FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

2018

GYNE: DYSMENORRHEA, PMS, PMDD & BREAST DISEASE

Dr. Julie Del Rosario Lim

DYSMENORRHEA
Pathogenesis
Dysmenorrhea – cyclic, painful, cramping lower abdominal
sensation often associated with other symptoms occurring just
before or during the menses

Other symptoms are:

 Sweating
 Tachycardia
 Headache
 Nausea
 Vomiting
 Diarrhea
 Tremulousness

PRIMARY VS. SECONDARY DYSMENORRHEA

PRIMARY DYSMENORRHEA
 No obvious pelvic pathology
 Cause: Endogenous prostaglandin
 Common in women below 20 years old

Epidemiology
 Best estimate: 75%
 Mild: 34.3%
 Moderate (requiring analgesia): 22.7%
 Severe (inhibited working ability): 15.4%
 Positive correlation between the severity of
dysmenorrhea and duration and amount of menstrual
flow, and early menarche
 Familial occurrence
 Decrease risk of developing dysmenorrhea:
 Younger age of first childbirth
 Higher parity
 Physical exercise
 Vaginal delivery
 Increase risk of developing dysmenorrhea:
 Age < 30
 BMI <20
 Premenstrual Syndrome Diagnosis
 Pelvic Inflammatory Disease (PID)
 Sterilization  History and Physical Examination
 History of sexual assault  Midline lower Abdominal (hypogastric area)
 Heavy Smoking cramps shorty before and during menses
 Pain radiating to the lower back or thigh
 May be associated with diarrhea, headache,
fatigue, malaise
 Gradual resolution in 12-72 hours
 Pain is absent at any other time of the cycle
 Pain occurs only in ovulatory cycles
 Normal pelvic exam
 No ancillary procedures needed

PINGU | 1
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

Management: Non pharmacologic  Condition Behavior

 Patient education and reassurance  Functional Bowel Disease
 Aerobic exercise
 Heat 1. Cervical Stenosis
 Behavioral interventions (relaxation training,
biofeedback, lamaze exercises, hypnotherapy, imagery,
coping strategies, desensitization procedures) – limited
data
 Vitamins and Diet (low fat vegetarian diet, Vit E, Vit B1,
Vit B6, fish oil supplements)

Management: Pharmacologic

1. NSAIDS  Impedance to menstrual flow and rise of

 First line of treatment intrauterine pressure from obstruction in the
 Prostaglandin synthetase inhibitors, cervical os
decreasing myometrial contractility  Leads to retrograde flow  pelvic
 Best taken a day prior to expected menses or endometriosis
at onset of menses
2. Combined oral contraceptive pills (COC) Causes:
 Suppress ovulation and endometrial o Congenital
proliferation o Cervical Injuries (electrocautery)
 Progestin component – blocks prostaglandin o Cervical procedures (Conization)
precursor production o Infections
 Continuous administration reduce pain o Caustic Agents
compared to monthly cyclic dosing o Hypoestrogenism
3. Progestin Only Formulations
 Depot Medroxyprogesterone – theoretically Signs and Symptoms
effective  Scanty menses
 Levonorgestrel IUD – leads to atrophic  Severe cramping throughout menstrual flow
endometrium  Hematometra or pyometra
 Etonogestrel releasing contraceptive
(Implanon) Diagnosis
 Copper T380A IUD – INCREASES pain o Scarred External OS
4. Tocolytics o Inability to insert uterine sound or cervical
 Nifedipine – block uterine contractility Pap Smear
o Difficulty in doing D&C and hysteroscopy
Management: Others o Hysterosalpingogram: Stringy appearing
 Narcotic analgesics canal
 Transcutaneous Electrical Nerve Stimulation (TENS)
o Less effective than analgesics
 Acupuncture
o limited evidence
 Laparoscopic Uterine Nerve Ablation (LUNA) or
Laparoscopic Presacral Neurectomy (LPSN)
o Insufficient evidence

Management:
SECONDARY DYSMENORRHEA  Cervical dilatation
 Underlying pelvic pathology o D&C with progressive dilators or use
 Usually older women more than 20 years old of laminaria
 Considered if symptoms are not relieved by NSAIDs or o Often recurs, necessitating repeat
OCPs procedures
 Pregnancy and vaginal delivery
Causes of Secondary Dysmenorrhea: o More lasting cure
 Cervical Stenosis
 Endometriosis
 Adenomyosis
 Pelvic Inflammation
 Pelvic Congestion Syndrome

