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G Y N E C O L O G I C N U R S I N G

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G Y N E C O L O G I C N U R S I N G

  1. 1. GYNECOLOGIC NURSING
  2. 2. TOPICS
  3. 3. SEXUALLY TRANSMITTED INFECTION
  4. 4. SEXUALLY TRANSMITTED DISEASES/INFECTION ( STD/STI) <ul><li>Trichomoniasis </li></ul><ul><li>Chlamydia </li></ul><ul><li>Gonorrhea </li></ul><ul><li>Syphilis </li></ul><ul><li>Herpes simplex </li></ul><ul><li>Condylomata acuminatum </li></ul>
  5. 5. TRICHOMONIASIS <ul><li>protozoan infection: Trichomonas vaginalis </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Frothy yellow-green malodorous vaginal discharge </li></ul><ul><li>“ strawberry” cervix </li></ul><ul><li>Vaginal irritation & inflammation </li></ul><ul><li>Dyspareunia </li></ul><ul><li>Dysuria </li></ul><ul><li>Vulvar itching </li></ul><ul><li>Among males: usually asymptomatic </li></ul>
  6. 9. TRICHOMONIASIS <ul><li>Diagnosis </li></ul><ul><li>microscopic exam of vaginal discharge </li></ul><ul><li>-positive motile flagellated protozoa in a saline wet mount </li></ul><ul><li>elevated vaginal pH 5.5+ (alkaline) </li></ul><ul><li>Management </li></ul><ul><li>Sexual partner should receive oral treatment. </li></ul><ul><li>Metronidazole (Flagyl) 500 mg BID for 7 days or a single 2 g dose (contraindicated during pregnancy) </li></ul>
  7. 10. <ul><li>Home Remedy </li></ul><ul><li>Acidic vaginal douche : 1 tablespoon vinegar with 1 liter water to counteract the alkaline environment of the vagina that favors the growth of Trichomonas vaginalis </li></ul><ul><li>A vaginal douche is a process of rinsing or cleaning the vagina by forcing water or another solution into the vaginal cavity to flush away vaginal discharge or other contents </li></ul><ul><li>Nursing interventions </li></ul><ul><li>Include sexual partner in treatment. </li></ul><ul><li>Advise use of condom during intercourse </li></ul><ul><li>Nursing alerts: </li></ul><ul><li>- Concurrent alcohol ingestion with Metronidazole causes severe GI symptoms (Antabuse-like reaction) </li></ul><ul><li>- Metronidazole is associated with preterm labor, premature rupture of membranes and postcesarean infection </li></ul>
  8. 11. CHLAMYDIA <ul><li>most common cause of mucopurulent cervicitis </li></ul><ul><li>most common bacterial STD in women </li></ul><ul><li>caused by gram (-) bacterium Chlamydia trachomatis </li></ul><ul><li>Vertical transmission to newborns may result in conjunctivitis and otitis media </li></ul><ul><li>Tends to coincide with gonorrheal infection </li></ul><ul><li>IP: 2-10 days </li></ul><ul><li>Risk Factors </li></ul><ul><li>Sexual activity < 20 years </li></ul><ul><li>Multiple sexual partners </li></ul><ul><li>Lower socioeconomic status </li></ul><ul><li>(+) others STDs </li></ul>
  9. 14. <ul><li>Signs and symptoms </li></ul><ul><li>May be asymptomatic </li></ul><ul><li>Gray white/ yellowish vaginal discharge </li></ul><ul><li>Burning and itchiness </li></ul><ul><li>Bleeding between periods </li></ul><ul><li>Mucopurulent cervicitis </li></ul><ul><li>Painful and frequent urination </li></ul><ul><li>Diagnosis </li></ul><ul><li>(+) culture/ antigen detection test on cervical smear </li></ul><ul><li>Polymerase chain reaction (PCR) </li></ul>
  10. 16. <ul><li>Management </li></ul><ul><li>Doxycycline 100 mg PO BID for 7 days </li></ul><ul><li>(causes fetal long bone deformity if used in pregnancy) </li></ul><ul><li>Azithromycin (Zithromax) 1 g PO in a single dose </li></ul><ul><li>Erythromycin 500 mg QID for pregnant patient </li></ul><ul><li>Patient may also be treated for gonorrhea with a single IM shot of Ceftriaxone 250 mg </li></ul><ul><li>Infant treated with Erythromycin ophthalmic ointment </li></ul><ul><li>Nursing interventions </li></ul><ul><li>Client teaching: </li></ul><ul><li>Teach the importance of completing the course of antibiotic </li></ul><ul><li>Use condom during sex </li></ul><ul><li>Sexual partner should receive treatment </li></ul>
  11. 17. <ul><li>Complications </li></ul><ul><li>Pelvic inflammatory disease (PID) </li></ul><ul><li>Ectopic pregnancy </li></ul><ul><li>Fetus transmittal (vaginal birth); </li></ul><ul><ul><li>may cause conjunctivitis </li></ul></ul><ul><li>(also associated with premature rupture of membranes, preterm labor and endometriosis, low birth weight and perinatal mortality due to placental transmission) </li></ul>
  12. 19. GONORRHEA <ul><li>Morning drop, Clap </li></ul><ul><li>Sexually transmitted disease caused by gram (-) Neisseria gonorrhea, which causes inflammation of the mucus membrane of the genito urinary tract </li></ul><ul><li>IP: 3-7 days </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Females: may be asymptomatic; may have purulent vaginal discharge, pelvic pain and fever; dyspareunia </li></ul><ul><li>Males: Painful urination ; purulent yellow penile discharge; urethritis </li></ul><ul><li>(decreased sperm count) </li></ul><ul><li>Newborn: yellow discharge, both eyes </li></ul>
  13. 20. <ul><li>Diagnosis </li></ul><ul><li>gram stain and culture of cervical secretions on Thayer Martin medium </li></ul><ul><li>Complications </li></ul><ul><li>PID </li></ul><ul><li>ectopic pregnancy </li></ul><ul><li>infertility </li></ul><ul><li>Chorioamnionitis </li></ul><ul><li>ophthalmia neonatorum in newborns (a ssociated with severe eye infection and blindness) </li></ul><ul><li>preterm delivery </li></ul><ul><li>sterility & pelvic inflammatory disease </li></ul>
  14. 23. <ul><li>Management (single dose only) </li></ul><ul><li>Ceftriaxone (Rocephin) 125 mg IM (drug of choice for pregnant women) </li></ul><ul><li>Ofloxacin (Floxin) 400 mg orally </li></ul><ul><li>Treat concurrently with Doxycycline or Azithromycin for 50% infected w/ Chlamydia </li></ul><ul><li>Ophthalmic ointment is routinely given as Crede’s prophylaxis to prevent opthalmia neonatorum </li></ul><ul><li>(0.5% Erythromycin or 1% Tetracycline ointment for newborn babies) </li></ul>
  15. 26. <ul><li>Nursing interventions </li></ul><ul><li>Health Teachings: </li></ul><ul><li>Avoid sexual intercourse until cured of the infection or use condom to prevent transmitting the infection. </li></ul><ul><li>Examination and treatment of sexual partner to prevent reinfection is necessary. </li></ul><ul><li>Return to clinic for check-up in 4 to 7 days after completion of treatment. </li></ul><ul><li>Monitor treatment </li></ul>
  16. 27. SYPHILIS <ul><li>caused by motile anaerobic spirochete Treponema pallidum </li></ul><ul><li>“ beautiful” fast moving but delicate spiral thread </li></ul><ul><li>can cross the placental barrier </li></ul><ul><li>IP: 10-90 DAYS </li></ul><ul><li>can cause 100% fetal infection if primary and secondary infection is untreated, and 6-14% fetal infection in latent syphilis </li></ul><ul><li>2 nd trimester infections cause spontaneous abortion, preterm labor, stillbirth and congenital anomalies </li></ul><ul><li>3 rd trimester infection causes enlarged liver, spleen, skin rash and jaundice in a newborn </li></ul>
  17. 28. <ul><li>Signs and Symptoms </li></ul><ul><li>Primary Stage - painless chancre on genitalia, anus or mouth; most infectious stage </li></ul><ul><li>Secondary Stage - about 2 months after primary syphilis resolves; generalized maculopapular skin rash including palms and soles </li></ul><ul><li>- painless condylomata lata on vulva </li></ul><ul><li>- hepato/ splenomegaly </li></ul><ul><li>- headache; anorexia; fever </li></ul><ul><li>Latent syphilis – asymptomatic </li></ul><ul><li>Tertiary Stage –most destructive stage; neurosyphilis/permanent damage (insanity); gumma (necrotic granulomatous lesions), aortic aneurysm </li></ul>
  18. 29. Primary – painless chancre Secondary – generalized rash Tertiary - gumma
  19. 30. PRIMARY
  20. 38. SECONDARY
  21. 40. TERTIARY
  22. 43. <ul><li>Diagnosis </li></ul><ul><li>VDRL (venereal disease research laboratory test) or RPR (rapid plasmin reagin) – nonspecific tests </li></ul><ul><li>- for screening and to follow treatment course (decrease fourfold in 3-6 months) </li></ul><ul><li>Fluorescent Treponemal Antibody AbsorptionTest </li></ul><ul><li>(FTA-ABS) or Microhemagglutination Assay for Antibodies to TP (MHA-TP)– specific tests for syphilis </li></ul><ul><li>Dark-field microscopic examination of lesion- 1 st and 2 nd stage </li></ul>
