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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:
Rhabdomyoma:
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:

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

Chronic:
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.

Menopause:
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.

Amenorrhea:
Absence of menses.

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

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

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

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

Endometriosis:
Glands and stroma located outside uterus.

Locations:
Most common is ovaries.

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

Treatment:
Laparoscopy.

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

Findings:
Pain, bleeding, adnexal mass, hypovolemic shock.

Complications:
Rupture, hematosalpinx.

Diagnosis:
Beta-hCG, ultrasound, laparoscopy.

Ovarian disorders:
Tumors:
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.

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

Findings:
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.

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

Treatment:
Chemotherapy.

Down syndrome triad:


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

Nipple discharges:
Bloody:
Intraductal papilloma, ductal cancer.

Purulent:
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:


Fibroadenoma:
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.