1. health and fitness
2. disease
3. cancer

Reproductive System Review
Gynecology
NCAPA 28th Annual Recertification Exam Review Conference
Angel Nieves, MD. PhD.
Assistant Professor
Department of OB/GYN
Duke University Medical Center
Anatomy
Ovaries – organs that produce eggs and sex
hormones
Fallopian tubes – tubes through which eggs
travel from ovary to uterus
Uterus – cavity where fertilized egg
(embryo) develops
Endometrium – inner lining of uterus
Cervix – lower part of uterus; juncture
between uterus and and vagina
Vagina – organ of sexual intercourse; birth
canal
Reproductive cycle - Menses
 Established by age 13, continues until age 45 to 50
 Depends on the cyclic interaction between
- hypothalamic gonadotropin-releasing hormone
(GnRH)
- pituitary gonadotropins: follicle stimulating
hormone (FSH) and luteinizing hormone (LH)
- ovarian sex steroids hormones: estradiol and
progesterone.
-(Hyphothalamic-pituitary-gonadal axis)
Reproductive Cycle - Menses
 Once established, it remains
regular and predictable—on
average, every 28 days
 Divided into two phases:
 Follicular  estrogen
(ovary)
 Luteal  progesterone (CL)
 It begins with menses
Reproductive Cycle - Menses
- Ovary:
- Immature egg develops into a
follicle in response to FSH (follicular
phase)
- LH triggers ovulation
- Follicle transform into a CL that
secretes estrogen and
progesterone—mostly progesterone
(luteal phase)
- Endometrium:
- During the follicular phase, stroma
thickens and glands become
elongated in response to estrogen
- In the luteal phase, stroma becomes
loose and edematous, and the blood
vessels become thickened and
twisted in response to progesterone
Clinical implications of Reproductive Cycle
Exaggerated responses
- Premenstrual syndrome (PMS):
- Etiology and pathogenesis poorly understood
- Include emotional, physical, and behavioral symptoms
- Breast tenderness, pelvic pain, abdominal bloating, headaches,
moodiness, irritability
- Symptoms occur during the luteal phase (by definition symptoms are
cyclical)
- Treatment:
- First, r/o serious pathology and provide reassurance
- Psychotherapy, stress management, acupuncture, oral
contraceptive pills (OCPs), antidepressants
- Primary dysmenorrhea:
- Characterized by debilitating cramps during the first few days of
menses
- Associated symptoms include diarrhea, nausea, vomiting, and
headaches
- Etiology linked to endometrial production and secretion of
prostaglandins
- Treatment:
-prostaglandin synthetase inhibitors (NSAIDs), OCPs ,
Levonorgestrel IUD, heat pads
Menstrual disorders - Amenorrhea
FAST FACTS
 Absence of menstruation
- PRIMARY  no menses by age 13 in the
absence of 20 sexual characteristics
- PRIMARY  no menses by age 15
despite 20 sexual characteristics
- SECONDARY  no menses in 6 months
Differential Diagnosis - 1o Amenorrhea
 Hypothalamic and pituitary disease
 Functional hypothalamic amenorrhea (characterized by abnormal
release of GnRH)
 Weight loss, excessive exercise, anorexia, chronic anxiety
 Congenital GnRH deficiency
 Kallman’s syndrome (associated with anosmia)
 Constitutional delay
 Hyperpolactenemia (galactorrhea often present)
 Neoplasia (eg. craniopharyngioma)
 Ovarian
 Gonadal dysgenesis (absence of ovarian oocytes and follicles)
 Turner’s syndrome (45, XO) most common
 Elevated FSH (reduction in negative feedback)
 PCOS
 Menstrual irregularity and hyperandrogenism
 Dx of hyperandrogenism
 clinically, by hirsutism, acne, or male pattern
balding or
 biochemically, by high levels of androgens
 Other: autoimmune oophoritis, chemo or rad-induced
Differential Diagnosis - 1o Amenorrhea
