DIAGNOSTIC TESTS FOR FEMALE REPRODUCTIVE ORGANS

CYTOLOGIC TEST FOR CANCER (PAP SMEAR)

The Pap smear is performed to detect cervical cancer.
 Cervical secretions are gently removed from the cervical os, transferred to a
glass slide, and fixed immediately by spraying with a fixative. A Thin-prep
Pap specimen is immersed in a solution rather than being placed on a slide.
This method allows for human papillomavirus (HPV) testing if the Pap smear
result is abnormal
 The patient should be instructed not to douche before this examination to avoid
washing away cellular material\
 The Pap smear should be performed when the patient is not menstruating
because blood usually interferes with interpretation
 Pap smears that reveal mild inflammation or atypical squamous cells are usually
repeated in 3 to 6 months, with findings often returning to normal
 If a specific infection is causing inflammation, it is treated
appropriately, and the Pap smear is repeated
 If the repeat Pap smear reveals atypical squamous cells, then a
colposcopy is appropriate these cells can also be used to determine the
presence of HPV DNA. If HPV DNA is present, it is more likely that
HSIL is present.
The Bethesda Classification system classifications
 Low-grade squamous intraepithelial lesion (LSIL), which is equivalent to
cervical intraepithelial neoplasia (CIN 1) and to mild changes related to
exposure to HPV
 High-grade squamous intraepithelial lesions (HSIL), which equates to moderate
and severe dysplasia, carcinoma in situ (CIS), and CIN 2 and CIN 3
COLPOSCOPY AND CERVICAL BIOPSY
 Used for suspicious Pap smears
 After inserting a speculum and visualizing the cervix and vaginal walls, the
examiner applies acetic acid to the cervix.
 Leukoplakia (white plaque visible before applying acetic acid)
 Acetowhite tissue (white epithelium after applying acetic acid)
 Punctation (dilated capillaries occurring in a dotted or stippled
pattern)
 Mosaicism (a tile-like pattern)
  Atypical vascular patterns
 An endocervical curettage may be performed during colposcopy if a problem
is suspected based on Pap smear findings
 This analysis of tissue from the cervical canal is used to determine
whether abnormal changes have occurred in the cervical canal. If these
biopsy specimens show premalignant cells or CIN, the patient usually
needs cryotherapy, laser therapy, or a cone biopsy (excision of an
inverted tissue cone from the cervix)

CRYOTHERAPY AND LASER THERAPY

Cryotherapy (freezing cervical tissue with nitrous oxide) and laser treatment are
used in the outpatient setting.
 Cryotherapy may result in cramping and occasional feelings of faintness
(vasovagal response)
 A watery discharge is normal for a few weeks after the procedure as the
cervix heals

CONE BIOPSY AND LEEP

 If the endocervical curettage findings indicate abnormal changes or if the lesion
extends into the canal, the patient may undergo a cone biopsy.
 This can be performed surgically or with a procedure called LEEP (loop
electrosurgical excision procedure), which uses a laser beam.

 The gynaecologist excises a small amount of cervical tissue, and the

pathologist examines the borders of the specimen to determine if they are
free of disease.

 A patient anesthetized for a surgical cone biopsy is advised to rest for 24

hours after the procedure and to leave any vaginal packing in place until the
physician removes it (usually the next day).

 The patient is instructed to report any excessive bleeding

 Because open tissue may be potentially exposed to HIV and other

pathogens, the patient is usually cautioned to avoid intercourse until healing
is complete and verified at follow-up.
  Cervical stenosis can be a complication of this procedure

DILATION AND CURETTAGE (D & C)

