Endo Repro Wooten Flashcards
Pap smears, cervical dysplasia and such
Ok
Incidence cervical cancer
Decreased 50%
13000 new cases each year and 4000 deaths
4th most common cancer
Cervical area vulnerable
Squamocolumnar junction
Between columnar and start nonkeratinized squamous epithelial
Colposcopy
Look with microscope
Little
Inside cervis
Nullpaous
Outside
Multiparous
More toward outside
Postmenopausal
Inside cervix
Transformation zone
Changes
How many high risk HPV
15
What are high risk
16, 18, 31, and 45
Risk factors HPV progress
Multiple sexual partners with multiple sex partner Yong age first intercourse preg Smoking** Organ transplant DES High parity HIV STD-alter transformation zone Lower socioeconomic status NO PAP TEST_people with bad paps. Had last baby and get busy —ppl with long periods of time between screening
If abnormal pap and smoke
Stop! Will help
Who needs pap and when
21 start
21-29 cytology every three years (if abnormal look for virus)
30-65pap every three yards or HPV and pap every five years
65 older stop unless risk if negative prior screening
19 yo maternal grandma cervical (NOT HEREEDITARY) smokes . What risk factor. Does she need pap
Smoking stop.
No doesn’t need one she’s not 21
40 yo african American female no complaints . No prob. Hemochromatosis from dad. Normal pap and negative HPV last year. When does she need next one ? If HPV status unknown when do next one (just had cytology)
5 years from then
Three years
Bethesda system
Tells specimen type or specimen adequacy (unsatisfactory if not enough cells or satisfactory) then general categorization (negative, epithelial cell abnormality, other-see interpretation result like endometrial cells ina woman older than 40-if endometrial cells have period or can be cancer)
Colposcopy
Gold standard for treatment and diagnosis
Use microscope
Cervix is washed with acetic acid cells turn bright white when looking at them
Looking for white cells to see changes with 3% acetic acid
Adequate colposcopy
Have to see entire squamocolumnar junction
Aceto white changes (just a bt abnormal)
Punctuations-little blood vessels coming out
Mosaicism-little tiles white tiles
Abnormal vessels-MORE WORRIES
MASS-cancer end point
Then what
Directed biopsy
Always take sample from inside cervix too caus cant see in there
What get from path with thess
Pathology CIN123 CIS and cancer
Negative
Normal to maybe inflammatory
CIN1 and 2 low grade see LSIL HSIL
High grade CIN2-3 see HSIL
for cancer see squamous cell carcinoma
This secondary biopsy test good to see what do
34 Asian female abnormal pap positive high risk HPV what is next step. She is inquiring about HPV vaccine. What advise her
Colposcopy this age group
HPV vaccine up to 46, the 9 valentine cover 9 most common types so if have two can protect from other 7 the more strains you have more activity of cervix
Treatment
Ablative(not common now dont know what cells are not)-destroy cervical tissue, cryotherapy, laser ablation
Excisional take tissue now do it
-cold knife cone, loop electrode excisional procedure , curretage
Risk of excisional procedure
Cervical incompetence-preg so get second trimester loss
Increased risk preterm premature rupture of membranes
Cervical stenosis
Bleeding infection
Cervical carcinoma
4% death rate
47 diagnosis
90% from HPV
- 80% squamous cell carcinoma
- 15% adenocarcinoma/adenosquamous
Symptoms cervical cancer
Posit cordial bleeding
Watery vaginal bleeding, spotting
How cervical cancer spreads
Lymphatic and direct invasion
Staged cervical carcinoma
Clinically
Manage cervical cancer
Microinvasive-cone , hysterectomy
Invasive-radical hysterectomy with lymph node dissection
