INTIMATE PARTNER VIOLENCE
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.
The USPSTF recommends that clinicians screen women of childbearing age for IPV including 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.
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 clinicians is required in California, Colorado, Kentucky, Mississippi, Ohio, and Rhode Island.
VA; U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Mar 19;158(6):478–86.
N. Intimate partner violence: prevalence, health consequences, and intervention. Med Clin North Am. 2015 May;99(3):629–49.
Eating disorders are common in women. Anorexia nervosa and bulimia nervosa are described in detail in Chapter 29. The female athlete triad, disordered eating in diabetic patients, and binge eating disorders are other eating disorders that should be considered in appropriate women.
ESSENTIALS OF DIAGNOSIS
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 diabetes mellitus.
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.
2. Disordered Eating in Diabetic Patients
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. Diabetic patients 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 patient who has worsening diabetic control, when other causes of worsening control have been ruled out.
Diabetic patients 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 communication.
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.
ESSENTIALS OF DIAGNOSIS
Binge eating disorder consists of episodes of eating a large amount of food in a discrete period of time with a sense of lack of control.
Binge episodes are 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 once a week for 3 months.
No compensatory behavior (purging, fasting, or excessive exercise) after eating.
Binge eating commonly occurs independent of anorexia nervosa or bulimia nervosa.
Binge eating disorder, more common than anorexia nervosa or bulimia nervosa, is recognized as a diagnosable eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
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. Whether cessation of binge eating disorder has an impact on subsequent weight loss or other obesity-related complications is not clear.
et al. Treatment of patients with severe and enduring eating disorders. Curr Opin Psychiatry. 2015 Nov;28(6):473–7.
et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep. 2014 Jul–Aug;13(4):219–32.
et al. Predictors of treatment outcome in individuals with eating disorders: a systematic review and meta-analysis. Int J Eat Disord. 2015 Nov;48(7):946–71.
SEXUALITY & SEXUAL HEALTH
Sexual dysfunction is common among women and can cause significant distress. Most recent estimates indicate that approximately 12% of women have sexual disorders, which include female sexual interest/arousal disorder, sexual aversion disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder (these are discussed in detail in Chapters 18 and 25). Low sexual interest is the most prevalent of the female sexual 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 using screening questions such as "Altogether, are you satisfied with your sex life?" and "Altogether, are there any problems with your sex life?" Positive answers can be explored further with a more complete sexual assessment, which encompasses details about medical, surgical, and psychiatric problems, as well as medications and reproductive history. Treatment depends on the diagnosed disorder and can include psychosexual and hormonal therapy (see Chapter 18). Flibanserin, which is a full agonist of the 5-HT1A receptor and, with lower affinity, an antagonist of the 5-HT2A receptor, has been shown to improve sexual desire and increase the number of sexually satisfying encounters among postmenopausal women with low sexual interest. Dizziness is its most common side effect occurring in up to 10% of treated patients.
et al. Female sexual dysfunction: focus on low desire. Obstet Gynecol. 2015 Feb;125(2):477–86.
et al. Efficacy and safety of flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the SNOWDROP trial. Menopause. 2014 Jun;21(6):633–40.
ESSENTIALS OF DIAGNOSIS
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. Chronic pelvic pain may result from gynecologic, urologic, gastrointestinal, musculoskeletal, or neurologic disorders. Although endometriosis is the most common gynecologic condition associated with it, postoperative adhesions, chronic pelvic inflammatory disease, and adenomyosis should also be considered. Interstitial cystitis, irritable bowel syndrome, and myofascial pain syndrome arising from trigger points in the abdominal musculature or pelvic floor have all been associated with chronic pelvic pain. Sensation to the pelvis is supplied by nerves arising from thoracolumbar and sacral nerve roots. Thus, spinal pathology or direct injury to the pudendal nerve can produce it. In fact, most women with chronic pelvic pain have multiple diagnoses contributing to their 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 interstitial cystitis. Patients with irritable bowel syndrome often report abdominal pain, distention, and diarrhea or constipation. Clinicians should ask patients about surgery or direct trauma involving the spine or pelvis, which may suggest musculoskeletal sources of pain. The physical examination, including the pelvic examination, is usually quite painful in the patient with chronic pelvic pain and should be done carefully. Palpation of the thoracic and lumbar spine, pelvic girdle, and abdomen can reveal areas of discomfort that refer to the pelvic area. A positive Carnett test (constituted by an increase in tenderness when the abdominal muscles are tensed) can be helpful for identifying abdominal wall trigger points. 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. Palpation of the pelvic viscera can help identify localized areas of tenderness in women with endometriosis or chronic pelvic inflammatory disease. 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.
All women should be screened with vaginal or cervical swabs for chlamydia and gonorrhea; cervical cytology may be considered if clinically appropriate.
