AGE RELATED CHANGES: PUBERTY

2) When does Adrenarche Occur?

3) When does Menarche Occur?

4) When does Thelarche Occur?

5) When does Pubarche occur?

2) Adrenal glands start growing 9-15

3) Menarche is first menses...around 12

4) Thelarche is breast bud development (happens earlier than used to)...8-18

5) 8-14

*Generally by age 12 everything is starting to function

AGE RELATED CHANGES: MENOPAUSE YEARS

1) What happens at Menopause? (and what is average age?)

2) Besides reproductive Estrogen Estradiol E2, what are the two other forms of Estrogen?

1) Average onset of menopause is 52.  That is when REPRODUCTIVE Estrogen stops.   (Estadiol E2 from Ovary).  Increases glycogen production...increased lactobacillus...keep other infections at bay.  So without Estrogen, have less glycogen....Lactobacillus is the predominant flora in the vagina, feed of glycogen produced from the estrogen.  Therefore, see more infections pre-puberty and post-menopause because have less estrogen.

-Vaginal Atrophy can be a concern in those who are hypoestrogneic
-Older women, if they are heavy, they may still make enough E1 to not have sx of menopause

2) There are two other forms.  Estriol (E3) comes the Placenta ONLY.  Estrone (E1) comes from coversion via aromatase from male hormone androstenedione.  Heavy men have gynecomastia for a reason: they have extra estrone.

1) CHIEF COMPLAINT

2) MENARCHE, MENOPAUSE

3) PREGNANCY

 a. Gravidity (pregnancies)

 b. Parity (deliveries)

 c. Unsuccesful pregnancies

 d. Ectopic Pregnancies

4) MENSTRUAL HISTORY

 a. Duration

 b. Frequency

 c. Flow

 d. Pain (Painful cycles may indicate many things, but perhaps the most common is endometriosis)

5) SEXUAL HISTORY

 a. Active or inactive

 b. Age at onset

 c. Contraception

 d. Dyspareunia (painful intercourse)

 e. STD history

6) IMMUNIZATIONS

 a. Def ask about HPV VACCINE

 b. Indicative for use between age 9-25 in women, and also perhaps older women who have not been vaccinated (HPV naiive)
 c. Young males: ages 9-26 (for men to preventing anal cancer and genital warts)

7) PELVIC SURGERY

8) HISTORY OF GYN CANCERS
9) PROMIENT MEDICATIONS

 a. Hormones

 b. OCP

 c. Anti-coags

10) History of PROCEDURES
 a. Mammogrophy

 b. Colonoscopy

 c. Cervical Screening (PAP SMEAR, THIN PREP...recommened every year...everybody gets thin prep, although we say "pap smear.")

MENSTRUAL ABNORMALITIES

1) Amenorrhea

2) Oligorrhea

3) Polyrrhea

4) Menorhhagia

5) Metrorrhagia

1) Amenorrhea: no menses for 6 months (Preggers, anovulation from Obeisity, medications, and many more can all lead to ammenorrhea)

2) Oligorrhea: no menses from 35 days to 6 months (Oligo: infrequent periods)

3) Polyrrhea: <21 days (Poly: frequent, many periods)

4) Menorhhagia >7 days or >80 ml (days is easier)

5) Metrorrhagia: Irregular and infrequent (Take metro, it takes frequent irregular stops)

1) Clitoris and Frenulum

2) Urethra and Anus

3) Labia Majora and Minor

4) Introitus

5) Perineum

1) Clitoromegaly (not just congenital, but also Androgen excess like from a tumor)

2) Vulvar Intraepithelial Neoplasia (pre-malig condition of Clitoral skin)

3) Cancer (Squamous Cell, Melanoma)

SIX SYMPTOMS OF URETHRITIS

CAUSES OF URETHRITIS

URETHRAL CARCINOMA

Urethra looks very erythematous.

Feels hard and firm on palpation.  This person had a stage 2 urethral cancer.

