Structural Disorders and Neoplasms of the Reproductive System

Hysterectomy for Endometrial Cancer

Uterine Displacement and Prolapse

The round ligaments normally hold the uterus in anteversion, and the uterosacral ligaments pull the cervix backward and upward (see Fig. 4-3). Uterine displacement is a variation of this normal placement. The most common type of displacement is posterior displacement, or retroversion, in which the uterus is tilted posteriorly, and the cervix rotates anteriorly. Other variations include retroflexion and anteflexion (Fig. 11-1).

By 2 months postpartum, the ligaments should return to normal length, but in about one third of women, the uterus remains retroverted. This condition is rarely symptomatic, but conception may be difficult because the cervix points toward the anterior vaginal wall and away from the posterior fornix, where seminal fluid pools after coitus. If symptoms occur, they may include pelvic and low back pain, dyspareunia, and exaggeration of premenstrual symptoms.

Uterine prolapse is a more serious type of displacement. The degree of prolapse can vary from mild to complete. In complete prolapse, the cervix and body of the uterus protrude through the vagina, and the vagina is inverted (Fig. 11-2).

Uterine displacement and prolapse can be caused by congenital or acquired weakness of the pelvic support structures (often called pelvic relaxation). In many cases, problems can be a delayed but direct result of childbearing. Although extensive damage may be noted and repaired shortly after birth, symptoms related to pelvic relaxation most often appear during the perimenopausal period, when the effects of ovarian hormones on pelvic tissues are lost, and atrophic changes begin. Pelvic trauma, stress and strain, and the aging process also are contributing factors. Other causes of pelvic relaxation include reproductive surgery and pelvic radiation.

Cystocele and Rectocele

Cystocele and rectocele almost always accompany uterine prolapse, causing the uterus to sag even farther backward and downward into the vagina. Cystocele (Fig. 11-3, A) is the protrusion of the bladder downward into the vagina that develops when supporting structures in the vesicovaginal septum are injured. Anterior wall relaxation gradually develops over time as a result of congenital defects of support structures, childbearing, obesity, or advanced age. When the woman stands, the weakened anterior vaginal wall cannot support the weight of the urine in the bladder; the vesicovaginal septum is forced downward, the bladder is stretched, and its capacity is increased. With time the cystocele enlarges until it protrudes into the vagina. Complete emptying of the bladder is difficult because the cystocele sags below the bladder neck. Rectocele is the herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum; it appears as a large bulge that may be seen through the relaxed introitus (see Fig. 11-3, B).

Urinary Incontinence

Urinary incontinence (UI) affects young and middle-aged women, with the prevalence increasing as the woman ages. Although nulliparous women can have UI, the incidence is higher in women who have given birth and increases with parity. Women who are overweight and those who have had a hysterectomy are also at increased risk (Sung & Hampton, 2009). There are conflicting data about ethnicity and race as contributing factors (Waetjen, Laio, Johnson, Sampselle, Sternfield, Harlow, & Gold, 2007). Conditions that disturb urinary control include stress incontinence due to sudden increases in intraabdominal pressure (such as that due to sneezing or coughing); urge incontinence, caused by disorders of the bladder and urethra, such as urethritis and urethral stricture, trigonitis, and cystitis; neuropathies, such as multiple sclerosis, diabetic neuritis, and pathologic conditions of the spinal cord; and congenital and acquired urinary tract abnormalities. Research also suggests that a significant number of women have undiagnosed urinary incontinence (Wallner, Porten, Meenan, O’Keefe Rosetti, Calhoun, Sarma, & Clemens, 2009).

Stress incontinence may follow injury to bladder neck structures. A sphincter mechanism at the bladder neck compresses the upper urethra, pulls it upward behind the symphysis, and forms an acute angle at the junction of the posterior urethral wall and the base of the bladder (urethrovesical angle) (Fig. 11-4). To empty the bladder, the sphincter complex relaxes, and the trigone contracts to open the internal urethral orifice and pull the contracting bladder wall upward, forcing urine out. The angle between the urethra and the base of the bladder is lost or increased if the supporting pubococcygeus muscle is injured; this change, coupled with urethrocele, causes incontinence. Urine spurts out when the woman is asked to bear down or cough in the lithotomy position.

Genital Fistulas

Genital fistulas are perforations between genital tract organs. Most occur between the bladder and the genital tract (e.g., vesicovaginal); between the urethra and the vagina (urethrovaginal); and between the rectum or sigmoid colon and the vagina (rectovaginal) (Fig. 11-5). Genital fistulas also may be a result of a congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection (e.g., in the episiotomy).

Collaborative Care

Assessment for problems related to structural disorders of the uterus and vagina focuses primarily on the genitourinary tract, the reproductive organs, bowel elimination, and psychosocial and sexual factors. A complete health history, a physical examination, and laboratory tests are done to support the appropriate medical diagnosis. The nurse must assess the woman’s knowledge of the disorder, its management, and possible prognosis. Possible nursing diagnoses for structural problems of the uterus and vagina include the following:

The health care team works together to treat the disorders related to alterations in pelvic support and to assist the woman in management of her symptoms. In general, nurses working with these women can provide information and self-care education to prevent problems before they occur, to manage or reduce symptoms and promote comfort and hygiene if symptoms are already present, and to recognize when further intervention is needed. This information can be part of all postpartum discharge teaching or can be provided at postpartum follow-up visits in clinics or physician/nurse-midwife offices, during postpartum home visits, or during gynecologic health examinations. In addition, information on how to prevent or recognize problems can be a topic for workshops for women or health fairs in community settings.

Besides providing information about prevention, nurses participate in a team effort to prepare the woman for surgery and self-care after discharge. Preoperative teaching involves the primary nurse, operating room nurse, surgeon, and anesthesia provider. Postoperatively, a nurse in the health promotion setting may be most aware of the woman’s living circumstances, physical limitations, and social problems and therefore may be best suited to coordinate continuity of care after discharge.

Interventions for specific problems depend on the problem and the severity of the symptoms. If discomfort related to uterine displacement is a problem, several interventions can be implemented. Kegel exercises (see p. 91) can be performed several times daily to increase muscle strength. A knee-chest position performed for a few minutes several times a day can correct a mildly retroverted uterus. A fitted pessary to support the uterus and hold it in the correct position (Fig. 11-6) may be inserted in the vagina. Usually a pessary is used only for a short time because it can lead to pressure necrosis and vaginitis. Good hygiene is important; some women can be taught to remove the pessary at night, cleanse it, and replace it in the morning. If the pessary is always left in place, regular douching with commercially prepared solutions or weak white vinegar solutions (1 tablespoon to 1 quart [liter] of water) to remove increased secretions and keep the vaginal pH at 4 to 4.5 is suggested. After a period of treatment, most women are free of symptoms and do not require the pessary. Surgical correction is rarely indicated.

