Reproductive/GU High-Yield Clinical Sciences Flashcards

Clinical Sciences

What is a breast abscess?

a pus-filled lump that grows under the skin as a result of an infection; symptoms same as mastitis but less severe

Causes of breast abscess?

most commonly as a progression of non lactational mastitis or cellulitis that does not respond to antibiotic treatment, but an abscess can also be the first presentation of breast infection

Symptoms of breast abscess?

localized, painful inflammation of the breast associated with fever and malaise, along with a fluctuant, tender, palpable mass

What is the treatment of breast abscess?

I&D and antibiotic therapy

In the setting of lactational infection, milk drainage (either by breastfeeding or pumping) is important for resolution of infection and relief of discomfort

What is mastitis?

Superficial infection of the breast (cellulitis)

In what circumstance does mastitis most often occur?

Breast-feeding - Mastitis usually occurs within the first few weeks of breastfeeding but may occur later on

Mastitis symptoms?

may include high fever and breast symptoms: erythema, induration, tenderness, pain, swelling, and warmth to the touch

Infectious vs. congestive mastitis

Infectious (unilateral) - Unilateral, fever, chills and color change

Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas (first pregnancy)

What is the treatment for acute mastitis?

Warm compresses to breast, analgesics, dicloxacillin, or a cephalosporin

Can a nursing mother with mastitis continue to nurse?

Yes! Nursing facilitates the drainage of the infection and the infant will not be harmed because he/she is already colonized

Why must the patient with mastitis/breast abscess have close follow-up?

To make sure that she does not have inflammatory breast cancer! Inflammatory breast cancer presents with breast tenderness and color change, but fever and chills are not usually present

What is the most common causative organism in mastitis, breast infection, or breast abscess?

Staphylococcus aureus

What is a fibroadenoma?

a benign, slow-growing breast tumor w/ epithelial and stromal components. Most common benign breast lesion in women <30yo

What is the clinical presentation of a fibroadenoma?

Solid, mobile, well-circumscribed round breast mass, usually < 40 years of age

What is the recommended work-up for suspected fibroadenoma?

Diagnostic mammogram with ultrasound. If indeterminant, fine-needle aspiration of the mass with pathology. In women younger than 25 years, fibroadenomatous mass should be biopsied

How is a well-defined solid mass with imaging features consistent with fibroadenoma managed?

A well-defined solid mass with imaging features consistent with fibroadenoma can be managed with core biopsy or short-term (three to six months) follow-up with a repeat ultrasound and breast examination. Definitive diagnosis can only be confirmed with a core biopsy or excision

What is the treatment of fibroadenoma?

Surgical resection for large or growing lesions; small fibroadenomas can be observed closely

What is fibrocystic breast disease?

a benign (noncancerous) condition in which the breasts feel lumpy. Fibrocystic breasts aren't harmful or dangerous, but may be bothersome or uncomfortable for some women

Symptoms of fibrocystic breast disease?

a change in breast texture, pain or tenderness, and lumpiness. These may be more bothersome before menses and usually resolves with the start of the menstrual cycle

Peak incidence of fibrocystic breast disease?

30 to 40 year old's

After the establishment of fibrocystic breast disease, what is the recommended treatment?

Avoiding trauma and by wearing a bra with adequate support. Combined oral contraceptive agents limit the severity of the cyclical changes in the breast tissue. Many patients report relief of symptoms after abstinence from coffee, tea, and chocolate

What is galactorrhea?

a milky nipple discharge unrelated to the normal milk production of breast-feeding. Galactorrhea itself isn't a disease, but it could be a sign of an underlying problem

What is the most common cause of galactorrhea?

prolactin-secreting pituitary adenoma (prolactinoma)

● May be caused by ingestion of certain drugs

● Primary hypothyroidism can cause hyperprolactinemia and galactorrhea

● Prolactin levels may rise in circulation as a consequence of renal insufficiency

● Nipple stimulation and pregnancy are physiologic causes of increased prolactin secretion

What pattern of nipple discharge would one expect with benign galactorrhea?

Bilateral, induced, clear/white/yellow color

Diagnosis of galactorrhea?

elevated prolactin levels (typically > 5 times normal, sometimes much higher)

● MRI is the method of choice in identifying microadenomas. High-resolution CT may be used when MRI is contraindicated or unavailable

● Primary hypothyroidism is easily ruled out by absence of elevated TSH

Treatment of galactorrhea?

