Nursing Management for Infertility

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					GU System - Handout Female Reproduction

Text: Brunner & Suddarth’s Medical Surgical Nursing: Ch. 46-48

Behavioral Objectives: By the end of this lecture the student will be able to:
    Review the anatomy and physiology of the female genito-urinary systems
    Describe the physical assessment of the female GU systems
    Discuss the application of the nursing process as it relates to patients with
      disorders of the female GU system
    Describe etiology, pathophysiology, clinical manifestations, nursing management
      and patient education for the following female GU disorders:
          o Vaginitis
          o Pelvic inflammatory disease (PID)
          o Endometriosis
    Discuss incidence, prevention and treatment of the patient with cancer of the GU
      system
    Discuss the nursing interventions in pre and post-operative care of patients
      undergoing the following surgeries
          o Hysterectomy
          o Mastectomy



   I.     Review the anatomy and physiology of the genito-urinary systems
          a. Brunner and Suddarth’s Medical Surgical Nursing pg 1614
          b. Breast
                  i. Female breast development _________ - _______ years
                 ii. Tail of ____________________
                 iii. _______________________ ligament
                 iv. 12-20 _______________
                 v. Nipple
                 vi. Areola
          c. External Genitalia
          d. Internal Reproductive Structures
                  i. Vagina
                         1. ___________ membrane
                         2. Posterior to _______________ & _______________
                         3. Anterior to ________________

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                       4. Anterior & Posterior walls _____________
                       5. Upper vagina surrounds _______________
                                a. “Inferior ______________________”
                ii. Uterus
                       1. ____________ shaped: _____________________
                       2. Size _____________ variable: _________________
                       3. Location: posterior to the ___________________
                       4. Ligaments: ____________________________________
                       5. Cervix: _________________ into the vagina
                       6. Fundus: _______________ of the uterus
                       7. Endometrium: __________________ of the uterus
               iii. Ovaries
                       1. Connected to the uterus by _______________ ________
                       2. Contains: _____________________________________
                       3. Ova / ovum: __________________________________
         e. Ovulation Process (pg 1615)




                 i. Definition: __________ of a __________ ovum from the _______
                ii. Follicular Stage
                       1. ovum ____________ _________(graafian follicle)
                       2. reaches ____ ________ (of the ovary)
                       3. ovum _______________
               iii. Ovulation
               iv. After ovulation
                       1. Ovum ______________________  _____________
                                a. If meets a spermatozoon

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                                             i. _______________& ________________
                            2. Ovum cyst  Corpus Luteum  stays in the __________
                                    a. Produces ________________
                                    b. Prepares the ____________ for the _______ ovum
              f. The Menstrual Cycle (pg 1615-1616)
                     i. Two system control menstruation: ______________ & _________
                    ii. Hormones
                            1. Ovaries
                                    a. _____________ & _________________
                            2. Pituitary
                                    a. ______________  Stim. _________ to _______
                                    b. __________  Stim. ___________ __________
                    iii. Cyclical Pattern (see table 46-1 pg. 1617)
                            1. Changes in ______________ & __________________
                            2. __________ day cycle
  Menstrual         Follicular Phase       Ovulation       Luteal Phase    Premenstrual
      Phase                                                                     Phase
Estrogen            Estrogen           Estrogen           Estrogen        Estrogen
Progesterone        Progesterone       Progesterone       Progesterone    Progesterone
FSH                 FSH                FSH                FSH             FSH
LH                  LH                 LH                 LH              LH
Ovaries




Endometrium         Endometrium        Endometrium        Endometrium     Endometrium




Day


              g. Menopausal Period: (Pg. 1616)
                     i. End of reproductive __________

