Women’s Health--GYN

Megan Louque, RN, CNS, ANP, FNP

Breast Examination

• Obtain History• Perform Clinical Breast Exam• Discuss/teach monthly self breast exam• Refer for Mammography at age 35/40

• Most Common Breast Problems—breast pain (mastalgia), nipple discharge, palpable mass

• Address symptoms• Rule out malignancy

Breast Pain

• More common in premenopausal women• Rarely a presenting symptom of breast

cancer• May be cyclic or non-cyclic (hormonal/fluid

retention?)• Fibrocystic disease-studies do not show a

causal relationship, may or may not be present in histologic findings

Breast Pain

• Obtain info on type of pain, location, & relationship to menstrual cycle

• Cyclic pain is usually bilateral & poorly localized

• Usually resolves spontaneously

• Non cyclic pain is usually a sharp, burning localized pain

• May be secondary to an underlying fibroadenoma or cyst

• Both types may be exacerbated by stress, medications, nicotine, caffeine

Nipple discharge

• Often a benign process• First step is to determine whether the

discharge is pathologic or physiologic• Pathologic--spontaneous, bloody, often

associated with a mass-usually unilateral & confined to one duct. Most common cause is intraductal papilloma.

• Physiologic—discharge only with compression, multiple duct involvement

Nipple Discharge Work-up

• A careful history can usually identify a physiologic discharge. If coexisting abnormalities &/or more than 35 years old-complete exam & mammography. Usually goes away when nipple is left alone.

• All spontaneous or unilateral nipple discharge should be referred for surgical exam

Palpable Breast Mass

• In premenopausal women normal glandular tissue is nodular (most pronounced in the upper outer quadrant & the inframammary ridge)

• Nodularity is a physiologic process & not an indication of breast pathology

• Differential diagnosis of a dominant breast mass: macrocyst, fibroadenoma, fibrocystic changes, fat necrosis, & cancer

Algorithm: New Palpable Mass (see handout)

Management of Breast Cysts

Breast Disease Summary• Most common

problems are breast pain, nipple discharge, & a palpable mass

• Goal of the evaluation is to address the symptoms & rule out cancer

Preinvasive Disease of the Cervix& Cervical Cancer

• Cervical Cancer is the second most common type of cancer in women worldwide.

• A causal link exists between HPV & cervical neoplasm.

• The presence of high-risk HPV types increases the risk of malignant transformation.

Pap Smear as a Screening Tool

How often?

Recommended at least every 3 years age 20 to 65

Methods?

Conventional smear

Fluid based (Thin Prep)

Pros/Cons

Alternatives

Risk Factors

Multiple sex partners

Smokers

Early initiation of intercourse

History of STIs

Views of the Cervix & Endocervical Canal

Pap Technique (see handout)• Visualize the external os

of the cervix• Squamous epithelium

covers the cervix• Squamocolumnar

junction (transformation zone) is where the pap is taken

• Columnar epithelium is beyond this junction into the os

Bethesda Reporting System

• Specimen Type• Specimen Adequacy• General Categorization• Automated Review• Ancillary Testing• Interpretation/Result• Educational Notes & Suggestions

Progression from Dysplasia to Invasive Cancer

Classification of HPV Types by Oncogenic Risk

HPV subtypes Risk Category

16, 18, 45, 56 High

30, 31, 33, 35, 39, Intermediate

51, 52, 58, 66

6, 11, 42, 43, 44, 53, 54, 55 Low

HPV Vaccine

• Has been approved by the CDC for females 9-26 yrs• Protects against types 6, 11 (cause most genital warts)• Protects against types 16, 18 (causes 70% of cervical

dysplasia)• 100% effective against these types

• GuardAsil (Merck)• Three injections over 6 months (0, 1, 6)• $$$ ($120/injection or $300-500 for series)• Not reimbursed by Insurance at present• Not a live virus; yeast sensitivity may > any reaction—

most common is localized at injection site

Other Risk Factors That Affect Susceptibility to HPV subtypes

• Smoking• Nutrition• Coexisting STI• Genetics

More severe infection may occur in women with immunosuppression.

CDC advises semiannual screening with pap smear the first year after diagnosis; then may revert to annual screening if no cytological abnormalities detected.

