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 disorder, disordered eating in diabetic patients, and binge eating disorders are other eating disorders that should be considered in appropriate women.
1. Female Athlete Triad Disorder
Female athletes who participate in sports and activities valuing thinness are at increased risk for developing the female athlete triad disorder. 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 Women
Eating disturbances have been estimated to be present in up to one-third of young women with diabetes mellitus. Eating disorders are more common in female adolescents with diabetes than in their non-diabetic peers, and in women with type 1 diabetes. 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 women. Proposed strategies for at risk women 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) (see Chapter 29).
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.
Affected women may present with weight gain or may describe binging episodes. There are no specific laboratory findings for this 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 (SSRI) is also helpful, but does not appear to be better than cognitive behavioral therapy. If the woman does not respond to an SSRI, then topiramate and lisdexamfetamine (a medication typically used for attention deficit hyperactivity disorder) have also shown some efficacy. Whether cessation of binge eating disorder has an impact on subsequent weight loss or other obesity-related complications is not clear.
et al. Binge-eating disorder in adults: a systematic review and meta-analysis. Ann Intern Med. 2016 Sep 20;165(6):409–20.
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. Most recent estimates indicate that approximately 40% of women will experience a sexual problem in their lifetime, and 12% will experience significant distress related to this problem. DSM-5 has updated the classification of female sexual dysfunction, combining hypoactive sexual desire, sexual aversion, and sexual arousal disorders into a larger category termed "female sexual interest or arousal disorder." Additional types of female sexual disorder include female orgasmic disorder and genitopelvic pain or penetration disorders. Symptoms must be present for 6 months, be personally distressing to the patient, and meet specific severity criteria (outlined in DSM-5) to ensure an accurate diagnosis.
Although female sexual disorders are common, only about one-third of women seek help from their clinicians so they should invite women to discuss their sexual concerns by routinely initiating dialogue about sexual health during office visits. Patient concerns can be explored with a more complete sexual assessment that should include the onset, duration, and severity of symptoms as well as associated distress. Screening instruments can be useful for identifying specific disorders.
LOW SEXUAL DESIRE DISORDER
The low sexual desire disorder (previously called the hypoactive sexual desire disorder) is the most common type of female sexual dysfunction. In a US study of more than 30,000 women, 12.3% of women ages 45–64 and 7.4% of women older than 65 reported low sexual desire and associated distress. The Decreased Sexual Desire Screener (http://www.sexhealthmatters.org/resources/decreased-sexual-desire-screener) is a validated self-administered questionnaire that can aid clinicians to diagnose this disorder.
The new DSM-5 criteria emphasize that low sexual desire may be associated with arousal disorders, so clinicians should ask patients about response to internal or external sexual cues and sensations during sexual encounters.
Several medical conditions (depression, anxiety, diabetes, urinary incontinence, and multiple sclerosis) and certain medications (antidepressants, hormonal therapy, antihypertensives) can contribute to low sexual desire, so a detailed history is essential for eliciting potentially modifiable risk factors. The gynecologic examination should focus on identifying areas of tenderness or discomfort that might be associated with painful intercourse, thereby reducing sexual desire. Laboratory evaluation rarely aids in diagnosis; testosterone levels do not correlate with female sexual function and should not be measured.
Treatment for low sexual desire includes office-based counseling, psychological therapy, and medications. Office-based counseling can be facilitated using an approach based on the PLISSIT model employed in sex therapy. (The letters of the model's name refer to the four different levels of intervention that a sex therapist can use: permission [P], limited information [LI], specific suggestions [SS], and intensive therapy [IT].) In addition to sex therapy, intensive psychological therapy may include cognitive behavioral training and mindfulness-based stress reduction training (see Chapter e4).
Flibanserin, which is a full agonist of the 5-HT1A receptor and, with lower affinity, an antagonist of the 5-HT2A receptor, is currently the only FDA-approved medication for the treatment of low sexual desire in premenopausal women. A 2016 systematic review evaluated the efficacy of flibanserin in 5914 premenopausal and postmenopausal women. Compared to women taking placebo, women who were taking flibanserin had a small increase in the number of satisfying sexual events (an increase of 0.5 events per 4 weeks) and sexual desire intensity (an increase of 1.6 points per 4 weeks [on an 84-point scale]). However, women in the treatment group were four times more likely to experience the side effects of dizziness and somnolence.
et al. Efficacy and safety of flibanserin for the treatment of hypoactive sexual desire disorder in women: a systematic review and meta-analysis. JAMA Intern Med. 2016 Apr;176(4):453–62.
et al. Female sexual dysfunction: focus on low desire. Obstet Gynecol. 2015 Feb;125(2):477–86.
