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Clinical Medicine 5 > GYN (part 1)-Exam 2 > Flashcards

GYN (part 1)-Exam 2 Flashcards

1
Q

Contraceptive Options
* What are the factors that you need to consider? (8)

A
  • Efficacy
  • Convenience (taken at the same time of day)
  • Duration of action
  • Reversibility and time to return of fertility
  • Effect on uterine bleeding
  • Frequency of side effects and adverse events
  • Affordability
  • Protection against sexually transmitted diseases
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2
Q

Basic Rules
* When can contraception be initiated?
* More reliable and faster protection from what?

A
  • Contraception can be initiated on any day of cycle if reasonably certain the woman is not pregnant
  • More reliable and faster protection from unplanned pregnancies
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3
Q

Basic Rules
* Advise how long of backed up protection or abstinence?
* Improves what?
* No increase in what?

A
  • Advise 7 days of back-up protection or abstinence
  • Improves short-term continuation
  • No increase in unscheduled bleeding
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4
Q

What are the most and least effective family planning methods? (general)

A
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5
Q

Reversible Methods
* What are the examplesof most effective methods (tier 1)?

A

Long-Acting Reversible Contraception (LARC)
* Levonorgestrel-releasing IUD (Mirena)
* Copper IUD (Paragard)
* Implant

In tier 1 are the most effective methods, with less than 1 pregnancy occurring per 100 women per year. The most effective reversible methods include implants and IUDs.

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6
Q

Reversible Methods
* What are the examples of moderately effective methods (tier 2)?

A
  • Injectable Medroxyprogesterone acetate (DMPA)
  • Pill
  • Patch
  • Ring
  • Diaphragm

Tier 2 methods include injectables, pills, patch, vaginal ring, and diaphragm; failure rates range from 6-12%.

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7
Q

Reversible Methods
* What are the examplesof least effective methods (tier 3)?

A
  • Condoms (male/female)
  • Cervical cap, sponge
  • Fertilitiy awareness based methods
  • Pull out method
  • Spemcides

Tier 3 methods include condoms, withdrawal, sponge, spermicide, and fertility awareness based methods; failure rates range from 18-28%.

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8
Q

Hormonal contraceptives
* What are the different examples?

A
  • Combination pill (estrogen and progesterone)
  • Progestin-only pill
  • Contraceptive patch – easier form of delivery
  • Contraceptive ring – NUVA ring for 3 weeks
  • DMPA (Depo-Provera) shots – IM q 3 months for up to 2 years (ACOG).
  • Implantable contraceptive rods
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9
Q

How long does NUVA ring and DMPA shot last?

A
  • Contraceptive ring – NUVA ring for 3 weeks
  • DMPA (Depo-Provera) shots – IM q 3 months for up to 2 years (ACOG)
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10
Q

Hormonal contraceptives
* What does progestin provide? What does it cause? (3)

A

Progestin component provides the major contraceptive effect
* Suppressing secretion of LH and, thus ovulation
* Thickens cervical mucus
* Alters fallopian tube peristalsis

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11
Q

Hormonal contraceptives
* What does the estrogen component cause

A
  • Suppresses FSH thus inhibiting follicle maturation
  • Potentiates the progesterone component
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12
Q

Combined Oral Contraceptives
* Used by who?
* What are the regimens? (2)

A
  • Used by 1/3 of sexually active women in the U.S.
  • Monophasic and triphasic regimens
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13
Q

Combined Oral Contraceptives
* How does monophasic work?

A
  • Contain the same dose of estrogen and progestin in each of the active pills
  • Traditionally give 21 days of active pills followed by 7 days of placebo pills (to reinforce the habit)
  • 12 week cycle pills are available (11 weeks of active pills followed by one week of placebo pills) + 1 week of no pills period. Have 4 periods a year.
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14
Q

Monophasic pills
* Newer pills contain how much of ethinyl estradiol?
* What other preparations are available?

A
  • Newer pills contain on average 30 – 35 mcg of ethinyl estradiol
  • 20 to 25 mcg preparations are available
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15
Q

Combined Oral Contraceptives-20 to 25 mcg preparations
* What is Lo-Estrin 1/20, Mircette, Alesse good for?
* What may be more common?
* Especially useful for who?
* Mircette contains 10 mcg of ethinyl estradiol on 5 of the placebo days to reduce what?

A
  • Lo-Estrin 1/20, Mircette, Alesse (lower amounts – good for those that are too sensitive (sick) to regular pills)
  • Breakthrough (brown discharge) bleeding may be more common
  • Especially useful for perimenopausal women due to low doses of estrogen
  • Mircette contains 10 mcg of ethinyl estradiol on 5 of the placebo days to reduce perimenopausal symptoms (weight gain, mood swings etc)
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16
Q

Under notes

  • Estrogen helps with what symptoms?
  • What are the SE of estrogen? (4)
  • Who should not be taking estrogen? Why?
A
  • Estrogen helps perimenopausal symptoms
  • SE: These include painful and swollen breasts, vaginal discharge, headache, and nausea.
  • Because oral estrogen can be hard on theliver, people with liver damage should not take it. Instead, they should choose a different way of getting estrogen.
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17
Q

Combined Oral Contraceptives
* How does triphasic pills work?

A
  • Dose changes every week throughout 1 cycle
  • Deliver a lower total dose of hormone
  • Have a higher incidence of break through bleeding

No clinical benefit over monophasic pills

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18
Q

Progestin only pills
* Option for who?
* Great option for OCP right after what?

