Women's Health

location of the female breasts

against anterior thoracic wall extending from the clavicle and the second rib down to the level of the sixth rib, from sternum (midline) to mid axillary line

axillary tail of breast tissues extends toward axillary fold

rectangular

Lymph nodes of breast

central

subscapular

pectoral

lymphatic system

• Collect excess fluid in body tissue and returns it to the blood stream

• Makes immune cells

anatomical structures of the breast

lymph nodes

breast

mammary glands

nipple

milk gland

milk duct

milk reservoir

areola

breast tissue

Concerning findings on breast

• Breast lump/mass

• Nipple discharge

• Breast pain

• findings

• Change in skin texture/color

• Retraction or indentation of nipple

• Atypical fullness or puckering

objective and subjective pain

• Pain is subjective, tenderness is objective and found during PE findings

Questions that are important to ask during breast exam

• Clarify when during the menstrual cycle that the exam is done

• Any discomfort/pain?

• If lump is present- ask how long, location duration, change in size during cycle

• Ask about history of discharge if present - color, consistency, quantity

Galactorrhea

flow of milk from breast other than with normal lactation

Location

production of milk for period of time after birth

Common palpable mass for ages 15-25

Fibroadenoma

Common palpable mass for ages 25-50

Cysts

fibrocystic changes

cancer

Common palpable mass for ages over 50

cancer until proven otherwise

Common palpable mass for women who are pregnant or breastfeeding

fibroadenomas, cysts, mastitis, cancer

fibroadenoma

benign tumor made of epithelial cells

usually fine, round, mobile, tender

simple cyst

closed sac that contains fluid

usually soft to firm, round, mobile, tender

complex cyst

closed sac that contains fluid and solid qualities

fibrocystic disease

condition marker by palpable lumps in breast, usually associated with pain and tenderness,

fluctuates with menstrual cycle, worse prior, relieved after

Breast examination parts

inspection, palpation, mammogram

inspection of breast

Look with eyes

Check for: asymmetry/symmetry, skin changes (texture, color), contour changes, retraction (skin pulled in)

positions of patient for inspecting breasts

arms at side, arms overhead, arms pressed against hips, leaning forward

palpation of breast

• Best performed in supine position

• Use finger pads of 2, 3, 4

• Breast may feel soft- feeling lumps/bumps are normal

1. Be systematic

2. Can be done in circular manner or up and down

3. Nipple should be palpated as well, squeeze base of nipple

4. Remember to palpate tail of breast and axilla

Description of physical findings for breast

• Breast is divided into 4 quadrants based on horizontal and vertical lines which intersect at the nipple

• Findings can be localized as the time on the face of a clock, time and distance in centimeters from nipple

• Most breast tissue is in upper outer quadrant, 50%

• Lower inner quadrant has least amount of breast tissue, 6%

Mammogram

• X-ray of the breast

• Breasts flattened between 2 plates, spreads breast tissue out

• May be uncomfortable

• 15-20 min in duration

• Black and white image

• Image read by radiologist and results provided 

what radiologists look for on mammogram

calcifications, mass, density

mammogram radiation

• Millisievert- measure of radiation dose

  • Normal is 3 millisievert per year

• Mammogram delivers 0.4 millisievert

calcifications

tiny mineral deposit within breast tissue, appear as white spots on images, may or may not be cancerous

Macrocalcifications

larger deposits, most likely caused by aging of arteries, old injury, inflammation

usually benign, may be cancerous,

in half of women 50+

microcalcifications

tiny specs of calcium in the breast

more concerning- benign or cancer

mass

important change that can occur with or without calcifications. A mass can represent a cysts, benign solid tumor, breast cancer

density

how fibrous, glandular, fatty a breast is

Linked to higher risk of breast cancer

Mammogram limitations

• Not diagnostic, unable to diagnose breast cancer

• Not perfect, false negatives and positives

• Patients with breast implants may need more or special imaging

• Does not work well in younger women due to higher density

breast MRI and ultrasound

• Ordered for younger patients with dense breasts

• Patients with small breasts

•  Ultrasound is most effective at finding fluid filled, more affordable

ACS Breast screening recommendations

• Guidelines for women with average risk

  • Age 40-44, choice to start annual breast cancer screening

  • 45-54, once per year

  • 55+, every 2 years or every year by choice

• Screening should continue as long as a woman is in good health and is expected to live more than ten years

