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1
Q

Who is responsible for infertility

A

35-40% d/t male issues
35-40% d/t female issues
20-30% d/t combination

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2
Q

what is the definition of infertility

A

No conception after 12 months of intercourse without contraception in women under 35
No conception after 6 months of intercourse without contraception in women over 35

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3
Q

why should you refer someone sooner rather than later for fertility issues?

A

chances of getting knocked up after 12 months (<35) or 6 months (>35) are 2%…..get them help

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4
Q

What are primary female issues that contribute to infertility from the pelvis?

A
  1. Infection: PID, STI, septic abortion, endometriosis, pelvic TB
  2. Surgical Hx: D&amp;C, ruptured appendix, endometriosis, adnexal surgery, fibroids
  3. Contraception/Pregnancy Hx: prior IUD use, DES exposure in utero, ectopic pregnancy, habitual abortion
  4. Menstrual cycle abnormalities: secondary amenorrhea, endometriosis, cyclic adbominal or pelvic pain
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5
Q

What are secondary factors that can lead to infertility in women?

A
  1. secondary amenorrhea
  2. AUB
  3. Luteal phase defect (short cycle)
  4. Premature ovarian failure (early menopause)
  5. Polycystic ovarian syndrome (high androgen)
  6. Elevated prolactin
  7. Hypothyroidism
  8. Prior use of anti-estrogens (lupron, depo-provera, danazol)
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6
Q

What are other causes of infertility in women?

A
  1. Delayed childbearing
  2. Overweight (BMI>25) or underweight (BMI <18)
  3. Depression
  4. Substance abuse (alcohol, tobacco, caffeine, weed)
  5. Insulin resistance
  6. Malabsortion (celiac)
  7. Unexplained 15%
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7
Q

How do you assess menstrual cycle?

A
  1. Day 3 FSH: < 10-15mlU/ml, day 3 E2: <80pg/ml
  2. Midcycle ultrasound to assess follicular growth and endometrial lining
  3. HSG to assess patency of Fallopian tubes
  4. Ovulation patency
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8
Q

How do you assess ovulation

A
  1. Mid-luteal Phase progesterone levels (<25 may be treated with pv progesterone)
  2. Basal body temperature
  3. Urinary lutenizing hormone kits
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9
Q

What should be tested in an infertile female patient with an irregular menstrual cycle?

A
  1. Testosterone
  2. Cortisol
  3. Dehydroepiandosterone sulfate (DHEAS)
  4. 17-OH progesterone
  5. Thyroid function
  6. Prolactin
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10
Q

What are normal semen numbers from an analysis completed after 2-5 days of abstinence?

A
  1. Number: >20 million
  2. Volume: 2-5ml
  3. Motility: >50% motile or >25% with rapid forward motility
  4. > 35% normal morphology
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11
Q

what are lifestyle factors that have been shown to increase longer time to pregnancy (TTP)

A
  1. Woman/partner smoked >15 cigarettes a day
  2. Partner consumed >20 alcohol units per week
  3. Woman’s BMI was >25
  4. Women’s caffee/tea intake was >6 cups per day
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12
Q

What should you know about BMI and pregnancy?

A
  1. BMI under 20 corresponded to 12% of ovulatory infertility and a BMI greater then 25 corresponded to 25% ovulatory infertility
  2. successful weight loss programs led to significant increases in pregnancy success and success of reproductive therapies (IVF)
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13
Q

How does fish consumption relate to infertility?

A

in studies couples that eat a lot of seafood and were infertile often had higher levels of blood mercury…

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14
Q

How does exercise relate to infertility?

A

Each hour per week of vigorous exercise corresponds to a 7% lower risk of ovulatory infertility. However, exercise before IVF is not recommended

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15
Q

Why does acupuncture help with infertility?

A
  1. Stress/anxiety reduction
  2. Increase pelvic blood flow (shown with US)
  3. Increased sperm count and sperm viability
  4. Decreases in depression
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16
Q

What should you recommend for supplements to women seeking to conceive?

A
  1. Prenatal vitamin (folic acid, iron, B12, arginine)
  2. Antioxidants (stop smoking, eat blueberries..etc)
  3. Magnesium and selenium
  4. Vitex (increase luteal phase, decrease prolactin)
  5. Greaan tea
  6. Tribulus and Rhodiola
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17
Q

Why would an infertile woman take topical, oral or vaginal natural progesterone?

A
  1. Normalize menstrual cycle
  2. Improve implantation rates
  3. Maintain pregnancies in women with repeated miscarriages
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18
Q

Which antioxidants improve sperm quality and quantity?

A

Vit C, E, glutathione, lycopene and CoQ10

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19
Q

What is an adnexal mass?

A
  1. Neoplasm (atypical cell growth)

2. Classified as: benign, low malignant potential and malignant

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20
Q

What are the types of malignant neoplasms in the ovaries?

A
  1. Solid/complex or fluid filled/simple

2. Tumor cell type

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21
Q

What are complications from ovarian neoplasms?

A
  1. Torsion
  2. Rupture
  3. Infection
  4. Hemorrhage
  5. Malignant potential (exception: functional cysts)
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22
Q

What are the different types of ovarian masses?

