Female Repro

Question 1

Vaginal infections DDx

Answer 1

• Bacterial vaginosis (Gardnerella)
  
  • >4.5
  • Discharge: thin, white/grey
  • Odour: fishy
• Trichomonas
  
  • pH>4.5
  • Discharge: frothy, yellow/green
  • Odour: fishy
• Candida vulvovaginitis
  
  • pH<4.5
  • white curdy “cottage cheese”
  • CC: itching/burning

Question 2

Lymph Drainage of the Breast

Answer 2

• Majority of lymph drains into ipsilateral axillary nodes along a chain which starts at:
  
  • ANTERIOR AXILLARY ( PECTORAL ) ->
  • CENTRAL **most freq. palpable ->
  • APICAL (Subclavian / Infraclavicular ) ->
  • Supraclavicular ->
  • Subscapular ( posterior axillary ) ->
  • Interpectoral nodes ->
• MEDIAL BREAST drains into Internal Thoracic and Mediastinal ( Internal Mammary ) nodes

Question 3

Colostrum and Milk

Answer 3

• Colostrum : Secretory IgA (against Enteric infection).
• Human Milk : Starts 5 days post partum
• Protein, Lactose, Water, Fat
• Lacks vitamin K.
• Lower iron than cows milk.
• Has T & B lymphocytes.

Question 4

External Female Genitalia Lymph Drainage/blood supply/nerves

Answer 4

• Lymphatic Drainage : LOWER Vagina and Vulva (External Genitalia ) to Inguinal Lymph Nodes
• Blood Supply : Vaginal Arteries (from middle rectal and pudendal arteries )
• Nerve Supply: Pudendal Nerve (S2-4)

Question 5

Uterus & Ovaries Lymph drainage, blood supply, nerves

Answer 5

Blood supply to:

• Uterus: Uterine a. (br of hypogastric /internal iliac artery)
• Ovaries: Ovarian aa (br off aorta ; and anastomoses with the ovarian branch of the uterine artery

Lymphatic Drainage :

• Uterus ,ovaries, tubes and drain into internal iliac and paraortic lymphatics
• Middle and upper vagina drain into iliac lymph nodes

Nerve Supply:

• sympathetic: lower thoracic T10-12
• some parasympathetic (S2-S4)

Question 6

SYMPTOM : BREAST TENDERNESS/PAIN/Mastalgia DDx

Answer 6

• Cyclic Changes in Reproductive age females
• Increased tenderness premenstrual (increased Estrogen & Progesterone )
• Fibrocystic Change
• Pregnancy –usually diffuse tenderness
• Diet : Caffeine may increase symptoms of tenderness
• Medications : Oral contraceptive / Hormone use Psychiatric Drugs / Herbal Rx
• Family History : Breast Cancer Maternal and Paternal , particularly in young women

Question 7

NIPPLE DISCHARGE features & DDx

Answer 7

• Sero-sanguineous ( watery-bloody ) or bloody : Intraductal papilloma (usually benign) Intraductal carcinoma
• Purulent : infection
• Milk or colostrum: pregnancy, psychiatric medications, pituitary adenoma

Question 8

FCC

Answer 8

**Clinical Presentation **

• Dense, usually bilateral, upper outer breasts
• DIFFUSE - no discrete mass
• Not a discrete mass
• Increased premenstrual
• Resolves or decreases post menses

Dx

• re-evaluate post menses in 1-2 cycles
• Consider Ultrasound if persistent or Strong Family History of breast cancer
• FNAC if suspicious ultrasound, clinically suspicious ie asymmetric, persists through menses patient feels mass

Question 9

Common Breast Masses felt on palpation

Answer 9

• Fibroadenoma
• Cysts
• Cancer

Question 10

Fibroadenoma

Answer 10

**Clinical Presentation **

• Young women ages 15-25
• Mobile
• Firm, rubbery
• Well circumscribed
• Usually not tender / may be tender in pregnancy

Dx

• US
• FNAC

Question 11

Breast Cysts

Answer 11

**Clinical Presentation **

• Ages : 25-50
• Tender area
• Most common breast mass
• Soft , well circumscribed , round , mobile mass, tiny or large
• May be tender; tenderness may increase pre menses
• One or both breasts

