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Womens Health Exam 1 > Breast Disorders > Flashcards

Breast Disorders Flashcards

1
Q

Tissues of the breast

A

Consists of glandular tissue, fibrous
stroma, and adipose tissue

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2
Q

The parenchyma of the breast contains _____

A

the mammary lobules, which produces milk, delivered to an opening of the nipple via the lactiferous ducts

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3
Q

The breast has two main physiologic functions:

A

Maternal and Sexual.
○ Maternal: The primary purpose is to secrete milk for breastfeeding
○ Sexual: The breast also plays an essential role in female sexuality

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4
Q

At puberty, the significant increase in circulating _____ in female individuals results in breast development

A

Estrogens and growth hormones

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5
Q

Estrogen function in breast development

A

○ Estrogens are responsible for initiating breast growth and resultant
external appearance of mature female breasts.
○ Estrogens cause 1) development of the stromal tissues of the breast, 2)
growth of an extensive ductal system, and 3) deposition of fat.

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6
Q

Progesterone function in breast development

A

○ Progesterone contributes significantly to the development of the
mammary lobules and alveolar cells of the breasts

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7
Q

Premenstrual phase breast changes

A

● In the premenstrual phase, as Estrogen levels increase biphasically and Progesterone levels increase, the lobules increase in size, the ductal lumens widen, and the breasts increase in size and
blood flow

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8
Q

If fertilization and implantation do not occur, what breast changes occur?

A

Progesterone levels fall and then
menstruation occurs.
○ Estrogen and Progesterone levels are at their lowest at this point, and there is a
reduction in the size of the lobules, ducts, and overall breasts

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9
Q

Pregnancy induces what changes to the breast?

A

● During pregnancy, extreme
amounts of Estrogen cause, among
other things, enlargement of the
breasts and growth of the ductal
structures in the parenchyma
● Extreme amounts of Progesterone
acts synergistically with Estrogen to
cause additional growth of lobules
and budding of secretory alveoli.

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10
Q

Although the extreme amounts of Estrogen and Progesterone during pregnancy
cause significant preparations of the breasts for lactation, a special effect of both
these hormones inhibits _____

A

actual secretion of milk

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11
Q

What hormone promotes secretion of milk after birth & drops in what hormones allow this to occur?

A

● Immediately after birth (parturition), the
levels of Estrogen and Progesterone
immediately drop, which allows the
lactogenic effect of Prolactin to kick in

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12
Q

When is prolactin produced during pregnancy?

A

Prolactin promotes secretion of milk and is released from the Anterior Pituitary in
increasing amounts from the 5th week of pregnancy until birth of the infant.

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13
Q

What does infant sucking cause in the breasts?

A

The sucking stimulates a neurogenic and
hormonal reflex that releases Oxytocin from
the posterior pituitary, which then triggers
milk “let-down” or “ejection.”

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14
Q

What initiates milk “let down”?

A

The sucking stimulates a neurogenic and
hormonal reflex that releases Oxytocin from the posterior pituitary, which then triggers milk “let-down” or “ejection.”

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15
Q

In later stages of life, especially after menopause, what breast changes occur?

A

the breasts undergo a significant regression in size secondary to the drop in circulating Estrogens

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16
Q

When a nonpregnant, nonlactating patient presents with concerns of nipple
discharge, there are several important factors to consider

A

○ Nature of discharge (serous, bloody, milky, other)
○ Association with or without a mass
○ Unilateral or bilateral
○ Discharge that is spontaneous, persistent or intermittent, or must be expressed manually
○ Discharge produced by pressure at a single site or by general pressure on the
breast
○ Relation to menstrual cycle
○ Premenopausal or postmenopausal
○ History of estrogen replacement for postmenopausal symptoms

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17
Q

Spontaneous, unilateral, serous or serosanguineous discharge from a single duct is usually caused by

A

■ Duct ectasia (benign widening of milk ducts, often near menopause, or
associated with Fibrocystic Changes)
■ Intraductal papilloma (a benign tumor of the milk duct)
■ Intraductal cancer (rare)

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18
Q

Bloody discharge is suggestive of _____

A

cancer but is more often associated with a benign Papilloma in the duct

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19
Q

In premenopausal females, spontaneous multiple duct discharge (unilateral or
bilateral), most noticeable right before menstruation, is often due to _____

A

Fibrocystic Breast Changes (condition discussed later).

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20
Q

A milky discharge from multiple ducts in the nonlactating breast (also called
Galactorrhea) may occur secondary to _____

A

Hyperprolactemia

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21
Q

Galactorrhea

A

Galactorrhea is a type of physiologic discharge from one or (usually) both
nipples that resembles breast milk, but is occuring in an individual who is not
actively lactating

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22
Q

The most common cause of Galactorrhea is ______

A

hyperprolactinemia due to a
prolactinoma (prolactin-secreting pituitary adenoma).

