Common Gynecologic Disorders

Gynecologic disorders
• Gynecological disorder is a condition which affects the female
reproduction organs, namely the breasts and organs in the
abdominal and pelvic area including the womb (uterus), ovaries,
fallopian tubes, vagina and vulva.
Menstrual Cycle Disorders:
• 1. Dysmenorrhea
• 2. PREMENSTRUAL SYNDROME (PMS)
• 3. AMENORRHEA
• 4. POSTMENOPAUSAL BLEEDING
• 5. ENDOMETRIOSIS
• 6. DYSFUNCTIONAL UTERINE BLEEDING
 • SECONDARY DYSMENORRHEA –
DYSMENORRHEA occurs due to an underlying
disease or condition
• PAINFUL MENSTRUAL FLOW
• CLASSIFICATIONS:
• PRIMARY AND SECONDARY
• PRIMARY DYSMENORRHEA –
occurs after ovulation is
established; characterized by
spasmodic lower abdominal pain
that begins with the onset of
menstrual flow and lasts 12 to
48 hours.
DYSMENORRHEA
• Pathophysiology: Primary Dys.
• Increased uterine prostaglandin
production
• Prostaglandin produced by the
endometrium during the luteal
phase stimulates the myometrium
and causes spasms which constrict
uterine blood flow resulting in
ischemia and pain
PREMENSTRUAL SYNDROME (PMS)
• A collection of symptoms
occurring each month during the
luteal phase of the menstrual
cycle; this is followed by relief
with menses and a symptom –
free phase.
• S/s:
• Headaches; migraine; depression;
breast tenderness; acne; urticaria;
edema; etc…
PREMENSTRUAL SYNDROME (PMS)
• Medications:
• Diuretics – for 10 days prior to
menstruation
• Progesterone – physical and
psychologic symptoms
• Bromocriptine mesylate – during
the luteal phase – to relieve breast
symptoms
• Meprobamate – 10 days before
menstruation –to relieve tension
Premenstrual dysphoric syndrome (PMDD)
• a much more severe form of
PMS.
• may affect women of
childbearing age.
• It’s a severe and chronic medical
condition that needs attention
and treatment; Lifestyle changes
and sometimes medicines to
help manage symptoms.
• Cause is unknown
• It may be an abnormal reaction
to normal hormone changes that
happen with each menstrual
cycle.
• The hormone changes can cause
a serotonin deficiency.
• Serotonin is a substance found
naturally in the brain and
intestines that narrows blood
vessels and can affect mood and
cause physical symptoms.
PMDD
• Risk factors: • Other possible risk factors
• family history of PMS or include lower education and
PMDD cigarette smoking
• personal or family history of
depression, postpartum
depression, or other mood
disorders
Symptoms of PMDD
• Psychological symptoms:

