Intimate partner violence (IPV) is a pattern of abusive behavior by a person who is in some type of intimate relationship with the victim. The abuse can be physical, sexual, or emotional and can include economic deprivation. Although anyone can be a victim of IPV, women are much more likely than men to be victims. Regardless of the type of abuse, the goal of the abuser is to gain control over the victim. IPV is common but is often not diagnosed, in part because patients try to hide the abuse.
The prevalence estimate of IPV varies depending on the setting.
Rates are higher when measured in emergency departments than when
measured in the general population. In a randomized controlled
trial of IPV screening in emergency departments, the prevalence
over 12-months ranged from 4% to 18%.
Risk factors for abuse include being young (under age 35 years);
being pregnant; being single, divorced, or separated; alcohol or
drug abuse in the victim or the partner; smoking; and being poor.
Since patients often do not volunteer that they have been abused,
clinicians must be alert to clues that suggest abuse, including
an explanation of the injuries that do not fit with what is being
seen; frequent visits to the emergency department; and somatic complaint
such as chronic headache, abdominal pain, and fatigue. The patient
may be vague about some of her symptoms and may avoid eye contact.
If the abusing partner is present, he or she may answer all the
questions or may decline to leave the room. It is critical that the patient have the opportunity to speak with the clinician alone. The patient's description of the events should be carefully
detailed in case there are any subsequent legal issues.
Physical examination often reveals injuries in the central area
of the body. There may be injuries on the forearms as well if the
patient tried to defend herself. As with any situation of expected abuse,
bruises that are in various stages of healing may be an important
clue. All physical examination findings should be well documented.
In addition to the physical consequences, abuse can have psychological
consequences. Posttraumatic stress disorder, depression, anxiety,
and alcohol or other substance abuse can develop in victims. Somatization
is also very common among victims.
Several instruments have been developed to screen for IPV. These
include the HITS (Hurt, Insult, Threaten, Screamed at) tool, the
Women Abuse Screening tool (WAST), the Partner Violence Screen (PVS),
the Abuse Assessment Screen (AAS), and the Women's Experience
with Battering (WEB) scale. A systematic review of these
screening tools showed that most tools only had been evaluated in
a relatively small number of studies and the sensitivities and specificities
varied widely within and between the tools.
Inclusion of one question in the context of the medical history, "Have
you ever been hit, kicked, punched or otherwise hurt by someone
within the past year? If so, by whom?" has been shown to increase
identification of IPV.
Many studies have addressed how the questions about IPV are asked.
In one randomized trial, women preferred written questionnaires
over face to face interviewing.
Screening for IPV (in contrast to asking questions when IPV is suspected) has been advocated by many experts, although there has been controversy about whether or not it improves outcomes. In January 2013, the USPSTF updated its previous guidelines. In the current recommendation, they now recommend that clinicians screen women of childbearing age for IPV such as domestic violence and provide or refer women who screen positive to intervention services.
Interventions can include encouraging the woman to leave the
abusive situation, ensuring that she has a safe place to go, and
counseling so that she can adequately assess her risk of danger
and create a plan for safety. There is no evidence that treatment
of the abuser changes abuser behavior.
When to Refer
- Victims should be referred to social services
so that they can provide information on local resources. There is
a national domestic violence hotline (1-800-799-SAFE) that can provide
information on local resources.
- In general, mandatory reporting of IPV or suspicion of it in adult women who are competent is not required in most states. However, mandatory reporting by physicians is required in California, Colorado, Kentucky, Mississippi, Ohio and Rhode Island.
|Nelson HD et al. Screening women for intimate partner violence and elderly and vulnerable adults for abuse: systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation. Evidence synthesis No. 92. AHRQ Publication No. 12-05167-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; May 2012.
Eating disorders are common in women. Anorexia nervosa and bulimia
nervosa are described in detail in Chapter 29: Nutritional Disorders. The female athlete
triad, disordered eating in diabetics, and binge eating disorders
are other eating disorders that should be considered in appropriate
- Disordered eating.
- Menstrual disorders.
- Low BMD.
Female athletes who participate in sports and activities valuing
thinness are at increased risk for developing the female athlete
triad. The definition of the triad includes disordered eating (a
spectrum of abnormal patterns of eating, including bingeing; purging;
food restriction; prolonged fasting; and the use of diet pills,
diuretics, or laxatives), menstrual disorders, and low BMD. Half
of all athletes with amenorrhea have bone density at least 1.0 standard
deviation below the mean. The bone density is decreased even in
those areas subjected to stress during exercise. The diagnosis is
made when the individual meets the three criteria of the triad.
