Overview | Treatment

Definition

Common, benign breast changes. The term "disease" in this case is misleading and many providers prefer the term "change." The condition is so commonly found in normal breasts, it is believed to be a normal variant. Other related terms include "mammary dysplasia," "chronic cystic mastitis," "benign breast disease," and "diffuse cystic mastopathy."

Alternative names

chronic cystic mastitis; mammary dysplasia; benign breast disease

Causes, incidence, and risk factors

The cause is not completely understood, but the changes are believed to be associated with ovarian hormones since the condition usually subsides with menopause. The incidence of it is estimated to be over 60% of all women. It is common in women between the ages of 30 and 50 and rare in postmenopausal women. The incidence is lower in women taking oral contraceptives (birth control pills). The risk factors may include family history and diet (such as excessive dietary fat, and caffeine intake), although these are controversial.

Prevention

Reduction of dietary fat and caffeine if you have fibrocystic breast changes has been suggested, although recent studies have questioned the role of caffeine and fat in fibrocystic disease.

Symptoms

• a dense, irregular and bumpy "cobblestone" consistency in the breast tissue
• usually more marked in the outer upper quadrants
• breast discomfort that is persistent or that occurs off and on (intermittent)
• breast(s) feel full
• dull, heavy pain and tenderness
• premenstrual tenderness and swelling
• breast discomfort improves after each menstrual period
• nipple sensation changes, itching

Note: Symptoms may range from mild to severe. Symptoms typically peak just before each menstrual period and improve immediately after the menstrual period.

Signs and tests

Physical examination reveals the presence of mobile (non-anchored) breast "masses." These masses are usually rounded, with smooth borders, and either rubbery or slightly fluctuant (changeable in shape). Dense tissue may make the breast examination more difficult to interpret.

• mammography may be difficult to interpret due to dense tissue.
• a biopsy of the breast may be necessary to rule out other disorders.
• aspiration of the breast with a fine needle is often diagnostic and therapeutic for larger cysts.

Overview | Treatment

Overview | Test Results

Definition

An X-ray picture of the breasts; used to detect tumors and cysts and help differentiate benign (non-cancerous) and malignant (cancerous) disease.

Alternative names

mammogram

How the test is performed

You will be asked to undress from the waist up and will be given a gown to wear. Depending on the type of equipment used, you will sit or stand. One breast at a time is rested on a flat surface that contains the X-ray plate, and a device called a compressor will be pressed firmly against the breast to help flatten out the breast tissue. The X-ray pictures are taken from several angles. You may be asked to hold your breath while the picture is taken.

How to prepare for the test

Deodorant, perfume, powders and ointments under the arms or on the breasts may cause the pictures to be obscured and should not be worn the day of the X-ray. Remove all jewelry from the neck. Notify your health care provider (and/or the radiologist) if you are pregnant or breast-feeding.

How the test will feel

When the breast is compressed, there may be some discomfort.

Risks

The level of radiation is low and any risk from the mammography is exceedingly low. If you are pregnant and need to have an abnormality checked, the abdominal area will be shielded by a lead apron.

Why is the test done

A mammogram is the most accurate test for breast cancer. Approximately 90 to 95% of breast cancers are detected with mammography. Mammography is important because it can detect cancers before you can feel them with your fingers.

Overview | Test Results

Normal values

The test is performed if a woman has symptoms of a breast disease such as a lump, nipple discharge, breast pain, dimpling of the skin on the breast, or a new retraction of the nipple.

Screening mammograms are important for early cancer detection, even when you donandamp;#8217;t have symptoms. The American Cancer Society recommends mammogram screening every year for all women age 40 and older.  The National Cancer Institute recommends mammogram screening every 1-2 years for women age 40 and older. 

In addition to mammography, clinical breast exams (where the clinician palpates with the fingers) and breast self-exam are important for breast cancer screening. Women age 20 and older should receive clinical beast exams every three years; women age 40 and older should receive clinical breast exams every year.  The American Cancer Society recommends that all women age 20 and older perform monthly breast self exam.

These are general recommendations for mammography, clinical breast exams, and breast self exam. Women should discuss with their personal physician how often to receive breast cancer screening, including mammography and clinical breast exam. Recommendations can vary depending on personal risk factors such a strong family history of breast cancer.

What abnormal results mean

Breast tissue that shows no evidence of mass (aggregations of cells) or calcification is considered normal.

Costs

A well-outlined, regular, clear spot is more likely to be a benign lesion, such as a cyst (non-cancerous).

A poorly outlined, opaque area is more likely to suggest a cancer.  However, not all benign lesions are perfectly round, and some cancers may appear well-defined.  When findings suspicious for a cancer are found on a mammogram, a biopsy is performed to determine if a lesion is benign or cancerous.

Additional conditions under which the test may be performed:

• breast cancer
• breast infection
• fibrocystic breast disease
• lumps in the breasts
• breast pain
• nipple discharge

Special Considerations

The estimated cost is $100 to $150.

Overview | Treatment

Definition

A disorder in which palpable lump(s) are felt in the tissue of one or both breasts. Such breast lumps may be either benign (noncancerous) or malignant (cancerous).

Alternative names

fibroadenoma; breast mass

Causes, incidence, and risk factors

There are many causes for lumps in the breast, including normal physiologic findings. Some lumps are age dependent. Both male and female newborn infants have lumps of enlarged breast tissue beneath the nipple, which have been stimulated by maternal hormones. These disappear within a few months of birth.

Beginning as early as age 8, girls may develop tender lumps beneath one or both nipples (frequently only one). These lumps are breast buds and are one of the earlier signs of the beginning of puberty. Boys at mid-puberty (usually around age 14 or 15) may develop tender lumps beneath one or both nipples, also in response to the hormonal changes of puberty. These tend to disappear over a period of 6 months to 1 year. It is also important to remember that hormonal changes just prior to menstruation may cause a lumpy or granular feeling to the breast tissue.

All lumps in the adolescent and adult female breast are not cancer, although the discovery of a lump brings that scenario immediately to mind. It is important to remember that 80% to 85% of all breast lumps are benign, especially in women less than age 40 to 50. Benign causes include fibrocystic breast changes, fibroadenoma, fat necrosis (damage to some of the fat tissue within the breast), and breast abscess.

Fibrocystic breast disease
The term "condition" is preferred to "disease" by many providers since it occurs so frequently in the normal population. The cause is not completely understood but is believed to be associated with ovarian hormones, since the condition usually subsides with menopause. The incidence is estimated at over 60% of all women. It is common in women aged 30 to 50 and is rare in postmenopausal women. The incidence is lower in women taking oral contraceptives (birth control pills). Risk factors may include heredity and diet (excessive dietary fat, caffeine intake).

Fibroadenoma
The cause is not known; however, some research suggests that increased fat consumption may play a role. The highest incidence is in women from their teen years into their 20s. Fibroadenomas rarely develop after age 30. Single or multiple fibroadenomas may develop in one or both breasts.

Fat necrosis
Trauma is presumed to be the cause. Bruising is occasionally noted near the lump. The area may or may not be tender. The mass may be associated with skin or nipple retraction. A fat necrosis mass cannot be distinguished from breast cancer without biopsy.

Breast abscess
In breastfeeding women, a local breast infection introduced through the nipple may wall off into an abscess. Young to middle-aged women who are not breastfeeding rarely develop subareolar abscesses (located beneath the areola, which is the darker area around the nipple). Potential abscesses in breast tissue other than the subareolar area are excessively rare in women who are not breastfeeding, and such abscesses should be surgically removed and biopsied.

Breast cancer
Breast cancer may occur in men and women, but it is much more common in women. The cause is unknown; however, a number of predisposing factors have been identified. Recent statistics say that 1 in 8 or 9 American women will develop breast cancer at some point in her life. Risk increases exponentially after age 30. The average age of women diagnosed with breast cancer is 60. In general, the rate of breast cancer is lower in underdeveloped countries and higher in more affluent countries (with the exception of Japan, where the rate is quite low). In the United States, whites (especially those of northern European descent) have a higher incidence compared to other racial groups. However, the incidence in blacks is increasing, particularly in women less than age 60.

Other risk factors include: family history of breast cancer, particularly in mother or siblings; past medical history of breast, ovarian, uterine, or colon cancer; menstrual history consistent with early menarche (start of menstruation before age 12) or late menopause (after age 50); no pregnancies or first pregnancy after the age 40; and radiation exposure. Postmenopausal estrogen therapy and oral contraceptive use are considered possible risk factors, but the majority of recent studies do not indicate such risk.