• Irritability • Anxiety
• Nervousness • Confusion
• Lack of control • Forgetfulness
• Agitation • Poor self-image
• Anger • Paranoia
• Insomnia • Emotional sensitivity
• Difficulty in concentrating • Crying spells
• Depression • Moodiness
• Severe fatigue • Trouble sleeping
Symptoms of PMDD
• Fluid retention • Eye complaints
• Swelling of the ankles, hands, and • Vision changes
feet • Eye infection
• Periodic weight gain
• Gastrointestinal symptoms
• Diminished urine output
• Abdominal cramps
• Breast fullness and pain
• Bloating
• Respiratory problems • Constipation
• Allergies • Nausea
• Infections • Vomiting
• Pelvic heaviness or pressure
• Backache
Symptoms of PMDD
• Skin problems • Other
• Acne • Decreased coordination
• Skin inflammation with itching • Painful menstruation
• Aggravation of other skin disorders, • Diminished sex drive
including cold sores • Appetite changes
• Neurologic and vascular symptoms • Food cravings
• Headache • Hot flashes
• Dizziness
• Fainting
• Numbness, prickling, tingling, or
heightened sensitivity of arms and/or
legs
• Easy bruising
• Heart palpitations
• Muscle spasms
Diagnostics:
• Physical and pelvic exam
• Evaluate for mental health
concerns
• During most menstrual cycles, 5 or
more of the following symptoms
must be present:
• Depressed mood
• Anger or irritability
• Trouble concentrating
• Lack of interest in activities once
enjoyed
• Moodiness
• Moodiness
• Increased appetite
• Insomnia or the need for more sleep
• Feeling overwhelmed or out of
control
• Other physical symptoms:
• belly bloating, breast tenderness, and
headache
• Symptoms that disturb the ability
to function in social, work, or other
situations
• Symptoms that are not related to,
or exaggerated by, another medical
condition
Treatment: No treatment
• Treatment approaches to help
relieve or decrease the severity
of PMDD symptoms:
• Changes in diet to increase
protein and carbohydrates and
decrease sugar, salt, caffeine,
and alcohol
• Regular exercise
• Stress management
• Vitamin supplements (such as
vitamin B6, calcium, and
magnesium)
• Anti-inflammatory medicines
• Selective serotonin reuptake
inhibitors (SSRI)
• Birth control pills
AMENORRHEA
• Absence of menstrual periods
• Classification:
• Primary amenorrhea
• Secondary amenorrhea
• Primary amenorrhea –
menstruation that has failed to
occur by age 16 years;
associated with anomalies of the
reproductive tract; poor
prognosis for fertility
AMENORRHEA
• ASSESSMENT:
• Family history of genetic
abnormalities, ambiguous genitalia at
birth, nutritional habits, past surgery
and emotional stress
• Menstrual and obstetric histories;
sexual activity and symptoms of
pregnancy
• Physical assessment – anomalies of
the genital tract or hormonal causes
such as short stature, lack of breast
development, lack of pubic and
axillary hair, and abnormality of
external genitalia
AMENORRHEA
• Management:
• Counselling and emotional
support
• Intervention based on the
causes of amenorrhea
• Hormone replacement
• Corrective surgery
• Ovulation stimulation
• Periodic progesterone withdrawal
POSTMENOPAUSAL BLEEDING
• Vaginal bleeding occurring after
a 12 months’ cessation of
menses after the onset of
menopause
• A symptom of gynecologic
disorder; can be caused by
benign or malignant conditions
• 3 most common causes –
atrophic vaginitis
• cervical polyps
• endometrial abnormalities
• Endometrial hyperplasia – a
precursor of endometrial cancer;
bleeding is caused by declining
ovarian function that leads to
prolonged estrogen stimulation,
producing the hyperplasia that
eventually breaks down and
bleeds.
• Assessment:
• Age at menopause
• Frequency and amount of bleeding
• Previous bleeding episodes
• Medications (estrogen
replacement therapy)
• Genitourinary symptoms
• Risk factors: obesity, hypertensive,
diabetic, who have never had
children
• Diagnostics and labs:
• Hematology
• Physical and pelvic exams - Pap
Smear
 • Provide information
• Management: • D&C
• Hysterectomy and chemotherapy
(Atypical hyperplasia)
• Receiving ERT – monthly
administration of a daily • Malignancy – combination of surgery,
progesterone for the last 10 days radiation therapy and chemotherapy
of the estrogen therapy or IM
injection once a month – decrease
abnormal endometrial
proliferation and to prevent
endometrial and breast cancer
• Management cont.:
