Gyn and breast disorders Flashcards
How do LH and FSH change from conception to birth in girls? Birth to 6mo? 6mo to 4yo?
Peak at 20wks gestation…and decrease ‘til birth
Increases again until 6mo
Gradually decreases until 4yo
What is going on at the hormone level from 4-8yo?
Low FSH, LH, and androgen d/t GnRH suppression
What is the order of events in normal female puberty?
Adrenarche (adrenal androgen production) Gonadarche (activation of gonads by LH and FSH) Thelarche (appearance of breasts) Pubarche (appearance of pubic hair) Growth spurt Menarche (~13yo)
What secretes estradiol and progesterone to maintain endometrium?
Corpus luteum
What initially secretes hCG? Why?
Endometrial cells (in response to implantation) to maintain corpus luteum
What is primary amenorrhea? What can cause it?
No menses by 16yo w/secondary sex characteristics; OR
No menses by 13yo w/o secondary sex characteristics
Hypothalamic or pituitary dysfunction, anatomic abnormalities (absent uterus, vaginal septa), chromosome abnormalities with gonadal dysgenesis
What is secondary amenorrhea? What can cause it?
Absence of menses for at least 6 months after previously normal menses
Pregnancy, ovarian failure, hypothalamic or pituitary disease, uterine abnormalities (Asherman syndrome…scarring), PCOS, anorexia nervosa/malnutrition, thyroid disease
What distinguishes primary from secondary dysmenorrhea?
Time…primary occurs at the beginning of menstruation and resolve over several days; secondary begins midcycle and increase in severity until conclusion of menstruation
Cause…primary has no pelvic pathology; secondary has pelvic pathology
How is primary dysmenorrhea treated?
NSAIDs or OCPs
What distinguishes PMS/PMDD from normal menstrual symptoms? How are they treated
They interfere with daily life
Exercise, B6, NSAIDs, OCPs, Progestins
SSRI +/- alprazolam for mood disorder (PMDD > PMS)
What is the most common cause of female infertility? How is it diagnosed?
Endometriosis (endometrial tissue outside the uterus)
Laparoscopy will show “powder burn” lesions and cysts on involved areas
What is adenomyosis?
Endometrial tissue invades myometrium –> uterine enlargement and cyclical pain
What does it take for uterine bleeding to be “abnormal”?
Less than 24 day interval
Greater than 35 day interval
Lasts more than 7 days
Loses more than 80mL blood
What causes amenorrhea with PCOS? Hirsutism?
Increased androgens –> increased estrogen –> abnormal LH and FSH (LH:FSH > 3)
Increased androgens (spironolactone can decrease this…but has to be stopped with pregnancy)
Do ovarian cysts cause PCOS symptoms?
No…the opposite really, excess androgen causes ovarian cysts
What bugs cause vaginitis?
Normal bacteria (Gardnerella vaginalis)…clue cells
Protozoans (Trichomonas)…green
Fungus (Candida albicans)…cottage cheese
How is vaginitis treated?
Gardnerella…Metronidazole
Trichomonas…Metronidazole (also treat partner)
Candida…azole or nystatin
A girl comes in really sick…vomiting, diarrhea, sore throat, headache, kinda shocky, and has desquamation of palms and soles. What is the cause? Risk factors? How is it treated?
Staph a exotoxin
prolonged tampon use, prolonged intravaginal contraception use, postpartum or postabortion infection
Remove object if there is one
Treat the shock
Clinda, PCN-beta lactam; vanc if necessary
Patient comes in with a painless ulcer on penis/vaginal wall. What is the likely cause? What is the near-future outcome?
Syphilis
It’ll heal w/in 9 wks…but secondary symptoms began as it heals
What are secondary syphilis symptoms?
Headache, malaise, fever, lymphadenopathy
Maculopapular rash on palms and soles
Papules in moist areas (condloma lata)
A patient returns from the tropics with a painful ulcer with a grayish base and foul odor. What is going on? What caused it? How is it treated?
Chancroid…can have large inguinal swelling
H. ducreyi
Ceftriaxone, erythromycin, or azithromycin
A guy returns from a developing country with a painless ulcer on his penis. What causes lymphogranuloma venereum? What is the concern if this is lymphgranuloma venereum? How is it treated?
L1-L3 serotypes of C. trachomatis
Significant inguinal buboes…can ulcerate or cause elephantiasis
Tetracycline, erythromycin, or doxycycline
Woman comes in with a painless ulcer with a beefy red bas and irregular borders. What is the likely diagnosis? What caused it? What would be seen on Giemsa stain?
Granuloma inguinale
Klebsiella granulomatis
Donovan bodies (red encapsulated intracellular bacteria)
What is the most common cause of postmenopausal bleeding? What has to be ruled out? How?
