
      • Avoid abdomen, pelvis during menstruation
      • Get information about possible underlying disorders
      • Otherwise massage is probably safe, effective, and very welcome
        • Parasympathetic balance
        • Pelvic adhesions?
  15. Endometriosis
    • Establishment of endometrial cells outside the uterus
    • Incidence:
      • Estimates: 5 million women in US
        • Cannot be diagnosed without surgery
      • Most diagnosed between 20 and 45 years of age
        • Mostly in women with heavy periods that last <28 days
  16. Endometriosis, cont.
    • How do endometrial cells escape?
      • Retrograde backflow through uterine tubes?
      • Circulatory, lymphatic dissemination?
    • Most women have some cells in peritoneal fluid during menstruation; not all have endometriosis
  17. Endometriosis, cont.
    • Factors in endometriosis:
      • Low killer T-cells, natural killer cells
      • High suppressor T-cells
      • High macrophages: stimulate proliferation, inflammation
      • High prostaglandins
        • Excessive inflammation, pain sensitivity
  18. Endometriosis, cont.
    • Endometrial growths get established on…
      • Uterus, uterine tubes, ovaries, bladder, colon (Fig. 10.3)
        • May interfere with fertility
      • May escape abdomen
    • Body attempts to encyst growths
      • Growths are sensitive to hormonal cycles:
        • Grow during proliferative phase
        • Degenerate during menstruation
          • Cannot exit body; stimulates inflammatory response, more scar
  19.  
  20. Endometriosis, cont.
    • Causes:
      • Genetic potential
      • Exposure to dioxins
      • Other environmental estrogens
    • Signs and symptoms:
      • Infertility
      • Dysmenorrhea
      • Spotting between periods
    • Complications:
      • Scar tissue
        • Ectopic pregnancy
        • Infertility
      • Anemia
  21. Endometriosis, cont.
    • Diagnosis:
      • Laparoscopic surgery
    • Treatment:
      • Goals:
        • Relieve pain, stop progression, prevent new growths, maintain/restore fertility
      • NSAIDs, birth control pills, laparoscopic surgery to remove growths, reduce adhesions
  22. Endometriosis, cont.
    • Massage?
      • Endometriosis can cause displacement of pelvic organs: deep abdominal/pelvic work is contraindicated
        • (Risk of bruising ovary)
      • Work elsewhere is highly appropriate and called for
  23. Fibroid tumors
    • Benign tumors in muscular wall of uterus
      • Also called leiomyomas
    • Incidence:
      • Diagnosed in 20% of fertile women
        • May be present in up to 80% fertile women
      • More common in African American women than others
      • Disappear after menopause (estrogen sensitive)
  24. Fibroid Tumors, cont.
    • Combination of genetic, hormonal, environmental factors
    • Classified by location (Fig. 10.4):
      • Submucosal
        • Close to endometrium
      • Intramural
        • Within muscular wall
      • Subserosal
        • Superficial to the muscular wall; deep to serous covering of uterus
  25.  
  26. Fibroid Tumors, cont.
    • Signs and symptoms:
      • Usually silent
      • May grow enough to…
        • Interfere with pregnancy
        • Put pressure on other structures
      • May cause heavy bleeding during menses
    • Complications:
      • Anemia, infertility, interrupted pregnancy, necrosis of twisted tumor
  27. Fibroid Tumors, cont.
    • Treatment:
      • Hormone therapy, interruption of blood supply, partial or total hysterectomy
        • 170,000-300,000 hysterectomies/year
    • Massage?
      • If a person knows she has them, deep abdominal work should be conducted with caution (displacement of pelvic organs)
      • Otherwise, massage has no particular impact: can improve quality of life, if not status of fibroid tumors
  28. Breast Cancer
    • Development of malignant tumors in the epithelial or connective tissue of the breast
    • Incidence:
