Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3156_Библиотеки_им_академика_М_И_Перельмана.pdf
11.4
Dysmenorrhea
Sanjeev Sharma
I. BACKGROUND. Dysmenorrhea can be defined as recurrent, crampy pain experienced during
or immediately before menstruation. This is the most common gynecologic symptom reported
by women (1).
II. PATHOPHYSIOLOGY (1, 2). Dysmenorrhea can be divided into two broad categories, pri-
mary and secondary. Primary dysmenorrhea is the most common form seen in women with no
identifiable pelvic pathology. It is usually caused by myometrial activity augmented by prosta-
glandins resulting in uterine ischemia causing pain. The prevalence of primary dysmenorrhea
is highest in younger women, affecting up to 90% of women at some point in their lives. Risk
factors include early menarche, heavy menstrual flow, nulliparity, cigarette smoking, disruption
of close relationships, depression, anxiety, obesity, and a family history of alcoholism. There
is controversy about the association of dysmenorrhea with obesity, alcohol, physical activity,
pregnancy history, and dietary factors.
Less commonly, secondary dysmenorrhea is encountered. By definition, secondary dys-
menorrhea is associated with some form of pelvic pathology. Common causes of secondary
dysmenorrhea include endometriosis, uterine myomas, chronic pelvic inflammatory disease,
pelvic adhesions, and obstructive malformations of the genital tract. A pelvic mass can some-
times present with secondary dysmenorrhea.
III. EVALUATION (1–3).
A. History
The diagnosis of primary dysmenorrhea is made clinically, while secondary dysmenorrhea
should be considered in the differential diagnosis if symptoms are atypical, or escalating
discomfort appears after several years of a stable pattern of menstrual symptoms.
Primary dysmenorrhea usually starts at the onset of ovulatory menstrual cycles, which
may be several years after menarche. Symptoms are typically colicky lower abdominal pain
starting just before, at the time or a few hours after the start of bleeding. Pain recurs during
every menstrual period. It may be associated with diarrhea, nausea and vomiting, fatigue,
dizziness, or lightheadedness.
Whenever a patient presents with menstrual pain a detailed menstrual history should
be obtained. Menstrual history should focus on the onset of menarche, the time between
menarche and onset of symptoms, recurrence of symptoms, duration and quantity of
bleeding, characteristics of the pain, including radiation, degree of disability, and any other
associated symptoms.
Additionally, a history of sexually transmitted infections, dyspareunia, contraception,
infertility, pelvic surgery, family history of endometriosis, the types of therapy tried, and the
presence of other medical or psychiatric conditions should be sought.
An atypical history, including pelvic pain beginning at menarche, an atypical pattern or
progressive worsening of the pain, or a history of a pelvic infection should alert the physician
to the possibility of secondary dysmenorrhea.
In younger women, secondary dysmenorrhea that is sufficiently severe to affect daily
functioning or relationships suggests endometriosis. This condition affects as many as 19%
of women. Deep dyspareunia and sacral backache with menses are common symptoms.
Premenstrual tenesmus or diarrhea correlates with endometriosis of the rectosigmoid area,
whereas cyclic hematuria or dysuria may indicate bladder endometriosis.
B. Physical Examination. A thorough physical examination is essential to rule out any pel-
vic pathology. A detailed pelvic examination, with attention to areas of tenderness, fullness,
nodules, or irregularity, is important. In addition, an assessment of the spine, abdomen,
248
and bladder is important. For adolescent patients who present with dysmenorrhea but have
never been sexually active, pelvic examination is rarely necessary. However, examination of
the external genitalia to exclude outlet abnormalities is important.
IV. DIAGNOSIS (1–5). Primary dysmenorrhea is primarily a clinical diagnosis, and routine labo-
ratory and imaging is usually not required. However, a wet mount, cervical cultures, pregnancy
test, urinalysis, and transabdominal or transvaginal ultrasound examination may be very help-
ful in the appropriate setting to rule out other pathology. Magnetic resonance imaging may be
helpful in making a diagnosis of adenomyosis.