 It may be diagnostic (identifies the cause of irregular bleeding) or therapeutic
(often temporarily stops irregular bleeding).
 The cervical canal is widened with a dilator and the uterine endometrium is
scraped with a curette and a perineal pad is placed over the perineum after the
procedure, and excessive bleeding is reported.
 The purpose of the procedure is:
1. To secure endometrial or endocervical tissue for cytologic
examination
2. To control abnormal uterine bleeding
3. A therapeutic measure for incomplete abortion
 This procedure is usually carried out under anesthesia and requires surgical
asepsis, it is usually performed in the operating room
 It may take place in the outpatient setting with the patient receiving a
local anesthetic supplemented with diazepam (Valium), midazolam
(Versed), or meperidine (Demerol). The patient who receives these
medications is carefully monitored until she has fully recovered.
 To reduce the risk of infection and bleeding, most physicians advise no
vaginal penetration or use of tampons for 2 weeks

ENDOSCOPIC EXAMINATIONS
Laparoscopy (Pelvic Peritoneoscopy)
 It involves inserting a laparoscope into the peritoneal cavity through a 2-cm
(0.75-inch) incision below the umbilicus to allow visualization of the pelvic
structures
 It may be used for diagnostic purposes (eg, in cases of pelvic pain when no
cause can be found) or treatment.
 A surgical instrument (intrauterine sound or cannula) may be positioned
inside the uterus to permit manipulation or movement during laparoscopy,
affording better visualization. The pelvic organs can be visualized after the
injection of a prescribed amount of carbon dioxide intraperitoneally into the
cavity. Called insufflation, this technique separates the intestines from the
pelvic organs.
  If the patient is undergoing sterilization, the fallopian or uterine tubes
may be electrocoagulated, sutured, or ligated and a segment removed
for histologic verification
 After the laparoscopy is completed, the laparoscope is withdrawn,
carbon dioxide is allowed to escape through the outer cannula, the small
skin incision is closed with sutures or a clip, and the incision is covered
with an adhesive bandage.
 The patient is carefully monitored for several hours to detect any
untoward signs indicating bleeding, bowel or bladder injury, or burns
from the coagulator
 The patient may experience abdominal or shoulder pain related to the
use of carbon dioxide gas

CT Scan
 It is more effective than ultrasonography for obese patients or patients
with a distended bowel.
 It can also demonstrate a tumor and any extension into the retroperitoneal
lymph nodes and skeletal tissue, although it has limited value in
diagnosing other gynaecologic abnormalities

Ultrasonography (Ultrasound)
 Saline may be instilled into the uterus (saline infusion sonogram) to help
delineate endometrial polyps or fibroids
Magnetic Resonance Imaging
 Risk Factors for Vulvovaginal Infections

 Pre-menarche
 Pregnancy
 Perimenopause/Menopause
 Poor personal hygiene
 Tight undergarments
 Synthetic clothing
 Frequent douching
 Allergies
 Use of oral contraceptives
 Use of broad-spectrum antibiotics
 Diabetes mellitus
 Low estrogen levels
 Intercourse with infected partner
 Oral–genital contact (yeast can inhabit the mouth and intestinal
tract)
 HIV infection

VULVAR CYSTS
Bartholin’s cyst results from the obstruction of a duct in one of the paired vestibular
glands located in the posterior third of the vulva, near the vestibule
 It is the most common of vulvar tumors
 A simple cyst may be asymptomatic, but an infected cyst or abscess may cause
discomfort
 Infection may be due to a gonococcal organism, Escherichia coli or S.
aureus and can cause an abscess with or without involving the inguinal
lymph nodes

