What is Pelvic Inflamatory disease?

- an infection condition of the pelvic cavity that may involve the fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum (peritonitis).

Etiology of PID:

- often result of untreated cervicitis (most common causative organisms N. gonorrhoeae and Chlamydia trachomatis).  Not all cases are a result of an STD, also preg termination, pelvic surgery, or childbirth.

Silent PID

- major cause of female infertility.  Chlamydial infections can be asymptomatic and unknowingly transmitted. 

- increased risk for chlamydial = younger than 24, multiple partners, or a new one (sex partner)!

Chronic pelvic pain

- pain 6 months in duration or longer, located below unmilicus and between hips.  1/3  have this after PID.

- other factors associated are interstitial cystitis, irritable bowel syndrome, adhesions, endometriosis, and dysmenorrhea.

PID manifestations:

• lower abd pain
• pain during walking or intercourse
• spotting after intercourse
• purulent discharge
• fever/chills
• abd pain

clincial dx

• lower abd, adnexal, and positive cervical motion tenderness
• fever
• discharge
• cultures and preg test to r/o STDs and ectopic pregnancy

PID treatment

drug therapy begins w/ minimal diag criteria are met

• abx: cefoxtin (Merfoxin) and doxycycline (Vibramycin)
• no intercourse for 3 weeks, exam partner!
• Important = physical rest and oral fluids
• reevaluate 48-72 hours

Unsuccessful

• possible admitted to hospital
• Corticosteroids - to reduce inflammation
• apply heat to lower abd or sitz bath - circulation/decrease pain
• Semi-fowler position - drainage (yuck), and prevent abscesses

PID and surgery

• presence of abscesses failed to resolve w/ IV abx
• drained - laparoscopy or laparotomy
• hysterectomy may be performed

Complications of PID

• septic shock
• Fitz-Hugh-Curtis syndrome, occurs when spreads to the liver and causes acute perihepatitis
• embolisms - thrombophlebitis of the pelvic vein
• ectopic pregnancy - risk increases 10 fold

Nursing management of PID

- Education of symptoms, treatment, followup, and how methods to decrease getting STDs.

Etiology of cervical cancer

• related to repeated injuries to the cervix
• strong relationship between dysplasia and HPV infections!

Clinical manifestations

• asymptomatic
• eventually leukorrhea and intermenstrual bleeding occurs
• pain is a late symptom followed by weight loss, anemia, and cachexia

Diagnostic studies for cervical cancer

• Pap tests
• HPV DNA test may be better for screening
• abnormal pap needs to be tested again in 4-6 months for up to 2 years (80% may revert).
• more prominent changes receive additional (biopsy or colpscopy)

Cervical cancer care

Vaccines against HPV!

depends on stage =

surgery - hysterectomy, rarely pelvic exenterations

irradiation - external or internal 4-6 weeks, followed by brachytherapy.

chemo in single or combination - when cancer has spread beyond the cervix

Endometrial cancer etiology

• major risk is estrogen, especially unopposed
• age
• nulliparity
• late menopause
• obesity - stores estrogen
• smoking
• diabetes mellitus
• family history
• grows slowly, metastases late, and is curable with therapy if diagnosed early.

Endometrial cancer clinical manifestations

• abnormal uterine bleeding (usually postmenopausal)
• Pain occurs late
• other  manifestations relate to metastasis to other organs

Treatment for endometrial cancer

total hysterectomy and bilateral salpingo-oophorectomy with lymph node biopsies

treatment of advanced or recurrent disease is difficult:

1. progesterone hromonal - megestrol (Megace)
2. Tamoxifen (Nolvadex) alone or in combination w/ progesterone therapy
3. Chemo only when progesterone is unsuccessful

Ovarian cancer etiology

5th leading cause of cancer deaths us U.S.

unknown etiology BUT -

• mutation of BRCA genes have increase risk
• major risk is family history
• breast or colon cancer
• nulliparity

Ovarian cancer manifestation

• pelvic/abd pain
• bloating
• urinary urgency/frequency
• difficulty in eating or feeling full quicklly

Ovarian cancer diagnostic studies

No screening test exist/has vague symptoms SO:

• yearly pelvic exams
• abd ultrasound- detect masses
• OVA1 test levels of 5 proteins that change due to ovarian cancer
• CA-125 - positive in 80% of women w/ epithelial ovarian cancer.  May be elevated with other malignancies.