A definitive diagnosis of endometriosis can be made by laparoscopy while hysteroscopic
examination can help diagnose endometrial polyps and submucosal leiomyomas which may
contribute to symptoms.
REFERENCES
1. Lefebvre G, Pinsonneault O, Antao V, Black A. Primary dysmenorrhea consensus guideline. J Obstet
Gynaecol Can 2005;27(12):1117–1146. Accessed at http://www.ncbi.nlm.nih.gov/pubmed/16524531#.
2. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain and irritable syn-
drome in primary care practices. Obstet Gynecol 1996;87:55–58.
3. Apgar BS. Dysmenorrhea and dysfunctional uterine bleeding. Prim Care 1997;24(1):161–179.
4. Proctor ML, Farquhar CM. Dysmenorrhoea. Clin Evid Concise 2005;14:573–576.
5. Chan PD, Winkle CR. Gynecology and obstetrics 1999–2000. Laguna Hills, CA: Current Clinical
Strategies Publishers, 1999:25–26.
11.5
Dyspareunia
Shailendra K. Saxena and Mikayla L. Spangler
I. BACKGROUND. Dyspareunia is defined as pain experienced during sexual intercourse. The
term is most often used in connection with female sexual dysfunction. However, it is important
to understand that a small proportion of males also suffer from dyspareunia.
II. EPIDEMIOLOGY. The World Health Organization reviewed 54 studies that included 35,973
women and found the prevalence of dyspareunia to be between 8% and 22% (1). In contrast,
it is estimated that only 5% of men suffer from pain associated with sexual intercourse (1). The
low incidence of dyspareunia in men may be due to social stigma or low reporting. Dyspareunia
may be defined as primary, beginning with first intercourse, or secondary, occurring after previ-
ous pain-free intercourse.
A. Diagnosis and Evaluation. Many patients are embarrassed by discussions about sexual
concerns or dyspareunia. It is important to begin the evaluation of dyspareunia by asking
open-ended questions. An important goal in the history is to assess the relative contribu-
tions of physical, social, and psychological factors leading to the symptoms that the patient
is experiencing. Superficial dyspareunia in females is often related to vulvodynia, vaginitis,
urethritis, or inadequate lubrication. Conversely, deep dyspareunia may be related to a pelvic
pathology, such as endometriosis or pelvic inflammatory disease (PID). It is often difficult to
distinguish vaginismus (muscular spasm of the outer third of the vagina preventing penetra-
tion) from other pathologies on the basis of history alone. Premenopausal women are more
likely to suffer from vulvodynia and endometriosis, while postmenopausal women tend to
have symptoms secondary to urogenital atrophy.
B. Physical Examination. Patients may have significant anxiety regarding examination, and
care should be taken to minimize this anxiety and any associated discomfort. It may be
249
helpful to have a support person in the examination room and to use a pediatric speculum
during the pelvic examination in female patients. The external genitalia, perineum, perianal
areas, and skin of the groin should be evaluated thoroughly. After careful evaluation of the
external genitalia for tenderness, application of topical lidocaine may help with speculum
insertion. Careful evaluation of the vaginal epithelium may reveal pallor or atrophy related
to estrogen insufficiency. Female patients will often require bimanual and rectovaginal
examinations with careful attention to areas of discomfort. Detection of urethral or vaginal
discharge should prompt careful evaluation for infection.
C. Common Causes of Dyspareunia in Women. Infections are a common cause of
dyspareunia in women. This may include vulvovaginitis due to candidiasis or trichomonia-
sis, and PID. Other common causes include vulvodynia, vaginismus, insufficient vaginal
lubrication, and endometriosis. Less common, but important causes include interstitial
cystitis, urethral diverticula, adnexal lesions, and pelvic adhesions. These may be detected
by cystoscopy, ultrasound, or laparoscopy, as indicated.