Management of the Abnormal Pap Smear

• Unsatisfactory—repeat in a timely fashion• Negative—repeat annually or every 3 years• No endocervical Cells—repeat in a timely

fashion• Organisms present—treat &/or discuss with

patient• ASC-US (atypical squamous cells of

undetermined significance)—repeat in 4-6 months

Management of Abnormal Pap Smears (cont)

• Low-grade squamous intraepithelial lesion) LGSIL—repeat in 4-6months or refer

• HG (High grade) SIL—refer• Squamous Cell Carcinoma—refer• Glandular Atypia—refer• Other Malignant Neoplasms (an abnormal

formation of tissue that serves no useful function & grows at the expense of the healthy organism, may be benign or malignant)--refer

Colposcopy

Staging System for Cervical Cancer (see handout)

Pap smears that suggest invasive disease require further

evaluation by: colposcopy, biopsy, endocervical curettage, cryotherapy laser vaporization,

loop excision, cone biopsy, hysterectomy

Uterine CancerRisk Factors• age (75% menopausal-late 60s)• obesity (especially upper body type)• PCOD• Unopposed exogenous estrogen• Diabetes• Personal or family history of ovarian or breast

cancer• Nulliparity• Late Menopause (after age 52)

Uterine Cancer• Directly related to the amount of estrogen

stimulation & endometrial hyperplasia• Postmenopausal bleeding is endometrial cancer

until proven otherwise• Early in disease state, normal findings on

examination• Metrorrhagia (any nonmenstrual or

intermenstrual bleeding)• Lower abdominal pain/pressure (10% of cases)• Rarely back pain or edema in lower extremities

secondary to metastasis

Diagnostic Evaluation for Endometrial Cancer

• Endometrial Biopsy• D&C (allows for more extensive sampling)• Transvaginal Uterine Sonography (endometrial

thickness <6mm, usually not associated with cancer)

• Hysteroscopy with directed biopsy (useful in staging)

• Pap Smear may be detected as “endometrial cells”

• Type 1—most common type is hormone sensitive, low stage, with excellent prognosis

Staging for Endometrial Cancer (see handout)

• FIGO staging for endometrial cancer• Stage IA G123: tumor limited to endometrium. • Stage IB G123: invasion to less than one half the myometrium. • Stage IC G123: invasion to more than one half the myometrium. • Stage IIA G123: endocervical glandular involvement only. • Stage IIB G123: cervical stromal invasion. • Stage IIIA G123:tumor invades serosa and/or adnexa, and/or positive

peritoneal cytology. • Stage IIIB G123:vaginal metastases. • Stage IIIC G123:metastases of pelvic and/or para-aortic lymph nodes. • Stage IVA G123: tumor invasion of bladder and/or bowel mucosa. • Stage IVB: distant metastases including intra-abdominal and/or inguinal

lymph nodes. • References• FIGO staging for corpus cancer. Br J Obstet Gynaecol 99(5): 440, 1992. • Corpus uteri. In: American Joint Committee on Cancer.: AJCC Cancer

Staging Manual. 5th ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1997, pp 195-200. 

Ovarian Cancer

• Risk factors-unopposed estrogen stimulation (anovulatory cycles, infertility, infertility drugs, nulliparity, low parity, exposure to toxins/carcinogens (dietary fat, perineal talc use, asbestos exposure)

• Heredity (breast, ovarian, Lynch II Syndrome-familial predisposition to breast, endometrial, colon, prostate, ovarian cancers)

Ovarian Cancer (cont)• Etiology-unknown

• Classification based on type-

a) epithelial cell tumors (>90%; increases with age)

b) germ cell tumors (most common in children/young adults)

c) sex cord-stromal tumors (rare-usually occur in postmenopausal women)

Clinical Presentation of Ovarian Cancer

• Abdominal bloating• Dyspepsia• Frequent urination• Pelvic pressure or

pain• Constipation

• Pelvic mass• Abdominal

distention• Pleural effusion• Ascites• Adenopathy• Cachexia

Symptoms are notoriously vague & nonspecific

Diagnostic Evaluation for Suspected Ovarian Carcinoma

• Pelvic exam• Pelvic transvaginal utrasonography• Color flow doppler of ovarian vessels• Serum tumor markers (i.e., CA125)• Serum beta HCG (germ cell tumors)• Genetic testing (BRCA1)

• Preoperative staging tests—CXR, CBC, serum chemistries, IVP, cystoscopy, proctoscopy, barium enema