Prevention

Avoiding excessive fat and caffeine in the diet may be helpful in avoiding fibrocystic changes in the breast tissue. Most of the associated risk factors for breast cancer cannot be controlled and this eliminates a means of primary prevention. Secondary prevention, early detection, and appropriate treatment early in the disease process may be promoted through routine breast self-examinations and screening mammography after age.

Experimental studies are underway to determine if the drug tamoxifen can decrease the risk of breast cancer in women with a family history of breast cancer (mother, maternal aunts, and the affected individual's sisters). Preliminary results showed that tamoxifen significantly decreased the incidence of breast cancer in women at high risk for the disease. In some women, the risk of breast cancer can be reduced by as much as 49% when drugs such as tamoxifen are taken regularly. Tamoxifen use is also associated with the development of blood clots in the legs and with uterine cancer. See your health care provider to find out if you should take tamoxifen to prevent breast cancer.

Symptoms

A potentially malignant breast lump (cancer) may show a number of these symptoms:

• breast mass noted upon self-examination
• usually painless, firm to hard, with irregular borders
• spontaneous nipple discharge
• usually bloody or serous (straw-colored fluid)
• nipple changes
• retraction, enlargement, or itching
• breast asymmetry aside from the previous norm
• skin changes
• dimpling, retraction, "orange peel" appearance
• redness, accentuated veins on breast surface and eventually, with late disease, skin ulceration
• bone pain
• weight loss
• armpit lump
• swelling of the arm

Note: Benign fibrocystic changes may range from mild to severe during the menstrual cycle. Symptoms typically peak just before each menstrual period and improve immediately after the menstrual period. The breast tissue has a dense, "cobblestone" consistency, usually more marked in the outer quadrants. An intermittent or persistent sense of breast "fullness" with dull, heavy pain and tenderness is experienced.

Signs and tests

Benign fibrocystic changes frequently are noted in both breasts. Benign lumps are usually rounded with smooth borders, either rubbery or slightly movable, and non-anchored. Associated nipple discharge occurs only after manipulation of the nipple, is milky looking, and may be expressed from both breasts.

For a potentially malignant breast lump (cancer), the health care provider confirms the breast changes noted by the patient. There may be spontaneous nipple discharge on one side from a single duct. Armpit (axillary) node enlargement/tenderness may be noted.

A mammography may delineate the breast mass. A needle aspiration does not yield fluid consistent with a cyst and the mass persists after aspiration. An ultrasound may be performed to differentiate between a solid and cystic mass. Cancer more commonly shows a solid mass.

Biopsies confirm or rule out suspected cancer in solid lumps:

• needle biopsy - removal of cells for evaluation directly from the mass (can be done in conjunction with needle aspiration procedure)
• incisional biopsy - surgical removal of a portion of the mass for evaluation
• excisional biopsy - surgical removal of entire mass for evaluation

Overview | Treatment

Treatment

For known, diagnosed fibrocystic breast changes, a woman should examine her breasts monthly. A well-fitting bra should be worn to provide good breast support. The effectiveness of vitamin E, vitamin B6, and herbal preparations such as evening primrose oil are somewhat controversial and should be discussed with your health care provider. Self-care may also include restricting dietary fat to approximately 25% of the total daily calorie intake and eliminating caffeine intake and cigarette smoking to see if symptoms subside.

Oral contraceptives may be prescribed because they often decrease symptoms.

The choice of initial treatment for biopsy-confirmed breast cancer is based upon the extent and aggressiveness of the disease. Currently, breast cancer is viewed as a systemic disease that requires both local and systemic treatment. Local treatment may include lumpectomy, mastectomy (partial, total, or radical with axillary dissection), and radiation therapy, all directed at the breast and surrounding tissue. Systemic treatment includes chemotherapy and hormonal therapy, which circulate throughout the entire body in an attempt to eliminate cancer cells that may be present in distant parts of the body. Most women receive a combination therapy including surgery, radiation, chemotherapy, and hormonal therapy.

Prognosis

The prognosis depends on the type of problem. See the specific condition for detailed information regarding prognosis.

Complications

Because fibrocystic changes may make breast examination and mammography more difficult to interpret, early cancerous lesions may occasionally be overlooked.

Even with aggressive and appropriate treatments, breast cancer often spreads (metastasizes) to distant sites such as the lungs, liver, and bones. The local recurrence rate is about 5% after total mastectomy and axillary dissection is performed when the nodes are found not to be involved. The local recurrence rate is 25% in those with similar treatment found to have nodal involvement.

Calling your health care provider

Call your health care provider if unilateral (one-sided), new, unusual, or changing lumps are noted in breast tissue.

Also call for an appointment if:

• you are a woman, aged 40 or older, who has not had a baseline mammogram
• you are a woman, aged 35 or older, with a mother or sister with breast cancer, or you have a past medical history of breast, uterine (endometrial), ovarian, or colon cancer
• you are a woman, aged 25 or older, years, and you are unfamiliar with how to perform breast self-examination

Overview | Treatment

Alternative names

self-examination of the breast

Information

Question:
What is the best time of the month to check for breast lumps?

Answer:
After your period and at the same time each month. See document on breast lump.

Question:
What is the best way to examine breasts for lumps?

Answer:
See the picture on breast self-examination. Be on the lookout for a lump that stands out, nipple discharge, changes in skin texture, unusual tenderness, and differences from the last time you checked.

Question:
What are the breast cancer clues women are most likely to miss?

Answer:
The areas around the nipple and in the armpit are most commonly missed during a breast self-examination.

Definition

Abnormal discharge from the nipple(s)

Alternative names

discharge from breasts; milk secretions; lactation, abnormal; witches milk; galactorrhea

Considerations

The likelihood of nipple discharge increases with age and number of pregnancies.

While a milky nipple discharge is rare in men and in women who have never been pregnant, it does occur; and when it does, it is more likely to be caused by some underlying disease (particularly when accompanied by other changes in the breast(s).

It is relatively common in women who have had at least one pregnancy. A thin, yellowish, or milky discharge (colostrum) is normal in the final weeks of pregnancy.

The nature of the discharge can range in color, consistency, and composition, and may occur on one side or both sides.

Witch's milk is a term used to describe nipple discharge in a newborn. The discharge is a temporary response to the increased levels of maternal hormones. Witch's milk should disappear within 2 weeks as hormone levels dissipate in the newborn.

Other nipple discharges can be bloody or purulent (containing pus) depending on the cause.

Common causes

• breast abscess (most common in lactating women)
• trauma can cause discharge from both breasts
• drugs such as cimetidine, methyldopa, metoclopramide, oral contraceptives, phenothiazines, reserpine, tricyclic antidepressants, or verapamil
• prolactinoma (prolactin-secreting tumor in the brain)
• intraductal papilloma (a small noncancerous growth in the duct of the breast)
• ductal ectasia

Note: There may be other causes of a nipple discharge. This list is not all inclusive, and the causes are not presented in order of likelihood. The causes of this symptom can include unlikely diseases and medications. Furthermore, the causes may vary based on age and gender of the affected person, as well as on the specific characteristics of the symptom such as quality, time course, aggravating factors, relieving factors, and associated complaints.

Home care

Follow provider-prescribed therapy.

Call your health care provider if

• there is any abnormal nipple discharge.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed.

Medical history questions documenting a nipple discharge in detail may include:

• Are you pregnant?
• Are you breastfeeding?
• What type of drainage is there?
• Does it look like milk (even though you are not breastfeeding)?
• Does it look bloody?
• Does it look like pus?
• Is the drainage from both breasts?
• How much drainage is there?
• Enough to stain the lining of the bra?
• Enough to soak through the bra?
• Does the discharge occur spontaneously, or only when expressed?
• Do you perform breast self-examination? How often?
• What medications do you take?
• What other symptoms are also present? Especially, is there:
• fever
• a breast lump
• breast pain
• headaches or change in vision

The physical examination will include examination of the breasts for lumps or other abnormality.

Diagnostic tests that may be performed include:

• breast biopsy (if lump is found)
• cytologic study of discharge (a study of the cells in the discharge)
• head CT scan to look for pituitary tumor
• mammography
• serum prolactin
• transillumination (a light is placed against the breast to help determine if there is an accumulation of fluid in the tissue)
• ultrasonography (ultrasound of the breast)

After seeing your health care provider:
You may want to add a diagnosis related to a nipple discharge to your personal medical record.

Definition

Pain or discomfort in the breast. See also premenstrual tenderness and swelling of the breasts.

Alternative names

pain in the breast; mastalgia; mastodynia; breast tenderness

Considerations

There are many possible causes for breast pain. The presence of discomfort associated with menses is well recognized by women. Breast pain not associated with menses may be a frightening experience. Since recent statistics indicate that 1 in every 7 women in the U.S. develop breast cancer, many women think that breast pain automatically means cancer. However, with breast cancer there is often no breast pain.

