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NUR 210: Pathophysiology Female Reproductive Problems Wanda Lovitz, ARNP Female Reproductive Problems: Objectives State the major risk factors and • Compare the age distribution and • • • • risk factors for cervical and endometrial cancer. Characterize the development of cervical cancer from the appearance of dysplastic cells to the development of invasive cervical cancer. Explain how the PAP test has impacted cervical cancer. Compare the pathology and manifestations of endometriosis. Cite the major risk factors and early symptoms of endometrial cancer. symptoms of ovarian cancer. Discuss the reason that ovarian cancer is lethal Describe the common causes and symptoms of pelvic inflammatory disease (PID). Describe the manifestations of fibrocystic disease. Cite the risk factors for breast cancer, the importance of breast self-examination, and recommendations for mammography. State the warning signs of breast cancer. NORMAL FEMALE PELVIC ANATOMY Endometrium is the inner lining of the uterus Female Reproductive Disorders Terms: Ectopic pregnancy- ovum fertilized in fallopian tube Leiomyomas (fibroids) – benign neoplasms of smooth muscle • Endometriosis – uterine tissue growing outside uterus • Endometritis – infection of the endometrium • Cervicitis – infection of the cervix • Vulvititis – inflammation and pruritus of the vulva Review of the menstrual cycle There is a CYCLIC release of hormones. Note estrogen dominates during the first half of the cycle. Progesterone is dominate in the last half. If no pregnancy occurs progesterone , and menses occurs. Vaginal Bleeding…What’s Normal? Cycle length: 21-35 days Menstrual flow: 20-80 cc. per menses Average flow: 35 cc. Flow up to 7 days Ectopic Pregnancy Fertilized egg implants in the fallopian tube instead of the uterine lining. Ectopic pregnancy Uterine fibroids: leiomyomas Leiomyomas (fibroids) are benign neoplasms of smooth muscle origin. Can cause menorrhagia (heavy menses) and cramps. Disorder of the Cervix (Cancer of the cervix) • Cancer of the cervix is one of the most curable cancers among females • Peak incidence in early 30’s • There is a very strong link between genital warts (HPV) and cervical cancer • Risk Factors: • Human papillomavirus (HPV) genital warts • If infected during teenage years= especially high risk. Possibly r/t high rate of cell division that occurs in cervix during those years Prevention: a new vaccine has been approved by the FDA (2010) Gardisil Cervical Cancer: Prevention Girls HPV Vaccine-Gardisil should receive vaccine before first sexual intercourse: recommended for females ages 9-26 Three dose vaccine (3 injections over 6 months) Long Has term SE unknown only been tested in ages 9-26. Safety in older women unknown The best protection • Abstain from sex • Condoms Risky Behaviors in Kentucky • 50.3% of Kentucky 9-12th graders have had sexual intercourse. (45.9% average in U.S.) Ky ranks 11th • 7.8% had intercourse before age 13 • 14.4% had four or more sex partners • 59% of Kentucky sexually active teens did not use a condom at last sexual encounter • 14.9% of Kentucky teens experienced dating violence 2007 Youth Risk Behavior Survey Cancer incidence in women • 1. lung cancer – most common cancer in women • 2. breast cancer – most common reproductive cancer • 3. ovarian cancer – most deadly cancer • 4. endometrial cancer –most • 5. cervical cancer –most common inherited GYN cancer curable cancer • Kentucky has the highest cervical cancer rate in the nation!! Cancer of the cervix Cervical metaplasia Cancer in situ = precancerous lesions Ectocervix = visible portion. Lined with squamous epithelium Endocervical canal is lined with columnar . epithelium. Transformation zone is the area where the squamous and columnar epithelium meet. It is this area that is sampled with the PAP smear. PAP Smear Sample taken from the transformation zone. A change seen on the Pap Smear must be further evaluated by either repeat Pap and/or colposcopy. Current recommendation: Every 3 years for women ages 21-65 What is Colposcopy? Human Papilloma Virus (HPV): the primary risk factor for cervical cancer Almost 100% of women with cervical cancer have HPV Transmission can occur from skin to skin contact There are over 32 serotypes of HPV. Also known as condolyomas Incidence of HPV Cervical Cancer:Pathogenesis Pre-malignant changes in cervix (cervical dysplasia) usually precedes CA by many years • Detection via Pap stain slide test – microscopic examination of cells • 1945 American Cancer Dyplastic changes identified and staged during cytological studies of a cervical smear PAP Dysplasia = disordered growth/atypical cells Society endorses Pap Smear as screening test Invasive Cervical Cancer Involves invasion and spread to adjacent pelvic areas or to distant sites through lymphatic system Job of Pap is to rate of invasive cervical cancer- is a screening test only A change in the Pap must be further evaluated by colposcopy ONLY 1% OF LESIONS PROGRESS TO INVASIVE