Lesson 15 • Obesity and a higher body weight (more than 20%
UTERINE FIBROIDS over the weight that's considered healthy for you).
Uterine fibroids are a common type of noncancerous
tumor that can grow in and on your uterus. Not all
fibroids cause symptoms, but when they do, symptoms can
include heavy menstrual bleeding, back pain, frequent
urination and pain during sex. Small fibroids often don’t
need treatment, but larger fibroids can be treated with
medications or surgery.
OVERVIEW
What are uterine fibroids and what are the risk
factors?
What are uterine fibroids?
Uterine fibroids (also called leiomyomas) are growths made
up of the muscle and connective tissue from the wall of the
uterus. These growths are usually not cancerous (benign).
Your uterus is an upside down pear-shaped organ in your
pelvis. The normal size of your uterus is similar to a lemon.
It’s the place where a baby grows and develops during
pregnancy.
Fibroids can grow as a single nodule (one growth) or in a
cluster. Fibroid clusters can range in size from 1 mm to
more than 20 cm (8 inches) in diameter or even larger. For
comparison, they can get as large as the size of a
watermelon. These growths can develop within the wall of
the uterus, inside the main cavity of the organ or even on
the outer surface. Fibroids can vary in size, number and
location within and on your uterus.
A variety of symptoms with uterine fibroids and may not be
the same symptoms that another woman with fibroids will
experience. Because of how unique fibroids can be, the
treatment plan will depend on individual case.
Are fibroids common?
Fibroids are actually a very common type of growth in the
pelvic cavity. Approximately 40 to 80% of people have
fibroids. However, many people don’t experience any
symptoms from their fibroids, so they don’t realize they
have fibroids. This can happen when you have small fibroids
— called asymptomatic because they don’t cause patients
to feel anything unusual.
Who is at risk for uterine fibroids?
There are several risk factors that can play a role in your
chances of developing fibroids. These can include:
• Family history of fibroids.
• Not having children.
• Early onset of menstruation (getting your period at
a young age).
• Late age for menopause.
Where do fibroids grow?
There are several places both inside and outside of the
uterus where fibroids can grow. The location and size of
fibroids is important for your treatment. Where fibroids are
growing, how big they are and how many of them will
determine which type of treatment will work best for the
client or if treatment is even necessary.
There are different names given for the places fibroids are
located in and on the uterus. These names describe not
only where the fibroid is, but how it’s attached. Specific
locations where uterine fibroids are found include:
• Submucosal fibroids: In this case, the fibroids are
growing inside the uterine space (cavity) where a baby
grows during pregnancy. Think of the growths
extending down into the empty space in the middle of
the uterus.
• Intramural fibroids: These fibroids are embedded
into the wall of the uterus itself. Picture the sides of the
uterus like walls of a house. The fibroids are growing
inside this muscular wall.
• Subserosal fibroids: Located on the outside of the
uterus this time, these fibroids are connected closely to
the outside wall of the uterus.
• Pedunculated fibroids: The least common type,
these fibroids are also located on the outside of the
uterus. However, pedunculated fibroids are connected
to the uterus with a thin stem. They’re often described
as mushroom-like because they have a stalk and then a
much wider top.
What do fibroids look like?
Fibroids are typically rounded growths that can look like
nodules of smooth muscle tissue. In some cases, they can
be attached with a thin stem, giving them a mushroom-
like appearance.