Individuals with the female athlete triad display some pattern
of disordered eating and have some menstrual irregularities. Many
women have amenorrhea but others have irregular menses. Typically,
the patient has concerns about weight and body image. A history
of stress fractures should also raise the clinician's concern.
Depending on the severity of the symptoms and whether or not
the patient is bingeing and purging, the laboratory abnormalities
can be similar to those seen in anorexia nervosa or bulimia nervosa.
BMD, if measured, is decreased.
The main differential diagnoses include anorexia nervosa, bulimia
nervosa as well as endocrine disorders such as hyperthyroidism and
Little evidence is currently available about treatment of the
female athlete triad. Strategies such as counseling, cognitive behavior
therapy, and possibly exercise restriction may be helpful. A multidisciplinary
approach, including consultation with a nutritionist and communication
with the coach and trainers, may enable common goal setting. The
desire to participate in sports and the lure of a performance enhancing
diet may motivate some patients to pursue treatment.
Eating in Diabetics
- Binge eating.
- Purging with laxatives or vomiting.
- Insulin omission.
- Taking less insulin than prescribed to lose weight.
Eating disturbances have been estimated to be present in up to
one-third of young women with diabetes. Eating disorders are more
common in adolescents with diabetes than in their non-diabetic peers.
Mortality is particularly high in individuals with both diabetes
and eating disorders.
For diabetes, the dietary regimen emphasizes intense meal timing
and consistency. In addition, the hunger associated with hypoglycemia
encourages binge eating. Diabetics with disordered eating have
been shown to have an increased risk of retinopathy. Given the emphasis
that young women often place on body weight, maintaining optimal
diabetes control is a particular challenge. The diagnosis is typically
made in a diabetic who has worsening diabetic control, when other
causes of worsening control have been ruled out.
Diabetics may report polydipsia, polyuria, or weight loss. In
addition, upon questioning, they may report disturbed eating patterns.
Other symptoms associated with eating disorders, such as disturbance
of body image and menstrual irregularities, may also be present.
The main laboratory finding will be a trend of increasing levels
of hemoglobin A1C.
The main differential diagnosis includes looking for other causes
of worsening glycemic control such as underlying infection or metabolic
disease such as hyperthyroidism.
There is currently no evidence to support any particular strategies
for the treatment of disordered eating in diabetic patients. Proposed
strategies for at risk diabetic patients include nutritional counseling
to promote healthy eating instead of dietary restraint, regular
(instead of fixed) meal and snack times, less intensive insulin
therapy to reduce weight gain, and family counseling to improve
No studies have evaluated the optimal treatment of diabetic patients
with established eating disorders. Presumably, strategies that are
effective for patients without diabetes, such as cognitive behavioral
therapy and medications, will be effective. In addition, diabetic
management strategies that do not require the patient to constantly
think about food may be beneficial.
- Binge eating disorder consists of episodes
of eating a large amount of food in a discreet period of time with
a sense of lack of control.
- Binge episodes characterized by at least three
of the following:
- Eating large amounts of food when not feeling hungry.
- Eating more rapidly than normal.
- Eating until feeling uncomfortably full.
- Eating alone because of embarrassment about the
amount of food consumed.
- Feeling disgusted, depressed, or guilty after eating.
- Episodes occur at least two times a week for at
least 6 months.
- No compensatory behavior (purging, fasting, or
excessive exercise) after eating.
Binge eating disorder is more common than either anorexia nervosa
or bulimia nervosa, but it is currently not recognized as a psychiatric
diagnosis. Currently, the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV) has criteria that are considered
research criteria. Individuals who meet these criteria are defined
as having eating disorder, not otherwise specified.
Binge eating disorder is much more common in women and is associated
with obesity, although not all individuals with binge eating disorder
are obese. Obesity-related complications are likely to occur, and
the disorder may be more common in weight cycling patients.
The patient may present with weight gain or may describe disordered
eating patterns and binge eating episodes. There are no specific
laboratory findings for binge eating disorder.
The main differential diagnosis includes other psychiatric and
eating disorders. Other diagnostic possibilities include hypothyroidism
and Prader-Willi syndrome.