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                   ii. Age _________ - __________yrs
                  iii. Menstruation ________________: No menses _______________
                  iv. _________ not active  ____________ estrogen
                          1.    Reproductive organs ___________________________
                          2. ___________ ova mature
   II.      Describe the physical assessment of the GU system: pg 1616
            a. Health history and clinical manifestations
                    i. Menstrual history
                          1. Menarche: ______________ of menstration
                   ii. Hx of pregnancies
                  iii. Hx of medications
                          1. _____________ therapy
                          2. Hormonal _______________________
                          3. ___________________ treatment
                  iv. Pain
                          1. Dysmenorrhea: Painful _____________________
                          2. Dyspareunia: Painful _____________________
                   v. Hx of vaginal discharge
                  vi. Hx of urinary problems
                  vii. History of B&B control
                 viii. Sexual history
                  ix. Hx of abuse
                   x. Hx of surgery
                  xi. Hx of chronic illness or disability
                  xii. Hx of genetic disorders
         b. Physical Assessment (Pg. 1623-1626)
                i. Breast: Frequency of self exam: ___________________
                       1. Assessment question
                               a. Palpable ____________
                               b. ________________ changes
                               c. Pain, swelling, redness

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                                d. ____________________ changes
                       2. Findings
                                a. Erythema
                                       i. Benign local _________________________ or
                                       ii. Superficial _______________
                                b. Prominent venous pattern
                                       i. _____ blood supply required by _______________
                                c. Edema & ____________
                                       i. Neoplasm blocking the ______________ drainage
                                          tubes
                                d. __________-peel appearance / Peau D’Oragne
                                   (__________)
                                       i. Advanced breast ___________________
                                e. _________________ inversion
                                f. Sign of dimpling, creasing, changes in contour
                                g. Palpation – Breast Cancer
                                       i. ______________ mass
                                       ii. ______________ breast
                                      iii. _______________, hard, embedded in tissue
                                      iv. ______-_________________
                ii. Mammography
                       1. Duration: ___________________________
                       2. Recommended frequency
                                a. ___________________
                                b. > ______________ years
               iii. Pelvic
                       1. Frequency: ___________
                       2. Initial: Age ___________ or ____________ ____________
               iv. Positioning: ___________________________________________
                v. Inspection
                       1. Inspects ____________ genitilia

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                         2. __________ examination
                                  a. ___________ canal
                                  b. ___________
                vi. Pap smear (pg 1627)
                         1.     _____________ sample of the ________________
                         2.     Purpose: Dx. ___________________________
                         3. Do not ___________________ before Dr. visit
                vii. Bimanual palpation (pg. 1626)
                         1. ___________ palpation
                         2. ____________ palpation
               viii. Colposcopy (pg. 1628)
                         1. Portable _________________________
                         2. Obtain _________________
   III.   Describe etiology, pathophysiology, clinical manifestations, nursing management and
          patient education for – Vaginitis: (pg 1661 -6)
          a. Pathophysiology of Vaginitis
                  i. Vaginitis : inflammation of the ___________
                 ii. Normal pH _________ - __________
                iii. Lactobacillus acidophilus,
                         1. ___________the growth of anaerobes
                         2. produces ___________ ________  ______ pH
                         3. Produces: hydrogen ____________
                iv.  risk if
                                  a. _______________ c. Altered ____________
                                  b. _______________ d. ________________
                 v. Candida,Trichomonas or other ________________invade the vagina.
          b. Clinical manifestations: General
                         1. Vaginal discharge +…
                                  a. Itching                e. Edema
                                  b. Odor                   f. Aggravated by ________
                                  c. Redness                g. Urethritis

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                               d. Burning
         c. Candida / Vulvovaginal Candidiasis (pg. 1662)
                 i. Fungal or ____________ infection
                ii. Asymptomatic  symptomatic (risk factors)
                       1. Use of _____________ bacteria   protective organisms
                       2. ________________
                       3. Diabetes ______________
                       4. Human immunodeficiency virus (HIV)
                       5. ________________ treatment
                       6. Oral _________________________ therapy
               iii. Clinical manifestations
                       1. Vaginal discharge
                               a. Color: __________, cottage cheese like
                               b. The pH of the discharge is ____________
                               c. ________________
               iv. Medical Management
                       1. _______ ___________ agents
                               a. Miconazole (Monistat); Nystatin (Mycostatin)
                               b. Available without prescription
         d. Bacterial Vaginosis
                 i. Overgrowth of ______________________bacteria ______________found
                   in the vagina and _____________________of lactobacilli
                ii. Characterized by:
                       1. ________________-like odor
                       2. ________________ vaginal pH
                       3. ________________ discharge
                               a. Color: _______________________
                       4. _____________ discomfort
               iii. Medical Management
                       1. Metronidazole (Flagyl)
                       2. Clindamycin (Cleocin)