D. Common Causes of Dyspareunia in Men. Male dyspareunia is less likely to have an
infectious etiology (2). The most frequent causes include chronic prostatitis/chronic pelvic
pain, phimosis, and Peyronie’s disease.
REFERENCES
1. Lathe P, Latthe M, Say L. WHO systemic review of prevalence of chronic pelvic pain: a neglected
reproductive health morbidity. BMC Public Health 2006;6:177–182.
2. Luzzi G, Law L. A guide to sexual pain in men. Practitioner 2005;249:73–77.
11.6
Menorrhagia
Jayashree Paknikar
I. BACKGROUND. Menorrhagia is defined as menstrual blood loss greater than 80 ml (1), which
occurs at regular intervals (≥21 to 35 days) or lasts ≥7 days in duration. Assessing the volume
of blood loss has limited utility, however. It fails to differentiate among etiologies, direct a
diagnostic strategy, or indicate prognosis (1). Practically, it is difficult to quantify the amount
of blood loss. Menorrhagia is diagnosed when a woman subjectively reports that menstrual
bleeding is heavier or longer than is typical for her.
II. PATHOPHYSIOLOGY
A. Etiology (Table 11.6.1) (2).
The etiology varies considerably with the patient’s age,
history, and physical findings. Pregnancy and its complications among women in their
reproductive years must always be excluded; if “missed,” it may be life threatening. Bleeding
as a side effect of hormonal contraceptives, intrauterine devices, contraceptive implants,
and other medications is common. Other frequent causes are anovulation, uterine fibroids,
polyps, endometriosis, adenomyosis, coagulation disorders, endocrinopathies, malignancy,
pelvic inflammatory disease (PID), and liver or kidney disease (2).
B. Epidemiology (1). Menorrhagia is common. In women aged 30 to 49 years of age, it
represents 5% of gynecologic visits (1). Once referred to a gynecologist, women have an
increased risk of operative interventions, including hysterectomy. Menorrhagia accounts for
two thirds of all hysterectomies; no pathology is identified in at least 50% of these.
250
III. EVALUATION
A. History
1. A menstrual and reproductive history is necessary. Ask about previous patterns of the
menstrual cycle: the regularity, duration, and frequency of all bleeding, including any
intermenstrual flow. Determine if dysmenorrhea is present and attempt to quantify the
number of pads or tampons per period.
2. Pregnancy should always be considered and excluded. All contraceptive methods,
even permanent ones such as tubal sterilization, are subject to failure; women may not
reveal sexual activity.
3. Weight change, excessive patterns, anxiety or stress disorders, as well as symptoms
of systemic disease (e.g., coagulopathy, and thyroid, renal, and hepatic diseases) should
be evaluated.
4. Medication history should include the use of contraceptives (3), anticoagulants, selec-
tive serotonin reuptake inhibitors, corticosteroids, antipsychotics, tamoxifen, and herbal
modalities such as ginseng, gingko, and soy.
5. Presence of easy bruising or any abnormal bleeding such as with toothbrushing or
minimal trauma may indicate a bleeding disorder.
6. The presence of moliminal symptoms (e.g., edema, abdominal bloating, pelvic cramp-
ing, and breast fullness) is more likely with ovulatory cycles; however, these symptoms
are not reliable enough to be truly diagnostic.
7. Psychosocial factors should be considered. One third of women with menorrhagia
have menstrual blood loss within a normal range. Anxiety, unemployment, and abdomi-
nal pain are more common in these women, and these factors may have influenced their
decision to seek health care.
8. Probable etiologies can be classified by age (4).
a. Neonatal period. Although not “menorrhagia” in this age group, vaginal bleeding
may occur during the first few days of life as the infant experiences a rapid decrease in
maternal-derived estrogen levels. This is generally treated with reassurance if no other
signs or symptoms are present.
