HMINDANAO SANITARIUM AND HOSPITAL COLLEGE San Miguel, Tibanga Iligan City

In partial Fulfillment of the Requirements of NCM 103 Related Learning Experience

Uterine Myoma

Members:
Sittie Raima Bayabao Sitti Ameli Harriet Blando

Precious Colita Rajiv Jun Fuentes Kathrine Hernando Marie Antoniette Ibasco Cristina Jayson Crizza Mae Maglasang Joy Molina Jessel Montefalcon Mae Kenneth Pranza

TABLE OF CONTENTS

Page number
Objectives . 1 Introduction . Definition of Terms ... Vital Information .

Nursing History . Genogram Gordons Assessment of Functional Health Patterns .. Physical Assessment and Review of Systems .. Diagnostic Tests .. Normal Anatomy and Physiology Risk Factors and Pathophysiology .. Nursing Care Plans ..... Medical/ Surgical Management ..

Drug Study .. Health Education Plan . Discharge Plan .. Prognosis .. Recent Updates and Researches.. Bibliography

Objectives

Presenters:

After 90 minutes of case presentation the presenters will be able to Present the anatomy and physiology of myoma related with our clients condition Describe the common characteristic of myoma. Discuss the etiology, pathophysiology and clinical manifestation of the clients condition Relate the significance of laboratory results to clients conditions or the disease process.

Participants: After 90 minutes of case presentation the participants will be able to CI: After 90 minutes of case presentation the Clinical Instructors will be able to Ask questions regarding the case presentation gain knowledge about the disease appreciate the importance of nurses role in providing appropriate management for a client having the disease Identify different medical and surgical management diagnosed with uterine myoma. of a patient

Enhance the skills in caring a patient with uterine myoma Recognized appropriate nursing care and management of the disease

Introduction

e learn more by looking for the answer to a question and not finding it than we do from learning the

answer itself

.
~Lloyd Alexander, American

Author, 1924

In the field of nursing, one encounters a wide-array of various diseases and conditions. In order to give adequate and holistic care to individuals, it is necessary that nurses be equipped with the proper knowledge and skills for dealing with different health states. It is only through continuous learning that nurses acquire the necessary skill. A case study is a means of continuing such learning. In doing a case study, the students delve into the question, what is this disease condition? Student nurses learn actively and will be able to handle patients and experience what it means to care for a patient with that particular condition. They learn, from continuous interaction with the patients along side with inquires into books and informative journals of the disease process, it symptoms, and corresponding treatments. Myomas are one of the conditions which the student-nurses encounter during their exposure at the clinical setting last September 5-7, 2012. The disease comprises of complexities of the anatomical concepts that surveys a thorough description to understand its manifestations and formulate interventions. It is interesting on our part to learn its definition, causes, and

proper management. The student-nurses chose the case to be able to have an insight about the condition. Brief Description Uterine myoma is the most common tumors of female genitalia tract. Myoma commonly called fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus. The fibroids start off very small, actually from one cell, and generally grow slowly over years before they cause any problems. Most fibroids are benign; malignant fibroids are rare. The cause of fibroids is unknown, although it is known that fibroids have a tendency to run in families. It may grow as a single nodule or in clusters, and may range in size from 1 mm to more than 20 cm in diameter. reason for hysterectomy. Fibroids are very common, with an estimated 50% of women having them. Fibroids can be diagnosed by pelvic examination or by ultrasound. Fibroids do not have to be removed unless they are causing symptoms such as heavy periods, irregular bleeding, or severe cramps with periods. A hysterectomy is the surgical removal of the uterus or womb, which usually includes the cervix. One or both of the ovaries may he removed at the same time as the hysterectomy. The operation to remove an ovary and fallopian tube is called a salpingo-oophorectomy. The uterus may he removed through an abdominal incision or through the vagina Fibroids can be present and be apparent. However, they are clinically apparent in up to 25% of the women. Approximately 25 % of the myomas will cause symptoms and need medical treatment. Myomas that that do not produce symptoms, do not need to be treated. The said 25 % of women cause significant pelvic morbidity, pressure or including pain, prolonged in rare or heavy menstrual bleeding, and cases, reproductive Myomas are the most frequently diagnosed tumor of the female pelvis, and the most common

dysfunction.

In the Philippines, the estimated number of women is

86,241,697 squared, and the 4,312,084 had been affected of Myoma.

Definition of Terms
1. Endometrium This is the innermost layer of the uterus.

2. Fallopian tubes are attached to the upper part of the uterus and serve as tunnels for the ova to travel from the ovaries to the uterus.

3. Hysterectomy is the surgical removal of the uterus. It may be total, as removing the body and cervix of the uterus or partial, also called supra-cervical.

4. Mesovarium the portion of the broad ligament of the uterus that covers the ovaries.

5. Myometrium This middle layer is a thick wall made of smooth muscle cells.

6. Oophorectomy - is the surgical removal of an ovary or ovaries. 7. ovaries are small, oval-shaped glands about the size of an almond that are located on either side of the uterus.

8. Partial hysterectomy

removal of just the upper portion of the uterus, leaving the cervix and the base of the uterus are left intact.

9. Radical hysterectomy - is the removal of the uterus, both fallopian tubes, both ovaries, and the upper part of the vagina. 10. Salpingo refers specifically to the fallopian tubes which connect the ovaries to the uterus.

11. Serosa The outermost layer consists of a membrane called the serosa.

12. TAH-BSO Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy. This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen.

13. Total hysterectomy - removal of the entire uterus and the cervix.

14. Uterine myoma is the most common tumors of female genitalia tract. Myoma commonly called fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus.