Breast pain or tenderness may also occur in the adolescent male in association with adolescent gynecomastia as a normal part of development.

Common causes

• chronic cystic mastitis
• tenderness at midcycle or just before a menstrual period, when estrogen levels are at their peak; both breasts are usually involved; the breasts are not necessarily lumpy
• puberty (in girls near the onset of menstruation)
• approaching menopause
• early pregnancy
• estrogen therapy
• milk engorgement after childbirth, especially if breastfeeding
• normal hormonal fluctuations
• medications such as digitalis preparations, aldomet, aldactone (Potassium-sparing diuretics - oral), anadrol, and chlorpromazine
• alcoholism with liver damage
• injury (such as a bite)
• nipple problems
• shingles (pain in only one breast)
• premenstrual syndrome (PMS)

Home care

Wear a well-fitting brassiere for support, especially for large breasts. A monthly breast self-examination is important. Follow prescribed therapy to treat the underlying cause.

For mastitis, avoid caffeine and try vitamin E supplements and a diet low in fat and high in carbohydrates.

An injury to the breast surface that shows evidence of infection should be treated with antibiotics.

Call your health care provider if

• there is any abnormal discharge from the nipples.
• there is prolonged, unexplained breast pain.

What to expect at your health care provider's office

A history will be obtained and a breast examination performed.

Medical history questions documenting breast pain in detail include:

• Are both breasts affected?
• Is there any nipple discharge?
• Do you perform breast self-examination?
• Have you noticed any lumps or anything unusual when you examine your breasts?
• What other symptoms are also present? Is there fever?

Diagnostic tests that may be performed include:

• breast biopsy
• culture of body fluids
• cytology (cell studies) of nipple discharge
• mammography
• thermography (similar to mammogram)

Intervention:
Analgesics may be prescribed.

After seeing your health care provider:
If a diagnosis was made by your health care provider as to the cause of breast pain, you may want to note that diagnosis in your personal medical record.

Overview | Test Results

Definition

A procedure that involves obtaining a sample of breast tissue and analyzing it in a laboratory for signs of cancer or other disorders.

Alternative names

biopsy of the breast

How the test is performed

There are 2 methods used to obtain the sample. One is a needle biopsy, and the other is called an open biopsy.

NEEDLE BIOPSY
You undress to the waist and sit or recline. The injection site is cleaned and sterilized, then injected with a local anesthetic. A syringe is then injected into the lesion or lump to be studied. Fluid may be removed first, then a tissue sample is obtained. The fluid is stored in a special tube, and the tissue sample is placed in a specimen bottle with preservative.

Once the tissue sample has been taken, the needle is removed and pressure is applied to the site to stop any bleeding. A bandage will be applied to absorb any fluid.

OPEN BIOPSY
This method is also called a lumpectomy. You undress to the waist and sit or recline. A local or general anesthetic is administered (depending on the size of the mass and your condition), and an incision is made to expose the lump. The entire mass may be removed (if smaller than 2 cm), or part may be excised (removed) if the lump is larger. The tissue may be tested before the entire lump is removed.

After the tissue sample is taken, the incision is sutured and a dressing and bandage are applied.

If general anesthesia is administered, vital signs (temperature, pulse, rate of breathing, blood pressure) will be monitored for at least 1 hour after completion of the procedure. Pain medication may be prescribed.

How to prepare for the test

Your medical history will be taken, and a manual breast examination performed. You must sign an informed consent form. For patients requiring general anesthesia, fasting for 8 to 12 hours before the test may be recommended.

How the test will feel

There may be a sharp, stinging sensation when the anesthetic is administered. During the procedure, there should be no pain and only slight discomfort.

After the test, the breast may be sore and tender to the touch for several days. Pain medication will probably be prescribed if an incision is made. Over-the-counter pain medication should be satisfactory for most needle biopsy patients.

Risks

There is a slight chance of infection at the injection or incision site.

Excessive bleeding is rare, but may require draining or re-bandaging.

Why is the test done

Most breast lumps consist of fatty tissue and lactiferous (milk) ducts. Tumors are usually detected during a manual examination or mammography test. Another indicator of a malignant tumor is nipple discharge.

Overview | Test Results

Overview | Test Results

Normal values

A biopsy is the only way to determine if tissue is benign (noncancerous) or malignant (cancerous).

What abnormal results mean

There should be no sign of malignancy. The sample may consist of connective tissue, fat lobules, or lactiferous ducts. The sample should appear pink.

Costs

Tumors may be benign, and they can indicate:

• adenofibroma
• fibrocystic disease
• intraductal papilloma
• mammary fat necrosis
• mastitis

Tumors may be malignant and they can include:

• adenocarcinoma
• colloid carcinoma
• cystosarcoma
• infiltrating carcinoma
• inflammatory carcinoma
• intraductal carcinoma
• lobular carcinoma
• medullary or circumscribed carcinoma
• Paget's disease
• sarcoma

Additional conditions under which the test may be performed:

• nipple problems

Special Considerations

The estimated cost is $110 to $250 depending on if it is a needle biopsy or an open biopsy and if anesthesia is required.

Definition

Any abnormal lump or swelling on the skin.

Alternative names

fibromas; lumps on the skin; lipomas

Considerations

Most lumps and swellings are benign; some are caused by infection, others by injury, external pressure, inflammation, or obstruction to the flow of blood. Some are cancers. In general, when a lump or swelling appears suddenly (over 24 to 48 hours) and is painful, it is usually caused by an injury or an infection. On the other hand, if the lump comes on gradually (over several days or weeks) and does not hurt, it may be a tumor and should be seen by the doctor.

Common causes

• lipomas, fatty lumps under the skin
• fibromas, smooth growths under the skin
• enlarged lymph glands, usually in the armpits, neck, and groin
• cyst, a closed sac in or under the skin that is lined with skin tissue and contains fluid or semisolid material
• boils, painful, red bumps usually involving a hair follicle
• corn or callus, caused by skin thickening in response to continued pressure (for example, from shoes) usually occurring on a toe or foot
• warts, a skin virus that develops a rough, hard bump, usually appearing on a hand or foot and often with tiny black dots in the bump
• moles, skin-colored, tan, or brown, bumps on the skin
• abscess, fluid trapped in a closed space from which it cannot escape that becomes infected
• cancer of the skin (any colored or pigmented spot that bleeds easily, changes size or shape, or crusts and doesn't heal)

Home care

Fibromas, lipomas, or warts are harmless and do not need to be removed unless for cosmetic reasons. If the cause of the lump is in question, consult your health care provider.

For boils, relieve pain with gentle heat from warm-water soaks, a heating pad, hot water bottle, or lamp close to the skin. Prevent the spread of boils by using clean towels only once, or using paper towels and discarding them.

For cancer, consult your health care provider for therapy.

For skin lumps resulting from any other cause, follow the recommended therapy.

Call your health care provider if

• there is any unexplained lump or swelling.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed.

Medical history questions documenting your skin lumps in detail may include:

• time pattern
• When did you first notice the lump?
• location
• Where is the lump?
• Is there more than one?
• type
• Is the lump rubbery or capable of changing shape (fluctuant)?
• Is it sac-like cystic?
• location
• Is it over a joint?
• Is it over the back of the elbow (olecranon)?
• Is it in the back of the heel (Achilles tendon)?
• Is it over a muscle that extends or straightens a joint (extensor surface)?
• What other symptoms are also present?

The physical examination will include a detailed examination of the lump(s). If cancer is suspected, a biopsy may be done.

Antibiotics may be prescribed for fighting infection (if indicated).

After seeing your health care provider:
If a diagnosis was made by your health care provider related to skin lumps, you may want to note that diagnosis in your personal medical record.

Definition

The enlargement of one or more lymph nodes. See also lymphadenitis and lymphangitis.

Alternative names

swollen glands

Considerations

The lymphatic system is a complex network of thin vessels, valves, ducts, nodes, and organs. It helps to protect and maintain the fluid environment of the body by producing, filtering, and conveying lymph and by producing various blood cells.

The lymph system is present throughout the body. Common areas where the lymph nodes can be felt (palpable nodes) include the groin area (inguinal region), armpit (axilla), the neck (there is a chain of lymph nodes on either side of the front of the neck, both sides of the neck, and down each side of the back of the neck), under the jaw and chin, behind the ears, and over the occiput (prominence on the back of the head).

