Breast Care

The nurse’s role is to educate women about the benefit of all three examinations and techniques of self-examination. The reader should consult a medical-surgical text for additional information about the diagnosis and treatment of breast cancer.

Vulvar Self-Examination

Women over 18 years of age (or younger, if sexually active) should perform a monthly examination of the external genitalia to identify lesions or masses that may indicate infection or malignancy. The woman should use a hand mirror in a good light to systematically inspect and palpate her vulva and mons pubis for any new growths of any type, any painful or inflamed areas, ulcers, sores, or changes in skin color. She should report any abnormalities to her health care provider.

Pelvic Examination

The pelvic examination should be scheduled between menstrual periods, and the woman should not douche or have sexual intercourse for at least 48 hours before the examination to avoid altering the Pap test. The purpose of the pelvic examination is to identify conditions such as tumors, abnormal discharge, infections, or unusual pain.

After the Pap test is obtained, the health care provider will perform an internal, or bimanual, examination to evaluate the internal organs. The index and middle fingers of one hand are inserted into the vagina and the other hand is placed on the abdomen to permit palpation of the cervix, uterus, and ovaries between the fingers. After the internal examination, a single lubricated finger is inserted into the rectum to identify hemorrhoids or other lesions. A test for fecal occult blood may be done at this time (see a medical-surgical text for details).

Amenorrhea

Treatment of amenorrhea begins with a thorough history, physical examination, and laboratory examinations to identify the cause. Pregnancy testing is done for any sexually active woman.

The specific treatment depends on the cause that is identified. For example, women who are very thin or have a low percentage of body fat may have amenorrhea because fat is necessary for estrogen production. This group of women may include athletes but may also include patients who have eating disorders such as anorexia or bulimia. Therapy for their eating disorder may result in the resumption of normal periods. Other treatments are aimed at correcting the cause, which may be an endocrine imbalance.

Abnormal Uterine Bleeding

Treatment of abnormal uterine bleeding depends on the identified cause. Pregnancy complications and benign or malignant lesions are treated appropriately. BTB may be relieved by a change in the oral contraceptive used. Abnormal hormone secretion is treated with the appropriate medications. Surgical dilation and evacuation (D&E [formerly known as dilation and curettage, or D&C]) may serve to remove intrauterine growths or aid in diagnosis. Hysterectomy may be done for some disorders if the woman does not want other children. A newer technique, laser ablation, can permanently remove the abnormally bleeding uterine lining without a hysterectomy. Menorrhagia can be treated with mefenamic acid (a nonsteroidal antiinflammatory drug, or NSAID) or tranexamic acid (an antifibrinolytic) if hormone therapy is contraindicated.

Menstrual Cycle Pain

Endometriosis

Endometriosis is the presence of tissue that resembles endometrium outside the uterus. This tissue responds to hormonal stimulation just as the uterine lining does. The lesions may cause pain, pressure, and inflammation to adjacent organs as they build up and slough during menstrual cycles.

Endometriosis causes pain in many women that is either sharp or dull. It is more constant than the spasmodic pain of dysmenorrhea. Dyspareunia (painful sexual intercourse) may be present. Endometriosis appears to cause infertility in some women.

Premenstrual Dysphoric Disorder

Treatment includes prescribing calcium, magnesium, and vitamin B₆ (helps convert tryptophan to serotonin) and a diet rich in complex carbohydrates and fiber (to lengthen effects of the carbohydrate meal). Stress management and exercise are also advised. Medical management includes oral contraceptives (low-estrogen, progestin-dominant), diuretics during the luteal phase of the menstrual cycle (between ovulation and onset of menstruation), and NSAIDs to prevent headaches.

Serotonin reuptake inhibitors such as fluoxetine (Sarafem) may also be prescribed for negative behavior. Medroxyprogesterone (Depo-Provera) may be indicated to inhibit ovulation and thus control estrogen levels. Patient education concerning maintenance of a monthly calendar of symptoms, stress management, and dietary guidance are important nursing responsibilities. Although eating chocolate has been shown to elevate depressed moods, excessive consumption should be avoided.

Toxic Shock Syndrome

Sexually Transmitted Infections

The incidence of STIs has increased over the past few decades. Teaching STI prevention to women across the life span is important because some viral STIs remain in the body for life and can have long-term complications. The most common viral STI is human papillomavirus (HPV), with more than 100 variations. HPV types 16 and 18 are associated with serious cervical cancer, and women who are immunocompromised are at the greatest risk. The use of condoms may not protect the woman if the male’s lesion is on the scrotum or inguinal folds. It may take 3 to 6 months after infection to develop visible warts. Treatment includes cryotherapy, laser vaporization, electrodiathermy, and electrofulguration with a loop electrode excision procedure. Topical agents are used, such as podofilox (Condylox), imiquimod (Aldara), and bichloroacetic acid (BCA). Lidocaine cream may be used 20 minutes before painful treatments. 5-Fluorouracil (5-FU) is no longer used for this condition because of serious side effects.