• Atrophic vaginitis
• Estrogen – via vaginal, oral,
transdermal or subdermal route
• Oral therapy:
• Once daily for the first 25 days
each month
• Transdermal or subdermal:
• Rotate sites for the patches or
injections
• Change the patches twice a week
as ordered
• Vaginal therapy:
• Use applicator to insert
suppository or cream
• Wear panty liner or mini pad to
protect clothing from soiling or
staining from the drug
ENDOMETRIOSIS/ ENDOMETRITIS
• A benign disease characterized
by implantation of endometrial
tissue outside the uterine cavity.
The tissue is commonly found on
the ovaries and cul – de- sac and
less commonly on other pelvic
organs and structures.
• Progresses slowly; regresses
during pregnancy and at
menopause.
• Cause - unknown
• Diagnostics
• Pelvic exam – tenderness;
nodular uterosacral ligaments;
fixed or limited movement of the
uterus
• Laparoscopy – key diagnostic
exam – implants are seen as
brown or blue – black nodules or
multiple foci – “powder burn
spots”
• Management:
• Surgical removal of endometrial
implants and adhesions
• Hysterectomy
• Non pharmacologic mgt:
• Heating pad application
• Relaxation techniques
• Yoga
DYSFUNCTIONAL UTERINE BLEEDING (DUB)
• Abnormal bleeding that is
excessive or abnormal in amount
or frequency without
predisposing anatomic or
systemic conditions
• Bleeding in the absence of
ovulation related to ovarian
dysfunction
• Estrogen stimulation of the
endometrium is prolonged , & it
grows past its hormonal support,
causing bleeding and
desquamation
• Laboratories:
• CBC & platelet – to identify
chronic blood loss
• Urinalysis – infection
• Stool exam – occult blood
• Pap smear – to detect malignancy
• Pregnancy test
• Nursing diagnosis:
• Anxiety r/t an unknown cause of
abnormal bleeding
• Fear r/t lack of knowledge about
treatments (hormonal therapy
and surgery) from abnormal
uterine bleeding
• Potential for self – esteem
disturbance r/t abnormal
bleeding as a threat to sexual
identity
• Pain r/t DUB or its surgical
treatments
• Sexual dysfunction r/t abnormal
uterine bleeding
• Powerlessness r/t infertility sec.
to anovulation
• Potential for activity intolerance
r/t weakness and fatigue sec. to
anemia.
PROBLEMS R/T PELVIC
SUPPORT TISSUES
UTERINE DISPLACEMENT
• NORMAL POSITION:
• Lies in the midline of the pelvis
and is freely movable
• Cervix is located posteriorly in
the vagina, and the body of the
uterus has a slight degree of
anterior flexion
• Symptoms:
• Asymptomatic
• History of backaches, secondary
amenorrhea, infertility,
dyspareunia, feelings of pelvic
pressure or heaviness
Uterine Prolapse
• Uterine prolapse occurs when
pelvic floor muscles and
ligaments stretch and weaken
until they no longer provide
enough support for the uterus.
UTERINE PROLAPSE
• More serious type of • Grade 3 – the body of the uterus
displacement and the cervix protrude through
• 3 stages of prolapse the entrance to the vagina. The
vagina is turned inside out.
• Grade 1 – the uterus bulges into
the vagina, but the cervix does
not protrude through the
entrance to the vagina
• Grade 2 – the uterus bulges
further into the vagina, and the
cervix protrudes through the
entrance to the vagina
Degrees of uterine prolapse
• Caused by:
• Congenital defects, persistent
high levels of intra – abdominal
pressure related to heavy
physical labor or exertion or any
other cause that weakens the
pelvic supports
• Assessment: • Interventions: based on the
• A feeling that the client relates – degree of prolapse
“something is in my vagina”; • Pessaries
dyspareunia, backache, a feeling • Vaginal hysterectomy with repair
of heaviness or pressure in the
pelvis, and bowel or bladder
problems
• Pelvic examination – protrusion
of the cervix when the woman is
asked to bear down
CYSTOCELE
• Protrusion of the bladder
through the vaginal wall due to
weakened pelvic structures
• Can be caused by:
• Obesity, advanced age,
childbearing or genetic
predisposition
• Assessment:
• Difficulty in emptying bladder,
urinary frequency and urgency,
UTI, and stress urinary
incontinence
• Management: • Surgery:
• Pessary – to support the bladder • Anterior Colporrhaphy – anterior
repair – a procedure to tighten
• Estrogen therapy – the pelvic muscles for better
postmenopausal woman to bladder support
prevent atrophy and weakening
of vaginal wall
• Kegel’s exercise – strengthen
perineal muscles