Lymph nodes play an important part in the body's defense against infection. Swelling might occur even if the infection is trivial or not apparent. Swelling of lymph nodes generally results from localized or systemic infection, abscess formation, or malignancy. Other causes of enlarged lymph nodes are extremely rare. By far, the most common cause of lymph node enlargement is infection.

As a rule, when swelling appears suddenly and is painful, it is usually caused by injury or an infection. Enlargement that comes on gradually and painlessly may result from malignancy or tumor.

Common causes

• infectious
• HIV disease or AIDS
• infectious mononucleosis (behind the ears or neck)
• rubella also known as German measles (behind the ears)
• tuberculosis (above the collar bone)
• mumps (salivary glands)
• ear infections or sore throat (neck glands, sometimes)
• infection in the scalp (behind the ears or in back of the head)
• impacted tooth (swollen gums)
• immune or autoimmune
• juvenile rheumatoid arthritis
• serum sickness
• HIV disease
• malignant
• leukemia
• Hodgkin's disease
• non-Hodgkin's lymphoma
• other
• canker sores
• drugs (such as phenytoin)
• typhoid vaccination
• salivary duct stones

Home care

Soreness in lymph glands usually disappears in a couple of days without treatment. If the glands are painful, it is because of the rapid swelling of the gland in the early stages of fighting the infection. It takes much longer for the gland to return to normal size than to swell, so be patient.

Follow prescribed therapy, if appropriate, to treat the underlying cause.

Call your health care provider if

• after several weeks of observation the glands don't get smaller (usually, however, this is not serious).
• swollen glands are red and tender.
• swollen glands are located behind the ear and there is also a scalp infection.
• one or more glands get larger over a period of 2 to 3 weeks.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed.

Medical history questions documenting swollen lymph nodes in detail may include:

• location
• Which node(s) are affected?
• Is the swelling the same on both sides?
• time pattern
• When did the swelling begin?
• How long has it lasted (how many months or weeks)?
• Did it begin suddenly?
• Did it develop gradually?
• Is the swollen node increasing in size?
• Is the number of nodes that are swollen increasing?
• associated complaints
• Is the node painful?
• Is the skin over or around the node red?
• Is the node tender when you gently press on it?
• other
• What other symptoms are occurring at the same time?

The physical examination may include pressing on many of the lymph nodes to look for size, texture, warmth, tenderness, and other features.

Diagnostic tests that may be performed include:

• liver function tests and kidney function tests
• liver-spleen scan
• lymph node biopsy (done only rarely)
• lymphography (an examination of the lymph nodes)
• platelet count
• routine blood tests (such as CBC or blood differential)
• X-rays of the chest

After seeing your health care provider:
If a diagnosis was made by your health care provider related to swollen lymph nodes, you may want to note that diagnosis in your personal medical record.

Overview | Test Results

Definition

An X-ray of the chest, lungs, heart, large arteries, and the diaphragm. X-rays are a form of radiation (like light) that can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray.

Alternative names

chest radiography; serial chest X-ray; X-ray of the chest

How the test is performed

The test is performed in a hospital radiology department or in the health care provider's office by an X-ray technician. Two views are usually taken: one in which the X-rays pass through the chest from the back (posterior-anterior view) and one in which the X-rays pass through the chest from one side to the other (lateral view). You stand in front of the machine and must hold your breath when the X-ray is taken.

How to prepare for the test

Inform the health care provider if you are pregnant. Chest X-rays are generally avoided during the 1st and 2nd trimesters of pregnancy. You must wear a hospital gown. You must remove all jewelry.

Infants and children:
The physical and psychological preparation you can provide for this or any test or procedure depends on your child's age, interests, previous experience, and level of trust. For specific information regarding how you can prepare your child, see the following topics as they correspond to your child's age:

• infant test or procedure preparation (birth to 1 year)
• toddler test or procedure preparation (1 to 3 years)
• preschooler test or procedure preparation (3 to 6 years)
• schoolage test or procedure preparation (6 to 12 years)
• adolescent test or procedure preparation (12 to 18 years)

How the test will feel

There is no discomfort. The film plate may feel cold.

Risks

There is low radiation exposure. X-rays are monitored and regulated to provide the minimum amount of radiation exposure needed to produce the image. Most experts feel that the risk is very low compared with the benefits. Pregnant women and children are more sensitive to the risks of the X-ray.

Why is the test done

There is a general agreement that routine chest X-rays should not be done on healthy people for screening purposes. There is little benefit of a chest X-ray in screening smokers who have no symptoms.

Overview | Treatment

Definition

The early stage of pregnancy from conception to 12 weeks gestation or about 14 weeks from the first day of the last normal menstrual period (LNMP).

Alternative names

early pregnancy; pregnant; first 3 months of pregnancy

Causes, incidence, and risk factors

Pregnancy is a normal condition and, in most situations, should not be approached as a problem or disease. There are many conditions that can affect the risk status of any pregnancy; an example is pregnancy at an extremely young age (less than 17 years old), because of increased medical risk to both the mother and baby and because of associated long-term psychological, social, and economic problems. (See adolescent pregnancy).

A pregnancy begins with conception, when a sperm from a fertile male joins with an ovum (egg) of a fertile female. Any fertile female, engaged in a sexual relationship with a fertile male, is at risk of becoming pregnant.

Prevention

A wide variety of contraceptive methods, designed to prevent pregnancy, are currently available. The user effectiveness rates vary from less than 1 pregnancy per 100 women per year with Depo-Provera injections or progestin implants to 20 to 30 pregnancies per 100 women per year with the rhythm or calendar methods. The only 100% effective means of contraception is complete abstinence, an unlikely choice for the majority of women of childbearing age.

Symptoms

• missed menstrual period(s)
• fatigue
• breast enlargement or breast discomfort (tenderness)
• abdominal distention
• nausea/vomiting
• light-headedness or actual fainting (syncope)
• skin areas appearing abnormally dark or light

Signs and tests

A pelvic examination may reveal an enlarged uterus, a bluish or purple coloration of the vaginal walls and cervix, and softening of the cervix. Weight changes are also noted (usually increased; decreased if nausea and vomiting are significant). The abdominal girth increases, and the fundus (top of the enlarged uterus) may be felt by touch (palpated).

Tests include:

• a positive urine and/or serum HCG (pregnancy test)
• a pregnancy ultrasound to confirm or check accurate dates for pregnancy

Pregnancy may also alter the results of the following tests:

• vitamin B-12
• TIBC
• RT3U
• serum progesterone
• serum iron
• estriol - urine
• estriol - serum
• ESR
• ceruloplasmin
• beta-carotene
• alpha fetoprotein

Overview | Treatment

Definition

The transition period in a woman's life when the ovaries stop producing eggs, menstrual activity decreases and eventually ceases, and the body decreases the production of the female hormones, estrogen and progesterone.

Alternative names

change of life; climacteric

Causes, incidence, and risk factors

Menopause (also called the "change of life" or climacteric) is a natural event in a woman's life, which normally occurs between the ages of 40 and 55. On average, menopause begins at about age 51. During menopause, ovulation (egg production) ceases, eliminating the possibility of pregnancy, and menstruation becomes less frequent and eventually stops. In some women, menstrual activity stops suddenly, but usually it tapers off, both in amount and duration of flow, and frequently the menstrual periods become more closely or more widely spaced. This irregularity may last for 2 or 3 years before menstruation finally ceases.

The symptoms of menopause are caused by changes in estrogen and progesterone levels. As the ovaries become less functional, they produce less estrogen/progesterone and the body subsequently reacts. Some women experience few if any symptoms, while others experience various symptoms ranging from mild to fairly severe. This variation is normal. A gradual decrease of estrogen allows the body to slowly adjust to the hormone change, but in some women a sudden decrease in estrogen level occurs, causing severe symptoms. This result is often seen when menopause is caused by surgical removal of the ovaries (surgical menopause).

Estrogen is responsible for the buildup of the epithelial lining of the uterine cavity. During the reproductive years this buildup occurs and is then shed (menstruation) on a monthly basis (usually). The menopausal decrease in estrogen prevents this buildup from occurring. However, androgenic hormones produced by the adrenal glands are converted to estrogen, and sometimes this will cause postmenopausal bleeding. This is usually nothing to worry about, but because postmenopausal bleeding may be an early indication of other problems, including cancer, a physician should always check any postmenopausal bleeding.

A reduction in estrogen is associated with a number of side effects that can be very annoying. Hot flashes, caused by an increase of blood flow in the blood vessels of the face, neck, chest and back, and vaginal dryness, caused by thinning of the tissues of the vaginal wall, are the two side effects most frequently experienced. The mood changes and lack of sex drive that are also sometimes associated with menopause may result partially from the hormone decrease, but may also result from having to adjust to hot flashes and vaginal dryness. In addition to these side effects there are others that may go undetected for many months or years. Decreased estrogen levels increase the risk for osteoporosis (loss of calcium from the bones, causing bone fragility), which sometime isn't detected until a bone fracture occurs.

