Chapter 51: Nursing Assessment: Reproductive System

STRUCTURES AND FUNCTIONS • The primary roles of male reproductive system are production and transportation of sperm, deposition of sperm in female reproductive tract, and secretion of hormones. o The primary male reproductive organs are the testes. • The primary roles of female reproductive system are production of ova, secretion of hormones, and protection and facilitation of the development of the fetus in a pregnant female. o The primary female reproductive organs are the ovaries. The hypothalamus, pituitary gland, and gonads secrete numerous hormones that regulate the processes of ovulation, spermatogenesis, fertilization, and formation and function of secondary sex characteristics. In women, follicle-stimulating hormone (FSH) production by anterior pituitary stimulates growth and maturity of ovarian follicles. o Mature follicle produces estrogen, which in turn suppresses the release of FSH. In men, FSH stimulates seminiferous tubules to produce sperm. Estrogen and progesterone are produced by the ovaries. o Estrogen is essential to development and maintenance of secondary sex characteristics, proliferative phase of menstrual cycle immediately after menstruation, and pregnancy uterine changes. o Progesterone is also involved in body changes of pregnancy. The major gonadal hormone of men is testosterone, which is produced by the testes. Testosterone is responsible for development and maintenance of secondary sex characteristics and spermatogenesis. Menarche is the first episode of menstrual bleeding, indicating that a female has reached puberty. o This usually occurs at 12 to 13 years of age. o The length of the menstrual cycle generally ranges from 20 to 40 days. The major functions of ovaries are ovulation and secretion of hormones. These functions are accomplished during the menstrual cycle. If fertilization occurs, high levels of estrogen and progesterone continue to be secreted due to continued activity of corpus luteum from stimulation by human chorionic gonadotropin (hCG). o If fertilization does not take place, menstruation occurs because of a decrease in estrogen production and progesterone. Menopause is the physiologic cessation of menses associated with declining ovarian function. It is usually considered complete after 1 year of amenorrhea. The sexual response is a complex interplay of psychologic and physiologic phenomena influenced by a number of variables, including daily stress, illness, and crisis. o Changes that occur during sexual excitement are similar for men and women.

o Sexual response can be described in terms of the excitement, plateau, orgasmic, and resolution phases. Gerontologic Considerations • In women, many changes relate to the altered estrogen production of menopause. • A reduction in circulating estrogen along with an increase in androgens in postmenopausal women is associated with breast and genital atrophy, reduction in bone mass, and increased rate of atherosclerosis. Changes in aging men include an increase in prostate size, decreased testosterone level and sperm production, decreased scrotum muscle tone and size and firmness of the testicles. Erectile dysfunction and sexual dysfunction can occur as result of these changes.

ASSESSMENT • Nurses have an important role in providing accurate and unbiased information about sexuality and age. Nurses should emphasize normalcy of sexual activity in older adults. • Reproduction and sexual issues are often considered extremely personal and private. o A professional demeanor is important when taking a reproductive or sexual history. o The nurse needs to be sensitive, ask gender-neutral questions, and maintain awareness of patient’s culture and beliefs. o It is helpful if the nurse begins with least sensitive information (e.g., menstrual history) before asking questions about more sensitive issues such as sexual practices or sexually transmitted diseases. Women should have a complete menstrual and gynecologic history taken, including oral contraceptive use. o The nurse should question the patient regarding current health status and presence of any acute or chronic health problems as problems in other body systems often relate to problems with reproductive system. Physical examination: o Male external genitalia: inspection and palpation of pubis, penis, scrotum and testes, inguinal region and spermatic cord, anus and prostate. o Female: begins with inspection and palpation of breasts and then proceeds to abdomen and external genitalia including mons pubis, labia majora, labia minora, perineum, and anal region. o Pelvic and bimanual examinations are considered advanced skills.

DIAGNOSTIC STUDIES • Serum hormone test, hCG, is used to identify pregnancy. • • • Prolactin assay is used for patient with amenorrhea. Serum progesterone and estradiol can also help in ovarian function assessment, particularly for amenorrhea. Hormonal blood studies are essential for a fertility workup.

****Chapter 52: Nursing Management: Breast Disorders
• Screening guidelines for early detection of breast cancer are yearly mammograms starting at age 40, and clinical breast examinations every 3 years for women between ages 20 and 30 and every year for women beginning at age 40. Women should report any breast changes promptly to their health care provider. Breast self-examination is an option for women. Women at increased breast cancer risk (family history, genetic tendency, past breast cancer) should talk with their health care provider about benefits and limitations of starting mammography screening earlier, having additional tests (breast ultrasound), or having more frequent examinations. Mammography is used to visualize internal structures of the breast using x-rays. This procedure can detect tumors and cysts not felt by palpation. Ultrasound is another procedure used to differentiate a benign tumor from a malignant tumor. It is useful for women with fibrocystic changes whose breasts are very dense. Definitive diagnosis of breast cancer is made by histologic examination of biopsied tissue. Biopsy techniques include fine-needle aspiration (FNA) biopsy, stereotactic or handheld core biopsy, and open surgical biopsy. Mastalgia (breast pain): o Mastalgia is the most common breast-related benign complaint in women. o It is described as diffuse breast tenderness or heaviness. o Breast pain may last 2 to 3 days or most of month. o Symptoms often decrease with menopause. o Some relief may occur with caffeine and dietary fat reduction; hormonal therapy, taking vitamins, and gamma-linolenic acid (evening primrose oil); and wearing of support bra. Mastitis: o Mastitis is a breast inflammatory condition that occurs most frequently in lactating women. o Lactational mastitis manifests as a localized area that is erythematous, painful, and tender to palpation. o Fever is usually present. Infection develops when organisms, usually staphylococci, gain access to breast through cracked nipple. o In its early stages, mastitis can be cured with antibiotics. Fibrocystic changes in breast: o Fibrocystic changes is a common benign condition characterized by changes in breast tissue including development of excess fibrous tissue, hyperplasia of epithelial lining of mammary ducts, proliferation of mammary ducts, and cyst