RECTOCELE
• A protrusion of the rectum through
a weakened vaginal wall
• Assessment:
• Constipation; hemorrhoids; fecal
impaction and feelings of rectal or
vaginal fullness
• Pelvic examination: may show a
bulge of the posterior vaginal wall
when the woman is asked to bear
down
• Rectal examination: reveals the
presence of a rectocele
• Barium enema – also confirms the
presence of rectocele
• Medical mgt: focused on
promoting bowel elimination
• High – fiber diet, stool softeners,
laxative
• Surgery: Posterior colporrhaphy –
posterior repair – to strengthen
pelvic support and reduces the
bulging
Vaginal Fistulas
• an abnormal opening between
the vagina and other nearby
organs in the pelvis, including
the bladder or rectum.
• A fistula can cause many
complications, such as urinary
and fecal leakage, abnormal
vaginal discharge, tissue
damage, kidney infections and
other irritative type symptoms.
Types:
• Vesicovaginal – opening
between the vagina and the
bladder
• Rectovaginal – opening between
the vagina and rectum/lower
part of the large intestine, which
carries stool out of the body
• Colovaginal – opening between
the vagina and colon
• Enterovaginal – opening
between the vagina and small
intestine
• Ureterovaginal – opening
between the vagina and the
tubes (ureters) that carry urine
from your kidneys to your
bladder
• Urethrovaginal – opening
between the vagina and urethra,
a part of the bladder
Symptoms •
•
Urinary and fecal leakage
Abnormal vaginal discharge
• A foul odor in urine or vaginal discharge
• Recurrent infection including recurrent
UTIs
• Abdominal pain
• Rectal or vaginal bleeding
• Tissue damage
• Kidney infections
• Fever
• Weight loss
• Nausea
• Vomiting
• Diarrhea
• Other irritative type symptoms
 Common causes of a vaginal fistula
include:
• Childbirth, especially • Infection
prolonged or • Other pelvic
obstructed childbirth injury
• Complications from • Retained
pelvic surgery foreign material
• Cancer/radiation in the vagina
treatment (e.g., vaginal
• Crohn’s Disease or pessary)
ulcerative colitis
Diagnostics:
• Review of history, physical and
pelvic exam
• Additional tests:
• Dye Test – inserting dye in the
bladder and or the rectum to
check for leakage of dye into the
vagina
• Imaging studies - such as
ultrasound, CT scan or MRI
• Colonoscopy - using a camera to
look into the colon to screen for
other potential causes of
fistulas, including inflammatory
bowel disease
• Cystourethroscopy - using a
camera to look into the bladder
and urethra to potentially
identify the location of the
fistula
Treatment
• Conservative treatment – some
fistulas may heal without
treatment
• Catheter insertion
• Surgery
• Medications – antibiotics if
caused by infection
Imperforate Hymen
• is a congenital anomaly of the
female genital tract in which the
hymen completely obstructs the
vaginal opening.
• Hymen – “membrane” - a thin
piece of fleshy, elastic tissue
shaped like an O around the
opening of the vagina
Symptoms during puberty
• abdominal pain and swelling • Back pain
that can last days - physical • Painful urination or no urination
symptoms generally occur at all
because of a buildup of
menstrual blood trapped in the
vagina; blood can also spill into
the uterus and fallopian tubes.
• Lack of a menstrual cycle
• Abdominal or pelvic pain, often
come and going each month.
Treatment
• Surgery
• Hymenectomy - a procedure
that is done to remove extra
tissue from the hymen that
partly or totally covers a female's
vaginal opening.
• Hymenotomy - a medical
procedure involving the surgical
removal or opening of the
hymen. It is often performed on
patients with an imperforate or
septate hymen, or other
situations where the hymen is
unusually thick or rigid such as
microperforate hymen
BENIGN PROBLEM
UTERINE LEIOMYOMAS ( Uterine fibroids)
• Also called myomas and fibroids
• Most frequent occurring tumors
• Benign , slow growing, solid tumors
• Classification: according to the
position in the layers of the uterus:
• Intramural leiomyoma – contained in
the uterine wall within the
myometrium
• Submucosal leiomyoma – protrude
into the cavity of the uterus
• Subserosal leiomyoma – may grow
laterally and extend to the broad
ligament (intraligamentous fibroid)
• Etiology – unknown
• Leiomyomas are usually a result of
a localized proliferation of smooth
muscle cells in their initial stages