15. Uterus is a hollow, pear-shaped organ that is the home to a developing fetus.

16. Vagina is a canal that joins the cervix to the outside of the body. It also is known as the birth canal.

Vital Information
Name: Ms. M Room number: 216 Age: 34 years old Gender: Female Civil status: Single Date of birth: March 24, 1978 Birthplace: Jasaan, Misamis Oriental Cultural group: Cebuano Primary Language: Bisaya Religion: Roman Catholic Highest Educational Attainment: College Graduate Occupation: Businesswoman Usual Health Care Provider: Dr. Marcella / Ob-gyne, Sonologist Reason for Health Contact: Vaginal bleeding, pale in appearance, increase abdominal girth Date of Confinement: September 3, 2012 8:54 AM

Source of History: patients chart 70%, patient 30% Attending Physician: Maria Lilagri Marcella, M.D/Ob-gyne, Sonologist Impression/Final Diagnosis: Uterine Myoma, Anemia Description of Patient: PATIENT VISIT September 4, 2012 (Pre operative) Awake, coherent, sitting at the edge of the bed with patent IVF of PNSS 1L at KVO hooked at the right metacarpal vein, 800cc IV left; with complaints of vaginal bleeding 2 pads/day; pain noted at the right periumbilical area with a pain scale of 4/10. Has slender medium body built with an apparent flabby abdominal girth and a height of 50. Skin color is brown, light colors of the skin are found in palms and nails. Skin is relatively dry through the body with minimal amount of perspiration on axilla and scalp. Skin temperature is relatively warm through the body with an axillary temp.of 36.0 C. Hair in the head and body are evenly distributed , texture is fine, short and black in color. No dandruff and lesions noted. Head is normocephalic and symmetrical; capable of facial movements like elevation of eyebrows, lowering of eyebrows, closing of eyes, able to smile, grin and frown. Facial movements symmetrical. Anicteric sclera noted, pale conjunctiva, equal chest expansion without adventitious sounds respiratory rate of 22 breaths per minute, capillary refill time of 2 seconds, pulse rate of 72 and blood pressure of 110/80 mm Hg. DAY 1 September 5, 2012 8:00 am (Pre operative) Awake, coherent @ semi fowlers position with patent IVF PNSS 1 L @ 30 gtts/min hooked at right metacarpal vein, 200 cc left; pain noted @ right periumbilical area with a pain scale of 4/10. Pallor and abdominal girth of 37.5 inches; complaints of vaginal bleeding 1 pad; V/S as follows: T=36.7, BP=110/70 mm Hg, PR=85, RR=19. 2:00 pm (Post operative) - Received awake, lying in supine position with patent IVF D5LR 500 cc @ 30 gtts/min hooked @ right metacarpal vein. Indwelling catheter noted. Pain noted @ surgical site with a pain scale of 7/10. Pallor and general weakness noted. Complaints of itchiness in the whole body, V/S as follows: T=37.4, BP=110/70, RR=21, PR=82. DAY 2 September 6, 2012 (Post operative) 8:00 am Awake, coherent @ semi fowlers position with patent IVF Bottle # 2 D5LR 1 L @ 30 gtts/min, 400 cc left hooked @ right metacarpal vein; indwelling catheter noted with 100 cc of urine, dark yellow in color; pain noted @ surgical site with a pain scale of 6/10; abdominal girth is 32.5 in V/S as follows: BP=100/70, T=37.3, PR=70, RR=22. 2:00 pm Asleep in supine position with patent IVF Bottle # 3 D5NM 1 L @ 30 gtts/min hooked @ right metacarpal vein, still with bearable pain in a scale of 4/10, complaints of slight itchiness in the upper extremities, V/S as follows: BP=100/70, T=37.2, PR=77, RR=20.

DAY 3 September 7, 2012 (Post operative) 8:00 am Awake, coherent, sitting @ the edge of the bed, without IVF, pain noted @ surgical incision with pain scale of 4/10, complaints of itchiness in the whole body, V/S as follows: T=36.9, BP = 110/80, PR= 86, RR=18 2:00 pm Awake, conversant, coherent and oriented to time place and person; has no mobility restrictions and ambulatory. still with pain @ the surgical incision with pain scale of 3/10, abdominal girth of 28 inches, no complaints of itchiness, T=36.2, BP=110/80, PR=70, RR=20.

Nursing History
A. CHIEF COMPLAINTS/ REASON FOR VISIT Patient was admitted to Mindanao Sanitarium and Hospital last September 3, 2012 8:54 AM with a complaint of vaginal bleeding, pale in appearance, increase abdominal girth.

B. HISTORY OF PRESENT ILLNESS

-

Two years prior to admission, patient have onset of profuse vaginal bleeding during her menstrual period, heaviest in the 2nd and 3rd day consuming up to 4pads per day, lasting 7days/period.CBC done noted, with decrease HGB, UTZ done with result of uterine myoma. Consulted and advise for TAHBSO at PGH. Few months prior to admission, patient consulted the attending physician, scheduled for hysterectomy hence admitted.

C. HISTORY OF PAST ILLNESS

-

Patient has no food allergies, no chronic illnesses of previous accident. Patient had mumps when she was still 8years old. Patient cannot recall her immunizations during her childhood. She had her menarche when she was 14 years old with a 28-30 day cycle; 7 days duration consuming up to 4 pads/day. She was hospitalized for three days at Cebu Doctors Hospital last 2006 due to delivery of her first baby girl via NSVD G1 P1. Last 2011 she had her flu vaccine, eye examination with a visual acuity of 20/20 and Papsmear.

GORDONS ASSESSMENT
HEALTH PERCTION /HEALTH MANAGEMENT PATTERN
Hospitalized client: Client was admitted in MSH due to vaginal bleeding on Sept. 3, 2012 at exactly 8:45 a.m. she believed that being admitted in the hospital would help her with her complaints. She was hospitalized at PGH in Manila 6 years ago due to her delivery via NSVD on her child because she wanted whats best for her baby and for her.