1. Dopamine agonist (Bromocriptine, Cabergoline)

2. Surgery if resistant/intolerant

3. Radiation if refractive & progressive

What is gynecomastia?

a common condition which results in enlarged male breast tissue. It can be seen in males of all ages, but usually occurs during the newborn period, puberty and older adulthood

What is the cause of physiologic gynecomastia that develops during puberty?

fluctuating hormones, including drops in testosterone and surges in estrogen that cause breast tissue to grow and usually resolves within about 6 months to 2 years

In adult men, what are the most common causes of gynecomastia?

persistent pubertal gynecomastia, idiopathic gynecomastia, and drugs (particularly spironolactone, anabolic steroids, and antiandrogens)

What is the lifetime risk of breast cancer?

12%

Percentage of women with breast cancer who have zero known risk factors?

75%

Percentage of breast cancers due to inherited mutations?

10%

How do you decrease breast cancer risk in women with BRCA mutations?

Prophylactic bilateral mastectomy (90% risk reduction)

What is the preferred screening for breast cancer mutation carriers?

annual MRI

Is normal fibrocystic disease a risk factor for breast cancer?

no

What are the signs of breast cancer?

- Mass (1 cm minimum palpable)

- Dimple

- Nipple rash

- Edema

- Axillary / supraclavicular nodes

What is the most common type of invasive breast cancer?

Infiltrating ductal carcinoma

Screening: Mammogram?

Mammogram every year or every other year after age 40

Best time for breast exam

1 week after menses

Indications for breast biopsy?

- Persistent mass after aspiration

- Solid mass

- Blood in cyst aspirate

- Suspicious lesion by mammography/ultrasound/MRI

- Bloody nipple discharge

- Ulcer or dermatitis of nipple

- Patient's concern of persistent breast abnormality

Suspicious mammographic findings?

- Mass

- Microcalcifications

- Stellate/spiculated mass

Workup for a breast mass?

1) Clinical breast exam

2) Mammogram or breast ultrasound

3) FNA, core biopsy, or open biopsy

Breast cancer sites of metastases?

- Lymph nodes (most common)

- Lung/Pleura

- Liver

- Bones

- Brain

Major treatments of breast cancer?

Segmental mastectomy (lumpectomy) + breast irradiation

+ adjunct chemo in lymph nodes

What breast cancers are candidates for breast-conserving therapy (lumpectomy and radiation) ?

Stage I & II (tumors <5 cm)

What is Paget's disease of the breast?

Scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma

What is the most common cause of pelvic pain in an adolescent girl?

Ovarian cysts

How common are ovarian cysts?

Most women of reproductive age develop small cysts each month. Large cysts that cause problems occur in about 8% of women before menopause

What is the most common type of ovarian cyst?

Follicular

A cyst that begins when the follicle doesn't rupture or release its egg, but continues to grow

Follicular cysts

A type of functional ovarian cyst that results when a corpus luteum fails to regress following the release of an ovum

Corpus luteum cysts

Often occur as multiple ovarian cysts due to gonadotropin stimulation and are associated with choriocarcinoma and moles

Theca-lutein cysts

Uncomplicated ovarian cysts usually present with what type of abdominal pain?

dull aching lower abdominal pain

What is the best initial test for the diagnosis of ovarian cysts?

Ultrasound

What is the gold standard for the diagnosis of ovarian cysts?

laparoscopy

What is the recommended treatment for uncomplicated follicular cysts?

Most resolve spontaneously within a few menstrual cycles (60 days) without treatment. NSAIDs. Combined oral contraceptive agents can be used if recurrent

What is the management of symptomatic ovarian cysts >5 cm?

laparoscopic surgical removal

What is the most common complication of ovarian cysts?

ovarian torsion, requiring emergency surgery

Which of the following types of cysts most commonly ruptures?

corpus luteum cysts

What is PCOS?

a condition in which the ovaries produce an abnormal amount of androgens. The name polycystic ovary syndrome describes the numerous small cysts that form in the ovaries. However, some women with PCOS do not have cysts, while some women without PCOS do develop cysts

What are the laboratory findings in PCOS?

Increased LH/FSH ratio (2:1) seen in 75% of cases

↑ Glucose

↑ Fasting insulin

↑ DHEA-S and/or Testosterone

Lipid abnormalities

What is the classic ultrasound finding in PCOS?

"string of pearls" or "oyster ovaries"

What is the first-line treatment for polycystic ovarian syndrome?

weight loss

In addition to weight loss what are the other treatment options for polycystic ovarian syndrome?

Combined oral contraceptive pills for menstrual regulation and ovarian suppression; Biguanides (metformin) for menstrual regulation, and to reestablish fertility; anti-androgen (spironolactone) for sex androgen suppression and hirsutism

Which of the following is considered a major risk factor for the development of polycystic ovarian syndrome (PCOS)?

insulin resistance

What is ovarian torsion?

twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia

How does ovarian torsion present?

acute onset of moderate to severe pelvic pain, which may be diffuse or localized to one side, often with nausea and vomiting, in a patient with an adnexal mass

What is the diagnostic test of choice for evaluating ovarian pathology?