A
  • Option for women who want a contraceptive pill, but need to avoid estrogen
  • Great option for OCP right after delivery _ continue breastfeeding and prevent pregnancy
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19
Q

Progestin only pills
* Associated with more what?
* Pills must be taken when?

A
  • Associated with more unscheduled (breakthrough) bleeding and slightly higher failure rates than combined OCPs
  • Pills must be taken at the same time each day and are taken every day without a pill free interval
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20
Q

Under notes

  • What is preferred for breast feeding?
A

Until breastfeeding is established, progesterone-only pill (POP) use is preferable over combined hormonal contraception (CHC), as the latter potentially reduces milk production

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21
Q

Intrauterine Contraception: Kyleena or Mirena (both are levonorgestrel/progestin)
* Prevents what?
* Thickens what?
* How long does it last?⭐️

A
  • Prevents sperm and egg from meeting
  • Thickens cervical mucus; “Hostile uterus”
  • 5 years; 0.2% failure rate
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22
Q

Intrauterine Contraception: Paragard (Copper IUD)
* Prevents what? (2)
* How long does it last? ⭐️

A
  • Prevent the egg from being fertilized or from attaching to the uterine wall
  • Prevents sperm from going into the uterus and fallopian tube
  • 10 years; 0.5 – 0.8% failure rate
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23
Q

Intrauterine Contraception
* What are the contraindications?

A
  • Severe uterine distortion (more than 1 cavity or disease distortion like adenomyosis)
  • Active pelvic infection
  • Known or suspected pregnancy
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24
Q

Intrauterine Contraception
* What are two indications? (non-medical)

A
  • Multiparous and nulliparous women at low risk for STDs
  • Women who desire long-term reversible contraception
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25
Q

Intrauterine Contraception
* What medical conditions are indications? (5)

A
  • DM
  • Thromboembolism
  • Menorrhagia/ dysmenorrhea
  • Breast CA
  • Liver Disease
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26
Q

Intrauterine Contraception
* What are the contraindications?(6)

A
  • Pregnancy
  • PID (current or w/in past 3 months)
  • Current STDs
  • Undiagnosed abnormal vaginal bleeding
  • Malignancy of the genital tract
  • Purulent cervicitis
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27
Q

Injectable contraceptives
* What is the example?
* When do you give it?
* Efficacy?
* DMPA use significantly reduces the risk of what?

A
  • Depo medroxyprogesterone acetate (Progestin only)
  • DMPA (150 mg) is given IM every three months
  • Efficacy is 99.7%
  • DMPA use significantly reduces the risk of developing endometrial cancer
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28
Q

Injectable contraceptives
* What are the SE of depo shot?

⭐️

A
  • Menstrual irregularities (bleeding or amenorrhea), weight changes, headache, abdominal pain or discomfort, nervousness, dizziness, decreased bone mineral density
  • ACOG states that the advantages of DMPA generally outweigh the theoretical concerns about skeletal harm secondary to BMD loss due to decreased estrogen levels: use no longer than 2 years.
  • Return of fertility may be delayed (need to educate them on this)
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29
Q

Contraceptive Implants: Nexplanon
* What is it?
* How long does it last?
* When does protection begin?

A
  • Nexplanon- A single rodprogestin implants
  • Contraception is provided for three years by slow release of progestin
  • Protection from pregnancy occurs within 24 hours of insertion
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30
Q

Contaceptive implants
* When does fertility return?
* What is common reason for discontinuation?
* Great option for who?

A
  • Fertility returns rapidly after removal of the rod
  • Irregular bleeding is a common reason for discontinuation
  • Great option for a college student
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31
Q

Non contraceptive benefits: fill in for which contaceptives would work
* Dysmenorrhea and reduced Anemia:
* Cycle Control:
* Cancer Protection:
* Ectopic Pregnancy:

A
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32
Q

Non contraceptive benefits: fill in for which contaceptives would work
* Acne:
* Menstrual Suppression:
* Endometriosis pain:
* Pre-menstrual related symptoms (PMS):

A
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33
Q

Oral Contraceptives
* What are the SE? (3)

A
  • Early SE: Bloating, nausea, breast tenderness
  • Breakthrough bleeding is the MC SE (10-30% of women during the first 3 months)
  • Amenorrhea (should r/o pregnancy first)
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34
Q

Oral Contraceptives
* What are the serious complications? When is this more likely?(4)

⭐️

A

more likely in high dose pills % with smoking
* Venous thrombosis
* PE
* Gallbladder Dz
* Stroke/ MI

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35
Q

Oral Contraceptives
* Estrogen has been shown to increase what?
* Progesterone has been shown to decrease what?

A
  • Estrogen has been shown to increase cholesterol production in the liver, with excess amounts precipitating in bile and leading to the formation of gallstones.
  • Progesterone has been shown to decrease gall-bladder motility, which impedes bile flow and leads to gallstone formation.
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36
Q

What is the US Medical Eligibility Criteria?

A
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37
Q
A
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38
Q

Combined Oral Contraceptives
* What are the absolute contraindications? (7)⭐️

A
  • Any previous thromboembolic event (clot) or stroke
  • Impaired liver function
  • Pregnancy
  • Undiagnosed abnormal vaginal bleeding (hormones can feed the carcinoma)
  • Cerebral vascular disease (past or current history)
  • Women over age 35 years who smoke
  • migraine with aura
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39
Q

Combined Oral Contraceptives
* Who do you need to be caustion with? (5)

A
  • HTN
  • Anticonvulsants (may decrease effectiveness of OCP’s)
  • Migraine headaches (with focal neurologic symptoms)
  • Obese women over age 35 (due to glucose and hyperlipidemia)
  • DM
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40
Q

Under notes

Combined Oral Contraceptives
* The World Health Organization contraindicates the use of estrogen-based combined oral contraceptives when?