 Congenital anatomical lesions of uterus and vagina
 Vaginal agenesis (also known as Müllerian agenesis or MayerRokitansky-Küster-Hauser syndrome)
 Transverse vaginal septum
 Imperforated hymen
 Receptor abnormalities and enzymes deficiencies
 Androgen insensitivity syndrome (46,XY  defect in androgen
receptor)
 Absence of upper vagina, uterus and fallopian tubes
 High serum testosterone
 Testes should be surgically excised due to increase risk of
testicular cancer (2-5%)
 5-alpha-reductase deficiency
 17-alpha-hydroxylase (CYP17) deficiency
 Vanishing testes syndrome
 Absent testis determining factor (also called Ullrich-Turner
syndrome)
 Estrogen resistance
Evaluation - 1o Amenorrhea
 History
 Physical exam
 Laboratory testing
Focused on
1) +/- breast development
 marker of estrogen action and therefore function of ovaries
2) +/- of uterus
 determined by U/S or MRI
3) FSH levels
Breast
No  elevated FSH  gonodal dysgenesis  karyotype
Yes  normal FSH
 U/S
no uterus  Mullerian Agenesis or androgen insensitivity
uterus  focus on causes for 2o amenorrhea
Treatment - 1o Amenorrhea
Correct the underlying pathology (if possible)
 Prevent complications of the disease
process (replace estrogen to prevent
osteoporosis)
 Psychological counseling
 Surgery
 Help with achieving fertility (if desired)
Differential Diagnosis- 2o Amenorrhea
 Pregnancy (most common) – ALWAYS exclude pregnancy FIRST!
 Hypothalamic dysfunction
 Functional hypothalamic amenorrhea most common (characterized by abnormal
release of GnRH)
 weight loss, excessive exercise, eating disorders, systemic illnesses, psychological
stress
 Pituitary dysfunction
 Hyperprolactemina most common (prolactin suppresses GnRH)
 pituitary tumor, medications (such Reglan and antipsychotics), hypothyroidism
 Ovarian dysfunction
 PCOS
 Premature ovarian failure (depletion of oocytes before age 40)
 Autoimmune destruction, fragile X premutation, radiation, chemotherapy
 Uterine disease
 Asherman’s syndrome – scarring of the uterine cavity
- D&C for retained products of conception particularly at risk
Evaluation - 2o Amenorrhea
 Rule out pregnancy
 History
 Stress, weight changes, diet and/or exercise habits, recent illness
 Medications
 Acne, hirsutism
 Headaches, visual defects, galactorrhea
 Symptoms of estrogen deficiency: hot flashes, vaginal dryness, poor sleep
 OB history: recent D&C
 Physical exam
 BMI (BMI >30 seen in 50% of women with PCOS; BMI < 18.5 associated with
functional hypothalamic amenorrhea)
 Hirsutism, acne, acanthosis nigricans
 Erosion of dental enamel suggest eating disorder (bulimia)
 Labs
 FSH, prolactin, TSH
 Testosterone, DHEA (adrenal source of androgens), 17-hydroxyprogesterone (r/o
nonclasic 21-hydroxylase deficiency
 Assess estrogen status  progestin withdrawal test
Treatment - 2o Amenorrhea
 Hypothalamic amenorrhea
 Lifestyle changes
 Cognitive behavioral therapy
 Estrogen therapy to prevent bone loss
 Hyperprolactenemia
 Treat underlying cause (thyroid supplementation, discontinue medications, surgery)
 Premature ovarian failure
 Estrogen therapy to prevent bone loss
 PCOS (depends on fertility desire)
 Directed to woman’s goal (relief of hirsutism, resumption of menses, fertility)
 Prevent long-term consequences (endometrial hyperplasia, obesity, metabolic
defects)
 Intrauterine adhesions
 Hysteroscopic lysis of adhesions followed by long-term estrogen to stimulate regrowth of endometrium
Menopause
Definition
 Permanent cessation of menstruation as a consequence of the loss of ovarian activity
 Can not be determined until 1 year after LMP
 Median age of menopause is 51
Cardinal Symptoms