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         e. Trichomonas AKA “Trich” (pg 1664)
                 i. _______ ___________ ______________
                ii. ________________ carrier
               iii. Clinical manifestations
                       1. Vaginal discharge
                               a. ___________________ c. ___________________
                               b. ___________________ d. ___________________
                       2. Cervical ________________
                       3. Multiple small _________________
                       4. pH ________________________
               iv. Complications
                       1. ___________ life threatening
                v. Medical Management
                       1. Metronidazole (Flagyl)
                               a. Anti______________ agent
                               b. Anti _____________ agent
                       2. ______________ partners
         f. Nursing process of Patients with Vulvovaginal infection
                 i. Assessment
                       1. Examine: Do not __________________
                       2. Observe the area for:
                               a. ___________________ c. ___________________
                               b. ___________________ d. ___________________
                       3. Describe symptoms
                               a. __odor_____________ c. ______burn_________
                               b. __itch_____________ d. _____dysuria_______
                       4. Prep a ________________ _____________
                       5. Test _____________ of discharge
                       6. Factors that might contribute
                               a. Physical /chemical factors
                                       i. Constant ___________; tight / synthetic ________

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                                      ii. Perfumes & __________
                                      iii. ______________ / ______________ baths
                                      iv. Poor _____________
                                      v. ______________ hygiene products
                                b. Psychogenic factors
                                       i. ___________ ________________ ____________
                                c. Medical conditions
                                       i. __________________
                                      ii. ________________
                                      iii. _____________ partners
                ii. Diagnosis
                       1. ______________related to burning, odor or itching from the
                           infectious process
                       2. _____________ related to stressful symptoms
                       3. Risk for _____________ or spread of infection
                       4. Deficient _____________about proper hygiene and preventive
                           measures
               iii. Planning and Goals
               iv. Nursing Interventions
                       1. Admin. ______________
                       2. ____________ baths
                       3. ____________powder
                       4. ______________ patient
                       5. ______________discouraged
                       6. __________ fitting underwear = good
                       7. ____________, _____________, non-________________,
                           heat-_______________ underwear = bad
                v. Evaluations/Expected patient outcomes
   IV.   Describe etiology, pathophysiology, clinical manifestations, nursing management &
         patient ed. for – Pelvic Inflammatory disease (pg. 1670-71)
         a. Pelvic Inflammatory Disease – Pathophysiology

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                 i. AKA: Pelvic _______________________
                ii. PID is an inflammatory condition of the pelvic cavity that begins with
                    cervicitis and may involve the _____________, ________________,
                    ____________ pelvic peritoneum or pelvic vascular system
               iii. Infection is usually caused by _____________
                        1. __________________ and ______________
               iv. PID is the most common STD but ______________________
                v. Enters through ______________  ___________ canal &
                    _______________ _____________ ______________ tubes & ovaries
                     _____________
         b. Risk factors
                 i. Early age ____________
                ii. ________ # sexual partners
               iii. Sex with a partner with an ___________
               iv. _____________ of STD’s
                v. Previous _____________ infection
               vi. ____________________ procedures
         c. Clinical manifestation
                 i. Vaginal discharge
                ii. ____________
               iii. _________________ _____________pain
               iv. ______________after menses.
                v. Pain  while ___________
               vi. Other S&S:
                        1. Fever                                            3. N/V
                        2. Gen. malaise                                     4. H/A
         d. Complications
                 i. Peritonitis
                ii. ______________
               iii. _______________ / adhesions
                        1. Chronic pelvic ____________