PINGU | 2
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

2. Endometriosis Diagnosis
o History and Physical Imaging
o Physical Imaging (Pelvic ultrasound, CT scan,
MRI)
o Rules out other causes of pelvic pain
o Laparoscopy – demonstrates uterine
congestion and engorgement or varicosities of
the broad ligament and pelvic sidewalls

Treatment:
 No standard treatment
 Sclerotherapy
 Hormonal suppression (Progestin, GnRH
agonist)
 Ectopic endometrial glands and stroma  Gonadal vein resection
outside of uterus  Embolization of hypogastric vein
 History of severe pain during menses
 Hysterectomy
 Symptoms: dyspareunia, infertility
 Physical findings: uterosacral ligament
6. Conditioned Behavior
nodules, evidences for endometriosis in the
 Strong family history of dysmenorrhea
vagina or cervix, lateral displacement of the
 Possibility of societal reward or control
cervix
 Psychological issues
 Endometriotic Implants – causes higher
 Careful evaluation including mental status
prostaglandin level therefore causes pain
exam to rule out other causes
 Referral to mental health provider
3. Adenomyosis
 Presence of endometrial glands and stroma in
7. Functional Bowel Disease
the myometrium
 Abdominal pain with altered bowel function
 Symptoms: heavy, painful menses
 61% with dysmenorrhea
 Physical findings: symmetrically enlarged
 Irritable Bowel Syndrome
uterus
 associated with increased dysmenorrhea
 Adenomyosis: higher PGF1 levels
 Patients on OCPs have less dysmenorrhea
4. Pelvic Inflammation
 Pelvic infections (gonorrhea, chlamydia)  8. Others Causes
 Small myomas or polyps at junction of cervical
cause pelvic inflammation or pelvic abscess 
os and lower uterine segment
adhesions, tubal damage  pain
 Non gynecologic conditions
 infections secondary to other conditions such
 Appendicitis
as appendicitis or intrauterine device (IUD)
 Lactose intolerance
may also create similar response
 Celiac sprue
 Chronic pelvic pain (30%)
 Abdominal mass
 Urinary tract conditions (UTI, nephrolithiasis,
5. Pelvic Congestion Syndrome
ureteral obstruction)
 results from the engorgement of pelvic
vasculature
 Etiology unclear
 Defined by chronic pelvic discomfort
(throbbing or burning pain), worse at night,
worsened by prolonged standing and
intercourse

Physical examination:
 vasocongestion of vagina and cervix,
uterine enlargement and global
tenderness of the cervix, uterus and
adnexa

PINGU | 3
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

PMS & PMDD

Somatic Symptoms Affective Symptoms
Premenstrual Syndrome (PMS)  Abdominal  Depressed mood
 defined as a group of mild to moderate physical and bloatedness, swelling,  Irritability, persistent
behavioral symptoms weight gain anger
 Occurs during the luteal phase followed by a period  Aches  Mood lability, crying,
entirely free of symptoms  Increased appetite, social withdrawal
 may disrupt work and relationship food cravings  Anxiety, tension
 Breast pain or  Feeling of hopeless or
tenderness guilty
Premenstrual Dysphoric Disorder (PMDD)
 Dizziness, poor  Poor impulse control
 More severe than PMS coordination, or feeling out of control
 Marked behavioral and emotional symptoms clumsiness  Decreased interest,
 Patients must have one severe affective symptom:  Cramps, change in change in libido
 marked depression bowel habits  Insomnia
 Fatigue  Loss of concentration,
 anxiety or tension
confusion
 affective lability
 persistent anger