Bulky disease-radical hysterectomy with lymph node direction or radiation therapy and cisplastin based chemotherapy
Stage IIb and greater-external beam radiation and concurrent cisplastin based chemotherapy
Prevent cervical cancer
Sex no
Use of barrier protection
Regular exams and paps
HPV vaccine
HPV vaccine
3 doses
1 2 months 2nd third dose 6 months
Routine 2 dose if less than 15
Mean and women
27-45
Can get HPV if have abnormal pap
Yup
Pregnant and HPV vaccine
No but breast feeding fine
Gardasil
6, 11, 16, 18
9 strain
6, 11, 16, 18, 31, 33, 45, 52, 58
Side effects HPV vaccine
Syncope
HA, N, fever, injection site pain
52 yo gp3p 6 month daily vaginal bleeding worse after intercourse . Smokes,
Cervical cancer
Do biopsy
Risk factors-smoking, hasn’t been screened in long time, multiparous,
What percent of pregnancies are unplanned
50%
Methods of birth control
Inhibit formation and release of egg
Barrier between sperm and egg
Typical failure rate
Rate when the methods is actually used by patient
Method failure
Rate of failure if used correctly
Most effective reversible contraception
Hormonal
Kinds of hormonal
Oral contraceptive
Injectable-depo
Implantable-etonogestrel rod implant
Hormone contain IUS
Contraceptive patches (orthoevra)
Contraceptive ring (nova ring)
Oral contraception
Suppress HPA GnRH and LH and FSH
Stop feedback
Progesterone-suppresses LH and ovulation, thickens cervical mucus , creates hostile uterine env
Estrogen-improve cycle control
Monophonic triphasic
Triphasic-change amount every week
Monophonic pills-same , less side effects
21 days active hormone7 days placebo, but now 24 days and 4 days for lighter period
Continuous regimens every 3 month or 6 month cycle of never
-get nice constant state , safe not harming
Progestin only
Cervical mucous thick mainly
Ovulation in 40% continue
Mainly for breastfeeding or contraindication for estrogen -if give estrogen can decrease supply
Note about progestin
Same time every day starting on first day of menses (if more than 3 hours late should use backup)
Not the msot efficacious
Benefits of hormonal
Men’s trail cycle regularity
Improve dysmenorrhea
Crease risk of iron defiency anemia
Lower incidence of endometrial and ovarian cancers, benign breast and ovarian disease
AE
Breakthrough bleeding at beginning
Amenorrhea
Bloating, weight gain, breast tenderness, n, fatigue, HA
Venous thrombosis, pulmonary embolism, cholestatic and gallbladder, stroke MI, hepatic tumros—-have you or family ever had blood clot, MI, stroke, family history self history, migraine with aura greater risk for stroke contraindication
Transdermal patch
E and p
Weekly for 3 weeks and 1 week without patch
Caution in fat girl no over 198
Same ae as oral contraception, except GREATER RISK OF THROMBOSIS
Vaginal ring
E and p
Insert into vagina for 3 weeks-people forget
Can be removed for up to 3 hours without affecting efficacy
Better tolerated since not going through GI tract and less breakthrough bleeding
Who cant use combination birth control pills
Women over 35 who smoke
History of thromboembolic event (personal-if have family history need to be checked for inherited thrombophlebitis)
Women with history of CAD, cerebral vascular disease, CHF or migraine with aura, uncontrolled HTN
DM, chronic HTN, systemic lupus erythematous is…individualized prescribing
Women with moderate to severe liver * disease or liver tumors
Injectable hormonal
Depo
How do it
IM injection 11-13 weeks
Maintains contraceptive level of progestin for 14 weeks
Give 1st day of period if not back up method for 2 weeks
Thickens cervical mucus, endometrium decidualization, blocks LH surge and ovulation
Efficacy is gooooood!!!!