NUTRITIONAL /METABOLIC PATTERN

Before Admission: Mrs. M has a poor appetite. She usually skips her breakfast, according to her dili jud ko ganahan mamahaw as verbalized by the Mrs. M. But usually eats during lunch and dinner time which usually consist of vegetables or oatmeal. And often drinks 5-6 glasses of water a day. She usually take vitamins such as Vit. C and multivitamins once a day. She likes any kind of food served. And often goes to the fast food 2-3x/week. She has no any discomfort upon swallowing or eating her food but has a denture on her upper front portion of her teeth and has no food restriction as well. During Admission: Day1 September 5, 2012 Mrs. M was in NPO 12a.m because she would undergo an abdominal hysterectomy w/c ends at 1:05p.m and lasted for about 1hr and 15 mins. She was in a soft diet and was able to consumed food served during her dinner time and have drank 1 glasses of water for the whole Shift. Day2 September 6, 2012 Mrs. M has a poor appetite. She was still in Soft diet and able to consumed only of food served on her breakfast and able to consumed food serve during her lunch. And had drink 3 glasses of water for the whole shift. Day 3 September 7, 2012 Mrs. M was prescribed to be on DAT diet. Still with poor appetite as evidenced by able to consumed half of food serve during her breakfast and consumed all food served on herf lunch. And able to drinks 7 glasses of water. ELIMINATION PATTERN Before admission: Mrs .M has a regular bowel pattern of once per 2-3 days and does experienced constipation and does not experience diarrhea not unless if she would eat something that could cause the problem such as too much peanut butter would cause her a diarrhea. She usually urinated ten times per day but no difficulty or pain upon urination. She doesnt have any skin problems such as rashes and lesions. And does not experience excessive perspiration not unless when expose to heat. During Admission: Day 1 September 5, 2012 Mrs. M was not able to defecate for the whole. And urinated for about 8x before her surgery. But she was cathethered since the operation begins using the two way type of catheter with no urine output noted on the catheter bag. She had also experience minimal skin itchiness on her extremities and had experience excessive perspiration in the evening. Day 2 September 6, 2012 Mrs. M was able to pass out flatulence early in the morning, but hasnt defecated for the whole shift. Still with catheter inserted with a urine output of 300cc for the whole shift. And with moderate skin itchiness in her extremities. And havent experience excessive perspiration. Day3 September 7, 2012 Mrs. M still hasnt defecated for the whole shift with the urine output of 300cc in her fbc. She is no longer experiencing skin itchiness in her extremities. And have not experience excessive perspiration. EXERCISE AND ACTIVITY PATTERN:

Before admission: Mrs. Ms usual day activities are as follows: watching TV, surfing in the internet, washing plates and staying in her room. She only leaves her room during lunch and dinner time. She usually spends her leisure time surfing in the internet and watching movies. She usually do Yoga every morning but since she had illness she is no longer doing it because she experience shortness of breath and lower abdominal pain with pain scale of 3/1O sometimes. During Admission: Day 1 September 5, 2012 Mrs. Ms activity in the hospital since she was admitted were as follows; lying down in bed, sleeping, since she had undergone a surgery on her abdomen. She was encouraged to do a deep breathing exercise according to her A.P. And experience pain in the incision site w/ a pain scale of 6/1O Day 2 September 6, 2012 Mrs. Ms activity during this day were as follows; lying on bed, talking with her SO, watching TV and eating her meals as well. Still w/ abdominal pain on the incision site w/ a pain scale of 5/10. Day3 September 7, 2012 Mrs. Ms activity during these is similar with the day 2, but these time she was able to ambulate but with assistance. Still in pain in the incision site with a pain scale of 4/10. SLEEP/REST PATTERN: Before admission: Mrs. M usually sleeps late at night usually at 1:00 a.m. and wakes up early around 4-7 a.m. in the morning. In general she feels unrested when she wakes up. She usually takes a nap in the afternoon for about two hours. she did experience any nightmares She have also experience insomnia around 45:30 a.m. her sleeping whenever these occur is surfing in the net until her eyes becomes tired. During Admission: Day 1 September t 5 2012 Mrs. M wakes up around 7 am in the morning to prepare herself because she would undergo an abdominal hysterectomy and sleeps for the whole afternoon after the procedure. Day 2 September 6, 2012 Mrs. M wakes up 7:30 a.m. in the morning and feel rested the whole time She also had taken her nap for about 2 hrs in the afternoon. And sleeps around 8p.m. in the evening and had really sleeps well. Day 3 September 7, 2012 Mrs. M hasnt experience insomnia not like before. She wakes up around 7 a.m. in the morning and had taken her nap around 10a.m. for almost an hour. PERSONAL HABITS Before/During admission: Mrs. M does not smoke and have not tried even once neither using street drugs. ALCOHOL: Before/During admission:

Mrs. M usually drinks alcoholic beverages such as red wine occasionally. But since she had her illness, she no longer drinks alcoholic beverages even if during occasions till now. ENVIRONMENT/HAZRDOUS Before/during admission: Mrs. M had work in Saudi for about a year all by herself, she was not exposed to certain hazardous environment as well as her neighbours according to her. ok ra man ko diadto wala man kayo problema as verb. by Mrs. M upon asking her if she were exposed to hazardous environment. And even her staying in the hospital as well is alright, instead she feels safe because there are a lot of medical heath care provider in the hospital according to her. INTIMATE PARTNER Mrs. M is not living with the father of her child because they had been separated by her mother since she got pregnant because they were too young before to get married according to her mom. OCUPATIONAL HEALTH Before admission: Mrs .M was a physical therapist in Saudi, her job was alright and not too stressful. She is not exposed to any hazardous chemical inhalants. She usually wears protective gears such as mask and gloves if necessary. And according to her it was her illness affects her job which lead her to quit for the meantime and seek for medical help. COGNITIVE AND PERCEPTUAL PATTERN Before admission: Mrs. M has no health problems with her vision, her hearing and other special senses such as ability to feel pain and ability to tastes. Able to distinguish taste such as sweet taste, sour and bitter taste. Her only problem is her lower abdominal pain that she usually experience with pain scale of 5/10. After admission: Day1 September 5-7, 2012 Mrs. M doesnt have any complaints regarding her visions as well her other senses her only complain this time is pain in her incision site when moving. SELF PERCEPTION Before Admission: Mrs. M feels worried since she had discovered that she had a myoma and needed to be removed as soon as possible. She is contented with her appearance, her illness really affects her because she could not work and makes her more stressed. She prays in order to alleviate her feeling.