Doppler transvaginal ultrasonography

What is the gold standard for the diagnosis of ovarian torsion?

laparoscopy

What is the treatment of ovarian torsion?

laparoscopy to uncoil the torsed ovary and possibly oophoropexy to fixate the ovary which is likely to twist again

What is the incidence of ovarian CA?

2nd most common gynecological cancer

What serum marker is associated with ovarian cancer?

CA-125

The majority of ovarian malignancies are derived from what cell type?

95 % derived from epithelial cells

What are considered protective factors for the risk of ovarian cancer?

- Multiparity

- Combined oral contraceptive use

- Breast-feeding

Symptoms of ovarian cancer?

usually absent in early stages and nonspecific in advanced stages. An adnexal mass, often solid, irregular, and fixed, may be discovered incidentally. Pelvic and rectovaginal examinations typically detect diffuse nodularity. Ovarian cancer is often fatal because it is usually advanced when diagnosed

Recommended screening for ovarian cancer?

not useful unless risk of BRCA mutations is high

Which of the following is accurate about Braxton-Hicks contractions compared with contractions that lead to labor?

often resolve with ambulation, unlike contractions that lead to labor

Which of the following statements about epidural anesthesia during labor is true?

it increases the risk of operative vaginal delivery

A 24-year-old primigravida comes to your office at 8 weeks of gestation for her first prenatal visit. She has asked you to be her family PA and to look after her during the entire pregnancy. You agree to provide her pregnancy care. Your patient had the first day of her last menstrual period on September 9, 20016. According to Nägele rule, what is the patient's estimated date of delivery (assuming a 28-day cycle)?

June 16, 20017

Which of the following tests is recommended at her 26- to 28-week prenatal visit?

screening for gestational diabetes

Patient is 5 feet 5 inches tall and weighs 130 pounds. How much weight gain do you recommend?

25-35 lbs

Abortion is diagnosed as pregnancy loss at less than _______ of gestation based on LMP

20 weeks

Early vs. late abortion?

Early abortion before 12 weeks gestation

Late abortion between 12 and 20 weeks gestation

Spontaneous vs induced abortion?

Spontaneous - noninduced abortion

Induced - termination of pregnancy for medical or elective reasons

Threatened spontaneous abortion?

Vaginal bleeding occurring before 20 weeks gestation without cervical dilation and indicating that spontaneous abortion may occur (+ vaginal bleeding, cervix is NOT open and NO products of conception have passed)

What is an inevitable spontaneous abortion?

the cervix has dilated, but the products of conception have not been expelled (+ vaginal bleeding + cervix IS open and NO products of conception have passed)

What is an incomplete spontaneous abortion?

some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes. (+ vaginal bleeding + cervix IS open and + SOME products of conception have passed)

What is a complete spontaneous abortion?

all products of conception have been passed without the need for surgical or medical intervention. (+ vaginal bleeding + cervix IS open and + ALL products of conception have passed)

What is a recurrent spontaneous abortion

three or more consecutive pregnancy losses

What is a missed abortion?

a pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception

How is spontaneous abortion diagnosed?

- Serum beta-hCG

- Transvaginal US

- Blood type & Rh

How often should the βHG should double in a viable intrauterine pregnancy?

every 48 hrs

What portion of the fallopian tube is the most common site of an ectopic pregnancy?

ampulla

What is the classic clinical triad of ectopic pregnancy?

1. Abdominal pain

2. Amenorrhoea

3. Vaginal bleeding

What is the most common sign of ectopic pregnancy on transvaginal ultrasound?

Absence of interuterine pregnancy or gestational sac with β-hCG level >2000 mIU/mL. Adnexal mass or gestational sac in adnexa (ring of fire sign) is less reliable finding. Follow-up ultrasound is always recommended in high-risk patients to ensure intrauterine pregnancy

When is an intrauterine pregnancy typically visible by ultrasound?

by week 5 or 6

How do β-hCG levels differ in women with ectopic pregnancy versus intrauterine pregnancy?

lower

What is the standard medication used in the treatment of an unruptured ectopic pregnancy?

MTX

Who is eligible for methotrexate treatment of an ectopic pregnancy?

unruptured gestations <3.5 cm in diameter on ultrasound and β-hCG <5000 mU

What criteria are used for assuring the success of methotrexate?

β-hCG levels should fall by 15% between days 4 and 7 and continue to fall weekly until undetectable