12 - Benign Gyn Disorders Flashcards
Describe the normal cycle for breast epithelial cells
Proliferate during luteal phase
Breast fullness and tenderness in the week preceding menses
Undergo programmed cell death at the ends of the luteal phase
Estrogen and progesterone levels decline
What happens to breast lobules at menopause?
They involute and are replaced with fat
Fibroadenomas are composed of:
Glandular and cystic epithelial structures surrounded by a cellular stroma
What is the MC breast mass ID’d in adolescence?
Fibroadenomas
When are fibroadenomas most frequently found?
Premenopausal women
Galactorrhea
Expressible nipple discharge - common, probably not a big deal
Spontaneous nipple discharge (galactorrhea) - must evaluate!
Commonly 2/2 prolactinoma or hypothyroidism (long list slide 15)
MC organism for mastitis?
- what’s a girl to do?
Staphylococcus
Keep breastfeeding or pumping
If sxs don’t improve rapidly with ABX, get US to r/o abscess
Nonpuerperal mastitis?
Uncommon
Image and bx to r/o inflammatory breast CA
Peripheral abscess? I and D and ABX
Subareolar abscess? Duct excision / removal of sinus tracts
Two main categories for breast pain
Cyclic or noncyclic
If it’s noncyclic -> more concerning…frequently a simple cyst, but COULD BE CA
How does vulvar dz most commonly present?
Itching
- but the working diagnosis is CANCER so get a biopsy if you see something
Lichen sclerosis
- definition
- presentation/sx
- dx
- tx
Post-menopausal women
Hormones/genetics/AI/we dont know
INFLAMMATION of the dermis
Pruritus, irritation, vulvar thickening
Burning, dyspareunia
CELLOPHANE paper appearance of gentle stretching of skin
May need to bx if suspicious lesions
Txt - minimize irritation, topical ‘roids - if severe, retinoids or phototherapy
Lichen simplex chronicus
- cause
- txt
2/2 chronic irritation - intense itch-scratch cycle
Excoriations - skin responds by thickening
Txt - eliminate the trigger, sitz baths, benadryl, wear cotton gloves at night, topical steroids
If no resolution in 3 weeks, bx
Red lesions (dermatoses) include:
Atopic dermatitis
Contact dermatitis
Psoriasis
Vestibulitis
Lichen planus
Atopic derm
Pt will have hx of allergies, eczema
Chronic relapsing course
Topical steroids, immunomodulators, treat the dry skin
Contact derm
Usually 2/2 irritant
20% of the time 2/2 allergy
Common vulvar irritants:
Slide 34 (review deck)
She mentioned dyes and laundry detergents
Psoriasis
Adherent silver scale
T-cell mediated
Stress or menses can exacerbate
Txt - emollients, steroids
Lichen planus
- definition
- presentation
Uncommon - affects men and women equally, ages 30-60
Autoimmune T-cell disorder
May be drug-induced
Cutaneous and mucosal surfaces
Pt c/o vaginal discharge, pruritus, burning pain, dyspareunia, postcoital bleeding
3 variants of licen planus
- Erosive (MC and most difficult to treat)
- Papulosquamous
- Hypertrophic
The 5 p’s of lichen planus?
Purple pruritic polygonal papules and plaques
Txt for lichen planus
Topical steroids
Vaginal hydrocortisone
Sxs of intergtrigo
Friction / moisture between skin folds
Burning and itching
Longstanding -> hyperpigmentation and verrucous changes
Txt of intertrigo
Drying agents
Mild topical steroid if inflamed
If infected, txt
Lose some weight
Wear loose-fitting clothing
What is the MCC of vaginal irritation after menopause?
- sxs?
- txt?
Atrophic vaginitis
Sxs - vulvar irritation, clear/yellow or blood-tinged discharge, urinary sxs, dyspareunia
Friable vaginal epithelium, loss of rugae, pale mucosa
Txt - topical estrogen (be careful with unopposed estrogen if uterus still present - if patient has a uterus, CANNOT have unopposed estrogen)
Bartholin’s Cyst
- overview
- txt
- risk
Reproductive-age women
Painless
No txt necessary if asxs, but women don’t like it, so - I and D plus packing, or Word cath placement, or marsupialization (taking out the whole cyst wall - done only if failed Word catheter)
If over 40yrs, concern for CA (get bx)
Bartholin’s abscess
- cause
- sxs
- txt
Usually a sequelae of the cyst
Polymicrobial - screen for STD’s
Sxs - severe pain, difficulty walking, sitting, or having sex
Txt - if fluctuant, I and D (immediate relief) and Word cath (if packing unavailable)
ABX if: recurrent OR high risk (i.e. preggo, cellulitis, systemic infx, immunosuppressed)
Cervical stenosis
- definition
- sxs
- cause
- tx
Scar tissue contraction or adhesions block the os
Sxs - dysmenorrhea, amenorrhea, infertility
Caused by certain procedures (i.e. LEEP), congenital, or spontaneously
Txt - cervical dilators - vaginal estrogen
If severe - increased risk for infection, uterine distention, dystocia
- 2/2 impeded menstrual flow
What cervical diameter is needed to be considered “sufficient” in the setting of cervical stenosis?