A
  1. Functional cysts (follicular, corpus luteum and theca lutein cysts)
  2. Neoplasms (dermoid)
  3. Endometrioma
  4. PCOS
  5. Tubo-ovarian abscess
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23
Q

Which of the functional cysts is most common? what is the order?

A
  1. Follicular (MC)
  2. Theca lutein (rare, benign, MC ovarian mass)
  3. Corpus luteum (LC)
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24
Q

What should you know about follicular functional cysts?

A
  1. Results from DOMINANT follicle failing to rupture OR IMMATURE follicle failing to undergo normal process of atresia
  2. Usually disappear within 1-3 months
  3. Blood can fill cavity of the cysts = chocolate/hamorrhagic
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25
What should you know about the less common but more clinically relevant corpus luteum cysts (functional)?
1. May be associated with normal endocrine function or prolonged progesterone secretion 2. Results is sac doesn't dissolve, seals off after egg is released (fluid filled) 3. Usually occurs 2-4 days post ovulation 4. usually resolves within 2 weeks 5. may BLEED or cause TORSION
26
Do corpus luteum cysts recur?
Yes, they have a 31% chance of recurrence
27
What should you know about the least common type o functional cysts: theca lutein?
1. Caused by prolonged/excessive stimulation of ovaries by endo/exogenous gonadotropins 2. From: multiple pg (twins), fertility drugs, molar pregnancies, choriocarcinoma, diabetes) 3. Typically resolve spontaneously
28
What are common symptoms of symptomatic functional cysts (often asymptomatic)?
1. Unilateral pressure, fullness or pain in lower abdomen 2. Dull ache in LB and thighs 3. Pain during intercourse 4. If producing excess hormones: painful menses, AUB, N/V, breast tenderness
29
What are symptoms from functional cysts requiring immediate referral?
1. Pain with FEVER and VOMITING 2. sudden, severe abdominal pain 3. Fainting, dizziness or weakness 4. Rapid breathing or HR
30
What are characteristics of dermoid tumors?
1. Monstrous growth 2. Contain all 3 germ layers 3. Composed of skin and filled with hair, glands, muscle, bone, teeth, cartilage. resp/GI epithelium, thyroid tissue...etc 4. Can be BENIGN or MALIGNANT
31
What are dermoid tumors/cysts?
Teratomas
32
Epidemiology of teratomas
1. MC in prepubescent girls and teens 2. half in ages 25-50 3. 20% of all benign ovarian tumors in postmenpausal women 4. Usually removed d/t malignant potential, which is very low
33
What is an endometrioma?
1. benign, estrogen-dependent cyst found in women of reproductive age 2. Often associated with infertility
34
What is a tubo-ovarian abscess?
1. Infection in the tubo/ovarian junction | 2. Often caused by chlamydia or gonorrhea
35
What are symptoms of tubo-ovarian abcesses?
1. Tubal/ovarian swelling/enlargement 2. Pelvic pain 3. Fever 4. Vaginal discharge 5. Long term sequelae: infertility, chronic pelvic pain
36
What is the malignant risk of ovarian masses in women?
Premenopausal: 13% Postmenopausal: 45%
37
Are adnexal masses common?
1. They are the 5th leading cause of cancer deaths (24,000 new cases annually) 2. Half of all gynocological cancer deaths 3. Peak age 60-65
38
What are risk factors for adnexal masses?
1. Family history 2. Nullparity 3. Early menarche/ late menopause 4. Fertility promoting drugs 5. Geography (highest in N. amercia, lowest in japan) 6. Sedentary lifestyle 7. High fat diet
39
Though adnexal masses are often asymptomatic until late stages, what should you look out for?
1. Pressure: LBP 2. Pain: associated with rupture, torsion, hemorrhage, cancer, functional cyst (LBP 3. GI symptoms: nausea, epigastric upset, gas/bloating 4. Menstrual abnormalities 5. Hormonal changes 6. Cancer symptoms
40
What labs should you run for suspected adnexal masses?
1. hCG 2. CBC 3. Renal/LFT 4. Tumor markers (Ca125) 5. CEA (carcinoembryonic antigen) 6. Pelvic US (gold standard), chest x-ray, CT scan
41
Is Ca125 a reliable marker for cancer? if not why?
No, there are many false positives (fibroids, benign ovarian tumors, adenomyosis, endometriosis, PID)
42
What should you know about screening for adnexal masses?
Despite recommedations that women should get screened, screening tests are invasive and there is not great evidence they help overall mortality...
43
What should a physical for ovarian masses include?
1. Lymph node survey 2. Breast exam 3. Abdominal exam 4. Bimanual exam 5. Rectovaginal exam
44
How can you tell the difference between benign and malignant pelvic masses on US?
1. Likely benign: cystic, smooth, unilocular, unilateral, small (<5cm) 2. Suspicious: solid, mixed cystic/solid, multilocular, bilateral, irregular, large (>10cm), with internal septae/papilla
45
When should you consider a laparoscopy for an ovarian mass?
1. >7-10cm 2. Continues to enlarge (progressive) 3. Looks suspicious on US 4. With suspicious history, presentation or physical
46
How can you prevent adnexal masses?