VULVAR HPV

6,11 subtypes for the condyloma
16,18 subtypes for the pre-malig conditions-Cancer

MOLLUSCUM CONTAGIOUSUM

Benign, condition of Vulva, Umbilicated lesions.  Pox Virus causes it.

SYPHILIS

1st: Asymmetry (right labia is more edematous than left)
2nd: Can see lesion...See primary syphalitic ulcer causing the problems.

CONDYLOMA LATA

Often seen in secondary Syphillus, but it is NOT an HPV related issue

BARTHOLIN'S GLAND CYST

Most are adenos arising from glands, and this is the most common gland which gives rise to cancers.

VULVAR MYOMA

Uncommon

Round ligament, goes from ant. uterine fundus, and inserts onto labial majoris.  Has smooth muscle fibers, and can get this myoma on it. 

Direct Hernia: out hasselbechs triangle
Indirect Hernia: Go down inguinal canal and into scrotom/labia. 

So a large indirect hernia in female can present with this scrotal mass.  Consider this before assuming it is a myoma and lopping it off.

LICHEN SCLEROSIS

Dermatitis.  Thinning or atorphy of skin, causes fusion of labia minora here.

LICHEN SCLEROSIS

More typical apperance.  Often see butterfly appearance.  Very irritating, a lot of pruritis, pts have a lot of discomfort with this.

Every once in a while, can give rise to a malignant condition. (BUT MOST of the malignant conditions arise from HPV). 

This woman has a squamus cell carcinoma (erosion from clitoris), that came from lichen sclerosus, not from HPV

Vulvar intraepithelial neoplasia

Looks diff in diff situations.  Very variable.  Here is is white and slightly raised.

Vulvar intraepithelial neoplasia

Red area is CIS.
-Will surgically cure with FLAP

PAGET'S DISEASE

Can be white, described as "frosting apperance," pretty extensive.  Must be excised.  Apocrine glands are deep, have to get down into the Sub-C.  Still superficial, just deeper than for VIN

VULVAR CANCER

Exphoriated, Indurated, Ill-defined.  This is more radical (goes down deeper)

Here would also take out ipsilalateral lymph node removal  (If central lesion, would have to take out lymph nodes on both sides)

VULVAR CANCER

Sometimes can get really big, esp if patient uneducated/silent.

PIGMENTED LESION

Remember that you can't tell without sending it to pathology with biopsy

Hemangioma.  Benign tumor of BV.  DON'T Biopsy.  just put finger on it and see it blanch

PIGMENTED LESION

A pigmented lesion is Melanoma until you figure out what it is

Lentigo.  Freckles.  Don't Biopsy if you know that is what it is

PIGMENTED LESION

Might be thinking Melanoma b/c of color and Irregular Border.  But this is the benign condition Vulvar melanosis: extra pigmentation.  Usually not isolated spot, in multiple places.  Also in contrast, Melanoma is NOT usually in multiple places. (won't see 6 patches on the vulva)

PIGMENTED LESION

Hamartoma.  Benign, normal tissue with abnormal growth.  Little raised, firm, not painful.  Most common to see in Lung

PIGMENTED LESION

Seb-K.  Scaly, raised.  Don't Biospy.  Prob see multiple of them if look around.

PIGMENTED LESION

Vulvar Melanoma  Raised borders, irregular, colored, etc.  Radically excise.

If confined to epithelium, not deeply invasive, then just excision will be good enough.

THREE THINGS TO LOOK FOR WHEN EXAMINING THE VAGINA (and several things under those main headings)

l, melanomaTHTT

ATROPHIC VAGINITIS

Normal in post-menopausal pts who are not making estrogen.  The vagina is smooth/flat, with very thin tissue and petechia are everywhere. 

Intra-vaginal Estrogen therapy is preferrred. (can be tx with systemic estrogen too)

VAGINITIS

1) May smell post-intercouse.  Semen can bring out the amine smell.  Vaginosis beause not inflam, no white cells.  Just overgrowth of bacterial that belong there (namely anerobic bacteria).  Usually caused by a recent course of antibiotics (kill off lactobaccilus).  Take wet mount to see bacteria/stuff.