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23
Q

Other potential causes of Galactorrhea:

A

○ Endocrine disorders (hypothyroidism, Cushing’s Disease)
○ Medications (antipsychotics, antidepressants, estrogens, verapamil, etc.)
○ Chronic renal failure
○ Menarche and menopause (brief, transient)
○ Head trauma

24
Q

A large prolactinoma can potentially cause loss of ______

A

peripheral vision (also
known as Bitemporal Hemianopsia)

25
Q

Lab evaluation for galactorrhea

A

Lab evaluation should include pregnancy testing, serum Prolactin levels, renal function tests, thyroid function tests, and appropriate endocrinological follow-up

26
Q

If prolactin levels are elevated and a possible prolactinoma is suspected,
______ should occur to look for the pituitary mass

A

imaging of the brain (preferably MRI)

27
Q

Prolactinomas are commonly treated with a ______

A

Dopamine Agonist medication,
such as Bromocriptine

28
Q

Gynecomastia

A

● Gynecomastia is defined as the presence of palpable glandular breast tissue
in male individuals.
● Relatively common and its incidence is increasing in all age groups.
● Pubertal Gynecomastia develops in 60% of teenage males, more commonly
among those who are overweight.
● About 20% of adult Gynecomastia is caused by drug therapy.

29
Q

Signs and Symptoms of Gynecomastia

A

○ Palpable enlargement of the male breast, often asymmetric or unilateral.
Gynecomastia WH-BD-5,8
○ Palpation of the breast tissue, both
seated and supine, helps distinguish
glandular from fatty deposition.
○ True glandular Gynecomastia is more
firm and often tender.
○ Fatty Pseudogynecomastia is soft,
diffuse, and nontender

30
Q

Laboratory tests to obtain for Gynecomastia

A

■ Total and free Testosterone
■ LH and FSH
■ TSH and fT4
■ Prolactin
■ Liver function tests
■ BUN and Creatinine
■ Beta-hCG
■ Estradiol

31
Q

What should you do with gynecomastia Patients with high serum hCG or Estradiol?

A

○ Patients with high serum hCG or Estradiol levels should have the test repeated.
■ Confirmed increased levels warrant a testicular ultrasound

32
Q

Investigation of unclear or unilateral gynecomastia cases should
include _____

A

bilateral mammogram
○ A chest CT should also be obtained to look for
bronchogenic or metastasis.
○ Suspicious mammogram or CT findings should
prompt ultrasound-guided biopsy to confidently
rule out malignancy

33
Q

Treatment of gynecomastia

A

○ If secondary to a medication, such as Spironolactone, the condition generally
resolves or improves within months after discontinuation.
○ Treatment of hypogonadism with testosterone may or may not help.
○ Selective estrogen receptor modulator (SERM) therapy can be effective for true
glandular gynecomastia (Raloxifene).
Gynecomastia WH-BD-5,8
○ Obviously, if cancer is discovered, treatment should be focused on the cancer.
○ Severe cases of Gynecomastia can be treated by experienced plastic surgeons.

34
Q

Mastitis

A

● Mastitis is cellulitis of the breast, and is almost always due to infection.
● Most commonly, Mastitis occurs in lactating females, usually within weeks of
delivery and initiation of nursing

35
Q

Etiology of mastitis

A

○ Staph aureus is the most common pathogen.
○ Less commonly Strep or (rarely) E coli.

36
Q

Signs and Symptoms of mastitis

A

○ Starts with an engorged and tender
breast.
○ Cellulitis is typically unilateral with the
affected area of breast being red, tender,
and warm.
○ A sore or fissured nipple is also common.
○ Fever and chills are common.
○ Females nursing for the first time and
those with difficulty breastfeeding appear
to be at greatest risk

37
Q

Mastitis diagnostic evaluation

A

○ Considered a clinical diagnosis, diagnosis can be made based on H&P.
○ If there is concern for possible abscess, a quick ultrasound provides a clear image of the breast tissue and may be helpful
○ Rarely, inflammatory carcinoma of the breast can be mistaken for mastitis. In this case, the patient would not respond quickly to antibiotics and that should initiate further work-up

38
Q

Treatment/Clinical Management

A

○ Treatment consists of broad-spectrum antibiotics for 10-14 days.
■ First-line options: Dicloxacillin or a Cephalosporin.
■ Reasonable alternatives: Augmentin or Clindamycin.
○ The patient should also regularly empty the breast by nursing or
pumping. There is no need to waste the milk
○ Failure to respond to antibiotics within 3 days may represent an abscess
or infection with a resistant organism. Re-evaluation is needed.
○ Acetaminophen and/or NSAIDs can be used for pain and fever

39
Q

Is the breast milk from mastitis safe for the infant?

