Women's Health Flashcards
Breast Exam includes
neck
chest wall
both breasts
axillae
Timing of breast exam
9 days after onset of menses
Palpable mass <30
usually benign attributed to normal physiologic changes fibrocystic fibroadenoma cyst
Management of palpable mass <30
recheck in 2 weeks
monthly BSE
Imaging by sonogram (harder to see on mammogram b/c younger breasts more dense)
for this pt you would get a sonogram of breast
Palpable mass 55 y.o.
R/O malignancy first
then consider a cyst
Management of palpable mass 55 y.o
Diagnostic mammogram
35 and older mammogram the test of choice
The triple test
physical exam70% accurate
radiographic imaging 85% accurate
pathology 95% accurate
BIRADS category #4
suspicious, core needle biopsy or neele localization biopsy as soon as possible
Breast pain 3 types
cyclic
noncyclic
extramammary
Refer breast issues when
any mass if imaging studies are neg
when in doubt
cyclic breast pain
follows mentrual pattern
common during leuteal phase and may last 7 days
hormones
noncyclical breast pain
does not follow menstrual pattern
unilateral
could describe menopause women on hormone therapy
coopers ligaments stretching from large pendulous breasts
extramammary breast pain
chest wall pain
shingles
pleuritic,cardiac,GI
(costrochondritis)
most important question with pain evaluation
does the pain change in menstrual cycle
Benign breast pain tx
NSAIDS, tylenol well fitting bra oral contraceptives primrose oil 1500 BID x 4 months Danazol Vitamin E
Nipple discharge
common in reproductive years
most benign
Galactorrhea
discharge of milk beyond 6 month PP
white or clear
Abnormal nipple d/c
uniductal unilateral persistent sanguineous/ serosanguineous mammogram in those >30
Questions to ask with nipple d/c
lymph nodes enlarged?
change in color?
dimpling?
Benign rashes
canida: keep dry, nystatin cream
eczema: nipple not involved
contact dermatitis: topical steroids
Paget’s disease
detect early to avoid lymph involvement
looks like eczema but involves nipple
most aggressive type of breast cancer
inflammatory breast cancer
BIRADS scoring
0-6 (mild-severe)
BIRADS 0
need additional imaging
spot compression and magnification with ultrasound
BIRADS 1
Negative
routine follow up
0% malignancy
BIRADS 2
Benign
routine follow up
0% malignancy
BIRADS 3
Probably benign finding
diagnostic view of breast in 6 months
2% malignancy
BIRADS 4
Suspicious
core-needle biopsy
>2-95% malignancy
BIRADS 5
Highly suspicious of malignancy
core-needle biopsy
95% malignancy
BIRADS 6
biopsy proven carcinoma
Documenting mass
location with measurement and distance from nipple
tender/nontender
mobile
Fibrocystic changes with breasts
normal to have grainy feeling bilaterally with pain
common in those 30-50
can be related to estrogen
Fibroadenoma
common in young women in teens
mass is rubbery, mobile and non tender
Breast cyst classifications
simple
complicated
complex
Simple cysts
common in peri-menopausal oval smooth mobile well circumscribed
Complicated/Complex cysts
contain mixed cystic and solid components
high rate of cancer
aspirate and send to cytology
Normal vaginal environment
can have thick, pasty, dry or stringy d/c that is odorless
1-4ml d/c/24 hours
normal pH 3.8-4.2
Whiff test and KOH
take vaginal swab and add to slide
add 10% potassium hydroxide
if smell fishy then positive and eval for yeast
3 most common causes of vaginitis
trich
BV
candida
protozoa flagella
Trichomoniasis
symptoms of trich
50% asymptomatic pruritis vulvovaginal erythema strawberry cervix frothy yellow-green d/c
Dx trich
pH > 4.0
+ whiff test
wet mount with pos motile trich
Tx trich
metronidazole 2g PO x1 dose
no alcohol with this or will feel ill
safe with pregnancy
Vulvovaginitis Candidiasis
Yeast infection bacterial over growth pH 4.0-4.5 thick, clumpy, white KOH test