After admission: Mrs. M feels relieved after the surgery since it was a successful surgery and the tumor was removed. She is really very thankful and happy that at last her burden was been eased. ROLE AND RELATIONSHIP PATTERN: Before /During Admission: Mrs. M lived in her parents house. With ___ family structured .she often calls her mom whenever she had a problem and asked for an advised. According to Mrs. M her family does not depend on her but depends on her mom and

dad. She also said that her illness really affects her relationship with her family she usually irritated easily and moody sometimes. Her family is also worried and concerned about her though theyre not verbalizing it but she can feel it according to Mrs. M. SEXUALITY AND REPRODUCTIVE PATTERN Before /During Admission Mrs. M is not comfortable talking about her sexual Relationship since she was separated with the father of her daughter. Her last menstrual period was on August 29, 2012. And sometimes experience dysmenorrhea. She usually had her pap smear once a year, last year it was on July. She usually practices breast self examination but since she was admitted she was no able to do it. She has a 6year old child and is not pregnant. COPING SRESS MANAGEMENT PATTERN Before /During Admission: Mrs. M hasnt experience major losses in the past. It is her illness that causes her to be stressed in the past and it is her surgery causes her stressed in present but now she is totally relieved after the successful surgery. Whenever she had a problem she asked an advice from her mother and of course prays to God and surrenders everything to him. She does not usually get what she wants according to her. VALUES AND BELIEF Before /During Admission: Mrs. Ms family was the most important thing for her. She does not usually get what she wants according to her. Before her major plan was to undergo a surgery for her mayoma but now that she had already undergone the surgery and the tumor was removed she is planning to work abroad again. She really believes that meditations and prayer really helps and her illness did not affect her relationship with God it even become much stronger. NORMAL ANATOMY AND PHYSIOLOGY

The female reproductive system consists of the ovaries, uterine tubes (or fallopian tubes), uterus, vagina, external genitalia, and mammary

glands. The internal reproductive organs of the female are located within the pelvis, between the urinary bladder and the rectum. The uterus and the vagina are in the midline , with an ovary to each side of the organ. The internal reproductive organs are held in place within the pelvis with ligaments. The most conspicuous is the brad ligament, which spreads out on both sides of the uterus and to which the ovaries and the uterine tubes attach.

Ovaries The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone). The two ovaries are small organs suspended in the pelvic cavity by ligaments. The suspensory ligament extends from each ovary to the lateral body wall, and the ovarian ligament attaches the ovary to the superior margin of the uterus. In addition, the ovaries are attached to the posterior surface of the broad ligament by folds of the peritoneum called the mesovarium. The ovarian arteries, veins, and nerves transverse the suspensory ligament and enter the ovary through the mesovarium. A layer of visceral peritoneum covers the surface of the ovary. The outer part of the ovary is made up of dense connective tissue and contains the ovarian follicles. Each of the ovarian follicles contains an oocyte, the female sex cell. Loose connective tissue makes up the inner part of the ovary, where blood vessels, lymphatic vessels, and nerves are located. The ovaries are about the size and shape of almonds. They lie against the lateral walls of the pelvis, one on each side. They are enclosed and held in place by the broad ligament. There are compact like tissues on the ovaries, which are called ovarian follicles. The follicles are tiny sac-like structures that consist of an immature egg surrounded by one or more layers of follicle cells. As the developing egg begins to ripen or mature, follicle enlarges and develops a fluid filled central region. When the egg is matured, it is called a graafian follicle, and is ready to be ejected from the ovary. (3) Process of egg production--oogenesis (a) The total supply of eggs that a female can release has been determined by the time she is born. The eggs are referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into primary oocytes, which contain 46 chromosomes and are surrounded by a layer of follicle cells. (b) Primary oocytes remain in the state of suspended animation through childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the anterior

pituitary gland secretes follicle-stimulating hormone (FSH), which stimulates a small number of primary follicles to mature each month.

Human ovary (c) As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is nonfunctional, and incapable of being fertilized. (d) By the time follicles have matured to the graafian follicle stage, they contain secondary oocytes and can be seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation (ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone (LH), which is released by the anterior pituitary gland. (e) The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which secretes estrogen and progesterone. (f) If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar body and an ovum, which combines its 23 chromosomes with those of the sperm to form the fertilized egg, which contains 46 chromosomes. (4) Process of hormone production by the ovaries.

(a) Estrogen is produced by the follicle cells, which are responsible secondary sex characteristics and for the maintenance of these traits. These secondary sex characteristics include the enlargement of fallopian tubes, uterus, vagina, and external genitals; breast development; increased deposits of fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual cycle. (b) Progesterone is produced by the corpus luteum in presence of in the blood. It works with estrogen to produce a normal menstrual cycle. Progesterone is important during pregnancy and in preparing the breasts for milk production. Uterine Tubes A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele Fallopio) is associated with each ovary. The uterine tubes extend from the area of the ovaries to the uterus. The open directly into the peritoneal cavity near each ovary and receive an oocyte. The opening of each uterine tube is surrounded by long, thin processes called fimbriae. The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries. The distal end of each fallopian tube is expanded and has finger-like projections called fimbriae, which partially surround each ovary. When an oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry the oocyte into the fallopian tube. Oocyte is carried toward the uterus by combination of tube peristalsis and cilia, which propel the oocyte forward. The most desirable place for fertilization is the fallopian tube

Uterus The uterus is a hollow organ about the size and shape of a pear. It serves two important functions: it is the organ of menstruation and during pregnancy it receives the fertilized ovum, retains and nourishes it until it expels the fetus during labor. The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments. The uterus consists of the body or corpus, fundus, cervix, and the isthmus. The major portion of the uterus is called the body or corpus. The fundus is the superior, rounded region above the entrance of the fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is the slightly constricted portion that joins the corpus to the cervix. The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. Vagina The vagina is the female organ of copulation and functions to receive the penis during intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to outside the body. The superior portion of the vagina is attached to the sides of the cervix so that a part of the cervix extends into the vagina. The wall of the vagina consists of an outer muscular layer and an inner mucous layer. The muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can increase in size to accommodate the penis during intercourse, and it can stretch greatly during childbirth. The mucous membrane is

moist stratified squamous epitheliam that forms a protective surface layer. Lubricating fluid passes through the vaginal epithelium into the vagina. In young females, the vaginal opening is covered by a thin mucous membrane known as the hymen. The hymen can completely close the vaginal oriface in which case it must be removed to allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The openings of the hymen are usually greatly enlarged during the first sexual intercourse. The hymen can also be perforated during a variety of activities including strenuous exercise. The condition of the hymen is therefore not a reliable indicator of virginity. The External Genitalia The external organs of the female reproductive system include the mons pubis, labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a group, these structures that surround the openings of the urethra and vagina compose the vulva, from the Latin word meaning covering. The external female genitalia, also called the vulva, or pudendum, consists of the vestibule and its surrounding structures. a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair. b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are the 2 elongated hair covered skin folds. They enclose and protect other external reproductive organs. c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra. d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus. (1) The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is sexual excitation. (2) The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular structure that drains urine from the bladder. (3) The vaginal introitus is the vaginal entrance.

