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● Breast Mass/Breast Cancer ○ Case Study ■ A 44-year-old female has made an appointment with an APN. She is in good health, has no major medical problems, and does not take any prescription medications. She admits to a high-fat diet on occasion and is moderately overweight; she has several alcoholic drinks per week. Menarche is 10 years old, and she has never been pregnant. During the intake, the patient stated that she palpated a single, firm, non-tender, ill-defined lump in her right breast. ○ Diagnostic Studies ■ Mammography ■ Breast ultrasound ■ Refer pt? ● Yes to Breast Specialist ■ Needle biopsy - Excisional biopsy ● The most reliable diagnostic test is when the staging of the tumor is done. ○ Breast Cancer ■ most commonly diagnosed cancer in women in the U.S. ■ 2nd leading cause of cancer death in American women ■ 2 main risk factors ● Female ● Advancing age ■ Other factors ● Family history of breast cancer and ovarian cancer ● Known gene mutations ● Early menarche, late menopause, nulliparity ● Alcohol consumption, smoking, higher body mass index ○ Breast Cancer - Management ■ Secondary prevention ● Clinical breast exam every 3 years to age 40 & every 1-2 years over age 40 (ACOG) ● Mammography is performed annually, beginning at age 40 or 10 years before the age of diagnosis in women with 1st-degree family history ● https://www.acog.org/news/news-releases/2017/06/acog-revises-b reast-cancer-screening-guidance-ob-gyns-promote-shared-decisio n-making ● https://www.uspreventiveservicestaskforce.org/uspstf/recommend ation/breast-cancer-screening. ■ Tertiary prevention ● Referral to the oncology team is required ● Dependent on the tumor stage, the presence of hormone receptors, and the patient’s symptoms and preferences.
● Cervical Screening/HPV ○ Pap Smear ■ https://www.youtube.com/watch?v=i2YZYUYqjEY ■ ○ Cervical Screening ■ Similar to Pap smear ■ Look specifically for Human Papilloma Virus (HPV) infection ● #1 cause of cervical cancer ■ Guidelines ● Women aged 21-29 years should have a Pap test alone every 3 years. HPV testing is not recommended. ● Women aged 30-65 years have 3 options: ○ Pap test only. Normal results can wait 3 years. ○ HPV test only. Normal results can wait 5 years. ○ HPV & Pap test ( preferred ) Normal results can wait 5 years. ○ HPV Vaccine ■ Protects against the types of HPV that most often cause cervical cancers. HPV can also cause other kinds of cancer in both men and women ■ HPV vaccination is recommended for all aged 11–26 who have not been previously vaccinated (can be given as early as 9 years) ■ In 2018, the FDA approved the vaccine for women and men up to age 45. While many adults have been exposed to some strains of HPV, most have not been exposed to all 9 types covered by the vaccine. ■ HPV vaccine does not treat existing infections or diseases ■ Screening should be continued even if a person is vaccinated ○ Condyloma (HPV) “Genital warts” ■ May need ● Biopsy to r/o dysplasia or carcinoma ● Test for other concurrent STIs ■ Treatment ● Podofilox gel 0.5% ● TCA (Trichloroacetic acid) ● Cryotherapy
■ Primary Ovarian Insufficiency ● Inconsistent, absent, or skipped menstrual cycle, occurring before age 40 ● This can indicate that menopause may occur or that few eggs are remaining; however, ovarian activity may resume ■ ○ Clinical Presentation ■ Symptoms and assessment findings vary widely, and not all women will experience symptoms with menopause ■ Vasomotor symptoms: night sweats, hot flashes (80% of women) ■ Variation in menstrual cycle until the final menstrual cycle (erratic ovarian function) ■ Sleep disturbances: may be related to hot flashes and depression/anxiety ■ Depression/Anxiety ■ Headaches and fatigue ■ Vulvovaginal symptoms: irritation, burning, itching, dryness, discharge, or dyspareunia ■ Vaginal atrophy ■ Hair loss or excessive hair growth ■ Skin thinning with the loss of elasticity ■ Dry eyes ■ Gingival thinning and recession ■ Bone and joint pain ○ Differential Diagnosis ■ Pregnancy ■ Diabetes Mellitus ■ Thyroid disease ■ Hyperparathyroidism ■ Polycystic Ovarian Disease ■ Pituitary Adenoma ■ Hypothalamic Dysfunction ■ Primary Ovarian Insufficiency ○ Diagnostic Steps To Make Diagnosis