A
  • The World Health Organization contraindicates the use of estrogen-based combined oral contraceptives in women with migraine with aura who are over 35. They are also contraindicated for women with migraine with aura who are under the age of 35 if they smoke due to their increased risk of cardiovascular disease.
  • Combined hormonal contraceptives are contraindicated in women who have migraine with aura, in whom these drugscan increase the risk of ischemic stroke. However, this contraindication is based on data from the 1960s and 1970s, when oral contraceptives contained much higher doses of estrogen
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41
Q

Emergency Contraception
* What are the options for up to 72 hours of unprotected sex?⭐️

A

Emergency contraceptive pills
* Levonorgestrel 0.75mg is given in 2 doses 12 hours apart; 1% failure rate; “plan B”
* 4 pills taken 12 hours apart of LoOvral, Nordettee or Levlen; 3% failure rate

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42
Q

Emergency Contraception
* What is the option for up to 120 hours after unprotected sex?⭐️

A

Copper IUD

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43
Q

Hormonal Contraception: Drug interactions
* What happens with the drug interactions? What are the examples? (3)

A

Several anticonvulsants accelerate the metabolism of hormonal contraceptives; women on these medications should not use hormonal contraception (with the exception of depo provera)
* Phenytoin
* Carbamazepine
* Topirimate

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44
Q

Hormonal Contraception: Drug interactions
* Hormonal contraceptives may do what?
* What is the ONLY antibiotic that requires a back-up method of birth control?

⭐️

A
  • Hormonal contraceptives may lower serum levels of lamotrigine
  • Rifampin
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45
Q

What are the multiple techiques for sterilization in women?

A

Multiple techniques (Laparoscopy or hysteroscopy)
* Electrocautery of tube (poor reversibility)
* Pomeroy Technique
* Filshie Clip (lower failure rate)
* Falope Ring (intermediate failure rates)
* Hulka Clip (Reversible with great failure rate)

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46
Q

Sterilization via Hysteroscopy
* Access to the fallopian tube is what?
* What is placed and where?
* A subsequent tissue reaction results in what?

A
  • Access to the fallopian tube is transcervical
  • A titanium-Dacron spring device is placed directly into the tubal ostia (Essure) or radiowaves scar surrounding tissue (Adiana)
  • A subsequent tissue reaction results in tubal occlusion
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47
Q

Sterilization via Hysteroscopy
* Often used for who?

A

Often used for obese patients who may not be a candidate for laparoscopy

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48
Q

Tubal Ligation Reversal Outcomes
* What are the success rate?
* What is the situation with ages?

A

Realistic success rate 25% – 50%

25% of women under 30yo who undergo sterilization later regret the decision
* Private insurance pays after age 18yo
* Medicaid, in some states after age 25yo
* Some OBGYNs will not do this until 30yo

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49
Q

Tubal Ligation Reversal Outcomes
* What do you need to counsel your patients on? (3)

A
  • Permanent nature of the procedure
  • Alternate methods of contraception
  • Risks and benefits of the procedure (including risk of ectopic pregnancy)
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50
Q

Sterilization in Men
* What are the different options?
* Easy or hard to reverse?

A

Various techniques for vasectomy
* Excision and ligation
* Electrocautery
* Mechanical or chemical occlusion of the vas deferens

More easily reversed than sterilization procedures for women

  • Failure rate is 1%
  • 1/3 of surgical sterilization procedures are performed on men
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51
Q

Sexual Violence
* What groups of people are the highest risk?

A

Heterosexual and Lesbian females, Bisexual Men are at highest risk

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52
Q

LY

Sexual Violence Facts
* What is the gender and age differences in rates?

A
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53
Q

Child Sexual Abuse
* What is the definition child sexual abuse?
* Involvement of a child in sexual activity that he/she… (3)

A

Definition: When Sexual Violence (SV) involves a victim less than 18 years old.

Involvement of a child in sexual activity that he/she:
* Does not fully understand
* Does not consent to or is unable to give informed consent or
* Is not developmentally prepared for and cannot give consent to

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54
Q

Adverse Childhood Experience (ACE)
* ACE may affect what?
* What are the consequences?

A
  • ACE may affect how a person thinks, acts and feels-over a lifetime
  • Short and long term physical and mental health consequences
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55
Q

Sex Trafficking
* Type of what?
* Form of what?
* What is the definition?
* What is hte hotline?

A
  • Type of human trafficking
  • Form of modern-day slavery
  • “use of force, fraud or coercion to make an adult engage in commercial sex acts”
  • 1 (888) 373-7888->National Human Trafficking Hotline
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56
Q

The Trafficking Victims Protection Act
* When?
* Framework for what?
* What are the 3 pronged approach?

FYI

A
  • Enacted in 2000
  • Framework for the federal response to human trafficking
  • 3 pronged approach – Prevention, Prosecution and Protection
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57
Q

The Trafficking Victims Protection Act
* Dept. of Homeland Security investigates what?
* FBI investigates what?