 It differs from PMS because there is substantial Etiology

impairment in personal functioning  Multifactorial psychoendocrine disorder
 Similar in PMS, symptoms manifest in the luteal phase  Major causative factor: Cyclic gonadal hormonal
of the menstrual cycle and resolve during menses alterations and serotonergic neural mechanisms in the
CNS
Incidence  Genetic contribution: high incidence rate in
 PMS:3-8% monozygotic twins than in dizygotic twins
 PMDD: 2%  Dietary and vitamin deficiency theories: high calcium
 Average age of onset: 26 and vitamin D intake reduce risk of PMS
 Arise as a consequence of ovulation which alters
Risk Factors neurohormonal and neurotransmitter functions
leading to lowering of serotonergic effects during the
 Maternal Family history
luteal phase
 Psychiatric Illness (Mood or Anxiety Disorder)
 The MOST effective evidence-based treatment are
 History of alcohol abuse those that BLOCK OVULATION (SSRIs)
 History of postpartum disorder
 Nulliparity Diagnosis:
 Earlier menarche  History if two consecutive menstrual cycles
 High alcohol or caffeine intake demonstrating luteal phase symptoms of PMS and
 Higher BMI PMDD
 More stress  Daily Record of Severity of Problems (DRSP): most
 Race (Hispanics) commonly utilized validated tool
 ACOG: presence of at least one symptom during luteal
phase of the cycle leading to significant impairment in
functioning
 Diagnosis made by symptom diary and by elimination
of other diagnoses

PINGU | 4
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

Management:
Diet and Exercise
 Eliminating or reducing sugar, alcohol, caffeine, salty
foods, red meat
 Calcium 1200mg/day
 Vitamin B6
 Aerobic exercise for at least 30 minutes, one most days
of the week, including during the luteal phase

Cognitive Behavioral Therapy

 Relaxation therapy

Pharmacologic Treatment
 Psychoactive agents:
o SSRIs – first in line of treatment; continuous or
luteal phase regimen
o Alprazolam – second line of treatment
 COCs
o MOA: inhibit ovulation
o Mainly help physical symptoms such as breast
pain, bloating, acne, appetite
o Monophasic COCs better
o Ethinyl Estradiol ug + Drosperinone 3mg for
PMDD treatement

 NSAIDs – for pain

 Diuretics – for bloating, fluid retention
 Bromocriptine – cyclic nostalgia
 GnRH Agonist – for ovulation supression but less
effective in treating psychiatric symptoms of PMDD

Surgery
 Hysterectory and Bilateral Salpingo-oophorectomy
 for severe disabling symptoms refractory to other
medical therapy

PINGU | 5
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

BEAST DISEASES  Others: lateral thoracic and thoracoacromial

BREAST
Breast - large modified apocrine/sweat glands located in the
superficial fascia anterior to the deep pectoralis major fascia of
the chest wall
Suspensory Ligaments of Cooper
 suspends breast tissue from the clavicle and deep
clavipectoral fasscia
 Maintain the natural shape of the breast
 Malignant involvement produce skin retractions
arteries,from the axillary artery, posterior third, fourth
and fifth intercostal arteries from the branches of
thoracic aorta
 Least vascular: inferior and central portion
Lymphatics
 Converge in the subareolar plexus of Sappy
 75%: drain to the 30-60 ipsilateral axillary regional
nodes
 25%: drain to the internal mammary or parasternal
node
 Parasternal nodes: provides routes for metastatic
disease to the liver, ovaries and peritoneum

Axillary Tail of Spence

Axillary Nodes
 Superolateral projection of glandular tissue
 Classified by the anatomic levels in relation to the
pectoralis minor muscle
Mature Breast  Level I: Lateral to the lateral border of the pectoralis
 20%: glandular tissue minor muscle
 80%: adipose (major determinant of breast size) and  Level II: Posterior to the pectoralis minor muscle
connective tissue  Level III: Include the infraclavicular nodes medial to the
 Peripheral Area: mainly adipose pectoralis minor muscle
 Central Area: mainly glandular
Sentinel Node Mapping
Breast Size and Shape depends on:  Used to evaluate nodal spread in the breast cancer as
 Genetics lymphatic fluid usually flows toward the most adjacent
 Racial group of nodes
 Dietary factors
 Age Premenstrual Breast
 Parity  Women experience cyclic breast fullness and
 Menopausal Status tenderness related to the 25-30ml average volume
fluctuation
Characteristics of Breast:  Symptoms are produced by an increase in blood flow,
leading to vascular engorgement and water retention
 Adult breast weighs about 250 grams
 Composed of 12-20 lobes distributed rapidlly from the
NIPPLE
nipples
 Each lobe contains its own duct system draining 10- CONGENITAL NIPPLE
100 lobules with alveoli (acini) POLYTHELIA INVERSION
 Lobules have epithelial (ductal) and stromal  Incidence: 2%
 Supernumerary or
components affected by hormonal changes resulting in  Etiology: shortening and
accessory nipples
development, maturation and differentiation tethering of breast ducts
 can occur along the
breast or milk line, and to the development
Areloar (Montgomery) Glands from the axilla to the of fibrous bands during
 5-20 groin intrauterine life
 accessory glands located in the areola and nipple  90%: inframammary  May increase mechanical
 Produce oily secretion keeping the nipple supple and region problems with
protected particularly during breastfeeding  Incidence: 1% breastfeeding
 Produce volatile compound implicated in stimulating (European descent),  Surgical correction –
infant’s appetite through the olfactory pathway 6% (Asian descent) often leads to loss of
 Generally sensitive  Occur in equal sensation and inability
frequency in men and to breast feed
Blood Supply women
 Treatment: reserved
 Principal: Perforating branches of the internal to manage irritation
mammary arteries from the internal thoracic artery
or to improve
cosmesis