      • 216,000 diagnoses in women/year
      • 1,450 diagnoses in men/year
        • 60,000 cases of “noninvasive” (in situ) /year
      • 40,000 deaths/year women; 500 deaths/year men
      • 77% of patients are > 50 years at diagnosis
      • 1:8 women will have breast cancer
      • 2 million people in the United States have had breast cancer
  29. Breast Cancer, cont.
    • Types of breast cancer:
      • Ductal carcinoma
        • Most common: 70%–80% diagnoses
      • Lobular
        • 5%–10% of all diagnoses; higher risk of appearing in both breasts
      • Other types:
        • 10%–15% of all diagnoses
          • Inflammatory breast cancer, Paget’s disease of the breast, medullary breast cancer (affects connective tissue)
  30. Breast Cancer, cont.
    • Growth pattern:
      • In situ growths, which may or may not become aggressive
      • Several years to reach 1 cm in diameter
      • Metastasis through lymph
        • 30%–40% have cells in axillary lymph nodes at diagnosis
        • Goes from nodes to liver, lung, brain
      • Each tumor may have different types of cells in it
  31. Breast Cancer, cont.
    • Risk factors:
      • No dependable risk profile
      • Statistical prevalence among…
        • Early menarche, late menopause, no or few children
        • Obesity
        • 2+ alcoholic drinks/day
        • History of proliferative breast disease
        • Genetic predisposition
          • BRCA 1, 2 account for <10% of all cases
        • Age
  32. Breast Cancer, cont.
    • Signs and symptoms:
      • Often none
        • Hard, thickened areas with self exam
        • Advanced cases:
          • Asymmetrical breast growth, “orange peel” skin; inverted nipples with discharge
          • Symptoms of metastasis: bone pain, weight loss, spinal cord compression, swelling in arms
  33. Breast Cancer, cont.
    • Diagnosis:
      • Self-examination, clinical examination, mammogram (Fig. 10.5)
      • Ultrasound, biopsy
        • Tracking sentinel lymph node, if possible
    • Treatment:
      • Surgery
        • Lumpectomy, partial, radical mastectomy
      • Radiation
        • External or with implanted pellets
  34.  
  35. Breast Cancer, cont.
      • Chemotherapy
        • Toxic drugs
      • Hormone therapy
        • To bind up receptors on potential cancer cells
    • Prognosis:
      • Survivors must be constantly vigilant
        • 5-year survival rate: 83%
        • 10-year survival rate: 65%
        • 15-year survival rate: 56%
  36. Breast Cancer, cont.
    • Massage?
      • Avoid tumor sites, obviously
      • Work with health care team to achieve best benefit, minimal risks
        • Base decisions on what treatment(s) the client must undergo
        • Risks with each option
          • Infection, blood clots, toxicity, lymphedema, etc…
        • Benefits: better tolerance of treatments, less pain, better sleep, appetite, immune system function, etc…
  37. Ovarian Cancer
    • Growth of malignant cells in the ovaries
    • Incidence:
      • 25,000 diagnoses/year
      • 1:60–70 women
      • 15,000 deaths/year
  38. Ovarian Cancer, cont.
    • Types of ovarian tumors:
      • Germ cells
      • Stromal cells
      • Epithelial cells (adenocarcinomas)
        • These are most common: 90% of cases
        • Several categories of adenocarcinomas
    • Metastasis through…
        • Peritoneal fluid
        • Direct extension to nearby structures
        • Lymph, blood flow
  39. Ovarian Cancer, cont.
    • Risk factors:
      • Familial history
        • 1 st degree relative has 50% chance of developing ovarian cancer
        • 2 nd degree relative, or relative with breast cancer, has greater than normal risk
      • Reproductive history
        • Most common in women who never had any interruption in menses (childbearing, birth control pills), or multiple miscarriages
      • Health history:
        • History of breast or colon cancer, breast cancer genes
      • Estrogen replacement therapy
      • Other:
        • Radiation, use of talc on genitals, high-fat diet, age
  40. Ovarian Cancer, cont.
    • Signs and symptoms:
      • None, or very subtle in early stages
      • In later stages, looks like ovarian cyst, other nonthreatening problems:
        • Heavy feeling in pelvis, bloating, nausea, diarrhea/constipation, weight gain or loss, ascites…
    • Diagnosis:
      • Pelvic examination, CT scan, ultrasound, laparoscopy…
        • Difficult to identify early
  41. Ovarian Cancer, cont.
    • Prognosis:
      • Found in Stage I or II only 25% of cases
      • Five-year survival rate is 50%
    • Treatment:
      • Surgery, chemotherapy
    • Massage?
      • As with other cancers, work with health care team for best benefits, minimal risks
  42. Ovarian Cysts
    • Any variety of cysts that grow on ovaries (Fig. 10.6)
      • Functional cysts related to hormonal imbalance
    • Incidence:
      • 30% women with regular menstrual cycle will have at least one
      • 50% women with irregular cycles will have at least one
      • Cysts found in premenarchal or postmenopausal patients have higher risk of being malignant
  43.  