Are fibroids cancer?
It’s extremely rare for a fibroid to go through changes that
transform it into a cancerous or a malignant tumor. In fact,
one out of 350 people with fibroids will develop
malignancy. There’s no test that’s 100% predictive in
detecting rare fibroid-related cancers. However, people
who have rapid growth of uterine fibroids, or fibroids that
grow during menopause, should be evaluated immediately.
SYMPTOMS AND CAUSES
What causes uterine fibroids?
The causes of fibroids are not known. Most fibroids happen
in people of reproductive age. They typically aren’t seen in
young people who haven’t had their first period yet.
What are the symptoms of uterine fibroids?
Most fibroids do not cause any symptoms and don’t require
treatment other than regular observation by your
healthcare provider. These are typically small fibroids.
When you don’t experience symptoms, it’s called an
asymptomatic fibroid. Larger fibroids can cause you to
experience a variety of symptoms, including:
• Excessive or painful bleeding during your
period (menstruation).
• Bleeding between your periods.
• A feeling of fullness in your lower
abdomen/bloating.
• Frequent urination (this can happen when a fibroid
puts pressure on your bladder).
• Pain during sex.
• Low back pain.
• Constipation.
• Chronic vaginal discharge.
• Inability to urinate or completely empty your
bladder.
• Increased abdominal distention (enlargement),
causing your abdomen to look pregnant.
The symptoms of uterine fibroids usually stabilize or go
away after you’ve gone through menopause because
hormone levels decline within your body.
What does uterine fibroid pain feel like?
There are variety of feelings experience in the presence of
fibroids. If with small fibroids, client may feel nothing at all
and not even notice they’re there. For larger fibroids,
however, client can experience discomforts and even pains
related to the condition. Fibroids can cause feel back pain,
severe menstrual cramps, sharp stabbing pains in abdomen
and even pain during sex.
Can fibroids change over time?
Fibroids can actually shrink or grow over time. They can
change size suddenly or steadily over a long period of time.
This can happen for a variety of reasons, but in most cases
this change in fibroid size is linked to the amount of
hormones in the body. When you have high levels of
hormones in your body, fibroids can get bigger. This can
happen at specific times in your life, like during pregnancy.
Your body releases high levels of hormones during
pregnancy to support the growth of your baby. This surge
of hormones also causes the fibroid to grow. If fibroids are
present before pregnancy, the healthcare provider should
be informed. Monitoring of the fibroid to see how the
fibroid grows throughout the pregnancy should e. Fibroids
can also shrink when your hormone levels drop. This is
common after menopause. Once a woman has passed
through menopause, the amount of hormones in her body
is much lower. This can cause the fibroids to shrink in size.
Often, symptoms can also get better after menopause.
Can fibroids cause anemia?
Anemia is a condition that happens when body doesn’t
have enough healthy red blood cells to carry oxygen to
your organs. It can make a person feel tired and weak.
Some people may develop intense cravings for ice, starch
or dirt. This is called pica and is associated with anemia.
Anemia can happen to people who have frequent or
extremely heavy periods. Fibroids can cause menstrual
periods to be very heavy or to even bleed between periods.
Some treatments like oral iron pills — or if patient is
significantly anemic, an iron infusion (by IV) — can improve
anemia.
DIAGNOSIS AND TESTS
How are uterine fibroids diagnosed?
In many cases, fibroids are first discovered during a regular
exam with your health provider. They can be felt during
a pelvic exam and can be found during a gynecologic exam
or during prenatal care. Quite often your description of
heavy bleeding and other related symptoms may alert your
healthcare provider to consider fibroids as a part of the
diagnosis. There are several tests that can be done to
confirm fibroids and determine their size and location.
These tests can include:
• Ultrasonography: This non-invasive imaging
test creates a picture of your internal organs with
sound waves. Depending on the size of the uterus,
the ultrasound may be performed by the
transvaginal or transabdominal route.
• Magnetic resonance imaging (MRI): This
test creates detailed images of your internal
organs by using magnets and radio waves.
• Computed tomography (CT): A CT scan uses
X-ray images to make a detailed image of your
internal organs from several angles.
• Hysteroscopy: During a hysteroscopy, your
provider will use a device called a scope (a thin,
flexible tube with a camera on the end) to look at
fibroids inside your uterus. The scope is passed
through your vagina and cervix and then moved
into your uterus.
• Hysterosalpingography (HSG): This a
detailed X-ray where a contrast material is injected
first and then X-rays of the uterus are taken. This is
more often used in people who are also
undergoing infertility evaluation.
• Sonohysterography: In this imaging test, a
small catheter is placed transvaginally and saline is
injected via the catheter into the uterine cavity.
This extra fluid helps to create a clearer image of
your uterus than you would see during a standard
ultrasound.
• Laparoscopy: During this test, your provider will
make a small cut (incision) in your lower abdomen.
A thin and flexible tube with a camera on the end
will be inserted to look closely at your internal
organs.
MANAGEMENT AND TREATMENT
How are uterine fibroids treated?
Treatment for uterine fibroids can vary depending on the
size, number and location of the fibroids, as well as what
symptoms they’re causing. If you aren’t experiencing any
symptoms from your fibroids, you may not need treatment.
Small fibroids can often be left alone. Some people never
experience any symptoms or have any problems associated