A

Yes
○ The patient should also regularly empty the breast by nursing or
pumping. There is no need to waste the milk.
■ Although nursing from the infected breast is safe for the infant, local
inflammation of the nipple may complicate latching

40
Q

Non-Lactating Mastitis

A

○ Mastitis can occur, although quite rare, in females who are not lactating
or are even postmenopausal.
■ This is usually considered Subareolar Mastitis due to chronic duct
inflammation. Could be due to E Coli, Group D Strep, or Staph.
○ Neonatal Mastitis is very uncommon and can occur in male or female
babies within weeks of birth

41
Q

Breast Abscess

A

● Breast Abscess is an uncommon
complication of infectious Mastitis.
● In Breast Abscess, a fluid collection
of pus develops within the breast
tissue, within the region of cellulitis

42
Q

Examination of a breast abscess

A

● Examination is similar to simple
Mastitis, although a palpable and fluctuant mass may also be appreciated (not always)
● In cases of Mastitis when Breast Abscess is possible, point-of-care Ultrasound can be particularly helpful in identifying or ruling out abscess

43
Q

Breast Abscess Treatment

A

● Often needle or catheter drainage is adequate to treat an abscess, but
surgical incision and drainage (I&D) may be necessary.
○ Obtain an urgent General Surgery consultation.

44
Q

As stated with Mastitis - In the nonlactating breast, _____
must always be considered

A

inflammatory carcinoma

45
Q

Fibrocystic Changes

A

Characterized by painful breast masses, Fibrocystic Changes/Condition is the
most frequent lesion of the breast.
○ Sometimes called “Fibrocystic Breast Disease,” although this is not
entirely accurate - Not actually a pathologic disorder.
● Common in females 30-50 years of age

46
Q

Common in females 30-50 years of age

A

Fibrocystic Changes

47
Q

Etiology of Fibrocystic Changes

A

○ Fibrocystic Condition is a broad diagnosis that encompasses a variety of
histologic changes of the breast tissue that are benign.
■ These changes are so commonly found in healthy breasts, suggesting
they are likely variants of normal.

48
Q

Signs and Symptoms of Fibrocystic Changes

A

○ Patients most commonly present with concerns of pain and tenderness
of one or both breasts.
○ Less common, accidental or incidental discovery of an asymptomatic breast mass may be the initial presentation.
○ Pain and tenderness generally occurs or worsens in the premenstrual phase of the cycle, and the breasts may enlarge as well.
○ Fluctuation in size and/or rapid appearance or disappearance of breast
mass(es) are common - frequently multiple masses or bilateral masses.

49
Q

Fibrocystic Changes diagnostic evaluation

A

○ Initial workup of the mass(es) should include Diagnostic Mammogram
AND a Breast Ultrasound
○ Ultrasound is quite useful for differentiating cysts from solid masses.
○ Potentially suspicious-looking lesions on imaging should be biopsied, as imaging alone cannot fully exclude malignancy.
■ Core needle biopsy is preferred over fine needle aspiration

50
Q

Fibrocystic Changes Treatment

A

○ Simple cysts are not worrisome and require no treatment or follow-up unless
they are symptomatic and causing pain, in which case they may be aspirated.
■ Generally done under ultrasound guidance by interventional radiology.
Fibrocystic Changes
○ The most significant treatment for Fibrocystic Condition is to avoid trauma and to wear a properly fitted, well supporting bra both day and night.
■ Provides significant relief for about 85% of patients.
○ NSAIDs and Acetaminophen are frequently prescribed, but most patients report little benefit and the evidence does not suggest their use.
○ Topical NSAIDs are commonly recommended, such as topical Diclofenac, and some sources suggest benefit, while other sources report little value
○ Oral Oil of Evening Primrose (a natural gamolenic acid) has been shown to
reduce pain in 44-58% of patients using it.
○ A low-fat diet has also been shown to be beneficial in reducing symptoms
○ Danazol is a synthetic androgen that can be used, but should only be used in
patients with severe pain unrelieved by other means

51
Q

Fibroadenoma

A

● A Fibroadenoma is considered a benign neoplasm of the breast.
● It occurs most frequently in younger females, generally within 20 years after
puberty (usually under 35 years of age).

52
Q

Fibroadenoma Signs and Symptoms

A

○ A nontender breast lump is generally the only symptom.
○ Generally discovered accidentally or incidentally.
○ On exam, the lump is usually round or ovoid, rubbery, generally discrete,
relatively movable, nontender, and 1-5 cm in size

53
Q

Fibroadenoma diagnosis

A

○ Diagnostic Mammogram and Breast Ultrasound are imaging of choice.
■ However, if patient is under 30, may consider US only.
○ Imaging generally reveals well-defined solid masses with benign features.
○ Definitive diagnosis can only be confirmed with a core biopsy or excision

54
Q

Distinguishing between a large fibroadenoma and a
phyllodes tumor requires _____

A

histologic examination after
excision

55
Q

Presumed fibroadenomas larger than ____ cm should be excised to rule out Phyllodes tumors

A

3–4

56
Q

Fibroadenoma treatment

A

○ No treatment is usually required if diagnosis is established with tissue.
Fibroadenoma
○ Short term follow-up (3-6 months) with repeat
US is reasonable to confirm stability and provide
the patient with reassurance.
○ Evidence suggests reassurance seems preferable
to treatment, but treatment can include
lumpectomy or cryoablation

57
Q

Breast augmentation is performed in one of two ways:

A

○ Placing implants under the pectoralis muscle (preferred method), or
○ Placing implants in the subcutaneous tissue of the breast

Womens Health Exam 1 (7 decks)

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