Ppcn2: Lecture 4 (Breast And Menstrual)

Front 1

ToF: gynecomastia is usually benign in adolescent males

Back 1

true

Front 2

what is gynecomastia?

Back 2

proliferation of glandular tissue of male breast with rubbery firm mass concentrically from the nipple

Front 3

what is a male "breast" is just fat?

Back 3

it is called pseudo-gynecomastia

Front 4

when are the peaks of gyencomastia?

Back 4

puberty and older adults.

usually onset between 10-12 and peaks at 14 (tanner 3)

true peak is 14-15.5 years

Front 5

60-90% of __ have transient gynecomastia

Back 5

infants

Front 6

ToF: approximately 40% of healthy boys have pubertal gynecomastia

Back 6

true

Front 7

how long does gynecomastia usually take to resolve

Back 7

2 years

Front 8

gynecomastia begins to regress __ after it starts

Back 8

18 months

Front 9

in 4% of cases of gynecomastia are more severe: what are the characteristics?

Back 9

more than 4cm diameter and are bilateral

Front 10

what causes gynecomastia?

Back 10

an increase in the ration of estrogen to androgen

Front 11

what is the treatment of gynecomastia?

Back 11

reassurance unless it does not resolve after 2 years and it develops rapidly

Front 12

what is the most common etiology of gynecomastia?

Back 12

idiopathic

-decrease in androgen and increase in estrogen
-increased availability of estrogen precursors for peripheral conversion to estrogen
-androgen receptor blockage
-increased binding of androgen to sex hormone binding globulin

Front 13

what disorder is common to find a decrease in the production of androgens in boys?

Back 13

kleinfelters

Front 14

what must be ruled out if a boy has small testicles?

Back 14

kleinfelters

Front 15

describe the pathophysiologic reasons behind an absolute increase in free estrogen leading to gynecomastia

Back 15

-testes, adrenal, maternal placental fetal unit
-extraglandular aromatization of precursors
-displacement from sex hormone binding globulin
-decrease metabolism
-exogenous estrogen

Front 16

what are the reasons that there may be a decrease in androgens leading to gynecomastia?

Back 16

-decreased secretin
-increased metabolism
-increased binding to sex hormone binding

Front 17

what are the pathologic conditions associated with gynecomastia?

Back 17

-neoplasms
-hypogonadism (kleinfelters, primary and secondary)
-conditions that decrease androgen levels
-conditions that increase estrogen levels

Front 18

what are conditions that decrease androgen levels in males?

Back 18

-enzymatic defect of testosteron
-androgen insensitivity
-DSDs: ovotesticular disorder (true hermaphodite)

Front 19

what are conditions that cause an increase in estrogen in males?

Back 19

-obesity
-liver disease
-starvation
-renal disease
-hyperthyroidism
-excessive extranglandular aromatase activity
-idiopathic
-drugs

Front 20

what are the drugs that increase estrogen?

Back 20

-the pill
-diethylstibestrol
-digitalis
-estrogen containing cosmetics

Front 21

what are the drugs that inhibit testosterone actions?

Back 21

-ketoconazole
-spirolactone***
-cimetidine
-isoniazid
-captropril
-tricyclics
-antidepressants
-diazepam
-Marijuana
-phenothiazine

Front 22

What blood work should be done as a screen in gynecomastia?

Back 22

-FSH
-LH
-HCG (tumor marker)
-LFTs
-TSH
-estrodiol and testosterone

Front 23

what are the pharmacologic treatments of gynecomastia that are not followed with RCTs?

Back 23

-danazol (synthetic derivative of testosterone)
-clomiphene (anti-estrogen)
-tamoxifen (estrogen antagonist)

Front 24

ToF: a CBC should be done as part of the work-up for gynecomastia

Back 24

false

Front 25

ToF: breast lumps in adolescents never need referral

Back 25

false

Front 26

what is the appropriate age to start teaching a young girl about breast self exam?

Back 26

tanner V

Front 27

what are the disadvantages to teaching breast self exam?

Back 27

-can raise level of anxiety
-time consuming- may not be cost effective

Front 28

what are the differential diagnoses for breast lump with pain?