TABLE 11.6.1 Overview of Diagnosis
1. Source of bleeding Vaginal, urinary, and bowel bleeding can be mistaken
for uterine
2. Age of the patient Consider
<20 y: perimenarcheal: mostly anovulatory, bleeding
diathesis needs to be ruled out
20−40 y: predominantly anovulatory rule out systemic
conditions
<40 y: perimenopausal distinctions between menopausal
transition vs. benign or malignant lesions
3. Pregnancy and associated
complications (e.g., spontaneous
abortion, ectopic, missed abortion,
and trophoblastic disease)
Must be ruled out in any patient
4. Systemic illness Weight changes: thyroid, liver, kidney
5. Personal/family history Bleeding disorder
6. Iatrogenic Anticoagulant therapy may exacerbate,
copper-containing intrauterine devices, hormonal
contraception, etc.
251
b. Neonatal period to menarche. Similarly, prepubertal bleeding is not “menorrhagia”
but should be carefully evaluated to exclude sexual abuse and assault, malignancy,
sexually transmitted infections, and trauma.
c. Early menarche. With no moliminal symptoms and irregular menses, anovulatory
cycles are likely. Almost all normal adolescents experience some degree of menstrual
irregularity; “heavy periods” should be evaluated. Pregnancy should be excluded if
there is any question of sexual activity. Abnormal bleeding may also occur as a side
effect for contraceptive hormonal methods taken correctly or incorrectly. Fever and
pelvic pain can indicate PID. Easy bruising or bleeding may indicate a bleeding disor-
der. With neurologic symptoms such as blurred vision, visual field defects, headache,
and the presence of galactorrhea, a pituitary lesion should be considered.
d. Late menarche to late thirties. Exclude pregnancy and contraceptive-related causes.
Anovulation is less common. Polycystic ovarian syndrome (the most common endo-
crine disorder affecting 6% of reproductive age women) (5), the female athlete triad,
and stress-induced conditions, such as eating disorders, may be present. Other gyneco-
logic conditions include endometriosis, endometrial hyperplasia, endometrial polyps,
PID, and endocrinopathies (both hypo- and hyperthyroidism, as well as pituitary and
hypothalamic conditions).
e. Late thirties and older. Exclude pregnancy. If the patient is not pregnant, abnormal
bleeding in this age group should arouse suspicion of cancer until proved otherwise.
Women are increasingly anovulatory as they approach the perimenopause. Inquire
about menopausal symptoms, exogenous use of estrogens, and personal or family his-
tory of gynecologic malignancy or genetically linked cancers, such as colon and breast.
Other causes include adenomyosis.
f. Postmenopausal period. See Chapter 11.8.
9. In >50% of women with menorrhagia, no etiology is found (4); the diagnosis is then
dysfunctional uterine bleeding.
B. Physical Examination
1. Assess vital signs and the patient’s general appearance, blood pressure, and pulse.
If orthostatic changes are present, evaluate for symptoms of shock. If present, these are
usually related to pregnancy and may indicate a ruptured ectopic pregnancy; alterna-
tively, trauma, sepsis, or cancer may be present.
2. Pallor with normal vital signs may be present if chronic blood loss has resulted in ane-
mia. Anemia, if present, may be due to the blood loss itself, blood dyscrasia, systemic
conditions, or malignancy.
3. Fever and pelvic tenderness are suggestive of acute PID.
4. Physical examination includes the vulva, cervix uterus, and adnexa. A pelvic
mass may indicate abscess, fibroid, ectopic pregnancy, or malignancy. Exclude genital
trauma.
5. Signs of thyroid disease (e.g., rapid or slow pulse, reflex changes, hair changes, and
thyromegaly) can be associated with menstrual abnormalities.
6. Excessive bruising can indicate nutritional deficiency, eating disorder, trauma, abuse,
medication overuse, or a bleeding disorder.