  23. 44. <ul><li>Management </li></ul><ul><li>Primary and secondary and early latent disease - Pen G (Benzathine Penicillin G 2.4 M U IM) </li></ul><ul><li>- Alternatives: Tetracycline 500 mg orally QID or Doxycycline 100 mg orally BID </li></ul><ul><li>Tertiary - IV Pen G </li></ul><ul><li>Erythromycin & Cefriaxone are the drugs of choice for pregnant women </li></ul><ul><li>Complications </li></ul><ul><li>Congenital syphilis in newborn if untreated in late pregnancy </li></ul><ul><li>Late abortion </li></ul><ul><li>Stillbirth </li></ul>
  24. 45. <ul><li>Health Teachings : </li></ul><ul><li>Educate women to recognize signs of syphilis. </li></ul><ul><li>Educate women to seek immediate treatment if known exposure occurs. </li></ul><ul><li>Encourage women to wear cotton underwear. </li></ul><ul><li>Use condom during intercourse. </li></ul>
  25. 46. <ul><li>Sexual partners must also be treated to prevent re-infection . </li></ul><ul><li>No sexual intercourse until lesions disappear </li></ul><ul><li>After completion of treatment, the woman is treated monthly & the sexual partner at 3 months, 6 mos & 12 mos. </li></ul><ul><li>Fetus will not be affected if the mother is treated before the 5 th month. Emphasize the importance of screening for syphilis during the first prenatal visit for early detection & treatment. </li></ul><ul><li>Inform patients treated with penicillin about Jarish Herxheimer reaction, a reaction to penicillin characterized by: fever, chills, malaise, headache, nausea, & tachycardia. This is a normal reaction that subsides within 24 hours. </li></ul>
  26. 47. HERPES GENITALIS <ul><li>Sexually transmitted disease caused by the Herpes Simplex Virus 2 (HSV 2) </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Flulike symptoms (malaise, myalgia, nausea, fever) </li></ul><ul><li>Vulvar burning and pruritus </li></ul><ul><li>Painful vesicles (cervix, vagina, perineum, glans penis) 2 - 20 days after exposure </li></ul><ul><li>Painful genital ulcer </li></ul><ul><li>Recurrent episodes 1-6x a year (during stress, fever, menstruation) </li></ul><ul><li>Dyspareunia </li></ul><ul><li>Diagnosis </li></ul><ul><li>Viral culture </li></ul><ul><li>Pap smear (shows cellular changes) </li></ul><ul><li>Tzanck smear (scraping of ulcer for staining) – multinucleated giant cells </li></ul>
  27. 48. <ul><li>Management </li></ul><ul><li>Antiviral agents – Acyclovir 200 mg PO q 4 hrs for 5 days </li></ul><ul><li>Sitz bath </li></ul><ul><li>Analgesics </li></ul>
  28. 51. <ul><li>Complications: </li></ul><ul><li>Meningitis </li></ul><ul><li>Neonatal infection (vaginal birth) </li></ul><ul><li>Trigeminal herpes zoster </li></ul><ul><li>(facial muscle paralysis) </li></ul><ul><ul><li>Health teachings </li></ul></ul><ul><ul><li>NO sexual activity in the presence of lesions and 10-14 days after lesions subsided </li></ul></ul><ul><ul><li>Keep vulva clean and dry in the presence of lesions (wearing of cotton underwear) </li></ul></ul><ul><ul><li>Sitz bath </li></ul></ul><ul><ul><li>use foley catheter if retention persists </li></ul></ul><ul><ul><li>Povidone- iodine douche and acyclovir NOT used during pregnancy </li></ul></ul>
  29. 52. CONDYLOMA ACUMINATUM <ul><li>Genital warts </li></ul><ul><li>Genital or venereal warts caused by Human Papilloma Virus (HPV) </li></ul><ul><li>May be a precursor to cervical cancer </li></ul><ul><li>HPV types 6 & 11 – condyloma acuminatum </li></ul><ul><li>HPV types 16, 18 and 31 – cervical cancer </li></ul><ul><li>Signs and Symptoms: Single or multiple dry soft, fleshy painless (wartlike) growths on the vulva, vagina, cervix, urethra, or anal area; penis </li></ul><ul><li>Can evolve into larger cauliflower-like growths </li></ul><ul><li>Vaginal bleeding, discharge, odor and dyspareunia </li></ul>
  30. 53. <ul><li>Diagnosis </li></ul><ul><li>Clinical </li></ul><ul><li>Pap smear-shows cellular changes (koilocytosis) Acetic acid swabbing (will whiten lesion) </li></ul><ul><li>Management </li></ul><ul><li>Small lesions – treated topically with podophyllin or trichloroacetic acid </li></ul><ul><li>Larger lesions – ablated with cryotherapy, laser vaporization or surgical excision. </li></ul><ul><li>Recurrence rate : 20% </li></ul><ul><li>Complications </li></ul><ul><li>Neoplasia </li></ul><ul><li>Neonatal laryngeal </li></ul><ul><li>papillomatosis </li></ul><ul><li>(vaginal birth) </li></ul>
  31. 60. <ul><li>Health Teachings </li></ul><ul><li>Inform the patient that infection with the virus increases the incidence of CERVICAL CANCER </li></ul><ul><li>Therefore: Annual PAP smear is indicated </li></ul>
  32. 61. Pelvic Inflammatory Disease <ul><li>Caused by microorganisms colonizing endocervix ascending to endometrium and fallopian tubes </li></ul><ul><li>Due to sexually transmitted microorganisms ie Neisseria, Chlamydia, Haemophilus influenza, streptococci </li></ul>
  33. 62. Risk Factors <ul><li>Multiple sexual partners </li></ul><ul><li>History of PID </li></ul><ul><li>Early onset sexual activity </li></ul><ul><li>Recent gyne procedure </li></ul><ul><li>IUD </li></ul>
  34. 63. Manifestations <ul><li>pelvic pain – sharp and cramping </li></ul><ul><li>Fever </li></ul><ul><li>Excessive vaginal discharge </li></ul><ul><li>Menorrhagia </li></ul><ul><li>Metrorrhagia </li></ul><ul><li>Urinary symptoms </li></ul><ul><li>Cervical uterine tenderness with movement </li></ul>
  35. 64. Diagnostics <ul><li>History and PE </li></ul><ul><li>CBC </li></ul><ul><li>Vaginal and endocervical culture </li></ul><ul><li>VDRL </li></ul><ul><li>Endometrial biopsy - endometritis </li></ul><ul><li>Sonography – tubo-ovarian abscess </li></ul><ul><li>Laparoscopy - salpingitis </li></ul>
  36. 65. Management <ul><li>Antibiotics </li></ul><ul><li>IV fluids/increase oral fluid </li></ul><ul><li>Pain medications </li></ul><ul><li>Remove IUD </li></ul><ul><li>Evaluation of sexual partners </li></ul>
  37. 66. Toxic Shock syndrome <ul><li>Reproductive age, near menses or postpartum period </li></ul><ul><li>D/t S. Aureus </li></ul><ul><li>R/t use of tampons, cervical cap or diaphragm </li></ul><ul><li>Manifestations: fever, rash on trunk, desquammation of skin, hypotension, dizziness, vomiting, diarrhea, myalgia, inflamed mucous membranes </li></ul>
  38. 67. <ul><li>Diagnostics: </li></ul><ul><li>Elev BUN, Crea </li></ul><ul><li>Elev AST, ALT, total bilirubin </li></ul><ul><li>Dec platelets </li></ul><ul><li>Management: </li></ul><ul><li>IV fluids </li></ul><ul><li>Antibiotics </li></ul><ul><li>renal dialysis </li></ul><ul><li>Client education – change tampons 3-6 hours, avoid tampons 6-8 wks after childbirth, do not leave diaphragms>48 hours </li></ul>
  39. 68. PMS
  40. 69. PREMENSTRUAL SYNDROME (PMS) <ul><li>it has such a wide variety of signs and symptoms. </li></ul><ul><ul><li>Mood swings, tender breasts, food cravings, fatigue, bloatedness, irritability and depression are among the most common symptoms of PMS. </li></ul></ul><ul><ul><li>Occurs during the 7-10 days before menstruation and disappear few hours after the onset of menstrual flow </li></ul></ul>
  41. 70. PREMENSTRUAL SYNDROME (PMS) <ul><li>CAUSES </li></ul><ul><ul><li>Unknown </li></ul></ul><ul><ul><li>Fluctuation in estrogen and progesteron </li></ul></ul>
  42. 71. PMS <ul><li>Treatment </li></ul><ul><ul><li>Symptomatic relief </li></ul></ul><ul><ul><li>Tranquilizer as prescribed </li></ul></ul><ul><ul><li>Dietary changes : increasing protein, decreasing sugar + vitamin B complex </li></ul></ul><ul><ul><li>counseling </li></ul></ul>
  43. 72. Treatments and drugs <ul><li>Antidepressants. </li></ul><ul><li>Nonsteroidal anti-inflammatory drugs (NSAIDs ). Taken before or at the onset of the period, </li></ul><ul><ul><li>NSAIDs such as ibuprofen (Advil, Motrin, others) or naproxen sodium (Aleve) can ease cramping and breast discomfort. </li></ul></ul><ul><li>Diuretics. swelling and bloating of PMS, taking diuretics, or water pills, can help your body shed excess water through your kidneys. </li></ul><ul><li>Oral contraceptives . stop ovulation and stabilize hormonal swings, </li></ul><ul><li>Medroxyprogesterone acetate (Depo-Provera).  used to temporarily stop ovulation. </li></ul>
  44. 73. Nursing care <ul><li>Patient education </li></ul><ul><ul><li>making changes in the way you eat, exercise and approach daily life. Try these approaches: </li></ul></ul><ul><ul><li>Modify your diet </li></ul></ul><ul><ul><ul><li>Eat smaller, more frequent meals each day to reduce bloating and the sensation of fullness. </li></ul></ul></ul><ul><ul><ul><li>Limit salt and salty foods to reduce bloating and fluid retention. </li></ul></ul></ul><ul><ul><ul><li>Choose foods high in complex carbohydrates, such as fruits, vegetables and whole grains. </li></ul></ul></ul><ul><ul><ul><li>Choose foods rich in calcium. If you can't tolerate dairy products or aren't getting adequate calcium in your diet, you may need a daily calcium supplement. </li></ul></ul></ul><ul><ul><ul><li>Take a daily multivitamin supplement. </li></ul></ul></ul><ul><ul><ul><li>Avoid caffeine and alcohol. </li></ul></ul></ul>
