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Breast Mass

At this point, what is her doctor most likely to recommend?

1. 6 month follow-up mammogram
2. fine needle aspiration of the mass
3. open surgical biopsy of the mass
4. reassurance and follow-up exam in 6 months
5. simple mastectomy and excision of lymph nodes as indicated

Mammograms can have as high as 15-20% false negative rate. In other words, the reassuring "negative" mammogram report can be wrong just because not all cancers show up on mammogram in their early stages.































Incorrect

A distinct breast mass is a very clear indication to perform a breast biopsy in which the entire mass is removed and sent for microscopic examination.

Correct

The distinct mass should be removed and sent for examination for malignancy. Mammograms and cytologic needle biopsies can have falsely negative results and can miss cancer.

On the other hand, if the mass is not distinct, but rather diffuse and rubbery like fibrocystic changes of the breast, fine needle aspiration and repeat mammograms both have a role in future management for this patient.































Incorrect

At this age, this mass could represent a cancer and it needs to be further evaluated.































Incorrect

Mastectomy, removal of the entire breast, would not be indicated without a microscopic diagnosis of cancer. She first needs an excisional biopsy of the mass.

Mammograms

1. A 27 year old woman who has just felt a 1.0 centimeter (1/2 inch) firm mass in her left breast. She has not previously has a breast cancer.
   
2. A 35 year old woman who eats a high fat diet but has no other risk factors for breast cancer.
   
3. A 38 year old woman who just had a needle aspiration of a breast lump suspected to be cystic, but no fluid was obtained.
   
4. A 42 year old woman who has no risk factors for breast cancer and had a normal mammogram 14 months ago.
   
5. A 53 year old woman with no risk factors for breast cancer and who had a normal mammogram 12 months ago.
   

The need for a mammogram before the age of 35 is quite rare. The only times this would be indicated would be for a highly suspicious lesion (irregular, skin retractions, or fixed to the chest wall and not freely mobile) or a positive family history of breast cancer in a mother or aunt in which the cancer occurred before the age of 40. In the case of the highly suspicious lesion, the actual reason for the mammogram is to make sure there is not a smaller lesion in the other breast prior to surgery. Any suspicious lesion must be removed even if a mammogram were negative!

In this patient, there is a discrete lump and even though is is extremely likely to be benign (most likely a fibroadenoma) it will have to be removed by surgical biopsy so a mammogram is not needed.































Incorrect

Screening mammograms below the age of 40 are only recommended in patients who are at high risk for breast cancer, such as having a close relative who has had cancer or having a previous biopsy showing either cancer or epithelial hyperplasia. Some physicians feel moderate fibrocystic changes are an indication for screening mammogram starting at age 35 because it is so difficult to pick up a small (early) cancer by self-exam or physycian's physical exam when the breasts are lumpy due to fibrocystic change.

While factors such as fatty diet, lack of breast feeding infants or early age of menstrual onset (less than 12 years old) have been found to be associated more often in women who get breast cancer, these are so low in magnitude of raising risk that they would not be reasons for starting routine screening mammograms before the age of 40.































Incorrect

A cystic breast mass is very rarely cancerous. If a breast lump is thought to be cystic on physical examination or ultrasound imaging of the breast, a small needle is used to draw off the fluid in the hope that the cyst will not recur.

A mammogram shouldn't be obtained right after a cyst aspiration because there may be small amounts of bleeding into the cyst and that could give a false positive result and cause unnecessary surgery to be performed. The doctor should wait at least two weeks after a needle aspiration of a cystic breast mass before obtaining a mammogram.































Incorrect

In the 40-50 year old age range, mammograms should be obtained every other year (each 24 months) in the low risk woman.

Correct Because breast cancer is usually a disease of the older woman, screening mammograms are recommended yearly (each 12 months).

* - family history of breast cancer in a close relative, previous breast cancer or biopsy showing epithelial hyperplasia, fibrocystic breast disease

** - family history of breast cancer before the age of 40

Heavy Menses

She is concerned that something is wrong such as a possible cancer. Which one of the following should be the most immediate course of action?