Herpes simplex virus II (HSV II) is another example of a viral STI that is recurrent and incurable. HSV infection during pregnancy can have serious consequences for the newborn.

Hepatitis B can be sexually transmitted if sexual practices include anal-oral sexual contact, digital rectal sexual intercourse, or multiple sex partners. Symptoms are nonspecific and include malaise, anorexia, nausea, and fatigue. Liver failure can develop. Hepatitis B vaccine can prevent the disease, and immunoglobulin can be given if known exposure has occurred.

Chlamydia trachomatis is the most common bacterial STI in the United States (Centers for Disease Control and Prevention [CDC], 2008). Treatment tends to be delayed because infection is often asymptomatic.

Gonorrhea (GC) is the second most common reportable infectious disease in the United States and a major cause of pelvic inflammatory disease (PID). The occurrence of gonorrhea in 2007 declined except for an increase of 1.8% in the black population. Casual sex in the 15- to 19-year age-group and sex associated with drug use are the highest-risk practices for GC infection (CDC, 2008). Several nucleic acid amplification tests are now available to detect chlamydia, GC, and trichomonas with a simple noninvasive urine sample, with results available in a few hours. Fluoroquinolones are no longer recommended for treatment of GC infections (CDC, 2008).

The rate of syphilis reached an all time low in 2000. However, over the past 7 years the rate has been increasing. Between 2006 and 2007, a 15.2% increase in the diagnosis of syphilis has been noted (CDC, 2008). Untreated syphilis is a risk factor in the spread of human immunodeficiency virus (HIV) infection and also leads to central nervous system (CNS), musculoskeletal, and heart complications. Most newborns of mothers infected with syphilis will have congenital syphilis or die. An external chancre is a characteristic first sign and resolves within 6 weeks without treatment; however, the disease spreads internally. A rash also occurs and resolves, and then the latent period of syphilis occurs and progresses to tertiary syphilis. Aortic aneurysms, dementia, and death can occur.

The number of women infected with HIV worldwide is staggering. Patient education plays a key role in prevention, quality of life, and compassionate and knowledgeable referral. Early diagnosis, access to care, medications, and safe sex practices are improving outcomes and decreasing occurrence. Universal HIV screening at pregnancy is a goal of the National Academy of Sciences Institute of Medicine, because many women do not realize they are infected in the early stages. Education for prevention is essential. Nurses may be less likely to consider the older age-group at risk and may miss opportunities for early detection and education for prevention. Sexual contact and intravenous (IV) drug use are the most common risk behaviors for HIV infection.

Prevention of disease is the key role of the nurse. The nurse must develop strategies, use initiatives, and contact adolescents in the community setting, schools, and churches. Teaching all age-groups healthy behaviors such as abstinence, safe sex practices, and discussion of STI prevention is essential. Improving access to care and early detection is also important. The CDC offers various free programs that are available over the Internet and can be used by nurses and teachers in the community to teach STI prevention.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an infection of the upper reproductive tract. Asymptomatic STIs are a common cause of PID. The cervix, uterine cavity, fallopian tubes, and pelvic cavity are often involved. Infertility may be the result.

The woman’s symptoms vary according to the area affected. Fever, pelvic pain, abnormal vaginal discharge, nausea and anorexia, and irregular vaginal bleeding are common. When examined, the abdomen and pelvic organs are often very tender. Laboratory tests identify common general signs of infection, such as elevated leukocytes and an elevated sedimentation rate. Cultures of the cervical canal are done to identify the infecting organism. Urinalysis is usually done to identify infection of the urinary tract.

Treatment may be administered on an inpatient or outpatient basis depending on the severity of the infection. Antibiotics are begun promptly to treat the infection. A change in antibiotic(s) is made if culture and sensitivity testing indicates that another one would be more effective.

Douching results in changes in the vaginal flora and predisposes the woman to the development of PID, bacterial vaginosis, and ectopic pregnancies. However, many women practice regular douching in the belief that it is cleansing. The nurse can play an important role in educating the woman to prevent PID. A diagnosis of PID is reportable to the local health department in many states.

Contraception

Natural Family Planning

Natural family planning, also called fertility awareness, involves learning to identify the signs and symptoms associated with ovulation. The couple either abstains from intercourse or uses a barrier method during the period that is presumed to be fertile. The ovum is viable up to 24 hours after ovulation, and sperm are viable for 48 to 72 hours in the fallopian tube, although most die within 24 hours.

Natural family planning methods are acceptable to most religions. They require no administration of systemic hormones or insertion of devices. They are not only reversible but also can actually be used to increase the odds of achieving pregnancy when the couple desires a child.

Natural family planning requires extensive assessment and charting of all the changes in the menstrual cycle. The woman must be highly motivated to track the many factors that identify ovulation. Both partners must be willing to abstain from intercourse for much of the woman’s cycle if the method is used to prevent pregnancy. They must also be willing to accept the relatively high failure rate of 20%. Most women use a combination of the following four methods for predicting when they are fertile to increase the predictive value over that of each method on its own.