7. Jaundice and hepatomegaly may signify an underlying bleeding disorder.
8. Obesity, hirsutism, acne, and acanthosis nigricans suggest polycystic ovary disease.
9. Galactorrhea may indicate pituitary pathology.
10. Edema may signify renal and hepatic diseases and anemia.
C. Testing
1. Laboratory tests
a. A baseline complete blood count and serum pregnancy test should be obtained.
b. A platelet count, bleeding time, and other tests for bleeding disorders should be
performed as indicated to exclude a bleeding disorder if no other etiology is read-
ily apparent. Inherited bleeding disorders occur in as many as 11% of patients
with menorrhagia compared with 3% of control women; most of these have von
Willebrand’s disease. Establishing this diagnosis is important, because many of the
diagnostic and therapeutic options are surgical and may present added risk if an
252
underlying bleeding disorder is present. The available data do not support routinely
screening all women with menorrhagia (6).
c. Screening for sexually transmitted diseases and thyroid dysfunction should be
considered.
d. A Papanicolaou smear should be performed if indicated, although cervical dysplasia
rarely causes significant vaginal bleeding.
e. Renal and liver function tests are useful if these etiologies are suspected.
2. Diagnostic imaging
a. Any nonpregnant woman with irregular bleeding and a pelvic mass requires complete
evaluation with ultrasound, computed tomography (CT) scan, or laparoscopy.
b. Transvaginal ultrasound detects leiomyoma, endometrial thickening, and focal masses but
may miss endometrial polyps and submucous fibroids. Although highly sensitive for endo-
metrial carcinoma, it may miss 4% more cancers than a dilation and curettage (D&C) (7).
An endometrial stripe of <5 mm is reassuring but does not conclusively exclude cancer.
c. Saline-infused sonography (sonohysterography) (5 to 10 mL sterile saline infused
into the endometrial cavity) with ultrasound imaging can be done. The utility of this
procedure is comparable to diagnostic hysteroscopy and is more accurate than trans-
vaginal ultrasound alone. The sensitivity is 95% to 97% and the specificity is 70% to
98% when combined with endometrial biopsy (8). A decision analysis recommends it
as the procedure of first choice (8).
d. Magnetic resonance imaging (MRI) may be useful for adenomyosis.
3. Endometrial sampling is recommended in women ≥35 years of age or those at
increased risk for endometrial carcinoma. This procedure is best performed on the first
day of menses to avoid unexpected pregnancy.
4. Hysteroscopy Diagnostic and/or Therapeutic.
5. D&C can be diagnostic and therapeutic.
IV. DIAGNOSIS (7). [TABLE 11.6.2]. Menorrhagia presents most frequently at the extremes of
the reproductive years, during menarche and in perimenopause. Pregnancy must be excluded.
Any pelvic mass must be evaluated with ultrasound, CT scan, or MRI. If no diagnosis can be
made, laparoscopy or hysteroscopy may be indicated.
TABLE 11.6.2 Synopsis of Diagnostic Testing
Physical exam • Vital signs, pallor, fever
• Pelvic exam to conrm the source of bleeding to rule out pelvic mass
• Signs of systemic disease affecting liver, kidney, bleeding disorders, or
endocrinopathies like PCOS and thyroid disorders
Laboratory • Pregnancy test
• CBC (including platelet count)
• Complete metabolic panel
• Thyroid panel
• Bleeding time
• STD testing
• Papanicolaou if indicated
Imaging • Pelvic ultrasonography for pelvic mass
• MRI and CT scan if indicated
Histopathology • Endometrial sampling, hysteroscopy, D&C
PCOS, polycystic ovarian syndrome; CBC, complete blood count; CT, computed tomography; MRI,
magnetic resonance imaging; STD, sexually transmitted disease; D&C, dilation and curettage.
253
REFERENCES
1. Zacur HA. Chronic menorrhagia or anovulatory bleeding. UpTodate. Accessed February 16, 2012.
2. Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69:1915–1926.
3. Schrager S. Abnormal uterine bleeding Associated with hormonal contraception. Am Fam Physician
2002;65(1):2073–2080.