FYI

A
  • Dept. of Homeland Security investigates bulk of sex and labor trafficking cases involving foreign nationals
  • FBI investigates domestic minor sex trafficking cases
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58
Q

Clinical care of sexual abuse
* What do you need to provide? (4)

A
  • Attention to physical injury
  • Evaluate for STI
  • Emergency contraception
  • Pscyhological counseling-30/35% lifetime risk of posttraumatic stress response, depression and contemplation of suicide
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59
Q

What are some of the Physical Injury from sexual abuse?

A
  • Landmark studies indicate ~ 52%
  • Serious injury requiring emergent intervention uncommon
  • Bruises and abrasions most common
  • Intracranial injury ~1%
  • Visceral injury ~3%
  • Fractures of face and skull ~2%
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60
Q

Collecting the History, Consent-Sexual abuse
* Do your best to do what?
* WHat do you need to document? (4)

A
  • Do you best to document the history in the patient’s own words
  • Document body cavities involved
  • Document number of assailants
  • Document last consensual intercourse
  • Document last LMP and if the patient is known to be pregnant
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61
Q

Collecting the History, Consent-Sexual abuse
* Not time of what?
* Assume your documention will be used when?
* Obtain what?

A
  • Note time since assault, if the patient has changed clothes, bathed.
  • Assume your documentation will be used in court
  • Obtain consent from patient or next of kin to proceed to pelvic examination and take photographs and document that consent
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62
Q

Examination-> Typically done by SANE nurse (Sexual Assault Nurse Examiner)
* Have the patient do what?
* Use what?
* Note any what?

A
  • Have the patient disrobe while standing on a white sheet-collect any debris or pubic hair that fall
  • Use a wood light to identify semen (fluorsces), collect with swabs
  • Note any skin injury-entire body
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63
Q

Examination-> Typically done by SANE nurse (Sexual Assault Nurse Examiner)
* What do you need to do with HEENT?
* What do you need to do with Pelvic exam?
* Look for what?

A
  • HEENT- Swab inside of cheeks and around molars in mouth
  • Pelvic exam-Swab vaginal walls-apply to slides, air dry
  • Look for motile or nonmotile sperm under microscopy and record
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64
Q

Examination by Colposcopy
* What can you do? (2)

A
  • When a stain is used on cervix, colposcopy raises the documentation of trauma to ~ 80% in adolescents, ~60% in women
  • Colposcopy with photographs has become the standard of care in the sexual assault forensic examination
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65
Q

Lab Tests- Sexual abuse
* All may be applied to what?
* What are the STIs?
* Wet mount for what?
* What do you need to be worried about?

A
  • All may be applied to vagina, anus or mouth as history dictates
  • Neisseria gonorrhoeae, Chlamydia
  • Wet mount for Trichomonas
  • Pregnancy
66
Q

Lab Tests- Sexual abuse
* What test can you do for syphilis?
* What should you do if indicated?
* Repeat what?
* Obtain what cx?

A
  • VDRL: Venereal Disease Research Laboratory (VDRL) test for syphilis
  • HIV viral load or antibody if indicated
  • Repeat pregnancy test if next LMP is missed, repeat VDRL in six weeks
  • Obtain blood and urine if forced drug or alcohol reported
67
Q

What is the treatment for sexual abuse patients? (6)

A
  • Analgesics or sedative if indicated
  • Tetanus toxoid
  • STD prophylaxis
  • HIV prophylaxis
  • Hep B vaccine
  • Counseling and psychologic support
68
Q

Prophylaxis Against STD
* What do you need to do for Gonorrhea/chlamydia? BV? Trichomonas?

A
69
Q

Prophylaxis Against STD
* What do you do for Hep B and HIV?

A
70
Q

Under notes

What does the CDC recommend for testing schedule for Hep C and B and HIV

A
  • The CDC recommends the following testing schedule:Hepatitis B testing: 1–2 months after exposure.
  • Hepatitis C testing: 4–6 months after exposure (or earlier, if desired)
  • HIV testing: administered at 6 weeks, 3 months, and 6 months.
71
Q
A
72
Q
A
73
Q

⭐️

A
74
Q

Psychological Therapy-Sexual abuse
* What should be done with skilled clinician?
* What may be needed for long and short term?
* What is key? (2)

A
  • Talk therapy with skilled clinician
  • Pharmaceuticals may be needed short and long-term
  • Supportive environment key
  • Insight key
75
Q

When do you refer for a sexual abuse patient?

A

Always refer to a facility that has providers qualified to perform an expert forensic examination, if available.

76
Q

Florida occupations who must report
* Who must report? (7)

A
77
Q

Consent
* Assess the patient’s ability to do what?
* Document what?

A
  • Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.
  • Document the informed consent conversation and the patient’s (or surrogate’s) decision in the medical record in some manner. When the patient/surrogate has provided specific written consent, the consent form should be included in the record.
78
Q

Consent
* Present relevant information how? What should you include?

A

Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about:
* The diagnosis (when known)
* The nature and purpose of recommended interventions
* The burdens, risks, and expected benefits of all options, including forgoing treatment

79
Q

Breast Exam: Screening with clinical breast exam (CBE)
* What does the ACS and ACOG say about timelines?
* USPSTF concludes what?

A
  • American Cancer Society (ACS) and the American Congress of Obstetricians and Gynecologists (ACOG): may begin every 1-3 years from age 25 to 39, and annually thereafter (Level C)
  • The US Preventive Services Task Force (USPSTF): concludes that evidence is insufficient to assess additional benefits of clinical breast examination beyond mammography (Level I)
80
Q

Breast Exam: Screening with self breast exam (SBE)
* What does ACS and ACOG and USPSTF recommend?