■ Detailed history of the patient's menstrual cycle ● Menstrual calendars are helpful ■ Detailed history of menstrual symptoms ● Hot flashes, sleep disturbances, depression or vaginal dryness ■ Vaginal exam as needed to assess for atrophy, dryness, or if c/o dyspareunia or sexual dysfunction ■ Labs ● What is indicated varies by age and presentation ● Pregnancy test ● FSH ● Prolactin ● TSH ○ Diagnostic Labs ■ During perimenopause, estrogen levels are generally normal; however, FSH begins to rise ■ As menopause progresses, estrogen levels decline and FSH and LH become more elevated ■ If the patient has an elevated FSH (>30 IU/L) AND no menstrual period for a year, that is menopausal ■ FSH >30 IU/L= perimenopause ■ FSH >70-90 IU/L is common for postmenopausal women. ■ The decision if a patient is perimenopausal or postmenopausal is made based on the menstrual history and presence of common menstrual symptoms . ○ ■ Menopause is diagnosed when amenorrhea has been present for 12 months. ■ Perimenopause is determined pending age and symptoms. ○ Pharmacological Treatment - HRT Therapy ■ Must use a combined estrogen/progesterone product for all women with a uterus
● SSRIs or SNRIs : fluxotenine, 20mg/day, paroxetine, 12.5 to 25mg/day, citalopram, 10 to 20mg/day, escitalopram, 10 to 20mg/ day, venlafaxine, 37.5 to 75mg/day, desvenlafaxine, 100mg/day ● Gabapentin : Daily dose of 300mg at bedtime; the dose may increase to 300mg twice daily and then to three times daily at 3 to 4 days interval ● Clonidine : initial oral dose for hot flash treatment 0.005mg twice daily, may increase to at least 0.1mg BID or the patch 0.1mg per day; limited use due to undesirable side effect profile ■ Vitamins & Minerals ● Vitamin D ● Calcium ● Iron ○ Non-Pharmacological Therapies ■ Lifestyle Options: ● Avoid hot drinks, alcohol, caffeine, and spicy foods ● Avoid warm environment ● Wear layered clothing ● Smoking Cessation ● Maintaining a healthy weight ● Regular exercise and weight bearing exercise ● Kegel exercises ● Low fat, high calcium diet ■ OTC devices or products: ● Bed fan ● Clothing and pajamas or gowns, bedsheets & pillowcases made from wicking material ■ Cognitive Behavioral Therapy (CBT) ■ Biofeedback and relaxation techniques ■ Yoga ■ Aromatherapy (Lavender) ■ Reflexology ■ Acupuncture ■ Herbal therapies ● Black cohosh ● Relizen ● Wild Yam ( Diascorea ) ■ Progesterone Cream ○ Follow Up ■ Reevaluate 1-2 months after initiating drug therapy to determine the effectiveness of the therapy ■ Patient Education : Initially, light spotting may occur with hormone therapy. This is more likely to occur in women receiving combination
therapy. incidence ranges from 40% to 70% within the 1st year of treatment. ■ Post-menopausal bleeding should be evaluated for possible uterine lining abnormalities or cancer. ■ Continue with normal screenings ○ Geriatric Considerations ■ Menopause symptoms increase with age ■ Urogenital atrophy is associated with vaginal dryness, itching, irritation, dyspareunia, & dysuria, which are more frequently seen among the elderly population. ■ Skin aging increases rapidly after menopause. ■ Low levels of estrogen Increased risk for heart disease, stroke, osteoporosis and urinary incontinence ● Sexually Transmitted Infections ○ What are STIs? ■ Infectious disease syndromes that are contracted primarily through intimate contact ■ Among the most common health problems in the U.S. ■ CDC estimates that almost 20 million Americans contract a new STI every year. ■ Almost half are between the ages of 15 and 24 ■ Their treatment costs society nearly $16 billion annually ■ STIs cause infertility in more than 20,000 women each year ○ STI Prevention ■ The critical first step is to question sexual history ● P artners ● P revention of P regnancy ● P rotection ● P ractices ● P ast History ■ Provide education about preventive measures (e.g. condoms & their correct use) ■ Educate about transmission, symptoms, & consequences of acquiring an STI ■ Counseling about risk-reduction measures (e.g. reduction of the number of partners, low-risk sex, avoiding exchange of body fluids, & vaccinations) ○ Herpes ■ A viral infection that can be spread by sexual contact is caused by 2 viruses: HSV-1 & HSV- ■ HSV-1 most commonly causes oral lesions that are spread in childhood through non-sexual contact. ■ HSV-1 or 2 can occur orally or in the genitals
