Pathophysiology

Endometriosis is endometrial (inner uterine) tissue implantation outside the uterine cavity. The tissue typically appears on the ovaries and the cul-de-sac (posterior rectovaginal wall) and less commonly on other pelvic organs and structures (Fig. 74-1). A “chocolate” cyst is an area of endometriosis on an ovary. The disease affects millions of women in the United States and Canada.

FIG. 74-1 Common sites of endometriosis.

Endometriosis responds to cyclic hormonal stimulation just as if it were in the uterus. Monthly cyclic bleeding occurs at the ectopic (out of place) site of implantation, which irritates and scars the surrounding tissue. Scarring can lead to adhesions, causing infertility (inability to become pregnant). Endometriosis progresses slowly and regresses during pregnancy and at menopause. Rarely does it become cancerous.

The cause of endometriosis is unknown. One theory is that the endometrial tissue migrates directly through the fallopian tubes during menses. The tissue then implants on pelvic structures or distant organs such as lungs or heart. The formation theory suggests that endometrial tissue develops outside the uterus as a birth defect. Other theories focus on immune, genetic, and environmental factors (e.g., exposure to dioxin, a toxic chemical). Many women with endometriosis have allergies and chemical sensitivities.

The disorder is most often found in women during their reproductive years, but it can affect women into their 80s. The prevalence among infertile women is higher than it is for women who are fertile. It is also common in those whose mothers had endometriosis.

Patient-Centered Collaborative Care

Pathophysiology

Dysfunctional uterine bleeding (DUB) is excessive and frequent bleeding (more than every 21 days). It is a diagnosis of exclusion, made after ruling out anatomic or systemic conditions such as drug therapy or disease. DUB occurs most often at the beginning or end of a woman’s reproductive years—when ovulation is becoming established or when it is becoming irregular at or after menopause.

Normally the menstrual cycle is a series of delicately timed hormonal events regulated by hypothalamic, pituitary, ovarian, and uterine functions. Menses, the sloughing of the endometrial lining, is an expected result. DUB occurs when there is a hormonal imbalance. Generally, it happens when the ovaries fail to ovulate. This decreases progesterone production, which is needed to mature the uterine lining and prevent overgrowth. Without progesterone, prolonged estrogen stimulation causes the endometrium to grow past its hormonal support, causing disordered shedding of uterine lining. Most cases of DUB are classified into two types: anovulatory DUB (most common) and ovulatory DUB (Ayers & Montgomery, 2009). Common risk factors for DUB during the reproductive years are listed in Table 74-1.

TABLE 74-1 RISK FACTORS FOR DYSFUNCTIONAL UTERINE BLEEDING

Patient-Centered Collaborative Care

Pathophysiology

Vaginal discharge and itching are two problems experienced by most women at some time in their lives. Women can suffer vaginal infections from both sexually and non–sexually transmitted sources. Gonorrhea, syphilis, chlamydia, and herpes simplex virus are sexually transmitted diseases (STDs) discussed in Chapter 76.

Vulvovaginitis is inflammation of the lower genital tract resulting from a disturbance of the balance of hormones and flora in the vagina and vulva. It may be characterized by itching, change in vaginal discharge, odor, or lesions. The most common causes include:

Primary infections that affect the vulva include herpes genitalis and condylomata acuminata (human papilloma virus, venereal warts) (see Chapter 76). Secondary infections of the vulva are caused by organisms responsible for the many types of vaginitis, including candidiasis. Pediculosis pubis (crab lice) and scabies (itch mite) are common parasitic infestations of the skin of the vulva. Other causes of vulvitis include:

Some women may have an itch-scratch-itch cycle, in which the itching leads to scratching, which causes excoriation that then must heal. As healing takes place, itching occurs again. If the cycle is not interrupted, the chronic scratching may lead to the white, thickened skin of lichen planus. This dry, leathery skin cracks easily, increasing the woman’s risk for infection.

