Female reproductive care
Diseases
Breast cancer
Along with lung cancer, breast cancer is a leading killer of women ages 35 to 54.
With early detection and treatment, however, the prognosis is influenced considerably. The American Cancer Society believes the combination of mammography, clinical breast examination, and finding and reporting breast changes early offers females the best opportunity for reducing breast cancer mortalities.
About half of all breast cancers develop in the upper outer quadrant, and growth rates vary. Theoretically, slow-growing breast cancer may take up to 8 years to become palpable at 1 cm. It spreads by way of the lymphatic system and the bloodstream through the right side of the heart to the lungs and to the other breast, chest wall, liver, bone, and brain.
Risk factors for breast cancer include:
female gender
increasing age (risk greater after age 60)
family history of breast cancer
genetic mutations BRCA 1 and BRCA 2
radiation exposure
obesity
menarche before age 12
menopause after age 55
women with their first child after age 35
postmenopausal hormone therapy.
Classified by histologic appearance and the lesion’s location, breast cancer may be described as:
adenocarcinoma (ductal)—arising from the epithelium
intraductal—developing within the ducts (includes Paget’s disease)
infiltrating—occurring in the breast’s parenchymal tissue
inflammatory (rare)—growing rapidly and causing overlying skin to become edematous, inflamed, and indurated
lobular carcinoma in situ—involving the lobes of glandular tissue
medullary or circumscribed—enlarging tumor with rapid growth rate.
Coupled with a staging system, these classifications provide a clearer picture of the cancer’s extent. The most common system for staging, both before and after surgery, is the TNM (tumor, node, metastasis) system.
Breast tumor sources and sites
About 90% of all breast tumors arise from the epithelial cells lining the ducts. About half of all breast cancers develop in the breast’s upper outer quadrant—the section containing the most glandular tissue.
The second most common cancer site is the nipple, where all of the breast ducts converge.
The next most common site is the upper inner quadrant, followed by the lower outer quadrant and, finally, the lower inner quadrant.
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Ductal carcinoma in situ
Infiltrating (invasive) ductal carcinoma
Signs and symptoms
Painless lump or mass in the breast or a thickening of breast tissue
Mass that most commonly appears on a mammogram before a lesion becomes palpable
Clear, milky, or bloody nipple discharge
Nipple retraction
Peeling, flaky, scaly skin around the nipple
Skin changes, such as dimpling, peau d’orange (orange peel), or inflammation
Cervical supraclavicular and axillary nodes that may show lumps or enlargement
Looking at breast dimpling and peau d’orange
Breast dimpling
Breast dimpling—the puckering or retraction of skin on the breast—results from abnormal attachment of the skin to underlying tissue. It suggests an inflammation or malignant mass beneath the skin surface and usually represents a late sign of breast cancer.
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Peau d’orange
Usually a late sign of breast cancer, peau d’orange (orange peel skin) is the edematous thickening and pitting of breast skin. This sign can also occur with axillary lymph node infection or Graves’ disease. Its striking orange peel appearance stems from lymphatic edema around deepened hair follicles.
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Treatment
Surgery that includes lumpectomy, partial mastectomy, simple or total mastectomy, modified radical mastectomy, radical mastectomy, sentinel node biopsy, and axillary node dissection
Lumpectomy, for patients with small, well-defined lesions
A cell-destroying technique, called cryolumpectomy, for small, early, primary tumors; radiation therapy possibly following cryolumpectomy, which has few complications and may prevent local recurrence
Before or after tumor removal, primary radiation therapy for a patient who has a small tumor in the early stages without distant metastasis; radiation therapy possibly also preventing or treating local recurrence
Chemotherapy, such as cyclophosphamide (Cytoxan), fluorouracil, methotrexate, doxorubicin, vincristine, paclitaxel (Abraxane), and prednisone
Hormonal blocking therapy that lowers levels of estrogen and other hormones suspected of nourishing breast cancer cells; for example, antiestrogen therapy (specifically tamoxifen, which is most effective against tumors identified as estrogen receptor-positive), for postmenopausal females
Aromatase inhibitors such as anastrazole (Arimidex): given to postmenopausal women to decrease estrogen levels by preventing androgen from converting to estrogen
For premenopausal women: oophorectomy and hormone therapy to discontinue ovarian hormone production
Targeted drugs: trastuzumab (Herceptin), a monoclonal antibody that blocks HER2 proteins, which stimulate cancer cell growth; kapatinib (Tykerb), which also blocks the effects of HER2 proteins and others with tumor cells
Nursing considerations
Evaluate the patient’s feelings about her illness, and determine her level of knowledge. Listen to her concerns, and stay with her during periods of severe anxiety.
