med-surg INFERTILITY.docx

**INFERTILITY\ ** **Definition** Infertility is defined as a couple's inability to achieve pregnancy after 1 year of regular, unprotected intercourse **Types** Infertility can be primary or secondary. **Primary infertility** is when a couple has never had a child and has not conceived after try...

**INFERTILITY\ ** **Definition** Infertility is defined as a couple's inability to achieve pregnancy after 1 year of regular, unprotected intercourse **Types** Infertility can be primary or secondary. **Primary infertility** is when a couple has never had a child and has not conceived after trying for at least 12 months without using birth control **Secondary infertility** is when the couples have previously conceived but are no longer able to. **Causes** Infertility is primarily a disorder of couples. The man is responsible in about 30% of cases, the woman in about 40% of cases and both in the remaining 30% Reproductive performance depends on amongst others the following: - Age of the female - Age of the male - Frequency of intercourse - Duration of coital exposure **Causes in men** The following are possible causes of infertility in men: **Low sperm count (Oligospermia):** The man ejaculates a low number of sperm. A sperm count of fewer than 20 million is considered low. Around one third of couples have difficulty conceiving due to a low sperm count. **Low sperm motility (Asthenospermia):** Large number of the sperm cannot \"swim\" as well as they should to reach the egg. **Abnormal sperm morphology (Teratospermia):** The sperm may have an unusual shape, making it harder to move and fertilize an egg. **Medical condition:** This could be a testicular infection, cancer, or surgery. **Overheated testicles:** This may be due to undescended testicle, a varicocele, or varicose vein in the scrotum, the use of hot tubs, wearing tight clothes, and working in hot environments. **Ejaculation disorders:** If the ejaculatory ducts are blocked, semen may be ejaculated into the bladder **Hormonal imbalance:** Hypogonadism, for example, can lead to a testosterone deficiency. **Genetic factors:** A man should have an X and Y chromosome. If he has two X chromosomes and one Y chromosome, as in Klinefelter\'s syndrome, the testicles will develop abnormally and there will be low testosterone and a low sperm count or no sperm. **Causes in women** **Ovulation disorders** appear to be the most common cause of infertility in women. Ovulation is the monthly release of an egg. The eggs may never be released or they may only be released in some cycles. Ovulation disorders can be due to: - Premature ovarian failure: The ovaries stop working before the age of 40 years. - Polycystic ovary syndrome (PCOS): The ovaries function abnormally and ovulation may not occur. - Hyperprolactinemia: If prolactin levels are high, and the woman is not pregnant or breastfeeding, it may affect ovulation and fertility. - Poor egg quality: Eggs that are damaged or develop genetic abnormalities cannot sustain a pregnancy. The older a woman is, the higher the risk. - Thyroid problems: An overactive or underactive thyroid gland can lead to a hormonal imbalance. - Chronic conditions: These include AIDS or cancer. **Problems in the uterus or fallopian tubes **can prevent the egg from traveling from the ovary to the uterus, or womb. If the egg does not travel, it can be harder to conceive naturally. Causes include: - **Scarring due to Surgery:** Pelvic surgery can sometimes cause scarring or damage to the fallopian tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the uterus. - **uterine fibroids**: They can interfere with implantation or block the fallopian tube, preventing sperm from fertilizing the egg - Endometriosis: Cells that normally occur within the lining of the uterus start growing elsewhere in the body. - Previous sterilization treatment: In women who have chosen to have their fallopian tubes blocked, the process can be reversed, but the chances of becoming fertile again are not high. **Other predisposing factors include:** - **Hypospadias:** The urethral opening is under the penis, instead of its tip. If the correction is not done, it may be harder for the sperm to get to the female\'s cervix. - **Radiation therapy:** This can impair sperm production. The severity usually depends on how near to the testicles the radiation was aimed. - **Some diseases:** Conditions that are sometimes linked to lower fertility in males are anemia, Cushing\'s syndrome, diabetes, and thyroid disease. - **Some medications** e.g. Anabolic steroids: Popular with bodybuilders and athletes, long-term use can seriously reduce sperm count and mobility. - **Chemotherapy:** Some types of anti cancer drugs may significantly reduce sperm count. - **Illegal drugs:** Consumption of