CH 8 Female MDT Flashcards
Fibrocystic condition
Painful breast masses are often:
Multiple and bilateral
Fibrocystic condition
Pain often worsens during:
Premenstrual phase of the cycle
Fibrocystic condition
What is considered a causative factor?
Estrogen
Fibrocystic condition
Increased risk in women who:
Drink alcohol
Most frequent lesion of the breast
Most common age is 30-50
Fibrocystic condition
Symptoms:
- Breast pain or tenderness
- Discomfort worsens during premenstrual cycle
- Fluctuation in size of masses
- Multiple or bilateral
- No lymphadenopathy
Fibrocystic condition
Imaging for fibrocystic condition
Mammography
U/S (Used alone when patient is <30 y/o)
Diagnostic testing for fibrocystic changes
Core needle biopsy
All suspicious lesions should be biopsied by a:
General Surgeon
Treatment for mild to moderate discomfort from fibrocystic changes
NSAIDs
Patient education for fibrocystic changes
Avoid Trauma
Wear supportive bra night and day
Decreasing dietary fat intake
Consider eliminating caffeine
Vitamin E, 400IU Daily
Monthly self exam just after menstruation
Common benign neoplasm occurs most frequently in young women
Usually within 20 years after puberty
Fibroadenoma
Symptoms:
- Round/Ovoid
- Rubbery
- Discrete
- Relatively moveable
- Nontender mass 1-5 cm in diameter
Fibroadenoma
Imaging for Fibroadenoma
U/S
All breast masses should be referred to _________ for further evaluation and work up
General Surgery
Breast mass
Biopsy is negative, what is the next step of treatment?
No treatment is necessary
What may be necessary for large or rapidly growing fibroadenomas?
- Larger than 3-4 cm
- Rule out phyllodes tumor
Excision
Lesion of the breast
Produces a mass
Commonly seen after breast surgery/injections or trauma
Fat necrosis
Fat necrosis if untreated
Gradually disappears
Safest course when dealing with Fat necrosis
Biopsy
Fat necrosis is common after:
Segmental resection
Radiation therapy
Flap reconstruction after mastectomy
MVA
Assault
Female breast carcinoma
__ in eight American women
_____ most common cancer in women
_____ leading cause of cancer death
One
Second
Second
What is the most significant risk factor for female breast carcinoma?
Age
Risk rises rapidly until early 60’s, peaks in 70’s, then declines
Female breast carcinoma
Reproductive history associated with female breast carcinoma
Nulliparous or late first pregnancy (after age 30)
Menstrual history associated with female breast cancer
Early menarche (under 12)
Late menopause (after 55)
Most reliable means of detecting breast cancer before a mass can be palpated
Mammography
Most slow growing cancers can be identified by mammography at least ___ years before they are palpable
2 years
Mammography screening for women age 40-49
Shared decision making with patient
Suggested every 2 years
Mammography screening for women age 50-74
Every 2 years
Mammography screening age 75 and older
Only recommended if life expectancy is greater than 10 years
Imaging for High Risk female breast carcinoma patients
MRI
U/S
Female Breast Carcinoma
__% of patients with a (usually) painless lump
__% discovered by the patient
70%
90%
Rare symptoms associated with female breast carcinoma
Axillary mass or swelling
Back or joint pain
Jaundice
Weight loss
Signs
- Single, nontender, firm to hard mass with ILL-DEFINED margins
- Mammographic abnormalities and no palpable mass
Female breast carcinoma EARLY SIGNS
Signs:
- Skin or nipple retraction
- Axillary lymphadenopathy
- Breast enlargement, erythema, edema, pain
- Fixation of mass to skin or chest wall
Female breast carcinoma LATE SIGNS
Laboratory findings associated with female breast carcinoma
Increase Alkaline Phosphatase
Increase Serum Calcium
Imaging for female breast carcinoma
Mammography
U/S
MRI
Diagnostic procedure of choice in both palpable and image detected abnormalities
Core needle biopsy
Treatment for female breast cancer
Surgical resection (Mastectomy)
Radiation
Systemic Therapy (Chemo, Targeted, Bisphosphonates)
Most reliable indication of female breast carcinoma prognosis
Stage of cancer
Female Breast Carcinoma
Recurrences occur most frequently within the first ___ years
2-5 years
Female breast carcinoma
Patients are examined every 6 months for the first:
2 years
Female breast carcinoma
Patients are examined annually after:
2 years (first 2 years is every 6 mo)
A new primary breast malignancy will develop in ___% of patients
20-25%
If female breast carcinoma is metastatic, it will travel to:
Bone
Liver
Lungs
Brain
Incidence is only 1% of all breast cancer
Male breast carcinoma
Male breast carcinoma
Average age occurrence is:
70
What increases the risk of men with breast cancer?