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. This disorder is common, with a prevalence rate of between 6.4% and 16.9%, and it is associated with diminished quality of life, increased fatigue, lessened work capacity, and marital dysfunction.
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, pelvic congestion syndrome, ovarian remnant, and adenomyosis should also be considered. Interstitial cystitis, irritable bowel syndrome, and pelvic floor myalgia arising from trigger points in the pelvic floor have all been associated with chronic pelvic pain. Tightness of the piriformis and obturator muscles, hip arthritis, labral pathology, lumbar spondylosis, and nerve entrapment can contribute to pelvic discomfort. 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 (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 confirming a suspected diagnosis, such as an ovarian endometrioma. Laparoscopy is considered the gold standard for diagnosis of gynecologic disorders, such as endometriosis or pelvic adhesions.
Chronic pelvic pain may be associated with gynecologic and nongynecologic conditions; it is not uncommon for more than one causative diagnosis to be present in a particular woman. Gastrointestinal disorders (irritable bowel syndrome) and functional urinary syndromes (interstitial cystitis) are the most common nongynecologic diagnoses that may contribute to chronic pelvic pain. Clinicians should perform a careful examination of the gastrointestinal, urologic, musculoskeletal, and neurologic systems in order to evaluate for these possibilities. Chronic pelvic pain may also be diagnosed in the absence of clear identifiable underlying pathology.
Successful treatment of chronic pelvic pain is typically multifaceted with its main goals being to improve the patient's quality of life and functional status while minimizing adverse effects.
Pharmacologic treatment strategies include analgesics, anxiolytics, antidepressants, hormonal therapies, anesthetics, and membrane stabilizers (eg, gabapentin).
Hormonal therapies are used primarily for treating gynecologic sources of chronic pelvic pain. Women with suspected endometriosis can be empirically treated with hormonal therapy before diagnostic laparoscopy is performed. Combined oral contraceptives, intrauterine levonorgestrel, and GnRH analogs are effective for treating the dysmenorrhea associated with endometriosis, although the side effects vary. 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.
The most common musculoskeletal source of chronic pelvic pain is pelvic floor myalgia, also known as levator ani syndrome. This condition is most effectively treated with pelvic physical therapy, which focuses on transvaginal muscle treatments. Additional therapies may include levator trigger point injection and perhaps botulinum toxin injections.
Treatment of irritable bowel syndrome and interstitial cystitis are discussed in Chapters 15 and 23.
Women with endometriosis may be offered laparoscopic surgical destruction of implants; presacral neurectomy may be a useful adjunct in those patients with midline pain. Women with significant dysmenorrhea, centrally-localized and cyclical pain who have persistent symptoms after medical and surgical therapies may benefit from hysterectomy.
Pelvic congestion syndrome may be treated with percutaneous embolization, or sclerotherapy of pelvic veins may also be effective.
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).
Some patients may benefit from a multidisciplinary approach, involving pain psychologists and psychosexual counselors to help manage the effects of chronic pelvic pain on quality of life.
et al. Chronic pelvic pain in women: an epidemiological perspective. Womens Health (Lond). 2015 Nov;11(6):851–64.
et al. Medical management of endometriosis in patients with chronic pelvic pain. Semin Reprod Med. 2017 Jan;35(1):38–53.
et al. Pharmacological management of chronic pelvic pain in women. Drugs. 2017 Mar;77(3):285–301.
et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016 Oct;27(10):1478–86.e8.
et al. Surgical management of endometriosis in patients with chronic pelvic pain. Semin Reprod Med. 2017 Jan;35(1):54–64.
et al. A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain. Int Urogynecol J. 2015 Jun;26(6):845–52.
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. Approximately two-thirds of patients with breast pain experience cyclical mastalgia, which is caused by the effects of ovulation-induced hormonal fluctuations on glandular breast tissue. Similarly, women who take combined oral contraceptives or hormone replacement therapy may also experience cyclical mastalgia. 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, thoracic vein thrombophlebitis, or 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 typically diffuse and bilateral and is associated with the menstrual cycle or hormonal therapies that are administered cyclically (contraception or hormone replacement). Conversely, noncyclical mastalgia, which may be constant or intermittent, is variable in location and can involve one or both breasts. Patients with noncyclical pain related to breast malignancy may describe progressively intense discomfort. 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. Women with large, pendulous breasts may have noncyclical mastalgia that is caused by stretching of Cooper ligaments. Extramammary causes of mastalgia, such as inflammation of the pectoralis major muscle or costochondral junction, can usually be diagnosed through careful palpation. Mondor disease, which is caused by superficial thrombophlebitis of the lateral thoracic vein, is associated with a red, tender, palpable cord.
