UWise - Objectives 40-44 Flashcards
What are the greatest risk factors for developing breast cancer?
Age and gender
True or false - transient breast tenderness is not a symptom of breast cancer.
True
What are other risk factors for breast cancer?
Having a first-degree relative with breast cancer
Risk of developing breast cancer before menopause is increased if BRCA-1 or BRCA-2 +
How does folliculitis present?
Painful erythematous raised tender nodule, often after shaving
How do fibroadenomas present?
Firm, painless, freely mobile
True or false - stimulation of the breast during the physical exam may give rise to an elevated prolactin level.
True
When are accurate prolactin levels best obtained?
Fasting state after no breast stimulation fofr 24 hours
If a prolactin is truly elevated, what is indicated?
TSH and brain MRI to rule out a pituitary tumor
Postpartum women may continue to produce milk for up to ___ (time) after cessation of breastfeeding.
Two years
Pathologic causes of elevated prolactin levels?
- Hypothyroidism
- Hypothalamic disorders
- Pituitary disorders (adenomas, empty sella syndrome)
- Chest lesions (breast implants, thoracotomy scars, herpes zoster)
- Renal failure
When is a ductogram indicated?
Patients who have bloody discharge from a single breast duct
What is the most common type of benign breast condition?
Fibrocystic breast changes
Fibrocystic disease is often associated with cyclic mastalgia, possibly related to a pronounced hormonal response. What can increase this pain?
Caffeine intake
What is typically the first noticeable symptom of breast cancer?
A lump that feels different from the rest of the breast tissue
If a fine needle aspiration of a breast mass returns bloody fluid and reduces the size of the mass to 1 cm, what should be done next?
Excisional biopsy to r/o breast cancer
If a fine needle aspiration of a breast mass returns clear fluid and the mass resolves, what should be done next?
Reexamination in two months to check that the cyst has not recurred
True or false - a normal mammogram does not rule out breast cancer, especially in the presence of bloody fluid.
True
Puerperal mastitis most often occurs when following delivery?
During the second to fourth week
How should puerperal mastitis be managed?
Ibuprofen + acetaminophen for pain relief
Continue breastfeeding/expressing milk during treatment
Oral or IV antibiotics
Breast U/S if suspicion of an abscess
A specimen obtained on fine-needle aspiration is examined both histologically and cytologically. If it is negative, what should be done and why?
Excisional biopsy - possibility of a false-negative
How can a breast U/S be used in the setting of a mass?
Distinguish between a cyst and a solid mass
How can a FNA under U/S be used in the setting of a breast mass?
Distinguish a fibroadenoma from a cyst and exclude cancer in certain situations
Breast MRI should not be used routinely as a screening test for breast cancer; however, it may be indicated in what patients?
Those with an increased risk of breast cancer
To whom does the ACS recommend offering breast MRI in addition to mammography?
- BRCA mutation carriers
- First degree relatives of BRCA mutation carriers
- Genetic mutations such as Li-Fraumeni syndrome
- Women with a >20-25% lifetime risk of breast cancer based on risk prediction modeling
- Women with a history of radiation to the chest between ages 10-30
Any solid dominant breast mass on exam should be evaluated cytologically with what or histologically with what?
FNA; excisional biopsy
Nipple itch is a common symptom of what issues?
Allergies, dry skin, inflammation, physical irritation, chemical irritants (laundry detergents, soaps, perfumes)
True or false - itching sensations are not associated with adenomas or ruptured breast implants.
True
What is indicated in a patient with cervical dysplasia?
Cervical conization by a LEEP procedure or cold knife cone in order to remove the abnormal cells
When is a radical hysterectomy an option for patients with invasive cervical carcinoma? (which stage)?
Ia2 through IIa
List # complications from a LEEP.
- Infection
- Bleeding
- Cervical stenosis
- Persistent disease
- Possible preterm delivery
What is the next step in management of a vulvar lesion unresponsive to treatment?
Biopsy
(Note - if initial diagnosis of condyloma, for example, is unsure, a biopsy should be performed prior to initiating therapy
When is an abdominal flat plate X-ray indicated in the setting of failed IUD removal?
If the IUD had not been visualized on U/S to determine whether the IUD had fallen out or migrated intra-abdominally
If an IUD migrates outside the uterus, what may be offered for removal?
