Medical - surgical

• Abnormal Uterine Bleeding (AUB)

  Irregular or excessively heavy menstrual bleeding
• Dysfunctional Uterine Bleeding (DUB)

  A subcategory of AUB, specifically anovulatory abnormal uterine bleeding that has no organic cause
• Causes of Anovulatory AUB

  • polycystic ovarian syndrome (PCOS)
  • uncontrolled DM
  • thyroid disorders
  • hyperprolactinemia
  • medications (antipsychotics and anti-epileptics)
  • Ovarian failure in perimenopausal women
  • Hypothalamic or pituitary dysfunction
• Causes of Ovulatory AUB

  • hypothyroidism
  • late-stage liver disease
  • bleeding disorders
  • Structural abnormalities: submucosal fibroids or endometrial fibroids
  • no identifiable cause
• Anovulatory AUB Patterns/Dysfunctional Bleeding

  • Amenorrhea—no bleeding for three cycles or more
  • Oligomenorrhea—significantly diminished menstrual flow; infrequent intervals (greater than 35 days) or irregular intervals
  • Metrorrhagia—bleeding from uterus between regular menstrual periods
  • Menometrorrhagia—excessive bleeding at the usual time of menstruation
• Ovulatory Patterns

  • Menorrhagia—excessive bleeding during regular menstruation cycles; can be increased in duration or amount
  • Polymenorrhea—frequent menstruation occurring at intervals of less than 21 days
  • Menometrorrhagia—excessive bleeding at the usual time of menstruation and at other irregular intervals
• Management of AUB

  • Hormonal contraceptives (birth control pills) to control chronic bleeding or induce regular withdrawal bleeding
  • Progesterone-only administration for women who cannot take estrogen
  • Parenteral conjugated estrogen in emergencies to stop acute bleeding
  • Iron, possible transfusions to treat underlying anemia
  • NSAIDs to decrease menstrual flow volume in menorrhagia
  • Tranexamic acid, an antifibrinolytic agent
  • Androgen therapy with a gonadotropin-releasing hormone to reduce menstrual blood loss or fibroid size
  • Surgical procedures: hysteroscopic polypectomy, resection of uterine submucosal fibroids, hysteroscopic endometrial resection or ablation
  • Hysterectomy in refractory cases
• Complications of AUB

  • Endometrial CA due to the impact of unopposed estrogen on the endometrium
  • Severe anemia may result from menorrhagia or menometrorrhagia
• Nursing Assessment for AUB

  • Ask patient for menstrual and gynecologic history, sexual activity, and possibility of pregnancy
  • Assess frequency, duration, and amount of menstrual flow
  • Assess for other symptoms of underlying pathology, such as systemic hormonal conditions, pelvic pain, fever, and abdominal masses or tenderness
  • Assess for signs and symptoms of anemia—fatigue, shortness of breath, pallor, tachycardia
• Nursing Diagnoses for AUB

  • Fatigue related to excessive blood loss
  • Fear of bleeding through clothing related to excessive or unpredictable bleeding
• Nursing Interventions for AUB

  • Administer medications, as ordered. Teach patient indications and side effects
  • Encourage good dietary intake with increased sources of iron fortified cereals and breads, meat (especially red meat), and green, leafy vegetables
  • Administer oral iron preparations with meals to prevent nausea and with vitamin C–rich foods or drinks to enhance absorption. Treat constipation, as necessary
  • Monitor hemoglobin and infuse packed red blood cells, as ordered
  • Encourage activity, as tolerated
  • Review pattern of menstrual flow with patient and help her plan for excessive bleeding
  • Suggest wearing double tampons (if able) and double sanitary pads
  • Tell patient to expect heavy gush of blood on arising from lying or reclining position
  • Prepare patient to carry an adequate supply of sanitary products and a change of clothing until bleeding is under control
  • Teach patient the causes of AUB and about the diagnostic process to rule out pathologic causes of abnormal bleeding
  • Teach patient to prevent anemia by eating a diet high in iron and by consuming vitamin C or citrus fruit to enhance absorption of iron
  • Teach about hormonal therapy, related adverse effects, and what adverse effects to expect and what to expect of bleeding
• Human Papillomavirus (HPV)