2) if its not acidic, it is not candida.

3) If its acidic, its not trich  Easy to see the dudes on wet mount.

CANDIDA

Can see the hyphea

TRICHOMONAS

On wet mount; Also tx with Flagellum

TRICHOMONAS

Ulcerations in cervix/vagina as strawberry red dots.

TRICHOMONAS

Ulcerations in cervix/vagina as strawberry red dots.

PROLAPSED MYOMA

Generally from Uterus, can prolapse through.  Pt will say they were fine, and then all of a sudden had pain and bleeding.  It was at that moment myoma had prolapsed.

1) UTERINE PROLAPSE

2) CYSTOCELE

3) RECTOCELE
4) ENTEROCELE
5) VAGINAL PROLAPSE (ex: had historectomy, and top of vagina is prolapsing and coming out.)

CYSTOCELE

1) Bladder is prolapsing here

2)Urethral tissue is where see this bulge.  A tip off is that rugation will be lost, it will be smooth like in atrophic vaginitis, compared to normally healthy female with good bladder support.  Just on otherside of this bulge and mucosa is bladder itself.

3) Birth of child can cause this.  Distorts and denervates the anatomy that supports the bladder.  If fascia was damaged way back in childbirth, can even manifest later.

4) Oftentimes cannot completely emtpy bladder, because can get stuck in this bulge.  so may have dribbling.

RECTOCELE

1) TOP LEFT: The entire perineal body is GONE, allows rectum to come down. Can be from pregnancy, trauma, etc.  There can be fecal incontenence, air trapping, etc.  Pretty serious.  .

2) TOP RIGHT: Most standard rectocele.  The perineum is still in tact, there has been loss of support between vagina and rectum.  From saggital view, the rectovaginal fascia (from cervix to perineal body) is gone, so lose the support, allows rectum to bulge

3) For same reason as cystocele can't evacuate bladder well, these pts Feel like can't empty colon completely, can have seepage and feel like can't completely empty

4) Patients can wear Pessories which are devices that can enter in vagina and hold things in their correct places.

CHLAMIDYA

Mucopurulent discharge.  Impt to ID early and treat.  MOst common cause of PID which is most common cause of infertility.

CHLAMYDIA

May see the stawberry apperance with chlamidyia.  Culture and tx with Doxycycline

CERVICAL POLYP

Benign.  In this case, Multiple previous kids, so distorted cervix, this is normal besides the polyp

ENDOMETRIOSIS (medical condition in which endometrial-like cells appear and flourish in areas outside the uterine cavity, most commonly on the ovaries.)

1) Ectopic endometrium.  It can be on many varied places. (even in unusual places like Bladder, forearm) 

2) Causes pain with intercouse, irregular bleeding, infertility, often results in repeated surgical treatment.  The only true therapy is removing both ovaries in the end because that is what drives the endometriosis, just like that is what drives the menstrual cycle.  But most with this are young, so try and preserve the ovaries.

3) Other cases will be completely asymptomatic, but others will have tremendous pain.  Amount of disease does not correlate well with pain.  Another oddity for this disease.

4) Does seem to run in families, but do not know on which gene.

CERVICAL HPV

1) Tx with laser or electrical excision (Leak)

2) Multiple Leak procedurs can cause cerival incompetence..cervix can dilater prematurely and lose baby.  Laser is preferred, but most private offices do not have laser

CERVICAL DYSPLASIA

1) Can see some cobblestoning of moderate dysplaia.  But DO NOT just look with naked eye.  Need to have 3 seperate visits.  Do Pap smear, then when that comes back look with microscope for worse spots with acetic acid and Take Biopsy, then when biopsy comes back, do the treatment,

CERVICAL DYSPLASIA

Punctations, raised, and white, pretty classic.  Treated with laser

METASTATIC ENDOMETRIAL CANCER

This is cervical met from pt with endometrial cancer.  This presents with abnormal pap smear, but it is from endometrium.  This is rare.

Just be aware that atypical glandular cells can indicate cancer somewhere higher up the genetalia.