A
  • ACS recommends that women be educated about the benefits and limitations of BSE
  • ACOG recommends routine teaching of BSE
  • USPSTF recommends against teaching women the procedure stating there is moderate or high certainty that the service has no net benefit or that the harms outweigh the ben
81
Q

BSE
* BSE alone has not been shown to reduce what?
* Because a negative BSE may tempt some women to what?

A
  • BSE alone has not been shown to reduce mortality rate, but evidence of its usefulness is mixed, and it is widely practiced.
  • Because a negative BSE may tempt some women to forego mammography or CBE, the need for these procedures should be reinforced when BSE is taught.
82
Q

BSE
* Patients should be instructed to do BSE how?

A

Patients should be instructed to do BSE on the same day each month. For menstruating women, 2 or 3 days after menses ends is recommended because breasts are less likely to be tender and swollen.

83
Q

Galactorrhea
* What is it ?
* Often result from what?

A
  • Any inappropriate secretion of milky discharge from the breast.
  • Often results from abnormally elevated levels of prolactin, although it may occur with normal levels
84
Q

What causes elevated Prolactin:
* What are physiologic causes?
* Abnormal stimulation of what?
* _

A
85
Q

What causes elevated Prolactin:
* What meds? (4)
* What systemic disease?(3)

A
  • Med- MOIs, SSRIs, Many antihypertensives, drugs of abuse
  • Systemic disease-Chronic renal failure, hypothyroidism, Cushing’s, acromegaly
86
Q

Diagnostic Approach: Galactorrhea
* Any history of what?
* Review all what?
* Check what? (2)

A
  • Any history of menstrual disorders, increased acne, hirsutism, infertility or libido
  • Review all medications, dietary supplements and drug use
  • Check thyroid function
  • Check for unknown pregnancy
87
Q

What is the txt of Galactorrhea?

A
  • If possible, stop any medications that may be contributing
  • Correct any underlying disorder
88
Q

Mastitis
* What are the sxs?
* Typically occurs when?
* Due to what?
* What will US show?

A
  • Severe pain, tenderness, swelling, redness
  • Fever, chills, myalgias
  • Typically occurs in second week postpartum
  • Due to milk stasis and infection
  • Ultrasound will reveal hypoechoic (dark) fluid surrounding subcutaneous fat lobules
89
Q

What are the common pathogens of mastitis?

A
  • Staphylococcus aureus ~40% of cases
  • E. Coli
  • Streptococcus species
  • If abscess present, consider MRSA
90
Q

Treatment- mastitis
* Referral to who and why?

A

Referral to breastfeeding support if desires breastfeeding
* Correct latch
* Drain plugged ducts

You do not have to stop the patient from breastfeeding

91
Q

treatment mastitis
* What is the proper topical therapy?

A
  • All Purpose Nipple Ointment: LANOLIN
  • Bactroban 2% ointment, betamethasone 0.1% ointment, miconazole powder 2% are not superior

You do not have to stop the patient from breastfeeding

92
Q

Treatment of mastitis
* If mastitis/cellulitis is significant, prophylax what?
* You cannot give what
* Should respond how?

⭐️

A

If significant, prophylax typical skin flora
You CANNOT give bactrim to lactating mothers with infants under 2 months old
Should respond rapidly, if not look for an abscess and broaden antibiotic coverage

You do not have to stop the patient from breastfeeding

93
Q

Breast Abscess
* Uncommon complication of what?
* What does it show on US?
* Management based on what?
* What is last resort?

A
  • Uncommon complication of Mastitis
  • Subcutaneous fluid collection on ultrasound
  • Management based no severity of infection-PO antibiotics, IV antibiotics, outpt/inpt
  • Surgical drainage last resort

Occurs in about 3% of Mastitis cases

94
Q

Cellulitis
* What are the sxs?
* May lead to what?
* Requires what?

A

Erythematous, tender to palpation
* May lead to mastitis

Requires referral to a breast surgeon for imaging and possible biopsy

95
Q

What are the RF of cellulitis? (6)

A
96
Q

What is found on exam with cellulitis?

A
  • Erythematous skin overlying a portion of, or the entire breast
  • Very tender to palpation
  • Possible enlarged axillary nodes, also tender
  • Infection can spread along lymphatic pathways (lymphangitis)
97
Q

Diagnosis & Treatment: cellulitis
* How do you dx it?
* What do you not need? Exception?
* What are the typical organisms?

A
  • Clinical diagnosis
  • No labs needed unless evidence of systemic infection or septic in appearance
  • Typically beta hemolytic streptococcus or staph-appropriate antibiotic coverage
98
Q

Diagnosis & Treatment: cellulitis
* If no rapid response to antibiotics, then what?
* May also request what?

A
  • If no rapid response (48hours) to antibiotics- US of breat to look for abscess or malignancy
  • May also request mammography and MRI
99
Q

Acute Mastitis/Abscess in Non-lactating Women
* What are the RFs? (3)
* What are the pathogens?
* What is the empiric treatment?

A
100
Q

Acute Mastitis/Abscess in Non-lactating Women
* If no improvement in 48 hrs then what?
* All women over 30 should get what?

A
101
Q

Benign Breast Disease: Mastalgia
* when does cyclic occur and how?
* Noncyclic is not associated with what? What are common causes?

