Interventions for Clients with

Gynecologic Problems

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Assessment of female genitalia
• History (demographic, family, personal,
reproductive), diet, socioeconomic status
• Complains (pain, bleeding, discharge,
masses)
• Assessment of external genitalia
• Speculum examination
• Bimanual examination
• Recto-vaginal examination

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Assessment of female genitalia
Lab tests
PAP
DNA papiloma virus,
Blood test (FSH, LH, Prod, E, PRL, T),
(serologic)
Microscopic (cultures)
X-ray (general, CT, Hysterosalpingography),
MRI
Ultrasound

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Assessment of female

genitalia

Endoscopic
• colposcopy, laparoscopy, hysteroscopy
Biopsy
• cervical, endometrial

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Primary Dysmenorrhea
• One of the most common gynecologic problems,
occurring most often in women in their teens and
early 20s.
• Treatment
– Postaglandin synthetase inhibitors, oral
contraceptives
– Complementary and alternative therapy

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Premenstrual Syndrome
• A collection of symptoms that are cyclic in nature
• Diet therapy
• Drug therapy: mild potassium-sparing diuretics,
progesterone, bromocriptine mesylate, Sarafem

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Amenorrhea
• Absence of menstrual periods
• Primary amenorrhea
• Secondary amenorrhea
• Treatment: hormone replacement, ovulation
stimulation, periodic progesterone withdrawal

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Postmenopausal Bleeding
• Manifestation (not disease)—vaginal bleeding
that occurs after a 12-month cessation of
menses after the onset of menopause
• Atrophic vaginitis
• Endometrial hyperplasia
• Treatment: endometrial biopsy, hysterectomy,
hormonal replacement therapy, vaginal
lubricants

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Endometriosis
• Endometriosis is usually a benign problem of
endometrial tissue implantation outside the
uterine cavity.
• Manifestations include pain, dyspareunia, painful
defecation, sacral backache, hypermenorrhea,
and infertility.
(Continued)

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Endometriosis (Continued)
• Erythrocyte sedimentation rate and white blood
cell count rule out pelvic inflammatory disease.
• Laparoscopy is the key diagnostic procedure.

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Interventions
• Drug therapy
• Mild analgesics, nonsteroidal anti-inflammatory
drugs, hormonal therapies, pseudopregnancy,
pseudomenopause, or medical oophorectomy
• Complementary and alternative therapy
• Surgical management

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Dysfunctional Uterine Bleeding
• Nonspecific term to describe bleeding that is
excessive or abnormal in amount or frequency
without predisposing anatomic or systemic
conditions

(Continued)

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Dysfunctional Uterine Bleeding (Continued)
• Associated with:
– Endocrine disturbances
– Polycystic ovary disease
– Stress
– Extreme weight changes
– Long-term drug use
– Anatomic abnormalities

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Collaborative Management
• Nonsurgical management includes hormone
manipulation.
• Surgical management includes:
– Dilation and curettage procedure
– Laser or balloon endometrial ablation
– Hysterectomy

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Menopause
• Normal biologic event marked for most women
by the end of menstrual periods (6 to 12
months of amenorrhea)
• Role of hormone replacement therapy in the
management of symptoms
• Perimenopause indicated by changes in ovarian
function
• Interventions, including hormone replacement
therapy

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Simple Vaginitis
• Inflammation of the lower genital tract
• Result of one or more of the following:
– Menopause
– Trichomonas vaginalis
– Candida albicans
– Changes in normal flora
– Alkaline pH
(Continued)

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Simple Vaginitis (Continued)
– Foreign bodies
– Chemical irritants
– Diabetes

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Management
• Perineal cleaning after urination or defecation
• Wearing cotton underwear
• Avoiding strong douches and feminine hygiene
sprays
• Avoiding tight-fitting pants
• Using estrogen creams
• Eating yogurt with antibiotics

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Vulvitis

• Inflammatory condition of the vulva (itching)

associated with symptoms of pruritus and a
burning sensation
• Other causes include the following:
– Atrophic vaginitis
– Vulvar kraurosis
– Vulvar leukoplakia
– Cancer
– Urinary incontinence