Prevention

Menopause is a natural and expected part of a woman's development and does not need to be prevented. However, there are ways (both medical and non-medical) to reduce or eliminate some of the symptoms that accompany menopause.

Symptoms

Symptoms, when present, may include:

• hot flashes and skin flushing
• mood changes
• decreased libido (sex drive)
• irregular menstrual periods
• vaginal dryness

Signs and tests

A Pap smear may indicate changes in the vaginal lining (mucosa) caused by changes in estrogen levels. Blood and urine tests can be used to measure the levels of estrogen, progesterone, and plasma estradiol and estrone (part of the reproductive steroid group).

Examples of tests of this type include:

• 17-hydroxycorticosteroids
• 17-OH progesterone
• serum progesterone
• estradiol - test
• FSH

Overview | Treatment

Treatment

Natural menopause usually requires no treatment. Surgical menopause that occurs prior to natural menopause may require estrogen replacement therapy (ERT). Not all postmenopausal women may need to be treated with ERT. Each woman should discuss her individual risks and benefits with her health care provider.

Many physicians recommend estrogen replacement therapy to:

• reduce the undesirable symptoms of menopause
• help decrease vaginal drying
• prevent osteoporosis after menopause

Some side effects of estrogen replacement therapy include:

• vaginal bleeding
• breast tenderness
• nausea
• vomiting
• abdominal bloating
• uterine cramps

To reduce the risks of estrogen replacement therapy and still gain the benefits of the treatment, physicians may recommend:

• adding progesterone to the estrogen
• adding testosterone to the estrogen
• using the lowest possible dose of estrogen
• having frequent and regular physical exams, including a pelvic examination and Pap smear to detect problems as early as possible

Numerous studies have been done on the effects of ERT and the results are conflicting. ERT reduces the severity of hot flashes and vaginal dryness, and helps to prevent osteoporosis. These effects are strongly supported by previous studies and agreed upon by physicians. Some long-term studies have suggested that ERT helps to prevent heart disease, although recent studies have been conflicting. Promising new research studies have suggested that ERT may help prevent Alzheimer's disease, although the results are too preliminary to regard seriously. Some studies show an associated increase in uterine and breast cancers, while others don't. Some show an increase in sex drive; others show a decrease. Rather than helping depression during menopause, estrogen may actually make it worse. Incidence of liver tumors and gallbladder disease may also increase, while the risk of colon cancer may decrease. Studies showed that endometrial cancer was associated with ERT, but when progesterone was added to the therapy (hormone replacement therapy, or HRT), that association disappeared. The addition of testosterone may decrease the amount of nausea experienced with ERT, but may also decrease the positive cardiovascular effect that estrogen alone might have. There are now many ongoing research studies investigating the effects of menopause. The results of these studies may help physicians advise their patients on how to effectively manage menopause. Until more is known about ERT and HRT, women should weigh the benefits and the possible risks against the symptoms being experienced. Thorough discussion with a physician is recommended.

Prognosis

Although menopause is a difficult period for some, most women will experience menopause without long-term problems. Many women report an increase in energy, more self-confidence, and a better attitude.

Complications

Decreased estrogen levels are associated with an increased risk of developing osteoporosis and an increased risk of cardiovascular disease.

Calling your health care provider

Call for an appointment with your health care provider if you are a woman older than age 40 who is experiencing the symptoms of menopause and would like treatment for them. Specifically:

• irregular menstrual periods
• hot flashes
• vaginal dryness

Call if you are postmenopausal and are experiencing any bleeding.

Also call if you are experiencing the symptoms of menopause and you are under age 40.

Definition

Profuse or extended menstrual bleeding.

Alternative names

periods, menstrual--heavy or prolonged; menorrhagia

Considerations

The menstrual cycle is not the same for every woman. Normal menstrual flow occurs about every 28 days, lasts about 5 days, and produces a total blood loss of 60 to 250 milliliters (2 tablespoons to about 1 cup). Periods may be regular, irregular, light, heavy, painful, pain-free, long, or short, and still be normal. Variation in the menstrual cycle is medically less significant than bleeding, pain, or discharge between periods.

Bleeding may be something to worry about for women over age 50 (postmenopausal) or younger than age 12 (prepubertal). The risk of malignancy increases with age.

Make sure that bleeding is coming from the vagina and not from the rectum or in the urine. This can be accomplished by inserting a tampon into the vagina to confirm that the vagina is the source of the bleeding. A serious problem can best be detected by a health care provider.

Common causes

• anovulation (failure of ovaries to produce, mature, or release eggs)
• endometrial polyps
• endometrial hyperplasia and cancers
• uterine fibroids
• abnormal thyroid or pituitary function

Note: There may be other causes of menorrhagia. This list is not all inclusive, and the causes are not presented in order of likelihood. The causes of this symptom can include unlikely diseases and medications. Furthermore, the causes may vary based on age, as well as on the specific characteristics of the symptom such as time course, aggravating factors, relieving factors, and associated complaints.

Home care

Bed rest may be recommended if bleeding is heavy.

The number of pads or tampons used should be recorded (so that the doctor can determine the amount of bleeding). Change tampons regularly, at least twice a day.

Because aspirin may prolong bleeding, it should be avoided if possible. For menstrual cramps, use ibuprofen (for example, Advil or Nuprin). Ibuprofen is usually more effective than aspirin for relieving menstrual cramps.

If you use an IUD for birth control, slight spotting is normal. If no other symptoms are present, the spotting is probably insignificant.

Call your health care provider if

• you have severe pain, or if periods have been heavy and recurrent over 3 or more months.
• you have bleeding after menopause.
• you have abnormal bleeding accompanied by other symptoms.
• you have severe pain that does not respond to home treatment.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed.

Medical history questions documenting abnormal menstrual periods in detail may include:

• menstrual history
• Are you a woman presently in a menstruating age group?
• Was the previous menstrual period a normal amount?
• Do you use tampons?
• Do you normally have regular periods?
• quality
• Has there been passage of blood clots?
• How long per menstrual period is the bleeding?
• How heavy is it?
• time pattern
• When was the last menstrual period?
• What was the age at which you had your first menstrual period?
• How long have you had the same menses pattern?
• aggravating factors
• Do you use birth control pills?
• Do you take an estrogen supplement?
• Do you use an IUD for birth control?
• Do you take aspirin more than once per week?
• Do you take Coumadin, heparin, or other anticoagulant?
• Has there been a recent childbirth, surgery on or near the vagina or uterus, vaginal infection, uterine infection, or other possible source of trauma to the vagina or uterus?
• other
• What other symptoms are also present?
• Is there abdominal pain?
• Is there pelvic pain?
• Is there morning nausea or vomiting?
• Is there a growth or lump on the genitals?
• Is there a genital lesion?
• Is there known pregnancy?
• Are you vomiting blood?
• Is there blood in the stools?
• Is there bleeding into the skin or easy bruising?

The physical examination may include a pelvic examination if the patient is in the premenstrual phase of the menstrual cycle (particularly if endometriosis is suspected). Uterine blood loss can be estimated if the patient knows how many sanitary napkins or tampons were used during a period.

Diagnostic tests that may be performed include:

• Pap smear (if bleeding is inactive)
• endometrial biopsy
• pelvic ultrasound
• lab tests such as thyroid function tests, CBC, pregnancy test

Intervention:
Ibuprofen or another prostaglandin inhibitor is often prescribed. Ibuprofen is also available in lower dosages (Advil, Nuprin) without prescription.

In some cases of heavy bleeding, dilation and curettage ("D and C") may be required. A hysterectomy may not be performed if having difficult periods is the only complaint.

If a tumor is found, surgery will sometimes be needed, but the common "fibroid" tumor (uterine fibroids) will often stop growing by itself, and surgery may not be needed depending on the amount of bleeding and the response to various treatment attempts. Such tumors often grow slowly and stop growing completely at the menopause, so an operation can be avoided by waiting. However, if the Pap smear is positive, surgery or other type of therapy may be necessary.

If the heavy bleeding is related to hormonal abnormalities, treatment of the specific abnormality will correct the bleeding. Female hormones (birth control pills or progestins) are commonly used to regulate menses.

After seeing your health care provider:
If a diagnosis was made by your health care provider related to abnormal menstrual periods, you may want to note that diagnosis in your personal medical record.