 Vasomotor (hot flashes)
 sudden sensation of extreme heat in upper body
 characterized by perspiration, flushing, chills, anxiety, and, on occasion, heart
palpitations
 may interfere with sleep
 pathophysiology poorly understood
 Vaginal (atrophy)
 symptoms include vaginal or vulvar dryness, discharge, itching and dyspareunia
 direct consequence of the hypoestrogenic state
Menopause
Evaluation
 Clinical diagnosis, elevation of FSH
Treatment
Hormonal
 Systemic estrogen-alone or combined with progestin
 most effective in therapy for vasomotor symptoms
 risks include thromboembolic events and breast cancer
• WHI study, large RCT of healthy menopausal women aged 50-77 years
• slight increase risk of breast cancer, CHD, stroke, and thromboembolic events
• decreased risk of fractures and colon cancer
 Therapy with estrogen alone
• increased risk of thromboembolic events
• but not an increased of CHD or breast cancer
 Transdermal estrogen may have lower risk for thromboembolic events
 treat with the lowest effective dose for the shortest duration
 Vaginal/Local estrogen
Nonhormonal
 SSRIs and SSNRIs
 Gabapentin
 Clonidine
 Vaginal lubricans (Replens)
 Ospemifene (estrogen agonist-antagonist)
Endometriosis
FAST FACTS
 Found in 5-15% of reproductive age women undergoing
laparoscopy
 Symptoms: none!, cyclic pre- and peri-menstrual pain,
dyspareunia, chronic pelvic pain, fertility (1/3)
Etiology




Retrograde menstruation
Lymphatic-vascular spread
Coelomic
Decrease cellular immunity
Pathology
 Ectopic endometrial glands and stroma
 Adjacent hemorrhage
 Common locations: uterosacral ligament, ovary, cul-de-sac
Treatment






Continuous OCPs
Depot medroxyprogesterone acetate
Gonadotropin-releasing hormone (GnRH) agonists (Lupron)
Danazol
Aromatase inhibitors (Femara)
Surgery
Cervical disorders: cervicitis  PID
FAST FACTS





Acute infection of upper genital tract (polymicrobial)
Often starts with cervical GC and/or Chlamydia leading to ascending infection
Negative endocervical screening does not r/o upper tract infection
Sequelae: adhesions, hydrosalpinx, 10X increase in ectopic, 4X increase in pelvic pain,
infertility
Early dx and tx key in prevention of sequelae
Diagnosis
( all 3 should be present)



Lower abdominal pain and tenderness on exam ( w or w/o rebound)
Cervical motion tenderness
Adnexal tenderness
( additional criteria that support dx)



Fever > 101 F (>38.3 C)
Abnormal cervical or vaginal d/c
Documentation of GC and/or Chlamydia
( definite criteria for dx)



U/S or other imaging showing thickened fluid-filled tubes, or TOA
Laparoscopic abnormalities c/w PID
Endometrial biopsy revealing endometritis
PID: Treatment (broad coverage)*
Outpatient  Mild/Moderate
 Ceftriaxone 250 mg IM + Doxycycline 100 mg BID X14-days
 Cefoxitin 2 g IM + Probenecid 1 g PO + Doxycycline 100 mg BID X14-days


Ceftriaxone preferred since it has better activity against GC
Add Metronidazole if trichomonas found or recent hx of uterine instrumentation (D&C)
PCN allergic  ask about the nature of the allergy


cephalosporin regimen preferred to cover GC (cross-reactivity between PCN and 3rd-generation cephalosporin
uncommon
If allergy to PCN is severe: hospitalize and treat with Clinda 900 mg IV q 8-hrs + Gent loading dose (2 mg/kg)
followed by maintenance dose (1.5 mg/kg) q 8-hrs
Criteria for hospitalization
 Pregnancy
 Nonadherence to therapy
 Inability to take Abx due to N/V
 Severe clinical illness (high fever, N/V, severe abdominal pain)
 Pelvic abscess (TOA)
 Possible need for surgical intervention or diagnostic exploration for alternative etiology (eg.