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Management
• Measures to relieve itching, including sitz baths
• Prescribed antibiotics
• Treatment of pediculosis and scabies, if needed
• Laser therapy

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Toxic Shock Syndrome (TSS)
• First recognized in 1980 when it was found to be
related to menstruation and tampon use
• Staphylococcus aureus
• Abrupt onset of high temperature, headache,
sore throat, vomiting, diarrhea, generalized rash,
hypotension
• Penicillin or vancomycin

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Uterine Prolapse
• Stages of uterine prolapse are described by the
degree of descent of the uterus.
• Dyspareunia, backache, pressure in the pelvis,
bowel or bladder problems
• Pessaries
• Surgery

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Cystocele
• Protrusion of the bladder through the vaginal wall
due to weakened pelvic structures
• Difficulty in emptying bladder, urinary frequency
and urgency, urinary tract infection, stress
urinary incontinence
• Kegel exercises
• Surgery

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Rectocele
• Protrusion of the
rectum through a
weakened vaginal
wall
• Constipation,
hemorrhoids, fecal
impaction, feelings of
rectal or vaginal
fullness
• High-fiber diet, stool
softeners, laxatives
• Surgery
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Cystocele and rectocele

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 Fistulas
• Abnormal openings
between two adjacent
organs or structures
• Leakage of urine, flatus,
or feces into the vagina,
irritation or excoriation of
the vulva and vaginal
tissues, fecal or urine
odor in the vagina,
feelings of wetness or
dribbling in the vagina
• Nonsurgical treatment
• Surgical treatment
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Follicular Cysts
• Cyst—usually small and may be asymptomatic
unless it ruptures
• Rupture of a follicular cyst or torsion—may
cause acute, severe pelvic pain
• Medical management
• Surgical management includes:
– Cystectomy
– Oophorectomy

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Corpus Luteum Cyst
• Occurs after ovulation and often with increased
secretion of progesterone; usually small,
purplish red
• May cause unilateral low abdominal or pelvic
pain that is dull or aching
• Intraperitoneal hemorrhage possible if cyst
ruptures

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Theca-Luatein Cysts
• These cysts are uncommon, often associated
with hydatidiform molar pregnancy.
• Cysts develop as a result of prolonged
stimulation of the ovaries by excessive amounts
of hCG.
• Cysts regress spontaneously within 3 months
with the removal of the molar pregnancy.

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Polycystic Ovary
• High levels of luteinizing hormone overstimulate
the ovaries, producing multiple cysts on one or
both ovaries.
• Endometrial hyperplasia or even carcinoma may
result.
• Typical client is obese, hirsute, has irregular
menses, and may be infertile.
• Treatment is with oral contraceptives, surgery, or
clomiphene.

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Other Benign Ovarian Cysts and Tumors
• Dermoid cysts
• Ovarian fibromas
• Epithelial ovarian tumors
• Uterine leiomyomas

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Potential for Hemorrhage Due to
Leiomyomas
• Interventions include:
– Examination every 4 to 6 months
– Uterine artery embolization
– Myomectomy
– Total abdominal hysterectomy
– Total vaginal hysterectomy
– Transcervical endometrial resection

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Complications of Hysteroscopic Surgery
• Fluid overload
• Embolism
• Hemorrhage
• Perforation of the uterus, bowel, or bladder and
ureter injury
• Persistent increased menstrual bleeding
• Incomplete suppression of menstruation

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Bartholin Cyst
• Obstruction of the duct of the Bartholin’s gland
caused by infection, thickened mucus near the
ductal opening, or trauma such as lacerations or
episiotomy
• Simple incision and drainage
• Marsupialization (formation of a pouch)
• Postoperative care

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Cervical Polyps
• Pedunculated tumors (on stalks) arising from the
mucosa and extending to the opening of the
cervical os
• Polyp removal—a simple office procedure

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Endometrial Cancer
• Endometrial cancer is a reproductive cancer, of
which adenocarcinoma is the most common
type.
• The main symptom is postmenopausal bleeding.
• Diagnostic assessment includes the following
tests:
– CA-125 tumor marker
– Chest x-ray
(Continued)

