Endometriosis/ Mastitis Flashcards
Endometriosis
general
Common, nonmalignant estrogen-dependent condition in which endometrial glands and stroma implant outside of theuterus
Endometrial implants, nodules, and endometriomas can:
Be highly inflammatory
Occur anywhere in the pelvis, the urinary and gastrointestinal tracts, and distant organs
Epidemiology
Incidencein the general female population: ~10-15%
White > Blacks
Average age at diagnosis: 27 years
Endometriosis
3 types of endometrial tissue
Implants
Small, superficial form of endometrial tissue
Nodules
Larger and more invasive form of endometrial tissue
Endometriomas
Cysts on the ovaries filled with menstrual blood
Also called chocolate cysts
endometriosis
RF
Prolonged endogenous estrogen exposure:
Nulliparity
Early age atmenarche
Latemenopause
Shorter menstrual cycles
Heavy menstrual bleeding
History ofinfertility
History of obstructed outflow (Müllerian anomalies)
Uterine surgery
Low bodymassindex (BMI)
Family historyof endometriosis
endometriosis
Sites of Ectopic Implantation
Ovary (most common site) → endometriomas
Pelvicperitoneum(2nd-most common)
Uterine ligaments (broad, uterosacral)
Within the uterine myometrium →adenomyosis
Rectovaginal septum
Fallopian tubes
Colon,rectum, andappendix
Bladderandureters
Priorsurgical incisionsites
Distant organs (rare):
Lungs
Breast
Bones
Liver,gallbladder,pancreas, andspleen
endometriosis
S/Sx
The location of implants determines the clinical presentation
Symptoms may becyclic, chronic, or progressive
Somepatients are asymptomatic – implants are found incidentally during surgery
Symptoms
Pelvic, abdominal and lower back pain, usually associated with menstruation – 80% of cases
Dysmenorrhea
Dyspareunia
Menorrhagia/Metrorrhagia
Dysuria/Dyschezia
Infertility - 25% of cases
Degrees of Endometriosis
Grade I and II
Grade I (minimal):
Isolated implants appear without adhesions
Grade II (mild)
Endometrial implants are superficial and smaller than 5 cm
May be adhesions to the surface of the peritoneum or ovary, but without affecting other organs
Degrees of Endometriosis
Grade III and IV
Grade III (moderate)
Multiple endometrial nodules with most of them invasive
May be adhesions in the fallopian tubes or ovary
Grade IV (severe)
Ectopic endometrial tissue that is superficial and deep
Formation of endometriomas (chocolate cysts) in the ovaries
endometriosis
PE findings and Dx
Often made clinically based on history and exam findings
Definitive diagnosis can only be made on histologic examination of a surgicalbiopsy
Physical examination findings suggestive of endometriosis
Tenderness on vaginal exam
Visible vaginal endometrial implants
Palpable nodules in the posteriorfornixor rectovaginal septum
Adnexalmass
“Frozenpelvis”:
Immobility of thecervix and/oruteruson bimanual exam
Due to adhesions andscarring
endometriosis
imaging
Transvaginal ultrasound
Endometrioma (chocolatecysts)
Nodules on the rectovaginal septum,abdominal wall, orbladder
Normal-sizeuterus
MRI
May be used if the diagnosis by ultrasound is not clear or before surgery, to determine the exact location and depth of lesions
Laparoscopy
Gold standard for diagnosis
Implant appearance:
Lesions may be red, white, clear, or black-purple
Biopsy for definitive histologic confirmation
Other findings:
Endometriomas
Pelvic adhesions
endometriosis
Pharm Tx
First-line medical management
Non-steroidal anti-inflammatory drugs (NSAIDs)
Hormonal contraceptives
Primary initial treatment
Often given continuously (without placebo days) to completely suppress menstruation
Progestins suppress endometrial growth
Options include:
Combinedoral contraceptivepills (OCPs)
Progesterone-only contraceptive pills (POPs)
Contraceptivepatch
Contraceptivevaginal ring
Levonorgestrel-containingintrauterine devices(IUDs)
Etonogestrel contraceptive implant
Medroxyprogesterone acetate injections