  45. 74. Nursing care <ul><li>Reduce stress </li></ul><ul><ul><li>Get plenty of sleep. </li></ul></ul><ul><ul><li>Practice progressive muscle relaxation or deep-breathing exercises to help reduce headaches, anxiety or trouble sleeping (insomnia). </li></ul></ul><ul><ul><li>yoga or massage as ways to relax and relieve stress. </li></ul></ul>
  46. 75. DYSMENORRHEA
  47. 76. Dysmenorrhea <ul><li>Is a menstrual condition characterized by severe and frequent menstrual cramps and pain associated with menstruation. </li></ul><ul><li>Dysmenorrhea may be classified as primary or secondary. </li></ul>
  48. 77. <ul><li>Primary dysmenorrhea (Functional)- cyclic pain associated with menses during ovulatory cycles but without demonstrable lesions affecting the reproductive structure </li></ul><ul><li>Secondary dysmenorrhea ( Acquired) - due to some physical cause and usually of later onset; painful menstrual periods caused by another medical condition present in the body (i.e., pelvic inflammatory disease, endometriosis). </li></ul>
  49. 78. What causes dysmenorrhea? <ul><li>The cause of dysmenorrhea depends on whether the condition is primary or secondary. </li></ul><ul><li>primary dysmenorrhea experience abnormal uterine contractions as a result of a chemical imbalance in the body (particularly prostaglandin and arachidonic acid - both chemicals which control the contractions of the uterus). </li></ul>
  50. 79. What causes dysmenorrhea? <ul><li>Secondary dysmenorrhea </li></ul><ul><ul><li>most often endometriosis </li></ul></ul><ul><ul><li>pelvic inflammatory disease (PID) </li></ul></ul><ul><ul><li>uterine fibroids </li></ul></ul><ul><ul><li>abnormal pregnancy (i.e., miscarriage, ectopic) </li></ul></ul><ul><ul><li>infection, tumors, or polyps in the pelvic cavity </li></ul></ul>
  51. 80. Who is at risk for dysmenorrhea? <ul><li>any female can develop dysmenorrhea </li></ul><ul><li>increased risk for the condition: </li></ul><ul><ul><li>females who smoke </li></ul></ul><ul><ul><li>females who drink alcohol during menses (alcohol tends to prolong menstrual pain) </li></ul></ul><ul><ul><li>females who are overweight </li></ul></ul><ul><ul><li>females who started menstruating before the age of 11 </li></ul></ul>
  52. 81. symptoms of dysmenorrhea <ul><li>Each adolescent may experience symptoms differently. </li></ul><ul><li>cramping in the lower abdomen </li></ul><ul><li>pain in the lower abdomen </li></ul><ul><li>low back pain </li></ul><ul><li>pain radiating down the legs </li></ul><ul><li>nausea </li></ul><ul><li>vomiting </li></ul><ul><li>diarrhea </li></ul><ul><li>fatigue </li></ul><ul><li>weakness </li></ul><ul><li>fainting </li></ul><ul><li>headaches </li></ul><ul><li>Start before or with menses and Peak 24Hrs and subsides after 2 days </li></ul>
  53. 82. Diagnosis <ul><li>Medical history and a complete physical examination </li></ul><ul><li>Pelvic examination. </li></ul><ul><li>ultrasound (Also called sonography.) – </li></ul><ul><li>magnetic resonance imaging (MRI) – </li></ul><ul><li>laparoscopy - a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic and abdomen area. </li></ul><ul><li>hysteroscopy - a visual examination of the canal of the cervix and the interior of the uterus using a viewing instrument (hysteroscope) inserted through the vagina. </li></ul>
  54. 83. Nursing care <ul><li>Patient education </li></ul><ul><li>Primary dysmenorrhea </li></ul><ul><ul><li>Assurance that her reproductive organ are normal  will give a physiologic support </li></ul></ul><ul><ul><li>prostaglandin inhibitors (i.e., nonsteroidal anti-inflammatory medications, or NSAIDs, such as aspirin, ibuprofen) - to reduce pain – given 24-48H before mense & continued through 1-2 days of the cycle </li></ul></ul><ul><ul><li>acetaminophen </li></ul></ul>
  55. 84. <ul><li>oral contraceptives (ovulation inhibitors) </li></ul><ul><li>progesterone (hormone treatment) </li></ul><ul><li>dietary modifications (to increase protein and decrease sugar and caffeine intake) </li></ul><ul><li>vitamin supplements </li></ul><ul><li>regular exercise </li></ul><ul><li>heating pad across the abdomen </li></ul><ul><li>hot bath or shower </li></ul><ul><li>abdominal massage </li></ul>
  56. 85. <ul><li>Secondary dysmenorrhea </li></ul><ul><ul><li>Relieved symptomatically or by correction of underlying abnormality </li></ul></ul><ul><ul><li>Counseling regarding symptoms may increase understanding and lead to activities for stress management. </li></ul></ul>
  57. 86. Endometriosis <ul><li>Endometrial tissue outside the uterine cavity. </li></ul><ul><ul><li>when cells from the uterus, called endometrial cells, are found outside the uterus. The cells attach to other organs. </li></ul></ul><ul><li>Pelvis most common location </li></ul><ul><li>Bleeding results to inflammation, scarring of peritoneum and adhesions </li></ul><ul><li>Cause unknown </li></ul><ul><li>Common in 20-45 yrs old </li></ul>
  58. 87. Endometriosis
  59. 88. Common Sites 0f Endometriosis Formation
  60. 90. Risk Factors: <ul><li>Retrograde menstrual flow of endometrium </li></ul><ul><li>Physiologic disruption after gyne surgery or cesarean birth </li></ul><ul><li>Hereditary </li></ul><ul><li>Possible immunologic effect </li></ul>
  61. 91. Manifestations: <ul><li>Pelvic pain – dull/cramping, r/t menstruation </li></ul><ul><li>Dyspareunia </li></ul><ul><li>Abnormal uterine bleeding </li></ul><ul><li>Fixed tender retroverted uterus </li></ul><ul><li>Palpable nodules in the cul de sac </li></ul><ul><li>Diagnostics: </li></ul><ul><li>laparoscopy </li></ul>
  62. 92. Management: <ul><li>OCP-combination contraceptives to induce amenorrhea </li></ul><ul><li>Analgesics </li></ul><ul><li>NSAIDS </li></ul><ul><li>Danazol – antiprogesterone; suppresses GnRH, low estrogen and high androgens to suppress ovulation, promote amenorrhea and decrease endometrial support </li></ul><ul><li>GnRH agonists ie leuprolide suppress the menstrual cycle through estrogen antagonism </li></ul><ul><li>Progestins ie Medroxyprogesterone – antiendometrial effect </li></ul>
  63. 93. AMENORRHEA <ul><li>Amenorrhea — the absence of menstruation — can happen during puberty or later in life. </li></ul><ul><li>2 types </li></ul><ul><ul><li>Primary amenorrhea describes a condition in which you haven't had any menstrual periods by age 16. </li></ul></ul><ul><ul><li>Secondary amenorrhea occurs when you were previously menstruating, but then stopped having periods. </li></ul></ul><ul><ul><ul><li>Pregnancy – most common </li></ul></ul></ul>
  64. 94. Symptoms <ul><li>No menstrual period </li></ul><ul><li>Primary amenorrhea. You have no menstrual period by age 16. </li></ul><ul><li>Secondary amenorrhea. You have no periods for three to six months or longer. </li></ul><ul><li>Depending on the cause of amenorrhea, </li></ul><ul><ul><li>milky nipple discharge </li></ul></ul><ul><ul><li>headache </li></ul></ul><ul><ul><li>vision changes </li></ul></ul><ul><ul><li>excessive hair growth on your face and torso (hirsutism). </li></ul></ul>
  65. 95. Causes Primary amenorrhea <ul><li>Affects less than 1 percent of adolescent girls </li></ul><ul><li>The most common causes of primary amenorrhea include: </li></ul><ul><li>Chromosomal abnormalities. </li></ul><ul><li>Problems with the hypothalamus . </li></ul><ul><ul><li>Functional hypothalamic amenorrhea is a disorder of the hypothalamus — an area at the base of the brain that acts as a control center for the body and regulates the menstrual cycle. </li></ul></ul><ul><ul><li>Excessive exercise, eating disorders, such as anorexia, and physical or psychological stress can all contribute to a disruption in the normal function of the hypothalamus. </li></ul></ul><ul><ul><li>Less commonly, a tumor may prevent your hypothalamus from functioning normally. </li></ul></ul>
