Exam 2 Flashcards
physiological consequences of ovarian failure
- vasomotor symptoms
- menstraul changes
- Sleep distrubances
- mood changes
- genital atrophy
- cardiovascular disease
- osteoporosis
cessation of menses for 6 months
menopause
average age of menopause
- 4
* 2 yrs earlier if a smoker and earlier if undernourished
late menopause-age _____
premature ovarian failure- age ____
late- age 50
premature- 40
amenorrhea, symptoms of estrogen deficiency, gonadotrophin (FSH/LH) in the menopause range
premature ovarian failure
*failure does not imply total cessation –> 5-10% have been able to conceive and deliver normal pregnancies because they may intermittently produce estrogen.
symptoms:
hot flashes
vaginal dryness
dyspareunia
premature ovarian failure
*normal puberty, and regulr menses prior
what labs do u check for premature ovarian failure
HCG (pregnancy)
prolactin
FSH
E2
additional labs: TSH, DEXA-scan, karyotype, auto-antibodies
*pelvic u/s and biopsy have no proven benefit
implications of premature ovarian failure
- osteoporosis
- CHD
- hot flashes
- vaginal dryness
treatment of premature ovarian failure
estrogen therapy/OCPs
*used to prevent complications of low estrogen state
what menopause stage?
cycle irregularity –> increased FSH, normal/high estradiol secretion (increased aromatase activity), low luteal progesterone secretion
early menopause
what menopause stage?
increased cycle variability, FSH and estradiol levels fluctuate
late menopause
what menopause stage?
no estrogen secretion by ovary; LH continues to be released which causes the ovary to continue to produce and secrete androgens
postmenopause
what is typically the 1st symptom in perimenopause/menopause
hot flashes/power surge
*75% of women affected
symptoms: sleep disturbance anovulatory bleeding irregular bleeding UTI, incontinence sexual dysfucntion forgetfulness, irritability joint pain, dry skin, breast pain, migraines
perimenopause/menopause
*sometimes heavy bleeding during perimenopause
How do you diagnose menopause?
- based on symptoms and mesnstrual cycle history
* 6 months of amenorrhea in a woman >45 yrs. w/ no biologic or physiologic cause (labs not routinely indicated: FSH/LH)
DDX of menopause
DDX: hyperthyroidism, pregnancy, hyperprolactinemia, medications (IUDs, chemo, radiation)
Increased FSH, variable cycle lengths, cessation of menstruation
menopausal transition
describe what causes menopause
Declining ovarian response to FSH results in decreased estrogen–> no feedback to cause an LH surge–>therefore no ovulation, no progesterone from corpus luteum, no progesterone drop off and no bleeding
why is there GU symptoms for menopause
due to less estrogen –> vaginal and urethral atrophy –> stress and urge incontinence from atrophic urethral changes and disrupted urethral seal, vaginal dryness, increased pH leading to increased vaginitis
why is there sexual dysfunction with menopause
decrease estrogen –> decreased blood flow to vagina and vulva
why are there skin/nails symptoms with menopause
increased testosterone leads to facial hair, skin is less elastic, nails become thin
what is the most common age group of abortions
45-50y/o and 14-18 y/o
risks associated with HRT
- thromboembolism (mostly in women with risk, E+P only)
- increased risk of Breast CA ( E +P only)
- increased risk of CHD (E+P only)
- increased risk of stroke (greater with E)
HRT has shown to be beneficial for what?
menopause/perimenopause
osteoporosis
how do you treat menopause
HRT
-low dose OCP (sadfe in non-smokes
alternative treatment options for menopause
- vaginal lubricants (replens)
- SSRIs/SNRIs
- gabapentin
recommendations for HRT in menopausal women
- short term therapy (2-3 yr but not more than 5 yrs)
- use lowest dose possible
- tailor to paitent’s needs
- women wit ha uterus need combination estrogen and progetin therapy
HRT for menopause is contraindicated in who?