5mm is sufficient for flow
Less than 2mm associated with retrograde flow
Nabothian cysts
- definition
- sxs
- txt
Trapped columnar cells that secrete mucus resulting in discrete cyst on cervix
Usually asxs, no txt necessary
If you have to txt, refer for electrocautery or excision
Cervical polyp
- what is it
- txt
- dont forget?
One of the most common benign cervical neoplasms
Less than 3cm
Txt - if small - grasp with forceps and twist off. If sessile, remove with biopsy forceps, cauterize the base.
Send ALL to pathology
What is the MC pelvic tumor in women?
- describe it
- sxs
- dx
- txt
Leiomyomas “fibroids”
Slow-growing, estrogen-dependent benign tumor
Common indication for hysterectomy
Round, rubbery
Sxs - most are asxs - bleeding, sensation of pressure, urinary frequency, pelvic pain, infertility possible
Dx - bimanual exam, US, path
Txt - observe, COCPs, mirena, surg, hysterectomy
Adenomyosis
- what is it
- who gets it
- dx
- txt
Nests of endometrial glands and stroma embedded within the muscular uterine wall
Uterus often globally enlarged
Age 40-50 heavy abnormal uterine bleeding
1/3 are asxs
Dx - MRI best, then TVUS, then bx
Txt - hysterectomy
Endometrial polyps
- what
- who
- sxs
- dx
- txt
Overgrowth of endometrium on a stalk
All ages, peaks in 50’s
MC sxs - metrorrhagia (intermenstrual bleeding)
Dx - TVUS
Txt - removal if large or symptomatic
Functional cyst syndrome
- size
- sxs
- dx
> 3cm
Pelvic pain, dull sensation, heaviness, hemorrhage
Dx - bimanual exam, US
MC benign ovarian neoplasm type?
Epithelial
Benign cystic teratoma
Dermoid cyst
Single most common ovarian neoplasm
Risk of torsion
Txt for premenopausal ovarian cysts 5-7cm (simple, benign qualities)
TVS repeated in 6-12 weeks
If over 7cm, MRI or surgical evaluation
Txt for postmenopausal ovarian cysts 1-5cm (simple, benign qualities)
CA125 level - if normal, TVS in 6-12 weeks
If over 7cm, MRI or surgical eval
25% of ovarian torsion cases occur during:
50-80% of cases have?
Pregnancy
Ovarian mass
Risk factor for ovarian torsion:
Large (>6cm) ovaries - rise up out of the confines of the pelvic bones where they’re more likely to twist
Presentation of ovarian torsion
Sudden onset progressive sharp lower abdominal pain
Low-grade fever suggests necrosis
N/V
Can mimic ectopic
Txt for ovarian torsion
Salvage if possible
Resect tumor or cyst
Possible oophoropexy
If necrosis or rupture with hemorrhage - remove adnexal structures
Fibrocystic changes
Palpably nodular breast tissue or to the
histologic pattern of dilated ducts and acini
invested with dense collagenous stroma
Not a breast CA risk by itself
Benign, characterized by hyperplasia
Pain and tenderness, usually premenstrual
Txt with less caffeine, chocolate, supportive bra
Slide 14
Lots of causes galactorrhea
Slide 77-78
Ovarian cyst txt guidelines - chart
Indications for surgical interventions in leiomyomas?
Rapid enlargement
Severe pelvic pain or secondary dysmenorrhea
Abnormal uterine bleeding with anemia
Urinary tract symptoms
Inability to evaluate the adnexa (usually corresponds with fibroid >12 week gestational size uterus)
Growth of fibroid after menopause
Infertility
Benign uterine d/o types?
Estrogen dependent
- Leiomyomata - “fibroids”
- Adenomyosis
- Endometrial hyperplasia
Non estrogen dependent
- polyp
Public cervix announcement
Get your pap today