- Prostate cancer
- First degree relatives of men with breast cancer
- BRCA 2 mutation
Signs:
- Male patient usually presents with a painless lump
- Hard, ill defined, nontender mass beneath the nipple or areola
- Gynecomastia
Male breast carcinoma
Imaging for male breast carcinoma
Mammography
U/S
Treatment for male breast carcinoma
Modified radical mastectomy
Radiation
Adjuvant systemic therapy
Prognosis for 5 year survival
- Node negative disease __%
- Node positive disease __%
Positive 88%
Negative 69%
Serous nipple discharge most likely suggests
Benign fibrocystic changes (FCC)
Bloody nipple discharge most likely suggests
Neoplastic papilloma
Carcinoma
Nipple discharge
If there is bloody discharge, the bloody duct and mass if present should be:
Excised
Nipple discharge with an associated mass more likely suggests:
Neoplasm
Bilateral nipple discharge is most likely:
Non-neoplastic (Endocrine etiology)
Common causes of Nipple Discharge in non-lactating women
Duct ectasia (FCC)
Intraductal papilloma (FCC)
Carcinoma
Milky discharge in the non-lactating woman may occur from:
Hyperprolactinemia
Nipple discharge
What lab levels are used to rule out pituitary tumor?
Serum prolactin levels
What class drugs can cause elevated prolactin levels which lead to lactation in men and women?
Antipsychotic
Nipple discharge
Oral contraceptives or estrogen replacement may cause what type of discharge?
Clear, serous or milky discharge
Nipple Discharge
Purulent discharge is associated with:
Breast Abscess
Labs for nipple discharge
Cytological evaluation of discharge
Imaging for nipple discharge when localized is not possible or in the absence of a palpable mass
Mammography
U/S
Treatment for Nipple Discharge
Refer to a breast clinic, OB/GYN, or General Surgery
Most discharge is ______ especially if bilateral
Benign
Follow up for a patient with nipple discharge if there are no signs of malignancy
Re-examined every 3-4 months
Normal menstrual bleeding lasts an average of:
5 days
Range of days for normal menstrual bleeding:
2-7 days
Mean blood loss per menstrual cycle is:
40 ml
Blood loss over 80 ml
Menorrhagia
Bleeding between periods
Metrorrhagia
Bleeding that occurs more often than every 21 days
Polymenorrhea
Bleeding that occurs less frequently than every 35 days
Oligomenorrhea
Classifications of descriptive terms denoting the bleeding pattern
Heavy
Light
Menstrual
Intermenstrual
Etiologies of Abnormal Uterine Bleeding
PALM-COEIN
Polyp Adenomyosis Leiomyoma Malignancy Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not yet classified
Structural etiologies of AUB
Polyp
Adenomyosis
Leiomyoma
Malignancy
In adolescents AUB is usually from:
Anovulation (not ovulating)
AUB-O
AUB from ovulatory dysfunction
Once regular menses is established, what is the most common cause of AUB?
AUB-O
AUB in women 19-39 is often the result of:
Pregnancy
Structural lesions
Anovulatory cycles
Hormonal contraceptives
Endometrial hyperplasia
AUB
Depending on the amount of blood, you could have signs of:
Anemia
AUB diagnosis depends on:
History of duration and amount of flow, associated pain, relationship to LMP
History of present illnesses
History of medications
History of coagulation disorders
Complete physical exam
Pelvic Exam
Labs for AUB
CBC
HCG
Thyroid function tests
Coagulation studies
Gonorrhea and chlamydia
Pap Smear
Endometrial Sampling
Imaging for AUB
Transvaginal US
Sonohysterography or Hysteroscopy
Treatment for AUB
ALL patients should:
Refer to OB-GYN
AUB can be secondary to:
Submucosal myomas
Infection
Early abortion
Thrombophilia
Pelvic neoplasm
AUB Treatment
Progestin (to oppose estrogen)
NSAIDs
AUB can cause:
Anemia
Infertility
Postmenopausal bleeding is _______ until proven otherwise
Cancer
Important tool in evaluating the etiology of bleeding
Transvaginal ultrasound measurement of the endometrium
Recurrent variable cluster of troublesome physical and emotional symptoms that develop during the 5 days before the onset of menses and subsides within 4 days after menstruation occurs
Premenstrual syndrome (PMS)
When emotional or mood symptoms predominate along with the physical symptoms and there is a clear junctional impairment with work or personal relationship
Premenstrual dysphoric disorder (PMDD)
PMS
Intermittently affects ___% of premenopausal women
40%
PMS primarily affects what age range?
25-40
PMS
__% symptoms are severe
5-8%
Signs/Symptoms
-Bloating, breast pain, ankle swelling, sense of increased weight, skin disorders, irritability, aggressiveness, depression, inability to concentration, libido change, lethargy, food cravings
PMS
PMS
Work up for the patient includes
Support for both emotional and physical distress
Daily diary of all symptoms for 2-3 months
-Record severity of problems
PMS
If symptoms occur throughout the month rather in the two weeks before menses, she may have:
Depression or other mental health disorders
Treatment for mild to moderate PMS
Aerobic exercise
Reduction of caffeine, salt and alcohol
Increase Calcium (1200mg/day)
Vitamin D or magnesium
Increase complex carbohydrates
Alternative therapies (acupuncture/herbal)
Medications for PMS
Hormonal contraceptives
When mood symptoms predominate, what has been shown to be effective in relieving tension, irritability, and dysphoria?