- Hx of breast CA/ovarian CA (R)
- CAD (absolute)
- Previous venous thromboembolism or stroke (absolute)
- undiagnosed vaginal bleeding (absolute)
- pregnancy (absolute)
- severe liver disease (absolute)
- acitve gallbaldder disease (R)
- migraine HA (R)
- atypical ductal hyperplasia of the breast (R)
- MUST use a progestin with estrogen in women with a uterus (Estrogen-only if previous hysterectomy)**
___% of women have incontinence
—% of women in US have prolapse
20-40% of women in mid-life and beyond have some incontinence
16% have prolapse
why is prolapse more common in older women?
more childbirths #1 risk factor for UI is childbirth
cystocele
bladder prolapse
*most common
apex prolapse
vaginal prolapse
rectocele
retum prolapse
what is a prolapse?
hernia= tissue weakness, and a different organ falls into the bladder
“splint”
needing to enter a finger in the vagina in order to fully empty the rectum/stool in a rectocele
how do you exam for a prolapse
- have pt. bare down or valsalva
2. do a split sepculum exam (Isolate and look at the front and back wall of the vagina)
treatments for prolapse
- nothing- not life threatening but is uncomfortable
- pelvic floor physical therapy
(Strengthen levator ani muscles with kegels) - Pessary
- Surgery
what is the gold standard treatment for prolaspse
abdominal sacral colpopexy
(The upper vaginal vault is secured to the sacrospinous ligament with sutures, restoring vaginal wall support and correcting prolapse)
how do you repair a rectocele
suture based
pull healthy tissue to create a shelf
what is a normal amount to void urine
daytime: no more than once every 2 hrs (8-12x/day)
nighttime: 1-2x
nocturia
voiding more than 2x at night
complications of nocturia
sleep loss–> depression
available assessments for UI
- history and physical (POP-Q)
- Voiding diary
- Post-void residual
- Urine culture
- Stress test
- Q-tip test
- Uroflow
- Urodynamics
- Cystoscopy
cough sneeze laugh exercise position change
stress UI
urgency
frequency
nocturia
dysuria
urge UI
hesitancy
interrupted flow
poor stream
incomplete void
overflow UI
hypermobile urethra
stress UI
detroucer mm. contracts too frequently “I know every bathroom in town”
urgency UI
UI caused by neurologic injury or DM
overflow UI
sections in a voiding diary
3 day diary intake output frequency activities associated w/ incontinence insensible loss
what do you check for on PE when evaluating for UI
- estrogen status
- Neuro screening (bulbocavernosus and anal wink reflexes)
- Anatomical defects resting and straining (POP-Q)
what nerves affect UI
S2, 3, 4 keeps your pee pee off the floor
Test that evaulate for UI
- CST (cough stress test)
- Postvoid residual (PVR)
- Multichannel Urodynamics (UDS)
* don’t do Q-tip test (no predictive outcome)
definitely abnormal PVR
> 200cc
what is the Q-tip test suppose to detect
urethral hypermobility
- Uses instruments to measure and display physiologic functions of lower urinary tract
- Pressure catheter in bladder and vagina or rectum
- Pdet calculated
Multichannel Urodynamics (UDS)
indications for Multichannel Urodynamics (UDS)
- Uncertain diagnosis (Findings don’t match complaint)
- Complex history
- Previous surgery
- Patient not satisfied with initial treatment
- Surgery planned in a complicated patient
- Comorbid conditions
treatments for UI
Nonsurgical: pelvic floor muscle training bladder training prompted voiding lifestyle modifications anticholinergic drugs
Surgical: open retropubic colposuspension (burch procedure) Sling procedure Sacral neuromodulation Botox
what lifestyle modifications can you do to help with UI
- restrict fluid intake
- avoid caffeine and alcohol
- Minimze evening intake of fluids (quit drink 2 hrs before bed)
- manage constipation
- smoking cessation
- treat pulmonary disease
* other irritants: white wine, vit. C, artificial sweetner
Frequent voluntary voiding to keep the bladder volume low
bladder training
- Bladder filling begins with an audible signal to let the patient know the bladder pressure is rising; tone varies with increasing pressure; bladder is repeatedly filled while patient focuses on suppressing detrusor contractions
- 1 hour session per week
biofeedback
*also used for pelvic floor strengthening exercise
Mainstay of medical treatment for overactive bladder
anticholinergic drugs
how do anticholinergic drugs help UI
prevents spasming of the bladder
*may cause dry mouth, eyes and consipation
Most commonly prescribed anticholinergic drugs
Oxybutinin (Ditropan)
Tolteridine (Detrol or Toviaz)
*typically takes 2-3 tries before finding one that works
sacral neuromodulation
“pacemaker” to the bladder to treat UI
(Minimally invasive, Minimal pain, Fluoroscopy, Simple technique)
-reversible
how does botox help UI
prevents bladder spasm
*need repeat shot every 6 months
how many kegels should you do
30 each day with 10sec squeezing: 10 sec rest
first-line of treatment of USI
kegels
1st line of therapy for prolapse
pessaries (supportive donut-like ring that go behind pubic bone)
- Collagen, carbon-coated beads, fat
- Periurethral/transurethral Injection around bladder neck and proximal urethra
- “Washer effect”
Periurethral bulking agents
proposes that urinary incontinence results from a failure of the pubourethral ligaments in the mid-urethra, therefore treat with
therefore use tension-free vaginal tape
placed at the miduretrha to raise the urethra back into place – can be performed vaginally
TFT
*likely new gold standard
refer to urogyn when?
