Endometriosis/ Mastitis Flashcards

1
Q

Endometriosis

general

A

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

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2
Q

Endometriosis

3 types of endometrial tissue

A

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

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3
Q

endometriosis

RF

A

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

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4
Q

endometriosis

Sites of Ectopic Implantation

A

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

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5
Q

endometriosis

S/Sx

A

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

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6
Q

Degrees of Endometriosis

Grade I and II

A

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

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7
Q

Degrees of Endometriosis

Grade III and IV

A

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

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8
Q

endometriosis

PE findings and Dx

A

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

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9
Q

endometriosis

imaging

A

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

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10
Q

endometriosis

Pharm Tx

A

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

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11
Q

endometriosis

Surgical management

A

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

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12
Q

endometriosis

Complications

A

Pregnancyimplications
↑ Risk ofpreterm birth
Infertility
Ectopic pregnancy
↑ risk of clear cell epithelialovarian cancer
Intestinal obstructionfrom adhesions

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13
Q

Adenomyosis

general

A

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

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14
Q

Adenomyosis

Clin man

A

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)

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15
Q

Adenomyosis

Dx and imaging

A

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

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16
Q

Adenomyosis

Pharm Tx

A

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

17
Q

Adenomyosis

surgical tx

A

Surgical options
Endometrial ablation

Hysterectomy
Definitive treatment
Best option once childbearing is complete
Histology specimens will confirm the diagnosis

18
Q

Mastitis

general

A

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

19
Q

Lactational Mastitis

General and RF

A

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

20
Q

Lactational Mastitis

Poor milk drainage or engorgement may result from

A

Oversupply of milk
Infrequent feedings/pumping
Rapid weaning
Partial blockage of a duct

21
Q

Lactational Mastitis

Clinical Presentation

A

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

22
Q

Lactational Mastitis

Diagnosis

Ultrasound imaging of a breast abscess:A: Complex, with ill-defined bordersB: Homogeneous in appearance with well-defined borders
A

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

23
Q

Lactational Mastitis

Tx

A

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

24
Q

Breast Abscess

General and clin man

A

Usually associated withmastitis

Clinical presentation:
Unilateral, painful, fluctuantmass
Erythematous and edematous breast
Possiblepurulent dischargefrom thenipple
Fever

25
Q

breast abscess

Dx and PE

A

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

26
Q

Breast abcess

Tx

A

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

27
Q

Galactocele

General and patho

A

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

28
Q

Galactocele

Clin Man

A

Clinical presentation
Unilateral, palpable, firmmassin the subareolar region
Presents with no fever or pain (painsuggests secondary bacterial infection)
Milky nipple discharge

29
Q

Galactocele

Dx and Tx

A

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

30
Q

InflammatoryBreast Cancer

General, Dx, Tx

A

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