  Infection may be asymptomatic but frequently causes Condyloma acuminatum or genital warts
• Pathophysiology and Etiology of HPV

  • Sexually transmitted; highly contagious
  • More than 40 types of HPV can infect the genital tract, many are asymptomatic
  • Ninety percent of visible genital warts are caused by HPV types 6 and 11
  • Other types (16, 18, 31, 33, 35) have been strongly associated with cervical neoplasia
  • Incubation period of up to 8 months
• Clinical Manifestations of HPV

  • Single or multiple soft, fleshy painless growths of the vulva, vagina, cervix, urethra, or anal area that may be irritating or uncomfortable
  • May be subclinical infection and still contagious
  • Occasional vaginal bleeding, discharge, odor, and dyspareunia
• Diagnostic Evaluation of HPV

  • Pap smear—shows characteristic cellular changes (koilocytosis)
  • Acetic acid swabbing on vaginal examination will whiten lesions and make them more identifiable in genital mucosa
  • Viral DNA tests to detect subclinical cases
  • Colposcopy is also used to diagnose subclinical HPV infection
  • Anoscopy or urethroscopy may be necessary to identify anal and urethral lesions
  • Genital warts are usually diagnosed on physical exam through visual inspection
• Management of HPV

  • External lesions may be treated by patient with multiple applications of a topical preparation: Podofilox, Imiquimod, Sinecatechins ointment
  • Noncervical lesions may be treated by health care provider with topical preparations, such as podophyllin resin, trichloroacetic acid, or bichloroacetic acid
  • Cryotherapy with liquid nitrogen or cryoprobe, electrocautery, laser treatment, or local excision of large warts or cervical lesions
  • Subclinical genital HPV infection typically clears spontaneously & treatment is not recommended
  • Two vaccines for HPV are available in the United States: Bivalent and Quadrivalent
• Complications of HPV

  • Implicated in cervical intraepithelial neoplasia
  • May cause neonatal laryngeal papillomatosis if infant born through infected birth canal
  • Obstruction of anal canal, vagina by enlarging lesions
  • Scarring and pigment changes if treatment not employed properly
• Nursing Assessment for HPV

  • Obtain history of STDs, Pap test results, sexual partners
  • Inspect external genitalia for lesions, perform vaginal examination
• Nursing Diagnosis for HPV

  Disturbed Body Image related to genital warts
• Nursing Interventions for HPV

  • Explain to patient that the goal of therapy is to remove visible lesions; however, HPV will not be cured or eliminated
  • Encourage patient to comply with treatment schedule and inspect areas for resolution of lesions or redevelopment of new lesions
  • Advise patient of high recurrence rate; 3-month follow-up visit is advisable; if lesions redevelop, patient should follow up for retreatment
• Genital HPV infection typically clears spontaneously & treatment is not recommended
• HPV vaccines available in the United States

  • Bivalent human papillomavirus vaccine types 16, 18; recombinant
  • Quadrivalent vaccine human papillomavirus vaccine types 6, 11, 16, 18; recombinant
• HPV vaccines

  1. Given as a series of three injections over 6 months

  2. The Centers for Disease Control and Prevention (CDC) recommends both vaccines for females ages 11 or 12 to 26 (licensed for ages 9 to 26)
• HPV vaccines are effective when all doses are administered before onset of sexual activity
• Complications of HPV

  • Implicated in cervical intraepithelial neoplasia
  • May cause neonatal laryngeal papillomatosis if infant born through infected birth canal
  • Obstruction of anal canal, vagina by enlarging lesions
  • Scarring and pigment changes if treatment not employed properly
• Nursing Assessment

  1. Obtain history of STDs, Pap test results, sexual partners

  2. Inspect external genitalia for lesions, perform vaginal examination
• Nursing Diagnosis

  Disturbed Body Image related to genital warts
• Nursing Interventions - Improving Body Image

