Spotlight – Women’s health

Case 5: Want to learn more about ovarian cancer?

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Q1: What are the risk factors for epithelial ovarian cancer?

Risk factors for epithelial ovarian cancer include age, infertility, endometriosis, polycystic ovarian syndrome, history of an intrauterine device, and cigarette smoking. Protective factors include prior pregnancies, history of breastfeeding, oral contraceptives, and tubal ligation.

Q2: How does ovarian cancer present?

Women with ovarian cancer are more likely to experience persistent symptoms of bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary frequency or urgency.

Q3: What should the initial evaluation be of women with symptoms and findings suggestive of ovarian cancer?

They should undergo pelvic exam and pelvic imaging. If there is high concern for malignancy, they should be referred to a gynecologic oncologist.

Case 4: Do you know the side effects of methylprednisolone?

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Q1: What is the pathogenesis of multiple sclerosis (MS)?

Multiple sclerosis is an autoimmune, inflammatory disorder that leads to demyelination of the central nervous system. These demyelinated lesions can be located all over the CNS, including optic nerves, spinal cord, brainstem, and cerebellum. MS primarily affects women, and most commonly affects women during child-bearing years.

Q2: How is MS diagnosed?

MS is primarily a clinical diagnosis. It involves demonstrating lesions of the central nervous system separated by time (more than one episode of symptoms) and space (different locations). This can be shown thrugh a history of clinically symptoms and MRI findings.

Q3: What is an MS exacerbations or “attacks”?

MS exacerbations are defined as focal neurologic deficits that last longer than 24 hours, and occur after the patient has been stable for at least 30 days. Other cause of the exacerbation, like infection or fever, must also be ruled out.

Q3: How are acute episodes of MS treated?

If the symptoms of MS leads to disability or impairs the patient’s cerebellar function, strength or vision, they can be treated with glucocorticoids, often methylprednisolone.

Case 3: Cardiac symptoms in women are often misdiagnosed, leading to harmful health delays in diagnosis and treatment

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Q1: How do symptoms of cardiac ischemia present in women?

Overall, there are more similarities than differences in chest pain in women and men. Chest pain with heaviness and pressure is the most common presenting symptom. One important difference is that women with ischemia are more likely to be induced by sleep, rest, and mental stress, instead of physical exertion. When compared to men, myocardial infarctions of women are more likely to present without chest pain.

Q2: When do women present with coronary heart disease compared to men?

Women, on average, present 10 years later than men with coronary heart disease. They are also more likely to present with a higher burden of disease.

Q3: What is peripartum cardiomyopathy and how does it present?

Peripartum cardiomyopathy is systolic heart failure towards the end of pregnancy or in the months following pregnancy. It often leads to a left ventricular ejection fraction of <45% without another obvious cause of heart failure. Symptoms are variable, with the most common presenting symptom being shortness of breath. It can also present with cough, orthopnea, or paroxysmal nocturnal dyspnea, pedal edema, and hemoptysis.

Case 2: Chlamydia ascites: a call for sexually transmitted infection testing

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Q1: Chlamydia trachomatis is the most common bacterial cause of sexually transmitted genital infections. What clinical syndromes can Chlamydia cause that are specific to women?

Most people infected with Chlamydia have no symptoms. Chlamydia can cause a variety of syndromes, including genital infection. The most common site of infection for women is the cervix, causing cervicitis. Uretheritis can also be caused by Chlamydia, which can cause dysuria and pyuria. The most concerning consequence of Chlamydia infection in women is pelvic inflammatory disease, which can lead to ectopic pregnancies, chronic pelvic pain, and tubal infertility. PID often presents with signs of cervical motion and adenexal tenderness.

Q2: Why is routine screening of young women for Chlamydia so important?

The majority of people infected with Chlamydia have no symptoms! Approximately 85% of young women with cervicitis have no symptoms at all, and as described above, it can lead to consequences including infertility, chronic pelvic pain, and ectopic pregnancies.

Q3: What test should you use to screen for Chlamydiaal infection of the genitourinary tract?

The diagnostic test of choice for chlamydial infection of the genitourinary tract is nucleic acid amplification testing (NAAT) of vaginal swabs for women or urine for men.

Case 1:Misconceptions surrounding pregnancy-associated breast cancer

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Q1: Imagine you are working in primary care clinic and a 30 year old woman presents with a breast lump. What is on your differential diagnosis?

Palpable breast masses in women are common, and most are benign. In fact, approximately 90% of palpable breast masses in women in their 20s to early 50s are benign. However, the concern is of course malignancy, which must always be on the differential for a palpable breast ‘lump.’ Benign causes include fibroadenomas, which are typically mobile and common in young women, benign cysts, which are common in perimenopausal women, and fibrocystic changes, which commonly presents as diffuse tenderness (not commonly a discrete mass) in a pre-menopausal woman. Malignant causes of breast masses are vast; the most common breast malignancy is an infiltrating ductal breast carcinoma, which accounts for 70-80% of breast cancer.

Q2: What are important risk factors for developing breast cancer?

Risk factors include deleterious BRCA1/BRCA2 genes, a mother or sister with breast cancer, age, <12 year old at first menarche, age >30 at first birth, age &gt;55 at menopause, past or current use of contraceptive pills, current (estrogen + progestin) hormone replacement therapy, and 2-5 drinks of alcohol per day. Many of these risk factors are related to exposure of estrogen, such as having earlier menarche or later menopause, and use of hormone replacement.

Q3: What diagnostic tests should be performed for women presenting with a palpable
breast mass?

All women with a suspicious breast mass should have a mammogram. Often, an ultrasound will also be performed as part of the evaluation. MRIs should only be performed if there is a diagnostic quandary. In a young woman <30 years old, who presents with a breast mass consistent with a benign cause such as fibroadenoma, and there is no family history of breast cancer, the first imaging choice can be an ultrasound.

References

  1. Khalil N, Fowler C. Misconceptions surrounding pregnancy-associated breast cancer. BMJ Case Reports CP 2018;11:e226719
  2. Morrow M. The evaluation of common breast problems. Am Fam Physician 2000; 61:2371
  3. Clemons M, Goss P. Estrogen and the risk of breast cancer. N Engl J Med 2001; 344:276
  4. Cady, B, Steele, GD, Morrow, M, et al. Evaluation of Common Breast Problems: A Primer for Primary Care Providers; prepared by the Society of Surgical Oncology and the Commission on Cancer of the American College of Surgeons for the Centers for Disease Control and Prevention, Publication no. 633-001/20900, US Department of Health and Human Services, 1998