4. Finley B, Harnisch DR, Comer B, et al. Women’s genitourinary conditions: FP essentials, Monograph No,
314 AAFP Home Study, Leawood, Kan: American Academy of Family Physicians, 2005:28–41.
5. Goodman A. Initial approach to the premenopausal woman with abnormal uterine bleeding.
UpToDate. Accessed September 24, 2010.
6. James A, Matchar DB, Myers ER. Testing for von Willebrand disease in women with menorrhagia: a
systematic review. Obstet Gynecol 2004;104(2):381–388.
7. Roy SN, Bhattacharya S. Benefits and risks of pharmacological agents used for the treatment of menor-
rhagia. Drug Saf 2004;27(2):75–90.
8. Dijkhuizen FPHLJ, Mol BWJ, Bongers MY, et al. Cost effectiveness of transvaginal sonography and
saline infused sonography in the evaluation of menorrhagia. Int J Gynecol Obstet 2003;83(1):45–52.
11.7
Nipple Discharge in
Nonpregnant Females
Hamid Mukhtar
I. BACKGROUND. Nipple discharge is the third most commonly encountered breast complaint
after pain and mass (1). Nipple discharge that is bilateral, that is multiductal, and that tends to
occur after manipulation is more likely to be of benign origin. Spontaneous discharge, particu-
larly if it is unilateral or bloody, is a source of greater concern.
II. PATHOPHYSIOLOGY
A. Etiology.
Galactorrhea results from the stimulation of breast tissue by prolactin. Prolactin
is released from the anterior pituitary gland. Under normal conditions, prolactin release is
inhibited by dopamine. Elevated prolactin levels, and factors that suppress dopamine, lead
to the secretion of milk from the lobular and ductal epithelium of the breast.
1. Common causes of physiologic nipple discharge include stress, nipple stimulation
(including that occurring from rubbing due to jogging and straps from a backpack),
as well as chest trauma or lesions such as herpes zoster, which may elevate circulating
prolactin levels.
2. Medications and other substances that affect dopamine levels, thereby resulting in
increased prolactin production include phenothiazines and other antipsychotics, tricyclic
antidepressants, metoclopramide, verapamil, digitalis, isoniazid, opiates, and marijuana.
3. Other causes of nipple discharge include infections, systemic diseases, benign tumors,
and malignancy. Intraductal papilloma is the most common cause of benign pathologic
unilateral discharge. The discharge is typically straw colored or clear. Ductal ectasia is
another cause of pathologic discharge. This condition is commoner in smokers and
women in the 40- to 60-year age group.
4. Pituitary adenoma: Classically presents with bilateral nipple discharge, amenorrhea, and/
or neurologic symptoms.
5. Thyroid disorders: Increased production of thyrotropin-releasing hormone may stimu-
late prolactin release.
6. Chronic renal failure: Approximately 30% of the patients with chronic renal failure have
elevated prolactin levels (2).
254
B. Epidemiology. Fifty percent to 80% of women will present with a nipple discharge at some
point in their reproductive years. Only 5% of these women have breast cancer (3). The risk of
malignant nipple discharge increases with age, unilateral and uniductal bloody discharge (3).
III. EVALUATION
A. History.
Initial history should begin with queries regarding the nature of the discharge and
characteristics of the patient. How old is the patient? What is the circumstance of discovery
of the discharge, including spontaneity, and the presence of a palpable mass? How does the
patient describe the characteristics of the discharge? A thorough history should include past
breast history, chest trauma, infection, and medication and substance use. Family history
of breast cancer is also critical to risk assessment. Is there a history of friction of the nipple?
Does the patient smoke?
1. Reproductive history. What is the patient’s menstrual status? Has there been a recent
pregnancy or abortion? This information helps identify normal lactation. Is the patient
using hormonal contraception?
2. Review of systems. Review of systems should include queries about thyroid function,
renal and hepatic disease, as well as adrenal or pituitary symptoms. Does the patient
have a history of headaches, visual disturbances, and associated amenorrhea or menstrual
disturbance?