A

Cyclic – begins with luteal phase and resolves with menses
* Bilateral

Noncyclic – not associated with menses
* Common causes: tumors (adenoma), mastitis, cysts

102
Q

Benign Breast Disease: Mastalgia
* What are common causes of nonmammary? (3)
* What is the treatment options for all mastalgias?(4)

A

Nonmammary
* Common causes: chest wall trauma, rib fractures, fibromyalgia

Treatment options:
* OCPs, supportive undergarments, danazol, tamoxifen

Under notes:
* Danazol is in a class of medications called androgenic hormones. It worksto treat endometriosis by shrinking the displaced tissue of the uterus. It works to treat fibrocystic breast disease by blocking the release of hormones that cause the breast pain and lumps.
* tamoxifen blocks estrogen’s action on breast cells,

103
Q

Nipple Discharge
* What is more concerning? Why?
* What indicates infection?

A
  • Bilateral nipple discharge is not as concerning as unilateral
  • Unilateral discharge carries a higher risk of cancer
  • Purulent likely indicates infection
104
Q

Nipple Discharge
* What discharge carries a higher risk of cancer? What does it require?

A

Pink, bloody, or serosanguinous discharge carries a higher risk of cancer -> Requires further investigation with ductogram
* Mammography and discharge fluid analysis warranted

105
Q

Fibrocystic Changes
* MC in who?
* Thought to be due to what?

A

Most common benign breast disease - ~50% of women of reproductive age
* Most common ages 30-50

Thought to be due to hormonal imbalance
* Estrogen

106
Q

Fibrocystic Changes
* What does it feel like?
* Tender? When?
* What are red flags?

A
  • Multiple, usually bilateral TENDER mobile masses in the breast
  • Cyclical bilateral breast tenderness, most prominent just before menstruation
  • Red flags: recurrent or severe symptoms, solid masses, nipple abnormalities, edema, skin changes, unilateral discharge
107
Q

What is the difference in characteristics of fibrocystic and breast cancer?

A
108
Q

Variation of normal or breast cancer risk:
* What are the true risk factors?

A

Although fibrocystic condition has generally been considered to increase the risk of subsequent breast cancer,only the variants with a component of epithelial proliferation (especially with atypia), papillomatosis, or increased breast density on mammogram represent true risk factors

109
Q

How do you dx fibrocystic changes?

A

Ultrasound: Especially in women under 30
* Too radiodense

Mammogram

Core needle biopsy

Suspicious lesions

110
Q

Treatment
* What is the at home treatment for fibrocystic breast changes

A
111
Q

Treatment
* What is the medical treatment for fibrocystic breast changes

A
112
Q

Under notes

Treatment: fibrocystic breast changes
* What is GLA known for? Once consumed what happens?

A
  • GLA is known for its anti-inflammatory properties and its ability tosupport hormonal balance.
  • Once consumed, GLA is converted into beneficial compounds called prostaglandins, which regulate various bodily functions, including inflammation, blood clotting, and hormone synthesis
113
Q

Fibroadenoma of the Breast
* More common in who? (Race)
* _ mass
* Occurs when (age)

A
  • African American>Caucasians
  • Benign mass
  • Usually occur ~20 years after puberty and regress after menopause
114
Q

Fibroadenoma of the Breast
* How does it feel?
* What is needed for definitive dx?
* _

A
  • Typically round, firm, discrete, relatively movable non-tender mass 1-5cm in diameter
  • Biopsy for definitive diagnosis
  • Excise
115
Q
A
116
Q

Female Breast Carcinoma
* What are major the different risk factors? (6)

A
117
Q

Female Breast Carcinoma
* What are some other the different risk factors? (6)

⭐️

A

KNOW FIRST THREE

118
Q

Basic Classification of breast cancer
* Where are the different areas that the cancer can begin?

A

Milk ducts: Ductal Carcinoma
* Can be both invasive and in situ

Milk-producing lobules: Lobular Carcinoma
* Usually invasive

Connective tissues (rare)
* Sarcoma (phyllodes tumor and angiosarcoma)

119
Q

Phyllodes tumor
* What type of tumor?
* Rate of growth?
* Dangerous? What should you do?
* Metatasis where?

A

Fibroadenoma like tumor

Grows rapidly

Benign or malignant
* Excise with margins of normal tissue

Metastasis to the lungs

120
Q

Categories of Breast Masses
* What are the non-prolifeative types? (3)

A
  • Fibrocysitc changes
  • Lactational adenomas
  • Fibroadenomas
121
Q

Categories of Breast Masses
* What are the prolifeative types without atypia? (3)

A
  • Epithelial hyperplasia
  • Sclerosing adenosis
  • Papillomas
122
Q

Categories of Breast Masses
* What are the prolifeative types with atypia? (2)

A
  • Lobular carcinoma in situ (LCIS)
  • Ductal carcinoma in situ (DCIS)
123
Q

Classification – Clinical and Histological: breast cancer
* Based on what?
* Considers what?
* What is determined post op
* What is used in prognosis?

A
124
Q

Histological staging is determined post op: breast cancer
* What are the three histological categories?
* What is the percentage breakdown?

A
  • Three histological categories: Ductal, lobular and nipple
  • 70-80% are ductal which spread to regional LN
  • 5-50% are invasive lobular carcinomas
125
Q

Breast cancer

Classification – Hormone Status
* When is it graded?
* What are the types and treatments?