Treatment goals focus on decreasing the patient’s binge eating episodes and may include weight loss and treatment of other psychiatric comorbidities. As in bulimia nervosa, cognitive behavioral therapy is the mainstay of treatment. Interpersonal therapy has also been shown to be effective. Pharmacotherapy with selective serotonin reuptake inhibitors is also helpful, but does not appear to be better than cognitive behavioral therapy.
|National Institute for Health and Clinical Excellence. Eating
disorders: core interventions in the treatment and management of
anorexia nervosa, bulimia nervosa and related eating disorders. http://www.nice.org.uk/CG009
|Vocks S et al. Meta-analysis of the effectiveness of psychological
and pharmacological treatments for binge eating disorder. Int J
Eat Disord. 2010 Apr;43(3):20517.
|Wilson GT et al. Psychological treatments of binge eating disorder.
Arch Gen Psychiatry. 2010 Jan;67(1):94101.
|Young V et al. Eating problems in adolescents with Type 1 diabetes: a systematic review with meta-analysis. Diabet Med. 2013 Feb;30(2):18998.
Sexual health is defined by the World Health Organization as a state of physical, emotional, mental, and social well-being in relation to sexuality. Healthy sexual functioning therefore depends on a complex interplay of physical, psychological, and societal factors. Among the more than 30,000 women who were surveyed about their sexuality in the PRESIDE study, 912% reported having a sexual problem that caused personal distress or interpersonal difficulties. Six female sexual disorders have been identified in the DSM-IV and include hypoactive sexual desire disorder (HSDD), sexual aversion disorder, female sexual arousal disorder, female orgasmic disorder, dyspareunia, and vaginismus; these are discussed in detail in Chapters 18: Gynecologic Disorders and 25: Psychiatric Disorders. Several medical conditions (depression, diabetes, urinary incontinence, and multiple sclerosis) and medications (antidepressants, hormonal therapy, antihypertensives) can contribute to the development of female sexual disorders. Clinicians should routinely assess patients’ sexual health during office visits; even a brief assessment provides patients with reassurance that this is an important topic. Providers can broach the subject using a broad question, such as “What concerns or questions do you have about your sexual functioning?” and then follow-up with more specific questions, including “Do you have difficulty with desire, arousal, or orgasm?” and “If you are not currently sexual, are there any particular problems that are contributing to your lack of sexual behavior?” Patient concerns can then be delineated more fully during the complete sexual assessment, which encompasses details about medical, surgical, and psychiatric problems, as well as medications and reproductive history. Treatment options depend on the diagnosed disorder and can include psychosexual and hormonal therapy (see Chapter 18: Gynecologic Disorders).
- Noncyclic pain.
- Duration of 6 months or more.
- Localized to anatomic pelvis, anterior abdominal wall at or
below the umbilicus, the lumbosacral back, or buttocks.
- Associated with functional disability.
Chronic pelvic pain is defined as noncyclic pain lasting at least 6 months that localizes to the pelvic girdle region; it must be of sufficient severity to cause functional disability or necessitate medical care. Endometriosis is diagnosed in up to one-third of women with chronic pelvic pain; other common etiologies include postoperative pelvic adhesions, pelvic varices, interstitial cystitis (IC), and irritable bowel syndrome (IBS). Musculoskeletal disorders such as myofascial pain syndrome and levator ani syndrome have also been linked to chronic pelvic pain. Women with a history of physical and sexual abuse, pelvic inflammatory disease, abdominopelvic surgery, or difficult obstetric deliveries are at increased risk for developing chronic pelvic pain.
Certain features of the history and physical examination can provide clues to the underlying diagnosis. Patients should be asked about the location, quality, and intensity of their pain as well as the relationship with the menstrual cycle, sexual activity, urination, and defecation. Dysmenorrhea and dyspareunia are often experienced by patients with endometriosis, whereas dysuria, urgency, and frequency in association with pelvic pain are characteristic of IC. Pain related to pelvic varices is usually postural, worsening with prolonged standing and improving with leg elevation. Patients with IBS often report abdominal pain, distention, and diarrhea or constipation. The physical examination, including the pelvic examination, is usually quite painful in the patient with chronic pelvic pain and should be done carefully. A single-digit internal vaginal examination should be done to localize the exact area of pain and to assess for trigger points along the pelvic floor muscles, which may indicate a musculoskeletal etiology for the pain. Palpable tenderness along the uterosacral ligaments or cul de sac is suggestive of endometriosis, whereas women with IBS may experience anorectal tenderness. Women with chronic pelvic infection may experience discomfort with palpation of the cervix and pelvic congestion may manifest as uterine enlargement or tenderness. The external genitalia should also be examined carefully to identify areas of vulvar discomfort because vulvodynia often coexists in patients with chronic pelvic pain. Notably, the absence of physical examination findings does not rule out significant pathology.