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               iv. Fallopian tube obstruction 
                         1. _____________ pregnancy
                         2. Occlude tubes _______________
                v. Bacteremia  ___________________________
               vi. Thrombophlebitis  ________________________
         e. Medical management
                 i. ______________ _____________ Antibiotics
                ii. Treat ____________________
               iii. Treatment at home: ______________________________
               iv. Intensive Therapy / Hospital: ___________; ____________; __________
         f. Nursing process of Patients with PID
                 i. Activity: ________________________
                ii. Position : _____________________
               iii. Vital signs
               iv. Assess: ____________________________
                v. Administer: ____________________________________
               vi. Pain Relief: ____________________________________
   V.    Describe etiology, pathophysiology, clinical manifestations, nursing management and
         patient education for – Endometriosis (pg. 1680)
         a. Endometriosis – etiology
                 i.   “A benign lesion or lesions with cells similar to those lining the uterus
                      grow aberrantly in the pelvic cavity outside the uterus.”
                ii. __________ pelvic pain & ________________
         b. Pathophysiology
                 i. Misplaced endometrial tissue responds to ____________________
                ii. During____________________, the extopic tissue bleeds, mostly into
                      areas having no __________  ____________ and _______________
               iii. Causes_____________ , _____________ and/or __________________
         c. Clinical manifestations
                 i. Dysmenorrhea                                       iii. Pelvic pain
                ii. Dyspareunia                                        iv. Depression

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                v. Loss of work                                    vii. Infertility
               vi. Relationship
         d. Assessment and diagnostic findings
                 i. _________________
                ii. _________________ exam
               iii. __________________ exam (pg 1630)
         e. Medical managements
                 i. ___________________________
                ii. ___________________________
                        1. Side effects: _______ retention, weight _________, ____________
               iii. Surgery
               iv. Pregnancy
         f. Nursing process of Patients with Endometriosis
                 i. Assessment
                       1. Hx & PE focus on specific symptoms, effects of meds,
                           reproductive plans
                ii. Diagnosis Planning and Goals
                       1. Relief of pain, Dysmenorrhea, dyspareunia
                       2. Avoidance of infertility
               iii. Nursing Interventions
                       1. Dispel myths and encourage the patient to seek care if
                           Dysmenorrhea or dyspareunia occurs
               iv. Evaluations/Expected patient outcomes
   VI.   Discuss incidence, prevention and treatment of the patient with cancer of the female
         GU system:
         a. Cancer of the Cervix (pg 1682-85)
                 i. Pathophysiology
                        1. Predominantly ___________________ cell cancer
                        2. Age _____________ - _____________
                        3. Risk factors
                               a. ___________ sex partners
                               b. _________ age at first coitus
                               c. Sex with men whose partner have had ________________
                               d. _______ __________ ____________virus


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                                        i. ____________
                                       ii. Causes _________ growths
                               e. _______________
                ii. Clinical Manifestations
                       1. Early  ___________________
                       2. Late symptoms
                               a. Discharge: __________, _________, _________, ______
                               b. Irregular _____________
                               c. Leg __________
                               d. Dysuria
                               e. ____________ bleeding
                               f. ____________of extremities
               iii. Assessment and diagnostic findings
                       1. ________________ smear
                       2. __________________
                       3. Colposcopy
                               a. ___________________
               iv. Medical management
                       1. CRYOTHERAPY
                       2. Surgery: ____________________________
                       3. Radiation
         b. Cancer of the uterus (pg 1685)
                 i. Pathophysiology
                ii. Risk factors
                       1. Age: ________________
                       2. Postmenopausal ____________
                       3. ____________
                       4. Unopposed _____________
                       5.   Nulliparity /Infertility
               iii. Assessment
                       1. Irregular _____________ should be evaluated