Laparoscopy
What is the next step when IUD removal with an IUD hook fails and it is visualized in the uterus?
Hysteroscopy to perform removal of IUD under direct visualization
What is the next step in working up an adnexal mass found incidentally?
Pelvic U/S
What test should be performed prior to placement of an etonogestrel implant?
Urine pregnancy test (as pregnancy is a contraindication to placement)
What are other contraindications to placement of the etonogestral implant?
Personal history of breast cancer or other hormonally sensitive cancer, history of thrombosis, history of liver tumors or liver disease, vaginal bleeding without explanation
How does an endocervical polyp present?
Spotting and bleeding between periods, common in women in their 40s and 50s, rarely malignant
How should an endocervical polyp be managed?
Polypectomy
What is the definitive treatment for a patient with pelvic pain due to endometriosis?
Hysterectomy
What is the normal and predictable sequence of sexual maturation in females?
- Thelarche (breast budding)
- Adrenarche (hari growth)
- Growth spurt
- Menarche
In a minority of cases, pubarche can occur before thelarche
Breast development begins around the age of ___, and the average age of menarche is ___ for Caucasian girls and ___ for black girls. Menarche also occurs earlier for ___ (thinner vs. heavier) girls.
10; 12.7; 12.1; heavier
What body weight is needed before menses begins?
85-106 lbs
In addition to adequate body weight, what are the two other critical elements for secondary sexual characteristic development?
- Sleep
2. Optic exposure to sunlight
What are psychosocial causes of delayed puberty?
Eating disorders, excessive exercise, stress, depression
What causes Turner syndrome?
Absence of one of the X chromosomes
How does Turner Syndrome appear in females?
Failure to establish secondary sexual characteristics, short stature, and characteristic physical features (pterygium colli, shield chest, cubitus valgus)
Partial deletions of the long arm of the X chromosome may cause ___.
Premature ovarian failure
True or false - the average age of puberty in females with Down syndrome is significantly different than normal females.
False - the average age of puberty in females with Down syndrome is NOT significantly different than normal females.
What causes Prader-Willi syndrome?
Partial deletion of chromosome 15
How does Prader-Willi syndrome present?
Hyeprphagia and obesity
How does Rokitansky-Kuster-Hauser Syndrome present?
Vaginal and uterine agenesis
What is the pathophysiology of Kallmann syndrome?
Olfactory tract hypoplasia -> arcuate nucleus does not secrete GnRH
How does Kallman syndrome present?
No sense of smell, no development of secondary sexual characteristics
What is a good first step in assessing for Kallman syndrome?
Olfactory challenge test
How is Kallman syndrome treated?
Pulsatile GnRH therapy
What is true precocious puberty?
Diagnosis of exclusion where the sex steroids are increased by the HPG axis, with increased pulsatile GnRH secretion
List CNS abnormalities associated with precocious puberty.
- Tumors (astrocytomas, gliomas, germ cell tumors secreting hCG)
- Hypothalamic hamartomas
- Acquired CNS injury (inflammation, surgery, trauma, radiation, abscess)
- Congenital anomalies (eg, hydrocephalus, arachnoid cysts, suprasellar cysts)
___ is characterized by premature menses before breast and pubic hair development.
McCune Albright Syndrome
What is the pathophysiology of congenital adrenal hyperplasia of the 21-hydroxylase type?
Adrenal gland is unable to produce adequate cortisol as a result of a partial block in the conversion of 17-hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens, leading to precocious adrenarche
How is congenital adrenal hyperplasia treated?
Steroid replacement
How does Mullerian agenesis present?
Absent uterus and cervix, present ovaries that function normally -> normal secondary sexual characteristics
In a patient with Mullerian agenesis, what should be evaluated next?
Renal anomalies (occur in 25-35% of females with Mullerian agenesis)
Lower genital tract malformations occur in 1/10,000 females and are most commonly due to a ___.
An imperforate hymen, where the genital plate canalization is incomplete
How is imperforate hymen treated?
Surgical correction
The workup for amenorrhea (primary or secondary) should always rule out ___.
Pregnancy
When should HPV vaccination be offered to females?
