Algorithm for breast cystic lesion

Uninary Incontinence

Click to enlarge the table.

Hirsutism

Lab
DHEAS + --> adrenal tumor (abrupt onset)
17-OH progesterone --> congenital adrenal hyperplasia, 21-hydroxylase deficient
testosterone: mild --> PCOS, markedly -->ovarian tumor(abrupt onset)

PCOS also Stein-Leventhal syndrome
Hx: gradual, family hx, anovulation, bleeding, infertility, diabetes
PE: hirsutism, acne, obesity, palpable ovaries, acanthosis nigricans
Lab: testosterone, LH:FSH>3:1, SHBG decrease
Txt: OCP + metformin, OCP inhibit LH, increase SHBG

Idiopathic: increase 5-alpha reductase, all other labs are normal, Txt: spironolactone, eflornithine

Precocious puberty

Precocious puberty: girl <=8, boy <=9 Thelarche, adrenarche, growth spur, menarche: 9, 10, 11, 12 Incomplete Isosexsual: only one (Txt: conservative) Complete Isosexsual: all four A. Gonadotropin dependent: idiopathic (Txt: GnRH Agonist) or CNS B. Gonadotropin independent: 1. McCune-Albright syndrome: Txt: aramotase inhibitor

2. Granulosa cell tumor

Secondary amenorrhea

Dx:
1. previous regular: >3 mos
2. irregular: >6 mos

Management:
1. HCG
2. TSH, if high, treat with thyroid replacement
3. Prolactin: medication, tumor, if + then CT to see Kalman syndrome
4. Progensterone Challenge Test: differentiate anovulation and inadequate estrogen priming or anatomic problems
5. E-P Challenge Test: (+) --> inadequate estrogen, use FSH to differentiate ovarian or H-P problems,
(-) --> anatomic or Asherman syndrome, hysterosalpingogram

Primary amenorrhea

Dx:
1. No secondary sexual dev: without menses at 14
2. With secondary sexual dev: without menses at 16

Differentiation: breast and uterus is the key
1. (+)breast (+)uterus: many reasons,

2. (+)breast (-) uterus: Mullerian Agenesis and Androgen Insensitivity, to differentiate these two, simply look if pubic hair present. AI doesn't have pubic hair.

3. (-)breast (+)uterus: Turner or Hypothalamic-Pituitary failure, look for FSH. FSH high in Turner.

DUB: dysfunctional uterine bleeding

anovulation --> increased estrogen --> prolonged proliferation phase --> no secretary phase --> estrogen breakthrough bleeding

Dx: Hx + clear, thin and watery mucus + no midcycle temp rise + biopsy of proliferation phase

Txt:
1. cyclic progestin using OCPs, from day 14 to 25
2. correct anovulation: hypothyroidism, hyperprolactinemia, test TSH and prolactin level
3. endometrial ablation or hysterectomy

Mullerian Anomalies

Septate uterus


Bicornuate uterus

Uterus Didelphys


Unicornuate uterus



DES uterus

Cervix

Normal cervix:



Pap smear schedule

ASCUS

Cervical polyps vs. Nabothian cysts

Cervical polyps



Nabothian cysts: small, white, pimple elevation