Back 28

-breast infection
-mastalgia

Front 29

what are the differential diagnoses for nonpainful breast masses?

Back 29

-gynecomastia
-fibroadenoma
-fibrocystic breast disease

Front 30

what is the most common test to order a breast lump evaluation in a 14 year old?

Back 30

ultrasound

Front 31

what is mastitis?

Back 31

-unilateral bacterial infection of the breast

Front 32

what are the clinical manifestations of mastitis?

Back 32

warmth, tenderness, edema, erythema in one breast

-fever or influenza like symptoms can be present

Front 33

what is the cause of mastitis?

Back 33

--bacteria enters through a cracked nipple
-obstruction of the milk ducts from plugged ducts

Front 34

what are the common organisms of mastitis?

Back 34

-staph aurues
-E. coli
-pseudomonas

Front 35

what are the treatments for mastitis?

Back 35

-first gen ceph or bactrim if think MRSA
-erythromycin
-may need incision and drainage

Front 36

what is the most common cause of mastalgia?

Back 36

cyclic with menstrual cycle

Front 37

what are the treatments for mastalgia?

Back 37

-supportive
-supportive bra
-antibiotics
-alternative therapy not supported by evidence
-vitamin E, A, and B

Front 38

What is the most common benign breast issue?

Back 38

fibrocystic breast disease

Front 39

what is fibrocystic breast disease?

Back 39

-physiologic swelling and tenderness
-accounts for 50% of the complaints
-nodular breast tissue
-mastalgia
-breast swelling
-nodularity tends to be in the upper out quadrant
-fluctuates with menstrual cycle
-caffeine and chocolate increase it

Front 40

what are the treatments of fibrocystic changes?

Back 40

-eliminated methylxanthines and caffeine
-analgesia with NSAID
-support bras
-in severe cases, OC can be helpful with progesteron starting on day 15-25
-reduce nicotine
-alternative vitamins

Front 41

what is a benign neoplasm of mammary gland?

Back 41

fibroadenoma

Front 42

describe a fibroadenoma?

Back 42

-most common tumor of adolescent
-age 15-16
-twice as common in african americans
-80% are unilateral
-usually asymptomatic
-lasts around 5 months
-usually solitary
->60% in lateral quadrant

Front 43

what is the most common tumor of adolescents

Back 43

fibroadenoma

Front 44

What group has the highest incidence of fibroadenomas?

Back 44

african american

Front 45

what location is the most common for fibroadenomas?

Back 45

>60% in the lateral quadrant

Front 46

what is the treatment for fibroadenomas?

Back 46

-If >5cm, Juvenile giant ademona
-can watchfully wait
-refer to pediatric surgery for excision
-unclear is increased risk of breast cancer

Front 47

what is the name for an inappropriate secretion of milk?

Back 47

galactorrhea

Front 48

what are the common causes of galactorrhea?

Back 48

-pituitary adenoma
-pregnancy
-hypothyroidism
-illicit drugs: alcohol, marijuanan, heroin
-meds: OC, anabolic steroids, reserpine, phenothiazines, opiates, CCBs, omeperazole

Front 49

what accounts for a difference in breast size?

Back 49

juvenile hypertrophy

Front 50

what is juvenile hypertrophy of the breast?

Back 50

-pendulous, diffusely firm breast- up to 30-50 pounds
-occurs in tanner 4
-? breast tissue more sensitive to puvertal estrogen secretion

Front 51

what is the treatment for juvenile breast hypertrophy?

Back 51

-weight loss**
-reduction mammoplasty
-subcutaneous mastectomy
-hormonal therapy (danazol) combo

Front 52

What is the number one answer in this section if it appears as a question option to choose!?

Back 52

PREGNANCY!

Front 53

what are the causes of breast atrophy?

Back 53

-premature ovarian failure
-weight loss
-chronic illness: IDDM, IBD, connective tissue
-androgen excess

Front 54

what is tuberous breast deformity?

Back 54

-overdeveloped areola
-underdeveloped breast

-normal variation

Front 55

what is a jogger's nipple?