Treatment for uterine prolapse depends on the degree of prolapse. Pessaries may be useful in mild prolapse. Estrogen therapy also may be used in the older woman to improve tissue tone. If these conservative treatments do not correct the problem, or if there is a significant degree of prolapse, abdominal or vaginal hysterectomy (see later discussion) is usually recommended (Lentz, 2007).

Mild to moderate urinary infections can be significantly decreased or relieved in many women by bladder training and pelvic muscle (Kegel) exercises (Bersuk, 2007; Dumoulin & Hay-Smith, 2010). Other management strategies include pelvic flow support devices (i.e., pessaries), vaginal estrogen therapy, serotonin-norepinephrine reuptake inhibitors, electrical stimulation, insertion of an artificial urethral sphincter, and surgery (e.g., anterior repair) (Tarnay & Bhatia, 2010).

Nursing care for women with urinary incontinence includes assessment for depression that can result from decreased quality of life and functional status. Women also may need guidance about changes in lifestyle (e.g., losing weight) and education about pelvic muscle exercises (Peterson, 2008; Sung, West, Hernandez, Wheeler, Myers, Subak, et al., 2009).

Treatment for a cystocele includes use of a vaginal pessary or surgical repair. Pessaries may not be effective. Anterior repair (colporrhaphy) is the usual surgical procedure and is commonly performed for large, symptomatic cystoceles. This involves a surgical shortening of pelvic muscles to provide better support for the bladder. An anterior repair is often combined with a vaginal hysterectomy. Kegel exercises may be beneficial for symptoms of urinary and fecal incontinence (Lentz, 2007).

Small rectoceles may not require treatment. The woman with mild symptoms may derive relief from a high-fiber diet and adequate fluid intake, stool softeners, or mild laxatives. Vaginal pessaries usually are not effective. Large rectoceles that are causing significant symptoms are usually repaired surgically. A posterior repair (colporrhaphy) is the usual procedure. This surgery is performed vaginally and involves shortening the pelvic muscles to provide better support for the rectum (Lentz, 2007). Anterior and posterior repairs may be performed at the same time and with a vaginal hysterectomy.

Management of genital fistulas depends on the location. Surgical repair is the usual treatment; however, it may not be successful.

Nursing care of the woman with a cystocele, rectocele, or fistula requires great sensitivity, because the woman’s reactions are often intense. She may become withdrawn or hostile because of embarrassment caused by odors and soiling of her clothing that are beyond her control. She may have concerns about engaging in sexual activities because her partner is repelled by these problems. The nurse can tactfully suggest hygiene practices that reduce odor. Commercial deodorizing douches are available, or noncommercial solutions, such as chlorine solution (1 teaspoon of household chlorine bleach to 1 quart of water) may be used. The chlorine solution also is useful for external perineal irrigation. Sitz baths and thorough washing of the genitals with unscented, mild soap and warm water help. Sparse dusting with deodorizing powders can be useful. If a rectovaginal fistula is present, enemas given before leaving the house may provide temporary relief from oozing of fecal material until corrective surgery is performed. Irritated skin and tissues may benefit from use of the heat lamp or application of an emollient ointment. Hygienic care is time consuming and may need to be repeated frequently throughout the day; protective pads or pants may have to be worn. All of these activities can be demoralizing to the woman and frustrating to her and her family. If surgical repair is performed, nursing care focuses on preventing infection and helping the woman avoid putting stress on the surgical site.

Follicular Cysts

Follicular cysts develop most commonly in normal ovaries of young women as a result of the mature graafian follicle failing to rupture, or when an immature follicle does not resorb fluid after ovulation. A cyst is usually asymptomatic unless it ruptures, in which case it causes severe pelvic pain. If the cyst does not rupture, it usually shrinks after two or three menstrual cycles.

Corpus Luteum Cysts

Corpus luteum cysts occur after ovulation and are possibly caused by an increased secretion of progesterone that results in an increase of fluid in the corpus luteum. Clinical manifestations associated with a corpus luteum cyst include pain, tenderness over the ovary, delayed menses, and irregular or prolonged menstrual flow. A rupture can cause intraperitoneal hemorrhage. Corpus luteum cysts usually disappear without treatment within one or two menstrual cycles.

Theca-Lutein Cysts

Theca-lutein cysts are uncommon and in up to 50% of cases are associated with hydatidiform mole (see Chapter 28). Theca-lutein cysts develop as a result of prolonged stimulation of the ovaries by human chorionic gonadotropin (hCG). They also may occur if the woman has taken ovulation induction drugs; if she is pregnant and a large placenta is present, such as in the presence of a multiple gestation; or if the woman has diabetes (Katz, 2007). The cysts are almost always bilateral. A feeling of pelvic fullness may be noted by the woman if the ovary is enlarged, but most women are asymptomatic.

Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) occurs when an endocrine imbalance results in high levels of estrogen, testosterone, and luteinizing hormone (LH) and decreased secretion of follicle-stimulating hormone. This syndrome is associated with a variety of problems in the hypothalamic-pituitary-ovarian axis and with androgen-producing tumors. The condition can be transmitted as an X-linked dominant or autosomal dominant trait (Stein-Leventhal syndrome). Multiple follicular cysts develop on one or both ovaries and produce excess estrogen. The ovaries often double in size. Clinical manifestations include obesity, hirsutism (excessive hair growth), irregular menses or amenorrhea, and infertility. Impaired glucose tolerance and hyperinsulinemia occur in about 40% of women with PCOS (Lobo, 2007). Affected women are at high risk for developing type 2 diabetes mellitus and possibly cardiovascular diseases (Benson, Hahn, Tan, Janssen, Schedlowski, & Elsenbruch, 2010). PCOS is often diagnosed in adolescence when menstrual irregularities and other symptoms appear (Lobo).

Collaborative Care

A variety of interventions may be implemented for the woman with a functional cyst. If expectant management is the treatment, the woman is advised to keep appointments for pelvic examinations to monitor the changes in size of the cyst (enlarging or shrinking). Pharmacologic interventions such as analgesics may be prescribed for pain management. Oral contraceptives may be ordered for several months to suppress ovulation for functional cysts. Large cysts (greater than 8 cm) or cysts that do not shrink may be removed surgically (cystectomy). Corpus luteum cysts are treated similarly. Theca-lutein cysts are usually managed conservatively (they usually regress) or by removal of the hydatidiform mole (Katz, 2007).

Nursing care focuses on educating the woman regarding treatment options as well as pain management with analgesics or comfort measures such as heat to the abdomen or relaxation techniques. If surgery is performed, the nurse provides preoperative and postoperative care. Discharge teaching includes signs of infection, postoperative incision care, the possibility of recurrence, and advice regarding follow-up appointments.

The treatment for PCOS depends on what symptoms are of greatest concern to the woman. Lifestyle modifications (e.g., losing weight) and management of presenting symptoms such as infertility, irregular menses, and hirsutism are the focus. Oral contraceptives (OCs) are the usual treatment for irregular menses, if pregnancy is not desired, because they inhibit LH and decrease testosterone levels. OCs can also lessen acne to some degree. Gonadotropin-releasing hormone (GnRH) analogs may be used to treat hirsutism if oral contraceptives do not improve this condition. If pregnancy is desired, ovulation-inducing medications are given (Lobo, 2007). Metformin and other insulin medications for type 2 diabetes also are used to lower insulin, testosterone, and glucose levels, which in turn can reduce acne, hirsutism, abdominal obesity, amenorrhea, and other symptoms in women with PCOS (Lobo).