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                         2. Endometrium aspirations
                         3. Ultrasound
                iv. Medical management
                         1. _________________
          c. Cancer of the Ovary (pg. 1689)
                  i. Pathophysiology
                         1. About ________detected in the late stage – with metastasized
                         2. Age ________ - ___________
                         3. Risk factors: _________________ & ____________________
                 ii. Clinical Manifestations
                         1. ___________ abdominal girth
                         2. pelvic ___________
                         3. ______________
                         4. ______________
                         5. ________ waist size
                         6. _______________pain
                iii. Assessment and diagnostic findings
                         1. NONE
                iv. Medical management
   VII.   Discuss the nursing interventions in pre and post-operative care of patients
          undergoing hysterectomy (pg 1691)
          a. Pathophysiology
                  i. Hysterectomy is the surgical removal of the ___________________
                 ii. Total Hysterectomy: removal of the ____________ & ___________
                iii. Sub-total or supra-cervical hysterectomy: removal of the ____________
                     but not the _______________
                iv. Radical hysterectomy: removal of the uterus & , __________ (upper 1/3)
                     pelvic ___________ nodes, _____________ tubes; and __________
                         1. Usually performed due to _______________ condition
          b. Variety of approaches
                  i. ____________________

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                ii. ____________________
               iii. ____________________
         c. Pre-op management
                 i. _______________?
                ii. Empty ___________________
               iii. Empty ___________________
               iv. ________________________
         d. Nursing Diagnosis/interventions
                 i. Anxiety related to the diagnosis of cancer, fear of pain, possible
                    perception of loss of femininity, and disfigurement
                        1. ___________________________
                        2. ___________________________
                ii. Disturbed body image related to altered fertility and fear about sexuality
                    and relationships with partner and family
                        1. Discuss _____________________
                        2. Orgasm
               iii. Acute pain related to surgery and other adjuvant therapy
                        1. Assess: ________________
                        2. Administer: __________________________
                        3. Teach alternatives
                               a. _________________ techniques
                               b. Early _________________
                               c. _____________________
         e. Potential complications
                 i. Hemorrhage
                        1. Assess _________ pads
                        2. Assess _____________
                        3. Educate on ______________ restrictions
                ii. Deep vein thrombosis
                        1. Prevention
                               a. Elastic compression _________________

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                                 b. Early _________________
                           2. Assess for DVT’s
                                 a. ______________ ( ______________; __________;
                                     _____________; ____________)
                           3. Assess of PE
                                 a. ________________ pain
                                 b. __________ pulse
                                 c. ___________________
                 iii. Bladder dysfunction / Urinary ______________
                           1. ______________
                           2. Assess bladder _______________________
                           3. Stim. bladder: _________________________________________
                           4. ____________
   VIII.   Breast Cancer
           a. Risk Factors
                  i. Gender ________________________
                  ii. Age: __________________________
                 iii. Personal History ____________________________________
                 iv. Hormonal factors
                           1. Early _____________________
                           2. _________parity
                           3. ____________ menopause
                  v. ____________________
                 vi. ____________________ use
                vii. **No evidence that oral _____________________________increase risk!
           b. Characteristics
                  i. Most common location: _________________________________
                  ii. __________-tender
                 iii. __________________, ____________________, Irregular boarders
           c. Advanced signs
                  i. _______________dimpling

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                ii. Nipple _____________________
               iii. _____________________ ulceration
         d. Types of surgeries
                 i. Modified Radical Mastectomy
                        1. Removal of
                                 a. _____________________
                                 b. Nipple –areola
                                 c. __________________ lymph nodes
                        2. Not removed
                                 a. Pectoralis major and pectoralis minor _________________
                ii. Total mastectomy
                        1. Removal of
                                 a. ___________________
                                 b. Nipple-areola
                        2. Not removed
                                 a. Axillary ___________________ nodes
                                 b. _________________ groups
               iii. Breast Conservation Treatment / AKA (_____________________)
                        1. _________________ or segmental mastectomy
                        2. Removal of _________________
                        3. May include axillary ___________________________
   IX.   Discuss the nursing interventions in pre and post-operative care of patients
         undergoing mastectomy: (pg. 1716-1725)
         a. Postoperative nursing diagnosis and interventions
                 i. Pain
                        1. Assess
                        2. Administer
                                 a. Analgesics
                                 b. Oxycodone & acetominaphen (Percocet)
                                 c. Propoxyphene & acetominaphen (Darvocet)
                        3. Non-pharmaceutical measures