Back 55

-nipple irritation during exercise
-wear a supportive bra
-protect the nipple with vaseline

Front 56

what are the characteristics of breast cancer?

Back 56

-hard, fixed, irregular, painful masses
->98% of the cases occur in women >25

Front 57

what is the increase risk of breast cancer in teens with first degree relative with it?

Back 57

3-4 times

Front 58

what are other malignancies that can present as breast masses?

Back 58

-lymphoma
-neuroblastoma
-rhabdomyosarcoma
-hodgkin disease
-leukemia

Front 59

ToF: menses is a vital sign?

Back 59

true

Front 60

ToF: most girls have a fairly normal monthy menstrual cycle during the first year after menarche

Back 60

true

Front 61

what is the average age of menses for african americans, hispanics and caucasian girls?

Back 61

12.1; 12.3; 12.6

Front 62

what is considered a normal menstrual cycle interval?

Back 62

21-45 days

Front 63

what is the average menstrual flow length and the number of products used a day?

Back 63

length: </= 7 days

3-6 in a day

Front 64

What are the 3 characteristics of physiologic menstrual cycles from the slide?***

Back 64

-An intact CNS
-proper end organ or gonadal responsiveness
-intact outflow tract

Front 65

What are the 3 phases of the menstrual cycle?

Back 65

-Follicular phase
-ovulation
-luteal phase

Front 66

What occurs in the follicular phase?

Back 66

proliferation of endometrium

-in the first 6 days, all the eggs want to be chosen
-this stage is run by estrogen

Front 67

what stage is the copus luteum formed?

Back 67

ovulation phase

Front 68

what occurs in the luteal phase of menstruation?

Back 68

-changes within the endometrium
-secretory activity

Front 69

increasing pulsatile secretion of GnRH by hypothalamus triggers ___

Back 69

puberty

Front 70

___ begin follicular development and estrogen production

Back 70

ovaries

Front 71

Increase estradiol --> ___ --> ovulation

Back 71

LH surge

Front 72

ToF: the maturation of HPO axis may not occur consistently for several years

Back 72

true

Front 73

in the first year post menarche __ of cycles of 21 to 45 days and include 2-7 days bleeding

Back 73

80%

Front 74

three years post menarche 60-80% of cycles are __ to __ days

Back 74

21-34

Front 75

Less than 0.5% of all bleeding episodes in the first 2 years last ___ days

Back 75

>10

Front 76

what are the causes of prepubertal bleeding?

Back 76

-foreign objects
-vulvovaginal infection, resulting in pruritis
--pinworms
--strep
-sexual abuse
-trauma
-tumor
-condylomata (warts)
-hemangiomas
-polyps

Front 77

anovulatory cycles are associated with ___ of the HPA axis

Back 77

immaturity

Front 78

what are anovulatory cycles?

Back 78

portion of lining slough at irregular intervals

Front 79

anovulatory cycles are due to excess __ stimulation of endometrium without __ levels that are high enough to support vasoconstriction

Back 79

estrogen; progesterone

Front 80

what are the pathophysiologies of abnormal uterine bleeding?

Back 80

-an immaturity of the hypothalamic pituitary ovarian axis with resultant anovulatory cycles

-no surge in LH and ovulation does not occur and the progesterone secreting corpus luetum never forms

-influence by estrogen only endometrial shedding is incomplete and irregular

-eventually fluctuating estrogen cause a decrease in GnRH, GSH, LH

-vasoconstriction and collapse of thickened hyperplastic endometrial lining during the anovulatory cycle result in withdrawal bleeding

Front 81

what hormone is responsible for stimulation of the egg?

Back 81

FSH/estrogen

Front 82

what is the term for excess bleeding?

Back 82

menorrhagia

Front 83

what is the definition of abnormal uterine bleeding?

Back 83

excessive, prolonged or irregular bleeding from the endometrium that is unrelated to anatomic lesions of the uterus

-> 7 days
-> 6 pads per day
-< every 21 days

Front 84

what is the first test to do with a women with abnormal uterine bleeding?>

Back 84

pregnancy test

Front 85

what is dysfunctional uterine bleeding (DUB)?