 Skene’s duct cysts may result in pressure, dyspareunia, altered urinary

stream, and pain, especially if infection is present

 Vestibular cysts, located inferior to the hymen, may also occur

Medical Management of Bartholin’s cyst
The usual treatment for a Bartholin’s cyst is: Incision + drainage followed by
antibiotic therapy
 If a cyst is asymptomatic, treatment is unnecessary
 Moist heat or sitz baths may promote drainage and resolution
 If surgery is necessary, a Word Bartholin gland catheter is usually used.
 It creates a tract that preserves the gland and allows for drainage
 A nonopioid analgesic agent may be administered before this procedure
 Technique:
1. A local anesthetic agent is injected, and the cyst is incised or lanced and
irrigated with normal saline
2. The catheter is inserted and inflated with 2 – 3 mL of water.
3. The catheter stem is then tucked into the vagina to allow freedom of
movement.
4. The catheter is left in place for 4 - 6 weeks until the tract re-
epithelializes
5. The patient is informed that discharge should be expected, as the
catheter allows drainage of the cyst.
6. She is instructed to contact her primary health care provider if pain
occurs because the bulb may be too large for the cavity and fluid may
need to be removed.
7. Routine hygiene is encouraged
8. Skene’s duct cysts can be excised or drained with a Word catheter.
9. Vestibular cysts are excised if symptomatic

OVARIAN CYSTS
Ovarian cysts are simple enlargements of normal ovarian constituents:
 The graafian follicle
 The corpus luteum
 An abnormal growth of the ovarian epithelium
Dermoid cysts are tumors that arise from parts of the ovum that normally
disappear with ripening (maturation)
 There are consisted of undifferentiated embryonal cells and contain
structures such as hair, fluid, teeth, or skin glands that can be found on or in
the skin.
  Symptoms:
1. May or may not report acute / chronic abdominal pain.
2. Larger cysts may produce abdominal swelling and exert pressure on
adjacent abdominal organs
Polycystic ovary syndrome
It is a complex endocrine condition involving a disorder in the hypothalamic-
pituitary and ovarian network or axis resulting in anovulation, that occurs in women
of childbearing age.
 Onset may occur at menarche or later
 Persons are giving medication which stimulate ovulation if they want to get
pregnant
 These women are at high risk of developing type 2 diabetes later in life because
they are resistant to the action of insulin in their body and produce higher
levels of insulin to overcome this which contributes to the increased
production and activity of hormones like testosterone.
 These women are also at high risk of developing cardiac disorder and having
high cholesterol levels
Polycystic ovaries occur when the ovaries become enlarged and contain many fluid
– filled sacs {follicles} that surround the eggs but are not actual cysts. The eggs
develop in these sacs and are often unable to release an egg, which means ovulation
does not take place.
Symptoms of polycystic ovary syndrome: Related to androgen excess (male
hormone)
 Irregular periods (Due to lack of regular ovulation)
 Obesity
 Hirsutism
 Difficulty getting pregnant
 Thinning hair or loss of hair from head
 Oily skin or acne
Medical Management
 Large cysts are usually surgical removal
 Small cysts that appear to be fluid-filled or physiologic in a young healthy patient
are treated with oral contraceptives which suppress ovarian activity and resolve
the cyst.
 Oral contraceptives are also usually prescribed to treat polycystic ovary
syndro’/me.
Postoperative nursing care after ovarian cyst removal
 Is similar to after abdominal surgery except the marked decrease in intra-
abdominal pressure resulting from removal of a large cyst usually leads to
considerable abdominal distention
 This complication may be prevented to some extent by applying a snug-
fitting abdominal binder.

BENIGN TUMORS OF THE UTERUS

FIBROIDS (LEIOMYOMAS, MYOMAS)
Fibroids arise from the muscle tissue of the uterus and can be found in the lining
(intracavitary), muscle wall (intramural), and outside surface (serosal) of the
uterus
 Common reason for hysterectomy as they often result in menorrhagia that can be
difficult to control
 Develop slowly in women between the ages of 25 - 40 and may become large
Risk Factors: Genetic predisposition & over 30 years