Overview | Treatment

Definition

Benign tumors of muscle and connective tissue that develop within or are attached to the uterine wall.

Alternative names

leiomyoma; fibromyoma; myoma; fibroids

Causes, incidence, and risk factors

The cause of fibroid tumors of the uterus is unknown. However, it is suggested that fibroids may enlarge with estrogen therapy (such as oral contraceptives) or with pregnancy. Their growth seems to depend on regular estrogen stimulation, showing up only rarely before the age of 20 and shrinking after menopause. As long as a woman with fibroids is menstruating, the fibroids will probably continue to grow, although growth is usually quite slow. Fibroids can be microscopic, but they can also grow to fill the uterine cavity, weighing several pounds. Uterine fibroids are the most common pelvic tumor and they may be present in 15 to 20% of reproductive-age women, and 30 to 40% of women over 30. Fibroids occur 3 to 9 times more frequently in African-American women than in Caucasian women.

It is possible for a single fibroid to develop although normally there are a number of them, which begin as small seedlings spread throughout the muscular walls of the uterus. They slowly enlarge and become more nodular, frequently intruding into the cavity of the uterus or growing out beyond the normal boundary of the uterus. Rarely, a fibroid will hang from a long stalk attached to the outside of the uterus. This is called a pedunculate fibroid.

Prevention

Prevention is unknown.

Symptoms

• sensation of fullness or pressure in lower abdomen
• abdominal fullness, gaseous
• increase in urinary frequency
• presently in a menstruating age and having heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots
• sudden, severe pain (a pedunculate fibroid twists causing the blood vessels feeding the tumor to kink) Note: Hospitalization and surgery may be needed in this instance,

Note: There may be no symptoms.

Signs and tests

A pelvic examination reveals an irregularly shaped, lumpy, or enlarged uterus. Frequently, this diagnosis is reliable, however, on occasion, diagnosis is difficult, especially in obese women. Fibroid tumors have been mistaken for ovarian tumors, inflammatory processes of the tubes, and pregnancy.

A transvaginal ultrasound or pelvic ultrasound is usually performed to confirm the findings.

A Dandamp;C procedure or a pelvic laparoscopy may be necessary to rule out other, potentially malignant, conditions.

Overview | Treatment

Treatment

Methods of treatment depend on the severity of symptoms, age, pregnancy status, desire for future pregnancies, general health, and characteristics of the fibroid(s). Treatment may consist of simply monitoring the fibroids, specifically their rate of growth, with periodic pelvic exams or ultrasound. This method is usually sufficient in pre menopausal women.

Hormonal treatment, involving drugs such as Nafarelin and Leuporlide, causes fibroids to shrink. This method is sometimes used in pre-menopausal women who desire to bear children, but have problems conceiving because of the tumors. If fibroids become large enough, they may block the fallopian tubes or fill the uterine cavity. The hormones produce an environment in the body that is very similar to that of menopause, thus, pseudo-menopause. The treatment spans over several months and during this time the reduction in estrogen concentration allows the fibroids to shrink. Since fibroids will begin to enlarge as soon as treatment stops, the woman is encouraged to begin attempting to conceive almost immediately.

For women who do not want to conceive, but also don't want to undergo surgery, hormone treatment is frequently an option. The side effects of this type of treatment usually include menopausal symptoms, which for some women may be rather annoying. If treatment is discontinued, fibroids will regrow and another method of treatment will need to be used.

A myomectomy, which is a surgical procedure to remove just the fibroids, is frequently the chosen treatment, especially for pre-menopausal women who want to bear more children. Another advantage of a myomectomy is that it controls pain or excessive bleeding that some women with uterine fibroids experience.

A total hysterectomy, which involves removal of the uterus, is another option.

Prognosis

Prior to menopause, fibroids are likely to grow slowly. Women with known fibroids who choose to have children, may be counseled to become pregnant earlier in adulthood. As a general rule, fibroids don't interfere with fertility, however, on occasion a tumor will block the fallopian tubes and prevent sperm from reaching and fertilizing the egg. In some cases, fibroids may prevent the fertilized egg from implanting in the uterine lining. However, proper treatment may restore fertility.

After a pregnancy is established, existing fibroids will grow due to the increased blood flow and estrogen levels. These usually return to their original size after the baby has been delivered. Many women are able to carry their babies to term, but some of them end up delivering prematurely because there is not enough room in the uterine cavity to sustain full term. Cesarean section is often needed for delivery since fibroid tumors may block the birth canal or cause the baby to be positioned abnormally. After menopause, new fibroids rarely develop and those already present usually shrink.

Complications

Fibroids may cause infertility because they interfere with conception or implantation. They may cause premature delivery because of decreased area within the uterine cavity. Severe pain or excessively heavy bleeding with fibroids may necessitate emergency surgery. Rarely, malignant changes may occur, however, these usually take place in postmenopausal women. The most common warning sign is rapid enlargement of a fibroid and definitive diagnosis is usually not made until the time of surgery.

Calling your health care provider

Call for an appointment with your health care provider if gradual changes in your menstrual pattern occur (heavier flow, increased cramping, bleeding between periods); or if fullness or heaviness develops in your lower abdomen. Frequently there is associated pressure or discomfort and interference with normal urination frequency.

Picture:
P0523.pctReproductive anatomy - female
P0457.pctPelvic laparoscopy

Definition

Intermenstrual bleeding is uterine bleeding that occurs between menstrual periods.

Alternative names

bleeding between periods; periods, menstrual - bleeding between; intermenstrual bleeding; spotting

Considerations

Normal menstrual flow lasts about 5 days, produces a total blood loss of 60 to 250 ml (about 2 to 8 tablespoons), and occurs normally every 28 days.

Vaginal bleeding may be something to worry about for women over age 50 (postmenopausal) or younger than age 11 (premenarchal). The risk of malignancy increases with age.

Make sure that bleeding is coming from the vagina and is not from the rectum or in the urine. Inserting a tampon into the vagina will confirm the vagina/cervix/uterus as the source of bleeding.

A careful exam by your health care provider is frequently the best way to sort out the source of the bleeding. This exam can be accomplished even while you are bleeding. Do not delay getting an exam just because you are currently bleeding.

Common causes

• stress
• injury or disease of the vaginal opening (caused by intercourse, infection, polyp, genital warts, ulcer, or varicose veins)
• vaginal injury from insertion of foreign objects, from malignancy, or from infection
• dry vaginal walls resulting from lack of estrogen after menopause
• abortion (spontaneous or induced)
• fluctuation in hormone levels
• stopping and starting birth control pills or estrogens
• low thyroid function
• IUD use can cause occasional spotting (if bleeding is slight, it can be ignored)
• drugs such as anticoagulants
• cervical conization or cauterization procedures

Note: There may be other causes of bleeding between periods. This list is not all inclusive, and the causes are not presented in order of likelihood. The causes of this symptom can include unlikely diseases and medications. Furthermore, the causes may vary based on the age of the affected person, as well as on the specific characteristics of the symptom such as quality, time course, aggravating factors, relieving factors, and associated complaints.

Home care

Bed rest is recommended if bleeding is heavy.

The number of pads or tampons used should be recorded (so that the amount of bleeding can be determined). Change tampons regularly, at least twice a day.

Because aspirin may prolong bleeding, it should be avoided if possible.

Call your health care provider if

• there is any unexplained bleeding between periods.
• there is any bleeding after menopause.
• abnormal bleeding is accompanied by other symptoms.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed.

Medical history questions documenting vaginal bleeding between periods detail may include:

• time pattern
• When did this bleeding between periods begin?
• Does it occur consistently, such as every month?
• When (during the course of a menstrual cycle) does this bleeding begin?
• How long does the in-between bleeding last?
• quality
• Is the bleeding heavy?
• How many tampons or pads are required?
• Do cramps accompany the bleeding?
• aggravating factors
• What makes it worse?
• Does increased physical activity make the bleeding worse?
• Is increased stress associated with the bleeding?
• relieving factors
• Does anything relieve or prevent it?
• other symptoms
• What other symptoms are also present?
• Do you have abdominal pain or cramps?
• Increased bruising elsewhere on the body?
• Do you have any difficulty, pain or burning with urination?
• Is there bloody urine or blood in the stools?
• other important information
• Are you pregnant?
• Have you had a miscarriage or abortion?
• Have you had a D andamp; C?
• What medications are being taken?
• Are tampons used? What kind? What size?
• At what age did menstruation start?
• Have there been normal periods without bleeding between in the past?
• Is sexual activity occurring?
• Is birth control being used? What kind?
• Have there been any injuries?
• Have there been any medical or surgical treatments?