Back 85

-painless AUB with no underlying pathologic condition

Front 86

what are the coagulations disorders often associated with AUB>?

Back 86

Von Willebrand disease and ITP

Front 87

what systemic diseases can cause AUB?

Back 87

hepatic failure, renal failure, malignancy

Front 88

what are the abnormalities of the uterine tract that can cause AUB?

Back 88

polyps, endometritis, endometriosis

Front 89

what are the menstrual signs that are suggestive of coagulopathy?

Back 89

-periods for more than 7 days
-doubling up or using extra protection overnight
-passing blood clots greater than 1 inch
-flooding or sudden unexpected flow
-anemia
-mucosal bleeding or easy bruising

Front 90

why must you check BP on a patient with suspected coagulopathy?

Back 90

othrostatic hypotension

Front 91

why is ovulation important?

Back 91

-anovulation is associated with low progesteron state
-continuous unopposed estrogen levels lead to stimulation of the endometrium --> overgrowth
-endometrium eventually is unstable and bleeds irregularly, rather than in controlled, orderly or predictable

Front 92

bleeding disorders are present in 7-20% of all females with ___

Back 92

menorrhagia

Front 93

10% of girls with ____ have excessive uterine bleeding as a presenting symptom

Back 93

coagulopathies

Front 94

What are the types of Von Willebrand's disease? Which is the most common to present in menses?

Back 94

-Type 1: (most common and tends to be mild) often presents in menses.

-Type 2 and 3: more severe and likely to present earlier

Front 95

other than van willebrand's disease, what are other coagulopathyies that can cause AUB?

Back 95

-platelet storage pool defects
-platelet function abnormalities
-ehlers danlos syndrome
-ITP
-clotting factor deficiencies aside from von willebrands
-leukemia

Front 96

what are the first line tests to conduct with DUB?

Back 96

-pregnancy test
-CBC with reticulocyte
-STI testing

Front 97

What are the second line lab tests for DUB?

Back 97

-TSH, free T4
-LH, FSH
-PT, PTT, von willebrand's clotting factor
-if evidence of hyperadrogenism: 17-OH progesterone, DHEA-S, Androstenone, DHEA, and total and free testosterone

Front 98

what is considered mild DUB?>

Back 98

no anemia, erratic bleeding.

Supplement with vitamins

Front 99

what would be considered moderate severity DUB? any treatment?

Back 99

more prolonged and profuse bleeding.

use therapeutic levels of iron

Front 100

what is considered severe DUB>?

Back 100

anemia with Hgb < 10, hemodynamically unstable, sometimes life threatening.

May have to be admitted for a blood transfusion

Front 101

Describe the process for Rx'ing OC for moderate DUB.

Back 101

-one pill every 6-12 hours for 24-48 hours until bleeding stops then taper to tone a day until day 5, then begin new 28 day packet.

Must Rx for 2 packets
Chief side effect is N/V so Rx zofran

continue for 3-6 months

treat with iron if anemic

if estrogen intolerant, give progesterone

Front 102

what is the process for OC Rx for severe DUB?

Back 102

on the 4-4; 3-3; 2-2, 1

-one pill qid for 4 days then
-one pill tid for 3 days, then
-one pill bid for 2 weeks, then
-one pill every day

-requires 3 months of pills to compelte and must discard the placebo pills!

prescribe sprintac (ortho-tricycline lo)

may also use NSAIDs because they decrease flow through inhibition of prostaglandin synthesis

Front 103

what is the dosing of IV estrogen when hospitalized for severe DUB with active bleeding?

Back 103

20 mg IV q 4 hours until bleeding controlled, then add progesterone within 24-48 hours

-transfusion rarely needed but consider

Front 104

what are the situations when AUB should be referred?

Back 104

-Severe bleeding that does not respond to IV estrogen
-moderate bleeding not responding to the QID oral contraceptives within 3 days
-severe pain with the bleeding
-suspect underlying pathology
-refer to GYN or hematology

Front 105

What is primary amenorrhea?