  66. 96. Causes Primary amenorrhea <ul><li>3 . Pituitary disease . The pituitary is another gland in the brain that's involved in regulating the menstrual cycle. A tumor or other invasive growth may disrupt the pituitary gland's ability to perform this function. </li></ul><ul><li>4 .Lack of reproductive organs . Sometimes problems arise during fetal development that lead to a baby girl being born without some major part of her reproductive system, such as her uterus, cervix or vagina. Because her reproductive system didn't develop normally, she won't have menstrual cycles. </li></ul><ul><li>5 .Structural abnormality of the vagina . An obstruction of the vagina may prevent visible menstrual bleeding. A membrane or wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix. </li></ul>
  67. 97. Causes : Secondary amenorrhea <ul><li>Secondary amenorrhea is much more common than primary amenorrhea. </li></ul><ul><li>Many possible causes of secondary amenorrhea exist: </li></ul><ul><ul><li>Pregnancy -most common cause of amenorrhea. </li></ul></ul><ul><ul><li>Contraceptives . Some women who take birth control pills may not have periods. When oral contraceptives are stopped, it may take three to six months to resume regular ovulation and menstruation. </li></ul></ul>
  68. 98. Causes : Secondary amenorrhea <ul><li>. </li></ul><ul><li>Breast-feeding . Mothers who breast-feed often experience amenorrhea. Although ovulation may occur, menstruation may not. Pregnancy can result despite the lack of menstruation. </li></ul><ul><li>Stress . Mental stress can temporarily alter the functioning of your hypothalamus —Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases. </li></ul>
  69. 99. Causes : Secondary amenorrhea <ul><li>. </li></ul><ul><li>Medication . antidepressants, antipsychotics, some chemotherapy drugs and oral corticosteroids </li></ul><ul><li>Illness. Chronic illness may postpone menstrual periods. As you recover, menstruation typically resumes. </li></ul><ul><li>Hormonal imbalance . A common cause of amenorrhea or irregular periods is polycystic ovary syndrome (PCOS). </li></ul><ul><ul><li>This condition causes relatively high and sustained levels of estrogen and androgen, a male hormone, rather than the fluctuating levels seen in the normal menstrual cycle. This results in a decrease in the pituitary hormones that lead to ovulation and menstruation. </li></ul></ul><ul><ul><li>PCOS is associated with obesity; amenorrhea or abnormal heavy uterine bleeding; acne and sometimes excess facial hair. </li></ul></ul>
  70. 100. Causes : Secondary amenorrhea <ul><li>Low body weight . </li></ul><ul><ul><li>interrupts many hormonal functions in your body, potentially halting ovulation. Women who have an eating disorder, such as anorexia or bulimia, </li></ul></ul><ul><ul><li>Excessive exercise. Women who participate in sports that require rigorous training, such as ballet, long-distance running or gymnastics, may find their menstrual cycle interrupted. </li></ul></ul><ul><ul><li>Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress and high energy expenditure. </li></ul></ul><ul><li>Thyroid malfunction . </li></ul><ul><ul><li>hypothyroidism commonly causes menstrual irregularities, including amenorrhea. </li></ul></ul><ul><ul><li>Thyroid disorders can also cause an increase or decrease in the production of prolactin — a reproductive hormone generated by the pituitary gland. </li></ul></ul><ul><ul><li>An altered prolactin level can affect the hypothalamus and disrupt the menstrual cycle. </li></ul></ul>
  71. 101. Causes : Secondary amenorrhea <ul><li>Pituitary tumor . </li></ul><ul><ul><li>A noncancerous (benign) tumor in the pituitary gland (adenoma or prolactinoma) can cause an overproduction of prolactin. Excess prolactin can interfere with the regulation of menstruation. This type of tumor is treatable with medication, but it sometimes requires surgery. </li></ul></ul><ul><li>Uterine scarring . </li></ul><ul><ul><li>Asherman's syndrome, a condition in which scar tissue builds up in the lining of the uterus, </li></ul></ul><ul><ul><li>occur after uterine procedures, such as a dilation and curettage (D and C) </li></ul></ul><ul><ul><li>Caesarean section or treatment for uterine fibroids. </li></ul></ul><ul><ul><li>Uterine scarring prevents the normal buildup and shedding of the uterine lining, which can result in very light menstrual bleeding or no periods at all. </li></ul></ul>
  72. 102. Causes : Secondary amenorrhea <ul><li>Premature menopause. </li></ul><ul><ul><li>Menopause usually occurs between ages 45 and 55. </li></ul></ul><ul><ul><li>If menopause before age 40,  premature. </li></ul></ul><ul><ul><ul><li>The lack of ovarian function associated with menopause decreases the amount of circulating estrogen in the body, which in turn thins the uterine lining (endometrium) and brings an end to the menstrual periods. </li></ul></ul></ul><ul><ul><ul><li>Premature menopause may result from genetic factors or autoimmune disease, but often no cause can be found. </li></ul></ul></ul>
  73. 103. Nursing care <ul><li>Patient education </li></ul><ul><ul><li>For primary or secondary amenorrhea, consult : </li></ul></ul><ul><ul><ul><li>never had a menstrual period, and you're age 16 or older </li></ul></ul></ul><ul><ul><ul><li>previously menstruated, but have missed three or more periods in a row </li></ul></ul></ul>
  74. 104. Tests and diagnosis <ul><li>Not life threatening </li></ul><ul><li>Finding the underlying cause and may require more than one kind of testing. </li></ul><ul><li>History and physical assessment </li></ul><ul><li>pregnancy test. </li></ul><ul><li>perform a pelvic exam </li></ul><ul><li>In young women, check for signs and symptoms of changes that are normal to puberty. </li></ul>
  75. 105. Tests and diagnosis <ul><li>Blood tests </li></ul><ul><ul><li>hormone levels, </li></ul></ul><ul><ul><li>thyroid function test or evaluation of prolactin level. </li></ul></ul><ul><ul><li>A progestin challenge test — in which they take a hormonal medication (progesteron) for seven to 10 days to trigger bleeding </li></ul></ul><ul><li>Imaging tests </li></ul><ul><ul><li>computerized tomography </li></ul></ul><ul><ul><li>magnetic resonance imaging </li></ul></ul><ul><ul><li>ultrasound, can reveal pituitary tumors or structural abnormalities in your reproductive organs. </li></ul></ul><ul><ul><li>laparoscopy or hysteroscopy — minimally invasive surgical techniques to view the internal organs — may sometimes be recommended. </li></ul></ul>
  76. 106. Nursing care <ul><li>if any — depends on what's causing the amenorrhea. </li></ul><ul><ul><li>suggest that they make changes to their lifestyle depending on their weight, physical activity or stress level. </li></ul></ul><ul><ul><li>If with PCOS or athletic amenorrhea, may prescribe oral contraceptives to treat the problem. </li></ul></ul><ul><ul><li>Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. </li></ul></ul>
  77. 107. DYSFUNCTIONAL UTERINE BLEEDING ( DUB) <ul><li>is the most common cause of abnormal vaginal bleeding during a woman's reproductive years. </li></ul><ul><li>The diagnosis of DUB should be used only when other organic and structural causes for abnormal vaginal bleeding have been ruled out. </li></ul>
  78. 108. <ul><li>AUB- diagnosis referring to any uterine bleeding that is irregular in amount, duration, or timing </li></ul><ul><ul><li>DUB- most common type of AUB and is frequently defined as irregular uterine bleeding unrelated to organic pathology, medication, pregnancy related disorders, systemic condition, </li></ul></ul>
  79. 109. <ul><li>causes of AUB: </li></ul><ul><li>1. pregnancy-ectopic, spontaneos abortion </li></ul><ul><li>2.endocrine problem- cushing syndrome,diabetes </li></ul><ul><li>3.medication-amphetamines,anticoagulants,steroids,INH,SSRIs </li></ul><ul><li>4. systemic dse.- thyroid dysfunction,leukemia,ITP </li></ul>
  80. 110. <ul><li>Types: </li></ul><ul><ul><li>1.anovulatory DUB- due to lack of progesterone in the luteal phase of anovulatory cycles leads to unstable ,excessively vascular endometrium, often lead to abnormal cycle interval, or abnormal amount of bleeding </li></ul></ul><ul><ul><li>2. ovulatory DUB- are regular and tend to be cyclic,although the bleeding pattern are often abnormal,menorrhagia is commonly observed and is commonly associated with pelvic pathology </li></ul></ul>
  81. 111. <ul><li>Causes of anovulation: </li></ul><ul><ul><li>Physiologic: </li></ul></ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul><ul><ul><ul><li>Lactation </li></ul></ul></ul><ul><ul><ul><li>Perimenarche </li></ul></ul></ul><ul><ul><ul><li>Perimenopause </li></ul></ul></ul><ul><ul><li>Pathologic causes: </li></ul></ul><ul><ul><ul><li>Hyperandrogenic disorder </li></ul></ul></ul><ul><ul><ul><li>Hyperprolactinemia </li></ul></ul></ul><ul><ul><ul><li>Extreme stress </li></ul></ul></ul>