● CDC does not recommend screening for HSV-1 or HSV-2 in the general population. Exceptions are: ○ recurrent genital symptoms or atypical symptoms and negative HSV PCR or culture ○ clinical diagnosis of genital herpes but no laboratory confirmation ○ report having a partner with genital herpes; ○ STD evaluation (especially those with multiple sex partners) ○ HIV infection ■ Management ● Episodic Treatment ○ Oral ■ Valcyclovir 2 g x 1 dose. Repeat in 12 hours ○ Genital ■ Acyclovir 400 mg TID for 7-10 days ■ Valacyclovir 1 g BID for 7-10 days ■ Famciclovir 250 mg TID for 7-10 days ● Suppressive Treatment ○ Acyclovir 400mg BID ○ Valacyclovir 500mg-1000mg OD ○ Famciclovir 250mg BID ○ Chlamydia ■ Prevalence/Incidence ● The most commonly reported STI in American women** ● Sexually active women ages 20 to 24 have the highest rate of infection, highest in African American women ● Approximately 1.6 million cases were reported in 2016 ● Silent & highly destructive, it can lead to acute salpingitis or PID ● Difficult to diagnose; can be asymptomatic or have nonspecific symptoms ● Causes cervical ulcerations that increase the risk of acquiring HIV and other STIs ● ■ Screening/Symptoms ● Multiple partners & nonuse of barrier methods of birth control increase risk
● CDC recommends yearly screening for all sexually active women under 25 & older than 25 who are high-risk ● All pregnant women need to be screened at their first prenatal visit ● Asymptomatic in a high percentage of cases. ● Men : penile discharge, burning/painful urination, testicular swelling ● Women : vaginal discharge, burning/painful urination, bleeding between periods ● *yellowish color, absent odor, purulent consistency ● *location: introitus, vagina, cervical osa ● *normal vulva and vaginal ● *cervix: purulent discharge ● *wet prep: numerous white cells ■ Diagnosis/DDx ● Laboratory diagnosis : culture, DNA probe, or enzyme immunoassay ● CDC recommends the nucleic acid amplification test (NAAT) of urinary, vaginal, or endocervical specimens, which has the highest sensitivity ● Differentials : N. Gonorrhoeae, Trichomonas vaginalis, or Mycoplasma genitalium ■ Management ● Doxycycline 100 mg PO BID for 7 days ○ New Guideline ● Alternative: Azithromycin 1g PO (high rate of resistance) ● Pregnancy or lactating women: ○ Azithromycin 1 gm PO once or ○ Amoxicillin 500 mg PO TID for 7 days ● Pregnant women should be retested within 3-4 weeks for efficacy and 3 months after treatment. ● No retesting is needed unless the woman is pregnant or non-compliance is suspected ● All exposed partners should be treated ● Complications : PID, ectopic pregnancy, infertility ■ Ophthalmia Neonatorum ● Chlamydia is the most common infectious cause of ophthalmia neonatorum ● More than 50% of infants born will develop conjunctivitis or pneumonia after exposure to the mother’s infected cervix ● If left untreated, it can progress to chronic follicular conjunctivitis with conjunctival scarring & corneal microgranulations. ● Neonatal ocular prophylactic treatment with silver nitrate or ABX ointment does not prevent perinatal transmission ● The treatment for chlamydial conjunctivitis is oral erythromycin or azithromycin
● DDx: Chlamydia, Trichomonas vaginalis, Mycoplasma genitalium , HSV, & syphilis ■ Pregnancy ● Can affect the mother & fetus ● Salpingitis can develop in the first trimester ● Perinatal complications include: pre-labor rupture of the membranes, preterm labor, neonatal sepsis, intrauterine growth restriction, & maternal postpartum sepsis ● Ophthalmia neonatorum in newborns is highly contagious & can lead to blindness if untreated ● Erythromycin ointment is routinely applied to all newborns to prevent ophthalmia neonatum. ■ Management ● ****Coinfection with chlamydia is high**** ● Treatment of choice for all infected is Ceftriaxone 500mg IM x 1 (New Guidelines as of 2020) ○ the change was made due to increased resistance seen to macrolide ● Pregnant women need a test for cure after 3 to 4 weeks ● Notify partners – all recent partners should be tested & treated, as most treatment failures are from reinfection ● All those infected should be retested 3 months following treatment to evaluate for reinfection ○ Syphilis ■ 88,042 cases were reported from 2015 to 2016, & of these, 27,814 were primary & secondary syphilis. ■ The highest rates of primary & secondary syphilis in women were aged 20–24 years. ■ Transmission occurs during sexual intercourse, kissing, biting, & oral-genital sex. ■ Transplacental transmission can occur during pregnancy at any time; the degree of risk is related to the number of spirochetes in the maternal bloodstream. ■ With untreated maternal syphilis, the rate of miscarriage, stillbirth, or perinatal death is approximately 40%. ■ Primary Stage ● primary lesion (chancre) appears 5 to 90 days after infection ● Chancre begins as a painless papule at the site of inoculation ● Then, it erodes into a nontender, shallow, and indurated ulcer several mm to cm in size. ●