CERVICAL CANCER

VASCULARITY is what is esp different.  Can see abnormal vasculature and VENOUS LAKES.  More BF--faster growth--out compete

FIVE RISK FACTORS FOR CERVICAL CANCER

1) Early Sexual Debut

2) Promiscuity

3) HPV

4) Smoking (Smoking will not cause cervical cancer in the absence of HPV.  But it is a huge co-factor, very highly incresed rate of cancer if have BOTH HPV and SMOKING.)

5) NO SCREENING

FOUR THINGS TO LOOK FOR WHEN EXAMINING THE UTERUS (and several items under those headings)

**What is the most common cause of Gynecological cancer?

1) PREGNANCY

2) INFECTION

 a. Pyometria (Older women w/ cervical stenosis, get vaginal atropy, secretions get trapped and infected)

 b. Endometriosis (After childbirth, or chronic with chronic bacteria)

3) LEIOMYOMA, POLYPS

4) CANCER

 a. Adenocarcinoma (Endomtrium gives rise to Adenocarcinomas)

 b. Sarcoma (Sarcomas come from mesenchyme (muscle or CT of Uterus)

**Cancer of Uterus is most common cause of gynceogical cancer.  Heavier you are, more E1 you make, causes endometrium to proliferate--more cancer.

PELVIS

1) That band of tissue just above the uterus is the uterosacral ligament holding up the Uterus

2) If uterosacral ligaments are lost, can cause uterus to collapse down into vagina

3) Rectum is just behind Uterus.  In some procedures, it is not uncommon to go through the back of the uterus into the rectum.  Grab ant cervix with clamp and straighten it out.  To take uterus out, have to seperate cervix from Rectum, and have to make flap in bladder so can get to it.

4) Bladder base on anterior vagina.  Ant Rectum sits on posterior vagina.

5) A very large uterus or ovarian tumor can obstruct either the venous outflow or lymphatics.  After surgical removal of large uterus, can get PE, as result of clearing obstruction that has been present for long time with large uterus.  Do a lot of anti-coag to prevent this.

6) Ureter draining into bladder courses through Pelvis, so be aware of this when doing pelvic procedures

UTERINE LEIOMYOMATA

Fibroid.  This uterus had multiple fibroids.  All look very different (one more calcified, some fleshy, some liquified).  Can get very heavy, but most small.  ABout 1/2 women have fibroids of some size (very common).  Only when malignant or symptomatic do they require surgical removal.  Fibroids alone are NEVER an indication for historectomy.

UTERINE CANCER: Endometrial Cancer

1) Start in uterine lining.  is deeply invasive into outer half of uterine muscle.  Increases risk for...recurrence in Pelvis and elsewhere, and Lymph Node involvement

2) Present with sign.  When pts have bleeding, it means something.  Esp in post-menopausal women, because they should not be bleeding.  So most of time find it in early stage, and cured with surgery

1) ECTOPIC PREGNANCY

2) INFECTION

 a. SALPINGITIS (PID)

 b. HYDROSALPINX

3) CANCER

 a. ADENOCARCINOMA

Fallopian tubes come off back of uterine fundus.  Round ligament comes off front of uterine fundus (here you can see it coursing through the inguinal canal...TOP LEFT OF IMAGE)  A lot of ovarian cancers and peritoneal cancer might actually be very small fallopain tube cancer, they are very hard to figure out as far as origin....all come from serous producing epithelium

RELATIONSHIPS
-Uterosacral ligaments on either side of the rectum
-Infindibular Pelvic Ligament, with ovarian arteries and veins and Ureter (bottom right and left).  Need to be aware of blood supply when removing ovaries, because have to take Blood Supply, but retain the ureter, so need to know where it is.
-Common and external iliac artery down here as well.

