Clin Med OB/GYN Exam 2: Vagina, Breast, Cervix, Ovaries (might as well be everything)

What provides structural support and maintains breast contour?

Cooper's Ligaments

What causes skin dimpling when a tumor is in a breast?

Cooper ligament retraction

When should you schedule breast exams?

7-10 days after menstrual onset

3 skin changes to look out for with breast malignancy.

dimpling, puckering, or orange-peel appearance

Mastalgia =

Breast pain (most pain is not cancer)

Cyclical mastalgia correlates with hormones; when is cyclical mastalgia most intense?

luteal phase, better after menses

How does physiologic nipple discharge present?

bilateral, milky/green, expression, multiple ducts, benign

How does a pathologic nipple discharge present?

Unilateral, spontaneous, bloody/serous, single duct

Most common cause of pathologic nipple discharge. (STOMP)

Intraductal Papilloma (definitive tx = surgery)

Nipple discharge imaging studies would be a ___________ in patients under ___, and mammography in those older than ___. (STOMP)

Ultrasound in patients under 30, mammography with patients over 30.

Inappropriate male breast enlargement

gynecomastia

What can you use for persistent/painful gynecomastia (within a year)?

SERMs like tamoxifen

Most effective tx for gynecomastia (severe cases) affecting quality of life.

sub-q mastectomy

Most common benign breast condition?

fibrocystic changes

Pathognomonic term for fibrocystic changes? (STOMP)

"rope-like" densities on exam

What can you do for a patient with severe persistent pain in fibrocystic changes?

Oral contraceptives to control hormones

When to biopsy a patient during a fibrocystic change.

A dominant/suspicious area that does not fluctuate with hormones, or the imaging is weird.

What is a simple breast cyst?

round/smooth, fluid, black on US, tender, size fluctuates, benign.

What is a complex breast cyst?

Internal echoes visible, solid components, thick wall, hemorrhage/infection, evaluation/biopsy needed.

When would you aspirate a simple cyst?

pain, anxiety, or atypical features present

First-line imaging for suspected cystic lesions, especially in women under 40.

Ultrasound

Most common benign breast tumor.

Fibroadenoma (breast mouse)

When do fibroadenomas mainly occur in a woman's life?

2x African American risk, under 35 (95% under 25)

First-line imaging for fibroadenoma. What provides a definitive diagnosis?

Ultrasound, core needle biopsy

Breast infection in nursing mothers =

Lactational Mastitis

What must you educate the mother on when treating mastitis?

To NOT STOP breastfeeding, keep going.

Antibiotic therapy for mastitis? (STOMP)

Dicloxacillin or cephalexin for 10-14 days (clindamycin if anaphylactic to PCN)

First-line treatment for most abscesses.

Ultrasound guided needle aspiration

First-line antibiotics for breast abscess.

Clindamycin 300-450mg PO or TMP-SMX DS BID

Benign condition that is the leading cause of spontaneous unilateral bloody nipple discharge in the absence of a palpable breast mass.

Intraductal Papilloma

Definitive diagnosis for intraductal papilloma

surgical excision of duct

#1 most common cancer in women worldwide

Breast cancer

What are the most significant non-modifiable risk factors in breast cancer? (STOMP)

Female gender and aging

About 50% of breast malignancies are in the ________ _________ quadrant.

Upper outer quandrant, closest to axilla

Chronic, eczematous nipple and areolar lesions that fail to respond to topical treatments. Represents nipple carcinoma (DCIS or invasive cancer)

Paget disease of the nipple

The patient is non-lactating; the breast is swollen, large, and hurts. What is it most likely? What is it NOT?

Most likley inflammatory breast cancer, it is NOT mastitis.

GOLD STANDARD for diagnosing breast cancer. (STOMP)

Biopsy!

Core = Standard; Stereotactic = mammographically detected lesions; Excisional = when you can't do a needle biopsy.

Most common type of breast tumor?

Infiltrating ductal carcinoma

When do you start screening with mammograms?

Start at age 40

Premalignant cellular changes on the cervix caused by persistent HPV infection.

Cervical Dysplasia

Where does cervical dysplasia originate?

transformation zone

Which HPV infections are responsible for 70% of cervical cancers? (STOMP)

HPV 16 and 18

When do you start screening for cervical cancer?

Begin at 21 regardless of sexual history

What HPV causes genital warts and benign changes?

6 and 11

If the patient is >___ and the HPV lab comes back with a negative ASC-US, they can _________ to routine screening. If positive? (STOMP)

>25, negative = return to routine screening, Positive = colposcopy

What is colposcopy?

Like a pelvic exam but with cytology

80-90% of cervical cancers are _________ cell.

squamous cell

HPV 18 is commonly associated with _____________.

adenocarcinoma

Surgical treatment for early-stage (IA) cervical cancer?

cone biopsy

Surgical treatment for early-stage (IB) cervical cancer?

Radical hysterectomy

What is the most common cause of cervicitis? (STOMP)

Chlamydia trachomatis, can run with gonorrhea.

Standard treatment for cervicitis (antibiotics)? What if they are pregnant?

Ceftriaxone 500mg IM once (gonorrhea) + Doxycycline 100mg PO BID x7 (chlamydia). 1g PO once if they are pregnant.

Ovarian cysts that come from normal ovarian function. Usually <8 cm.