SSRIs (Antidepressants)
SSRIs are contraindicated in:
Patients taken MOAI in the past 2 weeks
Results from:
- Pathogens
- Allergic Reactions
- Vaginal Atrophy
- Friction during coitus
Vaginitis
History taking for Vaginitis should include
Onset of LMP
Recent sexual activity (use of products)
Contraceptives, tampons, or douches
Changes in medications or use in antibiotics
Signs/Symptoms:
- Vaginal irritation
- Pain
- Unusual or malodorous DISCHARGE
- Bimanual exam shows inflammation, cervical motion tenderness, adnexal tenderness
Vaginitis
What predisposes patients to Candida infections?
Pregnancy
Diabetes
Antibiotics
Corticosteroids
Heat, moisture, occlusive clothing
Pruritus, vulvovaginal erythema, white curd-like discharge that is not malodorous
Vulvovaginal Candidiasis (Yeast infection)
Sexually transmitted protozoal flagellate
Trichomonas
Pruritus and a malodorous frothy, yellow-green discharge occur, along with diffuse vaginal erythema
Strawberry Cervix
Trichomonas
Polymicrobial disease that is not sexually transmitted, chronic in nature
Overgrowth of Gardnerella and other anaerobes
Increased malodorous discharge without obvious vulvitis or vaginitis
Bacterial Vaginosis (BV)
Labs for Vaginitis
KOH
Wet Prep
NAAT urine testing
Vaginal pH
Vaginitis KOH
Branched hyphae and budding yeast in:
Candidiasis
Vaginitis KOH
Positive whiff test (amine or fishy odor)
BV
Vaginitis Wet Prep
Motile flagella is found in:
Trichomonas
Vaginitis Wet prep
Clue cells is found in:
BV
NAAT urine testing is for:
Chlamydia and gonorrhea
Vaginal ph
Frequently greater than 4.5 in:
Trichomonas
BV
Treatment for vulvovaginal candidiasis
Fluconazole
150mg tab
Treatment for Trichomonas
Metronidazole
2g PO x1
500mg BID x7
TREAT BOTH PARTNERS
Treatment for BV
Metronidazole 500mg BID x7 days
Clindamycin vaginal cream 2%, 5g once daily x7 days
Treatment for Chlamydia
Doxycycline
100mg BID x 7 days
Treatment for Gonorrhea
Ceftriaxone
500 mg IM x 1 dose
What may cause the Bartholin duct to be obstructed?
Trauma or infection
Bartholin gland infection usually:
Resolves
Pain disappears
Signs/Symptoms
- Periodic painful swelling on either side of the introitus
- Dyspareunia
- Fluctuant swelling 1-4 cm in diameter later to either labium minus
- Tenderness is evident of active infection
Bartholin’s Gland Abscess
Labs for Bartholin’s Gland Abscess
Culture of drainage
- Chlamydia
- Gonorrhea
- Other pathogens
Treatment for Bartholin’s Gland Abscess
Manual aspiration or incision and drainage of abscess
Antibiotics if STI is suspected
Warm Soaks
Marsupialization (OB/GYN)
Bartholin’s Gland Abscess
Women under ___ years of age, asymptomatic cysts do not require therapy unless they’re large or cause problems with intercourse
Under 40
Bartholin’s Gland Abscess
Women over age __, biopsy or removal are recommended to rule out vulvar carcinoma
Over 40
Cervical dysplasia starts in _____ because of hormonal changes and pH of tissue
Puberty
Infection with HPV may lead to cellular abnormalities. Over a period of time this can lead to:
Cervical dysplasia or Cancer
All atypia (abnormal cells) must be observed and treated if:
Persistent or worsening
CIN
Cervical Intraepithelial Neoplasia (CIN)
Cervical dysplasia presumptive diagnosis is made by an ________ of an asymptomatic woman with no grossly visible cervical changes
Abnormal PAP smear
All visible abnormal cervical lesions should be referred to:
OB/GYN for biopsy and therapy
In immunocompetent women, cervical cancer screening should begin at age:
21
USPSTF recommends screening for cervical cancer in women aged 21-65 with cytology every ___ years
Or, 30-65 screening with a combination of cytology and HPV every __ years
3 years
5 years
Cervical cancer with HPV testing, alone or in combination with cytology in women younger than age 30 is not recommended because:
HPV can “go away” in younger women
USPSTF recommends against cervical cancer screening for women older than age ___ with no prior history
65
What puts you at a greater risk for Cervical Intraepithelial Neoplasm (CIN)?
HIV
Immunosuppression
Exposure to diethylstilbestrol (DES) in utero
Previous treatment for CIN 2, CIN 3, or cervical cancer
Diagnosis for Cervical Dysplasia is made by:
Papanicolaou Smear
Colposcopy
Biopsy
Diagnostic procedure with a colposcope, dissecting microscope with various magnification lenses, used to provide an illuminated, magnified view of the cervix, vagina, vulva, or anus
Colposcopy
Women with Atypical squamous cells of unknown significance (ASC-US) with a negative HPV must be followed up in _____ for a repeat Pap smear and HPV co-testing
1 year