A

Graded after biopsy is performed

Cancers are fueled by hormones
* Estrogen receptor (ER) positive-> Treated with antiestrogens
* Progesterone receptor (PR) positive->Treated with progesterone blockers
* Hormone receptor (HR) negative->Endocrine treatment is not useful

126
Q

Breast cancer

Classification – Hormone Status
* What is the specific genetic mutations?
* What are the different types that will have combinations?
* Which ones grow faster and slower?

A
  • Specific genetic mutations: HER2 gene
  • Different types with combo: Triple negative (KNOW THIS ONE) or ER/PR or HR-/HER2 negative. Here BRCA1 gene is common too
  • HR + cancer grows slower, HR - faster, triple negative are the fastest
127
Q

What are the four molecular subtypes of breast cancer?

A
128
Q

Clinical Findings: breast cancer
* Usually found how?
* If palpable mass is present, is it painful?
* May have what?

A
  • Usually found via mammogram, less often from finding palpable mass
  • If palpable, mass is typically not painful
  • May have nipple discharge, erosion, retraction, enlargement or itching of the nipple
129
Q

Clinical Findings: breast cancer
* What is rare?
* Fewer than 10% of breast cancers are found on what?

A
  • Rare – bone pain, swelling of arm
  • Fewer than 10% of breast cancers are found on Physical Exam
130
Q
A
131
Q

How do you do a breast exam?

A
  • Inspect the. Breasts – asymmetry, retraction or dimpling of skin
  • Palpate breasts and axillary and supraclavicular areas thoroughly
132
Q

Characteristics of Mass in Breast Cancer (2)

A
  • Non-tender, hard or firm with poorly defined margins
  • Lesions >1cm are generally palpable
133
Q

Characteristics of Mass in Breast Cancer
* What are the characteristics of advanced carcinoma? (7)

A
  • Edema
  • Redness
  • Peau d’orange
  • Fixated to chest wall
  • Retraction of breast
  • Marked axillary lymph nodes
  • Supraclavicular lymphadenopathy
134
Q

Breast Carcinoma
* Dx how?
* Most common positive sentinel node is what?

A
  • Diagnosis by H&P, mammography, needle aspiration, biopsy
  • Most common positive sentinel node is Axillary
135
Q

Breast Carcinoma
* Management depends on what?
* What are the different types? (6)

A

Management depends on staging
* Lumpectomy
* Mastectomy
* Axillary LN dissection
* Radiation
* Chemotherapy
* Hormonal therapy

136
Q

Paget’s Disease of the Breast (PDB)
* What happens to the nipple?
* Associated with what?
* There is what present?

A

Eczematoid eruption and ulceration of the nipple

Associated with underlying carcinoma
* Adenocarcinoma cells

There is a palpable mass in ~50% of patients with paget’s disease

137
Q

Paget’s Disease of the Breast (PDB)
* Of these masses-95% are found to be what?
* If no palpable mass, what is present in 75% of cases?
* What is uncommon?

A

Of these masses-95% are found to be invasive cancer
* Ductal carcioma in situ
* 2 cm from nipple areolar complex

If with no palpable mass-noninvasive breat cancer or cancer in situ is present in 75% of cases

Uncommon (~1%) but important due to it’s being frequently misdiagnosed

138
Q

What is this?

A

Paget’s Disease of the Breast (PDB)

139
Q

What are these?

A

Paget cells
* These cells are found in the epidermis (surface layer) of the skin of the nipple and the areola.
* Paget cells often have a large, round appearance under a microscope; they may be found as single cells or as small groups of cells within the epidermis.

140
Q

Inflammatory Carcinoma
* _
* What is the clinical appearance?
* Usually has underlying what?
* 35% of patients will have what?

A
  • Aggressive
  • Clinical appearance – diffuse, brawny edema with erysipeloid boarder
  • Usually has an underlying palpable mass.
  • 35% of patients will have metastasis at presentation
141
Q

Inflammatory Carcinoma
* Inflammatory breast cancer isa type of breast cancer in which the cancer cells do what?

A

block the lymph vessels in the skin of the breast. This causes the breast to look red and swollen. The skin may also appear dimpled or pitted, like the skin of an orange (peau d’orange), and the nipple may be inverted (facing inward).

142
Q

Breast Cancer during Pregnancy or Lactation
* When does pregnancy associated occur?
* Typically present when?
* Formerly, what was done?

A
  • Pregnancy associated-breast cancer that occurs during pregnancy, in the first post-partum yeat or anytime during lactation
  • Tyically present at a later stage
  • Formerly, pregnancies were terminated within first two trimesters-this has been dtermined not to improve the outcome
143
Q

Breast Cancer during Pregnancy or Lactation
* What can preg women get?
* What must be individualized?

A
  • Women can receive some chemotherapeutic agents in second and third trimester, no radiation treatments.
  • There is a teratogenic risk and decision must be individualized
144
Q

Bilateral Breast Cancer
* Common or rare?
* however what is there an increase risk?

A
  • <1%
  • However – breast cancer in one breast increases risk of future cancer in the other breast.
145
Q

Mammography
* Breast imaging modality of what?
* Estimates what?
* A skilled radiologist correctly interprets what?

A
  • Breast imaging modality of choice and the only screening method found to decrease mortality of breast cancer
  • Estimates that lesions can be detected 2 years earlier than on palpation
  • A skilled radiologist correctly interprets mammograms with a 90% rate
146
Q

Ultrasound breast
* Useful as a next step in evaluation what?
* Recall what?
* Useful in initial evaluation of what?

