Gynecology- Dr Albao
encoded by: ACLB/EDBS
Breast Anatomy
-Large, modified sebaceous glands
contained within the superficial fascia
of the anterior chest wall.
Axillary tail of Spence
>lateral projection of glandular tis
extends from the upper, outer portion
of the breast towards the axilla
-The average wt of the adult Breast is
200 to ___ during the menstruating
yrs.
BENIGN BREAST DISEASE
-There is a 2-3 fold inc risk of
developing Ca in women w/ benign
Breast Ds w/ assoc atypical epithelial
hyperplasia depending on the deg.
FIBROCYSTIC CHANGES
-The most common benign breast
condition
-non specific term used to described
multiple irregularities in contour and
cyclically painful Breasts
-an exaggeration of the Normal physio
response of Breast Tis to the cycle lvls
of ovarian hormones
-Clinical manifestation of benign ds
cause anxiety & fear in px who often
thinks the symptoms may be related
to Breast Ca
-classic symptoms: CYSTIC BILATERAL
BREAST PAIN
-Symptoms of Breast disease:
-Inc engorgement & density of the
Breast
-Pain & Tenderness
Signs:
PE:
-Excessive Nodularity
-Mass or nipple discharge
-Rapid Change & Fluctuation in the
size of cystic areas
(Malignant or Benign)
-Inc Tenderness
Breast pain
-Occasionally Spontaneous nipple
discharge
-Late symptom of Breast Ca
CLINICAL MIFESTATION
BREAST AND MENSES
-During 2nd half of menstrual cycle, the
breast increased in:
-size
-Density
-BOTH signs and symptoms are more
prevalent during the premenstrual
phase of the cycle
-the pain os most frequently located in
the upper, outer quadrants of the
breasts
-Nodularity
-often the pain radiates to the
shoulders and upper arms
These are assoc w/ Inc sensitivity to
pain
MANAGEMENT OF FIBROCYSTIC
CHANGES
Breast Ca Risk:
Appropriate:
Gynecology- Dr Albao
encoded by: ACLB/EDBS
-Imaging techniques
-Fine needle aspiration cytology
(FNAB)
-Histologic evaluation w/ either a core
needle or excision biopsy
-A persistent dominant mass or any
uncertainty in the exam, do biopsy of
the area to rule out a malignancy
FIBROADENOMAS
-Are firm, rubbery, freely mobile, solid,
usually solitary
-2nd most common type of benign dse.
1. Mammography rarely done in
younger than 35
2. Ultrasound- differentiate Solid from
a cystic mass
3.Surgical removal- if cause cannot be
established by FNAB
4. Removal of mass if fast growing
regardless of age & if px is above 35
yrs old
Fibroadenomas can be removed w/o
difficulty under local anesthesia
NON-OPERATIVE MANAGEMENT
-most frequently present in adolescent
& women in their 20s
-Women younger than 35 with 3
separate clinical parameters supports
dx of:
-Growth of the mass is usually
extremely slow but may be quite rapid
1.Clinical exam
-do not change in size w/ menstrual
cycle
-do not produce Breast pain or
tenderness
Approximately:
2.Imaging evaluation (Mammo or Uz)
3.FNAB cytology
The only way to distinguish a
fiboradenoma from malignant is
histologic or cytologic evaluation
-30% spontaneously disappear
-10% to 12% become smaller in yrs.
INTRADUCTAL PAPILLOMA
PATHOPHYSIOLOGY:
-Spontaneous & Intermittent bloody
discharge from one nipple
-Considered as an abnormality of
normal development rather than true
neoplasm
-symptoms appear in pre-menopausal
group
-however, the long term risk of
invasive Breast Ca is approximately
twice for Control px
-Women w/ fibroadenoma should be
made aware of the risk and
encouraged to maintain annual
mammographic screening
commencing at age 40
-consistency: WATERY, SEROUS,
SEROSANGUINOUS
-amount of discharges vary: Few drops
to several ml
-Approx 75% of intraductal papillomas
are located Beneath the Areola
-often these tumors are difficult to
palpate bec they are small and soft
MANAGEMENT
2
Gynecology- Dr Albao
encoded by: ACLB/EDBS
TREATMENT
-Several categories:
-Excisional Biopsy of the involved duct
and small amount of the surrounding
tis
Heredity, Age, Hormones, nutrition,
demography, radiation, and prev
breast disease
-Regresses in postmenopausal px and
occasionally diminish in size in premenses
Others:
-Should be excised bec of 2 fold inc
risk of subsequent dev of Ca
-Environmental carcinogenesis
NIPPLE DISCHARGE (ND)
-Genetic predisposition
-viral agents
-Radiation exposure
-Seen in either benign or malignant
Breast dse
-nipple discharge is a complaint of 0%
to 15% of women w/ benign Breast
dse
-nipple discharge is present in < 3% of
women w/ Breast Ca
-Significant in non lactating women w/
spontaneous and persistent ND
Women at inc risk may benefit from:
-Screening at more frequent intervals
-consider some risk reduction
measures
Pharmacologic or surgical prophylaxis
has been proven to significantly dec.