1. She needs an endometrial biopsy to rule out cancer of the uterus (endometrium).
2. She needs a PAP smear to rule out cancer of the cervix.
3. She needs a pelvic exam which, if normal, gives reassurance that she is unlikely to have a serious problem.
4. She needs diagnostic imaging such as ultrasound or a CAT scan to rule out ovarian cancer.
5. She should observe her bleeding pattern over the next year and, if it continues as it is or gets worse, schedule a physician visit.

Cancer of the endometrium is very infrequent under the age of 40. Less than 1% of endometrial cancers occur this early and then most of those women have had some form of long standing anovulation (skipping menses) such as that associated with polycystic ovarian disease. In women with predisposing factors, an endometrial biopsy might be performed as early as 35 years of age. Sometimes other forms of abnormal menstration may require an endometrial biopsy before age 35 but not with this pattern of bleeding.































Incorrect

Pap smears screen for cancer or premalignant conditions of the cervix. Cancer of the cervix is often assymptomatic in early stages but when it does give symptoms, usually it presents as bleeding in between menses or as spotting or bleeding after sexual relations. This woman should have an annual PAP smear, but her current bleeding pattern doesn't make it more or less likely to be abnormal.































Correct

She is too young for endometrial cancer and therefore would not benefit from an endometrial biopsy at this time. A PAP smear is always a good idea on an annual basis at this age but a recent normal PAP should be trustworthy and this bleeding pattern is not worrisome for cancer of the cervix.

Ovarian cancer would also be highly unusual at this age and even if present, it is unlikely to present as heavy menses. She needs just a pelvic at this point to make sure there are no fibroids of the uterus, any adnexal masses, or any gross cervical lesions or polyps. If the exam is normal, she can be followed without further studies at this point.































Incorrect

Ovarian cancer is usually silent (without symptoms) in its early stages. As it progresses it may present with pelvic fullness or pressure or early fullness (satiety) with eating but it would be unlikely to just present as heavier menstrual periods as the only symptom.

Incorrect

This woman at least needs a pelvic exam before waiting to observe her bleeding pattern.

Skipping Periods

What are the three most likely diagnoses to consider?

1. pregnancy, menopause, cervical stenosis (blockage)
2. stress-type (hypothalamic) amenorrhea, polycystic ovarian disease, hypothyroidism
3. endometriosis, pelvic inflammatory disease, adenomyosis
4. uterine fibroids, endometrial polyps, endometritis (infection)
5. another combination than the above

Incorrect

All of these can cause missing or skipping menstrual periods. This woman had a menses 3 months ago but hasn't had sexual relations in 6 months. It is unlikely that she is pregnant.

At age 32 it would be very unlikely to start menopause unless she had taken some drugs that were toxic to the ovaries. Menopause before age 40 would be considered premature.

Cervical stenosis is due to a scarring process that blocks the cervix so that menstrual blood cannot come out. Such scarring is usually associated with a past procedure to the cervix such as cryotherapy, laser, conization or cautery.































Correct

With the given history, the most likely cause of skipping menses is a condition in which ovulation is suppressed at the brain level by a stress condition. Another cause can be suppressed ovultation because of the ovaries. This is called polycystic ovarian disease. While hypothyroidism is not common at this age, it can cause skipping of menses.

Incorrect

Endometriosis is more often associated with pain during menses rather than skipping menstrual periods. If it does cause any abnormal uterine bleeding, it is usually premenstrual spotting rather than missing menses.

Pelvic inflammatory disease is also associated more with pelvic pain rather than delayed bleeding. Any abnormal pattern of bleeding caused by pelvic inflammatory disease is likely to be intermenstrual spotting rather than skipping menses.

Adenomyosis is really endometriosis that has been confined to the muscle of the uterus. It produces pelvic pain and sometimes heavier menses. It doesn't lead to skipping menses.

Incorrect

Fibroids (uterine leiomyomata) are benign muscle growths that may cause heavy menstrual bleeding if they are located near the inside lining of the uterus.