PINGU | 6
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

ATHELIA • Corrective procedures: augmentation, mastopexy,

combined augmentation/mastopexy and tissue
• Complete unilateral or bilateral absence of nipple expansion followed by augmentation
and areola
• Familial (autosomal dominant)
BENIGN BREAST DISORDERS
• May be associated with amastia or other
syndromes such as Poland Syndrome (Fibroadenoma, Phyllodes Tumor, Fibrocystic Change,
Mastalgia, Mastitis, Nipple Discharge, Fat Necrosis)
• Treatment: nipple and areola reconstruction
using tissue flaps or tattooing  90% of breast complaints and abnormalities
 Includes developmental abnormalities, inflammatory
lesions, epithelial and stromal proliferation and
neoplasms
BEAST TISSUE  May be incidental or detected clinically or
radiographically
AMASTIA POLYMASTIA  Begins to rise in second decade of life, peaks in fourth
• Complete absence of • Accessory or supernumerary to fifth decades while malignant disease incidence
breast tissue and breasts continues to increase after menopause
nipple-areola complex • 1-2%
• Occurs with regression • Female preponderance Symptoms:
or failure to develop • Luteal Phase
• Most commonly presents in
mammary ridge
the axilla • Increase in size, density and nodularity often
• Usually asymptomatic associated with increased sensitivity or breast
pain
• Surgery indicated if with
discomfort or cosmetically • Breast Pain
unacceptable but may be • Generally a late symptom in cancer
associated with • Nipple Discharge
postoperative unattractive
• Less frequent sign of cancer
scars, movement restriction
or pain
ANDI CLASSIFICATION
 Incorporates symptoms, signs, histology, physiology,
ASYMMETRIC BREAST BREAST HYPERTROPHY pathogenesis, and degree of breast abnormality
DEVELOPMENT  Classified in relation to the normal processes of
• Common in • May be asymmetric reproductive life and involution through spectrum of
adolescence and breast conditions from ”normal” to “disorder” to
• Classified as: Pubertal
maturity “disease”
(Virginal Hypertrophy),
• Benign, normal Gestational (Gravid
variation unless a Macromastia) or Adult Type
palpable abnormality • Reduction mammoplasty not
is present indicated until significant
• Full breast volume of breast tissue
development occurs by requires removal to relieve
18-21 years old associated symptoms of
• If deemed necessary, headache, neck or back pain,
breast augmentation upper extremity paresthesia,
or reduction should be brassiere strap grooving or
timed appropriately intertrigo

TUBULAR BREAST/TUBEROUS BREASTS

• Exact cause: unclear, but genetic collagen deposition
disorder implicated
• Breast development stymied during puberty, the transverse
breast diameter narrowed and the base constricted