Appendicitis –if symptoms are in RLQ)
Inpatient
 Cefoxitin 2 g IV q 6-hrs or cefotetan 2 g IV q 12-hrs + doxycycline 100 mg PO BID X14-days
 Clinda 900 mg IV q 8-hours + Gent loading dose (2 mg/kg) followed by maintenance dose (1.5
mg/kg) q 8-hrs
* Male sex partners should be examined and treated if they had sexual contact with patient the previous 60 days prior to
onset of symptoms to decrease risk of reinfection
Cervical disorders:
Cervical Intraepithelial dysplasia
FAST FACTS
– High-risk HPV infection necessary but not sufficient for
development of cervical neoplasia/carcinoma.
– Only a small fraction with HPV will develop high-grade cervical
abnormalities and cancer (most infections are transient).
– HPV infection common in teenagers and women in their early
20s. The majority will clear by 8-24 months.
– Persistent HPV infection at 1 and 2 years strongly predicts highgrade lesion regardless of age.
– Risks factors for persistent infections include: cigarette
smoking, compromised immune system, HIV infection.
Cervical disorders: Evaluation with colposcopy
• Cervical Intraepithelial dysplasia
– CIN-1
• Manifestation of acute HPV infection
• Most will regress on their own
• Expectant management
– CIN-2
•
•
•
•
Represent a mix low- and high-grade lesions
Cancer precursor lesions
Treatment recommended
Very close surveillance (young population)
– CIN-3 and adenocarcinoma in situ (AIS)
• Cancer precursor lesion
• Treatment strongly recommended
• Progression into invasive cancer averages 8.1 – 12.6 years
Vaginitis
FAST FACTS
 Most frequent reason to visit an OB/GYN
 Spectrum of conditions that cause vulvovaginal symptoms such as:
 itching, burning, irritation, and abnormal discharge
Differential diagnosis
 Bacterial vaginosis (22-50%)
 Candidiasis (17-39%)
 Trichomoniasis (4-35%)
 Undiagnosed (7-72%)
 Atrophic vaginitis
 Vulvar dermatological conditions
 Vulvodynia
Evaluation
 Physical exam – external genitalia, speculum
 Wet prep
Vaginitis
Evaluation
 Physical exam – external
genetalia, speculum
 Wet prep
Characteristic
Physiologic
Complaint
None
Discharge
Candida
Trichomonas
Bacterial
Vaginosis
Bad odor, frothy d/c,
itching/burning,
postcoital bleed
Bad odor, worse
after sex, +/itching
White, clear, Thick, curdy,
flocculent
“cottage cheeselike”
Green-yellow, frothy
Thin,
homogeneous,
gray-white
pH
3.8-4.2
< 4.5
> 4.5
> 4.5
Hyphae
Absent
Present
Absent
Absent
Trichomonads
Absent
Absent
Present
Absent
Clue Cells
Absent
Absent
Absent
Present
KOH “whiff test”
Negative
Negative
+/-
Positive
Itching/burning,
irritation, dysuria,
dyspareunia
Vaginitis - treatment
Candida
Trichomonas
Bacterial
Vaginosis
Azoles (1,3, and 7-day courses)
- Miconazole (Monitast)
- Clotrimazole (Gyne-Lotrimin)
- Tioconazole (Vagistat-1)
- Terconazole (Terazol)
Metronidazole (Flagyl)
- 2 gms PO X1
- 500 mg PO BID X 7-days
Metronidazole
- 0.75% gel (5 g daily X 5-days)
- 500 mg PO BID X 7-days)
Fluconazole 150-mg PO X1
Tinidazole 2 gms PO X1
Clindamycin
- 2% cream (5 g daily X 7-days)
- 300 mg PO BID X 7-days
- 100 mg ovules daily Xs3-day
Nystatin 100,000 U vag sup X14-days
(Partner needs treatment)
Menstrual disorders - Abnormal Uterine Bleeding (AUB)
FAST FACTS
 Duration of normal menstrual flow is 5 days with
normal intervals ranging from 21-35 days
 Descriptive terms to characterized AUB include:
– Menorrhagia (heavy bleeding)
– Metrorrhagia (bleeding between periods)
– Polymenorrhea (bleeding that occurs more often than
every 21-24 days)
– Oligomenorrhea (bleeding that occurs less than every 35-38
days)
 Dysfunctional uterine bleeding frequently used to
describe AUB unrelated to systemic medical illness,
endocrinopathy, or structural uterine anomaly.