the risk of developing breast cancer
-Important Dx of the cause of
spontaneous non milky discharge from
the nipple is to rule out Ca
INCIDENCE
-color does not differentiate Benign
form malignant
-almost non-consistent before puberty
-In Breast Ca: ND is clear, serous,
serosanguinous or bloody
-ND should be related to Ca until Dx
has been ruled out
FAT NECROSIS
-Rarely important, confused w/ Ca
-Firm, tender, indurated, ill-defined
mass w/c may have area of
surrounding eechymoses
-May liquefy and becomes cystic in
consistency
THE RISK FACTORS: BREAST CA
-Inc as px age inc
-the incidence gradually inc during the
reproductive yrs
85% of Breast ca occurs after age 40
-After menopause the incidence of
Breast Ca inc directly w/ inc age.
BREAST CA (BC) & ESTROGEN
-The risk of Breast Ca is related to the
intensity & duration of exposure to
unopposed endogenous estrogens
-Breast Ca is most unusual in
prepubertals
-Bilateral oophorectomy before age
35, w/o hormonal replacement,
reduces the risk of Breast ca by 70%
3
Gynecology- Dr Albao
encoded by: ACLB/EDBS
-Obese has higher risk of BC during
postmenopausal
intervals to discover breast
malignancies
Pathophysio:
-Advantage of early detection & Dxreduced mortality
-Inc amount of peripheral conversion
of androstenedione to estrone
-Dec lvls of sex-hormone-binding
globulin
BREAST CA AND MENSES
-An inc risk assoc w/ prolonged
menstrual function
-spontaneous menopause before age
45 decreases the risk of BC by half
compared w/ px who are menopausing
at age 54.
Self exam of breasts; periodic exam by
physicians and mammography
DIAGNOSIS: -By Biopsy or FNAB
-most importantly, a negative
mammogram does not rule out BC
SELF EXAM OF BREASTS
-It is ideal to test the px ability to
palpate masses in manufactured
breast nodules
Other risk factors:
-Models should contain masses w/
diameters as small as 0.3 to 0.5 cm
1.Ionizing radiation-
-instruction should emphasize:
-definite risk factor
Timing, Inspection, Palpation
-long accepted relationship bet
radiation and malignant
transformation
A few days immediately after a
menstrual period---the best time to
detect changes in normal lumps or
texture of the breasts
2.Prev hx of Breast Disease
RISK DETERMINANTS IN BENIGN
BREAST DSE
-the extent of epithelial hyperplasia &
atypia
In women w/ benign breast dse
-determines the magnitude of risk of
developing Ca
PREVENTION
-No proven benefit for women w/ low
to normal risk:
TAMOXIFEN; SURGICAL PROPHYLAXIS
Detection of Breast Ca
-defined as the use of screening tests
in asymptomatic women at periodic
-Postmenopausal women or women
who have had a hysterectomy
-Perform BSE on the same calendar
days each month
TECHNIQUE SBE
-Women should be instructed that
bilateral soft thickening and nodularity
are normal physical findings
-Palpate the breasts in a clockwise
fashion beginning at the nipple and
gradually circumscribing larger circles
-Express secretions from nipples
-A thorough Breast exam by the
physician should take 3 to 5 minutes
to complete