  1. Explain to patient that the goal of therapy is to remove visible lesions; however, HPV will not be cured or eliminated. Genital warts are not life-threatening

  2. Encourage patient to comply with treatment schedule and inspect areas for resolution of lesions or redevelopment of new lesions

  3. Advise patient of high recurrence rate; 3-month follow-up visit is advisable; if lesions redevelop, patient should follow up for retreatment

  4. Advise patient about proper use of male or female condoms to reduce the risk of transmission, although not fully because HPV can infect areas not covered by the condom. Condom use, abstinence, and monogamy will protect against other STDs

  5. Encourage female patients to follow up regularly for Pap tests because HPV has been associated with cervical neoplasia

  6. Advise patient of risk to neonate during delivery; patient should receive close prenatal care if pregnant
• Patient Education and Health Maintenance


  1. Advise patient to discuss HPV with her partner. He should receive treatment for visible lesions. Screening for other STDs in both patient and partner is recommended

  2. Make sure patient realizes that even though lesions may be gone, she may still transmit HPV to new sexual partners. Abstinence, monogamy, and condoms are advisable to prevent transmission of all STDs
• Presents with no visible lesions at follow-up visit
• Pelvic Infection (PID) is several inflammatory disorders of the upper female genital tract, often with infection that may involve the fallopian tubes, ovaries, uterus, or peritoneum
• Incidence of PID has been increasing; high recurrence rate because of reinfections
• Causative agents of PID


  • N. gonorrhoeae
  • C. trachomatis
  • Anaerobes (Gardnerella vaginalis)
  • Gram-negative bacteria
  • Streptococci
• Predisposing factors for PID


  • Multiple sexual partners
  • Early onset of sexual activity
  • Use of IUDs (the wick promotes ascension of bacteria)
  • Procedures such as therapeutic abortion, cesarean sections, and hysterosalpingograms
• Clinical Manifestations of PID


  • Pelvic pain—most common presenting symptom; usually dull and bilateral
  • Fever >38 C (101° F)—especially with gonococcal infections
  • Cervical discharge—mucopurulent
  • Irregular bleeding
  • GI symptoms—nausea, vomiting, acute abdomen usually signify abscess
  • Urinary symptoms—dysuria, frequency
  • Presentation with chlamydia may be mild
• Diagnostic Criteria for Empiric Treatment of PID


  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness
• Other Diagnostic Findings


  • Cervical exudate
  • A friable cervix
  • White blood cells on microscopic examination of cervical secretions
• Diagnostic Tests


  • Endocervical DNA testing or culture to identify organisms (Gonorrhea or chlamydia)
  • CBC may show elevated leukocytes
  • Elevated C-reactive protein or elevated erythrocyte sedimentation rate show inflammation
  • Some cases may warrant endometrial biopsy, hysterosalpingostomy, transvaginal ultrasound, MRI, or laparoscopic visualization of the fallopian tubes
• Management of PID


  1. Patients with mild to moderate symptoms can be treated on an outpatient basis with oral antimicrobial regimens and timely follow-up at 48 to 72 hours after initiation of antibiotic and at completion of 2-week antibiotic course

  2. Inpatient treatment is required for surgical emergencies; abscess; pregnancy; severe infection with nausea, vomiting, and high fever

  3. Parenteral antimicrobial regimens recommended by the CDC during hospitalization

  4. Outpatient, oral antimicrobial regimens recommended by the CDC

  5. Parenteral therapy can be switched to oral therapy 24 to 48 hours after improvement is shown

  6. Surgical treatment or interventional drain placement may be necessary to drain abscess or later to treat adhesions or tubal damage
• Complications of PID


  • Abscess rupture and sepsis
  • Infertility because of adhesions to fallopian tubes and ovaries
  • Ectopic pregnancy caused by inability of fertilized egg to pass stricture
  • Dyspareunia because of adhesions