Nurses can provide information and counseling for women with PCOS. Information may be needed about the syndrome or about its long-term effects on the woman’s health. Research has shown that women report symptoms of psychologic distress including depression, anxiety, and social fears (Benson et al., 2010). Women may need to discuss their feelings about the physical manifestations of PCOS and may need emotional support if they have self-image problems related to the symptoms. Teaching about lifestyle modifications such as exercise and diet may be needed as well as education about the medications that are prescribed. Information about finding a support group or information on the Internet may be useful.

Other Benign Ovarian Cysts and Neoplasms

Two other ovarian neoplasms are dermoid cysts and ovarian fibromas. Dermoid cysts are germ cell tumors, usually occurring in childhood. These cysts contain substances such as hair, teeth, sebaceous secretions, and bones. Unless the cyst is large enough to put pressure on other organs, it is usually asymptomatic. Dermoid cysts may develop bilaterally and are often attached to the ovary. Treatment is usually surgical removal.

Ovarian fibromas are solid ovarian neoplasms developing from connective tissue and most often occurring after menopause. Fibromas range in size from small nodules to large masses weighing more than 23 kg. Most fibromas are unilateral. They are usually asymptomatic, but if large enough, they may cause ascites, feelings of pelvic pressure, or abdominal enlargement. Treatment is usually surgical removal.

Nursing care of women who have surgery for the removal of dermoid cysts and ovarian fibromas is similar to that described for functional ovarian cysts.

Collaborative Care

Clinical management of endometrial polyps is by surgical removal. Cervical polyps are usually removed in an office or clinic procedure without anesthesia. The polyp is grasped with a clamp and twisted or cut off. All polyps should be sent for pathologic examination. Endometrial sampling (which may require local anesthesia) should be done to determine if other pathologic conditions are present (Katz, 2007).

Nursing care includes preparing the woman for what to expect during the removal procedure and encouraging relaxation and breathing exercises and providing support during the procedure. After the procedure the woman is advised to avoid using tampons, sexual intercourse, and douching for up to 1 week or until the site is healed. She is taught how to identify signs of infection and to notify her health care provider if she experiences heavy bleeding (more than one pad in 1 hour).

Clinical Manifestations and Diagnosis

The cause of leiomyomas remains unknown, although genetic factors may be involved in their development. Most of the tumors are found in the body of the uterus. Leiomyomas are classified according to the location in the uterine wall. Subserous leiomyomas develop beneath the peritoneal surface of the uterus and appear as small or large masses that protrude from the outer uterine surface (Fig. 11-9, A). Intramural leiomyomas are tumors that develop within the wall of the uterus (see Fig. 11-9, B). Submucosal leiomyomas are the least common tumors, but often cause the most symptoms. These tumors develop in the endometrium and protrude into the uterine cavity (see Fig. 11-9, C). Leiomyomas can develop in the cervix and on the broad ligaments (see Fig. 11-9, D). They can grow on pedicles or stalks (see Fig. 11-9, E). Occasionally these break off the pedicle and attach to other tissues (become parasitic).

Most women are asymptomatic; abnormal uterine bleeding is the most common symptom of fibroids. If the tumor is very large, pelvic circulation may be compromised, and surrounding viscera may be displaced. A woman may complain of backache, low abdominal pressure, constipation, urinary incontinence, or dysmenorrhea (painful menstruation). Nausea and vomiting may occur if the tumor is obstructing the intestines. The woman also may notice an abdominal mass if the tumor is large. Anemia can occur if the woman has excessive bleeding. Pedunculated tumors can twist and become necrotic, causing pain.

The tumors appear to be influenced by the presence of estrogen. Fibroids can affect implantation and maintenance of pregnancy. During pregnancy, the tumors may produce complications such as preterm labor, miscarriage, or dystocia (difficult labor). The severity of the symptoms seems to be directly related to the size and location of the tumors.

Medical Management

Surgical Management

In addition to the surgical options of hysterectomy and myomectomy, other techniques have been developed to treat leiomyomas. These include laparoscopic techniques; hysteroscopic techniques; myolysis by heat, cold, and laser; and magnetic resonance–guided focused ultrasound surgery. Not all of these

techniques are suitable for every woman nor are all of them universally available to women (Istre, 2008).

Bartholin Cysts

Bartholin cysts are the most common benign lesions of the vulva. They arise from obstruction of the Bartholin duct, which causes it to enlarge. Small cysts often are asymptomatic; however, large cysts or infected cysts cause symptoms such as vulvar pain, dyspareunia (painful intercourse), and a feeling of a mass in the vulvar area (Eckert & Lentz, 2007).

Vulvodynia

Vulvar pain is a common gynecologic problem. Vulvodynia, also called vulvar pain syndrome or vulvovestibulitis, is reportedly experienced by 4% to 27% of women. The incidence is thought to be the same for women of all races and ethnicities (Kingdon, 2009).

Vulvodynia is a complex condition thought to be a chronic pain disorder of the vulvar area. The term vulvodynia is used if pain is present with no visible abnormality or no identified neurologic diagnosis (Katz, 2007). Pain can be described as provoked (e.g., by inserting a tampon or having vaginal intercourse) or unprovoked and localized to the vestibule or generalized over the vulvar area (Kingdon, 2009).

Etiology has not been established although psychologic and biologic theories have been proposed. The most common theory is that vulvodynia is caused by a chronic neuropathic pain syndrome. Inflammation may also be a causative factor and continues to be investigated. (Zolnoun, Hartmann, Lamvu, As-Saine, Maixner, & Steege, 2006). Past sexual and emotional experiences and personality traits are being investigated as causes because they can influence the perception and interpretation of nerve impulses (Kingdon, 2009).

A feature of neuropathic pain is allodynia, which is a painful sensation that is from something not supposed to be painful. It commonly occurs in women with vulvodynia. Several triggers that reportedly cause allodynia in the vulvar area include use of oral contraceptives; presence of candidiasis or human papillomavirus; wearing tight-fitting underwear and pants, especially synthetic materials; being a victim of childhood sexual abuse; and using chemical irritants such as scented detergents, soaps, and bubble baths (Arnold, Bachmann, Rosen, & Rhoads, 2007; Goldstein & Burrows, 2008; Harlow, Vitonis, & Stewart, 2008). However, with all these triggers, research evidence is conflicting and the need for scientific evidence is ongoing.