 Use of term discouraged
 New classification system (acronym PALM-COEIN)
adopted to standardize the terminology used to
describe AUB
– Classifies AUB by bleeding pattern as well as etiology
Menstrual disorders - Abnormal Uterine Bleeding (AUB)  etiolo
-
Heavy menstrual bleeding (AUB/HMB)  patte
- Intermenstrual bleeding (AUB/IMB)  patte
PALM – Structural Causes
COEIN – Nonstructural Causes
Polyp (AUB-P)
Coagulopathy (AUB-C)
• Inherited – von Willebrand’s disease
• Acquired – Thrombocytopenia, acute leukemia,
advanced liver disease
Adenomyosis (AUB-A)
Ovulatory dysfunction (AUB-O)
(Typically the result of an endocrinopathy and bleeding
pattern is related to unopposed estrogen)
• PCOS, elevated androgen, thyroid disease,
hyperprolactinemia
Leiomyoma (AUB-L)
Endometrial (AUB-E)
Malignancy & hyperplasia (AUB-M)
Iatrogenic (AUB-I)
• Anticoagulation therapy
• Contraception:
oral/transdermal/implants/injectable/ring/IUD
Not yet classified (AUB-N)
Menstrual disorders - Abnormal Uterine Bleeding (AUB)
Evaluation
•
History
– Timing, nature, associated symptoms, pertinent medical hx,
hx of bleeding disorders, changes in weight/exercise/stress
•
PE
– General: ecchymosis, thyroimegaly, evidence of
hyperandrogenism, acanthosis nigricans
– Pelvic: site of bleeding, assess size and contour of uterus,
evidence of malignancy
•
Labs
– Pregnancy test, CBC, pap smear, TSH, von Willebrand’s
panel (especially in adolescents or family hx)
•
Endometrial biopsy
– Consider in all women 35-45 years of age
– Perform in all women >45 of age
– Perform in all women with hx of unopposed estrogen (risk
for hyperplasia):
• Obesity, chronic anovulation, hx of breast cancer, tamoxifen
use
•
Ultrasound: Saline Infusion Sonogram (SIS) preferred
Menstrual disorders - Abnormal Uterine Bleeding (AUB)
Treatment
• Acute menorrhagia
– High-dose IV or oral estrogen
– Blood transfusion—if needed
– Surgical: D&C, uterine embolization
• Chronic menorrhagia
– Medical
• OCP’s, Mirena IUD, NSAIDs,
antifribinolytics (tranexamic acid),
GnRH agonist ( Depo-Lupron)
– Surgical/non-surgical
• Hysteroscopy, D&C, endometrial
ablation, myomectomy,
hysterectomy
• Uterine embolization, MRI-guided
focused ultrasound
AUB - Leiomyomas
 Benign smooth muscle tumors of
the uterus
 70-80% of women
 Symptomatic in about 25%
 Bleeding, pain, pressure, infertility
 Significant impact on health and
quality of life
 Leading cause of hysterectomies
AUB - Endometrial Malignancy & Hyperplasia
Fast Facts
 Hyperplasia is characterized by a proliferation of endometrial glands that may
progress to or coexist with endometrial carcinoma.