marijuana and cocaine can lower the sperm count. - **Age:** Male fertility starts to fall after 40 years. - **Exposure to chemicals:** Pesticides, for example, may increase the risk. - **Excess alcohol consumption:** This may lower male fertility especially in those who already have a low sperm count. - **Overweight or obesity:** This may reduce the chance of conceiving. - **Mental stress:** Stress can be a factor, especially if it leads to reduced sexual activity. **Diagnosis** **Men** - - To assess fertilizing capacity of the semen sample - Abstinence of 3-7 days - Volume -- 2-5mls/ ejaculation - Liquefaction time -- within 30minutes - Count -- 20millions/ml or more - Motility - \>60% progressive motility - Morphology -- 60% normal forms - White cells - \ - Providing better obstetric and post-abortion care. - Providing contraceptive knowledge and services to prevent unwanted pregnancies that may end in unsafe abortions. - Educating mothers about the hazards of Female Genital mutilation**.** - Maintaining a healthy body weight with regular exercise. - Eating balanced diet which should include whole grains, fresh fruits, vegetables and low fat milk. - Illegal drugs such as marijuana and cocaine should be avoided. **\ PELVIC INFLAMMATORY DISEASE (PID) Pelvic inflammatory disease** (PID) is an inflammatory condition of the pelvic cavity that may begin with cervicitis and may involve the uterus (endometritis), fallopian tubes (**salpingitis**), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system. The infection may be acute, subacute, recurrent, or chronic and localized or widespread, and is usually a results of an ascending infection from the lower to upper genital tract **Definition\ **Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that\ involves any combination of the uterus, endometrium, ovaries, fallopian tubes, pelvic\ peritoneum and adjacent tissues. PID can also be defined as a clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, and/or adjacent structures. **Causes\ **Most cases of PID can be categorized as sexually transmitted or endogenous and are usually\ associated with more than one organism or condition including:\ *Neisseria gonorrhoeae* *Chlamydia trachomatis*\ *Trichomonas vaginalis\ * *Mycoplasma genitalium\ * *Mycoplasma hominis\ * *Ureaplasma urealyticum\ * Bacterial vaginosis **Predisposing/ Risk Factors** - Early age at first intercourse, - Multiple sexual partners, - Frequent intercourse, intercourse without condoms, - Sex with a partner having an STI - A history of STI or previous pelvic infection - Procedures involving the upper female genital tract including:\ - dilatation & curettage (D&C)\ - intrauterine device (IUD) insertion\ - therapeutic abortion (T/A) etc **Pathophysiology\ **The organisms usually enter the body through the vagina, pass through the cervical canal, colonize the endocervix, and move upward into the uterus. Under various conditions, the organisms multiply rapidly and spread to one or both fallopian tubes and ovaries and into the pelvis. The infection tens to be unilateral, but in some instances becomes bilateral, and can result in narrowing and scarring of the fallopian tubes, which increases the risk for ectopic pregnancy (fertilized eggs become trapped in the tube), infertility, recurrent pelvic pain, tubo-ovarian **abscess**, and recurrent disease. Infections can cause perihepatic inflammation when the organism invades the peritoneum. Pathogens can also be disseminated directly through the tissues that support the uterus by way of the lymphatics and blood vessels, especially in bacterial infections that occur after childbirth or abortion. In rare instances, organisms (e.g., tuberculosis) gain access to the reproductive organs by way of the bloodstream from the lungs. **Signs & Symptoms** - Fever \38ºC - Dyspareunia - Dysuria - Post coital bleeding - Abnormal vaginal bleeding - Abnormal vaginal discharge - Urinary frequency - Pelvic pain - Nausea or vomiting - Low back pain - lower abdominal pain -- usually bilateral **Diagnosis** History- a thorough history of past infections, a sexual history, and a history of contraceptive use are essential to evaluate a woman with PID Physical examination (specifically pelvic examination) Laparoscopy Ultrasonography Computed tomography (CT) scan Magnetic resonance imaging (MRI) Erythrocytes sedimentation rate Full blood count Chlamidial and gonococcal DNA test **MANAGEMENT\ Medical Management** - **Women with mild infections may be treated as outpatients, but hospitalization may be necessary.** - **Intensive therapy includes bed rest, intravenous fluids, and intravenous antibiotic therapy.** - **Broad-spectrum antibiotic especially the cephalosporins (e.g. cefixime,** **ceftriaxone) in combination with doxycycline or azithromycin, and metronidazole are prescribed as recommended by CDC.