A Case

Study
about
Cervical
Cancer
 Introduction

Cervical Cancer is the second most common malignancy and the most common cause of
Cancer-related mortality among women. World wide more than 238,000 of women die each
year because of having the disease.

Cervical cancer is the term for a malignant neoplasm arising from cells originating in the
cervix uteri. One of the most common symptoms of cervical cancer is abnormal vaginal
bleeding, but in some cases there may be no obvious symptoms until the cancer has
progressed to an advanced stage. It develops in the thin layer of cells called the epithelium,
which cover the cervix. Cells found in this tissue have different shapes:

Squamous cells (flat and scaly). Most cervical cancer arises from changes in the
squamous cells of the epithelium (squamous cell carcinoma).

Columnar cells (column-like). These cells line the cervical glands. Cancers found here
are known as adenocarcinomas.

Mixed carcinomas are cells that combine features of squamous cells and
adenocarcinomas.

Risk Factors:

Exposure to Human papillomavirus

Multiple sex partners
Early age of First Intercourse
Family history of Cancer
Sex with uncircumcised males
Smoking and exposure to secondhand Smoke
Nutritional Deficiencies
Low socioeconomic Status
Chronic Cervical Infection
Multiple Pregnancies
Overweight Status
Causes:

Age
Smoking
Race
Promiscuity
STD
Reproductive History
Oral Contraceptives

Signs and Symptoms

Early Signs and Symptoms

Water vaginal Discharge after intercourse

Irregular bleeding
Pain or bleeding after intercourse

Advanced Signs and Symptoms

Watery dark foul smelling discharge

Metrorrhagia
Leg pains
Dysuria
Rectal Bleeding
Edema
Bleeding after menopause
Pelvic pain

Stages of Cervical Cancer:

Stage I:

The tumor has invaded the cervix beneath the top layer of cells. Cancer cells
arefound only in the cervix

Stage II:

The tumor extends to the upper part of the vagina. It may extend beyond the
cervix into nearby tissues toward the pelvic wall (the lining of the part of the
body between the hips). The tumor does not invade the lower third of the
vagina or the pelvic wall.

Stage III:
 The tumor extends to the lower part of the vagina. It may also have
invadedthe pelvic wall. If the tumor blocks the flow of urine, one or both
kidneys may not beworking well.

Stage IV:

The tumor invades the bladder or rectum. Or the cancer has spread to
otherparts of the body.

Recurrent cancer:

The cancer was treated, but has returned after a period of time duringwhich it
could not be detected. The cancer may show up again in the cervix or in
otherparts of the body.

Diagnostic Tests:

Pap Test

simple test used to look at cervical cells. Pap tests can find cervical cancer or
abnormal cells that can lead to cervical cancer

Conization

Removal of Cone shaped piece of the cervical tissue for examination and
investigation\

Colposcopy
The doctor uses a colposcope to look at the cervix. The colposcope combines
a bright light with a magnifying lens to make tissue easier to see.

Punch Biopsy
The doctor uses a sharp tool to pinch off small samples of cervical tissue.

Medical Management

Hyterectomy
 Entails the removal of the cervix and the uterus

Pelvic Exentration

Removal of the cervix, uterus, vagina, ovaries, lymph nodes, lower colon,
rectum and the bladder

Cyrosurgery

Freezing and destruction of the cancerous tissue

Laser Surgery

Laser beam is used as a knife to make a blood less incisions to excise smaller
tissues.

Chemotherapy

Used after surgery.

Nursing Management:

1. Listen to the patients fears and concerns, and offer reassurance when
appropriate.
2. Encourage the patient to use relaxation techniques to promote comfort
during the diagnostic procedures.
3. Monitor the patients response to therapy through frequent Pap tests
and cone biopsies as ordered.
4. Watch for complications related to therapy by listening to and
observing the patient.
5. Monitor laboratory studies and obtain frequent vital signs.
6. Understand the treatment regimen and verbalize the need for
adequate fluid and nutritional intake to promote tissue healing.
7. Explain any surgical or therapeutic procedure to the patient, including
what to expect both before and after the procedure.
8. Review the possible complications of the type therapy ordered.
9. Remind the patient to watch for and report uncomfortable adverse
reactions.
10. Reassure the patient that this disease and its treatment shouldnt
radically alter her lifestyle or prohibit sexual intimacy.
11. Explain the importance of complying with follow up visits to the
gynecologist and oncologist.