Administer ordered analgesics, as required. Monitor and record their effectiveness.
Perform comfort measures, such as repositioning, to promote relaxation and relieve anxiety.
If immobility develops late in the disease, prevent complications by frequently repositioning the patient, using a convoluted foam mattress, and providing skin care (particularly over bony prominences).
Watch for treatment complications, such as nausea, vomiting, anorexia, leukopenia, thrombocytopenia, GI ulceration, and bleeding. Provide comfort measures and prescribed treatments to relieve these complications.
After surgery
Inspect the dressing anteriorly and posteriorly. Report excessive bleeding promptly.
Record the amount and color of drainage. Drainage appears bloody during the first 4 hours; then it becomes serous.
Monitor vital signs. If a general anesthetic was given during surgery, monitor intake and output for at least 48 hours.
Prevent lymphedema of the arm, which may be an early complication of lymph node dissection. Such prevention is crucial because lymphedema can’t be treated effectively.
Use strict sterile technique when changing dressings or I.V. tubing or performing an invasive procedure. Monitor temperature and white blood cell count closely.
Inspect the incision. Encourage the patient and her partner to look at her incision.
Provide emotional support and references to available support systems.
Teaching about breast cancer surgery
Clearly explain all procedures and treatments.
Besides the usual preoperative teaching, show the mastectomy patient how to ease postoperative pain by lying on the affected side or by placing a hand or pillow on the incision. Point out where the incision will be. Inform the patient that after the operation, she’ll receive analgesics because pain relief encourages coughing and turning and promotes well-being. Explain that a small pillow placed under the arm anteriorly may provide comfort.
Tell her that she may move about and get out of bed as soon as possible, usually as soon as the effects of the anesthetic subside or the first evening after surgery.
Explain that she may have an incisional drain or some type of suction to remove accumulated fluid, relieve tension on the suture line, and promote healing.
Urge the patient to avoid activities that could injure her arm and hand on the side of her surgery. Caution her not to let blood be drawn from or allow
injections into that arm. She should also refuse to have blood pressure taken or I.V. therapy administered on the affected arm.
To help prevent lymphedema, instruct the patient to exercise her hand and arm on the affected side regularly and to avoid activities that might allow infection of this hand or arm. Tell her that infection increases the risk of lymphedema.
Inform the patient that she may experience “phantom breast syndrome,” a tingling or pins-and-needles sensation in the area where the breast was removed.
Females who have had breast cancer in one breast are at higher risk for cancer in the other breast or for recurrent cancer in the chest wall. For this reason, urge the patient to continue examining the other breast and to comply with recommended follow-up treatment.
Teach relaxation techniques and gentle exercises to improve well-being.
Provide reassurance regarding follow-up support for reconstructive surgery and rehabilitation, as appropriate.
Cervical cancer
Cervical cancer is the third most common cancer of the female reproductive system. It’s classified as either preinvasive or invasive.
Preinvasive cancer ranges from minimal cervical dysplasia, in which the lower third of the epithelium contains abnormal cells, to carcinoma in situ, in which the full thickness of epithelium contains abnormally proliferating cells (also known as cervical intraepithelial neoplasia). Preinvasive cancer is curable in 75% to 90% of patients with early detection and proper treatment. If untreated, it may progress to invasive cervical cancer, depending on the form.
Signs and symptoms
Preinvasive cancer produces no symptoms or other clinical changes.
Early invasive cancer
Vaginal bleeding, such as a persistent vaginal discharge that may be yellowish, blood-tinged, and foul-smelling; postcoital pain and bleeding
Bleeding between menstrual periods
Unusually heavy menstrual periods
Advanced invasive cancer (into the pelvic wall)
Gradually increasing flank pain (sciatic nerve involvement)
Leakage of urine (metastasis into the bladder with formation of a fistula)
Leakage of stool (metastasis to the rectum with a fistula)
Looking at cervical cancer
Staging cervical cancer
Treatment decisions depend on accurate staging. The International Federation of Gynecology and Obstetrics defines the following cervical cancer stages.
