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Benign breast disease includes mastalgia, fibrocystic breast disease (FBD), breast cellulites and abscesses, nipple discharges, and galactorrhea. FBD is the most common benign breast disease. FBD starts as microcysts and accompanying fibrosis in 65% of women. The cysts become larger as the woman ages, and can reach 3 to 4 cm. Breast infections can affect the skin, producing a primary cellulitis, or may be secondary to an infection of a sebaceous gland, axillary gland, or lymph node, such as in hidradenitis supparativa. Most mastitis occurs in breast-feeding women. Nipple discharges are the third most common complaint concerning 5% of women attending breast clinics. Discharges associated with a breast mass are more likely to be related to cancer. Diseases that affect the hypothalamic and pituitary areas such as sarcoidosis, tuberculosis, histocytosis, and multiple sclerosis can cause galactorrhea. Galactorrhea is often physiological or caused by medication or treatable hormonal disorders.
Women's causes of infertility include ovarian and tubal or mechanical factors. Cervical and uterine factors can include an abnormally shaped uterus (bifid, bicornuate, or anatomy changed by fibroids) or inimical cervical mucus. Both partners should be examined and cultured for sexually transmitted disease, especially chlamydia. Counseling the couple about the normal menstrual and ovulation cycle, about the effects of medications and alcohol on fertility, and about expectations on becoming pregnant is important. The effect of the infertility depends on the age of the couple, their personality and coping styles, pre-existing psychopathology, medical causes, and motivations for pregnancy. Five percent of children born to unmarried mothers during the 1990s were placed in adoption. The family physician can often make a positive impact on a couple's quest for fertility, using simple office-based diagnosis and treatment. The physician can help couples through fertility treatment and also through the problems and concerns of adoption.
This chapter discusses the etiology, diagnosis and treatment of certain sexually transmitted diseases (STDs), including gonococcal (GC) infections, chlamydia infections, syphilis, genital herpes, pelvic inflammatory disease, HIV/AIDS, and hepatitis B. Gonorrhea is frequently asymptomatic in both men and women. Patients with gonococcal infections need to be evaluated for other sexually transmitted diseases, including chlamydia, HIV, hepatitis B and/or syphilis when appropriate. Neurosyphilis can occur, with symptoms of central nervous system (CNS) changes such as tabes dorsalis or dementia. All patients with syphilis should be tested for hepatitis B and HIV infections. Sex partners of women with pelvic inflammatory disease (PID) should be treated, especially to cover chlamydia and gonorrhea. Testing for HIV should be offered to all women, not just those whose behaviors may put them at risk of transmission, but to all women with an STD, including HPV.
This practical handbook provides a clear and comprehensive evidence-based guide to the care of women in primary care, intended for general and family practitioners, nurses, physician assistants, and all those who practise primary care of women. It emphasizes preventive and well-woman care throughout the life-cycle of a woman, including sexuality, contraception, medical care in pregnancy, and psychological and important medical concerns. This second edition, revised and updated throughout with several new contributing authors, incorporates the latest evidence and research-findings on a wide range of problems for which women seek medical guidance. There is an expanded section on menstrual problems and menopause-associated conditions, including clear guidance on the use of hormone replacement therapy.
This chapter presents the definition, risk factors, symptoms, diagnosis and treatment of chronic pelvic pain (CPP), dysmenorrhea, and dyspareunia. The most common causes of CPP are gastrointestinal. Irritable bowel syndrome (IBS), constipation, and diverticulitis, all can cause chronic pelvic pain. Women with high stress levels have two times the risk of dysmenorrhea. A higher risk of suffering dysmenorrhea occurs in women who are overweight. Women with dyspareunia had higher pain scores and higher levels of psychological distress, low levels of marital adjustment and more problems with sexual function. Treatment of dyspareunia is based on one of the three types: insertional dyspareunia, pain in a specific location, and pain with deep penetration. Pain associated with menopausal disorders and sexual relations is common and often the presenting complaint to the physician. The case of dyspareunia may be difficult to discover but an organized approach including psychological expectations may produce improvement.