** - **If the patient has abdominal distention or ileus, nasogastric intubation and suction are initiated.** - **Monitoring vital signs and symptoms assists in evaluating the status of the infection.** - **Treating sexual partners is necessary to prevent re-infection.** **Goals of Treatment** **The major goals in the treatment of PID are to:** - Preserve fertility - Treat infection - Alleviate symptoms - Prevent further complications - Prevent spread of infection **Criteria for Potential Hospitalization** The following criteria may indicate the need for hospitalization or parenteral therapy for patient with PID: - Surgical emergencies, such as appendicitis or ectopic pregnancy - Pregnancy - Client cannot tolerate oral treatments - Client is under the age of 19 - Severe abdominal pain - Client has abdominal guarding, rigidity, or rebound tenderness - Severe nausea, vomiting, or a fever \>38.5ºC - Underlying illnesses such as diabetes, HIV or active hepatitis infection - Concerns with the client's ability to complete oral antibiotic therapy **Nursing management** - Admission - for those who cannot be treated as outpatients. - The hospitalized patient is maintained on bed rest and is usually placed in the semi-Fowler's position to facilitate dependent drainage of discharge. - Accurate observation and recording of vital signs. - Assessing the characteristics and amount of vaginal discharge is necessary as a guide to therapy. - Administration of analgesic agents as prescribed for pain relief. - Heat applied safely to the abdomen may also provide some pain relief and comfort. - Carefully handling and disposal of perineal pads to minimize the transmission of infection to others. - Patient education on proper perineal hygiene, nutrition, medication and complications of PID. Nursing diagnoses Acute pain related to inflammatory process Deficient fluid volume Deficient knowledge Ineffective coping Sexual dysfunction **Complications** - Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis or perihepatitis syndrome) - Tubo-ovarian abscess - Ectopic pregnancy - Chronic pelvic pain - Tubal factor infertility - Recurrent PID - Bacteremia with septic shock - Thrombophlebitis **Prevention** - Using barrier methods such as condoms during intercourse, especially if the partner is suspected of having STI. - Seeking medical attention for experiencing symptoms of PID. - Seeking medical attention if you observe that a current or former sex partner has or might have had STI. - Avoiding sexual intercourse immediately after the end of pregnancy or certain gynecological procedures to ensure the cervix closes. - Reducing the number of sex partners. - Regular testing for sexually transmitted infections. - Proper and safe perineal hygiene especially after voiding or having bowel movement. **\ ** **UTERINE PROLAPSE** The uterus (the womb, in which a fetus develops) is normally held in place inside the pelvis by various muscles and ligaments. Sometimes, because of childbirth or difficult labour and vaginal delivery, these tissues are weakened. As a woman ages and with age-related decrease in the concentration of the hormone estrogen, the uterus can move downward into the vaginal canal, causing the condition known as a prolapsed uterus. Prolapse is the protrusion of an organ or structure beyond its normal anatomical confines. Therefore, **uterine prolapse** is the descend or protrusion of the uterus through the vaginal canal. **Uterine prolapse** can also be defined as the herniation of the uterus into or beyond the vagina as a result of failure of the ligamentous and fascial supports. It accounts for one of the common gynecological problems in the developing countries and also a common indication for hysterectomy in middle- and old-aged women Other terms that have also been used to describe uterine prolapse include pelvic organ prolapse, genital prolapse, urogenital prolapse, uterovaginal prolapse, and vaginal prolapsed. Uterine prolapse occur due to defects in the supporting structures of the uterus and vagina, namely, uterosacral and cardinal ligaments complex and connective tissue of the urogenital membrane. **Classification of Uterine Prolapse** Uterine Prolapse can be described based on the degree of protrusion of the uterus/cervix into the vaginal cannal in the following stages: **First degree:** The cervix descends downward into the vagina. **Second degree:** The cervix comes down to the opening of the vagina. **Third degree:** The cervix is outside the vagina. **Fourth degree:** The entire uterus is outside the vagina. This condition is also called uterine procidentia. This is caused by weakness in all of the supporting ligaments. Other forms of prolapse associated with the uterine prolapse include: **Cystocele:** A