Stage 0
Carcinoma in situ, intraepithelial carcinoma.
Stage I
Cancer is confined to the cervix (extension to the corpus should be disregarded).
Stage IA
Preclinical malignant lesions of the cervix are diagnosed only microscopically.
Stage IA1
Minimal microscopically evident stromal invasion measures less than 3 mm deep and 7 mm wide.
Stage IA2
Lesions are detected microscopically, measuring 3 to 5 mm from the base of the epithelium, either surface or glandular, from which it originates; lesion width shouldn’t exceed 7 mm.
Stage IB
Lesions measure more than 5 mm deep and 7 mm wide, whether seen clinically or not (preformed space involvement shouldn’t alter the staging but should be recorded for future treatment decisions).
Stage IB1
Visible lesions measure less than 4 cm.
Stage IB2
Visible lesions measure more than 4 cm.
Stage II
Extension goes beyond the cervix but not to the pelvic wall.
Stage IIA
Cancer involves the vagina but hasn’t spread to the lower third.
Stage IIB
Parametrial involvement is obvious.
Stage III
Cancer extends to the pelvic wall; on rectal examination, no cancer-free space between the tumor and the pelvic wall; involves the lower third of the vagina; may block the ureters.
Stage IIIA
No extension to the pelvic wall exists.
Stage IIIB
Extension is to the pelvic wall and ureters are blocked.
Stage IV
Extension is beyond the true pelvis or involvement of the bladder or the rectal mucosa.
Stage IVA
Cancer has spread to adjacent organs.
Stage IVB
Cancer has spread to distant organs.
Pap smear findings in cervical cancer
Treatment
Based on accurate clinical staging
Excisional biopsy, cryosurgery, laser destruction, conization (followed by frequent Papanicolaou [Pap] test follow-ups) or, rarely, hysterectomy, for preinvasive lesions
Radical hysterectomy and radiation therapy (internal, external, or both), for invasive squamous cell carcinoma
Rarely, pelvic exenteration (resection of the uterus, cervix, vagina, bladder, and rectum), for recurrent cervical cancer
Nursing considerations
Find out whether the patient will have internal or external therapy or both. Usually, internal radiation therapy is the first procedure.
Listen to the patient’s fears and concerns, and offer reassurance when appropriate. Encourage her to use relaxation techniques to promote comfort during diagnostic procedures.
If you assist with a biopsy, drape and prepare the patient as for a routine Pap test and pelvic examination. Have a container of formaldehyde ready to preserve the specimen during transfer to the pathology laboratory. Assist the physician, as needed, and provide support for the patient throughout the procedure.
If you assist with cryosurgery or laser therapy, drape and prepare the patient as for a routine Pap test and pelvic examination. Assist the physician, as needed, and provide support for the patient throughout the procedure.
Watch for and immediately report signs of complications, such as bleeding, abdominal distention, severe pain, and wheezing or other breathing difficulties. Encourage deep breathing and coughing. Administer analgesics and prophylactic antibiotics, as ordered.
For internal radiation therapy
Check to see whether the radioactive source will be inserted while the patient is in the operating room (preloaded) or at the bedside (afterloaded). If the source is preloaded, the patient returns to her room “hot,” and safety precautions begin immediately.
Remember that safety precautions—time, distance, and shielding—begin as soon as the radioactive source is in place. Inform the patient that she’ll require a private room.
Encourage the patient to lie flat and to limit movement while the source is in place. If she prefers, elevate the head of the bed slightly.
Avoid leg exercises and other body movements that could dislodge the source. If ordered, administer sedatives to help the patient relax and remain still. Organize your time with the patient to minimize your exposure to radiation.
Check the patient’s vital signs every 4 hours; watch for skin reactions, vaginal bleeding, abdominal discomfort, and evidence of dehydration. Make sure the patient can reach everything she needs without stretching or straining.
Assist the patient with range-of-motion arm exercises.
Provide diversional activities that require minimal movement.
Inform visitors of safety precautions and post a sign listing these precautions on the patient’s door.
Watch for treatment complications by listening to and observing the patient and monitoring laboratory studies and vital signs. When appropriate, perform measures to prevent or alleviate complications.