An ultrasound, mammogram, or both should be obtained in women who have a palpable breast mass or in whom Mondor disease is suspected since this diagnosis may be associated with breast cancer. Additionally, imaging may be considered for women who experience localized mastalgia that is not clearly associated with a specific diagnosis.
Clinicians can reassure young women who experience cyclical mastalgia that has been present for less than 6 months about the benign (likely hormonal) nature of their symptoms. Similarly, if screening mammography is normal, clinicians can reassure women over the age of 35 with this symptom.
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 or cyclical hormonal treatment.
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. Dietary changes, which include minimizing caffeine, fat, and salt intake, may also be beneficial. Women who experience mastalgia related to combined hormonal contraception may benefit from skipping the hormone-free week, whereas postmenopausal women may consider minimizing the dose of hormone replacement therapy or discontinuing it altogether. Tamoxifen, a selective estrogen receptor modulator, is effective for the treatment of moderate to severe cyclical mastalgia that has not responded to conservative therapy. Symptoms are reduced in up to 75% of women who are treated for 3 months. Danazol, the only FDA-approved medication for cyclical mastalgia, is also effective, but is associated with significant side effects (nausea, headaches) and is contraindicated in women who are attempting to become pregnant.
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 specialist.
ACOG Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 164: Diagnosis and management of benign breast disorders. Obstet Gynecol. 2016 Jun;127(6):e141–56.
et al. Benign breast diseases: evaluation and management. Clin Obstet Gynecol. 2016 Dec;59(4):710–26.
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). 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. Clinicians should note the size, site, mobility, and texture of the mass, as well as areas of skin dimpling, retraction, or erythema. A thorough examination of the axillary and supraclavicular lymph node areas is essential. 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 cysts are common, affecting nearly one-third of women aged 35–50 years. 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. Patients with phyllodes tumor may report rapid growth of a large, painless breast mass. Fibroadenomas typically affect women between the ages of 20 and 40 years and present as firm, nontender, and mobile masses on physical examination. Cysts are solitary, smooth, and firm and are associated with changes in the menstrual cycle.
A. Women Younger Than 30 Years
In this age group, management of the palpable breast mass depends on the clinician's suspicion for malignancy as well as the results of the initial ultrasound. Masses with a low likelihood of malignancy in the setting of a normal ultrasound can be monitored closely with serial physical examinations. Highly suspicious masses that appear normal on ultrasound should be further evaluated with diagnostic mammography.
Simple cysts can be followed expectantly, whereas a complex cyst may require additional evaluation with fine-needle aspiration and cytology or with biopsy. Cysts can be categorized as probably benign, suspicious, or highly suspicious based on their ultrasound characteristics. Again, if clinical concern for malignancy is high, even patients with probably benign findings on ultrasound (or mammogram) should be referred for biopsy. All patients with suspicious or highly suspicious findings require biopsy.
B. Women Aged 30 Years and Older
Diagnostic mammography is the initial test of choice in women age 30 years and older with a palpable breast mass. If the mammography results are negative, benign, or probably benign, then additional management depends on clinical suspicion and breast ultrasound results. In the setting of a low clinical suspicion for malignancy, masses with negative ultrasound results can be monitored closely. Conversely, in the setting of worrisome history or physical examination findings, tissue biopsy should be pursued even if both mammogram and ultrasound are normal.
The management of simple cysts in women age 30 years and older is similar to that in younger women. Solid masses that are classified as probably benign on mammography and ultrasound should be monitored very closely if clinical suspicion is low but otherwise referred for biopsy. Biopsy is recommended to evaluate any mass that appears suspicious or highly suspicious on ultrasound or diagnostic mammogram.
Certain benign breast masses may be classified as nonproliferative (breast cysts, ductal ectasia) or proliferative (sclerosis, adenosis, radial scars, ductal hyperplasia, intraductal papilloma). Proliferative lesions are associated with a slightly increased risk of subsequent breast cancer diagnosis, although the absolute risk is low in most patients.