1) BENIGN CYSTS AND TUMORS

 a. Endometrioma ((endometrial-like cells appear and flourish in areas outside the uterine cavity, most commonly on the ovaries.)) (when endometriosis causes a cystic blood filled tumor of the ovary..can cause pain, infertility, abnormal bleeding)

 b. Mature Cystic Teratoma (Teratomas are the most common, can make any kind of tissue in body)

 c. Cystadenoma (serous or mucinous)

2) INFECTION

 a. Oophoritis (PID) ((Pelvic inflammatory disease (or disorder) (PID) is a generic term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs.))

 b. abscess

3) CANCER

 a. Adenocarcinoma (Unlike endometrial cancer, does NOT present with Bleeding.  So about 70% present with late stage cancer, and it is essentially incurable in its advanced stages.)

ENDOMETRIOSIS

Right in middle.  Blood filled, inflamed, often adherent cystic tumor of the ovary

MATURE CYSTIC TERATOMA

Very common.  They will make hair, sebum, teeth, bones, all kinds of abnormal mesenchymal tissue, and can get quite large.  The teeth make the dx easily when see calcifications on imaging

OVARIAN MUCINOUS CYSTADENOMA

Large tumors.  Have mucinous material

OVARIAN MUCINOUS CYSTADENOMA

1) Same tumor from previous page opened up...like Gelatin.  When rupture in abdomen, the mucin and mucinous cells can grow on the surface of other organs in the abdomen.  Continues to produce mucin, and can eventually cause the bowel to stop functioning.

2) SO even though benign, can cause end of life and/or serious problems.

OVARINA DYSGERMINOMA

Solid germ cell tumor in young women.  They are very treatable.  Homolog to semanoma (Lance had it) in the male.  Very radiosensitive. 

Even mets disease can be cureable (Lance)

SEROUS OVARIAN CANCER

Pretty freqient.  Papillary apperance on ovarian surface.  By time we see it, often fluid in abdominal cavity.  Often Mets in omentum and upper abdomen.  In surg, try to reduce as much of that as possible.   They can be big operations, taking off parts of other organs and other tissues.

COMPOSITION OF BREAST

LYMPHATICS

TANNER STAGES

1) Glandular Tissue Atrophies

2) Fatty Tissue Increases

BREASTS

1) What do breasts develop secondary to?

2) Estrogen stimulates the development of what?

3) Progesterone stimulates the growht of what?

4) What is Prolactin Release stimulated by?

5) What can Bromocriptine block the release of?

1) Breasts develop secondary to stimulation from ESTROGEN and PROGESTERONE

2) Estrogen stimulates the development of the MAMMARY DUCT

3) Progesterone stimulates the growht of the ALVEOLAR DUCT

4) Prolactin Release is stimulated by sucking and stimulates Lactation

5) Bromocriptine can block the release of PROLACTIN

GALACTORRHEA

1) What is it?

2) Name A physical cause

3) Hyperprolactinemia can cause it.  Name many causes of this.

4) What can block the release of Prolactin?

1) Lactation that occurs in the ABSENCE of nursing (It is normal for women to lactate up to A YEAR after having last lactated during nursing)

2) Chronic Breast/Nipple Stimulation

3) HYPERPROLACTINEMIA

 a. Pituitary Tumor

 b. Hypothyroidism

 c. Chronic Renal Failure

 d. Medications

   i. Antipsychotics

   ii. Anti-depressants

   iii. Antihypertensives

   iv. Narcotics

   v. Metaclopramide (SHe has seen this w/Metaclopramide, in a man actually
And may give it to women having trouble lactating)

4) DOPAMINE AGONISTS can block the release of Prolactin

 a. Bromocriptine

 b. Cabergoline

 c. Pergolide

GYNECOMASTIA

1) What is it?

2) WHen is it normal? (what ages, and when does this resolve?)

3) Unilateral or bilateral?

4) Name Five causes in ADULTS

1) Glandular enlargement of the male breast

2) Physiologic at puberty (12-14 y/o, resolve in 18 mos

3) May be either

Pathologic in Adults, caused by...

1) Neoplasm

 a. Adrenal Tumors

 b. Testicular Tumors

2) Hyperthyroidism (Graves)

3) Chronic Renal Failure

4) Cirrhosis

5) Drugs

 a. Spironolactone

 b. Marijuana, Alcohol, Methadone

 c. Anabolic Steroids

FIBROCYSTIC BREAST CHANGES
1) What is it?