Between ages 9 and 26
Anorexia nervosa or significant weight loss may cause ___ dysfunction that can result in amenorrhea. Describe the pathophysiology.
Hypothalamic-pituitary; lack of the normal pulsatile secretion of GnRH leads to a decreased stimulation of the pituitary gland to produce FSH and LH, leading to anovulation and amenorrhea
List the causes of hypothalamic-pituitary amenorrhea.
- Functional (weight loss, obesity, excessive exercise)
- Drugs (MJ and tranquilizers)
- Neoplasia (pituitary adenomas)
- Psychogenic (chronic anxiety and anorexia nervosa)
- Certain other chronic medical conditions
When considering hypothalamic-pituitary amenorrhea, what lab test should be done initially?
FSH, which would be expected to be in the low range
When are DHEAS and 17-OH progesterone labs useful?
Working up hyperandrogenism
How is PCOS treated?
OCPs
What constellation of findings suggests PCOS?
Irregular cycles, obesity, hirsutism
What is the most common cause of amenorrhea?
Pregnancy
Hypergonadotropic amenorrhea is the result of ___ or ___.
Ovarian failure; follicular resistance to gonadotropin stimulation
What can cause Asherman’s syndrome?
Curettage or endometritis
How can Asherman’s syndrome cause amenorrhea?
Intrauterine synechiae or adhesions result from trauma to the basal layer of the endometrium, which causes amenorrhea
Why do individuals with PCOS have a higher risk of developing endometrial hyperplasia and cancer?
Chronic unopposed estrogen exposure
Although some have suggested links between PCOS and breast and ovarian cancer, these links are related primarily to ___ in the case of ovarian cancer and ___ in the case of breast cancer, and not to the syndrome itself.
Clomiphene use; obesity
Women with hypothalamic amenorrhea (such as those with female athlete triad or nutritional deficiency) are hypoestrogenic due to prolonged suppression of ovarian function. How should menstruation be stimulated?
Combined estrogen and progestin to cause enough proliferation of endometrial tissue for a withdrawal bleed to occur
___ with PCOS are less likely to present with overt hirsutism than other ethnic groups.
Asians
When Cushing’s syndrome is suspected, what should be done to evaluate?
Dexamethasone suppression test or a 24-hour urinary measurement for cortisol (elevated cortisol would be indicative of Cushing’s)
How is late onset 21-hydroxylase deficiency evaluated?
17-hydroxyprogesterone level
What are the diagnostic criteria for PCOS?
2/3 of the following:
- Chronic anovulation
- Hyperandrogenism (clinical/biologic)
- Polycystic ovaries on U/S
*Pelvic U/S is not necessary for the diagnosis if the other 2 criteria are met
What is postpartum telogen effuvium?
Postpartum hair loss (affects 40-50% of women)
What is the pathophysiology of postpartum telogen effuvium?
High estrogen levels in pregnancy increase the synchrony of hair growth. Therefore, hair grows in the same phase and is shed at the same time. Occasionally, this can result in significant postpartum hair loss at 1-5 months postpartum, with three months after delivery being the most common time
How does hair normally grow in the non-pregnant state?
Asynchronous hair growth occurs such that a portion of hair is in one of the three hair growth cycles at all times
Presentation of Sertoli-Leydig cell tumors in women?
- Commonly diagnosed between 20 and 40 y/o
- Most often unilateral ovarian mass
- Rapid onset of hirsutism and virilizing signs (hallmarks)
- Acne, hirsutism, amenorrhea, clitoral hypertrophy, deepening of the voice
- Suppression of FSH and LH, elevated of testosterone
List the two estrogen-secreting tumors.
Granulosa cell tumors and thecomas
What is a more severe form of PCOS?
Hyperthecosis
How does hyperthecosis present?
Virilization due to high androstenedione production and testosterone levels
In addition to OC’s, what can be used to treat hirsutism?
Spironolactone, an aldosterone antagonist diuretic
Second-line treatments: leuprolide, depot medorxyprogesterone
What is danazol used for?
Treatment of endometriosis
How do OC’s lower testosterone to treat hirsutim?
Increase the amount of sex hormone binding globulin, effectively lowering circulating free testosterone
For patients who are bothered by ethnic pattern hair growth, what would be appropriate?
Cosmetic hair removal via laser or electrolysis