All patients with suspicious or highly suspicious masses on diagnostic imaging (mammography or ultrasound) should undergo breast biopsy, regardless of age.
Even with normal diagnostic mammography and ultrasound, if clinical suspicion for malignancy is high, all women should be referred to a breast specialist.
ACOG Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 164: Diagnosis and management of benign breast disorders. Obstet Gynecol. 2016 Jun;127(6):e141–56.
et al. ACR Appropriateness Criteria: palpable breast masses. J Am Coll Radiol. 2016 Nov;13(11S):e31–42.
et al. Benign breast diseases: evaluation and management. Clin Obstet Gynecol. 2016 Dec;59(4):710–26.
Female pattern hair loss is the most common type of alopecia in women. This condition is characterized by shortening of the hair growth (anagen) phase, shedding of terminal hairs, follicular miniaturization, and prolongation of the resting phase (telogen), during which the hair follicle remains empty. 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. A positive "pull test" (greater than 6 hairs extracted with firm grasping and pulling) is suggestive of female pattern hair loss. There are no specific laboratory abnormalities associated with this condition, although some clinicians recommend checking serum thyroid, iron, zinc, and vitamin D levels. The majority of women with female pattern hair loss have normal serum testosterone levels. However, clinicians should perform testosterone, DHEAS, and prolactin testing in any patient presenting with female pattern hair loss and other signs of hyperandrogenism, such as virilization or severe acne.
The goals of 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 minoxidil increases hair growth and is well-tolerated; both the 2% and 5% preparations are equally efficacious. Noticeable improvement may require at least 12 months of treatment, and hair loss will resume if the medication is stopped. Side effects of minoxidil include facial hypertrichosis, scaling, and dryness. Although finasteride, a 5 alpha-reductase inhibitor, is effective for the treatment of male pattern hair loss, there are few data to support its use in female pattern hair loss. The results of a systematic review demonstrated that low-level light therapy (in the form of a laser hair comb) increases total hair count; it may be used as adjunctive treatment. Data are limited regarding the efficacy and safety of spironolactone, dutasteride, and cyproterone acetate, and these agents should not be used as first-line therapies.
et al. Interventions for female pattern hair loss. Cochrane Database Syst Rev. 2016 May 26;(5):CD007628.
ASYMPTOMATIC OVARIAN MASSES
ESSENTIALS OF DIAGNOSIS
Transvaginal ultrasound is the preferred test for evaluating an ovarian mass in both premenopausal and postmenopausal women.
CA-125 is a useful tumor marker for the evaluation of ovarian masses in postmenopausal women but has limited specificity in premenopausal women.
The Risk for Malignancy Index (RMI) is a helpful tool for assessing the risk of malignancy in women with an ovarian mass.
Ovarian masses are common, affecting up to 20% of women. Many of these masses are found incidentally, often as part of a radiologic work-up for another symptom, such as abdominal pain. Although the vast majority of ovarian masses in premenopausal women are benign, the incidence of ovarian cancer increases with age. Additionally, up to 10% of suspected ovarian masses may be related to nonovarian disease (see eTable 18–3 for more details). The role of the primary care clinician is to provide prompt referral to a gynecologist or gynecologic-oncologist based on the likelihood of malignancy and the need for potential surgical management.
Although many ovarian masses are discovered incidentally, patients should be asked about any potential symptoms that might be associated with ovarian malignancy, such as persistent abdominal bloating, anorexia, early satiety, pelvic or abdominal pain, or increased urinary urgency and frequency. Clinicians should also assess the patient's underlying risk by obtaining a thorough family history, especially with regards to diagnoses of breast, uterine, colon, or ovarian cancers.
Although the physical examination is relatively insensitive for the diagnoses of ovarian masses, it is important to examine for any associated findings, such as lymphadenopathy. Palpable pelvic masses that are irregular, solid, fixed, nodular, bilateral, or associated with ascites are particularly concerning for malignancy, and should prompt urgent referral to a gynecologist.