- Symptoms do not respond to initial treatment within 2 to 3 months
- recurrent symptomatic UTI
dimpling or pulling of breast tissue occur when what is affected?
Cooper’s ligament
how often do you perform a breast exam
1-3 yrs for women 20-39
annually if >40
*encourage breast awareness exams
how do u describe the location of a breast lump
use a clock-like description (3 oclock, 2cm from nipple)
women start having a mammogram yearly at what age
40
- in a pt with 1st degree relative w/ early onset of breast CA, start screening 10 yrs prior to relatives dx
(ex. mom dx at 45, start mammogram at 35) - *could get false + if done too early
mammogram screening vs 3D (digital breast tomosynthesis)
- 3D allows for multiple view (screening has 2 views)
- 3D better for women with dense breast
- 3D has 8% more radiation
BI-RADS
breast imaging reportin and data system
1 inadequate pic, 2 neg—> 6 known bipsy-proven
why are breast u/s useful
differentiating between cystic and solid
when are breast MRIs recommended
for women with >20% CA risk
*not good for screening bc a lot of false positives are picked up (high sensitivity, low specificity)
describe a malginant lump
poorly defined
usually less mobile
non-tender
may cause skin dimpling or nipple retraction
may have nipple discharge
may have overlying skin changes (pea d’ orange)
how do u further assess a palpable lump
- imaging
2. breast biospys (incisional or excisional) vs core-needle biospy or FNA
obtains clusters of epithelial cells
- interprets as bengin or mallignant
- higher insufficient sample rate
FNA
vacuum-assisted device that removes multiple cores of tissue
core needle
triple test
clinical exam
imaging
needle biopsy
*99% accurate when all 2 c/w benign lesion
mastodynia or mastalgia
severe breast pain >5 days/month
*most common in perimenopausal women
when is cyclic breast pain worst
right before menses
tx of cyclic breast pain
- NSAIDS or tylenol
-supportive bra
OCPs
limiting caffeine (not proven)
evening primrose oil
warm or cool compresses
what do u want to check out with non-cyclic breast pain
bilateral: PRL (prolactin) and BHCG (pregnany test)
r/o musculoskeletal, cardiac, chest wall, meds, cyst, mass
Probable hormonal influence since _______ wax and wane with the menstrual cycle,
fibrocytic changes
- becoming more palpable (and tender) just prior to menses
- not a disease
how do u dx breast simple cysts
u/s
sonolucent, smooth margins
how to tx breast simple cysts
- often go away on own or fluctuate w/ menstrual cycle
- can be aspirated if symptomatic
- can excise if recurrent
May see septations or intracystic masses
Wall thickening or irregularity
complex cyst
*require excision or biopsy
Benign, focal abnormality of a breast lobule
fibroadenoma
Feel rubbery, firm, well-marginated, very mobile, usually painless
fibroadenoma
how to f/u with fibroadenoma
Imaging at minimum with potential biopsy or excision
what is the most common cause of breast infection
S. aureus
Symptoms: localized swelling, erythema, pain, warmth, chills, fever, flu-like symptoms
Puerperal Breast Infections: mastisis
mastisis affects ___% of nursing moms
2-3%
how to treat Breast Infections: Puerperal
antibiotics (consider abscess if no improvment after 48 hrs)
*Continue nursing, apply heat, avoid cracked nipples
examples of Breast Infections: Nonpuerperal
cellulitis
abcess
olliculitis, infection of epidermal inclusion cysts
peripheral abcess
how do u tx an abcess
antibiotics or incision and drainage (I and D)
how do u tx cellulits
antibiotics
*Uncommon, should prompt imaging if unresolved
arise from keratin-plugged milk ducts
subareolar abcess
how do u tx subareolar abcess
incision and drainage or duct excision
Mastitis Treatment
Course of abx for 7 – 10 days Cephalexin** Amoxicillin/Clavulante Azithromycin Dicloxacillin** Clindamycin *F/U w/ documented resolution is imperative
who expresses nipple discharge
40% of premenopausal women
55% of parous women
74% of women who have lactated in the last 2 yrs
Benign Characteristics of nipple discharge
White, green, or yellow
NOT spontaneous (after intercourse or shower)
Bilateral
pathologic characteristics of nipple discharge
Unilateral or single duct
Spontaneous
Persistent
Bloody/red, pink, orange, brown, black, or clear
causes of nipple discharge
Physiologic (Manual stimulation, traum)