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Endometrial Cancer (Continued)
– Intravenous pyelography
– Barium enema
– CT of the pelvis
– Liver and bone scans
– Functional dilation and curettage

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Radiation Therapy
• External and internal
• Teletherapy
• Brachytherapy
• Intracavitary radiation

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Surgical Management
• Total abdominal hysterectomy and bilateral
salpingo-oophorectomy
• Radical hysterectomy with bilateral pelvic lymph
node dissection for stage II cancer

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Cervical Cancer
• Common reproductive cancer among women in
the U.S.
• Disorder is a progression: from totally normal
cervical cells to premalignant changes in
appearance of cervical cells (dysplasia), to
changes in function, ultimately to transformation
to cancer
• Carcinoma in situ
• Preinvasive or invasive

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Clinical Manifestations
• Client often asymptomatic
• Classic symptom: painless vaginal bleeding
• Watery, blood-tinged vaginal discharge that may
become dark and foul-smelling as the disease
progresses

(Continued)

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Clinical Manifestations (Continued)
• Leg pain
• Flank pain
• Unexplained weight loss, pelvic pain, dysuria,
hematuria, rectal bleeding, chest pain and cough

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Diagnostic Assessment
• Pap smear
• Squamous atypia, inflammatory atypia, or minor
atypia abnormalities
• Bethesda system
• Colposcopic examination
• Endocervical curettage

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Nonsurgical Management
• Local ablation of electrosurgical excision using
the loop electrosurgical excision procedure
• Laser therapy
• Cryotherapy
• Radiation therapy
• Chemotherapy
• Conization

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Surgical Management
• Clinical staging performed before surgery to
establish extent of the disease
• Simple hysterectomy
• Radical hysterectomy
• Pelvic exenteration

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Postoperative Care
• Early stages of recovery, assess for:
– Hemorrhage and shock
– Pulmonary complications
– Fluid and electrolyte imbalances
– Renal or urinary complications
– Pain
(Continued)

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Postoperative Care (Continued)
• Later stages of recovery, assess for:
– Deep vein thrombosis
– Pulmonary emboli
– Paralytic ileus
– Wound infections
– Wound dehiscence
– Wound evisceration
– Pain

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Ovarian Cancer
• Most common type—serous adenocarcinoma
• Vague abdominal discomfort, dyspepsia,
indigestion, gas, and distention
• Ovarian antibody CA-125, ultrasound,
intravenous pyelography, barium enema, upper
gastrointestinal radiographic series to rule out
tumors

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Nonsurgical Management
• Chemotherapy with agents such as cisplatin,
carboplatin, and paclitaxel
• Radiation therapy

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Surgical Management
• Total abdominal hysterectomy and bilateral
salpingo-oophorectomy
• Staging
• Second-look procedure usually after 1 year of
chemotherapy

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Vulvar Cancer
• Most are squamous cell carcinomas.
• Women often report irritation or itching in their
perineal area or a sore that will not heal.
• Toluidine blue test identifies abnormal cells.
• Keyes dermal punch is used for tissue biopsy.

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Management
• Laser therapy
• Radiation therapy
• Surgical management: vulvectomy or skinning
vulvectomy, or radical vulvectomy

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Postoperative Care
• Providing wound care
• Promoting urinary and bowel elimination
• Managing pain
• Addressing sexuality

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Vaginal Cancer
• Rare, accounting for less than 2% of all
gynecologic cancers
• Associated with intrauterine exposure to
diethylstilbestrol
• Treatment with any of the following:
– Laser therapy
– Topical chemotherapy
(Continued)

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Vaginal Cancer (Continued)
– Radiation therapy
– Surgical management—vaginectomy for
invasive disease

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Fallopian Tube Cancer
• Rarest of all gynecologic cancers (<1%)
• Most common symptoms: postmenopausal
bleeding, increased abdominal pain, watery
vaginal discharge, leukorrhea
• Treatment: total abdominal hysterectomy and
bilateral salpingo-oophorectomy with
omentectomy.

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