Adolescence CH 4

Question 1

When should breast exams begin

Answer 1

as soon as breast budding occurs

Question 2

Organic causes of breast asymmetry

Answer 2

Asymmetry is common; caused by unilateral breast hypoplasia, amastia, absence of pectoralis major muscle, unilateral juvenile hypertrophy (rapid overgrowth of breast tissue after thelarche)

Question 3

What makes young women at increased risk for breast CA

Answer 3

hx of malignancy, adolescents who are at least 10 years postradiation therapy to the chest, adolescents 18-21 years of age whose mothers carry BRCA1 or BRCA2 gene (all of these reasons mean they should do monthly exams)

Question 4

Fibroadenoma, what are they, describe them

Answer 4

most common breast mass in adolescents, made of glandular and fibrous tissue. typically non tender and described as rubbery, smooth, well circumscribed mobile mass often in upper outer quadrant of breast

Question 5

Mammogram results of fibroadenoma

Answer 5

fibroglandular tissue of adolescent breast may cause false positive results on mammo, use US instead

Question 6

Fibroadenoma monitoring (under 5cm)

Answer 6

fibroadenomas less than 5 cm can be monitored for growth or regression over 3-4 months. Further eval will be dictated by semiannual clinical evals for a few years.

Question 7

Fibroadenoma monitoring (over 5cm)

Answer 7

fibroadenomas that are over 5 cm, enlarging, have overlying skin changes, or hx of previous malignancy should be referred to breast specialist

Question 8

Symptoms of fibrocystic breast changes

Answer 8

more common in advancing age, mild swelling, palpable nodularity in upper outer quadrants. Mastalgia just before menstruation.

Question 9

tx of fibrocystic breast changes

Answer 9

reassure pt that is is benign, NSAIDs for pain. Oral contraceptive may beneficial. Supportive bra and decreased caffeine for symptomatic relief

Question 10

Breast abscess symptoms and causes

Answer 10

associated with mastitis and purulent discharge; caused by breast feeding, shaving and plucking periareolar hair, nipple piercing, and trauma during secual activity. causative organisms are normal skin flora. pt will have unilateral breast pain and inflammatory changes

Question 11

breast abscess tx

Answer 11

culture fluid (may need incision and drainage) before giving antibiotics. give broad spectrum antibiotics that cover staph aureus until cultures come back and more specific antibiotic can be given

Question 12

complications of breast abscess secondary to nipple piercing

Answer 12

endocarditis, cardiac calve injury, cardiac prosthesis infection, metal foreign body reaction, and recurrent infection

Question 13

clinical findings of Giant Juvenile fibroadenoma and tx

Answer 13

large >5 cm fibroadenoma with overlying skin stretching and dilated superficial veins. Benign but requires excision for confirmation of diagnosis and for cosmetic reasons

Question 14

Cystosarcoma phyllodes clinical findings and tx

Answer 14

large rapidly growing tumor associated with overlying skin changes, dilated veins, skin necrosis, requires excision. Usually benign but can be malignant

Question 15

Intraductal papilloma clinical findings and tx

Answer 15

palpable intraductal tumor, often subareolar with nipple discharge (bloody or serosanguineous). may be in periphery of breast in adolescents. requires surgical excision. associated with increased risk of malignancy in adults

Question 16

Juvenile papillomatosis clinical findings and tx

Answer 16

rare breast tumor characterized by grossly nodular breast mass described as having swiss cheese appearance. requires surgical excision

Question 17

Fat necrosis clinical findings and tx

Answer 17

localized inflammatory process in the breast; typically follows trauma (sports or seat belt). subsequent scarring may be confused with changes similar to those associated with malignancy.

Question 18

Ductal ectasia symptoms

Answer 18

common cause of nipple discharge in developing breast. Symptoms: dilation of mammary ducts, periductal fibrosis, and inflammation, nipple discharge can be bloody, brown, or sticky multicolored, may have cystic breast mass usually in the subareolar region. pt will have erythema, warmth, tenderness, and mastitis

Question 19

ductal ectasia tx

Answer 19

oral antibiotics to cover normal skin flora if infection suspected. but should resolve spontaneously.

Question 20

Galactorrhea characteristics and common causes

Answer 20

milky nipple discharge usually from both breasts. usually benign. common cause: chronic stimulation or irritation of nipple, medications and illicit drugs, pregnancy, childbirth, abortion, prolactin secreting tumor, hypothyroidism, tumors of hypothalamus and pituitary.