with fibroids. Your fibroids will be monitored closely over
time, but there’s no need to take immediate action.
Periodic pelvic exams and ultrasound may be recommend
by your healthcare provider depending on the size or
symptoms of your fibroid.If you are experiencing symptoms
from your fibroids — including anemia from the excess
bleeding, moderate to severe pain, infertility issues or
urinary tract and bowel problems — treatment is usually
needed to help. Your treatment plan will depend on a few
factors, including:
• Number of fibroids
• The size of fibroids.
• Where fibroids are located.
• What are the symptoms experience related to the
fibroids.
• Desire for pregnancy.
• Desire for uterine preservation.
The best treatment option will also depend on future
fertility goals. If client wants to have children in the future,
some treatment options may not be an option for her.
Treatment options for uterine fibroids can include:
Medications
• Over-the-counter (OTC) pain medications:
These medications can be used to manage discomforts
and pain caused by the fibroids. OTC medications
include acetaminophen and ibuprofen.
• Iron supplements: If you have anemia from the
excess bleeding, your provider may also suggest you
take an iron supplement.
• Birth control: Birth control can also be used to help
with symptoms of fibroids — specifically heavy
bleeding during and between periods and menstrual
cramps. Birth control can be used to help control heavy
menstrual bleeding. There are a variety of birth control
options you can use, including oral contraceptive pills,
intravaginal contraception, injections and intrauterine
devices (IUDs).
• Gonadotropin-releasing hormone (GnRH)
agonists: These medications can be taken via a nasal
spray or injection and they work by shrinking your
fibroids. They’re sometimes used to shrink a fibroid
before surgery, making it easier to remove the fibroid.
However, these medications are temporary and if you
stop taking them, the fibroids can grow back.
• Oral therapies: Elagolix is a new oral therapy
indicated for the management of heavy uterine
bleeding in people who haven't experienced
menopause with symptomatic uterine fibroids. It can
be used up to 24 months. Talk to your doctor for pros
and cons of this therapy. Another oral therapy,
Tranexamic acid, is an antifibrinolytic oral drug that’s
indicated for the treatment of cyclic heavy menstrual
bleeding in people with uterine fibroids. Your doctor
will monitor you during this therapy.
Fibroid surgery
There are several factors to consider when talking about
the different types of surgery for fibroid removal. Not only
can the size, location and number of fibroids influence the
type of surgery, but your wishes for future pregnancies can
also be an important factor when developing a treatment
plan. Some surgical options preserve the uterus and allow
you to become pregnant in the future, while other options
can either damage or remove the uterus.
Myomectomy is a procedure that allows your provider
to remove the fibroids without damaging the uterus. There
are several types of myomectomy. The type of procedure
that may work best for you will depend on where your
fibroids are located, how big they are and the number of
fibroids. The types of myomectomy procedure to remove
fibroids can include:
• Hysteroscopy: This procedure is done by inserting a
scope (a thin, flexible tube-like tool) through the vagina
and cervix and into the uterus. No incisions are made
during this procedure. During the procedure, you
provider will use the scope to cut away the fibroids.
Your provider will then remove the fibroids.
• Laparoscopy: In this procedure, your provider will
use a scope to remove the fibroids. Unlike the
hysteroscopy, this procedure involves placing a few
small incisions in your abdomen. This is how the scope
will enter and exist your body. This procedure can also
be accomplished with the assistance of a robot.
• Laparotomy: During this procedure, an incision is
made in your abdomen and the fibroids are removed
through this one larger cut.
If you aren’t planning future pregnancies, there are
additional surgical options your healthcare provider may
recommend. These options are not recommended if
pregnancy is desired and there are surgical approaches that
remove the uterus. These surgeries can be very effective,
but they typically prevent future pregnancies. Surgeries to
remove fibroids can include:
• Hysterectomy: During this surgery, your uterus is
removed. A hysterectomy is the only way to cure
fibroids. By removing your uterus completely, the
fibroids can’t come back and your symptoms should go
away. If your uterus alone is removed — the ovaries
are left in place — you will not go into menopause after
a hysterectomy. This procedure might be
recommended if you’re experiencing very heavy
bleeding from your fibroids or if you have large fibroids.
When recommended, the most minimally invasive
procedure to perform hysteroscopy is advisable.
Minimally invasive procedures include vaginal,
laparoscopic or robotic approaches.
• Uterine fibroid embolization: This procedure is
performed by an interventional radiologist who works
with your gynecologist. A small catheter is placed in the
uterine artery or radial artery and small particles are
used to block the flow of blood from the uterine artery
to the fibroids. Loss of blood flow shrinks the fibroids
— improving your symptoms.
• Radiofrequency ablation (RFA): This is a safe and
effective treatment for people with symptomatic
uterine fibroids and can be delivered by laparoscopic,
transvaginal or transcervical approaches.
There’s also a newer procedure called magnetic resonance
imaging (MRI)-guided focused ultrasound that can be used
to treat fibroids. This technique is actually done while
you’re inside a MRI machine. You are placed inside the
machine — which allows your provider to have a clear view
of the fibroids — and then an ultrasound is used to send
targeted sound waves at the fibroids. This damages the