**Dx: **

• US
• Aspirate
• Cytology

Question 12

Signs of Breast Cancer

Answer 12

• Nipple Retraction and deviation,
• Paget’s disease of the nipple,
• edema of skin (peau d’ orange)

Nipple

• Some women have always had inverted nipples ( Not Pathological ), often bilateral
• Signs of Malignancy :
• Thickening or loss of elasticity of the nipple
• Nipple deviation
• Retractions
• Inversions
• Serosanguinous
• hard, non-painful, non-mobile, bloody nipple dischg, no chg with menstrual cycle

Areolar : Paget’s Disease

• Symptom:Dry, Scaly, itchy nipple
• Eczematous ,excoriated nipple – areola complex
• May be associated with underlying malignancy

Dx

• Small non palpable lesions
• Diagnosis is 7 years prior to palpable size ( 1-2cm )
• Palpable lesions REQUIRE biopsy
• Core Biopsy is for mammographic lesions:
• role of mammography in palpable lesions is to evaluate the remainder of the breast , and the contralateral breast

Question 13

Mentrual pain (dysmennorhea)

Answer 13

• endometriosis
• leiomyoma

Question 14

Vulva lesionsDDx

Answer 14

• Benign vs Malignant
• Common Benign Mass: Bartholin’s cyst/ abscess
• Candida Vulvovaginitis ( Pruritis / redness )
• Lesions : Condyloma , HSV, Chancre,
• Malignant : Persistent pruritis ( itching ) or , raised, bleeding , malodorous lesion

Question 15

Cervix lesions DDx

Answer 15

• Cervical polyps are red soft benign growths seen coming through the cervical os (opening)
• Post coital bleeding is associated with cervical polyps and cervical cancer

Screening

• Cytology (Pap; image below) alone every 3 years
• HPV and cytology co- testing every 5 years

Question 16

Uterus lesion DDx

Answer 16

• Surface irregularities ie leiomyoma, (fibroids )
• Tenderness (PID, Adenomyosis ,endometriosis)

Question 17

Uterine bleeding DDx

Answer 17

Endometrial polyp

• Cervical Polyp
• Leiomyoma
• Endometrial hyperplasia
• Hormone producing tumors of ovary
• Endometrial cancer
• Cervix Cancer
• Thyroid disease
• Blood dyscrasias
• Leukemia
• ITP
• Medications and Herbal products
• PREGNANCY (Ectopic)

Question 18

Fibroids

Answer 18

• Heavymenstrualbleeding,often with anemia
• Progressive dysmenorrhea
• Pelvic pain,or back, flank or leg pain
• Pelvic pressureor heaviness, abdominal bloating (particularly premenstrual)
• Urinary pressure, bladder outlet obstruction, stress incontinence, dyspareunia
• Infertility?, Repeated miscarriage?, premature labor

Question 19

Endometrial Cancer

Answer 19

**Risk Factors **

• Obesity (over 30 lbs-3X; over 50 lbs-10X)
• Nulliparity
• Late menopause
• Complex Endometrial Hyperplasia
• Diabetes
• Hypertension
• Unopposed Estrogen

**Symptoms and signs **

• Post menopausal Bleeding / Spotting
• Heavier or longer menses
• Or shorter interval
• Uterus is normal size

Question 20

Ovarian mass DDx

Answer 20

Sx

• Irregular menses
• Pain
• Lump /Mass
• Abdominal Distention
• Vague abdominal symptoms
• Ascites

Dx

• Enlarged , cystic – soft , fullness
• Firm , mobile , well circumscribed: Benign teratoma (dermoid)
• Hard , firm , or poorly defined , irregular (malignancy)
• Bilateral : Teratoma, Metastatic Krukenberg tumors
• Pathological Ovaries are evaluated by pelvic AND rectovaginal exam

Question 21

Epithelial Ovarian Cancer

Answer 21

**Symptoms and Signs **

• None or Vague
• Fullness after meals Increase in abdominal girth Pressure
• Late Diagnosis as no approved screening and vague symptoms
• Exam : Ascites
• Irregular fixed adnexal
• mass (es ) on pelvic and
• rectovaginal exam