1. Proper diet and nutrition 2. Breast feeding 3. Hormonal contraception 4. Bilateral tubal ligation 5. Prophylactic bilateral oophorectomy
47
What are common ovarian masses by age?
1. Newborns: small functional cysts that regress quickly 2. Premenarche: teratomas/dermoids 3. Reproductive: functional cysts, endometriomas, tubo-ovarian abscessess, PCOS, ectopic, teratomas 4. Post-menopausal: increased risk of malignancy
48
What type of women get most cervical cancers in the US?
1. Those never screened 2. Those not screened in last 5 years 3. Those without proper follow up to abnormal Pap smears Proper screening reduced cervical cancer by 50%!
49
What cell types are present in and around the cervix?
1. Outside cervix and vagina = sqaumous cells 2. Canal of cervix = columnar cells 3. Junction between the two is where dysplasia (disordered growth) occurs
50
What are the grades of cervical dysplasia?
1. Mild: CIN I (cervical Intraepithelial Neoplasia) 2. Moderate: CIN II 3. Severe: CIN III (carcinoma in-situ)
51
What is the difference between dysplasia (carcinoma in-situ) and Invasive cancer?
With dysplasia the abnormalities are confined to the surface of the cervix and with invasive types e disordered throughout the entire thickness of the lining and invade underlying tissues
52
When should regular pap smears begin?
at age 21 or 3 years after first intercourse
53
What are screening guidelines for cervical dysplasia by age group?
1. Women <30: annually 2. Women 30-65: every 2-3 years after 3 consecutive normal paps (unless high risk) 3. Women >65: no routine screening if normal paps throughout last 10 years
54
What are screening guidelines for cervical dysplasia post hysterectomy?
1. Discontinue screening if for benign disease and no history of CIN 2. Continue screening if cervix present and history of cervical cancer, Diethylstilbestrol (DES) exposure, history of CIN until 3 normal tests
55
What is the bethesda classification of paps?
1. Normal 2. Atypia (variation of normal; irritation/inflamed) 3. ASCUS: abnormal squamous cells of undetermined significance 4. CIN I (LGSIL: low grade squamous intraepithelial lesion) 5. CIN II: high grade .... 6. CIN III: high grade .... 7. CIS: carcinoma in situ (precancer) 8. Cervical cancer
56
If your pap is normal are you cancer free?
Not necesarily: 2500-3000 cervical cancers cases per year in the US are in women with normal paps
57
is there a lot of cervical cancer in the US?
10,000 cases per year with 4,000 deaths
58
What are risk factors for cervical cancer?
1. Lack of screening 2. Sexual activity at a young age (prior to 20) 3. High lifetime number of sexual partners (>3) 4. Smokers (2x) 5. HPV (10x) present in 99.7% cases 6. OC use for more than 5 yrs 7. Multiparity 8. History of STIs 9. DES exposure in utero 10. Steroid use
59
What decreases risk for cervical cancer?
1. Barrier contraception use (decreased HPV) 2. Quit smoking or no smoking 3. Stop OCP
60
General HPV facts
1. More than 30 types 2. Very contagious during intercourse, condoms do nto totally protect 3. Found in >70% of sexually active adults but only 1% develop venereal warts 4. In teens/20s up to 70% of HR-HPV and 90% of LR-HPV regress after 3 years
61
How do low risk and high risk strains of HPV affect the body?
2. High risk strains more likely to result in high grade lesions (HSIL) that lead to cervical cancer 3. Low risk strains lead to cervical changes that are less likely to be precancerous (may cause warts)
62
What are the high risk types of HPV?
16, 18, 31, 33, 35, 45, 51, 52, 56, 58 (~20% of population)
63
What are the low risk strains of HPV?
6, 11, 42, 43, 44 (~50-75% of population)
64
What is the bad news about HPV?
Rates of progression of carcinoma in situ to invasive cancer range from 22-60% when followed more than 10 years. Often no early signs or symptoms
65
Is there a vaccine for HPV?
Currently being tested by the FDA 1. Girls 9-26 2. Series of 3 injections over 6 months with cost of $360
66
What should your patient with an abnormal pap do next?
Colposcopy: direct magnification of cervix, vulva, vagina and perianal tissue plus biopsy if needed
67
What are indications for colposcopy?
1. Persistent ASCUS/LGSIL, 2 consecutive abnormal paps 2. ASCUS/LGSIL in patient unlikely to return for adequate follow up care 3. Persistent cervical inflammation on pap 4. AGCUS atypical glandular cells on pap 5. Persistent cervical bleeding 6. history of DES exposure 7. HIV +
68
Treatment recommendations for different levels of abnormal paps
1. ASCUS, Atypia, CIN I: most go away. pap tests every 4 months in 1st year and every 6 months in 2nd year 2. CIN II: most don't go away. cryotherapy, loop excision (LEEP), same pap testing as above 3. CIN III, CIS, Cancer: Gyn oncologist, surgical treatment, LEEP, conization or laser treatment, hysterectomy, same pap testing as above
69
What is cryotherapy?
1. Probe placed against cervix which damages cells by freezing them 2. Cells are shed over next month in heavy watery discharge 3. Depth is hard to control 4. Has had failure rate for treating large areas of dysplasia and lesions that extend into the canal