 Hyperplasia virtually always results from chronic unopposed estrogen stimulation.
 Endometrial carcinoma  most common gynecological malignancy.
 AUB is the cardinal symptom (present in 75-90%) .
 Large number of women (68%) are diagnosed with local disease and have a 96% 5year survival rate.
 Suspicion of malignancy depends on symptoms, age, and presence of risks factors.
AUB - Endometrial Malignancy & Hyperplasia
 Following bleeding patterns prompt evaluation (biopsy and/or U/S)
 Postmenopausal bleeding – any bleeding (including spotting or staining)
 3-20% - malignancy
 5-15% - hyperplasia
 Age 45 to menopause – any AUB (heavy, prolonged or intermenstrual)
 Age 45 to menopause – prolonged periods of amenorrhea (> 6-months)
 Younger than 45 – persistent AUB that occurs in the setting of unopposed
estrogen exposure (obesity, chronic anovulation, failed medical management,
high-risk for carcinoma (eg, Lynch syndrome)
Effectiveness of contraceptive methods
Most
effective
Reversible
Implant
Permanent
Intrauterine Device
Male Sterilization
Female Sterilization
(IUD)
(Vasectomy)
(Abdominal, Laparoscopic, Hysteroscopic)
< 1 pregnancy per
100 women in a year
0.05%*
Injectable
LNG – 0.2% Copper T – 0.8%
0.15%
0.5%
Pill
Patch
Ring
Diaphragm
9%
9%
9%
12%
6-12 pregnancies per
100 women in a year
6%
18 or more pregnancies
Per 100 women in a year
Male Condom
Female Condom
18%
21%
Fertility-Awareness
Based Methods
Withdrawal
22%
Sponge
24% parous women
12% nulliparpous women
Spermicide
Emergency
Contraception
Lactational
Amenorrhea
28%
24%
Least
effective *Percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the 1st year
Best method is one that does not require ongoing
effort on the part of the user for long-term and
effective use!
Long-Acting Reversible Contraceptives (LARC): Implants and
Intrauterine Devices
Copper T380A
 Contraceptive CHOICE project (a prospective
cohort of women 14-45 yrs) showed that in the
absence of financial, knowledge, health care
provider or logistical barriers, the rate of
initiation of LARC was higher than any other
contraceptive method
 Pregnancy rates are lower and continuation
rates are higher, when compared with OCPs.
Levonorgestrel intrauterine system
 Both types of IUDs were among the 3 least
expensive over a 5-yr period
Contraceptive implant
 T-shape polyethylene device wrapped with copper
 MOA: inhibition of sperm migration and viability, change in transport speed
of egg, and damage to or destruction of egg
 Approved for use for up to 10-yrs
 Highly effective: failure rate 0.8 per 100
 Most common adverse effects: abnormal bleeding and pain
Copper T380A
Levonorgestrel intrauterine system
Contraceptive implant
 T-shape polymethysiloxane sleeve containing 52 mg of levonorgestrel
 MOA: similar to copper IUD, plus endometrial suppression (thinning of lining)
and changes in amount and viscosity of cervical mucus
 Approved for use for up to 5-yrs (may be effective for up to 7-yrs)
 Highly effective: failure rate 0.2 per 100
 Releases 20 μg of levonorgestrel daily
 some may experience HA’s, nausea, breast tenderness, cyst formation
 most ovulate normally but menstrual bleeding decreases due to the local
effect of levonorgestrel on endometrium
 Complications uncommon: expulsion (2-10%), perforation (1 per 1,000 insertions)
 Ethylene vinyl acatate copolymer core containing 68 mg of etonogestrel
 MOA: suppression of ovulation, changes in viscosity of cervical mucus
 Approved for use for up to 10-years
 Most effective reversible method: failure rate 0.05 per 100
 Most common adverse effects: abnormal bleeding, HA’s, acne, weight gain
 Complications associated with insertion and removal uncommon 1-1.7%:
pain, slight bleeding, hematoma.