Incidence and Etiology

Endometrial cancer is the most common malignancy of the reproductive system (ACS, 2010a). It is most commonly seen in perimenopausal and postmenopausal women between ages 50 and 65. Certain risk factors have been associated with the development of endometrial cancer, including obesity, nulliparity, infertility, late onset of menopause, diabetes mellitus, hypertension, PCOS, and family history of ovarian or breast disease (ACS; Creasman, 2007a). There appears to be an increase in risk for endometrial cancer in families with hereditary nonpolyposis colorectal cancer (HNPCC). Hormone imbalance, however, seems to be the most significant risk factor (American College of Obstetricians and Gynecologists [ACOG], 2008). Numerous studies have correlated the use of exogenous estrogens (unopposed stimulation, i.e., absence of progesterone) in postmenopausal women with an increased incidence of uterine cancer. Tamoxifen taken by women for breast cancer also has been related to a slight increase in endometrial cancer (Creasman). Pregnancy and use of low-dose oral contraceptive pills appear to offer some protection (ACS). The incidence of endometrial cancer among Caucasian women is higher than that among African-American and Hispanic women; however, the mortality rates are more than one and one half times higher in African-American women (Ries, Melbert, Krapcho, Stinchcomb, Howlader, Horner, et al., 2008).

Endometrial cancer is slow growing and for that reason has a good prognosis if diagnosed at a localized stage. Most endometrial cancers are adenocarcinomas that develop from endometrial hyperplasia. The tumor usually develops in the fundus of the uterus and can spread directly to the myometrium and cervix, as well as to other reproductive organs. Metastasis (spread of cancer from its original site) is through the lymphatic system in the pelvis and through the blood to the liver, the lungs, and the brain.

• Deficient knowledge related to:

• Decisional conflict related to:

• Fear/anxiety related to:

• Impaired skin integrity related to:

• Acute or chronic pain related to:

• Disturbed body image related to:

• Sexual dysfunction related to:

Incidence and Etiology

Cancer of the ovary is the second most frequently occurring reproductive cancer and causes more deaths than any other female genital tract cancer (ACS, 2010a). Because the symptoms of this type of cancer are vague and definitive screening tests do not exist, ovarian cancer is often diagnosed in an advanced stage. The 5-year survival rate for cancer diagnosed at a localized stage is about 94%; however, only about 15% of all ovarian cancers are found at this stage. For advanced stages, the rate is about 28% (ACS). Malignant neoplasia of the ovaries occurs at all ages, including in infants and children. However, cancer of the ovary is seen primarily in women older than age 50 with the greatest number of cases found in women ages 60 to 64 years (Copeland, 2007).

Major histologic cell types occur in different age-groups, with malignant germ cell tumors most common in women between 20 and 40 years of age and epithelial cancers occurring in the perimenopausal age-groups. The spread of ovarian cancer is by

direct extension to adjacent organs, but distal spread can occur through lymphatic spread to the liver and the lungs.

The cause of ovarian cancer is unknown; however, a number of risk factors have been identified. These factors include nulliparity, infertility, previous breast cancer, family history of ovarian or breast cancer, and history of HNPCC. Inherited BRCA1 and BRCA2 mutations increase the risk, but 90% of women do not have inherited ovarian cancer (Coleman & Gershenson, 2007; Copeland, 2007). Women of North American or northern European descent have the highest incidence of ovarian cancers. Pregnancy and use of oral contraceptives seem to have some protective benefits against ovarian cancer, whereas use of postmenopausal estrogen may increase the risk (ACS, 2010a). Genital exposure to talc, a diet high in fat, lactose intolerance, and use of fertility drugs have been suggested as risk factors, but research findings are inconclusive (Berek, 2010; Coleman & Gershenson; Copeland).

Clinical Manifestations and Diagnosis

Ovarian cancer has been called a silent disease because early warning symptoms that would send a woman to her health care provider are absent (e.g., no bleeding or other discharge and no pain). Abdominal bloating, noticeable increase in abdominal girth, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary urgency or frequency have been identified as the four most common symptoms of early ovarian cancer (Goff, Mandel, Drescher, Urban, Gough, Schurman, et al., 2007). The increase in abdominal girth (caused by ovarian enlargement or ascites) is usually attributed to an increase in weight or a shift in weight that is seen commonly in women entering their middle years. An ovary enlarged 5 cm or more than normal that is found during routine examination requires careful diagnostic workup. Pelvic pain, anemia, and general weakness and malnutrition are signs of late-stage disease.

Early diagnosis of ovarian cancer is uncommon. Attempts at early detection have not proven to be reliable. Taking a family history is important because it may reveal cancer of the uterus or breast. Transvaginal ultrasound, CA-125 antigen (a tumor-associated antigen) testing, and frequent pelvic examinations have all been used without a great deal of success because these tests do not have high levels of sensitivity and specificity (Fields & Chevlen, 2006). Research continues on the use of proteomics (study of proteins in blood) to identify ovarian cancer in its earlier stages (ACS, 2010a; Cesario, 2010). Emerging technology includes tumor cell profiling and nanotechnology (use of microchips to sense biomarkers that are unique to a specific cancer).

Transvaginal ultrasound and CA-125 screening currently are not recommended for routine screening in the general population but are recommended for women who are at high risk (e.g., BRCA1 mutation carriers) (ACS, 2010a). Routine pelvic examination continues to be the only practical screening method for detecting early disease, even though few cancers are detected in women without symptoms. Any ovarian enlargement should be considered highly suggestive and needs further evaluation by laparoscopy or laparotomy. Responsibility for diagnosis rests with the pathologist. The size of the tumor is not indicative of the severity of disease. Clinical staging is done surgically and gives direction to treatment and prognosis (Copeland, 2007).

Therapeutic Management

Treatment is dictated by the stage of the disease at the time of initial diagnosis. Surgical removal of as much of the tumor as possible is the first step in therapy. This may involve just the removal of one ovary and tube or the radical excision of the uterus, ovaries, tubes, and omentum. Cytoreductive surgery (the debulking of the poorly vascularized larger tumors) also is done. The smaller the volume of tumor remaining, the better the response to adjuvant therapy. Because about three fourths of women are in stage II, III, or IV disease at the time of diagnosis, surgical cure is not possible; therefore, after tumor reduction surgery is performed, women with epithelial cell carcinoma will receive chemotherapy.

A combination of antineoplastic drugs such as paclitaxel and cisplatin or carboplatin and paclitaxel is recommended for most women with advanced disease. Women being treated with chemotherapy are followed up closely with laboratory and radiologic tests and CA-125 levels to monitor their response to the therapy (Copeland, 2007).

Second-look surgery is a technique used to determine the response of the disease to chemotherapy and to determine whether treatment should be continued; however, this procedure usually is not done unless it is part of a research protocol (Copeland, 2007).

Radiation has been used to treat early-stage disease, and some women have had long-term survival after debulking surgery followed by radiation therapy. It has also been used as a palliative measure in advanced disease (Coleman & Gershenson, 2007).

Nursing Implications

Lockwood-Rayermann, Donovan, Rambo, and Kuo (2009) reported on data analyzed from a survey conducted by the National Ovarian Cancer Coalition. These researchers concluded that awareness of the symptoms of and risk factors for ovarian cancer are low in the general population. Therefore, nurses need to be involved in raising the awareness of these risks and symptoms with the public and with women who are seeking care in health care settings such as clinics and physician offices (Cesario, 2010).