C. Diagnostic Testing and Imaging
Pelvic ultrasonography is useful for evaluating the pelvic anatomy, investigating localized areas of tenderness, and identifying pathology. Laparoscopy is considered the gold standard for diagnosis of gynecologic disorders, such as endometriosis or pelvic adhesions.
Chronic pelvic pain is frequently a manifestation of another disease, as noted above. When considering various diagnoses, it is important to differentiate extra-pelvic from intra-pelvic sources of pain. Musculoskeletal disorders involving the spine, hips, and sacroiliac joints may cause referred pelvic pain, whereas endometriosis, adenomyosis, and chronic pelvic inflammatory disease are typically associated with tenderness of the pelvic viscera. Similarly, abdominal wall or hip girdle trigger points that cause chronic pelvic pain can be easily differentiated from trigger points in the levator ani and perineal muscles.
The main goals of chronic pelvic pain treatment are to improve the patient's quality of life and functional status while minimizing adverse effects. Thus, diagnosis-specific treatment options should be offered initially, with more general therapies (analgesics, including nonsteroidal anti-inflammatory drugs [NSAIDs]) reserved for situations in which the underlying etiology remains unclear. However, long-term use of NSAIDs can cause significant gastrointestinal toxicities. Antidepressants (eg, amitriptyline) and antiseizure medications (eg, gabapentin) (see Table 5–4), 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 suspected endometriosis can be empirically treated with hormonal therapy for a period of at least 3–6 months before diagnostic laparoscopy is performed. Oral contraceptives, GnRH analogs, progestogens, and danazol all have proven effective, although side effects with these therapies differ significantly. The effects on bone mineral density associated with GnRH analog therapy can be mitigated by "add-back" low-dose estrogen therapy, which also improves treatment-associated hot flashes. Medroxyprogesterone acetate and GnRH analogs have also been shown to be efficacious in the treatment of patients with chronic pelvic pain secondary to pelvic congestion syndrome or pelvic adhesions.
Medical therapies directed at the treatment of nongynecologic sources of chronic pelvic pain, including irritable bowel syndrome and interstitial cystitis, are discussed in Chapters 15 and 23. Physical therapy and injection of identified trigger points provide significant pain relief in patients with musculoskeletal sources of pain. Psychological evaluation and treatment should also be strongly considered as many women with chronic pelvic pain experience anxiety and depression.
Women with endometriosis may be offered laparoscopic surgical destruction of implants or laparoscopic utero-sacral (LUNA) nerve ablation for relief of their chronic pain. According to a systematic review, however, laparoscopic utero-sacral nerve ablation was no more effective than diagnostic laparoscopy for improvement in pain scores. Similarly, laparoscopic lysis of adhesions does not improve pain as compared with diagnostic laparoscopy alone. Women with endometriosis who have persistent disease after medical and surgical therapies may benefit from hysterectomy.
Patients should be referred to a gynecologist for diagnostic or therapeutic surgical procedures, if the underlying diagnosis is unclear, or if expertise is needed to manage the side effects associated with medical treatments (ie, GnRH agonist therapy).
et al. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev. 2014 Mar 5;3:CD008797.
et al. Persistent pelvic pain: rising to the challenge. Aust N Z J Obstet Gynaecol. 2012 Dec;52(6):502–7.
ESSENTIALS OF DIAGNOSIS
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. 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.
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.
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. Topical NSAIDs, such as diclofenac gel or patch, 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.
Patients with mastalgia and a palpable breast mass should be referred to a breast surgeon, even if the results of diagnostic imaging are normal.
et al. A systematic review of current understanding and management of mastalgia. Indian J Surg. 2014 Jun;76(3):217–22.
et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):343–9.
ESSENTIALS OF DIAGNOSIS
Diagnostic imaging is essential for any woman 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). Common benign causes of palpable breast masses include fibroadenomas, cysts, and hamartomas.
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.
B. Diagnostic 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.
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. Diagnostic mammography should be performed in women aged 30 or older with a palpable breast mass. Combining ultrasound with diagnostic mammography may increase the sensitivity of testing; some benign palpable masses may only be visualized on ultrasound.
The differential diagnosis of palpable masses includes benign etiologies, such as simple cysts, fibroadenomas, hamartomas, and phyllodes tumor. 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. Fibroadenomas are typically diagnosed in reproductive age women between the ages of 20 and 40 years and present as firm, nontender, and mobile masses on physical examination. Hamartomas are well-circumscribed and painless on examination and are most common among women aged 30–50 years.
Management of the palpable breast mass depends on the results of diagnostic imaging. If ultrasonography or mammography suggest a benign lesion and this is consistent with the patient's history and physical examination, close clinical and short-interval radiologic follow-up are typically sufficient.
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 concerning and persistent 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. The "triple test," which is composed of the findings on physical examination, the results of diagnostic imaging, and the pathologic diagnosis obtained from 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 biopsy should confirm a benign diagnosis, such as a fibroadenoma. If the results of any of the tests are discordant, further evaluation is warranted.