Breast cancer is one of the most common cancers in women. The goal of the primary prevention of breast cancer is to avert the development of cancer in healthy women. Medications such as tamoxifen and raloxifene prevent development of breast cancer by interrupting the process of initiation and promotion of tumor. The antiestrogenic effects of these agents lead to growth inhibition of malignant cells. Screening for breast cancer can lead to the detection of preinvasive lesions such as ductal carcinoma in situ (DCIS) and early small node-negative cancers. Mammography reduces the mortality of breast cancer. Although the incidence of breast cancer increases with age, few studies have investigated the efficacy of mammography in women older than age 70. In women at high risk for breast cancer because of genetic syndromes, MRI of the breast is found to be more sensitive than mammography alone.
Prevention for the older person includes maintaining quality of life, preserving function, preventing collapse of family support systems, and maintaining independence in the community. Older women often have substantial responsibilities caring for spouses, siblings, children, and grandchildren. Significant levels of depression are seen in caregivers of Alzheimer's patients. Women access the health care system more frequently than do men. They receive more health services and prescriptions, undergo more examinations, laboratory tests, and blood pressure checks than men. Depression is the most commonly diagnosed mental illness in older adults in the primary care setting, although it often goes unnoticed. Abuse is best correlated with the emotional and financial dependence of the caregivers on the geriatric victims. By attending to the differing risk factors of older women and following a systematic periodic evaluation, physicians can assist older women in maintaining their health and functional status.
The menstrual and urogenital changes associated with perimenopause can be very distressing. Seventy-five percent of postmenopausal women experience atrophic genital changes. Vasomotor symptoms are often the most disruptive perimenopausal symptoms that a woman experiences. These can occur even before she sees any change in her menstrual pattern. There is significant variation in an individual woman's response to these, and the symptoms can be distracting, cause insomnia, and lead to unpleasant social situations. Menstrual patterns are altered in many ways, including menorrhagia, menometrorrhagia, oligomenorrhea, intermenstrual bleeding, polymenorrhea, postcoital bleeding and postmenopausal bleeding. In one small survey, 93% of women reported one of these changes in the five years prior to menopause. Etiologies of abnormal menstrual bleeding include endocrine abnormalities, pregnancy related, infectious (genital and systemic), neoplasms (benign and malignant) of pelvic organs, uterine abnormalities, coagulation disorders, liver disease, medication (iatrogenic), and trauma. Women with life-threatening bleeding need immediate treatment.
This introduction presents an overview on women's health. It also presents societal differences, inherent physical and medical differences between men and women. Much of the research on women's health concerns has emphasized women's genitourinary organs and diseases and childbearing diseases. Men and women often live different lives within society and the way they live affects their health. In caring for the woman with addiction, dealing with her individual circumstances is very important. Women are less likely to use smoking cessation programs, especially work-related programs, and are less likely to quit. Women are usually less likely to become infected (except with AIDS) and more likely to develop autoimmune diseases. Women are more likely to be caregivers, elderly, poor, alone and uninsured, making their health care needs and treatment different than those of men. Women's immunology, drug use and metabolism may differ and may affect the treatment of diseases.
Contraception is an inherent part of good health care for women. Emergency contraception (EC) is birth control used to prevent pregnancy after known or suspected failure of contraception or unprotected intercourse, including sexual assault. Women who use EC should be given additional opportunities to consider whether a more permanent or better method of contraception is warranted. Once adolescents have had a sexual experience, they may be even more open to reconsidering abstinence and should be encouraged to consider abstinence as a potential choice. Certain types of condoms provide some protection against sexually transmitted infections. Oral contraceptive pills (OCPs) are hormonal methods of birth control. For most women, pregnancy and/or abortion are associated with a greater risk of mortality and morbidity than oral contraceptives. Male sterilization is the most cost-effective contraceptive method, with a failure rate of 0.1 to 4%. Many circumstances affect a woman's access to contraception.