Endometrial polyps are fleshy growths of the lining of the uterus. They may cause bleeding in between menses or after sexual relations. Except for the rare case in which the polyp would act as a "ball valve" to block the egress of menstrual tissue, polyps do not cause delay of menses.

Incorrect

One of the other choices is a reasonable set of the most likely causes.

Acute Pain

Of the following list of gynecologic problems, which one do you think is the most likely cause of her pain?

1. acute appendicitis
2. bleeding ectopic pregnancy
3. ruptured or bleeding ovarian cyst
4. acute pelvic infection
5. torsion of ovary or fallopian tube

Incorrect

Appendicitis usually has an onset over at least several hours, not minutes. It starts out with pain around the navel (umbilicus) and nausea is an early symptom. The pain then usually progresses to the right side rather than the left.

Incorrect

Ectopic pregnancy is a possible answer but it is not the best choice in this case. This woman has had a tubal ligation so pregnancy is not likely. It can happen though, since tubal ligations have an overall failure rate of 1-2%. When they do fail, the resultant pregnancy has a high chance of being ectopic. The ectopic pregnancy can present with sudden onset of pain brought on by physical activity. The pain is due to bleeding from the placental site into the tube or into the pelvic cavity.

Correct

Ovarian cysts are the most common cause of sudden onset of pelvic pain in reproductive age women. They result from the normal process of follicle (egg) development or ovulation which has somehow failed to undergo its usual course. Follicles that do not develop into the main egg for ovulation that month usually just dissolve. The cyst that forms after the egg ovulates (corpus luteum) also usually dissolves when menses starts. If either of these two "dissolving" processes fails to take place, a persistent cyst of the ovary may result.

Acute pain results either because of the pressure of a fluid-filled cyst or because of cyst rupture or bleeding. Frequently, physical activity will cause the rupture or bleeding.

Incorrect

Pelvic infection can cause pain but it is usually slower in onset. Symptoms often start within one week of the start of a menstrual period and they progress over 4-24 hours. The pain is usually all over the lower abdomen and pelvis rather than being on one side or the other.































+

Incorrect

Torsion (twisting) of the ovary or fallopian tube is a very good guess. It can present as a fairly acute event, sometimes precipitated by physical activity. When twisting occurs, the blood supply to the structure is blocked and subsequent tissue becomes markedly swollen because venous blood cannot get out.

In this case, however, torsion of the adnexa (tube or ovary) is very infrequent. There is a much more frequently occurring problem that is a better answer.

Oral Contraceptives

The bleeding is bothersome to her and she wishes to change the brand of birth control pills if that would help get rid of her symptoms.

In order to decide what is the best course of action for her at this point, we need to decide what is the most likely cause for her bleeding:

1. contraceptive pills cause decreased coagulation factors
2. estrogen has produced a hyperplastic (overgrown) endometrium
3. progestin has produced an atrophic endometrium
4. polyps in the endometrium are a likely cause of bleeding
5. the pills may be absorbed much less than an injectable progestin such as Depo-Provera®

Incorrect

Oral contraceptives may increase coagulation factors rather than decreasing them.

Incorrect

In combined oral contraceptives with both an estrogen and progestin component, the progestin component dominates in its effect on the endometrium.

Correct

Most intermenstrual spotting while on birth control pills is due to a poorly estrogenized endometrium rather than a richly estrogenized or hyperplastic endometrium. This atrophic "thin" endometrium bleeds easily and would benefit from more estrogen to strengthen the basal layer.

Incorrect

Polyps can cause abnormal bleeding but at age 24 they are much less likely than just an hormonal cause.

Incorrect

Birth control pills are very effectively absorbed and are closely equivalent to injectable contraceptives. Injectable progestin will make the endometrium atrophic which would likely aggravate this woman's problem.