Complications:
>Narrowing of the Vagina

>Lymphoedema

>Kidney Failure

>Blood clots

>Bleeding

>Fistula

>Vaginal Discharge

Anatomy and Physiology

Physiology (External Female Organ)

Mons Pubis
a.k.a. Mons Veneris that protects the pubic bone and vulva from the impact of sexual
intercourse. After puberty, it is covered by pubic hair (responsible for not easily harboring
the microorganisms in the vagina.
Prepuce of Clitoris
protective cover of glans of clitoris.
Glans of Clitoris
a short erectile organ above the vagina that is responsible for sexual excitation or
pleasure.
Vestibule
the gland at the point where vagina and vulva join that secretes lubricatingsubstance. It
consists of 3 parts:
1.Urethral Opening
a.k.a. Meatus that drains urine from the bladder.
2. Clitoris
functions sexual pleasures.
3. Vestibule of Vagina
 a.k.a. Vaginal Introitus that is for the vaginal entrance.
Openings of Paraurethral
connected to the urethra and lubrication.
Labium
a fleshy and liplike structure folds that protect the openings from bacterial invasion. It has:
1) Labia Majora
o elongated hair covered skin folds that are responsible for lubrication.
2) Labia Minora
o smaller folds enclosed by the labia majora and their function is to protect the
vagina and urethra openings. And they also produce lubricant.
Vagina
receives penis and semen during mating, and passageway of childbirth and menstrual
flow.
Hymenal Caruncle
a.k.a. Hymen, a membrane which partially covers the vaginal passage.
Opening of Greater Vestibular Gland
a.k.a. Bartholins Glands, the two glands at the
side of the vagina and between the vulva that secretes a lubricating substance.
Vestibular Fossa
a.k.a. Navicular Fossa, a small cavity of between the vaginal orifice and fourchette.
Frenulum of Labium
the fold connecting the two labia minora posteriorly.
Posterior Labia Commissure
rear joining of the labia majora above the perineum.
Perineal Raphe
ridge along the median line that runs forward from the anus.
Anus
a.k.a. Anal Orifice, in which feces passes through

Physiology (Internal Female Organ)

Ovaries
paired shape of almonds. It produces ova (singular, ovum), or eggs.
The two ovaries present in each female are held in place by the following ligaments:
1) Broad Ligament
o is a section of the peritoneum that drapes over the ovaries, uterus, ovarian
ligament, and suspensory ligament. It includes both themesovarium and
mesometrium. The mesovarium is a fold of peritoneum that holds the ovary in place.
2) Suspensory Ligament
o anchors the upper region of the ovary to the pelvic wall. Attached to this ligament
are blood vessels and nerves, which enter the ovary at the hilus.
Ovarian Ligament
anchors the lower end of the ovary to the uterus.
The following two tissues that cover the outside of the ovary:
1) Germinal Epithelium
o is an outer layer of simple epithelium.
2) Tunica Albuginea
o is a fibrous layer inside the germinal epithelium.
The inside of the ovary, or stroma, is divided into two indistinct regions:
1) Outer Cortex and the Inner Medulla
o embedded in the cortex are saclike bodies called ovarian follicles. Each ovarian
follicle consists of an immature oocyte (egg) surrounded by one or more layers of
cells that nourish the oocyteas it matures.
2) Follicular Cells
o the surrounding cells if they make up a single layer, orgranulosa cells, if more than
one layer is present.
3) Uterine tubes (oviducts)
o transport the secondary oocytes away from the ovary and toward the uterus (the
ovaries consist of primary oocytes, which develop into secondary oocytes). The
following regions characterize each of the two uterine tubes(one for each ovary):
4) Infundibulum
o is a funnel-shaped region of the uterine tube that bears fingerlike projections called
fimbriae. Pulsating cilia on the fimbriae draw the secondary oocyte into the uterine
tube
5) Ampulla
o is the widest and longest region of the uterine tube. Fertilization of the oocyte by a
sperm usually occurs here.
6) Isthmus
o is a narrow region of the uterine tube whose terminus enters theuterus.
Wall of the Uterine Tube
consists of the following three layers:
1) Serosa
o a serous membrane, lines the outside of the uterine tube.
2) Middle Muscularis
o consists of two layers of smooth muscle that generateperistaltic contractions that
help propel the oocyte forward.
3) Inner Mucosa
o consists of ciliated columnar epithelial cells that help propelthe oocyte forward, and
secretory cells that lubricate the tube and nourish theoocyte.
Uterus
a hollow and pear-shaped organ that is to house, nourish and expel the fetus during
delivery; and for menstrual flow. It composes 3:
1) Body or Corpus
o the main body part of the uterus.
2) Fundus
o superior rounded region above the entrance of the uterine tubes.
3) Isthmus
o slightly constricted portion that joins the corpus to the cervix.
Uterus is held in place by the following ligaments:
Broad ligaments
o fold of peritoneum supporting the uterus, extending fromthe uterus to the wall of the
pelvis on either side
Utero-sacral ligaments
o a part of the thickening of the visceral pelvic fasciabeside the cervix and vagina;
called also Petit's Ligament.
Round ligaments
 o a fibromuscular band attached to the uterus near theuterine tube, passing through
the inguinal ring to the labium majus
Cardinal (lateral cervical) ligaments
- part of a thickening of the visceralpelvic fascia beside the cervix and vagina, passing laterally to
merge with theupper fascia of the pelvic diaphragm.
Wall of the Uterus consists of the following three layers:
1) Perimetrium
o is a serous membrane that lines the outside of the uterus.
2) Myometrium
o consists of several layers of smooth muscle and imparts the bulk of the uterine wall.
Contractions of these muscles during childbirth help force thefetus out of the uterus.
3) Endometrium
o is the highly vascularized mucosa that lines the inside of theuterus. If an oocyte has
been fertilized by a sperm, the zygote (the fertilized egg)implants on this tissue.
Vagina (birth canal)
serves both as the passageway for a newborn infant and as adepository for semen during
sexual intercourse. It consists of the following layers:
Outer Adventitia
holds the vagina in position.
Middle Muscularis
consists of two layers of smooth muscle that permitexpansion of the vagina during childbirth
and when the penis is inserted.
Inner Mucosa
has no glands. But bacterial action on glycogen stored in thesecells produces an acid
solution that lubricates the vagina and protects it againstmicrobial infection. The acidic
environment is also inhospitable to sperm. Themucosa bears transverse ridges called
rugae