Certain pathologic diagnoses increase the risk of breast cancer, including papillary lesions, radial scars, atypical ductal or lobular hyperplasia, and lobular carcinoma in situ. Biopsy results that indicate one of these diagnoses necessitate referral to a breast surgeon for further evaluation and management.
et al. ACR appropriateness criteria palpable breast masses. J Am Coll Radiol. 2013 Oct;10(10):742–9.e1–3.
et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):343–9.
Nipple discharge is a common breast complaint but is rarely indicative of malignancy. 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, spontaneous, and not associated with pregnancy or breastfeeding is termed "nonlactational galactorrhea." The most common cause of nonlactational galactorrhea is an elevated prolactin level, which may be associated with pituitary or hypothalamic lesions, systemic diseases (hypothyroidism, renal disease), or medications. Women who have bloody discharge, persistent spontaneous unilateral discharge from a single duct, or discharge associated with a palpable breast mass should be referred for diagnostic mammography and ultrasonography and surgical consultation. These features are suggestive of a pathologic diagnosis, such as intraductal papilloma, duct ectasia, or malignancy. Intraductal papilloma is most common, accounting for 57% of cases, and malignancy is the least common, occurring in only 5–15% of cases of pathologic nipple discharge. Surgical excision of the involved duct is the gold standard for diagnosis. See also Chapter 17.
et al. Evaluation and management of galactorrhea. Am Fam Physician. 2012 Jun1;85(11):1073–80.
et al. Management of nipple discharge and the associated imaging findings. Am J Med. 2015 Apr;128(4):353–60.
et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):343–9.
Female pattern hair loss is the most common type of alopecia in women. More than 55% of women over the age of 70 experience female pattern hair loss, which is characterized by a progressive decrease in the number of terminal hairs and an increase in the number of shorter, vellus hairs (so-called follicular miniaturization). Clinically, presenting signs include diffuse thinning over the central scalp and a prominent midline part, although hair loss can also occur in the parietal and occipital areas. Although occasionally female pattern hair loss may be a sign of hyperandrogenism associated with congenital adrenal hyperplasia, androgen-secreting tumors, or polycystic ovarian syndrome, most women have normal levels of serum testosterone.
The goals of its treatment are to slow hair loss and to stimulate new hair growth. Topical minoxidil is currently the only medication that has been approved by the FDA for the treatment of female pattern hair loss. Once-daily application of topical 5% minoxidil increases hair growth and is well-tolerated; noticeable improvement may occur after 3–6 months of treatment. Spironolactone and cyproterone acetate are oral antiandrogens that have been used for the treatment of female pattern hair loss, although there are limited data to support this practice. Importantly, both of these medications can cause feminization of a male fetus and should be used cautiously in reproductive-age women. Low-level light therapy (in the form of a laser hair comb) induces hair growth by an unclear mechanism and may be used as adjunctive therapy.
et al. Hair: what is new in diagnosis and management? Female pattern hair loss update: diagnosis and treatment. Dermatol Clin. 2013 Jan;31(1):119–27.
et al. The female pattern hair loss: review of etiopathogenesis and diagnosis. Biomed Res Int. 2014;2014:767628.
AGE-RELATED FACIAL CHANGES
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 changes in muscular tone and balance, volume loss, decreased skin elasticity, and changes in skin color and texture. Facial rejuvenation procedures can be grouped into three categories based on their mechanism of action. Neuromodulators are used to produce temporary chemodenervation of hyperactive facial muscles, thereby smoothing facial wrinkles. Soft-tissue fillers restore volume loss, and laser and light-energy based devices improve skin laxity and reflectance. Chemical peels and topical medications are considered adjunctive treatments for improving skin appearance.
For each of the three treatment categories, several options are available. The injectable neuromodulators currently approved by the FDA include various formulations of botulinum toxin A. These therapies are ideal for treating the upper one-third of the face and work best on dynamic wrinkles that form with facial muscle contraction. Contraindications include neuromuscular disorders, a history of keloidal scarring, and pregnancy or breast-feeding. Dermal fillers include collagen, hydroxylapatite, hyaluronic acid, and injectable poly-L-lactic acid, and differ from each other in their degree of cross-linking, gel hardness, and ability to resist dilution. Among these, hyaluronic acid fillers have been approved by the FDA for treatment of nasolabial folds and lip augmentation; they have also been used off-label to treat wrinkles and improve facial volume. Combination therapy with botulinum toxin A and hyaluronic acid is often used in the eyebrow and eyelid regions to achieve more satisfying cosmetic results. Light-based therapy, which includes laser, radiofrequency, and infrared devices, is typically used to improve elasticity in in the upper eye area.
R. Botulinum toxin injection for facial wrinkles. Am Fam Physician. 2014 Aug 1;90(3):168–75.
et al. Nonsurgical rejuvenation of the upper eyelid and brow. Clin Plast Surg. 2013 Jan;40(1):55–76.