External female genitalia. e. Perineum. This is the skin covered muscular area between the vaginal opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and anal opening. It also helps support the pelvic contents. f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands lie on either side of the vaginal opening. They produce a mucoid substance, which provides lubrication for intercourse.

BLOOD SUPPLY The blood supply is derived from the uterine and ovarian arteries that extend from the internal iliac arteries and the aorta. The increased demands of pregnancy necessitate a rich supply of blood to the uterus. New, larger blood vessels develop to accommodate the need of the growing uterus. The venous circulation is accomplished via the internal iliac and common iliac vein.

Mammary Glands Mammary glands are located inside the breasts of sexually mature female body. They are in actuality modified sweat glands which are in fact comprised of secretory mammary alveoli and the appropriate ducts. Mammary glands are considered to be part of the integumentary system rather than the reproductive system. The glands are associated with the female reproductive system in part due to their assistance in attracting a mate as well as their role in nourishing a baby. Size and shape of the female breast are different for every human body and factors such as race, age, body fat, and pregnancy can make a large difference in these variations. The release of estrogen during puberty releases hormones that stimulate the growth of the breasts and the functions of the mammary glands. Pregnant women as well as nursing women experience hypotrophy of the breasts while it is not uncommon for atrophy of the breasts to occur after menopause. Breasts are situated over ribs 2 through 6 and overlap the pectoral muscle as well as some portions of the oblique muscles. The lateral margin of the sternum creates an unintentional margin for the edge of each breast. Each breast also follows the anterior margin of the respective axilla. Coming within very close proximity to the Axillary vessels, the breasts upward and laterally toward the axilla, which contributes to the high incidence of breast cancer due to the axillary process lymphatic drainage. 15 to 20 lobes compose the mammary gland, and each lobe is equipped with its own duct to the outside of the body. Adipose tissue in varying amounts segregates each lobe. While this tissue controls the size and shape that the breast takes, there is no determination by this tissue when it comes to the womans ability to suckle her young. Lobules are subdivisions of each lobe. These subdivisions contain mammary alveoli. The milk of a lactating female are produced within the mammary

alveoli. Suspensory ligaments support the breasts which are attached between the lobules and run deep into the fascia which overlap the pectoral muscles. Breast milk is secreted into a network of mammary ducts which receive the milk from the clusters of mammary alveoli. These mammary ducts converge to form lactiferous ducts. Near the nipple, each lactiferous duct expands into the lumen to allow for outward flow of milk. The lactiferous sinuses store the milk before the suckling action, or additional pressure, releases it from the body. The milk leaves the body from the tip of the nipple. The nipple contains some erectile tissue that protrudes into a cylindrical projection. The circular area around the nipple that contrasts in color is the areola. Sebaceous areola glands create a bumpy surface around the areola which reside just under the surface of the areolas skin. These glands secrete fluids during lactation as well as when a woman is not lactating, which keep the nipple supple. The complexion of the areola is based on the complexion of the skin that covers the rest of the body, varying in pigments and tints. During gestation most areola surfaces darken. It also becomes larger in most cases. This is thought to be more obvious for a nursing infant to find. Branches of the internal thoracic artery are responsible for supplying blood flow to the nipple as well as the rest of the breast and mammary glands. Between the second, third, and forth intercoastal spaces these braches of the thoracic artery enter the mammary glands. These spaces are positioned laterally to the sternum and offer entry to the mammary artery, which only supplies supportive blood. The return veins run alongside the initial arteries which supply the blood. During pregnancy and lactation, and sometimes during other periods, a superficial venous plexus can be seen through the surface of the skin. The fourth, fifth, and sixth thoracic nerves innervate the breast principally through sensory somatic neurons. These neurons are derivative of the anterior and lateral branches of the thoracic nerves. The release of milk is dependant upon the sensory innervations as stimulus is the only natural release an infant can provide to be nourished. Menstrual Cycle Menstruation is the shedding of the lining of the uterus (endometrium) accompanied by bleeding. It occurs in approximately monthly cycles throughout a woman's reproductive life, except during pregnancy. Menstruation starts during puberty (at menarche) and stops permanently at menopause. Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except during pregnancy and lactation, when it is usually suppressed.

a. The menstrual cycle is controlled by the cyclic activity of follicle stimulating hormone (FSH) and LH from the anterior pituitary and progesterone and estrogen from the ovaries. In other words, FSH acts upon the ovary to stimulate the maturation of a follicle, and during this development, the follicular cells secrete increasing amounts of estrogen .

b. Hormonal interaction of the female cycle are as follows: (1) Days 1-5. This is known as the menses phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone results in the sloughing off of the thick endometrial lining which is the menstrual flow. This occurs for 3 to 5 days. (2) Days 6-14. This is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the anterior pituitary. FSH stimulates the maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as ovulation. (3) Days 15-28. This is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases progesterone, which increases the endometrial blood supply. Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic gonadotropin (HCG). Thehuman chorionic gonadotropin signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of progesterone prevent the release of FSH and ovulation ceases.

c. Additional Information. (1) The length of the menstrual cycle is highly variable. It may be as short as 21 days or as long as 39 days. (2) Only one interval is fairly constant in all females, the time from ovulation to the beginning of menses, which is almost always 14-15 days. (3) The menstrual cycle usually ends when or before a woman reaches her fifties. This is known as menopause. By definition, the menstrual cycle begins with the first day of bleeding, which is counted as day 1. The cycle ends just before the next menstrual period. Menstrual cycles normally range from about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days. Usually, the cycles vary the most and the intervals between periods are longest in the years immediately after menarche and before menopause. Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle usually ranges from to 2 ounces. A sanitary pad or tampon, depending on the type, can hold up to an ounce of blood. Menstrual blood, unlike blood resulting from an injury, usually does not clot unless the bleeding is very heavy.