B. Diagnostic Tests and Imaging
Serum CA-125 is a biomarker that is expressed by the majority of epithelial ovarian cancers. However, its serum level is also elevated in other benign conditions in premenopausal women, such as endometriosis, pelvic inflammatory disease, and adenomyosis. As a result, the serum CA-125, by itself, is unreliable for assessing the risk of ovarian cancer in reproductive-age women (sensitivity 50–74%, specificity 26–92%). In contrast, in postmenopausal women, the serum CA-125 is more useful for differentiating benign conditions from ovarian cancer. As a consequence, the serum CA-125 is often routinely sent in the assessment of ovarian masses in postmenopausal women. A CA-125 value above 35 units/mL is considered abnormal, but rising levels on serial determinations are more helpful than a single value. Serum lactate dehydrogenase (LD), alpha fetoprotein (AFP), and human chorionic gonadotropin (hCG) may be elevated in germ cell tumors, and these markers should be ordered in premenopausal women (under age 40 years) who have complex ovarian masses on ultrasound imaging.
Transvaginal ultrasound is the diagnostic test of choice in any premenopausal or postmenopausal woman presenting with an ovarian mass. Ultrasonography should be performed by clinicians with expertise in gynecologic imaging who can provide a thorough description of the morphology and ultrasonographic features of the mass.
Ultrasound detection of a simple cyst is associated with a benign process in 95–99% of postmenopausal women. Simple cysts are characterized by a round or oval shape, a thin wall, posterior acoustic enhancement, anechoic fluid, and an absence of septations or nodules. Complex cysts may have solid components, septations, and papillary projections.
Ovarian masses may be characterized according to the International Ovarian Tumor Analysis (IOTA) "rules" (http://www.iotagroup.org/), which help to differentiate benign from malignant ovarian masses processes (sensitivity 95%, specificity 91%). According to the IOTA classification, an ovarian mass is suspicious of being malignant when any of the following features are present: irregular multilocular solid tumor with largest diameter greater than 1 cm, four or more papillary structures, ascites, prominent blood flow on color Doppler. If an ovarian mass is suspected of being malignant, the patient should be urgently referred to a gynecologic oncologist.
Ovarian masses may be benign, malignant (both primary and secondary malignancy) or nonovarian in origin. See eTable 18–3 for additional details regarding differential diagnosis.
Women with ovarian masses can be managed conservatively, monitored closely with surveillance imaging, or referred for surgical intervention. Since the risk of ovarian cancer increases with age, a patient's menopausal status is a critical determinant for guiding management decisions, as detailed below.
Simple asymptomatic cysts that are less than 5 cm in diameter typically resolve over two or three menstrual cycles and do not require any further management. Pelvic ultrasound should be repeated yearly in women with simple cysts that are 5–7 cm in diameter. Women with larger cysts (greater than 7 cm) should be referred for gynecologic evaluation.
Premenopausal women with complex cysts or ovarian masses that have worrisome features on ultrasound should be referred for gynecologic evaluation. In these situations, measurement of the serum CA-125 may be helpful in guiding management. Serum CA-125 levels that are less than 200 units/mL may be associated with benign gynecologic conditions, such as endometriosis, whereas levels greater than 200 units/mL (and especially if rising on serial determinations) are concerning for ovarian cancer and should prompt consultation with a gynecologic oncologist.
Guidelines recommend measurement of serum LD, AFP, and hCG levels in all women under the age of 40 who present with a complex ovarian mass, in order to assess for the possibility of germ-cell tumors.
The serum CA-125 level should be measured routinely in all postmenopausal women with an ovarian mass. This value can then be used in calculating the RMI, which has a high sensitivity and specificity for predicting the likelihood of ovarian cancer. The RMI is a product of the patient's menopausal status, serum CA-125 level, and ultrasound score (higher scores assigned according to the presence of ascites, solid areas, metastases, multilocular and bilateral lesions). Using a cut-off value of 200, the RMI has a sensitivity of 78% and specificity of 87% for differentiating malignant from benign ovarian lesions.
If the RMI is less than 200, postmenopausal women with asymptomatic, small (less than 5 cm), unilocular and unilateral simple cysts can be monitored with surveillance imaging. Guidelines recommend repeat assessment with a transvaginal ultrasound and CA-125 measurement in 4-6 months; masses which are persistent, enlarging, or have any change in features should be referred for gynecologic evaluation and possibly surgical intervention.
Postmenopausal women with an ovarian mass and a calculated RMI greater than or equal to 200 have an increased risk of malignancy. A CT scan of the abdomen and pelvis should be performed to more fully stage disease extent, and these women may be referred to a gynecologic oncologist for additional evaluation and possible surgery.
et al. Evaluation and management of ultrasonographically detected ovarian tumors in asymptomatic women. Obstet Gynecol. 2016 May;127(5):848–58.
M. Investigation and management of an ovarian mass. Aust Fam Physician. 2015 Jan–Feb;44(1–2):48–52.