70
What is LEEP (loop excision)
1. Fine wire loop with electrical charge that removes tissue for lab testing 2. Good treatment outcomes and good diagnosis 3. Done under local anesthesia, causes little discomfort
71
What is conization?
1. Removes a cone shaped piece of the cervix 2. Better for diagnosing, but may have removed all the undamaged tissue as well 3. High success rate but may interfere with later childbearing
72
Which vaginal suppositories may help with HPV?
1. Green tea 2. Vitamin A and herbal compound 3. Riboflavin (B2): may cause regression of CIN II
73
What is DES (Diethylstilbestrol)
1. Non-steroidal estrogen 2. Used to prevent miscarriage and other pregnancy complications from 1938-1971 3. Higher rates of health complications in mothers, fathers and offspring
74
How are women affected by DES exposure?
1. Higher incidence of breast cancer 2. Structural reproductive abnormalities 3. vaginal/carvical dysplasia and adenocarcinoma 4. Infertility/ poor pregnancy outcomes 5. Autoimmune disorders
75
How are men affected by DES exposure?
1. Structural reproductive tract abnormalities | 2. Infertility
76
What are the lymph nodes around the female breast?
1. Superior: Interpectoral (Rotter's) nodes 2. Medial: Parastrernal nodes 3. Inferior: Inframammary nodes 4. Lateral: Anterior axillary (pectoral) nodes
77
What are flow patterns for lymph from the breasts?
1. Lateral: inframammary to anterior axillary to posterior axillary to central axillary to apical axillary (subclavian) to lymphatic duct (right) 2. Superior: interpectoral to apical axillary (subclavian) to lymphatic duct 3. Medial: parasternal to lymphatic duct
78
Where is the most common site for fibrous cystic changes (benign) and/or malignant disease in the breast?
Upper outer quadrant (UOQ)
79
What are the breast quadrants?
1. Upper inner (UIQ) 2. Lower inner (LIQ) 3. Lower outer (LOQ) 4. Upper outer (UOQ)
80
What is the inframammary line?
Lower arc of the breast. also a common fibrous area (bras can add to thickening)
81
When are fibrous areas in breasts less worrisome?
When they are symmetrical, painful and freely mobile
82
What should you know about the clinical breast exam (CBE)?
1. Optimal 5 days post menses (d/t increased hormonal influence) 2. Inspect: size, symmetry, contour, skin color, thickening, prominent pores, nipple size/shape (flattening, fixed, retraction, thickened), rashes, ulcerations 3. Palpation: between ribs 2 and 6 from sternal edge to midaxillary line. include "tail" in UOQ
83
What are the most common breast issues women consult a doctor for?
1. Breast pain 2. Nipple discharge 3. Palpable mass
84
What is mastalgia?
1. Breast pain/tenderness (cyclical/non-cyclical) 2. More common in premenopausal women 3. Rarely a symptom of cancer 4. Causes: hormonal, PMS, trauma, acute infection, cancer 5. 60-80% spontaneous remission, may treat with hormones
85
When should you recommend a mammogram for mastalgia?
1. Over 35: consider | 2. Under 35 with normal exam: not indicated
86
What is a fibroadenoma?
1. Fibrous stroma that affects 10% of women ages 15-50 2. Responds to estrogen/progesterone so size may fluctuate with cycle 3. Rubbery, firm, smooth, round, mobile, PAINLESS. Solid, well circumscribed on mammogram 4. Tend to regress over time but can be surgically removed
87
What is a simple cyst in the breast?
1. Fluid filled lesion that is soft, yet firm, mobile, well circumscribed and TENDER 2. Unilateral/bilateral and may fluctuate cyclically 3. Age 15-50 4. Difficult to differentiate from solid masses but large recurrent ones are most concerning
88
What are fibrocystic breast changes?
1. Common, non-cancerous changes in breast tissue which is a normal variant in 60% of women 2. Accompanied by swelling, pain and tenderness 3. Increased E, decreased P 4. Often resolves with menopause
89
What are symptoms of fibrocystic breast changes?
1. Cyclical/constant pain or tenderness 2. Multiple, highly mobile lesions that vary in size 3. Pre-menstrual aggravation 4. Diffuse swelling, heaviness 5. Itching of nipple 6. Usually UOQ
90
What is the role of methylxanthines in fibrocystic breast changes?
1. As much as 97.5% improvement in women who abstained 2. Found in : coffee, tea, cola, chocolate, caffeinated meds 3. Some controversy as to whether they contribute
91
How can you avoid fibrocystic breast changes?
1. Avoid caffeine and methylxanthines 2. Avoid exogenous estrogens 3. Low animal fat diet with increased dietary fiber 4. Vitamin E (hormonal aid) 5. Evening primrose oil
92
What is mastitis?
1. Infection seen during lactation or with skin disruption 2. Fever/chills, localized erythema, pain m induration, n/v, malaise 3. S aureus, S. epidermis, Strep 4. Risks: breast feeding, trauma, breast augmentation 5. MC 2-4 weeks postpartum
93
What is a galactocele?
1. Obstruction of breast duct (lactation) 2. Tender, enlarged breast 3. Treat: excise and drain
94
What should you be worried about with nipple discharge?
