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Prognosis
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The prognosis of breast cancer is poorer in men than in women The crude 5- and 10-year survival rates for clinical stage I breast cancer in men are about 58% and 38%, respectively For clinical stage II disease, the 5- and 10-year survival rates are approximately 38% and 10% The survival rates for all stages at 5 and 10 years are 36% and 17% For those patients whose disease progresses despite treatment, meticulous efforts at palliative care are essential (see 5)
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Agrawal A et al Male breast cancer: a review of clinical management Breast Cancer Res Treat 2006 Oct 11; [Epub ahead of print] [PMID: 17033919] Fentiman IS et al Male breast cancer Lancet 2006 Feb 18;367 (9510):595 604 [PMID: 16488803] Jemal A et al Cancer Statistics, 2007 CA Cancer J Clin 2007 Jan Feb;57(1):43 66 [PMID: 17237035] Karhu R et al Large genomic BRCA2 rearrangements and male breast cancer Cancer Detect Prev 2006;30(6):530 4 [PMID: 17113724] Weiss JR et al Epidemiology of male breast cancer Cancer Epidemiol Biomarkers Prev 2005 Jan;14(1):20 6 [PMID: 15668471]
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ABNORMAL PREMENOPAUSAL BLEEDING
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pelvic examination to look for vaginal or cervical lesions, pregnancy, uterine myomas, adnexal masses, or infection
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ESSENTIALS OF DIAGNOSIS
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Blood loss of over 80 mL per cycle Excessive bleeding, often with the passage of clots, may occur at regular menstrual intervals (menorrhagia) or irregular intervals (dysfunctional uterine bleeding) Etiology most commonly dysfunctional uterine bleeding on a hormonal basis
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B Laboratory Studies
Cervical smears should be obtained as needed for cytologic and culture studies Blood studies should include a complete blood count, sedimentation rate, and glucose level to rule out diabetes Diabetes may occasionally initially present with abnormal bleeding A test for pregnancy and studies of thyroid function and coagulation disorders should be considered in the clinical evaluation Up to 18% of women with severe menorrhagia may have a coagulopathy Tests for ovulation in cyclic menorrhagia include basal body temperature records, serum progesterone measured 1 week before the expected onset of menses, and analysis of an endometrial biopsy specimen for secretory activity shortly before the onset of menstruation
General Considerations
Normal menstrual bleeding lasts an average of 4 days (range, 2 7 days), with a mean blood loss of 40 mL Blood loss of over 80 mL per cycle is abnormal and frequently produces anemia When there are less than 21 days between the onset of bleeding episodes, the cycles are likely to be anovular Ovulation bleeding, a single episode of spotting between regular menses, is quite common Heavier or irregular intermenstrual bleeding warrants investigation Dysfunctional uterine bleeding is usually caused by overgrowth of endometrium due to estrogen stimulation without adequate progesterone to stabilize growth; this occurs in anovular cycles Anovulation commonly occurs in teenagers, in women aged late 30s to late 40s, and in extremely obese women or those with polycystic ovary syndrome
C Imaging
Ultrasound may be useful to evaluate endometrial thickness or to diagnose intrauterine or ectopic pregnancy or adnexal masses Endovaginal ultrasound with saline infusion sonohysterography may be used to diagnose endometrial polyps or subserous myomas MRI can definitively diagnose submucous myomas and adenomyosis
D Cervical Biopsy and Endometrial Curettage
Biopsy, curettage, or aspiration of the endometrium and curettage of the endocervix may be necessary to diagnose the cause of bleeding These and other invasive gynecologic diagnostic procedures are described in Table 17 1 Polyps, endometrial hyperplasia, and submucous myomas are commonly identified in this way If cancer of the cervix is suspected, colposcopically directed biopsies and endocervical curettage are indicated as first steps
Clinical Findings
A Symptoms and Signs
The diagnosis usually depends on the following: (1) A careful description of the duration and amount of flow, related pain, and relationship to the last menstrual period (LMP) The presence of blood clots or the degree of inconvenience caused by the bleeding may be more useful indicators (2) A history of pertinent illnesses or weight change (3) A history of medications taken in the past month (4) A history of coagulation disorders in the patient or family members (5) A careful
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