Back 105

-absence of menses by age 16 in presence of normal growth and secondary sex characteristics
-if there is no secondary sexual characteristics by age 14, consider work-up

Front 106

what is secondary amenorrhea?

Back 106

-cessation of menses for more than 3 months after menses are established with regularity

Front 107

what is oligomenorrhea?

Back 107

infrequent bleeding of > 42 day intervals

Front 108

why do patients need periods?

Back 108

-irregular prolonged bleeding
-psychological stress
-reduction in bone mineral density with an increased risk of fracture

Front 109

what are the differential diagnoses for amenorrhea?

Back 109

1. Pregnancy***
2. CNS: (pre-hypothal, hypothal, and pituit problems)
3. thyroid
4. adrenal
5. gonad
6. outflow tract

Front 110

what is kallmann's syndrome?

Back 110

disorder of hypogonadotropic hypogonadism that has a lack of smell and amenorrhea

Front 111

what are the findings of FSH/LH of hypogonadotropic hypogonadism

Back 111

Low to normal FSH/LH

Front 112

what are the disorders of hypogonadotropic hypogonadissm?

Back 112

-anorexia
-systemic illness
-stress
-GnRH deficiency
-hyperprolactinemia
-hypopituitarism
-athletic
-kallmann's
-CNS tumor
-endocrinopathies
-depression, drugs
-physiologic delays, prader willi
-hemochromatosiss (iron excess)

Front 113

what are the disorders of hypergonadotropic hypogonadism?

Back 113

end organ problems

-premature ovarian failure
-radiation, chemo, surgery, torsion
-17 hydroxylase deficiency
-hereditary conditions: galactosemia, trisomy, ataxia, telangiectasia
-Turners
XY gonadal dysgenesis

Front 114

what is the number 1 cause of Eugonadotropic hypogonadism? what are the others?

Back 114

polycystic ovarian disease**

-illness, stress, weight loss
-neoplasia
-conditions of mechanical obstruction to outflow: mullerian agenesis

Front 115

what are the etiologies of amenorrhea?

Back 115

-chromosomal or morphogenic
-chronic illness
-endocrinopathy
-drugs
-ovarian
-uterine

Front 116

what are the red flags of amenorrhea?

Back 116

-no menses by age 16
-outside the family pattern
-no menses by 2 years after 2ndary sex characteristics
-associated congenital anomalies
-virilization (acne, hursitism, clitiromegaly)
-short stature

Front 117

what are the key points of the physical exam for amenorrhea?

Back 117

-Height and weight (abnormal consider IBD)
-ophthalmologic, neurologic, and pelvic exam
-abnormalities of visual fields
-abnormalities of smell
-CNS function
-signs of virilization
-large thryoid, buffalo hump, vitiligo
-myxedematous facies
-hirsutism
-receding hairline
-deepening of voice
-presence of galactorrhea
-BMI< 18, osteoporosis
-pregnancy

Front 118

what can the presence of galactorrhea mean?

Back 118

can be neuroendocrine

Front 119

what are the lab evaulation for secondary amenorrhea?

Back 119

-pregnancy test
-TSH
-Prolactin
-LH, FSH, estradiol
-Testosterone, DHEAS, 17-OH progesterone
-comprehensive metabolic panel A1C

Front 120

what is the progestin challenge? Describe it.

Back 120

used to test for Amenorrhea.

-give oral medroxyprogestrone 5-10mg daily for 5-10 days

-bleeding suggests adequate estrogen levels and anovulation

-no withdrawal bleeding: cycle on estrogen and progestin
-No bleeding = end organ problem
+bleeding check LH, FSH

Front 121

In the situation where the physical exam is normal for a patient with amenorrhea, and there is an increase in FSH and LH, what is the differential? what should be done and ruled out?

Back 121

-premature ovarian failure

-do a karyotype analysis (unless hx of irradiation or chemo)

-rule out: autoimmune disorders

Front 122

if a physical exam of a female with amenorrhea is normal, but her FSH and LH are low, what is the differential and what test should be considered?

Back 122

-hypothalamic suppression or CNS tumor
-consider: MRI of the head

Front 123

how many mullerian tract abnormalities are there? what is the most common type?