Patient-Centered Collaborative Care

Assess for vulvovaginitis by asking questions about the symptoms, assisting with a pelvic examination, and obtaining vaginal smears for laboratory testing. Inquire about symptoms of itching and burning sensation. Erythema (redness), edema, and superficial skin ulcers also may be present. Use a nonjudgmental approach and provide reassurance during the assessment because the patient may be embarrassed or afraid to discuss her symptoms. Encourage her to talk about her problem and its effect on her sexual health.

Interventions for vulvovaginitis depend on the causes and the specific vaginal infection. Proper health habits can benefit treatment. Instruct the patient to get enough rest and sleep, observe good dietary habits, exercise regularly, and use good personal hygiene. Teach her about how to manage her infection (Chart 74-1). Chart 74-2 outlines measures to help prevent further infections.

Nursing interventions to relieve itching include applying wet compresses, sitz baths for 30 minutes several times a day, and using topical drugs such as estrogens and lidocaine. Encourage the removal of any irritant or allergen, such as changing detergents.

Treatment of pediculosis and scabies is used if needed and includes:

Pathophysiology

Toxic shock syndrome (TSS) was first recognized in 1980 when it was found to be related to menstruation and tampon use. Other conditions associated with TSS include surgical wound infection, nonsurgical infections, and gynecologic surgeries. Use of internal contraceptives has also been linked to this health problem.

In infection related to menstruation, menstrual blood provides a growth medium for Staphylococcus aureus (or, less frequently, Streptococcus). Exotoxins produced from the bacteria cross the vaginal mucosa to the bloodstream via microabrasions from tampon insertion or prolonged use. A small number of TSS cases are fatal. Extensive public education has led to a decreased number of women having the infection.

Patient-Centered Collaborative Care

Within 24 hours of contact with the causative agent, the abrupt onset of a high fever, along with headache, flu-like symptoms, and severe hypotension with fainting, is often present. A sunburn-like rash with broken capillaries in the eyes and skin is another warning sign of TSS. Because not all women have all these manifestations, the criteria established by the Centers for Disease Control and Prevention (CDC) are used to verify cases (Chart 74-3). Educate all women on the prevention of TSS (Chart 74-4).

Treatment includes removal of the infection source, such as a tampon; restoring fluid and electrolyte balance; drugs to manage hypotension; and IV antibiotics. Other measures may include transfusions to reverse low platelet counts and corticosteroids to treat skin changes.

Pathophysiology

The pelvic organs are supported by a sling of muscles and tendons, which sometimes become weak and no longer able to hold an organ in place. Uterine prolapse, the most common type of pelvic organ prolapse (POP), can be caused by neuromuscular damage of childbirth; increased intra-abdominal pressure related to pregnancy, obesity, or physical exertion; or weakening of pelvic support due to decreased estrogen. The stages of uterine prolapse are described by the degree of descent of the uterus (Fig. 74-2) through the pelvic floor.

FIG. 74-2 Types of uterine prolapse.

Whenever the uterus is displaced, other structures such as the bladder, rectum, and small intestine can protrude through the vaginal walls (Fig. 74-3). A cystocele is a protrusion of the bladder through the vaginal wall (urinary bladder prolapse), which can lead to stress urinary incontinence (SUI) and urinary tract infections (UTIs). A rectocele is a protrusion of the rectum through a weakened vaginal wall (rectal prolapse).

FIG. 74-3 In cystocele, the urinary bladder is displaced downward, causing bulging of the anterior vaginal wall. In rectocele, the rectum is displaced, causing bulging of the posterior vaginal wall.

Patient-Centered Collaborative Care

Pathophysiology

Leiomyomas, also called fibroids or myomas, are benign, slow-growing solid tumors of the uterine myometrium (muscle layer). They are classified according to their position in the layers of the uterus. The most common types are intramural, submucosal, and subserosal (Fig. 74-4).

FIG. 74-4 Classification of uterine leiomyomas.