Pathologic (Galactorrhea, prolactinomas, primary hypothyroidism)
-Pharmacologic (Psychoactive and antihypertensive agents, opiates, marijuana, estrogen-containing meds)
- Idiopathic
Gynecomastia
Literally means “female breasts”
Men may have visible enlargement of breast or palpable change (often feels like a firm, rubbery subareolar mass)
cause of Gynecomastia
- Results from excess estrogen or estrogen/testosterone imbalance
- Symptom of physiological change, drug side effect (drugs that increase estrogen level), other disease, tumor, idiopathic
- Prevalence increases with age
Pathophysiological causes of gynecomastia
hypogonadism, hyper/hypo-thyroidism, ETOH-induced liver cirrhosis, testicular tumors, adrenal tumors
what is the prevalence of breast CA
1: 8
* Women are 6 times more likely to die from heart disease
* risk increases w/ age (median age 61)
* incidence is highest in white women but mortalitiy is higher in AA
most common CA in women
breast cancer > colorectal > lung
factors that increase ones risk of breast CA
- female
- age
- genes (BRCA1/2)
- Fhx
- PMH
- high breast tissue density
- high-dose radiation to chest
- never breastfed, no full term pregnancies, recent OCP use
- alcohol
- height
estimates a woman’s risk of developing invasive breast CA over the next 5 yrs and in their lifetime (up to 90)
uses 7 risk factors
history of LCIS or DCIS
age
age at onset of menstration
age at the time of their first live birth
number of 1st degree relatives wiht breast CA
history of breast biopsy
race/ethnicity
Gail Model
When do u consider prophylatic Breast CA therapy for a woman?
5 year risk of > 1.7% according to Gail model
consider chemoprevention with tamoxifen/raloxifene (decreases rate of invasive breast cancer by 50% after 5 years of treatment)
> 20% lifetime risk: consider annual mammography plus breast MRI, CBE every 6 mo., monthly BSE
tyrer-cuzik model = adds in famililal risk
True or False?
Most cases of breast cancer are a result of inherited genetic mutations
false
*Genetic mutations likely account for between 5 and 10% of breast cancers
what types of genes are BRCA 1/2
tumor suppressor genes
*Accounts for 3 – 5 % of breast cancers (10% of ovarian cancers)
Chromosome 17
More common
More aggressive tumors grade III, Her2/neu and ER-negative
More risk of ovarian CA (39 – 46%)
BRCA 1
Chromosome 13
Responsible for the majority of male breast cancers
Carries increased risk for pancreatic, prostate, and stomach CA, and melanoma
Risk of ovarian CA 12 - 20%
BRCA 2
screenig when BRCA +
- CBE twice a year + annual mammography and MRI beginning at age 25 years (or sooner based on earliest age onset in the family)
- “Periodic” CA 125 and transvaginal US starting at 30 yo (or 5 – 10 years before age of first ovarian CA diagnosis)
treatment for BRCA +
- Bilateral mastectomy reduces the risk of breast cancer by 90–95%
- BSO by age 40 years (or after childbearing) reduces ovarian cancer risk by 85–90% and breast cancer risk by 40 – 70%
- Tamoxifen reduces breast cancer risk by up to 62% in BRCA2 patients
different types of breast CA
Ductal carcinoma
(most common)
Lobular carcinoma
Other types
DCIS
LCIS
*non-invasive CA, well localized
Originates in the cells lining the milk ducts
> 80% of all breast cancers are this type
invasive ductal carcinoma
10-15% of all breast cancers
Originates in the lobes of the breast
invasive lobular carinoma
1-5% all breast CA
Cancer cells block lymph vessels of the skin
Quite aggressive, often occurs in younger women and more common in AA women
Peau d’orange, inflamed appearance
inflammatory breast CA
Usually non-palpable and detected on mammogram
Often associated with calcifications
20% all mammographically detected cancers
DCIS (ductal carcinoma in situ)
*Risk of progression to invasive cancer is unknown
treatment of DCIS
lumpectomy (+/- radiation) or mastectomy
Incidental finding
May require surgical intervention
Most helpful as marker for increased risk (20-30%) for invasive breast ca in either breast
LCIS (Lobular carcinoma in situ)
breast CA Prognostic Factors
Size: the smaller, the better Grade: differentiation and rate of proliferation ER/PR status Her2/neu oncogene overexpression Lymph node (LN) involvement
breast CA treament
- chemo
- surgery
- radiation
- endocrine therapy
tx type?