Goff and associates (2007) developed a symptom index to be used in identifying women at risk for ovarian cancer who might benefit from early screening. The index includes asking about symptoms (pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating/feeling full) and the frequency and duration of the symptoms. The index is considered positive if any of the symptoms occurred more than 12 times per month and had been present for less than 1 year. Nursing can incorporate asking about these symptoms when women are seen for annual examinations or other gynecologic health visits and encouraging women to keep a symptom diary (Cesario, 2010).

The woman diagnosed with ovarian cancer has concerns similar to those described for the woman with endometrial and cervical cancer. Nursing interventions for the woman having surgery, chemotherapy, or external radiation therapy are described in other sections of this chapter.

Women with advanced ovarian cancer have a significant rate of recurrence. Follow-up for 5 years must be intensive. When a cure or remission cannot be achieved, palliative measures are initiated that alleviate symptoms of the progressing disease and provide comfort and maximal function. As the disease progresses, nutritional support, including enteral feedings and parenteral hyperalimentation, may be needed because of the effects on the gastrointestinal tract of both the disease and the treatments. The goal of nursing care is assisting the woman to maintain quality of life and to remain at home with her family as much as possible.

Because the period between a focus on cure and a focus on palliation is often prolonged, the woman with ovarian cancer is apt to experience most of the grief stages described by Kübler-Ross and to need support and encouragement through each stage. After diagnosis the woman often experiences denial and then anger. As treatment begins, she may “bargain” for a cure. If treatment is successful and death is forestalled by remission or cure, the process of adjustment to dying ceases, and the woman again focuses on life and its challenges. When treatment fails to secure a cure or remission ends, the woman must turn again to the task of adjustment (see Legal Tip).

Family and friends also have diverse feelings. When grieving is prolonged, as it often is when the woman has cancer, the stress can be enormous and can interfere with other interpersonal relationships. If the woman is hospitalized, the environment may further intrude on relationships, limiting privacy and access to the woman and hindering opportunities for caring gestures. The nurse can assist the woman and her family to share their feelings with each other and help them to develop a support network. Referral to a cancer support group may be useful (see National Ovarian Cancer Coalition, www.ovarian.org).

Incidence and Etiology

Cancer of the cervix is the third most common reproductive cancer. The accessible location of the cervix to both cell and tissue study and direct examination have led to a refinement of diagnostic techniques, contributing to improved diagnosis and management of these disorders. The incidence of invasive cancer has decreased over the last 30 years, reducing mortality rates. However, the incidence of preinvasive cancer has increased, and more women in their 20s and 30s are being diagnosed with preinvasive cervical lesions (ACS, 2010a).

Cancer of the cervix begins as neoplastic changes in the cervical epithelium. Terms that have been used to describe these epithelial changes or preinvasive lesions include dysplasia and cervical intraepithelial neoplasia (CIN); CIN is the term currently used. CIN 1 refers to abnormal cellular proliferation in the lower one third of the epithelium; this change tends to be self-limiting and generally regresses to normal. CIN 2 involves the lower two thirds of the epithelium and may progress to carcinoma in situ. CIN 3 involves the full thickness of the epithelium and often progresses to carcinoma in situ. Carcinoma in situ (CIS) is diagnosed when the full thickness of epithelium is replaced with abnormal cells (Creasman, 2007b) (Fig. 11-11). Terms used to describe neoplastic changes in abnormal cervical cytology reports are low-grade and high-grade squamous intraepithelial lesions (SILs); however, CIN continues to be a common term used in clinical practice.

Preinvasive lesions are limited to the cervix and usually originate in the squamocolumnar junction or transformation zone (Fig. 11-12). Intensive study of the cervix and the cellular changes that take place has shown that most cervical tumors have a gradual onset rather than an explosive one. Preinvasive conditions may exist for years before the development of invasive disease. These preinvasive conditions are highly treatable in many cases.

Invasive carcinoma is the diagnosis when abnormal cells penetrate the basement membrane and invade the stroma. There are two types of invasive carcinoma of the cervix: microinvasive and invasive. Microinvasive carcinoma is defined as one or more lesions that penetrate no more than 3 mm into the stroma below the basement membrane with no areas of lymphatic or vascular invasion (Creasman, 2007b). Invasive carcinoma describes invasion that goes beyond these parameters. The staging of invasive carcinoma extends from stage 0 (CIS) to stage IVb (distant metastasis or disease outside the true pelvis). A number of substages within each stage also exist. Clinical stages for cancer of the cervix are shown in Table 11-3.

Approximately 90% of cervical malignancies are squamous cell carcinomas; 10% are adenocarcinomas. Squamous cell carcinomas can spread by direct extension to the vaginal mucosa, the pelvic wall, the bowels, and the bladder. Metastasis usually occurs in the pelvis, but it can occur to the lungs and the brain through the lymphatic system.

The average age range for the occurrence of cervical cancer is 40 to 50 years; however, preinvasive conditions may exist for 10 to 15 years before the development of an invasive carcinoma. About 70% to 80% of cervical cancers are caused by human papillomavirus (HPV) (Creasman, 2007b). A strong link has been established between HPV types 16 and 18 and cervical neoplasia. Eighteen other types have been associated with genital tract infections and also may be associated with CIN (ACOG, 2008; Creasman). Other sexually transmitted infections that are identified as risk factors are herpes simplex virus 2 and possibly cytomegalovirus (Creasman). Risk factors include early age at first coitus (younger than 20 years); multiple sexual partners (more than two); a sexual partner with a history of multiple sexual partners; high parity, and belonging to a lower socioeconomic group. Potential factors include long-term use of oral contraceptives, cigarette smoking, and intrauterine exposure to diethylstilbestrol (DES) (ACS, 2010a; Creasman; Monk & Tewari, 2007). Low levels of beta-carotene, vitamin C, and folate are being investigated as potential risk factors (Monk & Tewari).

The incidence of cervical cancer in the United States is highest in Hispanic women and lowest in Native-American women, whereas the highest mortality occurs in African-American women (ACS, 2010a). Factors that may influence cervical screening behaviors for these groups include lack of a health promotion or disease prevention perspective, lack of knowledge about Pap tests and availability of services, financial barriers, and failure of health care providers to recommend screening (Giarratano, Bustamante-Forest, & Carter, 2005). There also is a high rate of CIN in human immunodeficiency virus–positive women, suggesting that altered immune status is a risk factor (Creasman, 2007b).

Clinical Manifestations and Diagnosis

Preinvasive cancer of the cervix is often asymptomatic. Abnormal bleeding, especially postcoital bleeding, is the classic symptom of invasive cancer. Other late symptoms include rectal bleeding, hematuria, back pain, leg pain, and anemia. Diagnosis includes taking a history that includes menstrual and sexual activity information, particularly sexually transmitted infections and abnormal bleeding episodes (Creasman, 2007b). A pelvic examination usually is normal except in late-stage cancer.