OVULATION

Ovulation release of an egg cell from a mature ovarian follicle . stimulated by hormones from the anterior pituitary gland, which apparently causes the mature follicle to swell rapidly and eventually rupture. When this happens, the follicular fluid, accompanied by the egg cell, oozes outward from the surface of the ovary and enters the peritoneal cavity. After it is expelled from the ovary, the egg cell and one or two layers of follicular cells surrounding it are usually propelled to the opening of a nearby uterine tube. If the cell is not fertilized by union of a sperm cell within a relatively short time,

it will degenerate.
Menopause When a woman is 40-50 years old, the menstrual cycles become less regular and ovulation does not consistently occur during each cycle. Eventually, the cycles stop completely. The cessation of menstrual cycles is called menopause, and the whole time period from the onset of irregular cycles to their complete cessation is called the female climacteric. The major cause of menopause is age-related changes in the ovaries. The number of follicles remaining in the ovaries of menopausal women is small. In addition to this, the follicles that remain become less sensitive to the stimulation of FSH and LH. As the ovaries become less responsive to stimulation by FSH and LH, fewer mature follicles and copora lutea are produced. Gradual changes occur in women in response to the reduced amount of estrogen and progesterone produced by ovaries. During the climacteric, some women experience hot flashes, irritability, fatigue, anxiety, temporary decrease in libido, and occasionally severe emotional disturbances. Many of these symptoms can be treated successfully with hormone replacement therapy, which usually consists of small amounts of estrogen or progesterone. A potential side effect of HRT is a slightly increased possibility of the development of breast cancer, uterine cancer, heart attacks, strokes, and blood clots. HRT does slow the decrease in bone density that can become sever in some women after menopause, and decreases the risk of developing colorectal cancer. HORMONES AND FEMALE CYCLES The ovarian cycle is hormonally phases. corpus regulated follicle in two The luteum secretes both the

estrogen before the ovulation; the secretes from estrogen and progesterone after ovulation. pituitary events uterus. Hormones and the control in the hypothalamus anterior ovarian the

cycle. The ovarian cycle covers ovary; menstrual cycle occurs in the

Menstrual cycles vary from between 15 and 31 days. The first day of the cycle is the first day of blood flow (day 0) known as menstruation. During menstruation, the uterine lining is broken down and shed as menstrual flow. FSH and LH are secreted on day 0, beginning both the menstrual cycle and the ovarian cycle. Both FSH and LH stimulate the maturation of a single follicle in one of the ovaries and the secretion of estrogen. Rising levels of estrogen in the blood trigger secretion of LH, which stimulates follicle maturation and ovulation (day 14, or mid cycle). LH stimulates the remaining follicle cells to form the corpus luteum, which produces both estrogen and progesterone. Estrogen and progesterone stimulate the development of the endometrium and preparation of the uterine lining for implantation of a zygote. If pregnancy does not occur, the drop in FSH and LH causes the corpus luteum to disintegrate. The drop in hormones also causes the sloughing off of the inner lining of the uterus by a series of muscle contractions of the uterus.

Menstruation At the time the ovaries are formed in the fetus, there are approximately 6000000 primordial follicles, which decrease to about 600000 at birth, to 300000 at the first menstrual cycle, to about 10000 at the time of menopause.

The Cycle - The average cycle is 28 days and has two distinct phases The Follicular Phase
starts on day one of the menstrual cycle (the first full day of bleeding) The hypothalamus in the brain releases gonadotropin-releasing hormone (GnRH)

GnRH signals the pituitary gland

release follicle stimulating hormone (FSH)

stimulates the eggs inside the ovaries to grow

About 20 immature eggs response and begin to develop within sacs known as follicles

Follicles provide nourishment to the eggs

As the eggs develop, the ovaries release estrogen

Estrogen signals the pituitary gland to reduce FSH production

Only enough FSH is now released to stimulate one egg to continue developing, the rest of the eggs shrivel away.

Estrogen stimulates the lining of the uterus to thicken

The primary follicle contains the contains the egg that has grown the most rapidly.

Estrogen continues to rise until it triggers a surge of luteinizing hormone (LH) from the pituitary gland

LH stimulates ovulation

The follicle ruptures and the egg is released along with the follicular fluid onto the surface of the ovary

The Luteal Phase The ruptured follicle continues to receive LH

The LH enables the follicle to turn into a small cyst known as the corpus luteum

The corpus luteum produces progesterone

Progesterone 1) builds and thickens the endometrium, developing glandular structures and blood vessels that supply nutrients to the developing embryo 2) it switches off FSH an LH 3) it raises the basal body temperature (BBT) by half a degree, warming the uterus and fertilized egg

Hysterectomy Alternate Names : Vaginal hysterectomy, Abdominal hysterectomy, Supracervical hysterectomy, Radical hysterectomy, Removal of the uterus, Laparoscopic hysterectomy, Laparoscopically assisted vaginal hysterectomy, LAVH, Total laparoscopic hysterectomy, TLH, Laparoscopic supracervical hysterectomy, Robotically assisted hysterectomy.

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth. The female reproductive organs are made up of the vulva, the vagina, the uterus, the fallopian tubes, and the ovaries. The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the lower part of the uterus that opens into the vagina is called the cervix, and the main body of the uterus, is called the corpus. The uterus has three layers. Endometrium This is the innermost layer of the uterus. The thickness of the endometrium is regulated by hormones and so varies according to the phase of the menstrual cycle. Another name for this lining layer is the mucosa. Myometrium This middle layer is a thick wall made of smooth muscle cells.

Serosa The outermost layer consists of a membrane called the serosa. This thin layer merges with connective tissue (ligaments) that suspends the uterus in the pelvis. The blood supply to the uterus is through the uterine arteries, which are branches of the Aorta, which is the main blood vessel of the body. The vagina is a canal that joins the cervix to the outside of the body. It also is known as the birth canal. The ovaries are small, oval-shaped glands about the size of an almond that are located on either side of the uterus. The ovaries produce eggs and hormones. The Fallopian tubes are attached to the upper part of the uterus and serve as tunnels for the ova to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to grow into an embryo.

A hysterectomy is the removal of the uterus, resulting in the inability to become pregnant (sterility). May be done through the abdomen or the vagina. Hysterectomy may be recommended for:

severe, long-term (chronic) infections (pelvic inflammatory disease) severe inflammation of the lining of the uterus (endometriosis) tumors in the uterus uterine fibroids, cancer of the endometrium cancer of the cervix, cancer of the ovary severe, long-term (chronic) vaginal bleeding

Hysterectomy is a very common operation. The uterus may be completely removed, partially removed, or may be removed with the tubes and ovaries. A partial hysterectomy is removal of just the upper portion of the uterus, leaving the cervix and the base of the uterus are left intact. A total hysterectomy is removal of the entire uterus and the cervix . A radical hysterectomy is the removal of the uterus, both fallopian tubes, both ovaries, and the upper part of the vagina. A hysterectomy may be done through an abdominal incision (abdominal hysterectomy) or through a vaginal incision (vaginal hysterectomy).