Women who are at high risk for sexually transmitted diseases should be screened with cervical swabs for chlamydia and gonorrhea. Laboratory testing may be considered in women who have symptoms of IBS but also have associated anemia, rectal bleeding, or persistent watery diarrhea.
Testing and Imaging
Pelvic ultrasonography is useful for investigating any abnormalities
detected on physical examination, for screening patients in whom
pelvic varices are suspected, and for providing reassurance to the
patient if the ultrasound is normal. Additional testing may be done
to confirm a suspected diagnosis. Patients with IC often have a
positive intravesical potassium chloride test or abnormalities detected
on cystoscopy. Laparoscopy may be helpful for diagnosing endometriosis
or pelvic adhesions, although 35% of diagnostic laparoscopies
are normal in patients with chronic pelvic pain.
Chronic pelvic pain is frequently a manifestation of another
disease, as noted above. The history, physical examination, and
diagnostic testing should be directed toward identifying patients
with the most common "benign" underlying conditions,
including endometriosis, pelvic adhesions, pelvic varices, IC, and
IBS. Clinicians should be aware that patients frequently have more
than one diagnosis contributing to the chronic pelvic pain syndrome.
Less common but serious causes of chronic pelvic pain should also
be considered in the differential diagnosis, including bladder malignancy,
colon cancer, endometrial cancer, and inflammatory bowel disease.
Accordingly, symptoms such as unexplained weight loss, hematochezia,
and abnormal vaginal bleeding should be investigated thoroughly.
Many patients have no clear pathologic basis for their symptoms,
and are thus diagnosed with idiopathic chronic pelvic pain.
Medical treatment may focus on managing the chronic pain, the
underlying condition, or both. Analgesics are commonly used, and
nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac
and naproxen, are typically helpful. However, patients and clinicians
should be cautious about long-term use of these medications because
long-term NSAID therapy can be associated with significant gastric
toxicity. Antidepressants (eg, amitriptyline) and antiseizure medications
(eg, gabapentin) (see Table 54), which have demonstrated
efficacy in the treatment of other pain syndromes, may also be useful
for chronic pelvic pain. Opioid therapy improves pain but not functional
or psychological outcomes and should generally be avoided.
Hormonal therapies are used primarily for treating gynecologic
sources of chronic pelvic pain. Women with endometriosis often benefit
from treatment with combined oral contraceptive pills, which suppress
ovulation and reduce dysmenorrhea. Gonadotropin-releasing hormone
(GnRH) agonists and progestins improve pain associated with endometriosis
and pelvic varices. The decrease in BMD associated with GnRH agonist
treatment can be mitigated with estrogen or progesterone add-back
therapy. Treatment with medroxyprogesterone improved pain scores in women with pelvic congestion, but symptoms returned with cessation of treatment.
Medical therapies directed at the treatment of nongynecologic
sources of chronic pelvic pain, including IC and IBS, are discussed
in Chapters 15: Gastrointestinal Disorders and 23: Urologic Disorders. Physical therapy and injection of identified trigger points provide significant pain relief in patients with musculoskeletal sources of pain. Similarly, physical therapy maneuvers that promote decongestion of the venous circulation (such as postural measures or manual drainage techniques) may be helpful in patients with pelvic congestion syndrome. Psychological evaluation and treatment should also be strongly considered in all patients, both to improve treatment outcomes (particularly in patients with pelvic varices) as well as to address a history of sexual or physical abuse.
Surgical treatment of chronic pelvic pain requires referral to a gynecologist. Condition-specific surgical treatments include ovarian or pelvic vein embolization in women with pelvic congestion syndrome, adhesiolysis in patients with pelvic adhesions and laparoscopic surgical destruction of implants in patients with endometriosis. Importantly, the efficacy of adhesiolysis in the treatment of chronic pelvic pain is controversial. Presacral neurectomy has been shown to improve dysmenorrhea in 80% of women with endometriosis. Women with endometriosis who have persistent disease after medical and surgical therapies may benefit from hysterectomy, although it is controversial as to whether concomitant oopherectomy improves symptoms further.