1. Nature: serous, bloody, other 2. Associated with a mass or not 3. Unilateral/bilateral 4. Single or multiple duct 5. Spontaneous or must be expressed 6. Relation to menses (OCs or HRT?) 7. Pre/post menopausal 8. Prolactinoma? (prolactin levels high= brain imaging)
95
What should you know about physiologic/benign nipple discharge?
1. Often bilateral 2. Nonspontaneous (needs stimulation) 3. Multiple ducts involved (determine quadrants) 4. Serous discharge may be caused by hormones
96
What should you know about pathologic nipple discharge?
1. Unilateral, spontaneous (intermittent and often localized on ONE DUCT) 2. Frank blood, serous, serosanguineous, greenish-grey 3. Secondary to breast carcinoma may be any color 4. Causes: intraductal papilloma (benign) is MC cause, breast cancer
97
What is galatorrhea?
1. inapproriate lactation in nonpuerperal (during/after pregnancy) woman 2. Unilateral/bilateral milky discharge 3. Evaluate prolactin levels (elevated = CT to r/o pituitary tumor) 4. Other causes: excessive estrogens, psychotropic meds, afferent nerve stimulation, primary hypothyroidism
98
What is an intraductal papilloma?
1. Benign papillary growth inside lactiferous duct that is the #1 cause of nipple discharge 2. d/c can be bloody or serous 3. Can recur if not fully excised (usually excised because they tend to grow)
99
How many ducts can be removed before breast feeding is altered?
3
100
What is a subareolar abscess?
1. Abscess caused by S. aureus or anerobic organisms 2. Recurrent in women with inverted nipples 3. Increased chance with/after nipple piercing 4. Treat: antibiotics, drainage, duct excision
101
Breast cancer facts
1. MC cancer in women, second leading cause of cancer deaths in women 2. Over 210,000 cases per year (1 in 8 women) and 43,000 deaths annually
102
What are current recommendations for breast mammography screening (breast cancer)
1. Biennial (every 2 years) mammorgraphy ages 50-74 | 2. Do not teach the self breast exam (BSE)
103
Is ultrasound a good screening tool for breast cancer
No, it is ineffective for breast carcinomas but can be used to find fluid filled vs. solid masses
104
Which potential breast cancer patients need MRI?
1. Current past diagnosis of BrCa 2. Dense breasts (determined by radiologist) 3. Rectify inconclusive mammogram or US 4. High risk patients 5. Mother with premenopausal breast cancer
105
What are needle aspirations used for in the breasts?
1. Evaluate fluid filled lesions 2. If bloody aspirate then biopsy 3. Cysts that reoccur within 2 weeks or require more than 1 aspiration need biopsy
106
What should you know about biopsies in the breast?
1. Incidence of positives increases with age 2. This is the definitive step in determining malignancy 3. Usually: mammogram, U/S then core biopsy
107
How are breast cancer cases different in men
1. Many fewer, most have no risk factors 2. More likely to have nipple discharge 3. Often start under the nipple
108
What are risk factors for breast cancer in men?
1. Radiation exposure 2. Estrogen administration (trans, prostate cancer) 3. Hyperestogenism (Klinefelter's, cirrhosis) 4. Heavy alcohol intake 5. Familial tendencies (many female relatives with breat cancer or BRCA2 mutation)
109
What are early signs and symptoms of breast cancer?
1. Firm to hard mass 2. Irregular contour 3. Immobile 4. Unilateral
110
What are late stage signs of breast cancer?
1. Skin/nipple retraction, tenderness, axillary lymphadenopathy, erythema, edema, fatigue 2. Skin retraction: peau d'orange
111
What is paget's disease of the breast?
1. Adenocarcinoma of the nipple 2. Itching/burning of skin or nipple 3. Nipple/skin erythema, rash and ulcerations 4. Easily missed diagnosis that is often treated as a dermatitis
112
What will be included in a pathology report for breast cancer?
1. Tumor size (2cm or less = stage I) 2. histopathology (ductal/lobular) 3. grade (well of poorly differentiated) 4. Receptor (ER/PR) status 5. S-phase fraction (rate of cell reproduction) 6. Excisional margins (size) DNA (Her-2-Nue) status associated with aggressive cancers 7. Nodal involvement
113
What are the types of surgeries for breast cancer?
1. Sentinel node 2. Lumpectomy (breast conservation) 3. Mastectomy 4. Breast reconstruction
114
What is recurrence of breast cancer correlated with (poorer prognosis)
1. Primary tumor size and status 2. Primary tumor type 3. Previous treatment
115
What are non-modifiable risk factors for breast cancer?
1. Age 2. Age of menarche and menopause 3. Family history (esp. first degree) 4. Genetic mutations (BRCA1, BRCA2, P53, P21) 5. Environmental exposures
116
What are modifiable risk factors for breast cancer?
1. Hormone use (HRT, OC in some groups) 2. Reproductive/breast feeding 3. Lifestyle (nutrition, exercise, smoking)
117
What are behaviors/signs of decreased risk for breast cancer?
1. Menarche after 15, early menopause 2. Three or more pregnancies prior to 30 3. Prolonged lactation 4. Healthy diet choices 5. Consistent and regular exercise 6. Minimal HRT/OC use
118
What are concepts in breast (and many) cancer prevention