Gynecology- Dr Albao
encoded by: ACLB/EDBS
-Ideal time to instruct the px in the
technique of BSE
-A complete BE involves inspecting
and palpating the Breasts w/ the px in
the sitting position and supine position
MAMMOGRAPHY
-The most practical method or
detecting Breast Ca at an early and
highly curable stage
-Can ID an occult Ca (<5 mm in
diameter)
-The Clinical Advantages of
discovering BC during the earliest
stage:
1.Higher percentage of localized
disease
2.Lower incidence of Positive regional
lymp nodes
3. Reduced mortality
EARLY DETECTION
-the 5-year survival rate for women
whose BC is believed to be localized to
the breast w/ Negative axillary nodes
is approx 85%
-In contrast, the 5 yr survival rate is
only 53% when axillary nodes are
positive
Other modalities:
-ultrasound; CT; Digital radiography;
MRI; Thermography; Transillumination;
Mammography; FNAB, Biopsy
TREATMENT
-The treatment of Breast Ca is complex
-Varies from Women to women
-The 4 most important variables for
treatment selection are:
1.Tumor size
2. Inherent Aggressiveness- as
determined by the histology of the
initial lesion
3. The presence of positive nodes
4. The receptor status of the tumor
RAPE, INCEST AND DOMESTIC
VIOLENCE
Discovery, Management,
Counseling
-Role of Doctor: Detect the problems
and offer tx and counsel when their
patients are victims
-Dx: Careful history (compassionate &
non-judgmental approach
Interview:
-Phyisicians- open minded questions
-allow px to comfortably discuss
truthfully the actual problems
RAPE- or sexual assault of children,
women and men defined as nay
sexual act performed by 1 person on
another w/o that persons consent
Rape
-often underreported
-44% of women have been victims of
actual or attempted sex assault (50%
of these are on more than 1 occasion)
-Reluctant to report due to:
-Embarrassment
-Feelings of guilt
-Fear of retribution
-Assumptions that little will be done
5
Gynecology- Dr Albao
encoded by: ACLB/EDBS
-Lack of knowledge of their rights
TYPE OF SEXUAL ASSAULTS
Marital Rape
-Involves forced coitus or related acts
w/o spousal consent but w/in marital
relationship
Date rape
-Woman may voluntarily participate in
sexual play, coitus performed forcibly
w/o consent
-often not reported
-Physical complaints: Soreness, Eating
probs, Headaches, Sleep disturbances
-Behavioral probs: Fear, mood swings,
irritability, guilt, Anger, Depression,
and difficulties in concentrating
-complain of Flashbacks to the attack
Medical care sought during acute
period:
-Assess the specific medical probs
-Offer emotional support and
reassurance programs
-can scar her self esteem
2. Second phase involves long term
adjustment,
Statutory rape
The Reorganization phase
-Coitus w/ a minor (<18) unless
married
-Flashbacks & nightmares continue
-consent is irrelevant bec the female is
defined by statue as being incapable
of consenting
PHASES OF RAPE-TRAUMA SYNDROME:
1.Immediate or acute phase
-lasts from hrs to days
-assoc w/ a paralysis of the individuals
usual coping mech.