When to Refer
Patients should be referred to a gynecologist for diagnostic
or therapeutic surgical procedures, if the underlying diagnosis
is unclear, or if the provider feels uncomfortable managing side
effects associated with medical treatments (ie, GnRH agonist therapy).
|Apte G et al. Chronic female pelvic painpart 1: clinical pathoanatomy and examination of the pelvic region. Pain Pract. 2012 Feb;12(2):88110.
|Daniels JP et al. Chronic pelvic pain in women. BMJ. 2010 Oct 5;341:c4834.
|Nelson P et al. Chronic female pelvic painpart 2: differential diagnosis and management. Pain Pract. 2012 Feb;12(2):11141.
|Shin JH et al. Management of chronic pelvic pain. Curr Pain Headache Rep. 2011 Oct;15(5):37785.
- Infection, malignancy, and extramammary conditions can
cause breast pain.
- Abnormal physical examination findings, such as a breast mass
or skin abnormalities, should prompt radiographic imaging.
Breast pain, or mastalgia, is categorized as cyclical, noncyclical, or extramammary. Although minor breast discomfort is commonly associated with the normal menstrual cycle, women with cyclical mastalgia typically have moderate to severe pain that can last more than 5 days. Cyclical mastalgia can be diagnosed only in reproductive-age women who experience breast pain as a result of the hormonally-mediated proliferation in breast tissue that occurs with ovulation. In contrast, noncyclical mastalgia has no relationship to the menstrual cycle and can occur in premenopausal or postmenopausal women. Causes of noncyclical mastalgia include large breast size (with stretching of Cooper ligaments), medications, pregnancy, thrombophlebitis, or inflammatory breast cancer. Extramammary mastalgia is caused by pain that is referred from other anatomic locations, including the chest wall, heart, gallbladder, or spine. Trauma or previous surgery may also produce extramammary pain.
Cyclical mastalgia is often described as a deep, heavy, aching pain, which is typically diffuse and bilateral and is clearly associated with the menstrual cycle. Conversely, noncyclical pain, which may be constant or intermittent, is variable in location and can involve one or both breasts. Chest wall pain, a frequent cause of extramammary mastalgia, typically causes unilateral, burning pain that may be either localized or diffuse. Malignancy-associated mastalgia is often severe, progressive, and unilateral.
Breast cancer may be associated with mastalgia, and thus a careful physical examination is essential in all women who report breast pain. Large, pendulous breasts may be observed in women who have noncyclical pain caused by stretching of Cooper ligaments. Chest wall pain is usually related to inflammation or injury to the pectoralis major muscle; it may be reproduced by palpation or by having the patient place her hand on her hip and push inward. Any palpable breast mass must be evaluated further with radiologic imaging.
An ultrasound, mammogram, or both should be obtained in women who have a palpable breast mass or localized breast pain or who are at an increased risk for breast cancer. Women with diffuse breast pain who are at average risk for breast cancer and who have a normal physical examination do not require further imaging and can be reassured. However, the clinician should ensure that all patients with mastalgia are up to date on routine screening mammography, as appropriate for their age and personal risk factors.
Malignancy must be ruled out in all patients with mastalgia, and this is usually accomplished through a careful history, physical examination, and diagnostic imaging in patients with clinical abnormalities, such as a palpable breast mass. Extramammary causes of breast pain include chest wall pain, spinal or gallbladder disease, and myocardial ischemia. Cyclical and noncyclical mastalgia are easily differentiated by assessing the temporal relationship between the patient’s pain and her menstrual cycle.
Women with cyclical mastalgia who have a normal physical examination and are up to date on routine mammographic screening should be reassured about the benign nature of their symptoms and monitored closely. Cyclical and noncyclical mastalgia often improve with use of a supportive bra. Although there is conflicting evidence regarding the benefit of vitamin E, some experts advocate its use (at a dose of 20003000 mg daily) for women with cyclical breast pain. Topical NSAIDs, such as diclofenac gel, improve localized breast pain.
Women who experience severe and persistent cyclical mastalgia despite adherence to conservative measures may be offered hormonal treatment. Danazol, a synthetic androgen that inhibits ovulation, is the only medication that has been approved by the Food and Drug Administration (FDA) for the treatment of cyclical mastalgia. However, side effects associated with treatment are common and include weight gain, menstrual irregularities, voice deepening, and hot flashes. Tamoxifen therapy is tolerated well by most women, and many experts recommend it as first-line therapy for the treatment of cyclical mastalgia. Patients treated with tamoxifen should be counseled about the possibility of hot flashes and menstrual irregularities (experienced by up to 10% of women), as well as the risk for more serious adverse events, such as thromboembolic disease and endometrial cancer.