1. Don't smoke 2. Reduce: total fat, animal protein, alcohol, exposure to carcinogens, BMI 2. Increase: Lignans, indoles, veggies/fruits, green tea, olive oil, cold water fish, antioxidants
119
How does flaxseed and fish oil help prevent cancer?
1. Flaxseed oil decreases TNF alpha and interleukin beta production by 30% 2. fish oil reduced TNF alpha and interleukin beta production by 74%
120
What does green tea contain that helps in cancer prevention
Polyphenols and catechins that capture and detoxify free radicals or various carcinogens, radiation exposure and light
121
What is most important to remember about the symptoms of STIs?
Many are asymptomatic, even serious ones requiring treatment
122
What should you remember about the gender differences of STI symptoms?
Women typically suffer more severe and longer term consequences (PID, infertility, ectopic pregnancy, chronic pelvic pain, pregnancy loss, ptreterm births or cervical cancer) Women are also more likely to get STIs from a single sexual encounter
123
What are common complaints from patients with vaginitis?
Itching, burning, discharge, odor and pain
124
What are common causes of vaginitis?
1. Bacterial vaginosis (40-50%): gardnerella 2. Candidiasis (20-25%) 3. Trichomonas (15-20%) STI 4. Streptococcal spp 5. Dermatitis (eczema); allergic/chemical reaction 6. Foreign body (tampon)
125
What is the normal vaginal pH?
<4.7 maintained by lactobacilli acidophilus. Imbalances allows normal, potentialy pathologic micoorganisms to overgrow
126
What are risk factors for vaginitis?
1. Antibiotics (reduce normal protective bacteria) 2. Tight fitting garments, synthetic fibers 3. Decreases in lactobacillus (low estrogen) 4. Douches, chlorinated pools, perfumed toilet paper, diet 5. Medical conditions (DM and candidiasis) 6. Unprotected sex, numerous partners, new male partner 7. IUD (string is a vector) 8. Women with STIs 9. Smokers 10. Oral contraceptives
127
What is the pH of semen?
7.5
128
What are possible agents that cause vaginitis?
Gardnerella, haemophilus, group B strep
129
What causes the "fishy" odor of vaginitis?
amines
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What are clinical criteria for bacterial vaginits (3 must be present)?
1. pH >4.5 2. Positive "whiff" test: fishy with KOH 3. Positive clue cells 4. Homogenous discharge
131
How does lactobacillus prevent vaginitis?
It helps maintain the correct low pH and produces hydrogen peroxide which inhibits the growth of anaerobes and other organisms
132
What are complications from bacterial vaginitis?
1. High recurrence rate (60% within 4 months) 2. Cervicitis 3. Pelvic inflammatory disease (PID): infertility and ectopic pregnancy 4. Post-surgical infection (abortion, hysterectomy) 5. Increased risk of HIV/STI 6. Pregnancy complications, miscarriage
133
What is used to treat bacterial vaginitis?
1. Metronidazole or clindamycin (topical/oral): 2. Treatment of partner is unnecessary unless they are a women as well 3. Lactic acid gel may be as effective (and safer) and increases success of metroidazole treatment 4. Boric acid 5. Providone-iodine vaginal suppositories
134
Facts about yeast infections!
1. Cause 20-25% of vaginitis cases 2. "yeast" is an over growth oif a fungus that lives in healthy vaginas 3. Candida albicans is most common .4 Not generally considered an STI but may be sexually associated
135
What are symptoms of yeast infections?
1. Puritis 2. Whit-yellow discharge 3. Erythematous tissue 4. Often vulvar component (fissures)
136
How are candida vulvovaginitis cases diagnosed?
10% KOH wet mount Look for: pseudohyphae, budding yeast pH of 3.8-4.5
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What predisposes someone to yeast infections?
Diabetes, pregnancy, antibiotics, corticosteroids, unprotected sex, HIV, douching, menses, hormones, occlusive clothing, dietary choices
138
What is the treatment for yeast infections?
1. Antifungal (azoles) 2. Boric acid suppositories 3. OTC topical steroids for symptom relief 4. Oral/vaginal acidophilus 5. Sitz baths 6. Diet: eliminate sugar, alcohol, processed foods
139
What is Trichomonas vaginalis?
A sexually transmitted protozoal flagellate associated with the presence of other STIs (that facilitate the transmission and acquisition of HIV and other STIs)
140
How is trichomonas vaginalis diagnosed?
Fresh normal saline wet mounts that show motile organisms with flagella and increased PMNs (polymophonuclear WBCs)
141
How does trichomonas present?
1. Infects vagina, skene's ducts and lower urinary tract in men and women 2. Vaginitis, cervicitis, urethritis: pain, dyspareunia, dysuria 3. Minimal to no symptoms in 50% of cases, can be years long 4. Yellow/green (frothy) discharge
142
what is strawberry cervix and what is it associated with?
Severe infection of the cervix (red macular spots) from Trichomonas infection
143
What is the treatment of trichomonas?
1. Metronidazole, tinidazole 2. Empirically treat partner even if asymptomatic 3. Adequate lactobacilli may prevent infections
144
What is chlamydia?