Functional cysts (follicular/corpus luteum)

Ovarian cysts that are true neoplasms needing different management.

Pathologic (dermoid, endometriomas, cystadenomas)

Is ovarian torsion an emergency?

Yes, surgery to fix ischemia and preserve fertility

Main imaging to diagnose ovarian torsion?

Ultrasound with Doppler

Immediate __________ (<6 hours) is needed for detorsion of the ovary; it can preserve the ovary.

laparoscopy

Endocrine-metabolic disorder and represents a leading cause of infertility and hyperandrogenism.

PCOS

Diagnosis for PCOS requires __ of 3 __________ criteria after excluding other causes of symptoms. (STOMP)

2 of 3 Rotterdam criteria

What are the 3 Rotterdam criteria?

Oligo/Anovulation, Clinical/biochemical hyperandrogenism, and polycystic ovarian morphology

PCOS has a _____ LH:FSH ratio. (STOMP)

high ratio

What is the leading cause of anovulatory infertility?

PCOS

Patients with PCOS have more unopposed ________ exposure, which increases the risk of developing ___________ cancer.

unopposed estrogen exposure, endometrial cancer

Gold standard for assessing ovarian morphology in PCOS. (STOMP)

Transvaginal Ultrasound

In treating PCOS, combined oral contraceptives are a first-line tx that provides cycle regulation; it provides predictable withdrawal bleeding. What does it reduce? (STOMP)

Reduces endometrial cancer risk

Higher pregnancy rates are seen in PCOS when ________ is used.

Letrozole

Alternative to letrozole, monitor for ovarian hyperstimulation syndrome

Clomiphene

What is the deadliest gynecologic malignancy due to late presentation?

Ovarian cancer

90% of all ovarian cancers are ________ __________ carcinomas.

epithelial ovarian carcinomas (serous is MC)

Which BRCA mutation gives a 30-50% risk for ovarian cancer?

BRCA-1

Strongest risk factor for ovarian cancer

family history

What surgery are high-risk women with BRCA mutations often offered?

prophylactic salpingo-oophorectomy

Virchow's node, Sister Mary Joseph nodule, & Blumer's shelf are signs for __________ in ovarian cancer.

metastasis

A cornerstone of ovarian cancer treatment, what is the first surgery that should be done?

Surgical cytoreduction (debulking)

Bartholin Cyst vs. Abscess

Cyst = unilateral, painless

Abscess = painful!!!

Small tube that is the standard of care for Bartholin abscesses.

word catheter

Usually antibiotics are not needed for Bartholin abscesses due to the I&D procedure, but when antibiotics are needed, what are the first-line options?

TMP-SMX: 160/800mg PO BID for 7-10 days (typical skin coverage)

Augmentin: 875/125mg PO BID for 7-10 days (broad)

Thin, white, wrinkled skin with a paper consistency. "Keyhole" pattern, pruritus at night.

Lichen Sclerosus

What age population does lichen sclerosus usually affect?

Postmenopausal women

Ointment used in lichen sclerosus for 12 weeks

clobetasol

How is lichen simplex chronicus different from lichen sclerosus?

It is thick, dark, leathery, chronic, and can happen in any age group.

What is the MC and challenging form of vulvar lichen planus?

Lichen Planus: Erosive variant

Term for painful bright red erosions surrounded by characteristic white, lacey, borders in lichen planus. (STOMP)

Wickham striae

If a vulvar lesion is persistent, atypical, or the diagnosis is uncertain, what do you do?

biopsy

Gold standard treatment for VIN (therapeutic AND diagnostic)

Surgical excision

What are the vast majority of vulvar cancers?

squamous cell carcinoma, 2nd is melanoma

The most common presenting symptom of vulvar cancer.

Pruritus

Stage 1 vulvar cancer (<2cm, no nodes) would lead to what kind of treatment? (STOMP)

wide local excision with 1cm margins

Thick, white, cottage cheese-like discharge, itching, burning with urination, and lack of odor.

candidiasis

What 4 factors can predispose you to candidiasis?

Recent antibiotics, high estrogen states, diabetes mellitus, and immunosuppression.

Preferred treatment for candidiasis?

Oral fluconazole 150 mg; for pregnancy, use topical (clotrimazole)

Disruption of normal vaginal microbiome, low lactobacilli, and overgrowth of anaerobic bacteria (Gardnerella vaginalis).

Bacterial vaginosis

4 parts of the amsel criteria to diagnose bacterial vaginosis.

gray/white discharge, positive whiff test (fishy) with KOH, vaginal pH >4.5, and clue cells on microscopy (epithelial cells covered with bacteria)

First-line treatment for bacterial vaginosis?

Metronidazole 500mg PO BID (AVOID ALCOHOL)

Frothy yellow-green discharge and a "strawberry cervix"

Trichomoniasis

Preferred diagnostic testing for trichomonas.

NAAT testing and wet mount microscopy

What to use to treat trichomonas?

Metronidazole 500 mg PO BID for ALL partners.

First-line tx for atrophic vaginitis, second-line?

non-hormonal moisturizers & water-based/silicone-based lubricants; the second line is low-dose estradiol cream/tablets/rings

Chronic vulvar pain w/o clear cause. Burning, stinging, or knife-like pain.

vulvodynia

Pain localized to vestibule, point tenderness at vestibular glands.

vestibulodynia