Most patients recover completely from hysterectomy. Removal of the ovaries causes immediate menopause and hormone replacement therapy (estrogen) may be recommended. The average hospital stay is from 5 to 7 days. Complete recovery may require 2 weeks to 2 months. Recovery from a vaginal hysterectomy is faster than from a abdominal hysterectomy. If the bladder was involved, then a catheter may remain in place for 3 to 4 days to help the bladder pass urine. Moving about as soon as possible helps to avoid blood clots in the legs and other problems. Walking to the bathroom as soon as possible is recommended. Normal diet is encouraged as soon as possible after bowel function returns. Avoid lifting heavy objects for a few weeks

following surgery. Sexual activities should be avoided for 6 to 8 weeks after a hysterectomy.

Medical/Surgical Management
Medical/Surgical Management: Operation done: total abdominal hysterectomy bilateral salpingo oopphorectomy Procedure: Spinal anesthesia induced Pt placed in supine position Abdomen aseptically and antiseptically prepared, drapes placed A vertical infraumbilical incision done, carried down to the perineum Peritoneum entered and extended, taking care to avoid the bladder and bowels Intra-op findings: -Uterus was enlarged approximately 19x15x14 cm in size -Fallopian tubes normally appearing -Right and left ovaries grossly normal The broad ligaments clamped, cut, sutured, and ligated bilaterally The tubo-ovarian ligaments were cross clamped, cut and suture ligated Broad ligaments were skeletonized down to the uterine vessels and a bladder flap was delveloped with blunt and sharp dissection The uterine vessels were cross clamped, cut and suture ligated Cardinal ligaments were cross clamped, cut and suture ligated Uterosacral ligaments were cross clamped, cut and suture ligated Uterus was removed by incising at the level of the vaginal fernix just below the cervix Specimen handed off the table Continuous interlocking sutures placed around the vaginal margin Operative site checked for bleeding Pelvis was irrigated with saline solution to check for bleeding Closure of the abdominal layer by layer after complete sponge and instrument count Sterile dressing applied Estimated blood loss is 500cc Pt tolerated the procedure well and was taken to the RR in stable condition

Other treatment and management: Patient was transfused with 2 packs of RBC for her anemia

HEALTH EDUCATION PLAN (HEP)

Objectives: After 1 hour of health education the patient and the significant others should be able to 1. Demonstrate and understand the importance of active and passive range of motion 2. Carry out deep breathing exercise and understand the rationale of it 3.
General Health Teachings Specific Health Teachings

Activity and Exercise

1. Encourage patients with abdominal or chest surgery to carry out deep breathing and coughing at least three or four times daily and at each session to take a minimum of five breaths and not greater than twelve in any one session. 2. Explains to the patient that deep breathing and coughing exercises will increase lung expansion and prevent the accumulation of secretions, which might occur after anesthesia or during prolonged bed rest. 3. Encourage ambulation promotes circulation and reduces the risk of thrombophebitis in lower and upper extremities. It also improves the function of bladder and bowel elimination and decreases abdominal distention and constipation. 4. Encourage patient to have adequate sleep and rest. Rest is facilitated by reducing worry and anxiety producing situations and promoting comfort. Sleep reduces fatigue and help gain energy. 5. Inform patient to avoid intercourse for 6 weeks until healing is complete. To ensure healing and vaginal cuff and risk of infection and vaginal hemorrhage.

Hygiene 1. Encourage Pt. to do perineal care and wound dressing daily. Perineal care Procedure: Start from the mons pubis then to labia majora right tolabia minora left then labia majora left to labia minora right. Cleaning of this area should be cleaned from. Front to back direction using cotton balls soaked in betadine solution or with water and mild soap. For the wound dressing: In wound dressing, wipe the wound with cotton balls or cotton applicator soaked in sterile water followed by

Diet

dry cotton balls or cotton applicator. Wipe the wound with cotton balls soaked in betadine solution or cotton applicator. Cleanse the wound using long or circular strokes from inner to outer in single stroke only. Apply sterile gauze on the wound and secure with plaster.

1. Encourage Pt. to eat food that is rich in vitamin c and iron. 2. Diet as Tolerated. In order to attain proper diet, the patient should be guided to the prescribed foods as advised by her physician. Her meals should include Vitamin C-rich foods for wound healing.

D MEDICATIONS

Medications Cefuroxime (Cefurex) Tramadol (Tramal)

Dosage/Frequency 5oomg 1Tab 2x a day for 5 days 50mg 1Tab 2x a day for 5 days

Nursing Instructions 1. Take drug with meal. 2. Complete the full course of drug even when you feel better. 3.

Multivitamins w/ iron 1Tab everyday EXERCISE: Instruct patients to carry out deep breathing and coughing at least three or four times daily and at each session to take a minimum of five breaths and not greater than twelve in any one session. Encourage ambulation promotes circulation and reduces the risk of thrombophebitis in lower and upper extremities. It also improves the function of bladder and bowel elimination and decreases abdominal distention and constipation.

THERAPY/TREATMENT: Medication upon discharge; instruct patient to take the complete course of medication, as ordered by the physician. Nurse instructs patient about the medications that are prescribed and their actions, it is also important to inform the patient and the family members about the symptoms that should be reported to the physician. Instruct patient to take medications religiously. HEALTH TEACHING: Instruct the patient the importance of proper taking of medication on time. Instruct the patient the importance of proper taking of the medication on time. Instruct the patient and her family the proper wound care to avoid contamination and infection at surgical site. Instruct patient to eat food that is rich in vit. C Encourage ambulation for early recovery. Good sanitation is advised. Inform patient to avoid intercourse for 6 weeks until healing is complete. To ensure healing and vaginal cuff and risk of infection and vaginal hemorrhage. OPD VISIT/REFERRALS: Inform the family and the patient to have checked up after 2 weeks after discharge for the continuity of treatment. Instruct the family of the patient to monitor if there is any sudden change to the patient and report immediately DIET: Instruct patient to eat nutritious foods that rich in iron such as ampalaya, chicken or pork liver and red meat especially green leafy vegetables and take any kind of foods as long as she can tolerate it. Instruct to drink 6-8glasses of water daily as a normal habit to maintain homeostasis of fluid in the body and maintain proper function of all the organs in the body. To promote wound healing, encourage patient to eat food rich in vitamin C such as oranges or calamansi.