• Surgery (definitive diagnosis & staging)

Staging for Ovarian Cancer• Staging System • Stage I: Ovarian cancer that is confined to one or both ovaries. Stage II:

Ovarian cancer that has spread to pelvic organs (e.g., uterus, fallopian tubes), but has not spread to abdominal organs. Stage III: Ovarian cancer that has spread to abdominal organs (e.g., abdominal lymph nodes, liver, bowel). Stage IV: Ovarian cancer that has spread outside to distant sites (e.g., lung, brain, lymph nodes in the neck). Recurrent: Ovarian cancer that has recurred (come back) even though the patient has completed treatment. Once ovarian cancer is assigned a stage, the classification does not change, even if the cancer recurs or metastasizes to other sites within the body.

• Ovarian cancer staging usually is described in terms of the FIGO system (staging scheme developed by the International Federation of Gynecology and Obstetrics) and the TNM system (classification system developed by the American Joint Committee on Cancer [AJCC]). According to the TNM system:

• T = Tumor SizeN = Node InvolvementM = Metastasis Status

• Ovarian cancer treatment ultimately depends upon such staging. In general, the lower the stage, the more favorable is the prognosis

Treatment Options & Prognosis for Women with Ovarian Cancer

• Early Stage: Surgery--Five year survival rate >90%

• Advanced Stage: Chemotherapy, autologous bone marrow transplantation, hormonal therapy Five year survival rate 30-40%

Dysfunctional Uterine Bleeding

• Definition: the bleeding manifestations of anovulatory cycles

• Causes: a thickened endometrium causes by perimenopause, puberty, PCOS, obesity, unopposed estrogen replacement therapy

• Other patterns of DUB: estrogen low relative to progesterone; results in a thinned endometrium (low estrogen pills < 30 mcg, POP, Depo-Provera, Norplant, Mirena IUS)

Hormones & Histologic Changes of the Menstrual Cycle

Clinical Presentation of DUB

• Acute: orthostatic BP changes, > heart rate, pallor, large amount of blood in vaginal vault, uterus may be enlarged due to retained clots

• Chronic: stable heart rate & BP, body habitus (obesity, stigmata of PCOS), pale or normal skin color, small amount or no blood in vaginal vault, uterus WNL

Evaluation of DUB

Key Terms for DUB

• Oligomenorrhea-scanty or infrequent menstrual flow

• Metrorrhagia-bleeding from the uterus at times other than menstrual period

• Menorrhagia-excessive bleeding at the time of a menstrual period, either in number of days amount of blood or both

• Menostaxis-prolonged menstruation • Dysmenorrhea-painful menstruation

Appropriate Lab Tests for DUB Evaluation

• Pregnancy Test• Hematocrit• Pap Smear• Cervical Cultures• Endometrial Biopsy• Prothrombin time• Partial Thromboplastin Time• Platelets

• Luteinizing Hormone• Follicle-stimulating hormone• Thyroid Function Tests• Prolactin• Testosterone• Hysteroscopy• Ultrasound

Differential Diagnoses for Abnormal Uterine Bleeding

Hormonal: a) anovulation (anorexia, puberty, perimenopause, obesity, hypothyroidism, extreme stress, prolactinoma, PCOS), b) BTB on OCPs, POPs, DepoProvera, HRT, etc

Anatomic & Physiologic: cancer (cervical, endometrial, ovarian), polyps (cervical, endometrial), uterine fibroids, pregnancy (SAB, ectopic, molar), ovulation, postpartum (atony, retained placenta, subinvolution)

Differential Diagnosis (cont)

Infectious: cervicitis (CT), endometritis (postpartum), PID (GC)

Hematologic: bleeding diathesis ( idiopathic thrombocytopenia purpura, hemophilia, various blood dyscrasias)

Pharmacologic Treatment Options

• DUB may be severe enough to cause anemia. Several measures may help: non-steroidal anti-inflammatory drugs (such as ibuprofen), progestins (provera and others), birth control pills, danazol (a weak androgenic hormone which causes suppression of ovarian estrogen/progesterone production) and GnRH agonists (gonadotropin releasing hormone agonists) such as Lupron, which lead to suppression of ovarian estrogen/progesterone production.

Non-Pharmacologic Treatment Options for DUB

• Endometrial Ablation

• Hysterectomy (last resort)

Treatment of DUB

Discussion