CANCER There has been a 70% reduction in US cervical cancer mortality over last 30 years! Cervical cancer Cervical Cancer • Prognosis • Preinvasive cancer very curable (75-90%). There is a very long latent period. • Only the epithelium is (not the entire gland) affected in preinvasive • Average age of dx is 30’s • Worse prognosis with adenocarcinoma (glandular involvement) = endometrial/uterine cancer Cervical Cancer: Descriptive Diagnosis Epithelial cell abnormalities - (normal PAP) -Atypical glandular cells of undetermined significance: ASCUS -low grade SIL -1/4 tissue (squamous epithelial lesion) -high grade SIL – 2/4 tissue -invasive cancer Cervical Cancer • Clinical Manifestations • Preinvasive: no sx • Invasive characterized: • Diagnostic Tools • Direct cytological sampling = punch biopsy or COLPOSCOPY • Sample of tissue taken for cytology studies • Unusual vaginal bleeding or discharge • Postcoital pain or bleeding Cancer cells Cervical Cancer Death Rates Cervical Cancer Incidence Rates* by State, 2008 Note dramatic in cervical cancer deaths over last 30 years Kentucky ranked #31 8.2 in incidence. Incidence in US is 7.8 Cervical Cancer Death Rates 2009 Cervical Cancer Rates per 100,000 women Kentucky ranks 50 in mortality Only Arkansas has higher rate Disorders of the Uterus Endometriosis The presence of uterine endometrial cells and tissue outside of the uterus, anywhere in pelvic or abdominal cavity Endometrial cells respond to estrogen and progesterone with: Proliferation, secretion, and bleeding during menstrual cycle Results in severe inflammation pain Continued inflammation scarring of pelvic or abdominal organs Endometriosis Endometrial tissue outside of the uterus Endometriosis: Cause • Evidence suggests: retrograde menstruation • Menstrual discharge moves up the fallopian tubes into peritoneal cavity • Who develops it? • Genetic tendency and depressed immune system may predispose • Early adolescence or perimenopause • Exposure to environmental toxins may contribute Endometriosis: Clinical Manifestations • Pain • Ranging from mild to severe • Before and during menstruation • Pain intensity is not proportional to amount of endometrial tissue in various extauterine sites • Dyspareunia (pain during intercourse) • Pain on defecation – if rectal tissue involved Endometriosis: Clinical Manifestations (cont) Dysmenorrhea Pelvic pain Infertility Irregular bleeding Backache May have adhesions These may cause bowel obstructions Endometriosis: Diagnosis • Diagnostic Tools • Laproscopy – exam of PERITONEUM with a laproscope • The abdomen Isinflated with CO2 and laprascope passed thru a small incision in the abdomen • Laparoscopy can DIAGNOSE disease and assign a stage • Laproscopic surgery can also be used to TREAT some gyn conditions. Endometriosis: complications • Complications of endometriosis • Ruptured cysts • Peritonitis • Infertility: 30-40% • Results from chronic inflammation and scarring of fallopian tubes • Hormonal disturbances may occur Endometriosis: chocolate cyst A ruptured chocolate cyst can cause *peritonititis *Peritonitis is inflammation of the serous membrane which lines the abdominal cavity Cysts formed from bleeding endometrial tissue= chocolate cysts What is Peritonitis? Peritionitis is an inflammation of the lining of the abdominal cavity It can occur from trauma or infection Usually represents a surgical emergency! Examples of conditions which may cause peritonitis ruptured chocolate cysts, appendicitis, diverticulitis, PID, abdominal trauma What are the clinical signs of peritonitis? • 1. Abdominal pain • Rigid abdomen “washboard abdomen” • 2. Abdominal tenderness • 3. Abdominal “guarding” ( pain with movement) • Rebound tenderness – pain is greater after the hand is removed when palpating the abdomen Endometrial Cancer • Role of estrogen in endometrial cancer 1. Estrogen is synthesized in body fat 2. Estrogen use without progesterone (unopposed) is CONTRAINDICATED 3. Estrogen causes proliferation of the endometrial cells. they grow and increase in number 4. Progesterone causes the endometrial cells to mature and withdrawal of progesterone leads to endometrial sloughing 5. Life long exposure to estrogen increases in women who are obese have never been pregnant experienced early menarche or late menopause So, who gets endometrial cancer? • Postmenopausal women • Users of unopposed • • • • • • • estrogen Increased age Family history Obesity Nulliparity HTN/DM Most common pelvic cancer White women (70% more common) Endometrial Hyperplasia Caused by the formation and growth of new normal cells. THE ENDOMETRIAL LINING THICKENS Can lead to dysplasia A major risk factor for the development of endometrial cancer Endometrial Cancer • Major Symptom: abnormal, painless vaginal bleeding • Diagnosed with endometrial biopsy, transvaginal ultrasound or d & c • 5 year survival rate for those dx early is greater than 90% Endometrial Biopsy Ovarian Cancer • Ovarian Cancer • The most LETHAL female reproductive cancers! • Difficult to diagnose = 60 % have