herniation (or bulging) of the upper front vaginal wall where a part of bladder bulges into the vagina, which may lead to urinary frequency, urgency, retention, and retention. **Enterocele:** The herniation of the upper vagina along with a segment of small intestine into the vagina. Standing leads to a pulling sensation and backache and is relieved when lying down. **Rectocele:** The protrusion forward of the posterior wall for the vagina, along with concomitant bulging forward of the rectum into the vagina. This may make bowel movements difficult to the point where the woman may need to push on the inside of the vagina to empty the rectum. **Causes of Uterine Prolapse** The following conditions can cause a prolapsed uterus: - Pregnancy - Difficult labor or trauma during child birth - Delivery of large baby: This may cause injury to the ligaments and muscles that support the walls of the uterus and vagina. - Weakening and loss of tissue tone after menopause due to loss of natural estrogen production by the ovaries. - Chronic cough. - Chronic constipation or straining with bowel movement - Being overweight or obese resulting in additional strain on pelvic muscles. - Radical surgery in the pelvic area leading to loss of external support. - Repeated heavy weight lifting resulting in increased intra-abdominal pressure due to straining. **2.5 Signs and Symptoms of Uterine Prolapse** - A feeling of fullness or pressure in the pelvis (it may be described as a feeling of sitting on a small ball) - Low back pain - Feeling that something is coming out of the vagina - Painful sexual intercourse - Difficulty with urination such as incontinency or urine retentuion - Trouble having a bowel movement - Difficulty walking **Diagnosis** - History taking - Pelvic examination - Ultrasound scan - Intravenous pyelogram **Management of the Uterine Prolapse** Treatment depends on how weak the supporting structures around the uterus have become. **Self- care measures** If the uterine prolapse causes few or no serious symptoms, simple self-care measures may provide relief or help prevent worsening the condition. Self-care measures include performing Kegel exercise to strengthen the pelvic muscles, losing weight and treating constipation. **Use of pessary:** a vaginal pessary is a plastic or rubber ring inserted into the vagina to support the bulging tissues. **Medication** Estrogen replacement therapy may be used to help strengthen the muscles in and around the vagina. Estrogen cream or suppositories inserted into the vagina help in restoring the strength and vitality of tissues in the vagina but only in selected postmenopausal women. **Surgical Treatment of Uterine prolapse** The choice of surgery for uterine prolapse depends upon many factors, including the patient\'s age, overall state of health, and desire for future child-bearing. Two types of surgical approaches are commonly used: **Repair of weakened pelvic floor tissues:** This surgery is generally approached through the vagina but sometimes through the abdomen. The surgeon might graft the patient's own tissue, donor tissue or synthetic material onto weakened pelvic floor structures to support the pelvic organs. **Removal of the uterus (Hysterectomy):** When indicated, and in severe cases of prolapse, the uterus can be removed (hysterectomy). During the procedure, the surgeon can also correct the sagging of the vaginal walls, urethra, bladder, or rectum. The surgery may be performed abdominally (through an incision on the abdomen), vaginally (through incisions made in the vaginal walls), or laparoscopically (using special instruments to perform the surgery through small tiny incisions. **Complications of uterine Prolapse** - Kinking of ureter with resulting renal damage can occur in procidentia and enterocele. The ureter can also be included in the sutures at the vaginal vault during surgery. - Urinary tract infection (chronic) in a large cystocele with residual urine can lead to upper renal tract infection and renal damage. - In rare cases, cancer of the vagina is reported over the decubitus ulcer and if the ring pessary is left in over a long period **Prevention of Uterine Prolapse /Health Education** - Reduce weight - Avoid constipation by eating a high-fiber diet - Do Kegel exercises to strengthen the pelvic muscles (may provide minimal protection against urinary leakage). - Avoid heavy lifting or straining - Seek for medical attention promptly on noticing any abnormal changes in the vulva. **\ ** **Cancer of the cervix** Cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. Cancer is not just one disease but many diseases. There are more than 100 different types of cancer. Most cancers are named for the organ or type of cell in which they start - for example, cancer that begins in the colon is