Classification of candidiasis
complicated
uncomplicated
uncomplicated candidiasis
sporatic or infrequent
mild to mod symptoms
C. albicans
not immunocompromised
complicated candidiasis
recurrent with 4 or more/yr
women with uncontrolled diabetes, immunosuppression or pregnant
severe symptoms
Tx candidiasis
uncomplicated: 3 day tx with azole
recurrent: 7-14 days with topicals
or
fluconazole 150mg x 1 dose and repeat in 3 days
Pregnancy tx for candidiasis
topical azole therapies x 7 days
Bacterial Vaginosis
most common cause of d/c without vulvitis or vaginitis
over growth of Gardnerella
lactobacilus
BV presentation
discharge
odor
vaginal irritation
feeling wet
Diagnose BV
with 3 of the following: thin white d/c that coats vaginal wall clue cells on microscope pH >4.5 pos whiff test
Tx BV
oral or vaginal metronidazole or clinda (5g of 2%cream if not pregnant
orals only with pregnancy
Cervicitis causes
Gc/chlamydia HSV HPV Trich trauma radiation malignancy
Symptoms of cervicitis
abnormal d/c
vaginal bleeding following intercourse
Dx 2 signs of cervicitis
purulent or mucopurulent endocervical exudate
endocervical bleeding induced by cotton swab
Tx cervicitis
Azithromycin1g PO x1
or
Doxy 100 BID x 7 days
Pelvic Inflammatory disease
ascending spread of microorganisms from vagina to endometrium, fallopian tubes and ovaries
Clinical manifestations of PID categorized
Subclinical- not dx, most common
Mild to Mod
Severe
Subclinical signs of PID
irregular bleeding
dysuria
Mild to Mod signs of PID
lower abd or pelvic pain cramping d/c fever cervical motion tenderness
Severe signs of PID
fever
chills
nausea
vomiting
Risks of PID
ectopic pregnancy
infertility
tubal infertility (increases with each time)
Minimum criteria to dx PID
uterine tenderness
adnexal tenderness
cervical motion tenderness
Other signs to dx PID
temp >101
abundant WBC on swab
elevated sed rate
Pos Gc/clyamydia
Oral tx for PID
Ceftriazone 250mg IM x1 plus Doxy 100mg PO BID x 14 days with or without metronidazole 500mg PO BID x 14 days
Follow up from PID treatment
consider retesting for Gc/clamydia 4-6 weeks after
treat male sex partners
Condyloma Acuminata
HPV
Types of HPV
Type 6 & 11 = genital warts (HSV II sexual contact)
Type 16 & 18 = cancers
Primary HSV presentation
incubation 4 days after exposure burning before lesion present neurologic pain that radiates to back and hips multiple vesicles rupture persist for 2-6 weeks flu like symptoms
Management of HSV
culture of vesicle (neg does not rule out genital herpes) VCR gold standard serologic assay oral antiviral pain meds
Recurrent HSV presentation
less sever of asymtomatic
tx with antivirals
Chancroid
haemophilus ducreyi
pustule ruptures
Tx haemophilus ducreyi
Azithro 1gm PO x1
Ceftriaxone 250 mg IM x1
Chancre
Syphilis
painless, rounded, indurated ulcer with serous exudate
resolves spont 3-6weeks
Ulcerative vaginal lesions diff dx
HSV
syphilis
H. ducreyi
Bartholin’s duct cyst
more common in women in reproductive age
most are small, larger result in more pain
IND to drain
Genital tract bleeding
most attributed to uterine source
can arise from urethral, bladder, bowel
Normal menstrual cycle
average of 28 days (21-35 days)
menstruation 4-7 days
blood loss 35ml
chronic menstrual blood loss
> 80 ml per cycle which can lead to anemia
pain with ovulation
Mittelschmerz
abnormal uterine bleeding
any bleeding that does not conform to the freq, duration or amount of bleeding that a woman considers normal
irregular menstrual cycles
Types of abnormal uterine bleeding
menorrhagia metrorrhagia menometrorrhagia polymenorrhea hypermenorrhea
Menorrhagia
bleeding occurs at normal intervals but is prolonged
Metrorrhagia
irregular bleeding between menstrual cycles
Menometrorrhagia
irregular noncyclic bleeding that is prolonged or excessive
Polymenorrhea