Physiology of the Cervix

Cervix is the 3rd lower portion of the uterus, neck line part, narrowed where it joins
the top end of the vagina. Cylindrical in shape and protrudes through the upper
anterior vaginal wall.

It has cervical mucus that is made of 90% of water, depending on the water content
which varies during the menstrual cycle that functions as a barrier. It is usually
contains electrolytes, mainly Calcium, Sodium, and Potassiun, organic compounds
such as Amino acids and soluble proteins. It is also composed of Zinc, Copper, iron,
Manganese and selenium elements.

After menstrual period, the external OS is blocked by mucus that is thick and acidic
and it undergoes a series of changes in position and texture of cervix uteri and wall.
Menstrual Cycle
The activities of the ovary and the uterus are coordinated by negative- and positive-
feedback responses involving gonadotropin releasing hormone (GnRH) from the
hypothalamus, follicle stimulating hormone (FSH) and luteinizing hormone (LH) from
the anterior pituitary, and the hormones estrogen and progesterone from the follicle
and corpus luteum. A description of the events follows):
Hypothalamus and anterior pituitary initiate the reproductive cycle:
The hypothalamus monitors the levels of estrogen and progesterone in the blood. In
a negative-feedback fashion, low levels of these hormones stimulate the
hypothalamus to secrete GnRH, which in turn stimulates the anterior pituitary to
secrete FSH and LH.2.

Follicle develops:
FSH stimulates the development of the follicle from primary through mature
stages.3.

Follicle secretes estrogen:

LH stimulates the cells of the theca interna and the granulosa cells of the follicle to
secrete estrogen. Inhibin is also secreted by the granulosa cells.4.

Ovulation occurs:
Positive feedback from rising levels of estrogen stimulate the anterior pituitary
(through GnRH from the hypothalamus) to produce a sudden mid cycle surge of LH.
This high level of LH stimulates meiosis in the primary oocyte to progress toward
prophase II and triggers ovulation.5.

Corpus luteum secretes estrogen and progesterone:

After ovulation, the follicle, now transformed into the corpus luteum, continues to
develop under the influence of LH and secretes both estrogen and progesterone.6.

Endometrium thickens:
Estrogen and progesterone stimulate the development of the endometrium, the
inside lining of the uterus. It thickens with nutrient-rich tissue and blood vessels in
preparation for the implantation of a fertilized egg.7.

Hypothalamus and anterior pituitary terminate the reproductive cycle:

Negative feedback from the high levels of estrogen and progesterone cause the
anterior pituitary(through the hypothalamus) to abate the production of FSH and LH.
Inhibin alsosuppresses production of FSH and LH.8.

Endometrium either disintegrates or is maintained, depending on whether

implantation of the fertilized egg occurs, as follows:

Implantation does not occur: In the absence of FSH and LH, the corpus luteum
deteriorates. As a result, estrogen and progesterone production stops. Without
estrogen and progesterone, growth of the endometrium is no longer supported, and
it disintegrates, sloughing off during menstruation.

Implantation occurs: The implanted embryo secretes human chorionic gonadotropin

(hCG) to sustain the corpus luteum. The corpus luteum continues to produce
estrogen and progesterone, maintaining the endometrium. (Pregnancy tests check
for the presence of hCG in the urine).

Menopause
is the cessation of menstruation. This usually occurs in women between the ages of
45 and 50. Some women may reach menopause before the age of 45 and some
after the age of 50. In common use, menopause generally means cessation of
regular menstruation. Ovulation may occur sporadically or may cease abruptly.
Periods may end suddenly, may become scanty or irregular, or may be
intermittently heavy before ceasingal together. Markedly diminished ovarian
activity, that is, significantly decreased estrogen production and cessation of
ovulation, causes menopause.