Diet as Tolerated. In order to attain proper diet, the patient should be guided to the prescribed foods as advised by her physician. Her meals should include Vitamin C-rich foods for wound healing.

SPIRITUAL CARE: Encourage patient to enhance spiritual relationship with God. Have faith and trust in Gods divine power, and believed that the lord will help in her early recovery. Keep on praying, because praying is the number one key to live a healthy life and to be close to God.

Prognosis
Most fibroids are asymptomatic and do not require treatment. For fibroids that do cause symptoms, surgical removal of the uterus (hysterectomy) is the only certain cure. Hysterectomy remains the most successful treatment of symptomatic uterine fibroids among women not desiring uterine preservation due to its efficacy in permanently ameliorating fibroid-related symptoms. Use the procedure significantly improves or resolves symptoms in 81% to 96% of individuals. Nevertheless, it is important in counselling patients to mention that up to 12% of patients undergoing hysterectomy will later report the development of new symptoms. Gonadotropin-releasing hormone (GnRH) agonists bring about a 40% to 60% decrease in fibroid size after 3 months of treatment. Half the fibroids regrow, however, after treatment is discontinued. Fibroids typically stop appearing and growing once a woman reaches menopause.

Recent Study and Researches

New Non-Surgical Treatment for Uterine Fibroids Can Improve Quality of Life
Science Daily (July 1, 2010) A new, effective, non-surgical treatment for uterine fibroids can help women with this condition maintain their fertility, an American scientist told the 26th annual meeting of the European Society of Human Reproduction and Embryology in Rome. Dr. Alicia Armstrong, Chief, Gynecologic Services, National Institutes of Health (NIH) Programme in Reproductive and Adult Endocrinology, Bethesda, Maryland, said that the outcome of two Phase II clinical trials of ulipristal acetate (UPA) had significant implications for both infertility and general gynaecology patients. UPA belongs to a relatively new class of drug, the selective progesterone receptor modulators or SPRMs. It is currently used for emergency contraception, and acts by blocking the progesterone receptor and hence ovulation (release of the egg). Recent research has shown that progesterone also plays a role in the development of uterine fibroids, which affect 24 million women in Europe and can lead to a range of symptoms such as abdominal pain and discomfort and heavy and irregular menstrual bleeding. Fibroids are the major indication for hysterectomy in Europe and the US, and they also contribute to infertility by interfering with the ability of the embryo to implant in the womb and causing miscarriage. "Both the fibroids and the surgical interventions commonly used to treat them can cause significant fertility problems," said Dr. Armstrong, "and we wanted to see whether fibroids could shrink and surgery could be avoided by using an SPRM." Results from two Phase II randomised, placebo-controlled, double-blinded studies performed at NIH were pooled and analysed. In the trials, women aged from 25-50 years with symptomatic uterine fibroids were randomised to receive UPA or placebo once a day for three menstrual cycles. The researchers found that, out of the 57 patients who it was possible to evaluate for efficacy, 18 received placebo, 20 10mg of UPA per day and 19 20mg per day. Those taking UPA had reduced total fibroid volume, with those taking the higher dose doing better -- 14 (70%) in the 10mg

group and 16 (84%) in the 20 mg group. The patients on placebo did significantly less well with only six (33%) showing reduction in fibroid volume. UPA also reduced bleeding compared with placebo and during the third month of treatment 16 (80%) of patients taking 10mg daily and 18 (95%) on a daily dose of 20mg experienced no menstrual bleeding. At the end of the treatment, patients on the active treatment scored higher in assessment of their quality of life, the severity of their symptoms, their energy levels and mood and their overall concern about the effects of fibroids. Estradiol levels remained adequate for bone health during treatment in 77%, 100% and 95% of patients in the UPA 10mg and 20mg and placebo groups, respectively, indicating that the action of the ovaries was not impaired, and neither were there any serious side effects. Some women taking UPA had transient increases in liver function tests and a few had the changes in the endometrium that have previously been seen with this class of compounds. "The results of these trials are convincing and lead us to conclude that UPA is an effective non-invasive treatment for fibroids that can help maintain fertility in women whose only option up to now was to have surgery," said Dr. Lynnette Nieman, Principal Investigator on the NIH trials. "We hope that the results from these trials, along with those from the Phase III trials currently being conducted by the Swiss company PregLem SA, will allow us to offer this treatment to women who do not want surgery or are unable to have it for medical reasons." Researchers at the National Institute of Child Health and Human Development are currently carrying out further studies of the molecular action of UPA, Dr Nieman said. "These studies will not only help us understand how the treatment works in women with uterine fibroids, but may give us pointers about which patients might benefit most."

BIBLIOGRAPHY

Books:

Hargrove-Huttel, Ray A. Lippincotts Review Series Medical Surgical Nursing. Lippincott Williams & Wilkins. 4th edition. 2005

Ignatavicius, Donna D. and M. Linda Workman. Medical Surgical Nursing: Critical Thinking for Collaborative Care. 4th edition.

Smeltzer, Suzanne C. and Brenda G. Bare. Brunner & Suddarths textbook of Medical Surgical Nursing.

Zerwekh, JoAnn & Jo Carol Clabborn. Illustrated Study Guide for the Nclex Rn exam. Elsevie Singapore pte ltd. 6th edition. 2007

Medical Surgical Nursing 6th ed. by Black, Pathologic Basic of disease 5th ed. by Robbins

Nurses Pocket Guide 7th edition by Doenges

Beers et. al.(2003). Merck Manual of Medical Information. 2nd Edition, Merck and Co, Inc. New York.

Hopper, Paula D. and Linda S. Willams, (2003). Understanding Medical-Surgical Nursing. 2nd edition, F.A. Davis Company: Philadelphia

Kozier, Barbara and Erb, Gleonora, et. al. (2008). Fundamentals of Nursing: Concepts, Process and Practice (7th ed.). Philippines: Pearson Education South Asia Pte. Ltd.

Websites:

http://bestpractice.bmj.com/best-practice/monograph/567/follow-up/prognosis.html

http://www.nlm.nih.gov/medlineplus/ency/article/000914.htm http://www.mayoclinic.com/health/uterine-fibroids/DS00078 http://www.mdguidelines.com/fibroid-tumor-of-uterus/prognosis http://www.sciencedaily.com/releases/2010/06/100630071144.htm