Symptoms of cyclical and noncyclical mastalgia improve without pharmacologic treatment in most women.
When to Refer
Patients with mastalgia and a palpable breast mass should be
referred to a breast surgeon, even if the results of diagnostic
imaging are normal.
|Rungruang B et al. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011 Mar;54(1):11024.
|Salzman B et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):3439.
- Diagnostic imaging is essential for any women with a palpable
dominant breast mass, regardless of her age.
- Ultrasound is the initial test of choice for women under the
age of 30; diagnostic mammography with or without ultrasonography
is performed initially in women over the age of 30.
Palpable breast masses may be detected by a patient during breast self-examination, or may be identified by the provider during a routine physical examination. A breast mass may be a presenting symptom of breast cancer, and thus a thorough work-up of any palpable breast mass is essential, regardless of age and personal risk factors for breast cancer (see Chapter 17: Breast Disorders). Common benign causes of palpable breast masses include fibrocystic condition, cysts, and fibroadenomas.
Clinicians should ask patients about temporal changes in the mass shape and size, as well as associated symptoms, including pain, skin thickening, and nipple discharge. A patient’s personal risk for breast cancer should be assessed, including age, previous breast biopsies, family history, and age at menarche and first pregnancy.
The location of the mass should be described using the clock-face position and distance from the nipple, as this aids the radiologist in the diagnostic evaluation. Examiners should also note the size, site, mobility, and texture of the mass, as well as areas of skin dimpling, retraction, or erythema. Benign masses are typically mobile with well-defined margins; conversely, malignant lesions may be fixed and have indistinct borders. Some women may have areas of indeterminate thickening in the absence of a discrete and well-defined palpable mass; if this finding is asymmetric it should be evaluated further with diagnostic imaging.
Tests and Imaging
As noted above, all women with a dominant palpable breast mass
require diagnostic imaging. Approved imaging techniques include
diagnostic mammography and ultrasonography. Diagnostic mammography
consists of the standard views that are used in screening mammography,
plus additional views, such as spot-compression and magnification,
to better delineate the area of concern. The breast ultrasound is
the most sensitive test for distinguishing a cystic from a solid lesion,
and also provides detailed information regarding the shape, borders,
and acoustic properties of an identified mass. In addition, ultrasonography
can be used to guide the biopsy of suspicious lesions.
Women over the age of 30 with a palpable breast mass should initially
be evaluated with diagnostic mammography. Features of a benign lesion
include a round shape with well-circumscribed borders; a suspicious
finding may have an irregular shape with spiculated margins. Ultrasonography
may be coupled with diagnostic mammography if the mass is mammographically
occult or has concerning mammographic features. For women under
the age of 30, ultrasonography is the initial diagnostic test of
choice because the dense breast tissue found in younger women limits
the sensitivity of mammography.
The differential diagnosis of palpable masses includes benign etiologies, such as cysts, fibroadenomas, fibrocystic condition, lymph nodes, galactoceles, lipomas, and hematomas. Breast cancer, including ductal carcinoma in situ, invasive lobular carcinoma, and invasive ductal carcinoma, can also initially present with a palpable breast mass. Certain history and physical examination features may be suggestive of a particular diagnosis. Cysts are fluid-filled structures that are commonly found in women aged 3550 years; acute enlargement of the cysts may cause abrupt and severe pain. Fibroadenomas are typically diagnosed in reproductive age women between the ages of 15 and 35 years and present as firm, nontender, and mobile masses on physical examination. Fibrocystic condition describes a pathologic diagnosis that may be accompanied by clinical symptoms and signs, including cyclical pain that is bilateral and poorly localized as well as tender, multifocal nodules.
Management of the palpable breast mass depends on the results of diagnostic imaging. If ultrasonography or mammography suggests that the mass is related to a simple cyst, fine-needle aspiration (FNA) may be offered to symptomatic women to relieve associated pain. Characteristics of the aspirated fluid guides further work-up. If benign fluid, which is typically yellow, straw-colored, green, or brown, is aspirated and the mass resolves, the patient can be monitored expectantly. Conversely, if bloody fluid is aspirated, or if the mass persists after aspiration, further intervention with either core biopsy or excision may be indicated. A complex cyst should always be aspirated because there is a small chance (0.4%) that it may be malignant.