Black box depo
Bone metabolism associated with decreased estrogen levels
Particular concern in adolescents
Reversible after discontinuation
After 2 years consider another optioN!!!!!!!!!!!!!!!!! Depo is low estrogen state
Side effects depo
Irregularly irregular bleeding
- decrease with use and can be amenorrhea
- short term estrogen add back can improve bleeding
- menses can take a year to regulate
Weight gain (progesterone makes us hungry), exacerbation of depression
If psychotic or suicidal
Don’t give dep
Indications for depo
Breast feeding Effective When e contraindicated Seizure disorder SS anemia Anemia secondary to menorrhagia Endometriosis Decrease risk of endometrial hyperplasia
Contraindication depo
Preg
Unevaluated vaginal bleeding
Malignancy breast-estrogen and progesterone positive breast c
Active thrombophlebitis, or current past history thromboembolic events or cerebral vascular disease
Liver dysfunction disease
Long acting reversible contraceptives (Larcs are great)
Implantable nexplanon
Implantable nexplanon
Single radiopaque, rod shaped implant containing 68 mg estpgestrel
Use for 3 years
-preferred to be inserted in first 5 days of menses and if not then use back up for 7 days after insertion
MOA nexplanon
Thickens cervical mucous
Inhibits ovulation
AE
Irregularly irregular vaginal bleeding HA Vaginitis Weight increase Acne Breast pain
Indications
Convient, efficacious can use in breast feeding
Contraindication
Preg
History thrombosis
Known suspected breast cancer
Complications
Infection, bruising, deep insertion, migration, persistent pain or paraesthesia at insertion sit
IUD
Copper T-non hormonal
Levonorgestrel releasing
- Mirene/liletta 5 years
- skyla/kyleena 3 years
Insert in office and 1-5% expulsion rate
Risk
Increased infection first 20 days (do test before to check(
Ectopic pregnancy
If pregnant remov eif strongs visible (decrease risk spontaneous abortion )
Risk of uterine perforation at time of insertion requiring laparoscopy for removal
Risk of malposition and necessitating hysteroscpy for removal
Contraindications IUD
Breast cancer-levonorgesterel containing only
Recent peurperal sepsis
Recent septic abortion
Active cervical infection
Wilson’s disease-copper T only
Uterine malformations (uterine septum’s/fibroids/significantly enlarged > 10cm)
Mirena/kyleena
5 years
Liletta
3 years
Skyla
3 years, designed originally for nulliparoid
Effectively IUD
Preg rate .2%
I want to get preg in three years
Let’s do liletta or skyla
I want a kid in ten years
Mirena/Kyla
Benefits leo
Keep watching
INTERLUDE PELVIC PAIN AND PROLAPSE THEN WE WILL GET BACK TO IT
Ok
Muscle
Lavator ani
Normal pelvic anatomy and pelvic support
Ok
Pelvic organ prolapse
Cystocele-anterior wall of vagina
Posterior wall of vagina-rectocele
Top of vagina -enterocele
50% parous or vaginal delivery
Have prolapse
Symptoms pelvic prolapse
Vaginal pressure heaviness, LBP, vaginal perineal pain, mass sensation, incontinence, anxiety , embarrassment
Prosendetia
Cervical prolapse
Risk factors
Perous 1 or more vagina birth
Genetic predisposition, menopause, age, CT disorder, pelvic surgery, elevated pressure(straining)
Anatomy
Levator ani, fascia , uterosacral and cardinal ligaments
Pop-q measures 6 points
0-no prolapse
1-leading prolapse 1 cm above hymen
2-leading prolapse less than or equal 1 cm above or below
III-1 cm beyond hymen but less than vaginal length
IIII complete
Symptomatic
Surgery or non
Pessaries
Device fit in as first line
Surgery
Hysterectomy cant just remove uterus need to do sacrospinal ligament suspension
Abdominal sacral colpopxey-complete obliteration of vaginal lumen
Urinary incontinence
Leak urine social clinical well being,
Stress
Increase intraabdominal pressure
Most common
25% 4-6 months after vaginal delivery
Urethral hypermobility -if loss of integrity of underling msucles, sphincter defiency
Treat stress
Kegel
Surgery-tension free vaginal tape,
Urge
Detrusor muscle overactivity
Volume increase but pressure in bladder low
Pressure rise and need to run to br frequently and urgently
Treat urge
Behavioral bladder aiming
Anticholinergic agents
Cystocele
Bladder form anterior wall
Cardinal ligament complex
Pubocervical fascia allow protrusion of the bladder , break speculum in half
Rectocele
Rectum pushed up on posterior
-could also be sigmoidocele enterocele
Enterocele
Bowel coming through
True hernia-only true hernia in vagina
True hernia
Peritoneum and abdominal contents
Apical prolapse
Level 1 defect can do down to opening
Vaginalis vault prolapse
Post hysterectomy
Cervic everts like a sock comes down
Urethrocele
Urethra lost support , usually birth trauma and comes in with tress incontinence …laugh cough sneeze, provocation
POPq
For how much prolapse
32 yo g4p4 pelvic pressure bulging sensation prolonged standing no urinary bowel complaints, no dysmenorrhea, sexually active husband BMI 46 , smoker, works in manufacturing .
What are risk factors.
One exam anterior bulging
- four kids, one big, straining and lifting a lot, obese, smoking, Caucasian and Asian more likely , someon ein family with marfan or erlos danlos, separation of aorta
- family history or personal history of stria or joint hypermobility? Must consider too.