Multiple regimens, often after surgery but may be pre-operative if large tumor, IV and oral agents
chemo
- tx 3-6 months
- Combination therapy best, anthracycline-containing regimens are usually best
tx type:
Lumpectomy (can be assisted by needle localization if non-palpable), mastectomy, sentinel lymph node biopsy, axillary dissection
surgery
____% dominant breast lesions are malignant
20%
a true hernia at the top of the vagina allowing the small bowel to herniate though
enterocele
what POP-Q stage? no prolapse( (the the cervix is at least as high as the vaginal length)
stage 0
what POP-Q stage?
leading edge is more than 1 cm beyond the hymen, but less than or equal to the total vaginal length
stage 3
what POP-Q stage?
complete eversion
stage 4
what POP-Q stage?
Leading part of prolapse is more than 1 cm above the hymen
stage 1
what POP-Q stage?
leading edge is less than or equal to 1 cm above or below the hymen
stage 2
Procidentia
when the cervix descends beyond the vulva
a clear or milky breast discharge is usually bilateral and associated w/ stimulation or elevated prolactin levels
galactorrhea
bilateral salpingo-oophorectomy
removal of fallopian tubes and ovaries
intraductal growths composed of abundant stroma and lined by both luminal and myoepithelial cells
papillomas
Polythelia
extra nipples
Polymastia
extra breasts
an increase in the number of glands with associated lobular growth
adenosis
more than 2 cell layers on basement membrane
Epithelial Hyperplasia
increased fibrosis within the expanded lobule with distortion and compression of the epithelium
Sclerosing Adenosis
- a nidus of tubules entrapped in a densely hyalinized stroma surrounded by radiating arms of epithelium
- mimic an invasive carinoma
Radial Scar-
- intraductal growths composed of abundant stroma and lined by both luminal and myoepithelial cells
Papillomas
obliteration of the lumina of the glandular acini by a uniform population of small, atypical cells
*relaed to atypical lobular hyperplasia
LCIS
*tx w/ excisional biopsy
the ducts are filled with atypical epithelial cells
DCIS
*evaluate with core needle biopsy followed by surgical biopsy or excision
5-15% of all breast CA
often multifocal and bilateral
invasive lobular carcinoma
70-80% of all breast CA
most likely to spread to lymph nodes
invasive ductal carcinoma
stage breast CA based on what system
TNM
tumor size, involvment of lymph nodes, and distant metastasis
used in the treatment of all stages of breast CA, regardless of lymph node status
-Includes chemotherapeutic drugs that kill CA cells and hormonal therapies such as tamoxifen that act as estrogen antagonists
adjuvant (systemic) medical therapy
prevent the production of estrogen in postmenopausal women
used to extend survival in women with metastatic CA, as a primary adjuvant therapy, an din conjunction with tamoxifen to prevent CA recurrence
aromaste inhibitors (AIs)
-acts on membrane-bound protein produced by Her2/neu
0if a pt’s CA is found to overexpress Her2/neu protein,_____ can be given as adjuvant therapy
trastuzumab
f/u after breast CA treatment
- OB/gyn screens for the first 2 years (f/u every 3-6 months and then annually after that)
- annual mammography and PE continue indefinitely after that
what percentage of breast CA are due a BRCA + gene?
3-5%
what percentage of ovarian CA are due to BRCA + genes?
10%