2) Does it increase the risk of Breast Cancer?

3) Does it change with Menses?

4) What are the THREE TYPES (and at what age do they occur and what is seen with them)

5) NAme SIX ASSOCIATED FACTORS

1) increased number of cysts or fibrous tissue in an otherwise normal breast

2) NO increased risk of breast cancer (with negative family history)

3) Changes with Menses (May be swollen, tender, and may feel certain nodules there that they do not feel any other time of the month)

FIBROCYSTIC BREAST CHANGES TYPES

1) Hyperplasia (women in their 20s)

 a. Stromal Proliferation causing upper outer quadran breast pain and an indurated axillary tail

2) Adenosis (women in their 30s)

 a. Proliferation of Glandular Tissue resulting in multiple breast nodules 2 to 10 mm in size and increasead amount of lobular tissue

3) Cystic Disease (women in 30s, 40s)

 a. Solitary or multiple cysts where acute enlargement may cause severe, localized pain of sudden onset

ASSOCIATED FACTORS (Prolonged Estrogen Exposure, High SES, Caffeine)

1) Early Menarche

2) Late Menopause

3) Nulliparity

4) Late age of birth of 1st child (after age 30)

5) High Socioeconomic Status

6) Caffeine consumption (Sometimes, if she advises pt to cut back on caffeine, they will have decreased fibrocystic changes)

BENIGN CAUSES OF BREAST LUMPS

FIBROADENOMA

1) Benign Solid Tumors containing Glandular and fibrous tissue

2) Well defined, mobile mass

3) Y, Common

4) MAY or MAY NOT Change with Menstrual cycle.

5) Age range 15-39 years (mean age 20)

6) Cannot differentiate from CARCINOMA on physical exam (Both non-tender, both well defined, both can be mobile.)

FIBROCYSTIC BREAST CHANGES TYPES

1) Hyperplasia (women in their 20s)

 a. Stromal Proliferation causing upper outer quadran breast pain and an indurated axillary tail

2) Adenosis (women in their 30s)

 a. Proliferation of Glandular Tissue resulting in multiple breast nodules 2 to 10 mm in size and increasead amount of lobular tissue

3) Cystic Disease (women in 30s, 40s)

 a. Solitary or multiple cysts where acute enlargement may cause severe, localized pain of sudden onset

BREAST: FIBROADENOMA

1) What is it?

2) What is the mass like?

3) Common?

4) Change with Menstrual cycle?

5) Age range? (mean age)

6) Cannot differentiate from ?? on physical exam

1) Benign Solid Tumors containing Glandular and fibrous tissue

2) Well defined, mobile mass

3) Y, Common

4) MAY or MAY NOT Change with Menstrual cycle.

5) Age range 15-39 years (mean age 20)

6) Cannot differentiate from CARCINOMA on physical exam (Both non-tender, both well defined, both can be mobile.)

TISSUE AND CYSTS

FIBROCYSTIC BREAST CHANGES TYPES

1) Hyperplasia (women in their 20s)

 a. Stromal Proliferation causing upper outer quadran breast pain and an indurated axillary tail

2) Adenosis (women in their 30s)

 a. Proliferation of Glandular Tissue resulting in multiple breast nodules 2 to 10 mm in size and increasead amount of lobular tissue

3) Cystic Disease (women in 30s, 40s)

 a. Solitary or multiple cysts where acute enlargement may cause severe, localized pain of sudden onset

BE SURE TO GO OVER BREAST CANCER STASTITICS AND SCREENING PROTOCOL, ETC!!!!

STARTING ON SLIDE 1182 to 1220!!