A thorough menstrual history will be obtained and a physical examination performed with an emphasis on the pelvic area. Uterine blood loss can be estimated if the patient knows how many sanitary napkins or tampons were used during a period.

Diagnostic tests that may be performed include:

• pap smear (if bleeding is inactive)
• endometrial biopsy

Overview | Test Results

Definition

A procedure in which a tissue sample is obtained from the endometrium (the inside lining of the uterus) and is then observed under a microscope. The tissue is thoroughly examined for any cell abnormalities or cancer.

Alternative names

biopsy of the endometrium

How the test is performed

This procedure may be performed with or without anesthesia. You will be asked to lie on your back with your feet in the stirrups. A pelvic examination will be done, and a speculum (an instrument used to hold the walls of thevaginal canal open in order to see the cervix) will be inserted into the vagina and opened slightly. The cervix is grasped with an instrument (tenaculum) to steady the uterus. Then a small, hollow plastic tube is gently passed into the uterine cavity.Gentle suction removes a sample of the lining. The tissue sample and instruments are removed, and the sample is examined under a microscope by a pathologist.

How to prepare for the test

Adults:
There is no special preparation for the biopsy.

Adolescent test or procedure preparation (12 to 18 years)

How the test will feel

The instruments may feel cold. There may be some pain as the cervix is grasped. Some cramping may occur as the instruments enter the uterus and when the sample is collected.

Risks

It is common to have slight spotting after the procedure. Prolonged bleeding may occur after the procedure. There is also a small chance of infection. Very rarely there is a chance of perforating the uterus or tearing the cervix.

Why is the test done

Not applicable.

Special Considerations

The estimated cost is $150 to $200.

Overview | Treatment

Definition

A cancerous growth of the endometrium (lining of the uterus).

Alternative names

endometrial/uterine adenocarcinoma; uterine cancer; adenocarcinoma of the endometrium/uterus

Causes, incidence, and risk factors

Endometrial cancer is the most common type of uterine cancer. Although the exact cause of endometrial cancer is unknown, increased levels of estrogen appear to have a role. One of estrogen's normal physiological functions is to stimulate the build up of the epithelial wall of the uterus. Excess estrogen administered to laboratory animals produces endometrial hyperplasia and cancer. The incidence of endometrial cancer in women in the U.S. is 1 to 2%. The incidence peaks between the ages of 60 and 70 years, but 2 to 5% of cases may occur before the age of 40 years. Increased risk of developing endometrial cancer has been noted in women with increased levels of natural estrogen. Associated conditions include obesity, hypertension, and polycystic ovarian disease. Increased risk is also associated with nulliparity (never having carried a pregnancy), infertility (inability to become pregnant), early menarche (onset of menstruation) and late menopause (cessation of menstruation). Women who have a history of endometrial polyps or other benign growths of the uterine lining, postmenopausal women who use estrogen-replacement therapy (specifically if not given in conjunction with periodic progestin), and those with diabetes also fit into the higher risk category.

Prevention

All women should have regular pelvic exams and Pap smears (beginning at the onset of sexual activity or at the age of 20 if not sexually active) to help detect signs of any abnormal development.

Since conditions associated with increased risk have been identified, it is important for women with such conditions to be followed more closely by their physicians. Frequent pelvic examinations and screening tests, including a pap smear and endometrial biopsy, should be done.

Women who are taking estrogen replacement therapy should also take these precautions. Any of the following symptoms should be reported immediately to the doctor:

• bleeding or spotting after intercourse or douching
• bleeding that lasts longer than 7 days
• periods that recur every 21 days or less
• reappearance of blood or staining after six months or more of no bleeding at all.

Symptoms

• abnormal uterine bleeding, abnormal menstrual periods
• bleeding between normal periods in premenopausal women
• vaginal bleeding and/or spotting in postmenopausal women
• in women over the age of 40, extremely long, heavy, or frequent episodes of bleeding (may indicate premalignant changes)
• lower abdominal pain or pelvic cramping

Signs and tests

A pelvic examination is frequently normal, especially in the early stages of disease. Changes in the size, shape, or consistency of the uterus and/or its surrounding, supporting structures may exist when the disease is more advanced.

• A Pap smear may be either normal or show abnormal cellular changes.
• Endometrial aspiration may assist the diagnosis.
• A dilation and curettage (Dandamp;C) procedure is usually necessary for diagnosing and staging the cancer.
• An endometrial biopsy may assist in diagnosis.

Stages of endometrial cancer:

• 1. The cancer is confined to the uterine body.
• 2. The cancer involves the uterine body and the cervix, but does not extend any further.
• 3. The cancer extends outside of the uterus but not beyond the true pelvis (gynecological organs).
• 4. The cancer has extended beyond the true pelvis and:
• 4a. spread to adjacent organs.
• 4b. spread to distant organs.

Overview | Treatment

Definition

The presence of blood in the urine.

Alternative names

hematuria; blood in the urine

Considerations

Blood in the urine should never be ignored!

Blood in the urine is usually caused by kidney and urinary tract diseases. However, there are a couple of exceptions:

• In women, the blood may appear to be in the urine when it's actually coming from the vagina.
• In men, the urethra carries both urine and semen out of the body and what may be mistaken for urinary bleeding is sometimes a bloody ejaculation usually due to a prostate problem.

Bladder infections are more common in women than in men and are especially common during pregnancy. Bladder infections are usually accompanied by pain or burning on urination, frequent urgent urination, and occasionally blood in the urine.

Discoloration from drugs or foods can mimic blood in the urine.

Common causes

• kidney stone
• bladder stones that lodge in the urethra
• tumors of the urinary tract.
• glomerulonephritis
• bladder tumor
• chronic or recurrent urinary tract infection
• cystitis
• pyelonephritis
• urethritis
• enlarged and infected prostate (prostatitis)
• post-streptococcal GN
• urethral ulceration
• hypercalciuria (increased amounts of calcium in the urine)
• distal renal tubular acidosis
• use of diuretics ("water pills")
• hyperparathyroidism
• hypothyroidism
• hypercalcemia
• hypertension
• juvenile rheumatoid arthritis
• medullary cystic disease
• metabolic acidosis
• neoplasm
• sarcoidosis
• acute tubular necrosis
• "hardening" of the urinary opening (meatal stenosis)
• trauma
• fracture of the pelvis
• renal contusion (bruised kidney)
• renal fracture ("broken" or torn kidney)
• urethral trauma
• surgical procedures, including catheterization, circumcision, surgery, and renal biopsy
• drugs
• anticoagulants
• cyclophosphamide
• metyrosine
• oxyphenbutazone
• phenylbutazone
• thiabendazole

Home care

Follow prescribed therapy to treat the underlying cause.

Drink lots of fluids unless it is difficult to breathe or unless the ankles are swollen. Fruit juices, such as cranberry juice, can be quite effective.

For "honeymoon cystitis" (a urinary infection following sexual intercourse), avoid sexual activity until symptoms subside.

For injury, obtain medical treatment (possibly surgery). A kidney stone may pass or it may need to be removed.

For an enlarged and infected prostate, see your health care provider for antibiotics (possibly surgery if it continues to recur).

For discoloration from drugs or foods, make sure of the origin of the red color.

Call your health care provider if

• there is blood in the urine. This should never be ignored.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed.

Medical history questions documenting dark or bloody urine in detail may include:

• time pattern
• When did the urine become dark or bloody?
• Did it occur suddenly?
• quality
• What color is the urine?
• Is there any pain associated with urination?
• Is it consistently the same color throughout the day?
• Is the quantity of urine per day decreased or increased?
• Is any blood visible?
• Is there an odor?
• aggravating factors
• Are medications being used that could cause this change in color?
• Have foods been eaten that could cause this change in color (such as colored candy, beets, berries, rhubarb)?
• relieving factors
• Does a change in diet change the color of the urine?
• Does a change in medication change the color of the urine? (Note: NEVER change medications without first consulting your health care provider.)
• other
• What other symptoms are also present?
• Is there pain when urinating?
• Is there pain in the abdomen?
• Is there back pain?
• Is there a fever?
• Has there been a decreased fluid intake or decreased thirst?
• Has there been a decreased appetite?
• Is there nausea, vomiting, or diarrhea?
• What medications are being taken?
• Have you had previous urinary problems or kidney problems?
• Do you have any allergies?
• Have you had previous similar symptoms?
• Has there been a recent injury?
• Has there been any recent diagnostic or surgical procedures involving the urinary tract?
• Has there been a change in sexual activities?