Question 21

Testing for galactorrhea

Answer 21

breast US, pregnancy test, prolactin level, thyroid function test. look for fat staining of discharge to confirm. Elevated TSH (hypothyroidism), Elevated prolactin and normal TSH accompanied by amenorrhea in the abscense of medication suggests hypothalamic or pituitary tumor (do MRI and send to peds endocrinologist)

Question 22

galactorrhea tx for those with breast mass

Answer 22

observation with serial examination for nipple discharge associated with breast mass (unless its papilloma). tx underlying cause. if hypothyroidism give thyroid hormone replacement.

Question 23

galactorrhea tx for those without breast mass

Answer 23

follow clinically if prolactin and TSH are normal. teach to avoid nipple stimulation, stress reduction, and monitoring for oligomenorrhea (could indicate hyperprolactinemia). symptoms should resolve spontaneously. may give dopamine agonist like bromocriptine

Question 24

gynecomastia, what is it, when does it start

Answer 24

benign subareolar glandular breast enlargement, affects up to 65% of adolescent males. starts at least 6 months after onset of secondary sex characteristics with peak incidence during SMR stages 3 and 4

Question 25

gynecomastia, what happens

Answer 25

breast tissue enlargement usually regresses within 1 to 3 years. and persistence beyond age 17 is uncommon., usually have a family hx.

Question 26

pathogenesis of gynecomastia

Answer 26

imbalance between estrogens that stiumulate proliferation of breast tissue and androgens which antagonie this effect. leptin levels are higher

Question 27

gynecomastia clinical findings

Answer 27

palpation needed to distinguish adipose tissue (pseudogynecomastia) from glandular tissue found in true gynecomastia . usually bilateral. more serious findings: hard/firm breast tissue, eccentric masses outside of nipple areolar complex, unilateral breast growth, and overlying skin changes

Question 28

GU exam in boys with gynecomastia, why?

Answer 28

to eval for SMR, testicular volume and masses, or irregularities of testes

Question 29

monitoring in gynecomastia

Answer 29

in absence of abnormalities on H&P, monitor for 12-18 months, do lab eval (thyroid, testosterone, estradiol, hcg, and LH) if patient is prepubertal, has mass, rapid breast enlargement, testicular mass, or gynecomastia persists after age 17

Question 30

testicular mass or lab results suggesting possible tumor , what should you do?

Answer 30

testicular US, may need adrenal or brain imaging

Question 31

gynecomastia differential diagnosis

Answer 31

gynecomastia may be drug induced or related to testicular, adrenal, and pituitary tumors, klinefelter syndrome, secondary hypogonadism, partial or complete androgen insensitivity syndrome, hyperthyroidism, cystic fibrosis, ulcerative colitis, liver disease, renal failure, AIDS. breast cancer extremely rare

Question 32

drugs that induce gynecomastia

Answer 32

antiandrogens (finasteride, ketoconazole, spironolactone), antineoplastics (cyclosporine, alkylating agents), antiulcers (reglan, omeprazole, ranitidine, cimetidine), heart drugs (amiodarone, ACE inhibitors, CCBs, digitoxin), abuse drugs (alcohol, amphetamines, weed, opiates), hormones (anabolic androgenic steroids, testosterone, estrogen, chorionic gonadotropin), infectious agents (antiretrovirals, isoniazid, flagyl), and psychoactive meds (diazepam, tricyclics, haldol, atypicals, phenothiazines)

Question 33

gynecomastia tx

Answer 33

idiopathic: reassurance that findings benign, explain resolution may take 2 years. Surgery needed for those whose with severe persistent enlargement and/or significant physiological trauma. IF drug induced, discontinue drug if possible, if pathological refer to endocrinologist

Question 34

indications for pelvic exam in adolescents

Answer 34

abdominal/pelvic pain, abdominal/pelvic mas, abnormal vaginal bleeding, menstrual disorders, pathologic vaginal discharge, need for cervical cytology screening.

Question 35

When to start Paps in adolesence

Answer 35

age 21 regardless of sexual experience, cotesting for HPV not recommended until age 30

Question 36

Pap after HIV diagnosis

Answer 36

every 6 months (twice) for 1st year (even under age 21), if both normal, do paps annually after

Question 37

primary amenorrhea

Answer 37

no menstrual period or secondary sex characteristics by age 13 or no menses in presence of secondary sex characteristics by age 15.

Question 38

secondary amenorrhea

Answer 38

absence of menses after menarche for 3 consecutive cycles or for 6 months in pt with irregular cycles.