metastatic disease at the time of dx • Major Risk factors • Ovulatory age • GREATEST INCIDENCE BETWEEN 65-84 • Incidence is much lower in countries where women have numerous children • risk with use of powders containing talc (talcum powder) • Genetic link – 2 or more first or 2nd degree relatives with ovarian cancers have a 50% risk for developing Ovarian Cancer • Multiple forms with epithelial tumors the most common • Clinical The longer the exposure to estrogen; the higher the risk manifestations None usually! Vague GI symptoms (flatulence, bloating, mild abdominal distress) abdominal girth Bowel & bladder dysfunction Menstrual irregularities Reason for these sx is not understood Ovarian Cancer • Diagnosis • NO GOOD EARLY SCREENING TEST • Serum tumor marker CA 125 (a cell surface antigen) • However marker is NOT specific to ovarian cancer • CA 125 may also be with fibroids or endometriosis • Transvaginal ultrasonography (TVS) – helps evaluate ovarian masses Prognosis: Female Reproductive Cancers • Death can occur with any of the reproductive cancers • Survival rates: • HIGHEST (75-95%) with cervical and endometrial cancer • LOWEST (25-30%) with ovarian cancer • Early detection can improve survival • Especially true for cervical cancer • Important nursing role is with education to encourage screening tests Reproductive cancer death rates Cancer Rates….no REAL progress 2001-2005 Cases Deaths Ovarian 1435 1037 72% Lung 9042 6676 74% Breast 16,708 3054 18% 2005-2009 Cases Deaths Ovarian 1474 1020 69% Lung 10,185 7010 69% Breast 18,022 2956 16% Prognosis: Female Reproductive Cancers • Death can occur with any reproductive cancer • Survival rates • Highest: cervical and endometrial cancer (75-95%) • Lowest: ovarian cancer (25-30%) • Early detection can improve survival • Especially true for cervical cancer • Important nursing role: EDUCATION • Screening tests Pelvic Inflammatory Disease (PID) • Cause: most cases d/t STD microorganism infectious of the pelvic cavity. May affect fallopian tubes, ovaries, uterus and pelvic peritoneum • Refers to inflammation of • Cervix (cervicitis) 1.Uterus (endometritis) 2.Fallopian tube (salpingitis) 3.Ovaries (oophoritis) 4.Peritoneum (peritonitis) OR any combination of organs PID-Symptoms • Sometimes asymptomatic • Dysuria • Fever • ABD pain- ↑ with movement, intercourse • Bleeding between periods • Abnormal vaginal discharge Prevention of female PID • Abstinence • Monogamy • Protected intercourse PID-Diagnosis • Physical Exam • Pelvic Exam • CERVIX TENDER to movement on pelvic exam (CMT) • Culture of discharge is obtained to ID organism • Serum WBC and ESR (erythrocyte sedimentation rate) are elevated • Possible direct visualization of pelvic organs with laparoscope • 25-40% require hospitalization! PID-Complications • Scarring and adhesions of uterus and fallopian tubes→Infertility • Adhesions also ↑ risk for ectopic pregnancy • Severe cases of PID have been associated with peritonitis • Rarely, death can occur due to septic shock Disorders of the Breast: benign vs cancerous • Fibrocystic Disease – AKA mammary dysplasia • Is a benign condition typified by the development of fibrosis and cystic tissue formation of the breast • Is the most common disorder of the breast • Accounts for 50-75% of surgical procedures on female breast • Biopsy done to r/o cancer Fibrocystic Breast Disease: the most common breast lesion • Presentation • Nodular, granular, painful breast masses, mobile masses (little BB’s under the skin) • Most common in women 30-50 years • Diagnosis • PE, Biopsy, Mammography BREAST CANCER SIGNIFICANCE/INCIDENCE Common malignant cancer among women in the nation One of the leading causes of death by cancer among females (#2) Especially prevalent between the ages of 45 and 64 Usually does not occur before age 35 Kills three times as many women as ovarian or uterine cancer Risk that a woman will develop cancer is about 1:8 Men can develop breast cancer although the incidence is very low 2009 Breast Cancer Deaths Kentucky ranks 37th (rate 23.2 versus US rate 22.2) Highest – 27.9 Lowest – 16.3 Breast Cancer: Risk Factors First degree relative (sister or mother) with history of the disease Lifetime exposure to estrogen Women who have experienced early menarche and late menopause. ( exposure to estrogen) Fibrocystic breast disease High fat diet Excessive alcohol consumption BRCA gene and breast cancer risk Warning signs of breast cancer - Hard irregular shaped lump in breast - Changes in size or shape of one breast - Changes in skin texture - Discharge from nipple - in breast skin temp - Breast pain “stellate” = star shaped lesion Breast Cancer • Exam findings: • Irregular contours • Lump is usually fixed (non-mobile) with irregular borders • Lymph node swelling • May have nipple discharge and/or retraction • Dimpling “peau d’orange apperance” Breast Cancer: Diagnosis Diagnostic Tools Regular breast self-exam and PE Mammography (85% sensitivity) Ultrasound Biopsy of the suspected lump Complications Widespread metastases THE END