Core-needle biopsy, which provides a sample of tissue for histologic diagnosis, is typically used to evaluate breast masses that have a suspicious appearance on diagnostic imaging. Ultrasonography, mammography, or MRI may be used to guide the biopsy, thereby resulting in few complications and minimal trauma to the breast tissue. Excisional biopsy may be necessary if the mass is not amenable to core-needle biopsy (because of location or imaging characteristics) or if additional tissue is needed to confirm a benign diagnosis.
Women who have palpable masses that are associated with normal ultrasound or mammographic imaging should be referred to a breast surgeon, with consideration given to performing a diagnostic core-needle biopsy. Benign biopsy results are reassuring but require close clinical follow-up for at least 12 years.
The radiologist may categorize certain breast masses as probably benign after review of ultrasound or mammographic images. In rare cases, these masses may be associated with malignancy, and so two diagnostic options may be considered. The patient may opt to forgo biopsy at that time and have imaging performed again in 6 months. Alternatively, diagnostic core excisional biopsy may be performed immediately (after consultation with a breast surgeon) if there are worrisome findings on physical examination or if there is a high clinical suspicion for malignancy. All masses categorized as probably benign require follow-up imaging at 6-month intervals for at least 2 years.
The “triple test,” which is composed of the findings on physical examination, the results of diagnostic imaging, and the pathologic diagnosis obtained from FNA or core-needle biopsy, helps clinicians determine the likelihood that a palpable breast mass is malignant. In all cases, the results of each of these tests should be concordant. For example, the diagnostic imaging should identify the palpable area of concern, and if benign features are noted, the results of the FNA biopsy or core-needle biopsy should confirm a benign diagnosis, such as a fibroadenoma. If the results of any of the tests are discordant, further evaluation is warranted. Thus, if the results of FNA biopsy or core-needle biopsy suggest a benign diagnosis, but the radiographic imaging indicates a suspicious lesion, it may be appropriate to repeat the biopsy or perform an excisional biopsy. Similarly, if there is a palpable breast mass that is not identified on radiographic imaging, referral to a breast surgeon is necessary to document resolution or persistence of the mass. If the mass is persistent, the surgeon may elect to perform a biopsy to obtain a definitive diagnosis.
In general, the benign causes of a palpable breast mass have a favorable prognosis. Many women with breast pain and palpable masses due to fibrocystic condition have spontaneous resolution or have improvement in their symptoms with menopause. Benign simple cysts that are asymptomatic may be followed clinically, and symptomatic cysts should resolve with aspiration.
Certain pathologic diagnoses increase the risk of breast cancer,
including papillary lesions, radial scars, atypical ductal or lobular
hyperplasia, and lobular carcinoma in situ. FNA biopsy or core-needle
biopsy results that indicate one of these diagnoses necessitate
referral to a breast surgeon for further evaluation and management.
When to Refer
- Women with a palpable breast mass should be
referred to a breast surgeon in the following situations:
- If diagnostic imaging indicates that the mass has suspicious features.
- If the mass persists and diagnostic imaging is normal.
- If the mass is categorized as probably benign on diagnostic imaging, but there are worrisome features on physical examination or there is a high clinical suspicion for malignancy.
- If diagnostic imaging demonstrates a complex cyst, or aspiration of a simple cyst reveals a bloody aspirate.
- If the biopsy demonstrates a lesion with an increased
risk of breast cancer (papillary lesions, radial scars, atypical
hyperplasia, lobular carcinoma in situ).
- If the biopsy results are discordant with the
physical examination and radiographic findings.
|Ferrara A. Benign breast disease. Radiol Technol. 2011 MayJun;82(5):447M62M.
|Rungruang B et al. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011 Mar;54(1):11024.
|Salzman B et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):3439.
Nipple discharge is a common breast complaint but is rarely indicative
of malignancy. In one retrospective study, invasive breast cancer
was subsequently diagnosed in only 5% of women in whom
nipple discharge was the presenting symptom. Nipple discharge that
comes from multiple ducts, is bilateral, and is produced only with
squeezing is considered physiologic, and no further work-up is necessary.
Milky discharge that is bilateral and spontaneous is consistent
with galactorrhea caused by an elevated prolactin level. Investigation
should focus on identifying the underlying causes of the hyperprolactinemia,
including pregnancy, pituitary tumors, and certain medications.