  44. Ovarian Cysts, cont.
    • Types of cysts:
      • Follicular cysts:
        • Follicle does not rupture completely; blister forms over ovum; most common
      • Corpus luteum cysts:
        • Blister forms over site of egg release; blocks hormonal release; look like pregnancy; may bleed into peritoneal space
      • Polycystic ovaries (Fig. 10.7):
        • Also called Stein-Leventhal syndrome; enlarged ovaries with multiple small cysts; hormone disruption causes symptoms; linked to metabolic syndrome
      • Other cysts:
        • Dermoid, benign tumors, endometrial cysts
  45.  
  46. Ovarian Cysts, cont.
    • Signs and symptoms:
      • Dull ache in lower abdomen
      • Hormonal symptoms:
        • Looks/feels like early pregnancy, hair growth, obesity, acne…
    • Complications:
      • Depends largely on size: pressure on other structures; bleeding with rupture, can mimic advanced ovarian cancer
  47. Ovarian Cysts, cont.
    • Diagnosis:
      • May be found during pelvic examination
        • Ultrasound, biopsy through laparoscopy
    • Treatment:
      • Oral contraceptives: give ovaries time to resolve
      • Aspiration
      • Oophorectomy, hysterectomy if risk of cancer is high
    • Massage?
      • At least a local contraindication; displacement of pelvic contents
      • Massage elsewhere is probably appropriate
  48. Benign Prostatic Hyperplasia
    • Prostate of mature men becomes enlarged
      • Not synonymous with prostate cancer
    • Incidence:
      • 50% men > 60 years
      • 70% men > 70 years, and so on
  49. Benign Prostatic Hyperplasia, cont.
    • Unclear why some men’s prostates enlarge;others do not
      • Dihydrotestosterone?
      • Endogenous estrogens?
    • Enlarged prostate can exert pressure on urethra, leading to symptoms and problems (Fig. 10.8):
      • Urinary tract infection
      • pyelonephritis
  50.  
  51. Benign Prostatic Hyperplasia, cont.
    • Signs and symptoms:
      • Difficulties with urination:
        • Weak flow, difficulty initiating urination, leakage, dribbling
          • Not usually pelvic pain—distinguishes from prostatitis
    • Diagnosis:
      • Palpation through wall of rectum
        • Typically deep, smooth nodules, not hard, superficial growths—distinguishes from prostate cancer
      • PSA test (helps to rule out prostate cancer)
  52. Benign Prostatic Hyperplasia, cont.
    • Treatment:
      • Monitor for growth
      • Medications to slow growth, relax smooth muscle tissue
      • Surgery to remove part or all of prostate
        • Tissue is always examined for prostate cancer; comes up positive 10% of time
    • Massage?
      • No particular impact on prostate growth
      • Can certainly improve the quality of life of the person with BPH, if not improving the situation directly
  53. Prostate Cancer
    • Growth of malignant cells in the prostate gland
    • Incidence:
      • 212,000 diagnoses/year, 29,000 deaths/year
      • Lifetime risk is 1:10
      • Incidence rises with age
        • Rare before age 40
        • Precancerous changes found in 25% of men >50
        • Precancerous changes found in 50% of men >80
      • Average age at diagnosis: 70–72 years old
      • African Americans 2× more likely to have it; 2× more likely to die of it
  54. Prostate Cancer, cont.
    • Causes unclear
      • Oncogenes activated
      • Tumor-suppressor genes inhibited
      • Absence of enzyme that neutralizes free radicals
      • Related to testosterone
        • Does not occur in men who have been castrated
      • High-fat diets increase risk
      • Genetic link: higher incidence within families
  55. Prostate Cancer, cont.
    • Signs and symptoms:
      • Pressure on urethra
        • Looks like BPH: difficulty with urination
        • Risk of urinary tract infection, kidney infection
      • Also pain with ejaculation, difficulty maintaining an erection, blood in urine
      • Low back pain may develop if tumor puts pressure on other structures, nerve roots
  56. Prostate Cancer, cont.
    • Diagnosis:
      • Digital rectal examination finds hard, superficial nodules
      • Blood test for PSA (prostate-specific antigen)
        • Not definitive, but indicative
        • Free vs. attached PSA: attached indicated higher risk of cancer
      • Ultrasound, biopsy
      • Early detection is possible
        • 5-year survival rate for early detection approaches 100%
  57. Prostate Cancer, cont.
    • Treatment:
      • Radiation, surgery, hormone therapy
      • For slow-growing forms, some elderly patients may opt not to treat it at all
    • Massage?