The single most reliable method to detect preinvasive cancer is the Pap test, which can detect 90% of early cervical changes. The U.S. Preventive Services Task Force (USPSTF) and the ACS recommend Pap tests to begin about 3 years after a woman becomes sexually active but not later than age 21. Annual screening is recommended to age 30 (with conventional Pap test; every 2 years if liquid-based Pap tests). After age 30 and three negative Pap tests, screening may be done every 2 to 3 years in consultation with the health care provider. Women ages 65 to 70 with no abnormal tests in the previous 10 years may choose to stop screenings. Women who have had total hysterectomies for benign disease can choose to stop having Pap tests (ACS, 2010a; USPSTF, 2009). Women in high risk categories should have more frequent Pap tests.

Pap test results in the past have been recorded by using several different classification systems. The reporting system most often used today is the Bethesda system, one that reports on gynecologic cytology as well as histology of cervical lesions (Box 11-5). Changes secondary to inflammation, treatment (e.g., radiation), and contraceptive devices can be reported, as well as changes caused by infections. Epithelial cell abnormalities are described in three categories: atypias, or atypical squamous cells (ASC); low-grade squamous intraepithelial lesions (LSILs); and high-grade squamous intraepithelial lesions (HSILs).

Several options for follow-up of a finding of ASC of undetermined significance (ASC-US) are suggested. These include immediate colposcopy, repeating cytology at 6 months and 12 months, or HPV testing and referral for colposcopy if test is positive. If the initial cytology test was obtained by a liquid-based method, HPV testing is preferred instead of follow-up with repeated cytology (ACOG, 2008). A finding of LSIL may include HPV and CIN 1. Colposcopy is recommended for evaluation of LSIL except in adolescents; teens can be followed with cytology tests at 6 and 12 months. HPV deoxyribonucleic acid (DNA) testing should not be used (ACOG). HSILs include lesions described as CIN 2, CIN 3, and carcinoma in situ (CIS). Follow-up for a report of HSIL includes colposcopy or loop electrosurgical excision (ACOG).

Colposcopy is the examination of the cervix with a stereoscopic binocular microscope that magnifies the view of the cervix. Usually a solution of 3% acetic acid is applied to the cervix for better visualization of the epithelium and to identify areas for biopsy. Colposcopy is not an invasive procedure and is usually well tolerated by the woman. However, the woman who is scheduled for colposcopy because of an abnormal Pap test may be anxious about the procedure and may need explanations or written information about what to expect during the procedure.

Biopsy is the removal of cervical tissue for study, and several techniques can be used. An endocervical curettage is an effective diagnostic tool in about 90% of cases. It can be performed as an outpatient procedure with little or no anesthesia. It may be uncomfortable, and interventions to help the woman relax and cope with the pain may be needed.

Conization and loop electrosurgical excision procedure (LEEP) (see later discussion) can be done as outpatient procedures, although neither is usually performed unless the biopsy is positive or the results of the colposcopy are unsatisfactory. Conization involves removal of a cone of tissue from the exocervix and endocervix (Fig. 11-13). It can be a cold knife procedure, a laser excision, or an electrosurgical excision (see later discussion). There are two advantages to a cone biopsy. It can be used (1) to establish the diagnosis and (2) to effect a cure. If CIS is diagnosed, and if the woman wishes to retain her childbearing capacity, conization removes the abnormal tissue; further treatment (e.g., hysterectomy) is unnecessary. The woman is monitored with Pap tests and colposcopy when indicated.

If invasive cancer is diagnosed, other diagnostic tests can assess the extent of spread (see earlier discussion under endometrial cancer). Once the extent of the cancer is known, treatment begins.

Medical and Surgical Management

Once a diagnosis has been identified, a course of treatment is planned. For preinvasive lesions, several techniques are used. As stated, because many preinvasive conditions are detected in

younger women who may wish to continue childbearing, treatment is geared toward eradicating abnormal cells while attempting to preserve the structure of the cervix. The techniques currently available for preinvasive lesions are cryotherapy, laser therapy, and LEEP, all of which have comparable success rates in treating CIN (ACOG, 2008).

Treatment for invasive cancer includes surgery, radiation therapy, and chemotherapy. Once the cancer is staged, treatment is begun. Microinvasive cancer is usually treated with conization, but a hysterectomy is often done if childbearing is not desired. The choice of treatment for early-stage invasive cancer is by either hysterectomy or chemoradiation therapy (Monk & Tewari, 2007). A radical hysterectomy is performed if the cancer has extended beyond the cervix but not to the pelvic wall. Locally advanced stages of cervical cancer usually are treated with radiation therapy, both external and internal, and chemotherapy. Late stages are usually treated with radiation and chemotherapy. Five-year survival rates are more than 97% when the cancer is localized (ACS, 2010a). Cisplatin is the most commonly used chemotherapy agent.

Recurrent and Advanced Cancer of the Cervix

Approximately one third of women with invasive cervical cancer will have recurrent or persistent disease after therapy. The 5-year survival rate is approximately 17% (Monk & Tewari, 2007). Irradiation of metastatic areas is commonly successful in providing local control and symptomatic relief. Irradiation for recurrent disease may be considered for women who were initially treated with surgery. Further radiation may not be effective for those women who were initially treated with radiation.

Incidence and Etiology

Vulvar carcinoma accounts for about 4% of all female genital malignancies and is the fourth most commonly occurring gynecologic cancer. It appears most frequently in older women in their middle 60s to 70s; DNA testing of these women often shows mutation of the p53 tumor suppressor gene (ACS, 2010b). Vulvar cancers in older women do not appear to be etiologically related to HPV infection. The incidence of vulvar cancer, specifically vulvar intraepithelial neoplasia (VIN), is increasing in younger women. Almost 20% of vulvar cancers occur in women younger than 50 years of age, and most women are in their twenties. HPV infection is thought to be responsible for most of these cancers (ACS). Women who have a history of genital warts (condylomata acuminata) and who smoke have an increased risk of developing VIN (ACS).

By far the majority (90%) of vulvar carcinoma is squamous cell; other vulvar neoplasms are attributed to Paget’s disease, adenocarcinoma of Bartholin glands, fibrosarcoma and melanoma, and basal cell carcinoma. VIN is the first neoplastic change, progressing over time to cancer in situ (CIS) and then to invasive cancer. Metastasis is by direct extension and lymphatic spread (Hacker, 2010b).

Prognosis depends on the size of the lesion and the tumor grade at the time of diagnosis. Fifty percent of women have symptoms for 2 to 16 months before seeking treatment. Fortunately, vulvar cancer grows slowly, extends slowly, and metastasizes fairly late. Even with a pattern of delayed diagnosis, survival rates are approximately 96% for all stages if nodes are negative. Survival rates drop to 66%, however, if lymph node metastasis has occurred (Stehman, 2007).