1. A bacteria that infects genital columnar epithelium. 2. May present as asymptomatic, with cervicitis, urethritis, PID 3. Associated with Reiter's syndrome
145
What is gonorrhea?
1. A bacteria that infects genital columnar epithelium | 2. May present as asymptomatic, with cervicitis, urethritis, PID, pharyngitis, arthritis
146
Chlamydia trachomatis facts
1. Most commonly reported communicable disease in Oregon since 1988 2. Females more than males (2.8:1) 3. Highest incidence at 15-24 4. Can be silent (50% in men, 75% in women) 5. Chlamydial PID can cause damage without symptoms (subacute)
147
Neisseria gonorrhoeae facts
1. Second to chlamydia in reported cases 2. higher incidence in young women 3. 5x more prevalent in african americans 4. Gonococcal PID (50% of women had one male sexual partner with gonorrhea)
148
What are symptoms of chlamydia/gonorrhea in women?
1. Asymptomatic 2. Vaginal discharge 3. Dysuria 4. Dyspareunia 5. Lower abdominal pain , CPP 6. Unusual bleeding (metorrhagia, menorrhagia)
149
What are symptoms of chlamydia/gonorrhea in men?
1. Asymptomatic 2. Penile discharge 3. Dysuria 4. Burning/pruritis around urethral meatus 5. Pain with ejaculation 6. Pain and swelling in testicles
150
What are signs of chlamydia or gonorrhea?
1. Mucopurulent Cervicitis 2. Urethritis 3. Gonorrheal conjunctivitis 4. Gonorrheal opthalmia neonatorum
151
How is testing for chlamydia/gonorrhea completed?
1. Cervical/urethral culture or via urine (ligase chain reaction to find chalmydial DNA) 2. DNA probe culture is gold standard, which can be done during liquid based pap 3. Test/treat partner
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Who should get screened for chlamydia/gonorrhea?
1. Clinical symptoms 2. New prenatal patients 3. Before inserting an IUD 4. Multiple partners in last 60 days 5. Sexual assault victims
153
What are treatments for gonorrhea?
1. Ciprofloxacin 500mg oral in single dose OR 2. Ofloxacin 400mg oral in single dose plus azithromycin 1g orally in single dose
154
What are treatments for chlamydia?
Single dose of azithromycin or a week of doxycycline are most common. Can also use tatracyclin, erthyromicin
155
How does epididymitis present?
1. Scrotal pain and swelling 2. Fever, chills 3. Penile discharge 4. Abdominal, pelvic pain 5. Frequent urge to urinate 6. Dysuria 7. Hematuria 8. Painful ejaculation
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How is epididymitis diagnosed?
1. DNA probe (intraurethral or LCR urine test) 2. Examination of first void urine for WBCs 3. Test/treat partner
157
If prostatitis common?
Yes, 50% of men experience this disorder in their lives. It is the most common urological disorder for those over 50 and third most common in men under 50
158
What causes prostatitis?
1. E. coli 2. Klebsiella 3. NG/CT
159
What are risk factors for prostatits?
1. Bladder outlet obstruction (stone, tumor, BPH) 2. Diabetes 3. Suppressed immune system 4. Urethral catheterization 5. STIs 6. Unprotected anal/vaginal intercourse
160
What is HPV?
Condyloma accuminata MC, more than 150 types of papilloma virus in humans. 40 affect genital and oropharynx
161
What should you know about HPV caused genital warts?
1. Raised/flat 2. single/multiple 3. small/large 4. Cauliflower like 5. Most often painless but can cause itching, irritation and bleeding
162
What should you know about subclinical HPV infections?
1. Implicated in the risk for some vaginal, vulvar, anal and penile squamous cell cancers 2. Most common strains: 16, 18, 31, 33, 35 that are associated with increased cervical cancer risk 3. Most often diagnosed in pap smear 4. Monitor for precancerous changes
163
What should you know about oropharyngeal HPV infections?
1. More common in men (3:1) 2. 7% of US 3. 8400 new established cases per year
164
What should you know about anal HPV infections?
1. Increases risk for anal cancer, especially in MSM (20x) 2. Genital warts MC symptom 3. Anal discharge, bleeding, itching, pain, pressure, lesions 4. Grayish hyperpigmented patches of HGAIN
165
Who should gets screened for anal HPV?
1. Infected men with history of sex with other men 2. HIV infected women with a history of cervical or vulvar dysplasia 3. Anyone with a history of anogenital condyloma
166
What are treatments for visible forms of HPV?
1. Cryotherapy: liquid nitrogen 2. Podofilox/podophylin 3. Trichloracetic acid (TCA) 4. Electrocautery 5. Laser therapy
167
What is your ddx list for genital ulcers?
1. Herpes simplex virus 2. Syphilis 3. Chancroid (Haemophilus ducreyi) 4. Lymphogranuloma venereum (LGV) - CT
168
What are the different herpes viruses?
``` HSV 1: herpes simplex HSV 2 VZV - varicella zoster viris (type 3) EBV - epstein-barr virus (type 4) CMV- cytomegalovirus (type 5) HHV 6 (roseola) - human herpes virus HHV 7 HHV 8 (linked with Kaposi's sarcoma) ```
169
Herpes Simplex Virus I and II facts
1. 50% of US population has HSV 1 2. 20% of US population has HSV 2 3. Condoms do not necessarily protect against it 4. Asymptomatic viral shedding spreads most of it (>70%) 5. Special populations on concern: pregnant, neonates, immune compromised