Urogynecology – sensation of prolapse
FAST FACTS
 Herniation of female genital tract
 Main symptom is swelling or discomfort in
the vagina
 Frequently also complaint of urinary
incontinence, difficulty with urination
and/or defecation
 Prevalence increases beyond age 50
 Most common indication of gyn surgery
after menopause
 Classified according to location
 Anterior vaginal prolapse (cystocele)
Cystocele
Rectocele
 Urinary incontinence common
 Posterior vaginal prolapse (rectocele)
 Constipation common
 Uterine prolapse
 Vault prolapse (enterocele)
 Urinary incontinence and/or constipation
common
Enterocele
Urogynecology – sensation of prolapse



Differential diagnosis
 Other causes of vaginal lump
 Bartholin’s cyst
 Genital tract tumor
 Cervical fibroid
 Cervical polyp
 Cervical cancer
 Vulvar cancer
 Neglected foreign body
Risks factors
 Estrogen deficiency (menopause)
 Vaginal delivery (large babies)
 Obesity
 Chronic constipation
 Chronic smoking
 Chronic cough
 Collagen disorders
Treatment
 Cystocele/Rectocele/Enterocele
 Lifestyle: weight loss, smoking cessation
 Physical therapy: pelvic floor exercises
 Pessary
 Hormone therapy
 Surgery
Bartholin’s cyst
Cervical fibroid/polyp
Genital tract tumor
Vulvar cancer
Non-malignant conditions of breast
Disease
Etiology
Pathophysiology
Clinical
Presentation
Treatment
Mastitis
Infection
Inflammatory
reaction to
infection (usually S.
aureus)
- Breast pain,
redness,
tenderness, +/fever
- Antibiotics
Abscess
Infection
Inflammatory
reaction to
infection
- Breast pain,
mass, redness,
tenderness, fever
- Drainage
- Antibiotics
Fat necrosis
Trauma,
ischemia
Degenerating
adipocytes
- Solitary, tender,
ill-defined mass,
frequent hx of
trauma
- Imaging and
biopsy/excision
to r/o
malignancy
Fibroadenoma
Estrogen
stimulation
Proliferation of
epithelial and
fibrous tissues
- Firm, painless,
freely movable
mass
- Imaging and
biopsy/excision
to r/o
malignancy
Non-malignant conditions of breast
Disease
Etiology
Pathophysiology
Clinical
Presentation
Treatment
Fibrocystic
disease
Exaggerated
response to
hormones
Proliferation of
stroma and large
cysts
- Cyclic,
bilateral pain
and
engorgement.
- On exam,
diffuse
nodularity and
cystic lesions
- Fine-needle
aspiration
- Biopsy
- Restriction of
caffeine
- Evening
primrose oil
Galactorrhea
Elevated levels of
prolactin:
- Pituitary tumor
- Hypothyroidism
- Drugs
Stimulation of
breast ducts
- Clear, milky
nipple
discharge
- Find cause
and treat
accordingly
Gynecomastia
Increase in the
ratio of estrogen
to androgen
activity
Benign
proliferation of
the glandular
tissue of the male
breast
- Palpable mass
of tissue at
least 0.5 cm in
diameter
(usually
underlying the
nipple)
- Reassurance
- Surgery
Breast cancer
Fast Facts
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Leading site of cancer in women (12.6% lifetime risk)
Leading cause of death from cancer in women 35-54 years old
80% of women with breast cancer have no known risk factor
Screening key
Risk Factor
Relative Risk
Age (50 yrs vs. <50 yrs)
6.5
Family hx of breast cancer
1st degree relative
2nd degree relative
1.4 - 13.6
1.5 – 1.8
Age at menarche (<12 yrs vs. >14 yrs)
1.2 – 1.5
Age of menopause (>55 yrs vs. <55 yrs)
1.5 – 2.0
Age of 1st live birth (<30 yrs vs. <20 yrs)
1.3 – 2.2
Benign breast disease
Breast biopsy (any histology)
Atypical hyperplasia
1.5 – 1.8
4.0 – 4.4
Hormonal therapy
1.0 – 1.5
Risk-assessment tools: Gail, Claus, and BRCAPRO model
Breast cancer
Management
 Follow-up!