Women who have bloody discharge or persistent spontaneous unilateral
discharge from a single duct, should be referred for mammography
and surgical consultation. These features are suggestive of a pathologic
diagnosis, such as papilloma, duct ectasia, or malignancy. In addition,
the presence of a palpable breast mass in association with the nipple
discharge significantly increases the likelihood of underlying malignancy.
Surgical excision of the involved duct is the gold standard for
diagnosis. See also Chapter 17: Breast Disorders.
|Dolan RT et al. Nipple discharge and the efficacy
of duct cytology in establishing breast cancer risk. Surgeon. 2010
|Rungruang B et al. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011 Mar;54(1):11024.
Female pattern hair loss (FPHL) affects more than 20 million women in the United States. This type of alopecia is characterized by shortening of the anagen (growth) phase and follicle miniaturization. Clinically, presenting signs include diffuse thinning over the central scalp and a prominent midline part; the frontal hairline may or may not be affected. There is no clear relationship between FPHL and serum androgen levels.
Topical minoxidil is currently the only medication that has been approved by the FDA for the treatment of FPHL. In a systematic review of several treatments for FPHL, treatment with topical minoxidil was consistently shown to result in moderate hair growth in affected women. The 2% solution of minoxidil, when applied twice daily, is as effective as the 5% solution, and is associated with fewer adverse events. In patients with suspected FPHL, minoxidil 2% is applied directly onto the scalp twice daily while symptoms persist. The most common side effect of minoxidil is facial hypertrichosis, which can affect 35% of women, but this typically resolves after 1 year of treatment. Some experts recommend using antiandrogen medications, such as spironolactone, for the treatment of FPHL, although there are limited data to support this practice.
|Trüeb RM. Systematic approach to hair loss in women. J Dtsch Dermatol Ges. 2010 Apr;8(4):28497, 28498.
|van Zuuren EJ et al. Evidence-based treatments for female pattern hair loss: a summary of a Cochrane systematic review. Br J Dermatol. 2012 Nov;167(5):9951010.
Minimally invasive aesthetic procedures are now commonly used to treat mild to moderate age-related changes in the face. These procedures are generally safe and are associated with long-lasting and natural results.
Visible signs of aging in the face result from loss of subcutaneous fat, gravitational changes, decreased cell turnover, and alterations in skin elasticity. Risk factors for premature skin aging include sun exposure, smoking, and sleeping positions. Facial rejuvenation procedures typically aim to restore facial symmetry, and thereby attractiveness; interventions focus on reducing wrinkles and folds, restoring volume loss, and smoothing the skin surface. Clostridium botulinum is an organism that produces potent neurotoxins with various serotypes; only serotype A (BTX-A) is used for cosmetic purposes. Injected BTX-A produces temporary chemodenervation of targeted muscles, thereby smoothing facial wrinkles. The onset of action is immediate, and results typically last 34 months. Adverse effects are mild and are typically limited to injection pain and bruising.
Dermal fillers are commonly used to restore volume and fullness. Several filler substances are currently used, including collagen, hydroxylapatite, hyaluronic acid, and injectable poly-L-lactic acid. Among these, hyaluronic acid fillers have become increasingly popular and have been approved by the FDA for treatment of nasolabial folds. They are also frequently used off-label to volumize and shape the lips. Several formulations are currently available, and they differ in their degree of cross-linking, gel hardness, and ability to resist dilution. Clinically, these differences result in various degrees of longevity, with the effects lasting between 6 months and 2 years. Combination therapy with botulinum toxin and hyaluronic acid is now commonly being used to achieve more satisfying cosmetic results.
Chemical peels, which cause “controlled destruction" of part or all of the epidermis and dermis, help improve the appearance of the skin surface and reduce uneven pigmentation. Glycolic acid, salicylic acid, and capryloyl acid are all superficial chemical peels that reduce the number of cornified cells in the horny layer and activate epidermal basal cells. These peels are effective for reducing fine lines in pigmented skin and decreasing surface roughness.
|Goldman A et al. Facial rejuvenation for middle-aged women: a combined approach with minimally invasive procedures. Clin Interv Aging. 2010 Sep 23;5:2939.
|Wollina U et al. Minimally invasive aesthetic procedures in young adults. Clin Cosmet Investig Dermatol. 2011;4:1926.