  82. 112. <ul><li>s/sx: uterine bleeding </li></ul><ul><li>Physical Examination: </li></ul><ul><ul><li>1. pelvic examination </li></ul></ul><ul><ul><li>2.Speculum examination </li></ul></ul><ul><ul><li>3. bimanual examination </li></ul></ul>
  83. 113. <ul><li>Management:Goal:1. normalize the bleeding </li></ul><ul><li> 2. correct any anemia </li></ul><ul><li> 3. restore quality of life </li></ul><ul><li> 4.prevent cancer </li></ul><ul><li>1. medication – oral contraceptives </li></ul><ul><li> 2. surgery- D and C, Hysterectomy </li></ul>
  84. 114. <ul><li>Dysfunctional bleeding from the uterus can be described as follows: </li></ul><ul><li>Menorrhagia - Prolonged (>7 d) or excessive (>80 mL daily) uterine bleeding occurring at regular intervals </li></ul><ul><li>Metrorrhagia - Uterine bleeding occurring at irregular and more frequent than normal intervals </li></ul>
  85. 115. <ul><li>Menometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular and more frequent than normal intervals </li></ul><ul><li>Intermenstrual bleeding (spotting) - Uterine bleeding of variable amounts occurring between regular menstrual periods </li></ul><ul><li>Polymenorrhea - Uterine bleeding occurring at regular intervals of less than 21 days </li></ul><ul><li>Oligomenorrhea - Uterine bleeding occurring at intervals of 35 days to 6 months </li></ul><ul><li>Amenorrhea - No uterine bleeding for 6 months or longer </li></ul>
  86. 116. Management <ul><li>pelvic ultrasonography. </li></ul><ul><li>Transvaginal ultrasonography (TVUS): if the patient may be pregnant or may have anatomic problems or polycystic ovarian syndrome. </li></ul><ul><li>D & C- can be both therapeutic and diagnostic. It may be the treatment of choice when bleeding is severe, and it allows more extensive sampling of the uterine cavity and also has a higher sensitivity than endometrial biopsy. </li></ul><ul><li>Hysteroscopy can be used in place of D&C and allows direct visualization of the endometrial cavity with directed biopsy. </li></ul>
  87. 117. <ul><li>Pelvic examination </li></ul><ul><li>Before instituting therapy, </li></ul><ul><ul><li>perform an endometrial sampling or endometrial biopsy to diagnose intrauterine pathology and to exclude endometrial malignancy. </li></ul></ul><ul><li>Perform endometrial biopsy for the following patients: </li></ul><ul><ul><li>All patients older than 35 years </li></ul></ul><ul><ul><li>Obese patients </li></ul></ul><ul><ul><li>Patients with diabetes mellitus </li></ul></ul><ul><ul><li>Patients with hypertension </li></ul></ul><ul><ul><li>Patients with suspected polycystic ovarian disease </li></ul></ul>
  88. 118. <ul><li>D&C is indicated in the following situations: </li></ul><ul><ul><li>Consider D&C in patients at high risk for endometrial hyperplasia and carcinoma. </li></ul></ul><ul><ul><li>Consider D&C rather than endometrial biopsy if suspected diagnosis is endometritis, atypical hyperplasia, or carcinoma. </li></ul></ul><ul><ul><li>Perform in patients having heavy, uncontrolled bleeding. </li></ul></ul><ul><ul><li>Perform if histologic examination is required but biopsy is contraindicated. </li></ul></ul><ul><ul><li>Perform if medical curettage fails. </li></ul></ul>
  89. 119. <ul><li>Medical management </li></ul><ul><ul><li>Estrogen therapy </li></ul></ul><ul><ul><ul><li>Conjugated estrogen ( 10 mg/day) controls most acute bleeding in 24hrs </li></ul></ul></ul><ul><ul><li>Progestin Therapy ( Provera) </li></ul></ul><ul><ul><li>Both hormones is continued 7-10 days </li></ul></ul><ul><li>For acute profuse DUB </li></ul><ul><ul><li>Parenteral estrogen-  bleeding stop in 12Hrs </li></ul></ul><ul><ul><li>Progestin must be started at the same time </li></ul></ul><ul><li>Oral contraceptive for 3 months to prevent recurrence </li></ul>
  90. 120. Nursing care <ul><li>Physical assessment & history </li></ul><ul><li>Monitor vital sign </li></ul><ul><li>Monitor bleeding </li></ul><ul><li>Monitor I & O </li></ul><ul><li>Administer IVF as prescribed </li></ul><ul><li>Nursing priority : Bleeding </li></ul><ul><li>Informed consent for the procedure </li></ul><ul><li>Emotional support </li></ul>
  91. 121. Disturbance in sexuality to women Dyspareunia Vaginismus
  92. 122. What is Dyspareunia? <ul><li>Vaginal pain after sexual intercourse. </li></ul><ul><li>Painful sexual intercourse. </li></ul>
  93. 123. TYPES Dyspareunia <ul><li>Superficial dyspareunia: Pain or dysfunction felt upon initial penetration </li></ul><ul><li>Deep dyspareunia: Pain or dysfunction felt deep within the pelvis during intercourse </li></ul>
  94. 124. CAUSES Dyspareunia <ul><li>Poor vaginal lubrication </li></ul><ul><li>Reduced libido </li></ul><ul><li>Reduced estrogen </li></ul><ul><li>Vaginal dryness </li></ul><ul><li>Inadequate foreplay </li></ul><ul><li>Menopause </li></ul><ul><li>Perimenopause </li></ul><ul><li>Lactation - causes vaginal dryness </li></ul>
  95. 125. Dyspareunia <ul><li>Post-childbirth </li></ul><ul><ul><li>Episiotomy - if performed for childbirth </li></ul></ul><ul><li>Vaginal infection </li></ul><ul><li>Cystitis </li></ul><ul><li>Urethritis </li></ul><ul><li>Vaginal infection </li></ul><ul><li>Vulva infection </li></ul><ul><li>Atrophic vaginitis </li></ul><ul><li>Vaginal changes from childbirth </li></ul>
  96. 126. CAUSES Dyspareunia <ul><li>Narrow vaginal </li></ul><ul><ul><li>Hymen </li></ul></ul><ul><li>Psychological disorders </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><li>Vaginismus </li></ul><ul><li>Endometriosis </li></ul><ul><li>Hemorrhoids </li></ul>
  97. 127. CAUSES Dyspareunia <ul><li>Pelvic infection </li></ul><ul><ul><li>Pelvic inflammatory disease </li></ul></ul><ul><li>Genital tract tumor </li></ul><ul><ul><li>Vaginal tumors </li></ul></ul><ul><ul><li>Vaginal surgery </li></ul></ul><ul><li>Pelvic disorders </li></ul><ul><li>Sexual organ disorders </li></ul><ul><li>Some causes of deep penetration intercourse pain in women include: </li></ul><ul><ul><li>Pelvic inflammatory disease </li></ul></ul><ul><ul><li>Pelvic tumor </li></ul></ul><ul><ul><li>Irritable bowel syndrome </li></ul></ul>
  98. 128. MANAGEMENT Dyspareunia <ul><li>History and physical examination with pelvic and rectal exams – Timing : Onset (e.g., upon entry, after intercourse), duration, persistence after intercourse, prior occurrence(s) – Associations : Symptoms may occur with all vaginal or vulvar contact, with intercourse only, with exams only, with masturbation, or with memories or recollections of prior occurrences or traumatic experiences – Alleviating and aggregating factors during intercourse – Qualifiers : Burning, sharp, dull, aching, throbbing, stabbing –Include complete psychiatric history and exam </li></ul>
  99. 129. Dyspareunia <ul><li>Routine studies include a CBC, sedimentation rate, urinalysis, urine culture and sensitivity, and vaginal smear and culture. </li></ul><ul><li>A Pap smear should also be done. </li></ul><ul><li>If pregnancy is suspected, a pregnancy test should be done. </li></ul><ul><li>If there is a pelvic mass, pelvic ultrasound may be helpful. </li></ul>
  100. 130. MANAGEMENT Dyspareunia <ul><li>Imaging studies </li></ul><ul><ul><li>pelvic and/or abdominal ultrasound and/or CT scan </li></ul></ul><ul><li>Management of psychiatric causes is particularly challenging and requires specific and specialized therapy </li></ul><ul><li>Consider gynecology and/or psychiatry consult </li></ul>
  101. 131. TREATMENT Dyspareunia <ul><li>Treatment varies depending on etiology </li></ul><ul><li>Psychological causes may require counseling with behavioral feedback and/or pharmacological treatment </li></ul><ul><li>Symptoms refractory to initial treatment of proper duration require prompt reconsideration and further workup </li></ul><ul><li>Referral may be necessary for specialized cases or cases with psychiatric components </li></ul>
  102. 132. Vaginismus: <ul><li>Vaginal entrance muscle spasms triggered by sex </li></ul><ul><li>Involuntary contraction of muscle at the outlet of the vagina when coitus is attempted prohibiting penile penetration. </li></ul>
  103. 133. CAUSES <ul><li>Fear of sex </li></ul><ul><li>Unpleasant sexual experience </li></ul><ul><li>Negative attitude to sex </li></ul>
  104. 134. TREATMENT PSYCHOLOGICAL COUNSELLING
  105. 135. Prognosis of Vaginismus Most women recover to normal sex life and motherhood with treatment.