■ Secondary Stage ● It occurs 6 weeks to 6 months after chancre ● There is a widespread symmetric maculopapular rash on the palms & soles & generalized lymphadenopathy ● patient might have a fever, headache, or malaise ● Condylomata lata (painless pink-gray warts) may develop on the vulva, perineum, or anus. ● If untreated, it goes into a latent phase where there are no clinical manifestations but are detected by serologic testing. ● ■ Tertiary Stage ● Significant Complications: ○ Neuro : meningitis, general paresis, & tabes dorsalis (slow degeneration of the nerve cells & nerve fibers that carry sensory information to the CNS) ○ Cardio: dilated aorta & aortic valve regurgitation ○ Musculoskeletal : osteochondritis, periostitis, & osteitis ○ Ocular : optic neuropathy, interstitial keratitis, anterior uveitis, & retinal vasculitis ● ■ Screening/Diagnosis ● All those diagnosed with another STI or HIV should be screened for syphilis, & vice versa ● Pregnant women need to be screened at the first prenatal visit, then in the 3rd^ trimester, & at the time of birth if they are high-risk ● Dark-field exams & detection of T. pallidum from lesion exudate or tissue are definitive methods ● Antibody tests may not be reactive in an active infection because it takes time for the body to develop antibodies; seroconversion usually takes 6 to 8 weeks ● Serologic tests are used: ○ Venereal Disease Research Laboratories (VDRL) & rapid plasma regain (RPR)
● *Location: pooled in vagina ● *edematous vulva, strawberry spots vaginal & cervical ● *wet prep: motile protozoa ● ■ Prevalence/Incidence ● Trichomoniasis is 1 of the 3 common infectious causes of vaginal complaints among reproductive-aged women & a cause of urethritis in men ● Women are affected more often than men ● Higher rates of infection are seen in Black women, women younger than 40 incarcerated women ■ Diagnosis ● Vaginal discharge can be collected by inserting a cotton-tipped swab inside the vagina or collected at the time of a speculum exam ● Measurement of vaginal pH is helpful in the diagnosis of vaginal discharge in reproductive-age women ● An elevated PH suggests bacterial vaginosis (pH >4.5) or trichomoniasis (pH 5–6); it helps to exclude candidal vulvovaginitis (pH remains normal, 4 to 4.5). ■ Management ● Treatment is Metronidazole or Tinidazole (2 g) in a single dose ● Alcohol consumption should be avoided during treatment to reduce the possibility of a disulfiram-like reaction ● Abstinence from alcohol use should continue for 24 hours after the completion of metronidazole or 72 hours after the completion of tinidazole. ■ Treatment for Partners ● Women can acquire the disease from both women and men, while men typically acquire the infection from women and do not usually transmit the infection to other men ○ Pelvic Inflammatory Disease (PID) ■ PID is a spectrum of inflammatory disorders of the upper female genital tract ■ It includes any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis ■ The most common causative agents are N. gonorrhoeae and C. Trachomatis ■ Other Bacteria associated:
● Streptococcus, E. Coli, Gardnerella vaginalis, & cytomegalovirus ■ ■ Diagnosis ● most common s/s of PID can mimic other disease processes, such as urinary, gastrointestinal, or reproductive tract problems ● Establish Menstrual History ● Other relevant history: ○ Surgery ○ Delivery ○ Abortion ○ Recent IUD Insertion ○ Vaginal discharge ○ Irregular bleeding ○ Sexual Risk history ■ Include current or most recent sexual activity, number of partners, and method of contraception, which will assist in identifying possible increased risk for STDs. ● Diagnosing PID can be very difficult. ● Menstrual history is useful in establishing the relationship between the onset of pain & menses & in identifying any variations. ● Minimum Criteria for Diagnosis ○ Uterine/adnexal tenderness or cervical motion tenderness ● Additional Criteria to Support Diagnosis ○ Oral Temperature greater than 101 °F ○ Abnormal Cervical or vaginal mucopurulent discharge ○ Presence of abundant white blood cells in vaginal fluid culture ○ Laboratory confirmed cervical infection with N. Gonorrhea or C. trachomatis ● Most Specific Criteria ○ Endometrial Biopsy ○ Transvaginal ultrasound, or MRI, shows thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex ○ Laparoscopic abnormalities consistent with PID ■ Management ● Mild Illness