B. Physical Examination
1. Breast Exam
a. Inspection. Observe the skin of the breast for erythema, crusting, or rash on the
nipple or areolar region. Document the color of the discharge if present. Look for
nipple retraction. Look for any chest wall scars, rash, eczematous changes, or inflam-
mation.
b. Palpation. Feel the skin for warmth. Palpate both breasts for a mass or tenderness.
Palpate the regional lymph nodes for lymphadenopathy. Document the size, shape,
location, consistency, and mobility of any mass.
c. Compression. Compress the base or the areolar region of the breast with thumb and
index finger to try to express any discharge. A warm compress prior to examination
may assist in identification of the discharge. Note the location and color of discharge
and the number of ducts involved.
2. Other Exam: A complete neurologic exam should accompany any history of headache or
visual disturbance. Thyroid and abdominal exam should also be performed if the history
is suggestive of pathology in these areas.
C. Laboratory Evaluation
1. Discharge. Guaiac testing of the discharge should be performed if the discharge is not
obviously bloody or serosanguineous in a unilateral, uniductal presentation. Although
the role of cytology is controversial, the presence of blood increases the positive predic-
tive value of cytology. A positive cytology is highly predictive of cancer (3).
2. Other Tests. Laboratory tests are based on clinical assessment. A pregnancy test should
be considered in all women of reproductive age. Further tests that should be considered
include prolactin level, thyroid, renal, and liver function tests.
3. Imaging. Ultrasound is a good diagnostic tool, which often provides good visualization
of dilated ducts and any nodules inside of them. Mammogram is indicated in all women
older than 30 years of age with a spontaneous discharge (3). The role of mammogram is
to identify occult disease and help in the characterization of any palpable mass. The roles
of ductography, ductoscopy, ductal lavage, and magnetic resonance imaging are under
investigation.
4. Surgery. Surgical referral for ductal exploration or further evaluation is indicated for
a patient with a unilateral and uniductal nipple discharge or a nipple discharge in the
presence of a mass or positive cytology.
5. Genetic Testing. A positive family history of a parent or sibling with breast cancer or
abnormal BRCA1/BRCA2 genes increases the chance that a discharge may be malignant.
Otherwise, genetic testing is not indicated in the evaluation of a nipple discharge (4).
255
IV. DIFFERENTIAL DIAGNOSIS
The main consideration in the differential diagnosis is to distinguish between physiologic and
pathologic nipple discharge. The differential diagnosis includes pregnancy, pseudodischarge,
friction or manipulation, systemic disease, pituitary disease, cancer, ductal ectasia, intraductal
papilloma, Paget’s disease, eczema, and local inflammation secondary to trauma or infection.
REFERENCES
1. Hussain A, Policarpio C, Vincent M. Evaluating nipple discharge. Obstet Gynecol Surv 2006;61(4):
278–283.
2. Leung A, Pacaud A. Diagnosis and management of galactorrhea. Am Fam Physician 2004;70(3):
543–550.
3. Golshan M, Iglehart D. Nipple discharge. UpToDate, A. Chagpar MD, UpTodate, Waltham, MA.
Accessed June 16, 2012.
4. Andolsek K, Copeland J. Conditions of the breast. In: David A, Fields S, Phillips D, Scherger J,
Taylor R, eds. Family Medicine: Principles and Practice. 5th ed. New York, NY: Springer-Verlag;
1998:326–342.
11.8
Pap Smear Abnormality
Mindy J. Lacey
I. BACKGROUND. In 2012, the American Cancer Society estimated that approximately 12,000
cases of invasive cervical cancer and 4,000 (1.5%) of cancer-related deaths annually in the
United States were due to cervical neoplasia (1). While once the leading cause of cancer
death in women, the incidence of squamous cell carcinoma of the uterine cervix has steadily
decreased in the United States after the widespread introduction of cervical cytology screening.
