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premenstrual tendernes
o fibrocystic changes
78 year old nursing home urinary incotinence, less mobile, solment,
normal temp, disoreiented, thin vaginal mucosa - managing uti next step
o urinalysis+culture
ovarian mass categorizing as malignant or benign
o ca-125 then w/pelvic ultrasound
33 year old w/amenorrhea of 9 months, no symptoms, had tubal ligation
aka not pregnant, 254lbs, obese, lab tests normal fsh and lh, cause of
amenorrhea?
o anovulation
fsh, lh normal, ovariies still produce estrogen
progesterone not produced normally
no progesterone withdraw
following leep or cryotherapy
o Followup Pap smears are performed every 6 months for 2 years to
ensure that the dysplastic changes do not return
hysterectomy
o Subtotal or supracervical hysterectomy
removes only the corpus of the uterus
leaving the cervix in place
o Total hysterectomy = simple hysterectomy
corpus+cervix
o Radical hysterectomy
early-stage cervical carcinoma
uterus, cervix, and surrounding tissues, including cardinal
ligaments, uterosacral ligaments, and the upper vagina
Hysteroscopy
o to biopsy lesions or to resect submucous leiomyomas, polyps, or
uterine septa
woman breast feeding first noticed redness a wee ago, worsened, exam
shows patch of erythema patch from areola, 3cm FLUCTANCE,
management?
o needle aspiration + antibiotics
diclo, cephalexin
Premenstrual Dysphoria
evaluation
Diary of symptoms for >2 cycles
temporal relationship of symptoms to cycle is important
Treatment
Selective serotonin re-uptake inhibitors (SSRIs)
severe PMS, PMDD
paroxetine is contraindicated in pregnancy
first trimester exposure may lead to congenital heart disease
Drospirenone + ethinyl estradiol (Yaz; Yasmin)
drospirenone is a spironolactone analog
antiandrogen and antimineralocorticoid effects
Gonadotropin-releasing hormone agonist (GnRH agonist)
Premenstrual Syndrome (PMS)
mostly occur 2 weeks before her menstruation
disappears with menses
more severe affective changes in premenstrual dysphoric disorder (PDD)
Diagnosis
o symptom diary the patient keeps throughout 3 menstrual cycles
o temporal relationship
o symptoms:
recurrent in at least 3 consecutive cycles
absent in the preovulatory phase of the menstrual cycle
present in the 2 postovulatory weeks
interfere with normal functioning
resolve with onset of menses
o secretory stage = symtpoms
o proliferative (variable length) = NO symptoms
fluoxetine, alprazolam (Xanax), and GnRH agonists have been shown in
controlled, double-blind trials to be superior to placebo for the more severe
symptoms
Yaz (drospirenone/ethinyl estradiol)
o progestin, drospirinon (DRSP)
o monophasic
o only a 4 day hormone-free
o DRSP = analogue of spironolactone
both antimineralocorticoid and antiandrogenic effects
MENOPAUSE
12 months of amenorrhea
elevation of gonadotropins (FSH and LH)
mean age 51
o smokers experience menopause up to 2 years earlier
Premature
o 3040
o mostly idiopathic but can occur due to:
radiation therapy or surgical oophorectomy
<30 = autoimmune or Y mosaicism
hot flashes
o profuse sweating and sensation of heat
hypothalamic thermoregulatory center
Chancroid
Incubation period: typically 410 days
Clinical features
o Very painful genital ulcers
o Deep, small ( 1020 mm in diameter), well-demarcated lesions with a grayish necrotic base
o Painful inguinal lymphadenopathy
An asymptomatic course is more likely in women.
In contrast to chancre, chancroid is often painful: causative pathogen is Haemophilus du-creyi ("do cry")!
Chancroid is a clinical diagnosis.
Microbiological analysis or culture may confirm the diagnosis - expensive
Gram-stain: gram-negative rods in ulcer exudate
Dark field examination for Treponema pallidum and HSV PCR to rule out primary syphilis
Antibiotic treatment: single dose oral azithromycin or IM ceftriaxone, examine and treat sexual partner(s).