PINGU | 7
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
FIBROADENOMA
 Common benign breast neoplasm (15-20%)
 Seen in adolescents, women in 20’s
 Related to aberration in normal lobular development
Physical Findings:
 Solitary, slow growing, painless, mobile, firm and
solid tumor
 “Rubbery” and well circumscribed
 Average size is 2.5cm and remains fairly constant in
size
 Discovered accidentally
 35% disappear spontaneously
 10% decrease in size
Diagnosis:
o Breast sonography – initial, non-invasive study to
differentiate solid versus cystic mass
o Mammography – rarely indicated for <35 years old
o Core Needle Biopsy – indicated if cause of palpable
mass cannot be established
Treatment:
 Surgical Excision – indicated if with rapid increase
in size, symptomatic or to relieve anxiety
 Non-operative management – small, asymptomatic
fibroadenoma in women <35 years old with 100%
concordance between clinical exam, imaging
evaluation and core needle biopsy
 Surveillance is 6 months interval for atleast 2 years
Long term Risks of Fibroadenoma: 20% in post-operative
recurrent risk and 2x risk for invasive breast cancer as
fibroadenomas are proliferative disorders
PHYLLODES TUMOR
 Previously known as Cystosarcoma Phyllodes
 Rare fibroepithelial tumor
 2.5% of fibroepithelial tumors
 <1% of breast malignancues
 Almost exclusively seen in females
Histology:
o Stromal elements dominate and invade ducts in a
leafy projection (phyllodes or leaf)
o Phyllodes tumors are divided into benign,
borderline and malignant types. All three types
usually present as a mass
Clinical Features
 Mass similar to fibroadenoma
 Most commonly found in the 4th and 5th decades of
life
2018
 Grow rapidly and often larger
Diagnosis
o Mammography and ultrasonography unreliable in
differentiating between fibroadenoma, benign and
malignant phyllodes tumor
o Difficult to distinguish histologically from
fibroadenoma, benign and malignant phyllodes
tumor
Treatment
 Wide local excision with 1 cm margins
 Local recurrence: 25%
o Associated with microscopic margin
involvement
 Malignant tumors metastasize hematogenously
with 25% risk of metastases
FIBROCYSTIC CHANGE
 Most common of all benign breast condition
 True frequency unknown
 Occurs in the reproductive age (20-50years old) and
unusual in adolescence and menopause
Cause: Exaggerated normal physiologic response to ovarian
hormones.
Physical Examination:
 Classic: Bilateral Breast Pain
 Increased engorgement and density
 Excessive nodularity
 Size fluctuations of cystic area
 Increased tenderness
 Infrequent spontaneous nipple discharge
 Associated with bilateral mastalgia, frequently in
the upper outer quadrants
 Excessive nodularity “multiple peas”
 Ill-defined thickening or palpable lumpiness
 Ballotable cysts “ water filled ballons
Both signs and symptoms are more prevalent during the
premenstrual phase of the cycle
Clinical Stages of Fibrocystic Change
Stage I
 Mazoplasia (Mastoplasia)
 Associated with intense stromal proliferation
 Occurs in early reproductive years (20)
 Breast pain usually in the upper outer
quadrant, most tender in the axillary tail
 There is intense proliferation of the stroma
Stage II
 Adenosis
 Marked proliferation and hyperplasia of ducts,
ductules and alveolar cells
PINGU | 8
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

 Women in 30’s Diagnosis:

 Less severe premenstrual pain and tenderness o Laboratory exam: hCG, Prolactin
 Multiple small breast nodules present o Simple Cyst: Aspirate
o Complex Cyst: Core-needle biopsy
Stage III Management
 Cystic Phase  Directed at the cause
 Women in 40’s  NSAIDS if pain is idiopathic
 No breast pain unless cyst size increases
rapidly with associated pain, point tenderness
and lump Medication Associated with Mastalgia
• Antihypertensives • Haloperidol
Diagnosis • B-blockers • Hormonal agents
o Imaging Technique • Hydrochlorothiazide • Estrogens
o Fine needle aspiration • Methyldopa • Progestins
cytology: for simple cysts
o Core needle biopsyis for • Minoxidil • Androgens
complex cysts with • Spirinolactone • Ginseng
internal septations, • Antidepressants and • Clomiphene citrate
debris or sold antipsychotics • Digoxin
components
• Chlorpromazine/ • Metochlopromide
promethazine
Treatment • Fluoxetine
 Support Brassieres
 Dietary Modification (decreased intake of
methylxanthines, caffeines, saturated fat)
 Diuretics – breast discomfort or engorgement
 Oral Contraceptives or progestins – decreased
MASTITIS AND INFLAMMATORY DISEASE
incidence of fibrocystic changes by 30%
 Danazol  It is subdivided into: Lactaion, non-lactation, post-
 Tamoxifen – decreased pain by 85% surgical

MASTALGIA Etiologic Agent: Staphylococcus aureus (most common)