-Phobias develop against the offending
sex, sexual act itself, fear of crowds or
heights (un related circumstances)
-victim institute important lifestyle
changes
-Medical complications: STD,
pregnancy
Second phase: involves:
-Medical care and counseling
-complete loss of emotional control to
a well-controlled behavior pattern
-Px contemplating a major lifestyle
change:
-the actual rxn may depend on factors:
>Force is used
-----MD should point out ehy the
change is being contemplated & its
complicating effects on the overall
well being
>Length of time victim was withheld
MD responsibilities:
Generally, the victim appears
disorganized and may complain of
both physical & emotional symptoms
Medical legal:
>Relationship of victim to the attacker
Acute Phase
-document Hx carefully
-Examine patient thoroughly and
specifically note injuries
6
Gynecology- Dr Albao
encoded by: ACLB/EDBS
-collect articles of clothing
-Collect vaginal, rectal, pharyngeal
samples for sperm
If px is at risk for pregnancy during
assault:
-comb pubic hair for hair samples
-Emergency Contraception- Morning
after pill prophylaxis-as long as preg
test negative
-Collect fingernail scrapings where
appropriate
-Pregnancy chances is slow in most
sexual assault centers
-collect saliva for secretions
-2-4% of victims has single
unprotected coitus
-Turn specimens over to forensic
authorities & Receive receipts for
chart
Caring for Rape-trauma victim
1. Emotional support
- discuss degree of injury, probability
of infection and possible pregnancy
-discuss general course that can be
predicted
-consult w/ rape-trauma counselor
-Arrange fllow-up visit for medical &
emotional evaluation in 1-4 wks
-Reassurance
2. Diagnose & Treat infection
-do gonorrhea culture For Neisseria g;
chlamyia, syphilis (RPR)
3 Prophylactic Antibiotics:
Useful in Acute rape management
-Cefuroxime 400mg PO for gonorrhea
prophylaxis
-Azithromycin 1 g PO for Chlamydia
-If preggy, no medications and followup screening in 2 weeks, then give
antibiotics
Pregnancy
-Review & assess: Menstrual hx,
Contraceptive hx; Pregnancy Status
MEDICOLEGAL DUTIES
-documentation of Evidences
---Evidences should be collected
within 96 hours from the attack
Generally, evidences of coitus will be
present in the Vagina for as long as 48
hours after attack, but in other orifices
its only up to 5 hours
Medicolegal History
-document the px physical and
emotional condition by History and PE
Documentation of sexual contact
-Prior hx of coitus before attack
Sperms is found in vagina or cervix of
a victim- it must not be confused with
such substances deposited during the
victims prior consenting sexual acts
-Pubic hair combings should be
performed in an attempt to obtain
pubic hair of the assailant
Saliva- px secretes antigen that could
differentiate her from substances
obtained from the perpetrator
-finally, fingernail scrapings should be
obtained for skin or blood if the victim
scratched the perpetrator
INCEST
-Child sexual abuse
7
Gynecology- Dr Albao
encoded by: ACLB/EDBS
2 types:
1. Victimized by strangers
2. Family member or friend is the
perpetrator
Actual physical abuses vary from:
-Minimal activity
-Verbal
Incidence
-Threat of violence
-Father-daughter incest- 75%
-Throwing objects at someone
Mother-son
-Pushing, slapping, kicking, hitting or
beating
Father son
Mother-daughter
Brother- sister
-incest involving another close family
member constituting the remaining
25%
-Brother-sister incest may be the most
common form but reported often
DOMESTIC VIOLENCE
-Term referring to violence occurring
between partners in an ongoing
relationship even not married
Battered Woman
-woman over the age 18 w/ evidences
of physical abuse on at least 1
occasion at hands of intimate male
partner
The Battered wife syndrome
-A symptom complex occurring as a
result of violence to w/c a woman at
any time received deliberate severe or
repeated abuse
INTIMATE PARTNER VIOLENCE
-can be same or opposite sex
-Actual or threatened physical, sexual
or psychological abuse by a current or
former spouse, dating partner, BF or
GF is considered intimate partner
violence
-Threatening w/ Weapons, use of
weapons
Partner abuse is often in conjunction
w/ abuse of children or elderly persons
in the same household
Physical Injury
-The most common sites are:
Head, neck, chest, abdomen, breast
and upper extremities
-Murder and suicides are frequent
components of domestic violence
PRENATAL CHILD ABUSE
-Physical abuse in pregnancy
-Incidence 1% to 20 %
-violence may increase postpartum
MDs should: inc their ability to
recognize the signs of domestic
violence and spouse abuse and treat
accordingly
Phases of Battering Cycles
1. Tension Building
2. Withdrawal
3. Apology of the battererforgiveness
Manipulation
Batterers profile
1. Men who refuse to take
responsibility for their behavior
8
Gynecology- Dr Albao
encoded by: ACLB/EDBS
2. Strong controlling personalities
and do not tolerate autonomy in
their partners
3. Rigid expectations of marriage
and sexual behavior and
consider their wives or partners
as chattel.
conditions- suicidal tendency,
depression anxiety rxn
POST-TRAUMATIC STRESS
DISORDER
MDs role:
-higher in women w Physical and
sexual assaults than women w/
physical abuse only
-Acknowledge to the px the
seriousness of the situation
-they may require psychotherapy
due to severe psychiatric probs
-Attend px injuries & assess the
emotional status from the
standpoint of psychiatric