Cystocele and urethrocele
Treatment cystocele
Pelvic floor PT
Pessary-for support or space occupying-first line non surgical
Surgical correction-anterior colporrhaphy (pubocervical fascia is sutured int he midline and laterally to the Argus tendinous fascia) ANTERIOR REPAIN
=paravaginal is repairing lateral cystocele
78 yo g2p2 Asian female presents with cancer something will fallout. She states that the symptoms have been present for years but a couple of months ago she noticed when using bathroom something different. Doesn’t empty bladder, poor control T2DM, HT, CHF, lung disease,
Firm-cervix soft-vaginal tissue,
What is the differential diagnosis
Asian risk, two kids, post menopausal, has had CT issues from umbilical repair,
Firm-cervix, soft-rectocele or cystocele,
Cervix coming out, uterine cervical prolapse
78 yo african American same case.
Less risk prolapse but more risk fibroid
Treat uterine prolapse
Pessary-conservative , she has health issues so lets try this first
Hysterectomy-
Colpocleisis-obliterate vaginal lumen, if dont want to have sex, not invading body cavity, not long procedure, use in 80s or 90s with severe prolapse
62 yo african g3p3 urinary incontinence cough and sneeze , wears pads , denies dysuria or hematuria. Note waking up once a night to use the br. She denies bowel complaints. One large baby . Cough sneeze and cant make it to br
- stress incontinence
- urge
Additional tests
PE, Q tip test (urethral hypermobility-coat Cotten tip applicator put in urethra advance slowly know and pull back till meet resistance and ask to cough or strain + if go more than 30 degrees and urethral hypermobility contributing to incontinence)
Urodynamics-fill and have cough or strain if squirt urine , complex for others
Postvoid residual (less than 50 mL is Normal)
Treat for stress incontinence
Topical estrogen
Pelvic floor PT/kegel
Pessary
Surgery-suburethral sling *(transvaginal tape or trasobturator tape for vaginal approach) abdominal approach with Marshall-marchetti-krantz or Burch procedure)
45 yo g6p7, MS, needing to splint to have bowel movements, rectocele. What clues
Constipation and lots of kids, on interferon for MS
Treat rectocele
Watch it, put is pessary
Surgical-posterior repair , pubocervical and rectovaginal fascia that overlies rectum and is under vagina we will do symmetric and altered closure
38 no kids urinary urgency and frequency. Has to rush to br drinks a lot of diet soda, little water, smokes,
PE normal no prolapse , no blood in urine
Urge incontinence
-diet soda, smoker, job holds urine for long
Treat urge incontinence
- diet drink water
- empty frequently every 90 min
- no smoke
- kegel PT (PT to overcome urge to make to bathroom safely)
If not work try anticholinergic meds
If not work Botox in bladder or nerve stimulators
IUD benefit
Decrease menstrual blood loss
Less dysmenorrhea
Protection of the endometrial lining from unopposed estrogen
Convenient long term
Copper T paragard
10 years
Copper interferes with sperm transport of fertilization and prevention of implantation
Same contraindications/insertion isssues as levorgestrel
Barrier contraceptives
Condoms, diaphragms, cervical cap, sponge, spermicides
-less effective
Condoms good for what
Only method with protection against sti
Condoms
Res our tip decrease breakage
Female condom-vaginal liner and have to leave in 6-8 hours after intercourse and slips out
Diaphragms
Must be used with spermicide
Inserted up to six hours before
May change fit after birth
Women who use as more likely to get urinary tract infections
More likely to get UTI
Cervical cap
Smaller diaphragm, put on cervic with spermicide left in for 6 hours after intercourse no more than 48
Sponge
Small pillow shaped sponge containing spermicide
Dimple in sponge fits over the cervic/opposite has an elastic loop for removal
One size
More effective in nullparous
Left in place for 6 hours but no more than 30 horus
Calendar methods
Calculate fertile period and avoid sex during time
Basal body temp method
,5-1 degree change at time of ovulation and avoid sex for 3 days
Cervical mucus method
Woman assess and not change long and stringy for ov and avoid for 4 days
Symptothermal method
Combines mucus and basal body temp
Awareness of ovulation signs, cramp, breast tenderness, changes in position or firmness or cervix
Emergency contraceptive QID had unprotected sex.
Prevent ovulation and ertilization
Within 72 hours
No medical contraindication!!