• Clinical breast exams and self exams are no longer recommended to a woman of any age

screening mammogram

patient has no symptoms

diagnostic mammogram

patient has symptoms or provider found change

clinical breast exam

exam that provider preforms in clinic

breast self exam

exam patient preforms on self based on recommendation

Peau d’orange

skin that appears thickened, dimpled, and pitted, resembling an orange’s surface

inflammatory breast cancer

entire breast is involved

Breast cancer risk factors

Risk factors

• Female

  • Males can get breast cancer

• Age

• Family history

• Previous exposure to radiation

• Previous breast cancer

• Smoking (relative risk)

• Estrogen use after menopause

• Dense breasts

• No children

• First child after 30

• Early periods and late menopause (increased period of time of estrogen and progesterone) 

• Genetic mutation (BRCA gene)

breast cancer prevention

• Limit smoking/alcohol use

• Follow mammogram screening

• Maintain health weight

• 30 minutes of physical activity per day

ACS risk from website

• Women at high risk should get breast MRI and mammogram every yeat

  • Typically starting at 30

• High risk includes:

  • Lifetime breast cancer risk of 20-25% using risk assessment tool

  • Have known BRCA1 or BRCA2 gene mutation

  • Have first degree relative with BRCA gene mutation, patient has not yet had genetic testing

  • Has had previous radiation therapy to chest

  • Have Li-Fraumeni, Cowden, or Bannayen-Riley-Ruvalcaba syndrome OR first degree relatives have syndrome(s)

external female pelvic anatomy (7)

• Clitoris- superior

• Labia majora

• Labia minora

• Vagina

• Urethra- external opening to urinary tract

• Perineum- tissue between vagina and anus

• Anus- external opening of GI tract

internal pelvic anatomy (5)

• Uterus- grows embryo and fetus

• Cervix- lower portion of uterus

• Fallopian tubes- extend from uterus

• Ovaries

• Endometrium- lining of uterus 

what two internal structures are technically one body

uterus and cervix

menstrual cycle

recurrent cycle of physiologic changes that occur in reproductive age women

ovarian follicle

cyst that contains egg

ovulation

release of egg from follicle

hCG

human Chorionic Gonadotropin hormone,

hormone produced by the placenta during pregnancy, crucial for supporting fetal development and signaling the body to continue pregnancy

Menstural cycle steps/phases

1. Driven by hormones 

   1. Biochemical substances produced in one area of the body and carried via blood to send signals that trigger responses in another part of body

2. Hypothalamus produces GnRH (gonadotropin releasing hormone) which stimulates anterior pituitary to produce FSH (follicle stimulating hormone)

3. FSH stimulates development of follicles in ovary, one of which will become dominant 

4. Developing follicles begin to produce estrogen

5. Estrogen produced by dominant follicle causes the endometrium to thicken in preparation for potential implantation of an egg

6. Dominant follicle produces a sharp rise in estrogen, peaks 1-2 days prior to ovulation

7. Estrogen surge signals release of LH (luteinizing hormone) from anterior pituitary

8. LH travels via blood to ovary causing an enzyme release that make a hole in dominant follicle, releasing an egg (ovulation)

9. Estrogen drops dramatically after ovulation

10. Dominant follicle, transformed by LH, becomes corpus luteum. Corpus luteum continues to produce some estrogen, and now also progesterone, Progesterone is needed to develop endometrium, so a potential fertilized egg can implant.