 Most common in perimenopausal years

 90% of conditions with mastalgia are benign Management:
 Divided into: Cyclic Pain and Non Cyclic Pain  Empiric treatment covering gram (+) organism
 Culture for MRSA if with poor response to treatment
 Doxycycline or TMP-SMX indicated for MRSA
Cyclic Pain
o Related to the menstrual cycle
o Diffuse and bilateral Lactation Mastitis
o Associated with fibrocystic change  Occurs in the first pregnancy during the first 6 weeks of
breastfeeding
 First Line Antibiotics: Cephalosphorin
Noncyclic Pain
 Continue breastfeeding or manual pumping of affected
o Localized breast to reduce engorgement
o Commonly related to a cyst
o Should be evaluated especially in older women
o Small association with malignancy Nonpuerperal Mastitis
o Mammography when indicated is valuable  Often associated with breast cyst and cyst rupture
 Inflammation not responsive to antibiotics
Differential Diagnosis of Mastalgia
 Warrants a tissue diagnosis
Cyst Mastitis
Chest-wall pain Pregnancy-related pain Causes:
Radicular pian Prolactinomas  Syphilis
Costochrondritis Medication Exposure  Tuberculosis
 Atyical Bacteria
 Fungal Infection

PINGU | 9
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

 Nipple piercing particularly in smokers due to Two Most Common Causes of Spontaneous Non-Milky
increase in subareolar abscess formation Discharge

Idiopathic Granulomatous Mastitis

 Also known as Idiopathic Granulomatous Lobular
Mastitis
 Rare cause of breast inflammation
 Affects any age group

Presentation
 Mass
 Abscess
 Inflammation
 Granuloma Formation

Diagnosis
INTRADUCTAL PAPILLOMA
o Core-needle biopsy – granuolagranuloma within
lobules and are noted to be sterile  Broad based or pedunculated polypoid epithelial
o Mammography may be equivocal or suspicious lesions that may obstruct and distend involved duct
 Common in perimenopausal women

Treatment
Gross findings:
 Prolonged antibiotics (3-6months) may be
Small, well-circumscribed
necessary
polypoid nodules occur in
 Evaluate for other diseases if unresponsive to
a dilated duct
antibiotics (Chronic Inflammatory Diseases such
as Lupus, Sarcoid, Wegner Granulomatosis)
 Steroids use have equivocal reults

Prognosis
o Usually self-limited, resolve in months
o Skin scarring and residual small abscess may
remain, necessitating surgical treatment
NIPPLE DISCHARGE
 Present in benign (majority) and malignant entities
Clinical Features:
 Classic Symptom: Spontaneous and intermitted
discharge from one nipple involving one or two
ducts
 Discharge may be watery, serous or bloody
 75% located beneath the areola
 Often small, difficult to palpate (1-3mm)

Malignant: Diagnosis: Circumferential Radial Pressure during Breast

 Spontaneous discharge exam to identify whether the discharge is from a single duct or
 Arises from a single duct multiple openings
 Blood stained
 Unilateral and persistent (>2x weekly) Treatment: Excisional Biopsy
 Associated with mass

Prognosis:
Evaluation
o Tends to regress during menopause
o Physical Examination o Solitary Papilloma gas two fold risk for carcinoma
o Imaging: Mammography, Ultrasound or MRI
o Other Techiniques: Ductoscopy, Ductal Lavage,
Ductography/Galactogram FAT NECROSIS
o Biopsy: Indicated if associated with mass
 Benign nonsuppurative inflammatory process of the
adipose tissue
 Rare (0.6%)
 Average age: 50
 Most common cause: breast trauma

PINGU | 10
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

 Other causes: radiotherapy, anticoagulation (warfarin), MAMMOGRAPHY

breast procedures (breast aspiration or biopsy,  Screening Mammogaphy:
lumpectomy, implant removal, breast reconstruction,  Goal: detection of cancer before it is clinically palpable
infection) and less likely to progress to the regional nodes or
distant metastases
Clinical Features  May identify cancer up to 4 years before it becomes
clinically evident
 Firm, tender, indurated, ill-defined
 May have
ecchymosis,
erythema,
inflammation,
pain, skin
retraction or
thickening,
nipple
retraction or
occasionally lymphadenopathy
Diagnostic Mammogaphy:
Diagnosis: Mammography – coarse calcifications, focal  Performed when women have complaints of breast
asymmetries, microcalcifications pain, palpable lump or mass, nipple discharge,
abnormality on screening study or to follow women
who have been treated for breast cancer
Treatment: Excisional Biopsy

