breast and female GU review

glandular tissue

15–20 lobes of mammary glands

drains

• lactiferous duct → lactiferous sinus → nipple

cooper ligaments

Suspensory ligaments tethering breast to skin & chest wall

tumor infiltration = SKIN DIMPLING

areola

Pigmented ring around nipple

contains Montgomery glands (keep nipple supple)

tail of spence

Axillary extension of breast tissue

UOQ

Upper Outer Quadrant

contains MOST glandular tissue = site of ~60% of breast carcinomas

axillary lymph nodes

75% of breast lymph drainage

• anterior

• posterior

• lateral

• central

• apical nodes

thelarche

breast bud

tanner stage 2

first sign of puberty

menarche

1st period

follows 2-3 years later

tanner stage

stage 1

• prepubertal

• Flat

• no palpable breast tissue

stage 2

• breast bud (thelarche)

• Elevation of papilla + areola

• avg age 8–13

stage 3

• enlargement

• Breast & areola enlarge together

• often asymmetric

stage 4

• Areola & papilla project ABOVE breast

• double-mound appearance

stage 5

• Areola recedes to breast contour

• papilla projects

• mature adult breast

infant breast change

transient enlargement from maternal estrogen

witch milk possible

resolve in weeks

pregnancy breast change

enlarge vein, visible

nipple/areola darken

colostrum

montgomery gland prominent

lactation breast change

maximal enlarged/firm

milk production

nipple tender/cracked

menopause/aging breast change

glandular tissue replaced…

• fat

• lobule atrophy

• breast sag

• nipple small/prominent

breast cancer risk factors

increasing age

Female sex

Family history of breast cancer

BRCA1, BRCA2, PALB2, TP53 mutations

Personal history of breast cancer

Dense breast tissue (mammographically)

Prior chest radiation (e.g., Hodgkin Tx)

Early menarche (<11 y)

Nulliparity / First pregnancy after age 30

Never breastfed

Obesity (especially postmenopausal)

Alcohol consumption

Physical inactivity

Combined HRT (estrogen + progesterone)

Recent hormonal contraceptive use

Weight gain in adulthood

Type 2 diabetes

High endogenous estrogen (postmenopausal)

Proliferative breast disease with atypia

protective factor of breast cancer

breastfeeding

warning signs of breast cancer

painless lump/thick

skin dimpling/puckering

nipple retraction

nipple discharge

redness/scaliness skin

change size/shape breast

enlarged lymph nodes

persistent breast pain

clinical breast exam inspection

pt seated/supine

› Arms relaxed at sides → baseline symmetry & skin

› Arms pressed on hips → contracts pectoralis → reveals dimpling

› Arms raised above head → elevates breast; reveals tethering

› Lean forward (large breasts) → hangs freely; check symmetry

notings of breast exam

inspect for: asymmetry, contour changes, skin color

look for: edema (peau d'orange), dimpling, puckering

check: nipple position, retraction, discharge, skin changes

note: visible masses, axillary fullness, erythema

palpate BSE

3 middle fingers with finger pads — dime-sized circular motions

pressure levels at EACH spot: Light → Medium → Deep (to chest wall)

Systematic pattern — vertical strip (lawnmower), concentric circles, or wedge

Cover ENTIRE breast including Tail of Spence — sternum to mid-axilla, clavicle to inframammary ridge

Patient SUPINE with small pillow under ipsilateral shoulder

lump found: document

location - quadrant + clock position

size - cm x 3 dimension

shape - round, oval, irregular

consistency - soft, firm, hard, rubbery

mobility - freely movable vs fixed

tenderness - present or absent

BSE: menstruating women

5–7 days AFTER start of period

breasts least tender & swollen

BSE: pregnant/menopausal

Same day each month (e.g., 1st of month)

monthly, consistent date

BSE: mirror inspection

Arms at sides → hands on hips → arms raised

look for asymmetry, dimpling, nipple changes

BSE: shower

Soapy skin makes lumps easier to detect

palpate with flat fingers

BSE: supine

Arm raised above head on side being examined

pillow under shoulder

3-finger dime-sized circles

BSE: nipple check

Gently squeeze each nipple

note any discharge

• color, consistency, unilateral?

BSE: methods

Vertical strip (lawnmower)

Concentric circles

Wedge

choose ONE, stay consistent

screenings: avg women risk

40-44 → OPTION to begin annual mammogram (shared decision-making with provider)

45-54 → Annual mammogram RECOMMENDED

55+ → May switch to every 2 years OR continue annually; continue while healthy & life expectancy ≥10 yrs

all women → Know your normal! Report breast changes to provider immediately

screenings: high risk women

18+ → Breast self-awareness education begins

25+ → CBE every 6–12 months

25-29 → Annual breast MRI with & without contrast

30-75 → Annual mammogram PLUS annual breast MRI with & without contrast

male → BSE education age 35+; CBE annually age 35+; consider annual mammogram starting age 50

HPV

cervical cancer

type 16/18

risk factor

• HPV infection — high-risk strains 16, 18, 31, 33, 45

• Early sexual debut

• Multiple sexual partners

• Smoking

• immunosuppression (HIV, transplant meds)

• Other STIs (chlamydia, HSV-2)

• Long-term OCP use (slight increase)

• No HPV vaccination

• Missed Pap screenings

• AA/Hispanic — higher incidence

Pap smear

< 21 → No screening — regardless of sexual activity

21-29 → Pap smear ALONE every 3 years (no HPV test)

30-65 → PREFERRED: Pap + HPV co-test every 5 years Acceptable: Pap alone q3y OR HPV alone q5y

65+ → DISCONTINUE if adequate prior screening history

post-hysterectomy → Discontinue if no cervix & no history of CIN 2+

HPV vaccine

Protects against HPV types

• 6, 11, 16, 18, 31, 33, 45, 52, 58

Recommended:

• age 11–12 (can start at 9)

• catch-up through age 26

2-dose series

• <15 y3-dose

3-dose series

• ≥15 y or immunocompromised

Does NOT replace Pap screening — vaccinated women still need Paps

chlamydia

asymptomatic

S/S

• mucopurulent cervical

• discharge

• cervical friability

• pelvic pain

• dysuria

diagnose: urine/vagina/cervical swab

treat: doxycycline

gonorrhea

Mucopurulent discharge

dysuria

pelvic pain

often

co-infects with chlamydia

frequently asymptomatic in women

diagnose: culture resistance

treat: ceftriaxone

syphilis

Primary: painless chancre

Secondary: rash palms/soles, condyloma lata

Latent: asymptomatic

Tertiary: gummas, CV, neuro

treat: benzathine penicillin G

herpes HSV 1/2

Painful vesicles/ulcers genitalia

primary: fever,lymphadenopathy

recurrent less severe; asymptomatic

shedding

treat: acyclovir or valacyclovir

HPV

genital warts

asymptomatic

high risk → cervical/anal/oral cancer

diagnose: Papsmear/HPV test

trichomonas

Frothy yellow-green discharge

pruritus → itch skin

dyspareunia → genital pain

strawberry cervix

up to 70% asymptomatic

bacterial vaginosis

Thin gray-white discharge

fishy odor (especially after sex)

vaginal itching

pH >4.5

diagnose: Whiff test +; clue cells; pH >4.5; Amsel criteria (3 of 4)