  106. 136. SEXUAL DYSFUNCTION IN MALE Erectile dysfunction impotence
  107. 137. Erectile dysfunction ( impotence) <ul><li>Inability of the man to produce or maintain erection , long enough for vaginal penetration or partner satisfaction. </li></ul><ul><li>Formerly called impotence </li></ul>
  108. 138. Causes: Erectile dysfunction ( impotence) <ul><li>Physical cause </li></ul><ul><li>Common causes of erectile dysfunction include: </li></ul><ul><ul><li>Heart disease </li></ul></ul><ul><ul><li>Clogged blood vessels (atherosclerosis) </li></ul></ul><ul><ul><li>High blood pressure </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Metabolic syndrome </li></ul></ul>
  109. 139. Causes: Erectile dysfunction ( impotence) <ul><li>Other causes of erectile dysfunction include: </li></ul><ul><ul><li>Certain prescription medications -antidepressants, antihistamines and medications to treat high blood pressure, pain and prostate cancer </li></ul></ul><ul><ul><li>Tobacco use </li></ul></ul><ul><ul><li>Alcoholism and other forms of drug abuse </li></ul></ul><ul><ul><li>Treatments for prostate cancer </li></ul></ul><ul><ul><li>Parkinson's disease </li></ul></ul><ul><ul><li>Multiple sclerosis </li></ul></ul><ul><ul><li>Hormonal disorders such as low testosterone (hypogonadism) </li></ul></ul><ul><ul><li>Surgeries or injuries that affect the pelvic area or spinal cord </li></ul></ul>
  110. 141. <ul><li>Psychological causes of erectile dysfunction </li></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Poor communication or conflict with your partner </li></ul></ul>
  111. 142. <ul><li>Psychological causes of erectile dysfunction The brain plays a key role in triggering the series of physical events that cause an erection, beginning with feelings of sexual excitement. A number of things can interfere with sexual feelings and lead to — or worsen — erectile dysfunction. These can include: </li></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Poor communication or conflict with your partner </li></ul></ul>
  112. 143. <ul><li>Ultrasound . This test can check blood flow to your penis. </li></ul><ul><li>Neurological evaluation. </li></ul><ul><li>Dynamic infusion cavernosometry and cavernosography (DICC). </li></ul><ul><ul><li>This procedure involves injecting a dye into penile blood vessels to permit view any possible abnormalities in blood pressure and flow into and out of your penis. It's generally done with local anesthesia by a urologist who specializes in erectile dysfunction. </li></ul></ul><ul><li>Nocturnal tumescence test. </li></ul><ul><ul><li>A simple test that involves wrapping a special perforated tape around the penis before going to sleep can confirm whether you have erections while you're sleeping. If the tape is separated in the morning, your penis was erect at some time during the night. Tests of this type confirm that there is not a physical abnormality causing erectile dysfunction, and that the cause is likely psychological. </li></ul></ul>
  113. 144. <ul><li>Oral medications Oral medications available to treat ED include: </li></ul><ul><ul><li>Sildenafil (Viagra) </li></ul></ul><ul><ul><li>Tadalafil (Cialis) </li></ul></ul><ul><ul><li>Vardenafil (Levitra) </li></ul></ul><ul><li>ACTION : </li></ul><ul><ul><li>Chemically known as phosphodiesterase inhibitors, these drugs enhance the effects of nitric oxide, a chemical that relaxes muscles in the penis. This increases the amount of blood flow and allows a natural sequence to occur — an erection in response to sexual stimulation. </li></ul></ul>
  114. 145. <ul><li>Hormone replacement therapy For the small number of men who have testosterone deficiency , testosterone replacement therapy may be an option. </li></ul><ul><li>Penis pumps </li></ul><ul><ul><li>This treatment involves the use of a hollow tube with a hand-powered or battery-powered pump. The tube is placed over the penis, pump is used to suck out the air. This creates a vacuum that pulls blood into the penis. </li></ul></ul><ul><ul><li>Once you achieve an adequate erection, slip a tension ring around the base of the penis to maintain the erection. then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. remove the tension ring after intercourse. </li></ul></ul><ul><li>Vascular surgery This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. </li></ul><ul><ul><li>The goal of this treatment is to correct a blockage of blood flow to the penis so that erections can occur naturally. But the long-term success of this surgery is unclear. </li></ul></ul>
  115. 146. <ul><li>Penile pump </li></ul>Penis pump
  116. 147. <ul><li>Penile implants The inflatable device allows to control when and how long you have an erection, These implants consist of either an inflatable device or semirigid rods made from silicone or polyurethane. This treatment is often expensive and is usually not recommended until other methods have been considered or tried first. As with any surgery, there is a small risk of complications such as infection. </li></ul><ul><li>Psychological counseling and sex therapy </li></ul><ul><ul><li>Stress, anxiety or depression is the cause of erectile dysfunction </li></ul></ul><ul><ul><li>Counseling can help, especially when your partner participates. </li></ul></ul>
  117. 148. Penile implant
  118. 149. Nursing care <ul><li>Patient education </li></ul><ul><ul><li>Limit or avoid the use of alcohol. </li></ul></ul><ul><ul><li>Avoid illegal drugs such as marijuana. </li></ul></ul><ul><ul><li>Stop smoking. </li></ul></ul><ul><ul><li>Exercise regularly. </li></ul></ul><ul><ul><li>Reduce stress. </li></ul></ul><ul><ul><li>Get enough sleep. </li></ul></ul><ul><ul><li>Get help for anxiety or depression. </li></ul></ul><ul><ul><li>advised regular checkups and medical screening tests. </li></ul></ul><ul><li>Communicate with patient and partner openly </li></ul>
  119. 150. ANOMALIES & MALFORMATION OF THE REPRODUCTIVE ORGANS Imperforate hymen Congenital absence of vagina Septate vagina Uterine malformation
  120. 151. Imperforate hymen: <ul><li>Lack of opening in the vaginal hymen </li></ul><ul><li>occurring in 0.1% of infant girls. </li></ul><ul><li>No menstrual bleeding </li></ul><ul><li>Enlarged uterus </li></ul>
  121. 152. S/S <ul><li>Amenorrhoea </li></ul><ul><li>Cryptomenorrhea - A condition where menstrual products are prevented from exiting the body by a partial or complete obstruction. </li></ul><ul><li>Dyspareunia </li></ul><ul><li>Female infertility </li></ul><ul><li>Haematocolpos- An accumulation of menstrual blood in the vagina </li></ul><ul><li>Haematometra - An accumulation of blood in the uterus </li></ul><ul><li>Hematosalpinx </li></ul><ul><li>Hydrometrocolpos - accumulation of secretions in the vagina and uterus </li></ul>
  122. 153. <ul><li>Physical exam </li></ul><ul><li>Laboratory studies are not necessary in the evaluation and treatment of imperforate hymen. </li></ul><ul><li>Abdominal and pelvic ultrasonography and MRI </li></ul>
  123. 154. TREATMENT <ul><li>Medical therapy has no role in the management of imperforate hymen </li></ul><ul><li>SURGICAL MANAGEMENT </li></ul><ul><ul><li>Hymen incision </li></ul></ul>
  124. 155. CONGENITAL ABSENCE OF THE VAGINA
  125. 156. CONGENITAL ABSENCE OF THE VAGINA <ul><li>The usual lesion consists: </li></ul><ul><ul><li>absence of the middle and upper vagina, </li></ul></ul><ul><ul><li>total absence or a rudiment in the location of the uterus, </li></ul></ul><ul><ul><li>an absence or one or both Fallopian tubes. </li></ul></ul><ul><li>The vagina may be totally absent, or represented by a rudimentary pouch of up to one half to three quarters of an inch deep. </li></ul>
  126. 157. Vaginal agenesis
  127. 158. CONGENITAL ABSENCE OF THE VAGINA <ul><li>is a rare anomaly, 1: 5000 birth </li></ul><ul><li>Known also as aplasia or dysplasia of the Müllerian (paramesonephric) ducts. </li></ul><ul><li>Referred to as ROKITANSKY-KUSTER-HAUSER SYNDROME </li></ul><ul><li>The external genitalia and vestibule, deriving from the urogenital sinus, are normal. </li></ul><ul><li>The sex chromatin pattern is female. </li></ul><ul><li>endocrine system is not affected. </li></ul><ul><li>Ovarian function is normal </li></ul>
  128. 159. CONGENITAL ABSENCE OF THE VAGINA <ul><li>Cause : </li></ul><ul><ul><li>UNKNOWN </li></ul></ul><ul><ul><li>no known gene is linked to this condition. </li></ul></ul>
  129. 160. Diagnostic: <ul><li>Imaging studies </li></ul><ul><ul><li>UTZ </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>Laparoscopy provides only indirect assessment of uterine cavitation. </li></ul></ul><ul><ul><li>Laparoscopy is the preferred procedure when uterine remnants or endometriosis cause cyclic pelvic pain requiring excision. </li></ul></ul><ul><ul><li>Pyelography: Perform intravenous pyelography to assess renal structure. </li></ul></ul><ul><ul><li>Radiography: Perform spinal radiography to exclude vertebral anomalies </li></ul></ul>
  130. 161. Management <ul><li>Treatment : Surgical </li></ul><ul><ul><li>Vaginal reconstruction </li></ul></ul><ul><ul><ul><li>modified McIndoe vaginoplasty </li></ul></ul></ul><ul><li>Prognosis: </li></ul><ul><ul><li>The patient may have normal sexual functioning after surgical reconstruction. </li></ul></ul><ul><ul><li>Surgical reconstruction does not establish the ability to conceive through natural means. </li></ul></ul>
  131. 162. modified McIndoe vaginoplasty
  132. 163. DOUBLE / SEPTATE VAGINA vaginal septum is a congenital partition within the vagina; such a septum could be either longitudinal or transverse.