11. If fertilization occurs, the corpus luteum’s life is extended by the presence of HcG. it continues to produce progesterone and some estrogen

12. As pregnancy progresses, hormone production is taken over by placenta

13. If no pregnancy, CL dies, progesterone levels fall, new cycle begins with onset of menses

Menstrual cycle length

• Cycle begins with in one day of menses 

• Ovulation occurs 14 days before next period/cycle

• Cycle length is important

• First half is follicular phase

• Second half is luteal phase

• Fertilization usually takes place in fallopian tube

pelvic exam

• Patient always in lithotomy position

• Inspection (view external genitalia)

speculum examination

• Uses speculum

• View vaginal walls

• Visualize cervix

• If needed, pap smear

• Cervical OS- opening into uterus, where pap smear sample is taken with spatula

• Squama columnar cell junction- where outer and inner cervix meet

speculum sizes

• Different sized speculums for different patients

  • Virginal- smallest

  • Pederson- small

  • Graves- normal

bimanual pelvic examination

• Both hands used

• Palpation of internal organs

  • Uterus, cervix, ovaries

• using one lubricated finger inside the vagina and the other hand pressing on the lower abdomen to feel for size, shape, position, and tenderness

Patient history

• Establish if it is a problem or routine visit

• 7 factors of HPI- onset of symptoms, alleviating/aggravating factors

• Last time pt had intercourse, partner(s)

  • Ask about sexual history

• Any previous pelvic problems

• Obstetrical history (how many babies)

• Gravidity (how many times pregnant)

• GTPAL - gravida, term, premature, abortion/miscarriage, live births

• Birth control, what kind

• Family history

• Last normal menstrual period (LNMP)

gravidity

how many pregnancies

GTPAL

gravida, term, premature, abortion/miscarriage, live births

Pelvic PE phases

Visual inspection of external genitalia

Speculum exam

Bimanual exam

Potential rectal exam

Pathophysiology disease of the vagina

discharge, flora, pH

normal discharge

clear or white vaginal fluid

normal flora

 lactobacillus acidophilus, staph epidermidis, beta-hemolytic strep

normal vaginal pH

3.8 to 4.5, very acidic

microscopic exam

long rods, epithelial cells, few to none WBCs

common vaginal symptoms

• May overlap between diseases processes

• Discharge (consistency, color, foamy, bubbly, curdlike)

• Swelling

• Itching

• Odor

• erythema

lab tests for vaginal infections

pH assessment, Amine (whiff) test, wet-mount microscopic exam

pH assessment

• Apply drop of vaginal discharge to pH paper

• Paper will change color based on pH level

  • < 7, basic

  • 7, neutral

  • > 7, acidic

• pH is decreased in yeast infections (candida)

• pH is increased in bacterial vaginosis and trichomoniasis

Amine test

• Put a small sample of discharge on a slide with a drop of 10% sodium hydroxide (KOH)

  • If aromatic amines released (fishy odor), indicates increased presence of anaerodes

    • Indicates bacterial vaginosis

wet-mount microscopic exam

Put a sample of discharge on a glass slide and mix with a drop of saline solution, put coverslip on top, put under microscope

bacteria on wet-mount

• yeast cells (yeast infection)

• Trichomonads (trichomonas)

• White blood cells (infection)

• Clue cells (bacterial vaginosis)

vaginitis

syndrome characterized by vaginal discharge/ irritation

Types of vaginitis

bacterial vaginosis (BV), candida vulvovaginitis (CVV), Trichomonas vaginitis (TV), Atrophic Vaginitis

Bacterial Vaginosis

change in balance of bacteria normally present in vagina

usually an overgrowth of bacteria- gardnerella vaginalis

gardnerella vaginalis

bacteria that causes BV

Clinical criteria needed for BV diagnosis

• ¾ needed for diagnosis

• Amsel’s Criteria

  • white/thin/yellowish discharge

  • pH is greater than 4.5

  • Positive whiff test

  • Presence of clue cells

  • not needed- (burning and itching may be present)

NAAT

nucleic acid amplification test

Cotton swab used intervaginally and sample sent in kit to lab to be tested

BV treatment

• Metronidazole 500 mg, one tab po BID x 7 days - not for pregnant women

• Clindamycin intravaginal 2%, 1 applicator (5 grams) intravaginally at night x 7 days (40 gram tube, no refills)

• Treatment of partner is not currently recommended

• Consider allergies, pregnancy, drug interactions, patient preference, insurance

Vaginal Candidiasis (Candida vulvovaginitis)

yeast/fungal infection

• 75% of women experience it

• Usually caused by candida albicans, can be caused by candida tropicalis or candida glabrata

• Associated with diabetes mellitus or recent antibiotic use (allows yeast to overgrow)

Common presentations of CVV

• intense vulvar or vaginal itching (pruritus)