• • •

formation. o These changes produce pain by nerve irritation from edema in connective tissue and by fibrosis from nerve pinching. o Types of treatment that might help fibrocystic breast disease include use of good support bra, dietary therapy (low-salt diet, restriction of methylxanthines such as coffee and chocolate), vitamin E therapy, analgesics, danazol, diuretics, hormone therapy, and antiestrogen therapy. o Fibroadenoma is a common cause of benign breast lumps in young women. A possible cause may be increased estrogen sensitivity in localized area of breast. Treatment includes surgical excision or cryoablation. o Gynecomastia is a transient, noninflammatory enlargement of one or both breasts and is the most common benign breast problem in men. BREAST CANCER • Breast cancer is the most common malignancy in American women except for skin cancer. • Although the etiology of breast cancer is not completely understood, a number of factors are thought to relate to breast cancer including a family history, environmental factors, genetics, early menarche and late menopause, and age 60 or over. However, most women who develop breast cancer have no identifiable risk factors. Noninvasive breast cancers include ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). o DCIS tends to be unilateral and most likely would progress to invasive breast cancer if left untreated. o LCIS is a risk factor for developing breast cancer, but it is not known to be a premalignant lesion. No treatment is necessary for LCIS. Tamoxifen may be given as a chemoprevention.

Paget’s disease: o Paget’s disease is a rare breast malignancy characterized by a persistent lesion of the nipple and areola with or without a palpable mass. o Treatment is a simple or modified radical mastectomy. Inflammatory breast cancer: o Inflammatory breast cancer is the most malignant form of all breast cancers. o The skin of the breast looks red, feels warm, with a thickened appearance described as resembling an orange peel (peau d’orange). o Metastases occur early and widely. Radiation, chemotherapy, and hormone therapy are more likely to be used for treatment than surgery. Breast cancer is detected as a lump or mammographic abnormality in the breast. It occurs most often in upper, outer quadrant of breast. If palpable, breast cancer is usually hard, and may be irregularly shaped, poorly delineated, nonmobile, and nontender. Nipple discharge may also be present. In addition to earlier listed tests, other tests useful in predicting risk of recurrence or metastatic breast disease include axillary lymph node status, tumor size, estrogen and progesterone receptor status, and cell proliferative indices.

• • •

Patients with breast cancer should discuss all treatment options with their health care provider, including local excision, mastectomy with breast reconstruction, breastconserving treatment (lumpectomy), radiation therapy, and/or tamoxifen. Common options for resectable breast cancer include breast conservation surgery with radiation therapy and modified radical mastectomy with or without reconstruction. Breast conservation surgery (lumpectomy) involves removal of entire tumor along with a margin of normal tissue. Modified radical mastectomy includes removal of breast and axillary lymph nodes, but it preserves pectoralis major muscle. Lymphedema can occur due to surgical excision or radiation of lymph nodes. Symptoms are heaviness, pain, impaired motor function in the arm, and numbness and paresthesia of the fingers as a result of lymphedema. Following surgery, radiation therapy is delivered to the entire breast, ending with a boost to the tumor bed. If there is evidence of systemic disease, then chemotherapy may be given before radiation therapy. Radiation therapy may be used for breast cancer as a primary treatment to prevent local breast recurrences after breast conservation surgery, adjuvant treatment following mastectomy to prevent local and nodal recurrences, and palliative treatment for pain caused by local recurrence and metastases. Breast cancer is one of the solid tumors most responsive to chemotherapy with the use of combinations of drugs, which is clearly superior to use of single drug therapy. Hormonal therapy removes or blocks the source of estrogen, thus promoting tumor regression. Nursing interventions at time of breast cancer diagnosis include exploring woman’s usual decision-making patterns, helping the woman accurately evaluate advantages and disadvantages of options, and providing information and support relevant to treatment decisions. The woman with breast conservation surgery usually has an uneventful postoperative course with only a moderate amount of pain. If an axillary lymph node dissection or mastectomy is done, drains are often left in place. Postoperative discomfort is minimized by administering analgesics 30 minutes before initiating exercises. With showering, the flow of warm water over the involved shoulder often has a soothing effect and reduces joint stiffness. Mammoplasty: o Mammoplasty is a surgical change in size or shape of the breast. o It may be done electively for cosmetic purposes to either augment or reduce the size of breasts or to reconstruct the breast after mastectomy. o In augmentation, an implant is placed in a surgically created pocket between the capsule of the breast and the pectoral fascia. o Reduction mammoplasty is performed by resecting wedges of tissue from upper and

• • •

lower quadrants of breast. • Breast reconstructive surgery may be done simultaneously with mastectomy or some time afterward to achieve symmetry and to restore or preserve body image.