Clinical Manifestations and Diagnosis

Itching is the most common symptom of VIN; a lump or lesion is more common with invasive cancer (Hacker, 2010b). The most common site for vulvar lesions is on the labia majora. The vulvar lesion is usually asymptomatic until it is 1 to 2 cm in diameter. When it is symptomatic, women may complain of vulvar pruritus, burning, or pain. Necrosis and infection of the lesion result in ulceration with bleeding or watery discharge.

VINs are usually multifocal in young women. Unifocal lesions are associated with invasive cancer and are more common in older women. Initially, growth is superficial but later extends into the urethra, the vagina, and the anus. In approximately 50% of late cases, superficial inguinal and femoral lymph nodes become involved (Stehman, 2007).

Simple biopsy with histologic evaluation reveals the diagnosis. The areas of pathologic involvement are identified by staining the vulva with toluidine blue (1%), allowing an absorption time of 3 to 5 minutes, and then washing with acetic acid (2% to 3%); abnormal tissue retains the dye. Biopsy is necessary to rule out such conditions as sexually transmitted infections (e.g., chancroid, granuloma inguinale, syphilis), basal cell carcinoma, and CIS. In situ malignancies are initially small, red, white, or pigmented friable papules. In Paget’s disease the lesions are red, moist, and elevated. Melanomas appear as bluish-black, pigmented, or papillary lesions. Melanomas metastasize through the bloodstream and lymphatics (Hacker, 2010b).

Collaborative Care

Cancer of the Breast

Approximately 1% to 2% of women are pregnant or lactating at the time of diagnosis of cancer of the breast (Tewari, 2007). Breast cancer complicates about 1 in 3000 pregnancies. The survival rate for women who are diagnosed with breast cancer while pregnant may be as low as 15% to 20% because the disease is generally in the advanced stages when first diagnosed (Tewari). Diagnosis is often delayed because breast engorgement may obscure the mass from palpation, and increased density of the tissue makes mammographic visualization more difficult. In addition, increased vascularity and lymphatic drainage in the breast of a pregnant woman may increase the speed of metastasis. Treatment is the same as for the nonpregnant woman, although surgery is usually the treatment of choice for breast cancer in pregnancy (Tewari). If an invasive tumor is found, it must be determined whether the tissue is positive or negative for estrogen receptors (ERs). ER-negative tumors spread more rapidly than ER-positive tumors and are more common in pregnancy.

Maternal-fetal management involves consideration of the gestational age of the fetus, the extent of disease, the tumor growth potential, and the proposed treatment. Termination of the pregnancy in early stages of the disease appears to have no effect on survival. There is little evidence to suggest that pregnancy affects the malignant process. Therapeutic abortion may become an issue in the presence of advanced disease and may be deemed necessary to achieve effective palliation. Lumpectomy or partial mastectomy is the most commonly used surgical procedure, but radical mastectomy is tolerated well in these women. For advanced disease in the second or third trimester, alkylating agents, 5-fluorouracil, doxorubicin, and vincristine are relatively safe for the fetus. Radiation therapy is avoided if at all possible until after the birth, because even with careful shielding the fetus may still receive sufficient radiation to produce detrimental effects (Tewari, 2007).

There is no agreement about whether a postpartum woman with breast cancer should breastfeed, although many surgeons recommend formula feeding. There are theoretic concerns that if one of the oncogenes for breast cancer is a virus, as many have postulated, the remaining breast may be contaminated, and the virus may be passed to the newborn, possibly acting as a latent inducer of breast carcinoma. Another reason is that lactation increases vascularity in the remaining breast, which may contain a neoplasm as well (Tewari, 2007).

Breastfeeding after lumpectomy is possible, but the site of the incision may interrupt the milk ducts or prevent the nipple from extending during feeding. Breastfeeding is contraindicated if the woman is receiving chemotherapy. Women receiving radiation will have diminished ability to lactate in the irradiated breast (Copeland & Landon, 2007; Tewari, 2007).

Pregnancy incidence after mastectomy is influenced by many factors, including prior treatment and duration of survival. About 7% of women will have one or more pregnancies within the first 5 years after mastectomy. In general, women with good prognoses (e.g., no positive nodes) are likely to be counseled to wait at least 2 years before attempting pregnancy (Cohn et al., 2009).

Cancer of the Cervix

The incidence of cervical cancer concurrent with pregnancy is reported to be 3% or about 1 in 2200 pregnancies, making it the most common reproductive tract cancer associated with pregnancy (Copeland & Landon, 2007). Birth can be accomplished by either the vaginal or the cesarean route; however, there is some concern regarding vaginal birth in the presence of invasive disease because the risk of hemorrhage and metastatic seeding from local trauma may be increased. The outcome for the woman with cervical cancer is roughly the same as that for the nonpregnant woman (Tewari, 2007).

Cervical abnormalities are diagnosed during pregnancy with an abnormal Pap test. If the report suggests that the pregnant woman has a squamous intraepithelial lesion, a colposcopy, possibly with directed biopsy, is done. If invasive disease is not found, treatment is delayed until after the woman gives birth. Colposcopy is often repeated every 6 to 8 weeks until the birth and again postpartum. Conization is not advised during pregnancy unless necessary to rule out invasive cancer because it is associated with bleeding, miscarriage, and preterm birth (Tewari, 2007).

The therapy of invasive carcinoma of the cervix during pregnancy is affected by many factors. The stage of the disease and the trimester in which the cancer is diagnosed are important. Equally important are the beliefs and desires of the woman and her family in terms of initiating therapy that can interrupt the pregnancy, as opposed to postponing the therapy until fetal viability is achieved. If the woman chooses not to continue the pregnancy, external radiation to the pelvis is done. Miscarriage usually occurs, and then internal radiation is done. If miscarriage does not occur, a modified radical hysterectomy may be performed. If the woman desires to continue the pregnancy, treatment of early-stage invasive cervical cancer can be delayed until fetal viability is reached, without harmful effects on the woman. Cesarean birth is usually performed, followed by radiation therapy (Copeland & Landon, 2007; Tewari, 2007).

Leukemia

The average age for pregnant women with acute leukemia is 28 years; incidence during pregnancy is about 1 in 75,000 (Cohn et al., 2009). Pregnancy seems to have no specific effect on the course of the disease, except that vigorous therapy is detrimental to early gestation. Preterm labor and postpartum hemorrhage are associated with acute leukemia (Tewari, 2007). Acute myelocytic leukemia (60% of cases) has a more fulminant course and requires immediate therapy; in the presence of chronic myelocytic leukemia, therapy can be delayed somewhat. Some pregnant women with the chronic form of the disease who had chemotherapy and radiation therapy directed at the spleen have given birth to apparently healthy infants. The decision to terminate the pregnancy rests with the woman and her family; however, prompt, aggressive therapy is always advisable if remission is to be achieved. Decisions may be influenced by the aggressiveness of the disease.

Hodgkin’s Disease

Hodgkin’s disease is a malignant lymphoma that affects many younger people and complicates about one in 6000 pregnancies. Younger women (younger than 40 years) have a better prognosis (Tewari, 2007).