Artherosclerosis Risk

• total cholesterol 225 mg/dl
• triglycerides were normal
• decreased high density lipoproteins
• normal low density lipoproteins

1. she is not on estrogens and is menopausal
2. her total cholesterol is above 220mg/dl
3. her high density lipoproteins are decreased below normal
4. she is not having hotflashes as a symptom
5. she is female versus risk of being a male at the same age

Incorrect

Across the board, not taking estrogen replacement therapy after the menopause does place a woman at risk for atherosclerotic heart disease (ASHD). Women start catching up with men in their ASHD risk after menopause. There are more specific findings, however, that place this woman at an even higher risk.

Incorrect

A general rule-of-thumb is to keep the total cholesterol less than 220 mg/dl. The exact level varies by age, however:

Correct

The absolute level of the "good cholesterol" (high density lipoprotein) is the most important value in predicting atherosclerotic heart disease (ASHD) risk. It overrides total cholesterol, and even "bad cholesterol" (low density lipoproteins) as a risk factor. For most women, a lipid profile is always better to draw than just a total cholesterol and this is what you should routinely request and be monitored with.

Actually many women can have total cholesterols that are elevated for their age but as long as their high density lipoproteins are in the normal range, their ASHD risk is low.

Incorrect

Almost 50% of menopausal women do not have any hot flashes. The presence or absence hot flashes doesn't correlate with estrogen levels, however, nor with risk for atherosclerotic heart disease.

Incorrect

Women always have a lower risk for heart disease than men at any age. After menopause women start to catch up with men in their rate. Estrogen replacement can slow this rate significantly.

Herpes Infection

She is concerned that she may have a sexually transmitted disease such as herpes. Which of the following statements about diagnosing herpes is FALSE:

1. the agent causing genital herpes belongs to the same family of viruses causing cold sores and chicken pox
2. culture of the lesion is the usual diagnostic method
3. diagnosis needs to be confirmed by biopsy of the vulva
4. exact diagnosis is important for her future childbearing desires
5. generalized symptoms range from nothing to fever, swollen glands and fatigue

Incorrect

This answer is incorrect because the statement is true. Herpes is one of a group of viruses that can cause chickenpox, mononucleosis and cold sores. In fact two closely related strains, herpes simplex virus Type 1 (cold sores or fever blisters) and Type II (genital sores) can sometimes cause infections in both the mouth and the genital area. Up to 10-30% of the genital sores can be caused by Herpes Type I and therefore be transmitted by partners with cold sores.

Incorrect

This answer is incorrect because the statement is true. While the diagnosis can be suspected by an experienced observer or a PAP smear showing virocytes, the best diagnosis is by culture. Cultures should be performed by opening a vesicle (blister) before it breaks open and culturing the serous fluid in the vesicle. If all the lesions have broken open, cultures are likely to be negative.

Correct

The statement is false. Diagnosis is established by culture rather than by a tissue biopsy. Once a typical lesion has been cultured and returned positive for herpes, subsequent outbreaks can be assumed to be herpes without always repeating the culture. A biopsy could confirm the diagnosis but it is too` expensive, invasive and painful to be used as the usual method of diagnosis.

Incorrect

This statement is true so the answer is incorrect. Active herpes infections during pregnancy can sometimes cause premature births and sometimes (infrequently) can cause a newborn baby to suffer severe skin infection, blindness, mental retardation and even death. These special situations can occur if there is an active infection at the time of delivery and if delivery is by the vaginal route. Thus if a mom has outbreaks of vulvar sores thought to be herpes, it is very important to document that a culture was positive for herpes during one of her typical outbreaks. Many doctors will perform delivery by Cesarean-section rather than vaginal birth if mom has an active outbreak when she goes into labor.

Incorrect

The statement is true, ie., the symptoms of generalized infection are variable. About 2-10 days after the virus enters the body, flu-like symptoms such as fever, chills, muscle aches, fatigue and nausea may occur. On the other hand, sometimes no symptoms of infection are noted except the breaking out of sores. The total bout of a primary herpes infection can last 3 weeks from the first chill to the last sore healing.

Abnormal Pap Smear

Assuming the biopsy returns the same as the PAP, mild dysplasia, what does this diagnosis mean?