Atrophic vaginitis is most common
Endometrial cancer must be ruled out with a biopsy (CA-125 may be elevated…but shitty marker until postmenopausal)
A woman presents with abdominal pain and fullness. A palpable, tender mass is found on bimanual exam. What would suggest follicular cyst? What is the treatment?
Granolas cells with a 3cm cyst in first 2wks of cycle
Observation (may regress over menstrual period)
Ovarian cystectomy if mass does not regress or for increased suspicion of cancer
A woman presents with abdominal pain and fullness. A palpable, tender mass is found on bimanual exam. What would suggest a corpus luteum cyst? What are some concerns? What is the treatment?
Theca cells; cystic or hemorrhagic…usually larger and firmer than follicular cyst, also more common later in cycle
Increased risk of torsion or rupture
Observation…cystectomy if stays or cancer…surgical hemostasis and cystectomy if hemorrhage
A large growth is felt during both the bimanual exam and abdominal exam. What would be seen that would indicate mucinous or serous cystadenoma? How is it treated?
May resemble endometrial or tubal histology; psammoma bodies
Unilateral salpino-oophorectomy; TAH/BSO if postmenopausal
What is an endometrioma? How is it treated?
Spread of endometriosis to the ovary
OCPs, GnRH agonists, progestins, danazol may lessen symptoms
Cystectomy or oophorectomy for recurrence
A girl has precocious puberty and a cyst is found in her ovary. What kind of tumor is it?
Stromal cell tumor…granulosa theca cell tumor
A girl has virilization and a cyst is found in her ovary. What kind of tumor is it?
Stromal cell tumor…Sertoli-Leydig cell tumor
A young woman has multiple small, mildly painful masses in her breasts that vary in size during her cycle. What is this? How is it treated?
Fiborcystic changes
Caffeine and dietary fat reduction, OCPs, progesterone, or tamoxifen…in confirmed benign lesions
A young woman (less than 30yo) has a solitary, solid, mobile mass with well-defined edges. What is likely going on? What should be ordered? How is it treated?
Fibroadenoma (most common benign breast tumor)…proliferative process in a single duct
FNA to confirm benign
Surgical excision or US-guided cryotherapy
A woman has a palpable mass behind the areola and there is discharge from her nipple on stimulation. What is likely diagnosis? What would make it more concerning for malignancy? How is it treated?
Intraductal papilloma
Bloody discharge…get an excisional biopsy
Surgical excision
What is the downfall to FNA of potential breast cancer?
Cannot differentiate between in situ and invasive carcinoma
A mammogram showed a mass, so a biopsy was done that showed malignant cells in a duct without stream invasion. What is the diagnosis? What is a risk? How is it treated?
Ductal carcinoma in situ…often unifocal and may have calcifications
Higher risk of subsequent invasive cancer than LCIS
Lumpectomy and possible radiation
A mammogram showed a mass, so a biopsy was done that showed malignant cells in lobules without stream invasion. What is the diagnosis? What is a risk? How is it treated?
Lobular carcinoma in situ…can be multifocal; no calcifications
Lower risk of invasion than DCIS, but increased risk of contralateral malignancy
Close observation and tamoxifen or raloxifene…bilateral mastectomy if woman doesn’t want to worry about it
A woman comes in because one of her breasts looks like an orange. A biopsy shows malignant cells in ducts with stream invasion and microcalcifications. What is the diagnosis? What else is likely to be seen?
Infiltrating ductal carcinoma (most common…80% of cases)
Fibrotic response in surrounding breast tissue
A woman comes in because her husband felt a firm mass in one of her breasts. A biopsy shows malignant cells in breast lobules with insidious infiltration. What is the diagnosis? What else distinguishes it from infiltrating ductal carcinoma?
Infiltrating lobular carcinoma
Less fibrous response
More frequently bilateral or multifocal
Slower metastasis
Greater association with hormone replacement therapy
A woman comes in because of a soft, well-circumscribed mass that has been growing rapidly in one of her breasts. What is the likely diagnosis? What is the prognosis?
Medullary carcinoma
Better than ductal carcinoma
An older woman comes in because of a gelatinous, well-circumscribed mass that has slowly grown. What is the likely diagnosis? What is the prognosis?
Tubular carcinoma
Better than ductal carcinoma
A woman in her late-40’s is found to have a mass on mammogram. Biopsy shows well-formed tubular structures that invade the stroma. What is the diagnosis? What is the
Tubular carcinoma
Excellent
A woman comes in because her breast is warm and painful. On exam, lymphadenopathy is found. What is the likely diagnosis? What is the prognosis? Treatment
Inflammatory carcinoma…subtype of ductal carcinoma characterized by rapid progression and angioinvasion
Poor prognosis
Mastectomy + hormones + chemo
When are hormones or chemo used to treat breast cancer?
All node-positive cancers
Tumors >1cm or with aggressive histology