Ovarian cancer care

Staging is critical.

     Stage I = TAH-BSO (Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy), might also chemo or instillation of radioisotopes.

     Gets more and more chemo and radiation therapy as stages increase, along with follow up.

     With metastasis recurrent pleural effusion often causes SOB requiring frequent paracentesis.

Polycystic Ovary Syndrome is

a chronic disorder in which many benign cysts form on the ovaries.

Can cause infertility

     Due to hormonal abnormalities, ovaries produce estrogen and excess testosterone but no pregesterone.

     Fluid filled cysts develop from mature ovarian follicles that fail to rupture each month.

PCOS clinical manifestations

• irregular menstrual periods
• ammenorrhea or oligomenorrhea
• dysfunctional uterine bleeding
• hirsutism
• obesity
• acne

 if left untreated CV disease and abnormal insulin resistance w/ T2 diabetes mellitus may develop

PCOS treatment

Management of symptoms

• Oral contraceptives - regulate menstrual cycle

• Hirsutism - spironolactone (Aldactone)

• Hyperandrogenism - flutamide (Eulexin), leuprolide (Lupron).  Reduces hyperinsulinemia as well and restore ovulation.

• Fertility - clomiphene (Clomid) to induce ovulation.

What to know about a hysterectomy post-operation

Urinary retention - cath if not urinated for 8 hours

Any complaint of backache or decreased urine output should be reported to surgeon

Ambulate is encouraged

Rectal tube may be perscribed to relieve abd flatus

Prevent DVTs

Loss of uterus may bring about grief.

Hormone replacement therapy

No intercourse for 4-6 weeks.

Heavy lifting avoided for 2 months.

Breast cancer risk factors

• female
• >50 year old
• family history
• personal hx of cancers
• early menatche; late menopause
• first preg after 30; nulliparity
• benign breast disease
• weight gain/obesity after menopause
• radiation exposure
• alcohol
• physical inactivity
• combined hormone replacement
• BRCA1 and BRCA 2 mutation

Pathology of breast cancer:

1. three types we need to know
2. and a little info about them

1. Noninvasive breast cancer - include ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS), risk to progress into breast cancer.  DCIS tends to be unilateral.  Tx is lumpectomy, mastectomy, radiation, and/or tamoxifen (Nolvadex).  LCIS - no treatment is necessary.  Tamoxifen may be given as a chemoprevention.
2. Paget's Disease - characterized by persistent lesion if the nipple and areola w/ or w/o palpable mass.  Itching, burning, bloody discharge.  Tx is mastectomy (simple or modified radical).  Prognosis is good.
3. Inflammatory Breast Cancer - most malignant, very fast and aggressive growing w/ high risk for, metastasis.  Skin is peau d'orange.  Tx is neoadjuvant chemotherapy (chemo given before surgery), first course, followed by radiation.  Surgery, hormone therapy, and biologic therapy (trastuzumab [Herceptin]) may be indicated.

Breast cancer menifestations and complications

Detected as lumps or abnormality.  Hard, irregularly shaped, poorly delineated, nonmobile, and nontender.  Possible nipple discharge (clear or bloody).

Main problem is recurrence.  Metastases by lymphatic system.

Diagnostic studies for breast cancer

Axillary lymph node dissection or sentinel lymph node dissection.  Determine if cancer has spread.

Breast cancer treatment

Depends on prognostic factors:

TNM system - tumor size, nodal involvment, and metastatsis.  I to IV, I  being a very small tumor (<2cm), IV metastasis spread.

Mastectomy, lumpectomy, adjuvant therapy, radiation, brachytherapy, chemotherapy, hormonal therapy, or biologic therapy.  You should know these by now!

Lymphedema

accumulation of lymph in soft tissue.  Can occur as a result of the excision or irradiation of lymph nodes.