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                               a. ___________________________________
                               b. Position __________________________
                               c. ____________________ techniques
                       4. Report
                               a. ____________________________________
                ii. Impaired skin integrity
                       1. _________________ tubes in place
                       2. _____________of tubes
                       3. Hematoma’s
                       4. ___________ packs
               iii. Risk for infection
                       1. Drainage tubes duration: ________________
                       2. Teach:
                               a. ____________, ______________, _____________
                               b. ______________ care
                               c. S&S of _______________
                                         i. _____________ drainage
                                         ii. _______________
                               d. No _____________ until completely healed
               iv. Disturbed body image
                       1. Support
                v. Impaired sensory perception related to sensations in arm, breast, or side
                       1. Tightness, pulling, burning, tingling in the chest wall, axilla, upper
                           arm
                       2. ____________ with healing  lasts ____________  diminishes
                       3. Teach “this is ______________”
                       4. exercise  _________ sensation
               vi. Knowledge deficit: Prevent complications from surgery – lymphedema
                       1. Results when lymphatic ____________ are inadequate to return
                           flow of lymph fluid.
                       2. Transient _____________

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                       3. Medication: __________________________
                       4. ____________________
                       5. Manual lymph drainage:
                               a. Light____________________________,
                               b. performed by a _________________________
                               c. assists moving the _____________________ to other parts
                                    of the body
                       6. Compression bandaging:
                               a. multi-layered _________________________after massage
                               b.   keep the fluid out of the arm
                       7. _______________________________
                       8. Do not perform ____________________ on affected arm
                       9. Do not take _________________________ on affected arm
                       10. Avoid ________________________ arm position
                       11. Compression garment:
                               a. _______________
                               b. helps maintain _______swelling achieved during treatment
   X.    Study questions for Female GU
         a. Describe anatomically the location of the vagina, uterus and ovaries
         b. Describe the processes of ovulation
         c. What hormones are involved with menstruation
         d. What happens to the ovum after ovulation?
         e. What happens to the ovum cyst after ovulation?
         f. Where does fertilization take place?
         g. What are the hormonal changes during the follicular phase of menstruation?
         h. What physiological changes happen during the proliferative phase of
             menstruation?
         i. What are the hormonal changes during the ovulation phase of menstruation?
         j. What physiological changes happen during the phase of menstruation?
         k. What are the hormonal changes during the Luteal phase of menstruation?
         l. What physiological changes happen during the luteal phase of menstruation?

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         m. Define menopause.
         n. What is the average age of menopause
         o. Name 10 questions you would ask a women during a GU assessment?
         p. What two exams should be done annually on a women?
         q. What is a pap smear? What is it used to diagnose?
         r. Bimanual palpation is palpation of what two things?
         s. What is vaginitis?
         t. What is the normal pH of the vagina? What maintains this pH?
         u. Describe the common S&S of vaginitis.
         v. What increases the risk of developing Candida?
         w. What is the typical vaginal discharge like for a patient with candida?
         x. How is Candida treated pharmacologically?
         y. What increases the risk of developing Trichomonas?
         z. What is the typical vaginal discharge like for a patient with Trichomonas?
         aa. How is Trichomonas treated pharmacologically?
         bb. Identify 8 nursing measures/interventions for a patient with vaginitis
         cc. Define PID
         dd. What are risk factors for PID
         ee. Name 6 clinical manifestations of PID
         ff. What is peritonitis
         gg. Name 6 complications of PID
         hh. What medications are used to treat PID?
         ii. Name 6 nursing interventions for a patient with PID
         jj. Define/describe endometriosis
         kk. What are the clinical manifestations of endometriosis? (name 4)
         ll. What is the medical management of a patient with endometriosis?
         mm.        What are the risk factors for cervical cancer?
         nn. What are the S&S for cervical cancer? Early and late stage
         oo. What are the risk factors for uterine cancer?
         pp. What are the S&S for uterine cancer?
         qq. What are the risk factors for ovarian cancer?

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         rr. What are the S&S for ovarian cancer? Early and late




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