      • As with other forms of cancer, work with health care team for best benefit, minimal risk
      • Elderly clients may elect not to treat prostate cancer; discuss risks of metastasis with primary health care provider (risks are probably minimal)
      • Massage can improve quality of life for people undergoing great challenges
  58. Prostatitis
    • Prostate becomes enlarged, inflamed, and often painful
      • Not synonymous with benign prostatic hyperplasia
    • Incidence:
      • 2 million doctor visits/year
      • 10%–50% of men 20–70 years old will have symptoms at least once
      • Most common urologic problem in men < 50 years old
  59. Prostatitis, cont.
    • Prostate anatomy:
      • Walnut-sized gland that surround urethra, distal to urinary bladder
      • Channels on a horizontal plane drain seminal fluid into urethra during ejaculation
        • Fluid can stagnate, even crystallize (prostate stones)
      • Bladder reflux can introduce caustic material into delicate environment
  60. Prostatitis, cont.
    • Types of prostatitis:
      • Type 1: Acute bacterial prostatitis :acute infection
        • E. Coli, Klebsiella —often part of sexually transmitted disease
      • Type 2: Chronic bacterial prostatitis :recurrent infection of the prostate
      • Type 3: Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CPPS): prostate enlargement with no demonstrable infection
        • Most common version (90%); could be referral from trigger points in perineal muscle
  61. Prostatitis, cont.
      • Type 3: subtypes:
        • Inflammatory chronic pelvic pain syndrome: white blood cells are found in the semen, expressed prostatic secretions, or urine
        • Noninflammatory chronic pelvic pain syndrome: white cells are not found in semen, expressed prostatic secretions, and urine
      • Type 4: Asymptomatic inflammatory prostatitis (AIP): no subjective symptoms, but white blood cells are found in prostate secretions
  62. Prostatitis, cont.
    • Signs and symptoms:
      • Acute prostatitis looks like urinary tract infection:
        • Pain, burning, frequent urination, low back pain, pain in groin, perineum, testes, penis
        • Penile discharge, fever
        • Prostate is extremely painful on palpation
      • CCPS has no fever or discharge; prostate is only mildly painful on palpation
  63. Prostatitis, cont.
    • Complication:
      • Urethral obstruction: medical emergency
    • Diagnosis:
      • Rule out BPH, prostate cancer
      • Urine analyzed for signs of infection
        • With and without prostate massage through the rectum
      • Semen may be analyzed
  64. Prostatitis, cont.
    • Treatment:
      • Types 1 and 2: antibiotics
        • May take long course for type 2
      • CPPD: antibiotics may be prescribed “just in case”; smooth muscle relaxants, frequent ejaculation, sitz baths, biofeedback: coping skills rather than “cures”
    • Massage?
      • Massage is contraindicated in the presence of acute infection
      • Otherwise, massage may be a helpful tool for someone dealing with a difficult, stubborn, painful, long-term problem
  65. Testicular Cancer
    • Growth of malignant cells in the testicles
    • Incidence:
      • 7,500 diagnoses/year
      • 400 deaths/year
      • Caucasians > other races, 8:1
      • Leading cause of cancer in men 15–35 years old
      • Rates climbed 51% 1973–1995
  66. Testicular Cancer, cont.
    • Only reliable risk factor:
      • Men born with cryptorchidism (undescended testicle) have slightly higher risk
    • Types of testicular cancer:
      • Stromal cell tumors: <5% of all diagnoses
        • Sertoli cell tumors
        • Leydig cell tumors
  67. Testicular Cancer, cont.
      • Germ cell tumors
        • Seminomas
          • 40%–45% of all diagnoses
          • Slow-growing, sensitive to radiation
        • Non-seminomas
          • Embryonic carcinomas
          • Yolk sac tumors
          • Teratomas
          • Choriocarcinoma (especially aggressive)
  68. Testicular Cancer, cont.
    • Signs and symptoms:
      • Painless lump on testicle, dull ache in pelvis or groin, tender breasts
        • Symptoms that last 2 weeks + should be investigated immediately
    • Diagnosis:
      • Rule out infection or injury
      • Ultrasound, blood tests
      • Orchiectomy (usually through abdomen to avoid risk of spreading cells)
      • Examination of inguinal lymph nodes for staging
  69. Testicular Cancer, cont.
    • Treatment:
      • Depends on type of cancer
        • Removal of affected tissue
        • Seminomas are sensitive to radiation
        • Non-seminomas treated with chemotherapy
        • Survival rates are generally good
    • Massage?