fibroids.
Are there any risks related to fibroid treatments?
There can be risks to any treatment. Medications can have
side effects and some may not be a good fit for you. Talk to
your healthcare provider about all medications you may be
taking for other medical conditions and your complete
medical history before starting a new medication. If you
experience side effects after starting a new medication, call
your provider to discuss your options.
There are also always risks involved in surgical treatment of
fibroids. Any surgery places you at risk of infection,
bleeding, and any inherent risks associated with surgery
and anesthesia. An additional risk of fibroid removal surgery
can involve future pregnancies. Some surgical options can
prevent future pregnancies. Myomectomy is a procedure
that only removes the fibroids, allowing for future
pregnancies. However, people who have had a
myomectomy may need to deliver future babies via
Caesarean section (C-section).
How large do uterine fibroids need to be before
being surgically removed?
The normal uterine size is the size of a lemon or 8 cm. There
isn’t a definitive size of a fibroid that would automatically
mandate removal. Your healthcare provider will determine
the symptoms that are causing the problem. Fibroids the
size of a marble for instance, if located within the uterine
cavity, may be associated with profound bleeding. Fibroids
the size of a grapefruit or larger may cause you to
experience pelvic pressure, as well as make you look
pregnant and see increased abdominal growth that can
make the abdomen enlarged. It’s important for the
healthcare provider and patient to discuss symptoms which
might require surgical intervention.
PREVENTION
Can fibroids be prevented?
In general, you can’t prevent fibroids. You can reduce your
risk by maintaining a healthy body weight and getting
regular pelvic exams. If you have small fibroids, develop a
plan with your healthcare provider to monitor them.
Can I get pregnant if I have uterine fibroids?
Yes, you can get pregnant if you have uterine fibroids. If
you already know you have fibroids when you get pregnant,
your healthcare provider will work with you to develop a
monitoring plan for the fibroids. During pregnancy, your
body releases elevated levels of hormones. These
hormones support the growth of your baby. However, they
can also cause your fibroids to get bigger. Large fibroids
can prevent your baby from being able to flip into the
correct fetal position, increasing your risk of a breech birth
or malpresentation of the fetal head. In very rare cases, you
may be at higher risk of a pre-term delivery or a C-section
delivery. In some cases, fibroids can contribute to infertility.
It can be difficult to pinpoint an exact cause of infertility,
but some people are able to become pregnant after
receiving treatment for fibroids.
Will fibroids go away on their own?
Fibroids can shrink in some people after menopause. This
happens because of a decrease in hormones. When the
fibroids shrink, your symptoms may go away. Small fibroids
may not need treatment if they aren’t causing any
symptoms.
A note from Cleveland Clinic
Uterine fibroids are a common condition that many people
experience during their life. In some cases, fibroids are
small and don’t cause any symptoms at all. Other times,
fibroids can cause challenging symptoms. Talk to your
healthcare provider if you experience any kind of
discomfort or pain. Fibroids can be treated and, often, your
symptoms can be improved.
6 Hysterectomy and TAHBSO Nursing
Care Plans
UPDATED ON MARCH 1, 2023
BY MATT VERA BSN, R.N.
In this article, we will discuss the nursing care plan for a
patient undergoing a total abdominal hysterectomy and
bilateral salpingo-oophorectomy (TAHBSO). Discover
everything you need to know about hysterectomy nursing
care plans and nursing diagnosis. This comprehensive guide
covers the essential aspects of patient care after a
hysterectomy.
What is Hysterectomy?
Hysterectomy is the surgical removal of the uterus. It is
most commonly performed for malignancies and certain
non-malignant conditions, like endometriosis or tumors, to
control life-threatening bleeding or hemorrhage, and in the
event of intractable pelvic infection or irreparable rupture
of the uterus. Less radical procedures such as myomectomy
are sometimes performed for removing fibroids while
sparing the uterus.
Total abdominal hysterectomy bilateral salpingo-
oophorectomy (TAHBSO) is the removal of the entire
uterus, the ovaries, fallopian tubes, and the cervix. TAHBSO
is usually performed in the case of uterine and cervical
cancer. This is the most common kind of hysterectomy.
Removal of the ovaries eliminates the main source of the
hormone estrogen, so menopause occurs immediately.
Types
• Subtotal (partial): The body of the uterus is
removed; the cervical stump remains.
• Total: Removal of the uterus and cervix.
 • Situational Low Self-Esteem
• Total with bilateral salpingo-oophorectomy
(TAHBSO): Removal of the uterus, cervix, fallopian May be related to
tubes, and ovaries is the treatment of choice for
invasive cancer (11% of hysterectomies), fibroid tumors • Concerns about the inability to have children,
that are rapidly growing or produce severe abnormal changes in femininity, and effect on the sexual
bleeding (about one-third of all hysterectomies), and relationship
endometriosis invading other pelvic organs.
• Religious conflicts
• Vaginal hysterectomy or laparoscopically
assisted vaginal hysterectomy (LAVH) may be Possibly evidenced by
done in certain conditions, such as uterine prolapse,
cystocele/rectocele, carcinoma in situ, and high-risk • Expressions of specific concerns/vague comments
obesity. These procedures offer the advantages of about the result of surgery; fear of rejection or reaction
less pain, no visible (or much smaller) scars, a shorter of significant other (SO)
hospital stay, and about half the recovery time, but are
contraindicated if the diagnosis is obscure. • Withdrawal, depression