Pregnancy appears to have no effect on the disease and vice versa, other than those effects resulting from therapy. Radiation therapy of the nodes and multiagent chemotherapy result in about a 90% cure rate. Unless gestation is well into the third trimester, delay in initiating therapy should be minimal, which brings up the dilemma of therapeutic abortion. Radiation therapy to diseased areas above the diaphragm can be initiated during the third trimester with proper shielding of the fetus (Cohn et al., 2009). Chemotherapy is strongly contraindicated during the first trimester but certain agents (antitumor antibiotics and antimicrotubule agents) appear safe to use in the second and third trimesters. Termination of the pregnancy during the course of the disease is not definitely indicated, although treatment decisions are easier (Tewari, 2007).

Melanoma

Malignant melanoma may be one of the rare cancers that can be affected by pregnancy. This is suggested by reports in which pregnancy has been shown to induce or exacerbate a melanoma. These suggestions are based on changes that occur naturally during pregnancy and include hyperpigmentation, an increase in melanocyte-stimulating hormone (MSH), and increased production of estrogen. ERs have been identified in about half of all melanomas (Tewari, 2007).

Although pregnancy has been implicated in the more rapid metastases to regional lymph nodes, stage for stage there does not seem to be a significant difference in the survival of pregnant and nonpregnant women. As a result, most authorities recommend that women who have histories of malignant melanoma delay pregnancy for 2 to 3 years after surgical excision, because this is the period of highest risk for recurrence (Copeland & Landon, 2007).

Diagnosis is established by biopsy. Therapy consists of radical local excision. For most other malignancies, the placenta is unexplainably resistant to invasion by maternal cancer. Although melanoma accounts for few cases of malignant disease during pregnancy, it is the most common cancer to metastasize to the placenta (Tewari, 2007).

Thyroid Cancer

The incidence of thyroid cancer in pregnancy is not established. Normally the thyroid gland enlarges during pregnancy, and an asymptomatic nodular mass is a common finding. Diagnosis is usually by cytologic testing of fine-needle aspirate. Thyroid suppression is the preferred treatment during pregnancy for a benign lesion. For a papillary or follicular malignancy found in the first or second trimester, the woman is advised to have a thyroidectomy in the second trimester followed by thyroid suppression (Tewari, 2007). If a tumor is found in the third trimester, surgery can be delayed until after the birth. With other thyroid malignancies, treatment is individualized based on the wishes of the woman and her family (Tewari).

Colon Cancer

The incidence of colon cancer in pregnancy is approximately 1 in 13,000 (Copeland & Landon, 2007). The signs and symptoms such as constipation, hemorrhoids, and backache are often attributed to pregnancy, resulting in diagnosis at a more advanced stage. Colonoscopy and biopsy are usually not done in pregnancy because these procedures can cause placental abruption and fetal injury from maternal hypoxia or hypotension.

Management of the cancer is based on the weeks of gestation and tumor stage. In a woman who is less than 20 weeks of gestation, surgery may be performed to remove the tumor. If she is more than 20 weeks of gestation, surgery may be delayed until after the birth. Chemotherapy and radiation are usually not used in pregnancy for colon cancer but may be used after the birth (Cohn et al.; Copeland & Landon).

Other Gynecologic Cancers

Cancer Therapy and Pregnancy

Decisions about the type and timing of therapy for cancer in the pregnant woman evoke moral and philosophic dilemmas, as well as complex medical judgments and intense emotional responses.

Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) is a term that encompasses a spectrum of disorders arising from the placental trophoblast. It includes hydatidiform mole (see Chapter 28), invasive mole, and choriocarcinoma. Gestational trophoblastic neoplasia (GTN) refers to persistent trophoblastic tissue that is presumed to be malignant (Soper & Creasman, 2007).

Box 11-6 describes the clinical classifications of GTN. For several reasons, GTN is recognized as the most curable gynecologic malignancy. There is a sensitive marker produced by the tumor (hCG); the tumor is extremely sensitive to various chemotherapeutic agents; high risk factors in the disease process can be identified, allowing individualized therapy; and the aggressive use of multiple treatment methods is possible.

Malignant disease follows normal pregnancy in about 30% to 50% of cases and hydatidiform mole in about 25% of cases. Miscarriage or ectopic pregnancy or another gestational event precedes about 25% of cases (Soper & Creasman, 2007). Metastasis occurs most often in the lungs, the vagina, the liver, and the brain.

Continued bleeding after evacuation of a hydatidiform mole is usually the most suggestive symptom of GTN. Other clinical signs include abdominal pain and uterine and ovarian enlargement. Signs of metastasis include pulmonary symptoms (e.g., dyspnea, cough). The diagnosis is usually confirmed by increasing or plateauing hCG levels after evacuation of a molar pregnancy. Once diagnosis is confirmed, other clinical studies (e.g., CT scan of lungs and brain, chest x-ray, pelvic ultrasound, and liver scan) are done to determine the extent of the disease (Soper & Creasman, 2007).

For women who wish to preserve their fertility and who have low risk nonmetastatic or low risk metastatic GTN, single-agent chemotherapy is chosen. Methotrexate has been the treatment of choice for years. High-dose methotrexate followed by folinic acid “rescue” within 24 hours also has shown excellent results and causes fewer toxic effects (Soper & Creasman, 2007). Dactinomycin also has been used with equally good results and is used for women with liver or renal disease, both of which are contraindications for methotrexate. Hysterectomy with adjuvant chemotherapy is often the choice of treatment for nonmetastatic tumors in women who have completed their childbearing (Soper & Creasman).

Women who have metastasis are classified as having either a good or poor prognosis, depending on the absence or presence of brain or liver metastasis, unsuccessful prior chemotherapy, symptoms lasting longer than 4 months, and serum β-hCG levels greater than 40,000 milli-International Units/ml. Treatment progresses from single-agent chemotherapy in the good-prognosis metastatic GTN to multiple-agent chemotherapy and multiple methods of treatment for the poor-prognosis group. Cure rates for the good-prognosis group are almost as positive as for those with nonmetastatic disease, both approaching 100% (Soper & Creasman, 2007).

Therapy is continued until negative hCG levels are obtained. After successful chemotherapy follow-up by serum hCG levels varies. One schedule is to obtain levels every 2 weeks for 3 months, every month for up to a year after completing therapy and every 6 to 12 months up to 3 to 5 years (Kavanagh & Gershenson 2007; Soper & Creasman, 2007). Physical examinations are done at least yearly as are chest radiographs if indicated. Contraception is needed until the woman has been in remission for 6 months to 1 year (Kavanagh & Gershenson; Soper & Creasman). Oral contraceptives are preferred, but barrier methods are acceptable if oral contraceptives are contraindicated; intrauterine devices (IUDs) are contraindicated (Gilbert, 2011). During a subsequent pregnancy, pelvic ultrasonography is recommended because the woman is at higher risk (1% to 2%) to develop another molar pregnancy. Serum hCG levels should be obtained 6 weeks after the birth (Kavanagh & Gershenson).