• Growth of leiomyomas may be

related to estrogen stimulation
because fibroids often enlarge
during pregnancy and diminish in
size after menopause
• Labs:
• CBC; Pregnancy test
• Dx:
• CT scan
• Ultrasonography

• Management:
• Removal of the uterus or
myoma (Hysterectomy
and Myomectomy)
 Surgical techniques used to remove the uterus
• Radical hysterectomy – all of the
• Total hysterectomy – all of the uterus is removed abdominally,
uterus is removed the lymph nodes, the upper
• Subtotal hysterectomy – all of third of the vagina, and the
the uterus except the cervix is surrounding tissues are also
removed removed
• Panhysterectomy – total
abdominal hysterectomy and
bilateral salpingo -
oophorectomy
Preoperative care
• Assess carefully to make sure the • Preoperative preparation:
woman understands all the options • Douche
for surgery, the advantages and • Enema
risks of having surgery, • Perineal shave
preoperative and postoperative • Laboratory tests:
procedures. • Blood tests – Bld typing, CBC
• Psychologic and preoperative • Chest x – ray
preparation • Electrocardiogram
• Urinalysis
• Preoperative teaching:
• Preparation for post op measures:
• Turning, coughing, deep breathing
exercises, early ambulation, and pain
relief measures

• Psychologic preparation:
• Discuss – significance of the loss of • FC for 24 to 48 hours
the uterus – childbearing ability
• Misconceptions about the effects
of the uterus – masculinization and
• Postoperative care:
• Assess vaginal bleeding (less than
one saturated pad in 4 hours)
• Assessing bleeding at the incision
site – intactness
• Pain medications or a heating pad
• Removal of sutures on the 5 th

weight gain postoperative day

• Assess support system needs –
inclusion of the partner in teaching
sessions
Postoperative complications:
• Abdominal: • Vaginal
• Intestinal obstruction (paralytic • Hemorrhage
ileus) • UTI
• Thromboembolism • Wound infection
• Atelectasis
• Pneumonia
• Wound dehiscence
Discharge Planning:
• Discharged 4 – 7 days
• Avoid stair climbing for 1 month
• Avoid tub baths and sitting for a long period
(pooling of blood in the pelvic vessels)
• Avoid strenuous activity or lifting anything
weighing more than 4.5 to 9 kg.
• Avoid driving a car for two weeks or longer
• Client / Family Education
• Physical changes:
• Cessation of menses
• Inability to conceive
• Weakness and fatigue
• Absence of menopausal symptoms if the
ovaries are removed
• Moderate exercise – walking
• Avoid jogging and aerobic exercise for 1
month
• Eat foods high in protein, iron & vit. C
• Avoid intercourse – 3 – 6 weeks
• Signs of infection
• Follow – up check up, 4 – 6 weeks
postoperatively
• Psychosocial preparation:
• Reactions can occur 3 months to
3 years after surgery
• Counsel about signs of
depression
• Evaluate unusual feelings of low
self – esteem or loss of interest
or pleasure in usual activities
and pastimes