Plan B
OTC for over 17
Progestin only 2 pills taken 12 hours apart
Within 120 hours
Failure 1.1%
Cheaper
Ella
Prescription
Ulipristal acetate
More effective
5 days after
Postpones follicular rupture/inhibit or delay ovulation
Sterilization
Highly effective, most frequently used meyjod
Prevent sperm and egg from meeting
PERMANENT
Counsel sterilization
Risk of regret
LARCS
Reasons for choosing
Discuss risk/benefits
Screen for indicator of regret (espicially with young age)
Possibility of failure and increase risk of ectopic if preg occur
Need to use condoms for STD
Vasectomy
Occlusion vas deferens
Safer, more easy,
Postoperative complications: bleeding, hematoma, acute/chronic pain, local skin infections
Easier to reverse
Not immediately effective-10 weeks!!!!
Female sterilization
Laparoscopy, mini laparotomy, hysteroscopy at time of c section
Safe, low cost, easy, permanent
Laparoscopy
Camera in belly button
Small incision,
Occlude Fallopian tubes
-electrocautery, clips(hulks most reversible method, fishie lower failure rate bc large diameter), bands intermediate reversibility and less failure, higher incidence of postop pain, increased risk of bleeding
Salpingectomy-increasing in use due to recent literature regarding decrease in ovarian cancer risk
High risk ovarian cancer
Salpingectomy
Completely non reversible
Mini laparotomy
Most common
Post partum, use small infraumbilical incision in postpartum period or suprapubic incision
Can do same epidural in from labor
Cut cut
Hysteroscopy
Not selling any more such complaints about post op pain from coils
Look in through cervix find tube and insert coil in and it scars…very effective so ok for obese or poor surgical patients, but complaints
26 yo g3p3 female presents for contraceptive advice. Sexually active using basal body temp. Wants more reliable but not permanent. Have DVT< cholecystectomy, appendectomy, smokes marijuana. What recommend? What’s contraindication?
LARC, no oral bop bc clot, depo (weight gain), lets do LARC
23 g2p2 want permanent contraception sure she doesn’t want more kids. BMI 58, mother breast cancer, denies alcohol tobacco
Permanent-salpingectomy,
Non permanent methods-risk of regret higher , depo
LARC
Biggest risk-risk of regret
Breast tissue tenderness cycle
Hormone sensitive
What causes growth of adipose tissue and lactiferous ducts
Stronger
What causes lobular growth and alveolar budding
Progesterone
Number one reason OBGY sued
Misssed Breast cancer
Need timely evaluation
=NEVER wait breaks complaint wait,
Bump
How long been there, pain, has it lasted more than one cycle, nipple discharge, change in size, risk factors
Risk factors breast cancer
Age older Personal history History atypical hyperplasia High breast tissue density First degree relatives with breast tissue Early menarche <12 Late cessation of menses>55 No term pregnancies LONGER ESTROGEN EXPOSURE Never breastfed Recent and long term ocp Post menopausal obesity Endometrial or ovarian cancer Alcohol Tall ppl High socioeconomic status Jewish
PE
Both breasts including axilla and chest wall
Mammogram, US, MRI, FNA, core biopsy
Palpable masses always get a biopsy from FNA/core excisional
Mammography
Able to detect 2 yrs before palpable
Densities and calcifications <1 cm
Best over 40, saggies less density
Just do over 40
Screening mammogram
4 images, 2 cariocaudal and 3 mediolateral
In and out
Diagnostic mammogram
Done with complaint or palpable mass or abnormal screening
Both breasts
When screen
Start at 40 annually
US
For inconclusive mammogram findings
<40 better
Differentiate cystic or solid lesions can show solid tissue near cyst
Guidance for core needle biopsy
25 found bump..lets start with US
MRI
Useful to adjunct mammography
Post cancer diagnosis for further evaluation
Used with implants
Women at high risk for breast cancer like BRCA
Screen if brca or implants, but used for adjunct for everyone else and used for staging
FNA
Patient had abnormal mammogram or ultrasound. GET BIOPSY
Let’s start FNA to determine solid vs cystic
22-24 guage needle
Fluid clear, dont send it, if bloody send it ff and repeat mammogram and US
Cyst-return in 3 months if gone with expiration
If no resolve bigger biopsy