bleeding intervals less than 21 days
Hypermenorrhea
amount of menses is abnormally hign or low
Dysfunctional uterine bleeding
abnormal bleeding without an organic etiology
anovulatory bleeding
ovulatory bleeding
example: >80ml bleeding in cycle
anovulatory bleeding
endometrium is cont. proliferating
endometrium is fragile and there is irregular sloughing
unpredicted bleeding
spotting
infrequent heavy bleeding
occurs in early menarche and premenopausal
ovulatory bleeding
regular cycle length prolonged or excessive bleeding less likely to respond to hormone therapy loss of hemostasis in endometrium NSAIDS good b/c they interrupt cycle
Testing for age 13-18 in abnormal uterine bleeding
screen for blood dyscrasias
CBC to rule out coag issue
Testing for age 19-50 in abnormal uterine bleeding
TSH
FSH
CBC
fasting prolactin to r/o pituitary adenoma
indications for endometrial biopsy with abnormal uterine bleeding
19-39 years old if chronic anovulation or unresponsive to medication
40-49 years unless pregnant or reason to avoid
Tx abnormal uterine bleeding
NSAIDS b/c they decrease prostaglandins oral contraceptives danazole gonadotropin releasing hormone agonists ablation hysterectoy
Primary amenorrhea
absence of menarche by age 16 in the presence of normal growth
Secondary amenorrhea
absence of menses for 3 consecutive cycles in women who were previously menstruating
could be stress or strict diet
lab for amenorrhea
prolactin thyrotropin, FSH dehydroepiandrosterone testosterone progesterone challenge test - give PO progesterone, stop pill and bleeding should occur within 10 days
dysmenorrhea
painful menstruation
primary (adolescents)
secondary (genital disorders)
dysmenorrhea with menstruation
with menstruation there is an increased prostaglandin synthesis and
increased markers of inflammation which causes decreased unterine blood flow and increased uterine contractility
Tx dysmenorrhea
NSAIDS
heat
Vit E
contraceptives
Location where you take Pap sample
SCJ zone or transormation zone
Optimal Pap testing
avoid anything in vaginal for 48 hours avoid with heavy bleeding take specimen before bimanual remove excessive mucous or bleeding gently ectocervical then endocervical
Squamous cell abnormalities
ASC- atypical squamous cells
LSIL- low grade squamous cell lesion (CIN1)
HSIL- high grade squamous cell lesion (CIN2-3)
Carcinoma
CIN 1
grade of neoplasia
corresponds to LSIL
mild dysplasia
confined to basal 1/3 of epithelium
CIN 2
grade of neoplasia
moderate dysplasia
basal 2/3 of epithelium
CIN 3
sever dysplasia
carcinoma-in-situ
may involve full thickness of epithelium
When pap is unsatisfactory
repeat in 2-4 months
if cells obscured then tx infection or colposcopy
HPV self cure
75-90% of HPV will clear within 1 year due to immune response
Adolescents may take up to 24 months
HPV screening
not recommended less than 20 y.o.
not recommended 21-29 just routine cytology
routine screening >30 HPV and cytology q5 years or just cytology q3 years
not recommended after 65 or after hyst
HPV screen prior to gardasil
not needed
Standard mammography screening
annually for asymptomatic women age 40 and older who have no risk factors
Mammography recommendations for women at risk
start annual mammogram at 30, not before 25
Women who have 1st degree relative with BRACA mutation mammogram
yearly starting at 30 age
woman with a 20% or greater lifetime risk for breast cancer recommendations for mammogram
yearly starting at 30 age
When should mammography be stopped
there is no reason to stop
View of mammogram
craniocaudal and mediolateral oblique view of each breast
Gardasil vaccination guidelines
1st dose
1-2 months give 2nd dose
3rd dose is given 6 months after 1st dose
Age to start Gardasil
recommended 11 to 12 years
Catch up Gardasil
Females 13 through 26 years of age
Males 13 through 21 years