• A very complex and aggressive surgical procedure may Desired Outcomes

be required to treat invasive cervical cancer. Total
pelvis exenteration (TPE) involves radical • The client will verbalize concerns and indicate healthy
hysterectomy with dissection of pelvic lymph nodes ways of dealing with them.
and bilateral salpingo-oophorectomy, total cystectomy,
and abdominoperineal resection of the rectum. A • The client will verbalize acceptance of self in the
colostomy and/or a urinary conduit are created, and situation and adaptation to change in body/self-image.
vaginal reconstruction may or may not be performed.
These patients require intensive care during the initial
Nursing Assessment and Rationales
postoperative period.

1. Assess the emotional stress the patient is

Nursing Care Plans
experiencing. Identify the meaning of loss for the
patient and SO. Encourage the patient to vent
The nursing goal for patients who are to undergo
feelings appropriately.
Hysterectomy or TAHBSO includes prevention or
Nurses need to be aware of what this operation means to
minimization of complications, supporting adaptation to
the patient to avoid inadvertent casualness or over-
change, preventing complications, and providing
solicitude. Depending on the reason for the surgery (cancer
information on the prognosis and treatment regimen is well
or long-term heavy bleeding), the woman can be frightened
understood, and management of pain.
or relieved. She may fear the loss of ability to fulfill her
reproductive role and may experience grief.
Listed below are six (6) nursing care plans
(NCP) and nursing diagnoses for Hysterectomy 2. Note withdrawn behavior, negative self-talk, use
and TAHBSO: of denial, or concern with actual and/or perceived
changes.
1. Low Self-Esteem Identifies the stage of grief and the need for interventions.
2. Impaired Urinary Elimination
3. Risk for Ineffective Tissue Perfusion Nursing Interventions and Rationales
4. Sexual Dysfunction
5. Constipation/Diarrhea 1. Provide accurate information, reinforcing
6. Deficient Knowledge information previously given.
7. Other Possible Nursing Care Plans Provides an opportunity for patients to question and
assimilate information.
1. Low Self-Esteem
2. Ascertain individual strengths and identify
Nursing Diagnosis previous positive coping behaviors.
 Helpful to build on strengths already available for the
patient to use in coping with the current situation.

3. Provide an open environment for the patient to

discuss concerns about sexuality.
Promotes sharing of beliefs and values about a sensitive
subject, and identifies misconceptions or myths that may
interfere with adjustment to the situation.

4. Provide time to listen to the concerns and fears of

patients and SO. Discuss the patient’s perceptions of
self-related to anticipated changes and her specific
lifestyle.
Listening conveys interest and concern. Give opportunities
to correct common misconceptions like women may fear
the loss of femininity and sexuality, weight gain, and
menopausal body changes.

5. Refer to professional counseling as necessary.

May need additional help to resolve feelings about loss.

Nursing diagnosis

• 1. Low Self-Esteem
• 2. Impaired Urinary Elimination
• 3. Risk for Ineffective Tissue Perfusion
• 4. Sexual Dysfunction
• 5. Constipation and/or Diarrhea
• 6. Deficient Knowledge
•