Teaching about cervical cancer treatmentFor biopsy
Explain to the patient that she may feel pressure, minor abdominal cramps, or a pinch from the punch forceps. Reassure her that the pain will be minimal because the cervix has few nerve endings.
For cryosurgery
Explain to the patient that the procedure takes about 15 minutes, during which time the physician uses refrigerant to freeze the cervix. Caution her that she may experience abdominal cramps, headache, and sweating, but reassure her that she’ll feel little, if any, pain.
For laser surgery
Explain that the procedure takes about 30 minutes and may cause abdominal cramps.
General
After excisional biopsy, cryosurgery, or laser therapy, tell the patient to expect a discharge or spotting for about 1 week. Advise her not to douche, use tampons, or engage in sexual intercourse during this time. Caution her to report signs of infection.
For preloaded internal radiation therapy
Explain to the patient that the procedure requires a 2- to 3-day hospital stay, bowel preparation, a povidone-iodine vaginal douche, a clear liquid diet, and nothing by mouth the night before the implantation. It also requires an indwelling urinary catheter.
Inform the patient that the procedure is performed in the operating room under general anesthesia.
For afterloaded internal radiation therapy
Explain to the patient that a member of the radiation team implants the source after the patient returns to her room from surgery.
If the patient will undergo outpatient external radiation therapy, explain that it will continue for about 4 to 6 weeks. Describe the procedure and measures she can take at home to prevent complications such as providing care around the radiation site to prevent skin breakdown.
Review the possible complications of radiation therapy. Remind the patient to watch for and report uncomfortable adverse effects. Because radiation therapy may increase susceptibility to infection by lowering the white blood cell count, warn the patient to avoid people with obvious infections during therapy.
Inform the patient that vaginal narrowing caused by scar tissue can occur after internal radiation and may be treated with dilation.
Describe the complications that can occur even years after high-dose radiation therapy.
Endometrial cancer
Cancer of the endometrium (uterine cancer) is the most common gynecologic cancer. It typically afflicts postmenopausal women between ages 50 and 60. It’s uncommon between ages 30 and 40 and rare before age 30. However, in premenopausal women who develop endometrial cancer, there’s usually a history of anovulatory menstrual cycles or other hormonal imbalance such as polycystic ovarian syndrome.
In most patients, endometrial cancer is an adenocarcinoma that metastasizes late, usually from the endometrium to the cervix, ovaries, fallopian tubes, and other peritoneal structures. It may spread to distant organs, such as the lungs and the brain, by way of the blood or the lymphatic system. Less common uterine tumors include adenoacanthoma, endometrial stromal sarcoma, lymphosarcoma, mixed mesodermal tumors (including carcinosarcoma), and leiomyosarcoma.
Signs and symptoms
Spotting and protracted menstrual periods (in premenopausal patients)
Bleeding that began 12 or more months after menses had stopped (in postmenopausal patients)
Discharge that’s initially watery, then blood-streaked, and gradually becoming bloodier (in both age-groups)
Enlarged uterus (in more advanced stages)
Lower abdominal or pelvic cramping
Progression of endometrial cancer
Staging endometrial cancer
Treatment decisions depend on accurate staging. The International Federation of Gynecology and Obstetrics defines the following endometrial cancer stages.
Stage 0
Carcinoma in situ.
Stage I
Cancer is confined to the corpus.
Stage IA
Cancer is limited to the endometrium.
Stage IB
Cancer has spread less than halfway through the myometrium.
Stage IC
Cancer has spread more than halfway through the myometrium, but is contained in the body of the uterus.
Stage II
Cancer has involved the corpus and the cervix but hasn’t extended outside the uterus.
Stage IIA
Cancer is in the corpus and the endocervical glands.
Stage IIB
Cancer is in the corpus and the cervical stroma.
Stage III
Cancer has extended outside the uterus but not outside the true pelvis.
Stage IIIA
Cancer is in the serosa of the uterus and in the adnexa; cancer cells are present in peritoneal fluid, but not in lymph nodes or distant sites.
Stage IIIB
Cancer has spread to the vagina but not to lymph nodes or distant sites.
Stage IIIC
Cancer is in lymph nodes close to the uterus but not at distant sites.
Stage IV
Cancer has extended outside the true pelvis or has obviously involved the mucosa of the bladder or rectum.
Stage IVA
Cancer has spread to adjacent organs.
Stage IVB
Cancer has spread to distant organs.