FNA clear cyst completely
Return in 3 months
If not cleared with FNA
Diagnostic mammogram /US and perform biopsy
FNA useful for what
Cystic
If return
Excision , get biopsy if doesn’t go away
Core needle biopsy
For solid masses 14-16 guage
3-6 samples taken
Use US to watch needle go into mass
Benign breast disease
Mastalgia
-cystic, noncyclic, extramammary
Mastalgia cyclic
Start lateral phase of menstrual cycle and ends after onset of menses
Noncyclic mastalgia
Not associated with menstrual cycle
Includes tumors, mastitis, cysts
Can be associated with some medications (antidepressants, antihypertensices, hormonal meds like OCP)
Extramammary benign breast disease
Chest wall trauma, shingles, fibromyalgia
Treat mastalgia
Danazol
-deepens voice, overweight, hair
Symptoms relief benign breast disease
Properly fitting bra, weight reduction, exercise, decrease caffeine intake and vitamin E supplementation, evening of primrose oil
Ocp help if cyclic
Nipple discharge
Hyperprolactinemia
Pituitary tumor or cancer
Unilateral-worse
Clear green-cyst
Milky-lactation
Bloody-yikes
Spontaneous or non
Fibrocystic changes or ductal ecstasia
Non spontaneous, non bloody, and bl
Bloody nipple discharge
Cancer till proven otherwise
What do bloody nipple
Intraductal or invasive ductal carcinoma, benign intraductal papilloma
Breast ductogrpahy-excise duct
Greater concern for malignancy
Greater 2 cm Immobility Poorly defined margins Firmness Skin dimpling/retraction/color changes Bloody discharge Ipsilateral lymphadenopathy
Benign categories
Non proliferative
Proliferative without atypia
Proliferative with atypia
Number one non proliferative
Fibrocystic changes
Cyst from response to hormones, fibrosis from rupture and scar
Number one lumpy
Fibrocystic changes
Cysts
Lobulares dilate and form
Fibrosis
Ares where cysts have ruptured and scarred
Adenosis
Lobular growth with increased number of glands
Lactational adenomas
Hormonal response
Fibroadenoma
Most common benign tumor in females
Late teen early 20
Solid, rubbery, mobile and solitary
2-4 cm in size but can reach up to 15 cm in diameter with malignant potential when reach that size
Galactocele
Cystic dilation of duct filled with Milky fluid
Occurs ear time of lactation
Secondary infection may produce acute mastitis
Typically can be needle aspirated
Proliferative without atypia
Not cancerous
Epithelial hyperplasia, sclerosing adenosis, complex sclerosing lesions, papillomas
NOT PALPABLE see on imaging
Epithelial hyperplasia
Overgrowth of he cells that line ducts
Sclerosing adenosis
Extra growth of tissue within the breast lobules
Complex sclerosing
Radial scar
Adenosis in which enlarged lobules are distorted by scar like fibrous tissue
Papillomas
Intraductal growths
30-50
Cause serous or serosanginous discharge
What do
Imagine and confirmed with biopsy
Proliferative with atypia
LCIS, DCIS
When malignant cells replace the normal epithelial lining in the ducts or lobules-the BM is intact and cant metasticize
LCIS
Not precursor
DCIS
Ducts filled with atypical epithelial cells and women’s re increased risk for developing invasive disease or reoccurrence of DCIS
Treat DCIS LCIS
Excision and followed with treatment with selective estrogen receptor modulators
Most common malignancy in women
Breast cancer
Second leading cause of cancer death
Bc
Lifetime risk of getting it and dying
1/8
1/28
Risk factor
Over 50
BRCA
Brca1
Early ovarian
BRCA2
Some early onset and lower risk ovarian
Gail model
Put in stuff risk of developing cancer if 5 year risk is 1.7% or more talk about prophylaxis
Most common histology
Ductal 50s
Lobular
5015 more aggressive
Nipple
Paget disease, bad 3%
Inflammatory breast cncer
1-4% people get diagnosed as mastitis and its not noticed for a while
Treat
Receptor status from lumpectomy
er+
Respond better
HER2/neu
Worst prognosis
Surgery
Lumpectomy radiation
Mastectomy
Equal outcomes
Meds
Hormonal, chemo, tamoxifen in pre menopausal, after get aromatase inhibits (decrease risk endometrial )
Trastuxumab hercepton-gives heart failure acts on HER2/neu but risk of heart failure
First 2 years
3-6 months MRI mammography
Then every year after 2 years
Most recur by when
5 years
