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Female Reproductive and Breast Disorders

Vulva Disorders:
Papillary hidradenoma:
Painful, benign tumor of apocrine sweat gland.

Vulvar Intraepithelial Neoplasia:

HPV 16 association. May advance to squamous cell carcinoma.

Squamous Cell Carcinoma:

Most common. HPV 16 association. Smoking, immunodeficiency.

Extramammary Paget's disease:

Red, crusted, lesion.

Intraepithelial adenocarcinoma:
Mucin is PAS +.

Malignant melanoma:
Similar to Paget's cells. PAS negative.

Vaginal disorders:
Benign tumor of skeletal muscle.

Embryonal rhabdomyoma:
Girls younger than 5 years old. Grape-like mass protrudes from vagina.

Clear Cell Adenocarcinoma:

Occurs in women exposed to DES. DES inhibits mullerian structures.

Vaginal Squamous Cell Carcinoma:

HPV 16 association.

Cervix disorders:
Acute and chronic cervicitis:

Inflammation due to infection by: C. trachomatis, N. gonorrhoeae, T. vaginalis, Candida, and HSV. Follicular cervitis: caused by C. trachomatis.

Persistent acute cervicitis.

Pap smear:
Screen out squamous dysplasia and cancer. Adequate estrogen = superficial squamous cells (SSC). Adequate progesterone = intermediate squamous cells (ISC). Lack of estrogen and progesterone = parabasal cells PC. Nonpregnant woman = 70% SSC + 30% ISC. Pregnant woman = 100% ISC. Elderly woman = PC. Woman with exposure to estrogen without progesterone: 100% SSC.

Cervical intraepithelial neoplasia (CIN):

Low risk: HPV 6, 11 association. High risk: HPV 16, 18 association. Risk: Early age for having sex, multiple sex partners, smoking, oral contraceptives, HPV, immunodeficiency.

Cervical cancer:
Uncommon. Detected early: CIN and Pap. Risk: Early age for having sex, multiple sex partners, smoking, oral contraceptives, HPV, immunodeficiency. Findings: Malodorous discharge; postcoital bleeding. Distant metastasis. CIN I: mild. CIN II: moderate. CIN III: severe.

Oral contraceptive pills:

Estrogen + progesterone. Estrogen: prevents mid-cycle estrogen surge. Progesterone: inhibit LH. Hostility to sperm.

Changes during pregnancy:

Increased plasma volume and RBC mass. Respiratory alkalosis. Increased serum thyroxine and cortisol.

Increased FSH, LH; decreased estrogen and progesterone. Secondary amenorrhea, hot flushes, night sweats.

Increased testosterone (ovaries) or increased DHEA-sulfate (adrenal origin) cause:

Hirsutism or virilization.

Polycystic ovarian syndrome (POS):

Increased LH and androgens and estrogen; decreased FSH. Findings: menstrual irregularities, hirsutism, infertility, obesity. Hypothyroidism.

Absence of menses.

Hypothalamic or pituitary disorder: decreased FSH/LH. Ovarian disorder: decreased estrogen and progesterone. End-organ defects.

Uterine disorders:
Due to bacterial infection; S. agalactiae.

Endometritis: chronic:
Retained placenta, gonorrhea, intrauterine device.

Stratum basalis invaginates into myometrium. Findings: menorrhagia, dysmenorrhea, pelvic pain.

Glands and stroma located outside uterus.

Most common is ovaries.

Dysmenorrhea, painful menses, intestinal obstruction, ectopic pregnancy, enlarged ovaries.


Endometrial hyperplasia:
Too much estrogen. Causes: nulliparity, obesity, POS. Findings: menorrhagia; increased risk of endometrial carcinoma.

Endometrial carcinoma:

Very common. OCPs decrease risk. Risk of breast cancer. Types: well-differentiated adenocarcinoma, papillary adenocarcinoma. Findings: post-menopausal bleeding.

Leiomyoma (fibroids):
Benign smooth muscle tumor. Findings: menorrhagia, obstructive delivery.

Fallopian Tube Disorders:

Pelvic Inflammatory Disease:
Causes: N. gonorrhoeae or C. trachomatis. Gives rise to hydrosalpinx. Complication: oophoritis.

Ectopic Pregnancy:
Most common cause is scarring from previous PID; endometriosis, altered tubal motility, SIN.

Pain, bleeding, adnexal mass, hypovolemic shock.

Rupture, hematosalpinx.

Beta-hCG, ultrasound, laparoscopy.

Ovarian disorders:
Risk: nulliparity, mutant BRCA1 and BRCA2; Lynch syndrome; Turner's syndrome; Puetz-Jeghers syndrome, smoking; OCPs decrease risk.

Types of tumors:
Surface-derived (most common), germ cell, sex cord-stromal tumors, metastasis. Findings: ascites, increased abdominal girth, induration in rectal pouch on DRE, intestinal obstruction with colicky pain; ovarian mass, pleural effusion, infarctions, hyperestrinism. Markers: CA 125.

Placental Abnormalities:
Placenta previa:
Implantation over cervical os; bleeding, painless.

Abruptio placentae:
Premature placental separation; due to smoking, cocaine, hypertension, advanced age.

Toxemia of pregnancy. Abnormal placentation. Decreased natural vasodilators. Increased vasoconstrictors. Premature aging of placenta. Infarctions, atherosclerosis of spiral arteries.

Hypertension, proteinuria, edema, seizures, renal and liver disease, HELLP syndrome.

Hydatidiform moles:
Benign tumor of chorionic villus. Neoplastic placenta. 46XX. Findings: preeclampsia, large uterus, increased hCG; snowstorm appearance on ultrasound.

Malignant tumor made of syncytiotrophoblast and cytotrophoblast. Spreads to: lungs, vagina; lesions are hemorrhagic.


Down syndrome triad:

Decreased urine estriol, decreased AFP, increased beta-hCG.

Nipple discharges:
Intraductal papilloma, ductal cancer.

Acute mastitis due to S. aureus.

Greenish-brown discharge:
Mammary duct ectasia.

Breast pain:
Causes fibrocystic change. Mondor's disease: superficial thrombophlebitis of breast veins; painful and palpable.

Fibrocystic change:
Blue domed cysts. No malignancy.

Sclerosing adenosis. Ductal hyperplasia.

Benign breast tumors:

Most common in women younger than 35 years old. Movable mass. Enlarges during pregnancy.

Phyllodes tumor:
From stromal cells. Leaf-like extensions.

Intraductal papilloma:
Blood discharge. Women younger than 50.

Breast cancer:
Mean age: 64 years old. Family history, genetics. AD disease. BRCA1 and BRCA2. Li-Fraumeni syndrome: inactivated TP53 suppressor. RAS, ERBB2, RB suppressor. Due to: prolonged estrogen exposure; smoking, radiation, endometrial cancer. Painless mass. Skin, nipple retraction. Mammography: screening; cannot differentiate benign from malignant. Spreading: first by lymphatics, then hematogenously. Spreads to: lungs, bone, liver, brain, ovaries. Treatment: radical mastectomy; damage to long thoracic nerve causes winged-scapula; lumpectomy; radiation.

Breast cancer in men:

BRCA2 mutated; Klinefelter's syndrome. Poor prognosis.