Women's Health

location of female breast

lies against anterior thoracic wall

extends from clavicle and 2nd rib to 6th rib

from sternum to axillary line

5 main parts of the breast

nipple

mammary gland

breast

lymph nodes

areola

what connects the mammary gland to the nipple

milk duct

areola

dark pink area

3 regions of breast

central

subscapular

pectoral

lymphatic system

collect excess fluid from tissue and return it to blood stream

make immune cells to fight infection

visual examination concerning findings for breasts

retraction or indentation of nipple

nipple discharge

lump or mass

atypical fullness of puckering

changes in skin texture

palpation concerning findings for breasts

pain or tenderness

is pain subjective or objective

subjective

is tenderness subjective of objective

objective

important questions to ask during clinical exam of the breasts

clarify when during the menstrual cycle that the exam is done

any discomfort, pain, lumps?

any nipple discharge?

follow up questions if patient answers yes to discomfort, pain or lumps in breasts

location

duration

change in size

follow up questions if patient answers yes to nipple discharge

when

color

consistency

quantity

galactorrhea

flow of breast milk other than normal lactation

lactation

production of milk for a period of time after birth

most common palpable masses for 15-25 year olds

fibroadenoma

how will a fibroadenoma present in a 15-25 year old patient

usually firm

round

mobile

tender

most common palpable masses for 25-50 year olds

cysts

fibrocystic changes

cancer

how will a cyst present in a 25-50 year old

usually soft to firm

round

mobile

often tender

how will fibrocystic changes present in a 25-50 year old

nodular

ropelike

how will cancer present in a 25-50 year old

irregular

firm

not clearly delineated from surrounding tissue

most common palpable masses for patients over 50

cancer until proven otherwise

most common palpable masses for pregnant/breastfeeding patients

fibroadenomas

cysts

mastitis

cancer

mastitis

inflammation of breast tissue

fibroadenoma

benign tumor made of epithelial cells

cysts

closed sac that contains fluid or fluid with solid qualities

simple cysts

fluid

complex cysts

fluid and solid qualities

fibrocystic disease

condition marked by palpable lumps in breast usually associated with pain and tenderness that fluctuates with menstrual cycle

when is the pain typically worst for fibrocystic disease

pre-mensturally

when do lumps tend to decrease in fibrocystic disease

post-menstrually

3 parts of examination of the breast

inspection

palpation

description of findings

inspection of breasts

asymmetry

skin changes

contour change

retraction

4 views for inspection of the breast

arms at side

arms overhead

arms pressed against hips

leaning forward

palpation of breasts

best performed in supine position using finger pads 2, 3, and 4

be systematic

can be done in circular manner of up and down

nipple should be palpated

palpate tail of breast and axilla

description of findings for breasts

divided into 4 quadrants with upper outer being the largest

can be localized as the time on the face of a clock

can also be describe in comparison to an object

mammogram

x-ray of breasts

how is a mammogram completed

breasts are compressed between 2 plates

ucomfortable

how long does a mammogram take

15-20 minutes

what are done with the results of the mammogram

read by a radiologist

how much radiation does normal environmental exposure accumulate to in a year

3 millisieverts

how much radiation is in a mammogram

0.4 millisieverts

radiographic findings of mammograms

calcifications

mass

density

calcification

tiny mineral deposits within the breast tissue that appear as white spots on the image and may or may not be cancerous

what are macrocalcifications most likely caused by

aging of arteries

old injury

inflammation

what type of conditions are macrocalcifications usually related to

benign conditions

about what percentage of women over 50 present with macrocalcifications

50%

microcalcifications

usually more concerning

does not usually mean cancer

mass

an important change that can occur with or without calcifications and can represent a cyst, a non cancerous tumor, or breast cancer

density

based on how fibrous/glandular the breast tissue is it can be harder to identify breast cancer

limitations of a mammogram

not a diagnostic test

not a perfect test

patients with breast implants may need more imaging

does not work well in younger women due to density

what other imaging can be done for younger women’s breasts

MRI

ultrasound

ACA recommendations for women 40-44 at average risk

choice to start annual breast cancer screening

ACA recommendation for women 45-54 at average risk

should get mammogram every year

ACA recommendation for women 55 and older at average risk

mammogram every 1-2 years

when should breast cancer screenings continue for women at average risk

if in good health and expected to live more than 10 years

what are no longer recommended for women of any age

clinical breast exams and self breast exams

external female genitalia

clitoris

labia majora

labia minora

vagina

urethra

perineum

anus

urethra

external opening of urinary tract

anus

external opening of GI tract

internal pelvic structures

uterus

cervix

fallopian tubes

ovaries

cervix

lower portion of uterus

fallopian tubes

extend out from ovary

ovaries

attached to ovarian ligament

menstrual cycle

recurrent cycle of physiological changes that occur in reproductive aged women

what is the menstrual cycle driven by

hormones

hormones

biological substances in one area of the body and carried via the blood stream to send signals that trigger responses in another part of the body

what is the first hormone released during the menstrual cycle and what does it stimulate

gonadotropin releasing hormone (GnRH)

anterior pituitary to release follicle stimulating hormone (FSH)

what does FSH stimulate in the menstrual cycle

development of follicles in an ovary one of which will become dominant

follicles

cyst that contains an egg

what do the developing follicles produce in the menstrual cycle

estrogen

what does the estrogen produced by follicles cause during the menstrual cycle

the uterine lining (endometrium) to thicken in preparation for potential implantation of an egg

what does the dominant follicle produce and when during the menstrual cycle

sharp rise in estrogen

1-2 days prior to ovulation

what does the surge in estrogen signal the release of during the menstrual cycle

luteinizing hormone from the pituitary hormone

where does LH travel to and what does it cause during the menstrual cycle

to the ovary which causes an enzyme release that makes a hole in the dominant follicle, releasing an egg (ovulation)

what drops dramatically after ovulation

estrogen

what does the dominant follicle become after being transformed by LH during the menstrual cycle

corpus luteum

what does the corpus luteum continue to produce

progesterone

what is progesterone needed for the development of

the endometrium so a potential fertilized egg can implant

what happens to the corpus luteum if fertilization occurs

its life is extended and it continues to produce progesterone and some estrogen

what takes over hormone production as pregnancy progresses

placenta

what happens to the corpus luteum is no pregnancy occurs

it dies

progesterone levels fall

new cycle begins

what is the first half of the menstrual cycle called

follicular phase

what is the second half of the menstrual cycle called

luteal phase

when does ovulation typically begin

14 days before period starts

what position does the patient need to be in for a pelvic exam

lithotomy position

2 parts of a pelvic exam

speculum examination

bimanual examination

speculum examination

speculum inserted intravaginally and opened manually

3 different types of speculums

virginal speculum

pederson speculum

graves sepculum

who is the pederson speculum used on

young and old patients

what is the graves speculum considered

normal size

what else is performed during the speculum exam

pap smear

bimanual pelvic exam

use both hands to perform exam with 2 fingers intervaginally and other hand presses on abdomen

what is the bimanual pelvic exam for

palpation of internal pelvic organs (uterus, cervix, and ovaries)

5 questions to ask during a pelvic exam

is it a problem or routine visit

birth control and what kind

family history of problem

LMNP

sexual history

questions to ask if it is a problem visit for a pelvic exam

onset

last time of intercourse

alleviating/aggravating factors

associated manifestations

obstetrical history

obstetrical history

GTPAL

what does GTPAL stand for

gravidity

term

premature

abortions

live births

gravidity

total number of pregnancies

term

how many have gone to term