  133. 164. <ul><li>A longitudinal vaginal septum develops during embryogenesis when there is an incomplete fusion of the lower parts of the two mullerian ducts. </li></ul><ul><li>As a result there is a double vagina . </li></ul>
  134. 165. Transverse vaginal septum <ul><li>is a horizontal &quot;wall&quot; of tissue that has formed during embryologic development and essentially creates a blockage of the vagina. </li></ul><ul><li>It can occur at many different levels of the vagina. </li></ul>
  135. 166. Transverse vaginal septum <ul><li>large percentage of women with a transverse vaginal septum have a small hole, or fenestration, within the transverse vaginal septum so they may have regular menstrual periods, although the periods may last longer than the normal 4-7 day cycle. </li></ul>
  136. 167. Transverse vaginal septum <ul><li>complete obstruction without a hole within the transverse vaginal septum </li></ul><ul><ul><li>when having menstrual cycles there will be a blockage of blood which will collect in the upper vagina </li></ul></ul>
  137. 168. Treatment <ul><li>Manual dilatation or surgical excision </li></ul><ul><ul><li>require a surgical procedure to resect the fibrous septal tissue </li></ul></ul><ul><li>Complication: </li></ul><ul><ul><li>stenosis or scarring of the vagina in the area of the transverse vaginal septum which can create an &quot;hour-glass&quot; effect in the vagina. </li></ul></ul>
  138. 169. Nursing care: <ul><li>Informed consent of procedure </li></ul><ul><li>Patient Education </li></ul><ul><ul><li>Teach patient that after resection of the transverse vaginal septum, she is required to use a vaginal dilator in order to avoid this &quot;hour-glass&quot; effect of the healing process. </li></ul></ul><ul><ul><li>Once the transverse vaginal septum has been surgically corrected, tell her that she can be able to have normal sexual relations and should also have no long-term effects on reproductive function and the ability to have a child. </li></ul></ul><ul><li>Emotional support </li></ul>
  139. 171. UTERUS
  140. 172. NORMAL UTERUS <ul><li>The womb or uterus is a pear-shaped organ, tucked away in your pelvis. </li></ul><ul><li>It is 7.5cm long, 5cm wide and 2.5cm in depth. </li></ul><ul><li>Inside, it is hollow with thick muscular walls. </li></ul><ul><li>The lower third of the uterus hangs down into the vagina and is called the cervix. </li></ul><ul><li>The upper portion is called the fundus and this is where the fertilized egg grows into a baby. </li></ul>
  141. 173. <ul><li>Approximately 0.1-3.2 % of women have a uterine abnormality. Many women will have an abnormality without ever knowing anything about it, because it has no effect on their fertility or on their ability to give birth. </li></ul>
  142. 174. Uterine malformation Types classification: <ul><li>Class I: Mullerian agenesis (absent uterus). </li></ul><ul><li>Class II: Unicornuate uterus (a one-sided uterus). </li></ul><ul><li>Class III: Uterus didelphys , (double uterus). </li></ul><ul><li>Class IV: Bicornuate uterus (uterus with two horns). </li></ul>
  143. 175. <ul><li>Class V: Septated uterus (uterine septum or partition). </li></ul><ul><li>Class VI: DES uterus . </li></ul><ul><ul><li>The uterine cavity has a &quot;T-shape&quot; as a result of fetal exposure to diethylstilbestrol. </li></ul></ul>
  144. 177. unicornuate uterus <ul><li>(a womb with one 'horn') happens when the tissue that forms the womb does not develop properly. </li></ul><ul><li>very rare condition. </li></ul><ul><li>A unicornuate uterus is just half the size of a normal UTERUS and the woman has only one fallopian tube. However, she usually has two ovaries </li></ul>
  145. 178. Unicornuate uterus <ul><li>is smaller than a typical uterus and usually has only one functioning fallopian tube. The other side of the uterus may have what is called a rudimentary horn. </li></ul><ul><ul><li>a second smaller hemi-uterus which is obstructed </li></ul></ul>
  146. 179. <ul><li>If the rudimentary horn is obstructed, </li></ul><ul><ul><li>S/s </li></ul></ul><ul><ul><ul><li>an enlarging pelvic mass. </li></ul></ul></ul><ul><ul><ul><li>painful menses/perimenstrual pain </li></ul></ul></ul><ul><ul><ul><ul><li>obstructed uterus does not have a means for the blood to Regress or leave the body. This can result in pain. </li></ul></ul></ul></ul><ul><ul><li>If the contralateral healthy horn is almost fully developed, a full-term pregnancy is believed to be possible </li></ul></ul>
  147. 180. Unicornuate uterus Most of the time it does not cause any gynecologic or obstetric problem
  148. 181. Unicornuate uterus
  149. 182. DIAGNOSTIC <ul><li>Imaging studies </li></ul><ul><ul><li>Hysterosalpingography (HSG), performed under fluoroscopy, allows evaluation of the uterine cavity and tubal patency </li></ul></ul><ul><ul><li>Hysteroscopy </li></ul></ul><ul><ul><li>three-dimensional ultrasound </li></ul></ul><ul><ul><li>laparoscopy might also be used to confirm the diagnosis. </li></ul></ul>
  150. 183. RISK <ul><li>PRETERM LABOR-is thought to be because of space restrictions; because a unicornuate uterus is smaller than a typical uterus, the growth of the baby might trigger early labor. </li></ul><ul><li>MISCARRIAGE-due to abnormalities in the blood supply of the unicornuate uterus that might interfere with the functioning of the placenta </li></ul><ul><li>ECTOPIC PREGNANCY </li></ul><ul><ul><li>miscarriage in 37% </li></ul></ul><ul><ul><li>preterm birth in 16%, </li></ul></ul><ul><ul><li>term birth in only 45%. </li></ul></ul>
  151. 184. MANAGEMENT <ul><li>The resection of the obstructed hemi-uterus can be performed laparoscopically. </li></ul><ul><li>Nursing management: </li></ul><ul><ul><li>Informed consent </li></ul></ul><ul><ul><li>Explain the procedure </li></ul></ul><ul><ul><li>Monitor vital sign </li></ul></ul><ul><ul><li>Emotional support </li></ul></ul>
  152. 185. BICORNUATE UTERUS a type of congenital uterine malformation (müllerian duct abnormality). uterus is heart-shaped with two joined cavities whereas a typical uterus has a single cavity.
  153. 186. Cause <ul><li>This can happen to women whose mothers took a medication called DES during pregnancy, </li></ul><ul><li>it can happen for unknown reasons. </li></ul>
  154. 187. Diagnosing Bicornuate <ul><li>hysterosalpingogram (HSG) </li></ul><ul><li>hysteroscopy </li></ul><ul><li>but diagnosis should be confirmed with a three-dimensional ultrasound or laparoscopy. </li></ul>
  155. 188. Risk <ul><li>preterm labor </li></ul><ul><li>cervical insufficiency </li></ul><ul><li>many women with bicornuate uteri carry pregnancies to full term without any problems, so the risk may vary for each woman. </li></ul>
  156. 189. Management <ul><li>reconstructive laparoscopic </li></ul><ul><li>cervical cerclage, a stitch placed in the cervix to stop premature dilation </li></ul>
  157. 190. Double uterus <ul><li>Definition </li></ul><ul><li>In a female fetus, the uterus starts out as two small tubes. As the fetus develops, the tubes normally join to create one larger, hollow organ  the uterus. Sometimes, however, the tubes don't join completely. Instead, each one develops into a separate cavity. This condition is called double uterus (uterus didelphys). </li></ul>
  158. 191. Double uterus <ul><li>Each cavity in a double uterus often leads to its own cervix. Some women with a double uterus also have a duplicate or divided vagina. </li></ul><ul><li>Double uterus is rare — and sometimes not even diagnosed. </li></ul><ul><li>occurs in 2 %t to 4 % of women who have normal pregnancies. </li></ul><ul><li>The percentage may be higher in women with a history of miscarriage or premature birth. </li></ul><ul><li>Treatment is needed only if a double uterus causes symptoms or complications, such as pelvic pain or repeated miscarriages. </li></ul>
  159. 193. Symptoms <ul><li>Some women have a double uterus and never realize it — even during pregnancy and childbirth. </li></ul><ul><li>Possible signs and symptoms may include: </li></ul><ul><ul><li>A mass in the pelvis </li></ul></ul><ul><ul><li>Unusual pain before or during a menstrual period </li></ul></ul><ul><ul><li>Abnormal bleeding during a period, such as blood flow despite the use of a tampon </li></ul></ul>
  160. 194. Causes <ul><li>Unknown . </li></ul><ul><li>The condition is associated with kidney abnormalities, which suggests that something may influence the development of these related tubes before birth. </li></ul>
  161. 195. Tests and diagnosis <ul><li>routine pelvic exam  observes a double cervix or an unusually shaped uterus. </li></ul><ul><li>Magnetic resonance imaging (MRI). </li></ul><ul><li>Ultrasound. </li></ul><ul><li>Hysterosalpingography. a special dye is injected into the uterus through the cervix. Then X-rays are taken to determine the shape and size of the uterus. </li></ul>
  162. 196. <ul><li>Hysteroscopy. inserts a tiny tube with a light into the vagina and through the cervix. This allows to examine the inside of the uterus. </li></ul><ul><li>Laparoscopy. With this surgical procedure, a small incision beneath the navel and inserts a laparoscope — an illuminated, fiber-optic device — into the abdomen to examine the uterus. Laparoscopy requires general anesthesia. </li></ul>
  163. 197. Complications <ul><li>Many women with a double uterus have normal sex lives, pregnancies and deliveries. </li></ul><ul><li>sometimes a double uterus leads to infertility or miscarriage. </li></ul><ul><li>A double uterus may also cause premature birth or unusual positions of the baby in the uterus, such as breech presentation. </li></ul>
  164. 198. Nursing Care <ul><li>Patient Education </li></ul><ul><ul><li>If you have a double uterus but no signs or symptoms, treatment is rarely needed. </li></ul></ul><ul><ul><li>Surgery to unite a double uterus is rarely done — although other surgical procedures may help partial division within the uterus. </li></ul></ul><ul><ul><li>Advised importance of prenatal care to prevent Preterm labor or miscarriage. </li></ul></ul><ul><li>Emotional / psychological support </li></ul>
  165. 199. BICORNUATE UTERUS
  166. 200. BICORNUATE UTERUS
  167. 201. ANOMALIES WITH PROLAPSE CYSTOCELE RECTOCELE ENTEROCELE
  168. 202. <ul><li>Cystocele – protrusion of the bladder through the vaginal wall </li></ul><ul><ul><ul><ul><li>Assessment – interference with voiding and stress incontinence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Management includes Kegel’s exercises; surgery (anterior colporrhaphy) to surgically shorten the muscles that support the bladder </li></ul></ul></ul></ul>