Back 123

7 types

most common the class 6: arcuate uterus (heart shaped uterus)

Front 124

what is class I mullerian tract abnormality?

Back 124

-hypoplasia/agenesis of the uterus and cervix

Front 125

what is the most common Class I mullerian tract abnormality?

Back 125

-Mayer-Rokitansky-Kuster-Hauser syndrome

-combine agenesis sof the uterus, cervix and upper portion of the vagina

-patients have no reproductive potential aside from medical intervention in the form of in vitro fertilization of harvested ova and implantation in a host uterus

Front 126

15% of MURCS syndrome is associated with ___

Back 126

renal anomalies

Front 127

12% of girls with MURCS have ___ ___ usually of the thoracic and lumbar spine

Back 127

skeletal anomalies

Front 128

what are the renal aplasias that can occur with MURCS?

Back 128

-renal ectopia
-fusion anomalies
-horseshoe kidneys

Front 129

what is Class 2 mullerian tract abnormality?

Back 129

unicornuate uterus

results from complete, or almost complete arrest of development of 1 mullerian duct. `

Front 130

what occurs if the arrest of one mullerian duct in class 2 is incomplete?

Back 130

a rudimentary horn with or without functioning endometrium is present

Front 131

ToF: a full term pregnancy is not possible in the healthy horn of class II mullerian tract abnormality

Back 131

false: it is thought to be possible

Front 132

What occurs in the rudimentary horn of unicornuate uterus?

Back 132

it becomes obstructed and presents as enlarging pelvic mass

Front 133

which class is a didelphys uterus>?

Back 133

class 3

Front 134

what is a didelphys uterus?

Back 134

complete nonfusion of both mullerian ducts (2 uteruses/cervices)

-

Front 135

didelphys uteri have the highest association with __ __ septa, but septa also may be observed in other anomalies.

Back 135

transverse vaginal

Front 136

ToF: the individual horns of didelphys uteri are not fully developed

Back 136

false: they are and they have been known to support a pregnancy

Front 137

what is class IV mullerian tract abnormality?

Back 137

-bicornuate uterus:

-results from partial nonfusion of the mullerian ducts
-the central myometrium may extend to the level of the internal cervical os or external cervical os

Front 138

in a bicornuate uterus, the central myometrium may extend to the level of the internal cervical os (___ ___) or external cervical os (___ __)

Back 138

bicornuate unicollis; bicornuate bicollis

Front 139

ToF: in a bicornate uterus there is some degree of fusion between the 2 horns

Back 139

true

Front 140

ToF: horns of the bicornate uterus are fully developed

Back 140

false: they are not and they are smaller than the didelphys uteri

Front 141

the classic didelphys utuerus, the two horns and cervices are ___ ___

Back 141

completely separated

Front 142

what is septate uterus?

Back 142

class V:

results from failure of reabsorption of the septum between the two uterine horns: partial or incomplete

Front 143

in a septate uterus, the fundus is typically ___ but may be flat or slightly ___

Back 143

convex; concave

Front 144

Class __ (septate uterus) has the highest incidence of ____ ___

Back 144

5; reproductive complications

Front 145

ToF: septate uteri can be treated

Back 145

true

Front 146

what is asherman's syndrome?

Back 146

abnormalities of the uterus where there are adhesions (band-like formations) crossing the lining of the uterus.

Front 147

ToF: IGF-1 and IGFBP-3 follow pulsatile release

Back 147

false they are continuous release

Front 148

If FSH is dominant in the girl, what is the outcome?

Back 148

prepubertal state

Front 149

if LH is the dominant hormone, what may be the outcome?

Back 149

late pubertal development

Front 150

Low values of IGF1 and IGFBP-3 suggest ___

Back 150

Growth hormone deficiency

Front 151

ToF: amenorrhea may occur in anorexia before significant weight loss

Back 151

true

Front 152

The most likely cause of ovarian failure is ___ __

Back 152

turner's syndrome

Front 153

ToF: autoimmune disorders can cause amenorrhea

Back 153

true