 In a palpable breast lump, mammography alone is not sufficient
 Listen to patient
 See indications for biopsy
Biopsy indications
 Cyst aspiration and fine needle aspiration are crucial in clinical evaluation of
breast disease
 Perform open biopsy if one of the following is present
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Equivocal findings on aspiration
Bloody cyst fluid
Recurrence of cyst after 1-2 aspirations
Bloody nipple discharge
Nipple excoriation
Skin edema or erythema suspicious of inflammatory breast carcinoma
Prognosis
 Axillary node status is the MOST important prognostic feature
Infertility
FAST FACTS
 Defined as 1-yr of
unproctected sex without
conception
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Affects 10-15% of couples
 Female fertility decreases
with maternal age
Causes of Infertility for Couples
 In each ovulatory cycle,
normal couple have ONLY about
30% chance of becoming
pregnant
Infertility
Cause of infertility in women
Tubal factor
Endometriosis
Ovulatory dysfunction
Diminished ovarian reserve
Uterine factor
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Failure to ovulate major problem (40%)
Tubal/pelvic pathology (40%)
Anatomical anomalies (10%)
Other (10%)
Infertility
Evaluation
 History
 Menstrual irregularity (AUB)
 Dysmenorrhea, dyspareunia
 Previous surgeries or pelvic infections (PID)
 Family hx of endometriosis or early menopause
 Laboratory testing
Prolactin/TSH
 Assessment of ovarian reserve
 Day 3 FSH or Antimüllerian hormone
 Semen analysis
 Evaluation of tubal patency
 HSG (hysterosalpingogram)
 Laparoscopy
Treatment  based on cause
Adnexal masses
FAST FACTS
 Most masses are benign and detected incidentally
(routine PE, imaging)
 Goal of the diagnostic evaluation is to exclude malignancy
 Masses in menstruating women almost always FUNCTIONAL CYST
 Most common masses in postmenopausal women BENIGN NEOPLASMS.
 Risk of malignancy increases with age (most important risk factor)
 For many women, the symptoms are gradual (abdominal swelling and
vague discomfort)
 Acute and severe symptoms almost always associated with torsion or
rupture of a mass requires immediate surgical intervention.
 Not ALL masses are gynecological in origin or arising from the ovary
Adnexal masses: Differential Diagnosis
Category
Diagnosis
Gynecological
Benign
Ovarian
• Functional cyst : simple, corpus luteum, hemorrhagic
• Endometrioma
• Mature teratoma (dermoid)
• Serous or mucinous cystadenoma
Non-ovarian
• Tuboovarian abscess
• Hydrosalpinx
• Leiomyoma
• Ectopic pregnancy
Malignant
• Germ-cell tumor
• Epithelial tumors
• Sex-cord stromal tumor
Non-gynecological
F
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a
l Endometrioma
c
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s
t
Mature teratoma
Benign
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Diverticular abscess
Appendiceal abscess or mucocele
Pelvic kidney
Paratubal cyts
Ureteral diverticulum
Bladder diveticulum
Malignant
• GI cancer
• Retroperitoneal sarcomas
• Metastatses
Mature teratoma
Hydrosalpinx
Adnexal masses
Evaluation
 Pelvic exam (limited, especially if BMI > 30)
 Transvaginal Ultrasound (gold standard for detection
and characterization)
 CT (only role is in evaluating metastasis when cancer is
suspected)
 Serum marker
 CA-125 (limited)
 Main value in postmenopausal women to
distinguish between benign and malignant
masses
Management
 Management decision influenced by the age, family hx
of patient, description of mass (simple vs. complex),
severity symptoms