1. surgical conization of the cervix is necessary to prevent further changes
2. the epithelium of the cervix has full thickness atypical cellular changes
3. this is likely to progress to more severe changes within a month
4. the PAP smear should be repeated in one year
5. if left untreated for 10-15 years, a third of cases will progress to invasive cancer of the cervix

Incorrect

Conization is too severe a treatment for mild dysplasia. Since most mild dysplasia eventually regresses to normal, it can be observed without treatment if the woman is reliable and willing to return for frequent PAP smears. Sometimes mild dysplasia is treated with cautery, cryotherapy, LEEP, dessication or even laser if there is extensive surface involvment or if it is continually recurrent or persistent on repeat biopsies.

Incorrect

Cervical dysplasia is classified by a gradation of atypical cellular changes through the thickness of the epithelium (moist skin) of the outside of the cervix. If just the lower 1/3 of the epithelium is atypical, it is classified as mild dysplasia; if the entire thickness is involved it is classified as severe dysplasia or even carcinoma-in-situ (confined to the surface).

Incorrect

Dysplastic changes usually progress and regress slowly over years rather than weeks. Rarely, progressive changes can take place rapidly and it is important not to miss the periodic PAP smears usually each 3 months.

Incorrect

This PAP smear needs to be repeated in 3 months. Even though dysplasia doesn't usually progress rapidly, it can on rare occasion. One year is too long to wait before screening again with a PAP.

Correct

Many patients and even some physicians do not realize that most instances of mild dysplasia do not get more severe and usually regress to normal. The process may take a year or two, however. It takes longer to regress in women who smoke and shorter to regress in nonsmokers. Anyone who has a supressed immune system, eg., HIV, cancer chemotherapy etc., will take longer to regress. These patients may need more aggressive follow-up and treatment.

Urinary Incontinence

Her medical health is good except for long standing diabetes (15 years) which is under control with oral pills. She has not taken estrogen replacement therapy because she didn't have any hot flashes when she underwent menopause.

In order to cure or improve the urine loss it must be determined what is the cause of her problem. Which of the following statements is correct about the diagnosis of urinary incontinence?

1. bladder spasms (detrusor instability) can be diagnosed by symptoms alone
2. interstitial cystitis is a cause of stress incontinence
3. mixed incontinence decreases as age increases
4. stress incontinence is diagnosed by observing urinary leakage with straining
5. a urinalysis is used to diagnose overflow incontinence

Incorrect

Uninhibited bladder (detrusor instability) contractions cause urge incontinence. In this condition there is an urge to void, but before a woman is able to get to the toilet, she uncontrollably loses urine. While bladder spasms can be suspected by symptoms, they must be diagnosed by cystometric studies in which the bladder is filled and its pressure is measured. It is important to know if a woman has these contractions because they must be treated nonsurgically.

Incorrect

Interstitial cystitis is an inflammatory condition of the bladder wall which causes extreme urinary frequency (up to 30 times a day). It may cause or be associated with urge incontinence but not usually with stress incontinence.

Incorrect

Mixed incontinence increases as women age. It can represent 10-30% of urinary leakage. It is basically the occurance of both stress incontinence and urge incontinence at the same time.

Correct

Stress incontinence is diagnosed by observing urine leakage with coughing or straining. It is almost always associated with urethrovesical neck hypermobility (bladder/urethra dropping). This is visually confirmed by a Q-tip test in which a sterile Q-tip is placed inside the urethra and as a woman strains, the end of the Q-tip rises more than 30 degrees. If this is present, surgery is often needed (bladder "tack") if pelvic muscle exercises fail to cure the loss. If hypermobility is not present, different treatment is necessary. There may be an intrinsic weakness of the urethral sphincter muscle.

Incorrect

After a woman urinates, she is catheterized to see if there is still urine in the bladder. If there is a significant amount, the cause of her leakage may be overflow incontinence. This test is called a "post-void" residual urine. Overflow incontinence may occur if there is obstruction of the urethra which results in overdistension of the bladder. Diabetes mellitus can also cause a denervation of the bladder and thus overdistension.

Completion of Quiz