• White curd-like discharge

• Erythema on outside (vulva)

• Burning after urination

Pruritus

itching

CVV Diagnosis criteria

1. Presence of budding yeast (hyphae) with a wet mount test

2. May require culture, only 50% of cases will have a positive KOH test

3. Clinicians may treat on typical ‘cottage cheese’ type discharge, then culture if no resolution of symptoms

4. Findings may be reported on cytology smear

5. Women may self diagnose based on symptoms and the availability of OTC treatments

CVV treatment

• OTC treatments include topical antifungals - Monistat (miconazole)

• Prescription antifungals (topical/oral) - Diflucan (fluconazole) 150 mg tab, one tabe po x 1 day

• Culture positive yogurt intake has not been consistently found to decrease recurrences or to prevent post antibiotic CVV

  • Yogurt changes pH of vagina

• Strict DM control may decrease recurrences

• Use cotton underwear

• Screen patient for diabetes with fasting blood sugar test if infections are recurrent or persistent

Trichomoniasis (trichomonas vaginitis)

Trichomonas vaginalis - organism

• Flagellated protozoans

• STI

• Clinical presentation:

  • Frothy yellow/green/white discharge

  • Potential foul smelling discharge

  • Erythema of vulva

  • Burning

  • Itching

  • Presence of strawberry spots on cervix, seen during pelvic exam- key in diagnosis

Trichomoniasis diagnosis

• Microscopic identification of actively swimming trichomonads- wet-mount

• NAAT- culture if patient has persistent symptoms and trichomonads not identified on prior exam

Trichomoniasis treatment

• Metronidazole 2 g, po as single dose 

• Metronidazole 500 mg, 1 tab po BID x 7 days

• Prolonged treatment may be needed if symptoms persist

• Treatment of all sexual partners is indicated

atrophic vaginitis

• Not bacteria related

• Result of decreased estrogen production

• Potentially asymptomatic

• Potential erythema, dryness, urinary symptoms, burning

• No vaginal discharge

what disease is common for post-menopausal women

atrophic vaginitis

atrophic vaginitis clinical presentation

• Vaginal epithelium is thin, susceptible to trauma from intercourse

• Vaginal dryness

• Friable- bleeds easily

• Spotting

• Dyspareunia- pain with intercourse

dyspareunia

pain with intercourse

atrophic vaginitis treatment

• Topical estrogen

  • Premarin vaginal cream 0.625 mg with applicator, 30 mg tube, 0.5 grams intravaginally twice weekly then prn (as needed)

Chlamydia (Chlamydia Trachomatis)

common STI, classified as a bacteria

Associated with infertility and ectopic pregnancy due to chronic inflammation caused by infection

Chlamydia clinical presentation

• Usually asymptomatic 

• Purulent discharge

• Inflammation- external and internal genitalia

• Urinary symptoms- frequency, burning, dysuria

chlamydia diagnosis

• Lab testing using NAAT, vaginal swab

• If testing for chlamydia, also test for gonorrhea

  • High number of co-infections, 50% of women have both

chlamydia treatment

doxycycline 100 mg 1 tab po BID x 7 days

Gonorrhea

• Positive organism - neisseria gonorrhea

• Usually asymptomatic

• May progress to infertility/ ectopic pregnancy, caused by chronic inflammation

Gonorrhea clinical presentations

• Usually asymptomatic

• Purulent discharge

• Inflammation (external and internal)

• Urinary symptoms- frequency, burning, dysuria

gonorrhea diagnosis

NAAT

test for both gonorrhea and chlamydia

gonorrhea treatment

• Ceftriaxone (Rocephin) 500 mg IM x 1

• If chlamydia is also present, Doxycycline 100 mg 1 tab po BID x 7 days

Pelvic inflammatory disease (PID)

• Acute chronic or recurrent infection of internal pelvic structures

• Usually caused by gonorrhea and Chlamydia, use of IUD (internal uterine device), post elective abortion

• Common in women with multiple sexual partners

PID clinical presentation

• Acute or insidious lower abdominal and/or pelvic pain

• Usually bilateral pain

• Pelvic pressure, back pain

• Elevated temperature, not necessary for diagnosis