Screening Mammography:
Prognosis: No Relationship between fat necrosis and
 Primary imaging technique for breast cancer detection
subsequent breast carcinoma
 The only breast imaging method found to reduce breast
cancer related mortality
 Utilizes x-ray photons
 Sensitivity: 80-90% but decreases with dense breasts
DIAGNOSTIC PROCEDURES  Breast density – refers to the ratio of glandular tissue
to fatty elements
 If with dense breasts: for digital mammography,
BREAST SELF EXAMINATION (BSE)
preferably with tomosynthesis or MRI
 Does not decrease breast cancer mortality but plays a
role in detecting breast cancer
 ACOG: recommends BSE Views:
 Option for women in 20’s  Mediolateral view
 Premenopausal: best performed few days immediately  Craniocaudal view
after menses
 Postmenopausal/Post-hysterectomy patients: same
calendar days each month
 Best done both in supine and upright positions using
the fingerpads of the 3 middle fingers
 3 levels of pressure employed (light, medium, firm)
 Techniques: clockwise fashion from the nipple
outwards, vertical pattern (up and down pattern)

CLINICAL SELF EXAMINATION

 Sensitivity: 54%
 Specificity: 94%
 Factor associated with greater accuracy: longer Mediolateral view
duration of exam
o Most important projection as it depicts the
 ACOG: recommends CSE every 3 years from age 20 – 39
greatest amount of breast tissue and the only view
and annually thereafter
that includes all of the upper quadrant and axillary
 Best performed in sitting and supine position
tail

PINGU | 11
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

Abnormalities ULTRASOUND
• Calcifications  Not used by itself as a screening tool in average risk
• Masses women
• Asymmetry  Highly operator and reader dependent test
• Architectural distortion  Effective in differentiating cystic from solid masses (96-
100%)
 First line of imaging for women <30 years old with focal
 Most specific mammographic feature of malignancy:
breast symptoms or findings
focal mass with spiculated margins

Breast Imaging Reporting and Data Systems (BIRADS)

Category 0 Incomplete assessment, required
additional evaluation
Category 1-2 Non malignant
Category 3 Benign but requires interval follow up
imaging to confirm stability
Category 4-5 Suspicious, warrants biopsy
Category 6 Malignant COMPUTED TOMOGRAPHY (CT SCAN)
 Not routinely used for breast
cancer screening or diagnosis
DIGITAL MAMMOGRAPHY  Useful for contrast enhancing
 Technique by which the radiographic image is obtained lesions, for lesions close to the
with digital detectors and recorded in a digital format chest wall, for studying the
most medial and lateral
 Advantages over conventional film screen aspects of the breasts
mammography:
 Disadvantages:
• Faster image acquisition, display and storage
• May miss areas of microcalcifications
• Greater contrast resolution, advantageous for
women with dense breasts and breast • Higher radiation doses and longer study times
implants compared with mammography
 Disadvantages:
• Cost and reduced spatial resolution TOMOSYNTHESIS
 Referred as three dimensional (3D) Mammography
MAGNETIC RESONANCE IMAGING (MRI)  Modification of digital mammography
 Sensitivity: 71-100%  Disadvantages: increased radiation exposure and
reading time
 Specificity: <65%
• Secondary to the overlap in the enhancement
pattern of benign and malignant lesions BREAST TISSUE SAMPLING
 Useful in women with dense fibroglandular breasts and  Indications:
implants • Bloody nipple discharge
 Limitations: • Persistent three dimensional mass
• Cannot identify microcalcifications • Suspicious mammography
• Loss of image quality with respiratory • Nipple retraction
movements • Elevation or skin changes (erythema,
• Contraindicated in patients with diminished induration, edema)
renal function, history of gadolinium allergy,  Imaging must precede biopsy
cardiac pacemakers, defibrillators or other • Inflammation and bleeding secondary to
implanted devices biopsy may significantly impair visualization
of the breast with imaging

PINGU | 12
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
2018

FINE NEEDLE ASPIRATION (FNA) CORE NEEDLE BIOPSY AND EXCISIONAL BIOPSY
 Least invasive first line sampling technique  Retrieves more
 For new, well circumscribed, usually tender simple tissue than FNA
cysts  Permits
 Disadvantage: difficulty in differentiating carcinoma in differentiation
situ and invasive cancer between
carcinoma in situ
 Biopsy: indicated on cyst that recurs within 2 weeks or
versus invasive
that necessitates more than 1 repeat aspiration
cancer
 Complications: hematoma formation and infection
 Provide adequate
tissue for genomic analysis and cancer profiling

PINGU | 13