  169. 203. <ul><li>Rectocele – protrusion of the rectum through the vaginal wall characterized by rectal pressure, heaviness, and hemorrhoids </li></ul>
  170. 204. Enterocele <ul><li>Prolapse of the small bowel into the wall of the vagina, usually caused by past damage to the pelvic floor muscle. </li></ul><ul><li>Herniation near the apex of the vagina between the major supporting uterosacral ligaments </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Bowel obstruction </li></ul></ul><ul><ul><li>Pelvic discomfort in presence of enterocoele due to </li></ul></ul><ul><ul><li>downward traction of viscera </li></ul></ul>
  171. 206. Causes of Enterocoele <ul><li>unknown although there seems to be an increased incidence associated with any other problems </li></ul><ul><li>trauma during parturition. </li></ul><ul><li>congenital inadequacy of endopelvic connective tissue. </li></ul><ul><li>chronic constipation. </li></ul>
  172. 207. Treatment <ul><li>Prevention </li></ul><ul><ul><li>pelvic floor exercises </li></ul></ul><ul><ul><li>avoid chronic constipation and straining </li></ul></ul><ul><ul><li>estrogen therapy </li></ul></ul><ul><li>Conservative </li></ul><ul><ul><li>pessaries (ring) </li></ul></ul><ul><ul><li>replace prolapse to reduce edema and cure ulceration </li></ul></ul><ul><li>Surgical measures </li></ul><ul><li>Vaginal </li></ul><ul><ul><li>Vaginal hysterectomy + Pelvic Floor Repair </li></ul></ul><ul><ul><li>Manchester [Fothergill] Repair + Pelvic Floor Repair </li></ul></ul><ul><ul><li>Le Fort’s operation </li></ul></ul><ul><li>Abdominal: Total abdominal hysterectomy & repair of </li></ul><ul><li>enterocoele [usually will also require vaginal repair]. </li></ul>
  173. 208. <ul><li>Nursing care </li></ul><ul><ul><li>well- ordered hygienic mode of living </li></ul></ul><ul><ul><li>a nutritious and bland diet </li></ul></ul><ul><ul><li>adequate mental and physical rest </li></ul></ul><ul><ul><li>daily exercise , agreeable, occupation, fresh air </li></ul></ul><ul><ul><li>regular hours of eating and sleeping </li></ul></ul><ul><ul><li>regulation of the bowels and wholesome companionship with others. </li></ul></ul>Enterocoele
  174. 209. Benign Lesions of the genital tract
  175. 210. Nabothian cyst <ul><li>Common findings </li></ul><ul><li>is a mucus-filled cyst on the surface of the uterine cervix. </li></ul><ul><li>appear most often as firm bumps on the cervix's surface. A woman may notice the cyst when inserting a diaphragm or cervical cap, or when doing the cervix check as part of fertility awareness </li></ul><ul><li>Cause is unknown </li></ul><ul><li>Diagnosis is made clinically </li></ul><ul><li>There are no symptoms </li></ul><ul><li>are not considered problematic unless they grow very large and present secondary symptoms </li></ul><ul><li>Treatment: no treatment </li></ul>
  176. 211. Cervical polyps <ul><li>Are a result of benign hyperplasia of the glandular tissue arising from the mucosa </li></ul><ul><li>Causes: unknown </li></ul><ul><li>most often occur in women older than 20 who have had several pregnancies </li></ul><ul><li>Symptoms : abnormal vaginal bleeding </li></ul><ul><ul><li>Between menstrual periods. </li></ul></ul><ul><ul><li>After menopause. </li></ul></ul><ul><ul><li>After sexual intercourse. </li></ul></ul><ul><ul><li>After douching. </li></ul></ul><ul><li>Treatment: removal of polyps </li></ul>
  177. 212. Uterine fibroids <ul><li>are noncancerous growths of the uterus that often appear during your childbearing years. </li></ul><ul><li>Also called fibromyomas, leiomyomas or myomas. </li></ul><ul><li>Types: subserosal( external surface of the uterus </li></ul><ul><li>intramural (within the myometrium) </li></ul><ul><li>submucosal (with in the endometrial layer) </li></ul>
  178. 213. symptoms <ul><li>Heavy menstrual bleeding </li></ul><ul><li>Prolonged menstrual periods or bleeding between periods </li></ul><ul><li>Pelvic pressure or pain </li></ul><ul><li>Urinary incontinence or frequent urination </li></ul><ul><li>Constipation </li></ul><ul><li>Backache or leg pains </li></ul>
  179. 214. CAUSE <ul><li>Genetic alterations . Many fibroids contain alterations in genes that code for uterine muscle cells. </li></ul><ul><li>Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and estrogen receptors than do normal uterine muscle cells. </li></ul><ul><li>Other chemicals . Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth. </li></ul>
  180. 215. DIAGNOSIS <ul><li>Pelvic examination </li></ul><ul><li>UTZ </li></ul>
  181. 217. Treatment <ul><li>Watchful waiting </li></ul><ul><li>Medications They don't eliminate fibroids, but may shrink them. Medications include: </li></ul><ul><ul><li>Gonadotropin-releasing hormone (Gn-RH) agonists. </li></ul></ul><ul><ul><li>Androgens :Danazol, </li></ul></ul><ul><ul><li>Oral contraceptives or progestins can help control menstrual bleeding, but they don't reduce fibroid size </li></ul></ul><ul><li>Hysterectomy </li></ul><ul><li>myomectomy </li></ul>
  182. 218. Benign Ovarian masses <ul><li>Ovarian cysts – physiologic variations in menstrual cycle </li></ul><ul><li>Dermoid cysts - (cystic teratomas) – cartilage, bone, teeth, skin or hair can be observed </li></ul><ul><li>Endometriomas (chocolate cysts) </li></ul>
  183. 219. Manifestations Benign Ovarian masses <ul><li>Sensation of fullness, cramping, dyspareunia, irregular bleeding </li></ul><ul><li>Diagnostics: </li></ul><ul><li>USG </li></ul><ul><li>Management: </li></ul><ul><li>OCP to suppress ovarian function </li></ul><ul><li>surgery </li></ul>
  184. 220. Leiomyoma <ul><li>Fibroid tumors </li></ul><ul><li>40 yrs old </li></ul><ul><li>Potential for cancer is minimal </li></ul><ul><li>Smooth muscle cells present in whorls and arise from uterine muscle </li></ul>
  185. 221. Manifestations <ul><li>Frequently asymptomatic </li></ul><ul><li>Lower abdominal pain </li></ul><ul><li>Fullness or pressure </li></ul><ul><li>Menorrhagia </li></ul><ul><li>Metrorhaggia </li></ul><ul><li>dysmenorrhea </li></ul>
  186. 222. <ul><li>Diagnostics: USG </li></ul><ul><li>Management: </li></ul><ul><li>Routine pelvic exam every 3-6 months </li></ul><ul><li>surgery </li></ul>
  187. 223. Malignant Lesions of the genital tract
  188. 224. <ul><li>Vaginal Cancer </li></ul><ul><li>Upper 1/3 most common site </li></ul><ul><li>S/S: painless vaginal bleeding and discharge, urinary retention, bladder spasm, hematuria, frequency of urination, tenesmus, constipation, blood in the stool </li></ul><ul><li>Dx: pap smear, biopsy </li></ul><ul><li>Mx: radiation, surgery </li></ul>
  189. 225. Cervical Ca <ul><li>Preventable </li></ul><ul><li>Risk Factors: </li></ul><ul><li>coitus at an early age </li></ul><ul><li>Multiple sexual partners </li></ul><ul><li>Sex partner w/ a hx of numerous sexual partners </li></ul><ul><li>Exposure to STD </li></ul><ul><li>HPV infections </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Contraceptive use>5 yrs </li></ul><ul><li>Smoking </li></ul><ul><li>Antenatal exposure to DES </li></ul><ul><li>History of dysplasia </li></ul>
  190. 226. <ul><li>Diagnostics: </li></ul><ul><li>Pap smear </li></ul><ul><li>Colposcopy </li></ul><ul><li>Endocervical curettage </li></ul><ul><li>Management: </li></ul><ul><li>surgery </li></ul>
  191. 227. Colposcopy is performed with the woman lying on her back, legs in stirrups, and buttocks at the lower edge of the table (a position known as the dorsal lithotomy position). A speculum is placed in the vagina after the vulva is examined for any suspicious lesions . Three percent acetic acid is applied to the cervix using cotton swabs Areas of the cervix which turn white after the application of acetic acid or have an abnormal vascular pattern are often considered for biopsy. If no lesions are visible, an iodine solution may be applied to the cervix to help highlight areas of abnormality
  192. 228. Endometrial Ca <ul><li>Postmenopausal </li></ul><ul><li>Risk Factors: </li></ul><ul><li>Obesity </li></ul><ul><li>Multiparity </li></ul><ul><li>DM </li></ul><ul><li>HPN </li></ul><ul><li>Use of unopposed estrogen </li></ul><ul><li>High fat diet </li></ul><ul><li>Early menarche and late menopause </li></ul><ul><li>Use of Tamoxifen - is an orally active selective estrogen receptor modulator (SERM). decreases DNA synthesis and inhibits estrogen effects. it acts as partial agonist on the endometrium </li></ul>
  193. 229. <ul><li>Manifestations: </li></ul><ul><li>Unusual bleeding, spotting, or other discharge </li></ul><ul><ul><ul><ul><li>abnormal vaginal bleeding such as bleeding between periods or after menopause </li></ul></ul></ul></ul><ul><ul><ul><ul><li>In about 10% of cases, the discharge associated with endometrial cancer is not bloody </li></ul></ul></ul></ul><ul><li>Pelvic pain and/or mass and weight loss </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Pap smear </li></ul><ul><li>Endometrial biopsy </li></ul><ul><li>USG </li></ul><ul><li>Management: TAHBSO </li></ul><ul><li>counseling </li></ul>
  194. 230. Table 1. Staging of Cancer of the Uterine Corpus Stage Characteristics Stage I (grade 1, 2, or 3)* IA Limited to the endometrium IB Invasion of less than one half of the myometrium IC Invasion of one half or more than one half of the myometrium Stage II (grade 1, 2, or 3) IIA Endocervical glandular involvement only IIB Cervical stromal invasion Stage III (grade 1, 2, or 3) IIIA Invades serosa and/or adnexa and/or positive peritoneal cytology IIIB Vaginal metastases IIIC Metastases to pelvic and/or para-aortic lymph nodes Stage IV (grade 1, 2, or 3) IVA Invasion of bladder and/or bowel mucosa IVB Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes
  195. 231. Ovarian Ca <ul><li>Risk Factors: </li></ul><ul><li>Increased age (mean age 59 yrs old) </li></ul><ul><li>Fertility drugs </li></ul><ul><li>Early menarche or late menopause </li></ul><ul><li>Asbestos and talc exposure </li></ul><ul><li>S/sx: abdominal swelling or inc abdominal girth, bloating, pelvic pressure, mild constipation </li></ul><ul><li>Management : surgery </li></ul>
  196. 232. -End - You better live your best and act your best and think your best today, For today, is the sure preparation for tomorrows that follow -Matineau-

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