Signs and symptoms of fibroids

 May cause no symptoms or may produce abnormal vaginal bleeding.
Other symptoms are due to pressure on the surrounding organs
 Pain
 Backache
 Constipation
 Urinary problems
 Menorrhagia (excessive bleeding) and metrorrhagia (irregular bleeding) may
occur because fibroids may distort the uterine lining
Medical Management
The patient with minor symptoms is closely monitored. If she plans to have children,
treatment is as conservative as possible.
 Large tumors that produce pressure symptoms should be removed
(myomectomy)
 The uterus may be removed (hysterectomy) if symptoms are bothersome and
childbearing is completed
 Alternatives to hysterectomy developed for the treatment of excessive
bleeding due to fibroids:
1. Hysteroscopic resection of myomas: A laser is used through a
hysteroscope passed through the cervix
2. Laparoscopic myomectomy: Removal of a fibroid through a
laparoscope inserted through a small abdominal incision
3. Laparoscopic myolysis: A laser or electrical needles are used to
cauterize (burn flesh) and shrink the fibroid
4. Laparoscopic cryomyolysis: Electric current is used to coagulate the
fibroid
5. Uterine artery embolization: Polyvinyl alcohol particles are injected
into the blood vessels that supply the fibroid, shrinking it; this
procedure may result in serious complications such as pain, infection,
and bleeding

Pharmacological Management of Fibroids

 GnRH analogs that induce medical menopause may be prescribed to shrink the
tumors
 This treatment consists of monthly injections, which may cause hot
flashes and vaginal dryness.
 This treatment is usually short term (ie, before surgery) to shrink the
fibroids, allowing easier surgery, and to alleviate anemia, which may
coexist due to heavy menstrual flow
 Mifepristone (RU 486), a progesterone antagonist, has also been prescribed
ENDOMETRIOSIS
A benign lesion or lesions with cells similar to those lining the uterus grow defiantly
in the pelvic cavity outside the uterus
 Pelvic endometriosis involves the ovary, uterosacral ligaments, cul-de-sac,
rectovaginal septum, uterovesical peritoneum, cervix, outer surface of the uterus,
umbilicus, laparotomy scar tissue, hernial sacs, and appendix.
 Endometriosis is found in young, nulliparous women between the ages of 25 and
35 years. It is also found in teens, particularly those with dysmenorrhea that does
not respond to NSAIDs or oral contraceptives

Risk Factors of Endometriosis

 Women who have a first-degree relative (mother, sister, daughter) with the
disease
 Women who are giving birth for the first time after age 30
 White women
 Women with an abnormal uterus
 Women with shorter menstrual cycle (less than every 27 days)
 Women with flow longer than 7 days
 Women with outflow obstruction
 Women who have menarche at younger age

SIGNS & SYMPTOMS OF ENDOMETRIOSIS

Extensive endometriosis causes few symptoms, while an isolated lesion may

produce severe symptoms

 Dysmenorrhea
 Dyspareunia
 Pelvic discomfort or pain
 Dyschezia (pain with bowel movements)
 Radiation of pain to the back or leg (may occur)

Pathophysiology
1. Misplaced endometrial tissue responds to and depends on ovarian hormonal
stimulation
2. During menstruation, this ectopic tissue bleeds, mostly into areas having no
outlet, which causes pain and adhesions.
 3. The lesions are typically small and puckered, with a blue/brown/gray powder-
burn appearance and brown or blueblack appearance, indicating concealed
bleeding. They may also have an atypical appearance as red, white, petechial,
and reddish-brown implants.
4. Endometrial tissue contained within an ovarian cyst has no outlet for the
bleeding; this formation is referred to as a pseudocyst or chocolate cyst
The best-accepted theory regarding the origin of endometrial lesions
Transplantation theory:
1. A backflow of menses (retrograde menstruation) transports endometrial tissue
to ectopic sites through the fallopian tubes.
2. Transplantation of tissue can also occur during surgery if endometrial tissue is
transferred inadvertently by way of surgical instruments.
3. Endometrial tissue can also be spread by lymphatic or venous channels

Assessment and Diagnostic Findings

 A health history + account of the menstrual pattern
 On bimanual pelvic examination, fixed tender nodules are sometimes palpated
and uterine mobility may be limited, indicating adhesions
 Laparoscopic examination confirms the diagnosis + stage the disease.
 Stage 1, the patient has superficial or minimal lesions
 Stage 2, mild involvement of pelvic structures in the disease
 Stage 3, moderate involvement of pelvic structures in the disease
 Stage 4, deep involvement of pelvic structures in the disease + dense
adhesions, with obliteration of the cul-de-sac