Pelvic examination shows a large, nontender left adnexal
mass
Hemoclynam,cal>,t Hemoclynamically
stable unstable
I I
I
TYUS Immediate surgical
consultation
i
Adnexal mass I tnlrauterine pregnancy I Nondiagnostic
Treat ectopic
pregnancy
?=t:2_
Repeal p..hCG level Repeat 13-hCG level
+ in2 days
TYUS in 2days
lWS=ullr.lsolnl
eUWorld
Endometrial hyperplasia/cancer
Excess estrogen
Obesity
Risk Chrome anovulation/PCOS
factors Nulhpanty
Earty menarche/late menopause
TamoXJfen use
Aromatase deficiency:
Choriocarcinoma suspected:
obtaining quantitative flhCG
helps confirm diagnosis
Predisposing factors
Breast cancer in the contralateral breast ; history of ovarian, endometrial, or colorectal cancer
Increased estrogen exposure
High number of total menstrual cycles
Early menarche, late menopause
Nulliparity
First full-term pregnancy after age 35 years
Exogenous estrogen intake: hormone replacement therapy after menopause
BRCA1 or BRCA2 gene mutations
Autosomal-dominant inherited gene mutation
Associated with an increased risk for breast cancer ( 70%) and ovarian cancer
BRCA-positive women = 1520 years earlier than women without the mutation
BRCA mutations are found in 510% of all women with breast cancer
Positive family history (e.g. affected first-degree relatives)
+ history of breast conditions (e.g., fibrocystic change, fibroadenoma) with cellular atypia
Previous radiation treatment in childhood
Lifestyle factors: low-fiber, high-fat diet, smoking, alcohol, obesity postmenopausal women
Associated diseases: Li-Fraumeni (Sarcoma, Breast, Leukemia, Adrenal cancer
Autosomal dominant inherited mutation of the p53 tumor suppressor gene
o ^^malignancies early: breast, osteosarcoma, leukemia, lymphoma, brain, adrenocortical
Peutz-Jeghers syndrome
Most breast cancers = adenocarcinomas = ductal tissue (80%) or lobular tissue (20%)
Noninvasive (in situ) carcinomas
o Ductal carcinoma in situ (DCIS) = 25% of all newly diagnosed breast cancers
o Localization: unifocal
o Frequently has a pattern of grouped microcalcifications
o Higher risk of subsequent invasive carcinoma (ipsilateral)
Lobular carcinoma in situ (LCIS)
o 15% of all newly diagnosed breast cancers
o Localization: multifocal
o Microcalcifications are rare
o LOWER risk of subsequent invasive carcinoma (ipsilateral and/or contralateral)
The noninvasive carcinomas are characterized by the absence of stromal invasion!
Invasive carcinomas
o Invasive ductal carcinoma (most common) = 7080% invasive carcinomas
Unilateral localization
Mostly unifocal tumors
More aggressive, early metastases
o Invasive lobular carcinoma = 1015% of all invasive breast carcinomas
Unilateral or bilateral
Frequently multifocal
Less aggressive than ductal carcinoma
Slower metastasis than ductal carcinoma
o Less common subtypes: mucinous (< 5% ), medullary (5%), tubular (12% )
o Inflammatory breast cancer
Patients with breast cancer develop clinical symptoms rather late at advanced tumor stages.
Typical signs may include:
o Changes in breast size and/or shape; asymmetric breasts
o Palpable mass: single, nontender, firm mass, poor margins, upper outer quadrant
o Skin changes: retractions , redness, dimpling, edema, or peau d'orange
o Nipple changes: inversion, blood-tinged discharge
o Axillary lymphadenopathy: firm, ^ nodes (> 1 cm ), fixed to skin/surrounding tissue
o In advanced stages: ulcerations
Paget disease of the breast
o ductal carcinoma (usually adenocarcinoma-in situ or invasive) infiltrates nipple/areola
o Clinical features
Erythematous, scaly, or vesicular rash affecting the nipple and areola
Pruritus, burning sensation, nipple retraction
The lesion eventually ulcerates blood-tinged nipple discharge
o Diagnostics
Nipple scrape cytology: large, round cells, prominent nuclei
Punch or wedge biopsy
Differential diagnosis: mamillary eczema
Surgical treatment, if possible using a breast-conserving procedure
Inflammatory breast cancer
rare advanced, invasive carcinoma
dermal lymphatic invasion cells = common ductal carcinoma, 25% metastatic at time
Clinical features:
o Erythematous, edematous/peau dorange skin plaques over rapid growing mass
o Tenderness, burning
o blood-tinged nipple discharge
o Axillary lymphadenopathy
Differential: mastitis, breast abscess, Paget disease of the breast
Treatment: chemotherapy + radiotherapy + radical mastectomy
Poor prognosis: 5-year survival with treatment = 50% (without treatment: < 5%)
Staging
early stage:
o local tumor + <5 cm
o sentinal node + </= 3 cm
local advanced
o large tumor >5 cm
o regional lymph node
o no distant metastasiis
advanced metastatic
o distant metastasis
Diagnostics
Women < 30 years w/self-palpated breast lump
o Clinical assessment FIRST
o Ultrasound in women with a high probability of malignancy
o low probability malignancy: reexamine 310 days after onset period
Women > 30 years w/self-palpated breast lump or mammo abnorm screen
o Clinical assessment AND
o Mammography (ultrasound if mammography is inconclusive)
Nonsuspicious
o Age < 35 years
o No family history
o Soft, movable mass
o Size changes with menstruation cycle
Suscipicious
o Age > 35 years
o Positive family history
o Firm, rigid mass with irregular borders
o Skin changes
o Axillary adenopathy
o Asymmetry to the contralateral breast, fixation to the skin or chest wall
Radiographic imaging
Mammography
o does not confirm the diagnosis
o primarily useful for early detection of abnormalities
Benign
o Well-defined, circumscribed mass
o Radiolucent ring surrounding the lesion (halo sign)
o Diffuse microcalcification or coarse calcification
Malignant
o Focal mass or density with poorly defined margins
o Spiculated margins
o Clustered microcalcifications
Breast ultrasound
o Distinguish between solid lesions + benign cysts
o Evaluates axillary, supraclavicular, infraclavicular lymph NODES
o Provides GUIDANCE in interventional procedures
fine needle aspiration, core needle biopsy
Biopsy
Core needle biopsy (CNB)
o confirms diagnosis = preferred test
o can distinguish between noninvasive + invasive carcinoma
o for a suspicious breast mass on ultrasound or mammography.