Approximately 60 million Pap smears are performed in the United States each year, with fewer
than 4% of these revealing abnormalities that necessitate additional testing, such as colposcopy
(2). Although most cytologic alterations found in Pap smears will likely regress without inter-
vention, the risk of progression to an invasive lesion underlies the rationale for the follow-up
of even low-grade lesions (3). In recent years, the introduction of a variety of molecular assays
that screen for high-risk human papilloma virus (HPV) have vastly altered diagnostic and
therapeutic algorithms.
II. PATHOPHYSIOLOGY
A. Etiology
1. Within the uterine cervis is the squamocolumnar junction, or transformation zone,
where the columnar epithelium of the endocervical mucosa abuts the squamous epithe-
lium of the ectocervix. This area is prone to numerous physiologic, inflammatory, and
mechanical stresses that commonly result in metaplastic change. In addition, the rapid
cellular turnover makes the transformation zone particularly susceptible viral oncogenesis
and genetic damage by environmental agents.
2. HPV replicates within epithelial cells at various mucosal sites, that include the basal
and parabasal epithelial cells. In most immunocompetent individuals, the infection is
transient and clears within 8 to 24 months, particularly among women younger than
30 (4). The clinical manifestations of HPV infection are somewhat dependent on the
viral subtype. Approximately 30 to 40 subtypes are known to infect the lower genital
tract, usually via sexual contact, and are broadly divided into those with low and high
oncogenic potential (“low risk” and “high risk,” respectively as shown in Table 11.8.1).
256
Low-risk viral subtypes are associated with condyloma acuminatum and other low-grade
cervical abnormalities with a small potential for the development of invasive lesions.
The high-risk subtypes may cause high-grade dysplasia and carry greater risk for the
subsequent development of malignancy (5).
B. Epidemiology
1. HPV has an estimated prevalence of 5% to 20% in the US population and up to half of
young women will develop a transient infection following the initiation of sexual activity
(6). Infections with HPV in older women are much less prevalent but carry a higher risk
of progression to cervical neoplasia. In most cases, progression of cytologic and histologic
abnormalities is sequential (from low grade to high grade, Table 11.8.2) and takes place
over a span of months to years, making it ideal for screening (7).
2. Risk factors for cervical neoplasia include HPV infection, early onset of intercourse, mul-
tiple and high-risk sexual partners, young age, low socioeconomic status, race, history of
other sexually transmitted diseases, compromised immunity, cigarette smoking, and oral
contraceptive use.
III. EVALUATION
A. History.
Most patients with cervical dysplasia are asymptomatic. They may also present
with evidence of external condyloma, vaginal discharge, or even vaginal bleeding. For most,
the initial discovery of cervical neoplasia is usually as an abnormality in the Pap smear. The
gynecologic and prior Pap smear history, which is essential in estimating a patient’s risk,
should be shared with the cytopathologist whenever possible.
B. Physical Examination. On physical examination, the cervix usually appears normal to
the naked eye. Grossly visible cervical lesions should be biopsied (not Pap smeared) to obtain
an accurate diagnosis.
C. Testing. The contemporary method for obtaining Pap smear specimen is a liquid-based
system, which has virtually supplanted the older “conventional” method. The cervix and
endocervix are sampled with a plastic “broom” or a similar apparatus and the specimen is
suspended in a bottle containing the fixative and transported as a suspension. Advantages of
TABLE 11.8.1 Human Papilloma Virus Types According to the Oncogenic
Potential
Oncogenic potential Virus type
Low risk 6, 11, 40, 42–44, 53, 54, 61, 72, 73, 81
High risk 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 82
TABLE 11.8.2 Natural History of Cervical Dysplasia
Regression (%) Persistence (%)
Progression to
severe dysplasia (%)
Progression
to cancer (%)
Mild dysplasia 57 32 11 1
Moderate dysplasia 43 35 22 5
Severe dysplasia 32
˜
56 – 12
257