      • Accommodate for risks of chemotherapy, radiation
      • Can improve tolerance to treatment stresses
      • Work with health care team for best benefits, minimal risks
  70. Menopause
    • The moment the ovaries stop secreting enough hormones to maintain a menstrual cycle
      • Perimenopause is term for symptoms leading up to menopause
    • Incidence:
      • All women go through it if they live long enough
        • Average age at onset is 47.5; completion at 51.4
        • 40 million women in the United States are postmenopausal
        • By 2020, 46 million will be postmenopausal
  71. Menopause, cont.
    • Hormones from ovaries work to establish menstrual cycle, other functions:
        • Bone density
          • Estrogen inhibits osteoclasts; progesterone stimulates osteoblasts
        • Cardiovascular health
          • Mechanism for influence on triglycerides, LDLs not understood; HRT does not work in the way it was assumed
        • Protection from some types of cancer
          • High estrogen associated with low colorectal cancer, increased risk of breast, ovarian cancer
        • Central nervous system function
          • Hormones influence mood, depression, cognitive function
  72. Menopause, cont.
    • As ovaries lose function, hormonal ratios shift
      • Estrogen, progesterone continue to be made in fat cells, but in wider difference
      • Environmental estrogens tip the scales too
    • Signs and symptoms:
      • Not identified until a full year after last menstrual cycle
        • Symptoms brought about by changing hormone levels (perimenopause):
          • hot flashes, night sweats, insomnia, mood swings, confusion, short-term memory loss, poor concentration, bone thinning, increased risk of heart disease
  73. Menopause, cont.
    • Treatment:
      • By symptoms
      • Hormone replacement therapy (HRT)
        • Combinations of estrogen and progesterone, depending on history of hysterectomy
        • Actually increases risk of heart disease, some cancers if used for more than 2 years
      • Topical applications of hormone (progesterone) cream
  74. Menopause, cont.
    • Massage?
      • No contraindications if osteoporosis, heart disease are ruled out
        • Can be supportive, nurturing, affirming activity during a time of shifting self-perception
  75. Menopause, cont.
    • Hormone replacement therapy
      • Women’s Health Initiative studied 160,000+ women on HRT to gather statistics about osteoporosis, cardiovascular disease
    37 % Decreased Colorectal cancer 33 % Decreased Hip fractures 105 % Increased Dementia 111 % Increased Blood clot: leg or lung 41 % Increased Stroke 26 % Increased Breast cancer 29% Increased Heart attack
  76. Sexually Transmitted Diseases, cont.
    • Syphilis ( Treponema pallidum )
      • Approximately 32,000 diagnoses/year (recent decrease)
      • Spirochetal bacterial infection
        • Spread through intimate contact (stages I and II) and from mother–child
        • Travels through blood, affects other tissues, including CNS
        • Increases risk of HIV transmission
      • Signs and symptoms (3 stages):
        • Primary: chancre (open ulcer); may be in vaginal canal
        • Secondary: rash, often on hands or feet
        • Tertiary: (only 1/3 go this far): bacteria affect bones, joints, blood vessels, brain
      • Treatment:
        • Single dose of penicillin
  77. Sexually Transmitted Diseases, cont.
    • Other STDs:
      • Nongonococcal urethritis : can be chlamydia, or related to other agents; treatable with antibiotics
      • Molluscum contagiosus virus : not always sexually transmitted, but can be an STD; appears on external genitalia, anus; treated with topical medication or cryotherapy
      • Genital warts ( condylomata acuminata ): from human papilloma virus; can lead to cervical cancer
  78. Sexually Transmitted Diseases, cont.
    • Massage?
      • Some STDs are spread by skin-to-skin contact (warts, syphilis, molluscum contagiosum); undiagnosed lesions contraindicate massage, and open lesions require the use of standard precautions
      • Most STDs are treated quickly and effectively with antibiotics; massage can be postponed until then
      • Clients with a history of STDs but no current infection are good candidates for massage

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