170
What are the 3 distinct syndromes from HSV?
1. Primary herpes (first infection with HSV 1 or HSV 2) 2. First episode, non-primary herpes (initial genital infection in a patient who has already experienced infection with the other HSV type) 3. Recurrent herpes (reactivation with either virus type)
171
What is the classic progression in primary herpes?
1. Erythematous papule 2. Vesicle 3. Pustule 4. Ulceration (most painful, increased with moisture) 5. Encrustation
172
What are the signs and symptoms of primary herpes?
1. Papules (see progression) 2. Regional lymphadenopathy 3. Systemic (fever, malaise, arthralgia, HA)
173
How is herpes transmitted and incubated?
1. Sexual contact to onset of symptoms and lesions is FOUR days (average, but ranges from 2-20) 2. Virus replicates in ganglion then migrates to mucosa and replicates in the epithelium 3. Length of viral dormancy varies
174
What type of herpes causes prodromal symptoms (local paresthesia, itching, pain)?
Recurrent herpes simplex virus
175
How is herpes diagnosed?
1. History: blisters, vesicles, pain, itching, partner with herpes 2. Physical exam: lesions, genitals... 3. Lab: viral culture** 4. Tzank smear or antigen detection tests: only if in pustular stage
176
What are complications of herpes simplex virus?
1. Perinatal transmission: 50% born through primary lesions become infected 2. Herpes Whitlow (hand) 3. Ocular herpes 4. Can cause: Keratitis (usually unilateral), blepharitis, keratoconjunctivitis
177
What causes syphilis?
Treponema pallidum a blood borne pathogen which is capable of infecting almost any organ or system
178
What is the progression of syphilis?
1. Spread thru body in bloodstream 2. Progress thru four stages 3. Last stage: severe heart disease, brain damage, spinal cord damage and death
179
What should you know about primary syphilis?
1. Chancre: usually occurs within 3 weeks (up to 90days) at the site of bacterial entrance (anywhere) 2. highly contagious 3. Chancre = PAINLESS ulcer with clean base and indurated borders 4. Regional lymphadenopathy
180
What should you know about secondary syphilis (the great imitator)?
1. Two to eight weeks after chancre patients often develop a rash 2. Fever (<101), sore throat, vague weakness/discomfort, weight loss, patchy hair loss (esp around eyes/scalp) 3. Lymphadenopathy 4, Nervous system: stiff neck, HA, irritability, paralysis, unequal reflexes, irregular pupils
181
What is the rash from secondary syphilis like?
1 diffuse, macular, papular or combined 2. Palms and soles 3. Patterned hair loss
182
What should you know about the latent stage of syphilis?
1. Progress to latent if not treated 2. Rash goes away, no symptoms 3. Ranges from 1-20 years 4. Diagnosis often in blood test, history or birth of a child with syphilis 5. Contagious in early latent period, even with no symptoms
183
What should you know about the tertiary stage of syphilis?
1. May come after a year of latency or never or in between 2. Symptoms depend on complications that develop 3. Gummata: large sores inside the body or on skin 4. Cardiovascular: heart and blood vessels 5. Neurosyphilis: brain and related structures
184
How is syphilis diagnosed?
1. Screening: antibody testing for non-specific 'reagin' antibody. False positive common 2. Confirmation: Flourescent treponemal antibody absorption (FTA-ABS), microhemagglutination test (MHA-TP)
185
What is chancroid?
1. An STI caused by infection with Haemophilus ducreyi that causes one or more ulcers on genitalia and associated inguinal lymphadenitis 2. Affected lymph nodes may progress to abscess formation 3. Can co-exist with other infections and is common
186
Where is chancroid endemic to?
tropical and subtropical locations
187
What is the progression of chancroid?
1. Macule or papule at site of inoculation 2. Vesicular and pustular stages 3. Well circumscribed non-indurated ulcer which is very painful 4. May be more than one 5. Incubation of 1-7 days
188
What is lymphogranuloma venereum (LGV)?
1. An STI involving the inguinal lymph glands caused by a specific strain of chlamydia 2. Highest incidence among sexually active people in tropical/subtropical climates 3. First symptom: small, painless pimple/lesion occurring on penis or vagina which spreads to lymph nodes 4. Complications: inflamed nodes which may drain and bleed
189
How is pediculosis pubis spread?
1. Sexual contact 2. Shared bedding 3. Shared clothing
190
What should you know about the crab louse (Pthirus pubis)?
1. Female louse lays eggs (nits) at base of hair shaft 2. Eggs hatch in 7-9 days and louse attaches to skin 3. Saliva production causes itching 4. Untreated ova can live on fomites for 1 month 5. Eggs look like small freckles at base of hair shaft
191
What is the treatment for crabs
1. Lindane lotion/cream (Kwell, Scabene) 2. Nits removed with fine comb thru dark and curlies 3. Wash bedding, linens, bag fabrics for 6 weeks

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