A
  • Useful as a next step in evaluation of a breast mass detected on mammography
  • Recall negative predictive value from PAM670
  • Useful in initial evaluation of suspected abscess, infection.
147
Q

MRI breast
* Excellent what?
* Offered as what?
* Leads to what more often?

A
  • Excellent visualization
  • Offered as initial test more frequently
  • Leads to biopsy more often
148
Q

Diagnosis: Breast cancer
* Requires examination of what?
* Safest course is what? (2)

A
  • Requires examination of tissue via biopsy
  • Safest course is to biopsy all suspicious masses
  • Also safest to biopsy all suspicious lesions demonstrated on mammography
149
Q

Diagnosis: Breast cancer
* Fine needle biopsy?
* What offer more definitive dx?
* Another type of biopsy?

A
150
Q

What is the process of breast cancer dx?

A
151
Q

What may be seen in advanced cases of metastatic breast cancer?

A

hypercalcemia

152
Q

Looking for Metastasis
* What do you order?
* _ Node
* Some cancer center will use waht?

A
  • CT and bone scans used most frequently
  • Sentinel Node
  • Some cancer centers will use a combo of PET and CT scans – allows for evaluation of visceral and bony metastases
153
Q

Screening Recommendations
* What does American College of Radiology, American Cancer Society and American Medical Association recommend?
* What does American College of Obstetricians and Gynecologists recommend?
* What does USPSTF recommend?

* TEST!!!

A
  • American College of Radiology, American Cancer Society and American Medical Association recommend annual mammograms for women starting at age 40.
  • American College of Obstetricians and Gynecologists recommend mammography every 1-2 years for women age 40-49 and annually thereafter.
  • USPSTF recommends biennial screening at 50-74

* TEST!!!

154
Q

Special Circumstance of screening:
* Women with a genetic predisposition for breast cancer should be screened when and how?
* Same women should undergo what?

* TEST

A
  • Women with a genetic predisposition for breast cancer should be screened using MRI beginning at age 25 or the age of the youngest occurring breast cancer in family
  • Same women should undergo a combo of mammogram and MRI after age 30

* TEST

155
Q

Treatment of breast cancer
* What is rarely indicated, rarely performed?
* What is Modified Radical Mastectomy ?
* What is breast conservation?
* What is based no biospy results?

A
156
Q

Follow up of breast cancer
* How long is the follow up
* Physical exam when?
* Mammogram when?
* What are the routine labs?

A
  • Breast cancer patients should have life-long follow-up
  • Physical exam every 3-6 months for first three years and then every 6-12 months until year 5, and annually thereafter
  • Mammogram within 6 months of treatment completion and annually thereafter
  • Routine labs-CBC, Chem panel with LFTs
157
Q

Lymphedema of the Arm
* Due to what?
* Significant what?
* May refer to who?
* _
* Therapeutic what?

A
  • Due to lymphatic disruption
  • Significant Edema
  • May refer to a PT or OT who specializes in lymphedema
  • Wrapping
  • Therapeutic exercise
158
Q

Bone Metastasis
* Bone is the most common site of what?
* What is the txt?
* What do you need to monitor?

A

Bone is the most common site of metastatic disease both at initial diagnosis and recurrence
* Thoracic spine 63.6% and Lumbar spine 53.8%

Bisphosphonate therapy has been shown to decrease pain and slow rate of skeletal events and complications

When given – monitor dental health, labs, renal function

159
Q

Prognosis of Breast cancer
* What is hte most reliable indicator?
* What is the best prognosis?
* What is not indicative of any true value?

A
  • Stage at diagnosis single most reliable indicator.
  • Localized disease without evidence of regional lymph spread carries best prognosis.
  • 5-year survival rates are not indicative of any true value
160
Q

Prognosis of Breast cancer:
* Women with breast cancer survive, on average what?
* What is the clinical cure rate with localized disease?
* Who is unlinkely to be cured and care shifts with time?

A
  • Women with breast cancer survive, on average, 20 years less than those at same as them at diagnosis
  • Clinical cure rate achieved in 75-80% of women with localized disease
  • Patients with metastatic breast cancer are unlikely to be cured and care shifts with time
161
Q

Breast Redness PEARLS
* If you see cellulitis, do what? What happens if it does not go ago?
* If there is no abscess, then what is next step?

A
  • If you see cellulitis, treat it. Should the cellulitis not go away with ABX within 3-5 days, consider ultrasound. In this case ultrasound will be most effective and superior to r/o abscess (which could be the reason why cellulitis did not get better).
  • If there is no abscess, then mammogram is the next step to look for inflammatory mass/cancer. If mass is identified, refer to surgeon for biopsy.
162
Q

Breast Redness PEARLS
* If you find a noncellulitic mass in a 30yo female, what is best? 40 yo?
* What is goal and explain?

A
  • The above process is slightly different in a noncellulitic mass noted in a patient. If you find a noncellulitic mass in a 30yo female, US is best. If patient is 40yo, the mammogram is best.
  • Sometimes a negative predictive value is the goal. Lets say a 40yo patient has no risk factors for breast cancer and you find a tender (cyclical) mass on exam. Considering most likely diagnosis to be fibrocystic change, getting an ultrasound may prevent a biopsy (if the negative predictive value is achieved). If patient has risk factors, then biopsy should be the next step.

Clinical Medicine 5 (10 decks)

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