endometriosis
Surgical management
The goal is to provide a definitive histologic diagnosis and resect any visible lesions to treatpain
Ovarian cystectomy for endometriomas
Resection or ablation of the endometrial lesions
Lysis of adhesions
Hysterectomy with or without salpingo-oophorectomy
Reserved forpatientswith moderate-to-severepain
Definitive procedure
Ifovariesremain → persistentestrogenproduction → stimulates any remaining implants → possible to have persistentpain
Supplemental hormone therapy may be considered ifovariesare removed
endometriosis
Complications
Pregnancyimplications
↑ Risk ofpreterm birth
Infertility
Ectopic pregnancy
↑ risk of clear cell epithelialovarian cancer
Intestinal obstructionfrom adhesions
Adenomyosis
general
Common, benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium
One of the structural causes ofabnormal uterine bleeding (AUB) - PALM
May be diffuse or focal
Diffuse → adenomyosis
Focal → adenomyomas
Epidemiology
Occurs in 20%–35% of reproductive-age women
Average age: 40–50 years
Often coexists with other uterine pathology, especially:
Leiomyomas (fibroids)
Endometriosis
Adenomyosis
Clin man
Dysmenorrhea
Abnormal uterine bleeding/heavy menstrual bleeding
Chronic pelvicpain
Dyspareunia
Physical exam may reveal auterusthat is
Symmetrically enlarged
Tender
Boggy (soft)
Mobile (as opposed to fixed, which may occur withendometriosis)
Adenomyosis
Dx and imaging
Based history, exam, and imaging
Transvaginal ultrasound
Preferred imaging modality
Findings suggestive of adenomyosis
Enlargeduterus
Myometrial cysts
Asymmetrical thickening of the myometrium (typically at thefundusor posterior wall)
↑ Myometrial heterogeneity
Loss of a clear endomyometrial border
Dopplerassessment shows ↑ vascularity in the myometrium
Adenomyosis
Pharm Tx
Management is directed primarily by the patient’s desire for future fertility
Non-hormonal medical therapies
NSAIDs: ↓ prostaglandin production → ↓ dysmenorrhea
Hormonal therapies:↓ estrogenic effects
Levonorgestrelintrauterine devices(IUDs): preferred medical treatment
Oral contraceptives (all are progestin dominant)
Gonadotropin-releasing hormone (GnRH) analogs
Both agonists and antagonists fully suppress thehypothalamic-pituitary-ovarian axisby disrupting the GnRH pulse
Adenomyosis
surgical tx
Surgical options
Endometrial ablation
Hysterectomy
Definitive treatment
Best option once childbearing is complete
Histology specimens will confirm the diagnosis
Mastitis
general
Inflammationof the breast tissue with or without infection
Classification
Lactational mastitis (most common)
Affects up to 10% ofbreastfeedingmothers
Most common in the first 3 months oflactation
Non-lactational mastitis:
Periductal mastitis
Inflammation of subareolar breast ducts
Most common in young women
Associated withsmoking
Most commonly pathogen Staphylococcus
Idiopathic granulomatous mastitis (IGM)
Rare, condition that presents with a peripheral inflammatory breast mass
Frequently involves Corynebacterium
Often associated with Hispanic ethnicity
Mimics breast cancer
peau d’orange of the skin, nipple retraction, and lymphadenopathy
Lactational Mastitis
General and RF
Most commonly associated with staphylococcal infection
Poor milk drainage leads to milk stasis and growth of microorganisms
Pathogens
Enter milk ducts duringbreastfeeding(breast milk isNOTsterile)
Usually come from mother’sskinor infant’s mouth/nose
Most common infectious agents
Staphylococcus aureus(most common); may be methicillin-resistantS. aureus(MRSA)
Group A or BStreptococcus
Escherichia coli
Corynebacterium
Bacteroides
Additional risk factors
Cracked or excoriated nipples
Illness in the mother or baby
Mother’s stress andfatigue
Depressed maternal immunity
Previous mastitis
Lactational Mastitis
Poor milk drainage or engorgement may result from
Oversupply of milk