called colon cancer; cancer that begins in melanocytes of the skin is called melanoma. **Cancer of the cervix** or **cervical cancer** is an abnormal cellular proliferation of the enterance of the uterus (the cervix). **Ectocervix - flat cells - squamous cell cervical cancer**\ The ***ectocervix*** is the portion of the cervix that projects into the vagina, also known as the *portio-vaginalis*. It is about 3 cm long and 2.5 cm wide. There are flat cells on the outer surface of the ectocervix. These fish scale-like cells can become cancerous, leading to ***squamous cell cervical cancer***. **Endocervix - glandular cells - adenocarcinoma of the cervix**\ The ***endocervix*** is the inside of the cervix. There are glandular cells lining the endocervix; these cells produce mucus. These glandular cells can become cancerous, leading to ***adenocarcinoma of the cervix***. General phathophysiology of cancer Many risk factors can increase the chances of developing cancer, but it is not yet known exactly how some of these risk factors cause cells to become cancerous. Hormones and other factors seem to play a role in many cases of cancer, but it is not fully understood how this happens. DNA is the chemical in each of our cells that makes up our genes and controls how our cells function. We usually look like our parents because they are the source of our DNA. But DNA affects more than how we look. Some genes contain instructions for controlling when our cells grow, divide, and die. Genes that speed up cell division are called ***oncogenes**. Others that slow down cell* division, or cause cells to die at the right time, are called *tumor suppressor genes. Certain* changes (mutations) in DNA that "turn on" **oncogenes** or "turn off" tumor suppressor genes can cause normal body cells to become cancerous. Cancers that are encapsulated and confined to a specific area of the body are less serious, and are called benign tumors. Advanced cancers that usually spread to other areas of the body (metastasis) are called malignant cancers. **Signs and symptoms** Often during the early stages people may experience no symptoms at all. That is why women should have regular cervical smear tests. The most common signs and symptoms are: - Bleeding between periods - Bleeding after sexual intercourse - Bleeding in post-menopausal women - Discomfort during sexual intercourse - Smelly vaginal discharge - Vaginal discharge tinged with blood - Pelvic pain **Causes** Scientists are not completely sure why cells become cancerous. However, there are some risk factors which are known to increase the risk of developing cervical cancer. These risk factors include: - **Having many sexual partners:** Cervical cancer-causing HPV types are nearly always transmitted as a result of sexual contact with an infected individual. Women who have had many sexual partners generally have a higher risk of becoming infected with HPV, which raises their risk of developing cervical cancer. - **Smoking:** Smoking increases the risk of developing many cancers, including cervical cancer. - **Weakened immune system:** **People with weakened immune systems, such as those with HIV/AIDS, or transplant recipients taking immunosuppressive medications have a higher risk of developing cervical cancer.** - **Giving birth at a very young age: Women who gave birth before the age of 17 are significantly more likely to develop cervical cancer compared to women who had their first baby when they were aged 25 or over.** - **Repeated pregnancies:** **Women who have had at least three children in separate pregnancies are more likely to develop cervical cancer compared to women who never had children.** - **Contraceptive pill:** **Long-term use of the contraceptive pill slightly increases a woman\'s risk of developing cervical cancer.** - **Other sexually transmitted diseases (STD): Women who become infected with chlamydia, gonorrhea, or syphilis have a higher risk of developing cervical cancer.** - **Certain genetic factors** - **Long-term mental stress** ***Preinvasive\ *Stage 0 Carcinoma in situ: cancer limited to epithelial layer; no evidence of invasion\ *Invasive\ *Stage I Carcinoma strictly confined to cervix\ Stage Ia** Micro-invasive; identified only microscopically\ Stage Ia1 Invasion no greater than 3 mm in depth and no wider than 7 mm\ Stage Ia2 Invasion \> 3 mm and no greater than 5 mm in depth and no wider than 7 mm\ **Stage Ib** Clinical lesion usually visible with the naked eye, but is confined to cervix\ Stage Ib1 Clinical lesions no greater than 4 cm in size\ Stage Ib2 Clinical lesions greater than 4 cm in size **Stage II Carcinoma extends beyond the cervix but not onto the pelvic wall\ **Stage IIa the cancer has reached the top of the vagina.