Medical Management
 If the woman does not have symptoms, routine examination may be all that is
required.
 NSAIDs, oral contraceptives, GnRH agonists, or surgery may treat symptoms
 Pregnancy often alleviates symptoms because neither ovulation nor menstruation
occurs
PHARMACOLOGIC THERAPY Palliative measures include use of medications,
such as analgesic agents and prostaglandin inhibitors, for pain. Hormonal therapy is
effective in suppressing endometriosis and relieving dysmenorrhea (menstrual pain).
Oral contraceptives are used frequently. Side effects that may occur with oral
contraceptives include fluid retention, weight gain, or nausea. These can usually be
managed by changing brands or formulations. Depo-Provera or Lunelle, injectable
contraceptive agents, may also be used. Several types of hormonal therapy are also
available in addition to the oral contraceptives. A synthetic androgen, danazol
(Danocrine), causes atrophy of the endometrium and subsequent amenorrhea. The
medication inhibits the release of gonadotropin with minimal overt sex hormone
stimulation. The drawbacks of this medication are that it is expensive and may cause
troublesome side effects such as fatigue, depression, weight gain, oily skin,
decreased breast size, mild acne, hot flashes, and vaginal at
1428 Unit 10 REPRODUCTIVE FUNCTION
rophy. GnRH agonists decrease estrogen production and cause subsequent
amenorrhea. Side effects are related to low estrogen levels (eg, hot flashes and
vaginal dryness). Loss of bone density is often offset by concurrent use of
estrogen. Leuprolide, another medication, is injected monthly to suppress
hormones, induce an artificial menopause, and thereby avoid menstrual effects
and relieve endometriosis. Some clinicians prescribe a combination of therapies.
Most women continue treatment despite side effects, and symptoms diminish
for 80% to 90% of women with mild to moderate endometriosis. Assisted
reproductive techniques may be warranted and effective in women with
infertility secondary to endometriosis (Olive & Pritts, 2002). Hormonal
medications are not used, however, in patients with a history of abnormal
vaginal bleeding or liver, heart, or kidney disease. Bone density is followed
carefully because of the risk of bone loss; hormone therapy is usually short-
term.
SURGICAL MANAGEMENT If conservative measures are not helpful,
surgery may be necessary to relieve pain and enhance the possibility of
pregnancy. Surgery may be combined with use of medical therapy. The
procedure selected depends on the patient. Laparoscopy may be used to
fulgurate (cut with high-frequency current) endometrial implants and to release
adhesions. Laser surgery is another option made possible by laparoscopy. Laser
therapy vaporizes or coagulates the endometrial implants, thereby destroying
this tissue. Other surgical options include endocoagulation and
electrocoagulation, laparotomy, abdominal hysterectomy, oophorectomy,
bilateral salpingo-oophorectomy, and appendectomy. For women older than 35
or those willing to sacrifice reproductive capability, total hysterectomy is an
option. Endometriosis recurs in many women.
Nursing Management The health history and physical examination focus on
specific symptoms (eg, pain) and when and how long they have been
bothersome, the effect of prescribed medications, and the woman’s reproductive
plans. This information helps in determining the treatment plan. Explaining the
various diagnostic procedures may help to alleviate the patient’s anxiety. Patient
goals include relief of pain, dysmenorrhea, dyspareunia, and avoidance of
infertility. As the treatment progresses, the woman with endometriosis and her
partner may find that pregnancy is not easily possible, and the psychosocial
impact of this realization must be recognized and addressed. Alternatives, such
as in vitro fertilization or adoption, may be discussed at an appropriate time and
referrals offered. The nurse’s role in patient education is to dispel myths and
encourage the patient to seek care if dysmenorrhea or dyspareunia occurs. The
Endometriosis Association (listed at the end of this chapter) is a helpful
resource for patients seeking further information and support for this condition,
which can cause disabling pain and severe emotional distress.