1) FAMILY HX of breast cancer

 a. esp if PREMENOPAUSAL

 b. also esp if are BRCA1/A2 carrier

2) Age of Menarche

3) Nulliparity

 a. For age of menarche and Nulliparity:  (Prolonged exposure to cycles of Estrogen and Progesterone we think increases risk of breast cancer.  If started early, have had more cycles.  If haven't had a 9 month break with baby, have had more cycles.  Same thing for first pregnancy after age of 30)

4) First pregnancy after age 30

5) Obesity

6) Smoking

7) Alcohol

8) Proliferative lesion WITHOUT ATYPIA (1.2-2X risk)

 a. Fibroadenoma

 b. Hyperplasia

 c. Sclerosing Adenosis

9) Proliferative Lesion WITH ATYPIA (4-6x risk)

HOW do you perform the Breast Exam? (each breast should take about 3 mins for a total of 6 mins)

1) INSPECTION

2) PALPATION

3) AXILLAE

1) INSPECTION (*Only time both breasts should be exposed)

 a. Arms relaxed at sides

 b. Arms over head

 c. Hands at sides & Contracting Pecs

 d. Leaning Forward (arms supported by examiner)

 e. Look at Skin, Symmetry (common to have slightly different sizes), Nipple (direction, rash, ulceration, discharge)

2) PALPATION (ONLY expose part you are palpating)

 a. lying flat on back, with rolled up towel under ipsilateral shoulder and pts arms ABOVE HEAD

 b. Use pads of 2 or 3 fingers in a rotary fashion

 c. Concentric Circles (prob this one), Vertical Stripes (some literature said better, not as used), or Radial Spokes (not as used), or back and forth

 d. Compress nipple gently between thumb and index finger (to see if can express fluid)

 e. Pay special attention to the UPPER QUADRANT and "tail" of the breast

3) AXILLAE (patient can be sitting or lying...if sitting, support pts left arm with left hand and palpate with right hand, etc)

 a. Palpate ALL SIX lymph node groups

 b. Use pads of 2 or 3 fingers in a rotary fashion

1) Location with cm from the nipple

2) Measure size in cm

3) Shape...round or discoid, regular or irregular

4) Consistency...soft, firm, hard

5) Tender or non-tender

6) Mobile or non-mobile

1) Location

2) Size

3) Fixed or Mobile

4) Tender or non-tender

5) Any discharge present?

6) Document appropriately

BREAST REVIEW SLIDE

1) Any increased risk of breast cancer with fibrocystic breast changes?

2) Fibroadenoma occurs most commonly in women in their ??'s

3) One in ?? women will develop breast cancer in their lifetime

4) Breast cancer risk factors include what SEVEN things?

5) ?? women have a higher incidence of breast cancer after 35.  ?? women are more likely to die from breast cancer at every age.

6) Mammography has a sensitivity of approximaltely ?? % and has been shown to reduce ??

7) Small tumors (<??cm) can be detected by screening

8) Always examine the ?? and ?? of the breast

1) NO increased risk of breast cancer with fibrocystic breast changes.

2) Fibroadenoma occurs most commonly in women in their 20's

3) One in EIGHT women will develop breast cancer in their lifetime

4) Breast cancer risk factors include: family hx, nulliparity, age of menarche, 1st pregnancy after 30, obesity, smoking, alcohol

5) WHITE women have a higher incidence of breast cancer after 35.  BLACK women are more likely to die from breast cancer at every age.

6) Mammography has a sensitivity of approximaltely 80% and has been shown to reduce MORTALITY

7) Small tumors (<1cm) can be detected by screening

8) Always examine the UPPER OUTER QUADRANT and TAIL of the breast

1) Inversion of Nipple (sometimes women were born with inverted nipples, but NEW onset inversion is AKWAYS concerning.)

2) Fissuring of Nipple

3) Excoriation or scaling of nipples

4) Dimpling or flattening of skin

5) Edema (esp localized)

6) Venous Engorgement or prominence

PAGET'S DISEASE OF THE BREAST

1) Uncommon form of Breast Cancer

2) Usually starts as a scaly, eczema-like Lesion

3) The skin may also weep, crust, or erode

4) A breast mass may be present

5) Suspect this disease when a woman has had persisting dermatitis if the nipple or areola, or in a women who has been treated over and over again with steroids to no avail.