Fine needle aspiration
o Preferred for assessing mass w/low probability of malignant
o CANNOT distinguish between noninvasive + invasive carcinomas
o if cytology suspicious = core needle biopsy is required to confirm the diagnosis.
Surgical excision
o If CNB is not feasible
o Results of CNB are inconclusive
Workup of diagnosed breast cancer
Receptor testing of biopsy samples - receptors on all breast cells, ^^^ in cancer cells
o Immunohistochemical estrogen and progesterone receptor. + 70% of cases
o FISH or immunohistochemical HER2/neu, + approx. 20% of cases
o Triple negative = approx. 10% of cases, more aggressive, high-grade tumors
Tumor markers
o CA 15-3
o CA 27-29
Axillary node status:
o suspicious nodes workup w/core needle biopsy PRIOR to surgery of breast
Bone metastasis:
o 1st: contrast-enhanced MRI (in patients with localized bone pain or elevated AP)
o 2nd bone scan: if MRI detects metastatic to identify additional occult lesions
Liver metastasis: abdominal CT
Lung metastasis
o CXR or chest CT: usually multiple lesions, mostly unilateral pleural effusion
o Thoracocentesis if pleural effusion: malignant cells in the fluid BLOOD-tinged
Brain metastasis
Axillary lymph node = suggests hematogenic spread has ALREADY OCCURRED!
Pathology
Noninvasive carcinomas
o DCIS
Macroscopic: firm mass may be visible
Microscopic: Enlarged ducts lined w/atypical epi, intact basal membrane
Microcalcifications are noted occasionally
Two growth patterns
Comedo necrosis: central necrosis, associated w/ ^risk malignancy
Noncomedo: cribriform, papillary, solid
o LCIS
Macroscopic: not visible
Microscopic: lobules filled w/monomorphic cells, intact basal membrane
Diffuse
Lapartomy for
-> cancer resection, staging, inspection
abdominal cavity =definitive treatment when
high suspicion of EOC, particularly with an
acute presentation (ie ascites symptoms)
Pelvic pain in a patient with a
known ovarian mass should be
suspected as ovarian torsion
until proven otherwise
Dermoid cysts HIGHER
rate torsion than other
Twisting around:
o infundibulopelvic
o utero-ovarian
ligament
Presents w/:
o unilat pelvic pain
o nausea/vomiting
o fever
Diagnosis:
o US w/absent blood
flow
Treatment:
o surgical detorsion
o cystectomy
o removal adnexa if
Ruptured cyst mangement: necrosis despite
CBC assess anemia, pregnancy test (exclude ectopic) restoring circulation
pelvic US pelvic free fluid, adnexal mass may be absent in complete rupture
uncomplicated cyst rupture (no fever, hypotension, tachycardia, hemoperitoneum, infection):
o conservatively with analgesics = outpatient.
Ruptured cyst differential:
adnexal torsion
o Both: sudden unilateral pain, ovarian mass is often present
o Torsion: Doppler veloclmetry = enlarged, edematous ovary w/decreased/absent blood flow
endometriosis
o US may show adnexal mass (endometrioma) BUT free fluid is typically NOT present
Tube-ovarian abscess
o fever and leukocytosis
o US: complex multilocular adnexal mass
rather than the simple cyst
cystic teratoma
o US shows an 8-cm left ovarian cyst with calcifications and hyperechoic nodules
Torsion vs ruptured cyst
suspect torsion in teratoma
ruptured cyst: peritoneal signs (pleuritic chest, rigid abdomen, rebound, involuntary guarding)
Simple ovarian and corpus luteum cysts, but typically not dermoid cysts, may rupture
excluding other causes of acute
abdominal pain:
ectopic pregnancy
non~ynecoiogic- appendicitis
wbc = nonspecific