Infrequent feedings/pumping
Rapid weaning
Partial blockage of a duct
Lactational Mastitis
Clinical Presentation
Edema, erythema, and warmth
Usually unilateral
Systemic symptoms of infection
Fever/chills
Fatigue/general malaise
Myalgias
Pain duringbreastfeeding
Regionallymphadenopathy
Fluctuant, tendermass(abscess)
Most common complication
Lactational Mastitis
Diagnosis
Lactating mothers
Diagnosis is established based on clinical presentation
Supportive studies:
Gram stain and culture of the milk
Can help identify the causative organisms
Only required in cases refractory to treatment
Blood culture
Severe progressive infection/signs ofsepsis
Ultrasound
To look forabscess→ appears as a fluid-filledmass
If a mass is present on exam
If there is no clinical improvement after 48–72 hours of empiric antibiotics
Lactational Mastitis
Tx
Supportive care
Analgesics (NSAIDs and/or acetaminophen)
Cold/warm compresses
Frequent, complete emptying of breast via:
Breastfeeding – encourage continuation
Pumping
Hand expression
Antibiotics: symptoms lasting beyond 12-24 hours
Non-MRSA
Anti-staphylococcalpenicillins: dicloxacillin 500 mg PO QID
Cephalosporins: cephalexin 500 mg PO QID
Erythromycin 500 mg PO BID
MRSA
Clindamycin450 mg PO TID
Trimethoprim-sulfamethoxazole (avoid in mothers who are breastfeeding infants < 1 month old)
Intravenous vancomycin may be required for severe/septic presentation
Surgical therapy: incision and drainage of needle aspiration of associated abscesses
Breast Abscess
General and clin man
Usually associated withmastitis
Clinical presentation:
Unilateral, painful, fluctuantmass
Erythematous and edematous breast
Possiblepurulent dischargefrom thenipple
Fever
breast abscess
Dx and PE
Clinical: history and physical examination findings of afluctuant, tender, palpablemass
Nipple discharge: Culture may help guide choice of antibiotic
Ultrasound: ill-definedhypoechoiccollection with internal septations
Needle aspiration reveals purulent contents
Breast abcess
Tx
Needle aspiration
Can be an initial treatment if overlyingskinis not ischemic orabscess < 3 cm
Repeated every 2–3 days until there is no collection
Incision and drainage
Ifneedle aspirationand/or antibiotics fail
Abscess > 3 cm
Antibiotics that target most common causative agent (Staphylococcus aureus)
Cephalexin,dicloxacillin, or amoxicillin-clavulanate
Galactocele
General and patho
A rare, benign retention cyst within themammary gland containing milk
Also referred to as a milk cyst
Most commonbenignbreast condition in lactating women
Pathophysiology
An obstruction of a lactiferous duct →accumulation of epithelial cells and milk → distention of the duct → cyst formation
Galactocele
Clin Man
Clinical presentation
Unilateral, palpable, firmmassin the subareolar region
Presents with no fever or pain (painsuggests secondary bacterial infection)
Milky nipple discharge
Galactocele
Dx and Tx
Diagnosis is predominantly clinical
Any new palpable lump in the breastrequires prompt investigation with a triple assessment
Clinical examination
Imaging: ultrasound or mammogram
Patients are usually lactating mothers with dense breasts → ultrasound is ideal after clinical examination
Cytologic or histologic assessment when needed
Management
Most cases resolve spontaneously
Increasedbreastfeeding,warm compresses, and massage
Needle aspirationor surgical excision for symptomaticcysts
InflammatoryBreast Cancer
General, Dx, Tx
Rare, aggressive, rapidly growingbreast cancer
Characterized by:
Erythema andedema
Lymphnode involvement in nearly all women
1/3 of women will have distant metastases upon presentation
Diagnosis
Suspected in women with rapidly progressive inflammation without improvement after antibiotics
Breast imaging
Diagnostic mammogram and ultrasound
Core needle biopsy (CNB) can confirm the diagnosis
Treatment
Surgery, chemotherapy, and radiation