\ Stage IIb the cancer has reached tissue around the cervix with or without vaginal involvement **Stage III The cancer has spread beyond the cervix and uterus and has reached the surrounding structures of the pelvic area; the lower portion of the vagina, and the pelvic wall** Stage IIIa the cancer has reached the lower third of the vagina, but not the pelvic wall. Stage IIIb the cancer has grown through the pelvic wall, or is blocking one ureter or both of them. **Stage IV Extension of carcinoma beyond the true pelvis:** Clinical involvement of the mucosa of the bladder or rectum and other distant organs. Stage IVa Spread of cancer to nearby organs e.g. bladder or rectum Stage IVb Spread to distant organs e.g. the liver, lungs, bones. **Diagnosis** - History taking and pelvic examination - **Cervical screening - LBC or Pap smear test** - **HPV DNA test** -- - **Cervical tissue Biopsy** - **Colposcopy** - **Blood tests (FBC, blood film}** - **CT (computerized tomography) scan** - **MRI (magnetic resonance imaging scan)** - **Pelvic ultrasound** **Management** Treatment for early stage cervical cancer - cancer that is confined to the cervix - has a success rate of 85% to 90%. The more the cancer has spread out of the area it originated from, the lower the success rate. Depending on the severity of the condition and intensity of metastasis, cervical cancer may be treated using chemotherapy, radiotherapy, surgery or a combination of two or more approaches. **\ ** **Chemotherapy** Chemotherapy for cervical cancer, as well as most other cancers, is used to target cancer cells that surgery cannot or did not remove, or to help the symptoms of patients with advanced cancer.\ Cisplatin is the common chemotherapy drug, and is usually used in combination with radiotherapy.\ Side effects of chemotherapy may vary, and depend on the specific drug being used. These include: - Diarrhea - Nausea - Hair loss - Fatigue - Infertility - Early menopause **Radiotherapy** For patients with advanced cervical cancer radiation combined cisplatin-based chemotherapy is the most effective treatment, according to gynecologic oncologists. Radiotherapy works by damaging the DNA inside the tumor cells, destroying their ability to reproduce.\ This may be delivered externally or internally (brachytherapy) by placing radioactive material near the cervix **Surgical management** - **Cone biopsy (conization)** - this procedure may also be used to remove any abnormality. The surgeon uses a scalpel to remove a cone-shaped piece of cervical tissue.   - **Laser surgery** - a narrow beam of intense light is used to destroy cancerous and precancerous cells.   - **LEEP** (loop electrosurgical excision procedure) - a wire loop which has an electric current cuts through tissue removing cells from the mouth of the cervix. - **Cryosurgery** - cancerous and precancerous cells are destroyed by freezing them. - **Hysterectomy** - the cancerous and precancerous areas, as well as the cervix and the uterus are surgically removed. This is not common and is only done in certain cases of noninvasive cervical cancer. **Nursing management** - Listen to the patient's fears and concerns, and offer reassurance when appropriate. - Encourage the patient to use relaxation techniques to promote comfort during the diagnostic procedures. - Monitor the patient's response to therapy through frequent Pap tests and cone biopsies as ordered. - Watch for complications related to therapy by listening to and observing the patient. - Monitor laboratory studies and obtain frequent vital signs. - Understand the treatment regimen and verbalize the need for adequate fluid and nutritional intake to promote tissue healing. - Explain any surgical or therapeutic procedure to the patient, including what to expect both before and after the procedure. - Review the possible complications of the type therapy ordered. - Remind the patient to watch for and report uncomfortable adverse reactions. - Reassure the patient that this disease and its treatment shouldn't radically alter her lifestyle or prohibit sexual intimacy. - Explain the importance of complying with follow up visits to the gynecologist and oncologist. **Prevention of cervical cancer** - **HPV (human papilloma virus) vaccine** - **Safe sex**: Using a condom during sex helps protect from HPV infection. - Regular cervical screening will make it much more likely that signs are picked up early on and dealt with before cancer develops at all or too far. - **Have few sexual partners**: The more sexual partners a woman has the higher the risk of developing cervical cancer. - **Delay first sexual intercourse**: The younger a female is when she has her first sexual intercourse the higher is her risk of developing cervical cancer. - **Avoid smoking**: People who smoke have a higher risk of developing cervical cancer than people who don\'t.