A physical examination will be performed, and vital signs (temperature, pulse, rate of breathing, blood pressure) may be monitored. With a pre-existing kidney infection, a more detailed history and physical are needed and extra laboratory studies may be necessary. In women with a discharge, an examination of the vagina and any discharge is usually necessary.

Diagnostic tests that may be performed include:

• blood studies such as a CBC and blood differential
• urinalysis
• cystoscopy
• kidney biopsy
• X-rays of the kidneys
• IVP
• abdominal ultrasound
• CT scan of the abdomen

Intervention:
If urinary tract infection is confirmed, antibiotics may be prescribed. If appropriate, pain medications will be administered.

After seeing your health care provider:
You may want to add a diagnosis related to bloody or dark urine to your personal medical record.

Overview | Treatment

Definition

An infection of the urinary bladder or urethra.

Alternative names

bladder infection; urinary tract infection; UTI

Causes, incidence, and risk factors

Cystitis is caused when bacteria enter the urethra and bladder and cause inflammation and infection. It is very common, occurring in 2 out of 100 people. Cystitis occurs most commonly in females, because their urethra is shorter and closer to the anus. Cystitis is rarer in males. Older adults are at high risk for developing cystitis, with the incidence in the elderly being as high as 33 out of 100 people.

Over 90% of cases of cystitis are caused by E. coli, a bacterium normally found in the intestine. Normally, the urethra and bladder have no bacteria. Bacteria that manage to enter the bladder are usually removed during urination. But if bacteria remain in the bladder, they grow easily and quickly and result in infection.

Risks for cystitis include obstruction of the bladder or urethra with resultant stasis of urine, insertion of instruments into the urinary tract (such as catheterization or cystoscopy), pregnancy, diabetes, and a history of analgesic nephropathy or reflux nephropathy. Sexual intercourse can increase the risk of cystitis in women because bacteria can be introduced into the bladder through the urethra.

The elderly population are at increased risk for developing cystitis due to incomplete emptying of the bladder associated with such conditions as benign prostatic hyperplasia (BPH), prostatitis, and urethral strictures. Also, lack of adequate fluids, bowel incontinence, immobility or decreased mobility, and placement in a nursing home, all place the person at increased risk for developing cystitis.


Related disorders include:

• pyelonephritis
• cystitis; acute bacterial
• chronic or recurrent urinary tract infection
• cystitis; noninfectious (acute urethral syndrome)
• recurrent cystitis (repeated bladder infections)

Prevention

Appropriate hygiene and cleanliness of the genital area may help reduce the chances of introducing bacteria through the urethra. The genitals should be cleaned and wiped from front to back to reduce the chance of dragging E. coli bacteria from the rectal area to the urethra.

Frequent urinating may reduce risk of cystitis in those who are prone to urinary tract infections.

Drinking plenty of fluids encourages frequent urination which flushes bacteria out the bladder. Urinating immediately after sexual intercourse may help flush out bacteria that may have been introduced with intercourse.

Symptoms

• pressure in the lower pelvis
• urination, painful (dysuria)
• frequent need to urinate (frequency)
• urgent need to urinate (urgency)
• need to urinate at night
• abnormal urine color (cloudy urine)
• blood in the urine (hematuria)
• foul or strong urine odor

Additional symptoms that may be associated with this disease:

• sexual intercourse, painful
• penis pain
• flank pain
• fatigue
• fever
• chills
• vomitting
• mental changes or confusion *

* Often in the elderly person, mental changes or confusion are the only signs of a possible urinary tract infection.

Signs and tests

• A urinalysis commonly reveals white blood cells (WBC) or red blood cells (see also RBC; urine).
• A urine culture (clean catch) or catheterized urine specimen maybe performed to determine type of bacteria in the urine and the appropriate antibiotic for treatment.

Overview | Treatment

• nitrofurantoin
• sulfa drugs (sulfonamides)
• amoxicillin
• cephalosporins
• trimethoprim-sulfamethoxazole
• doxycycline

Chronic or recurrent UTI should be treated thoroughly because of the chance of kidney infection (pyelonephritis). Antibiotics control the bacterial infection. They may need to be given for long periods of time (as long as 6 months to 2 years), or stronger antibiotics may be needed than for single, acute episodes of cystitis. Prophylactic low-dose antibiotics may be recommended after acute symptoms have subsided.

Phenazopyridine hydrochloride (pyridium) may be used to reduce the burning and urgency associated with cystitis. In addition, acidifying medications, such a ascorbic acid may be recommended to decrease the concentration of bacteria in the urine.

SURGERY:
Surgery is generally not indicated in the presence of a urinary tract infection.

OTHER THERAPY:
Preventive measures may reduce symptoms and prevent recurrence of infection. Keeping the genital area clean and remembering to wipe from front to back may reduce the chance of dragging E. coli bacteria from the rectal area to the urethra.

Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during intercourse. Refraining from urinating for long period of time may allow bacteria time to multiply, so frequent urination may reduce the risk of cystitis in those who are prone to urinary tract infections.

DIET:
Increasing the intake of fluids (2000 to 4000 cc per day) encourages frequent urination that flushes the bacteria from the bladder. Avoid fluids that irritate the bladder, such as alcohol, citrus juices, and caffeine.

MONITORING:
Follow-up may include urine cultures to ensure that bacteria are no longer present in the bladder.

Prognosis

Cystitis is uncomfortable but usually responds well to treatment.

Complications

• chronic or recurrent urinary tract infection
• complicated UTI
• pyelonephritis

Calling your health care provider

Call for an appointment with your health care provider if symptoms indicate cystitis may be present.

If you have cystitis, call if symptoms worsen, or new symptoms develop, especially fever, back or flank pain, and vomiting.

Definition

Flank pain refers to pain in the side of the trunk between the right or left upper abdomen and the back.

Alternative names

pain in the side; side pain

Considerations

Flank pain often means kidney trouble, but not always. If flank pain is accompanied by fever, chills, and urinary problems, then the kidney is the likely source.

One American in seven has kidney stones at some time. The pain from a kidney stone is agonizing, comes in sharp stabbing waves or spasms, and usually is not limited to the flank.

Common causes

• acute pyelonephritis
• muscle spasm
• kidney stone (calculi or nephrolithiasis)
• kidney abscess
• nephrolithiasis
• shingles (flank pain with one-sided rash)
• spinal arthritis
• disk disease

Home care

Treatment depends on the cause. Follow your health care provider's instructions.

Rest, physical therapy, and exercise are recommended for flank pain caused by muscle spasm.

Anti-inflammatory drugs and physical therapy may be prescribed for flank pain caused by spinal arthritis. Continue physical therapy exercises at home.

Call your health care provider if

• there is flank pain accompanied by high fever, chills, nausea, or vomiting.
• there is blood (red or brown color) in the urine.
• there is prolonged, unexplained flank pain.

What to expect at your health care provider's office

The medical history will be obtained and a physical examination performed. If the pain is related to an injury, the condition will be stabilized first.

Medical history questions documenting flank pain in detail may include:

• location
• Is the pain on one side only (unilateral) or both sides?
• Which side?
• quality
• Is the pain mild?
• Is the pain periodic and changing intensity over minutes; crampy (colicky)?
• Is the pain severe enough to require narcotics?
• time pattern
• Did the pain begin recently?
• Has the pain been gradually getting worse over months?
• Did the pain rapidly get worse?
• radiation
• Does the pain go into your groin?
• Does the pain go into your back?
• Does the pain go up into your chest?
• associated complaints
• Does the pain occur with nausea or vomiting?
• What other symptoms are also present?

Fluid intake and output may be monitored and recorded.

Diagnostic tests that may be performed include:

• urinalysis and urine culture
• renal or abdominal ultrasound
• abdominal CT scan
• cytoscopy
• intravenous pyelography
• retrograde ureteropyelography
• serial urine and serum analysis
• voiding cystourethrography
• lumbosacral spine x-ray

After seeing your health care provider:
You may want to add a diagnosis related to flank pain to your personal medical record.

Overview | Treatment

Definition

A condition in which one or more stones are present in the pelvis or calyces of the kidney or in the ureter (see also cystinuria).

Alternative names

renal calculi; kidney stones; stones - kidney

Causes, incidence, and risk factors

A kidney stone results when the urine becomes too concentrated and substances in the urine crystallize to form stones. Stones may not produce symptoms until they begin to move down the ureter, causing pain. The pain is severe, located in the flank, and often described as "the worst pain ever experienced."

Kidney stones are common. About 5% of women and 10% of men will have at least one episode by age 70. Kidney stones affect about 2 out of every 1,000 people. Recurrence is common, and the risk of recurrence is greater if two or more episodes of kidney stones occur. Kidney stones are common in premature infants.

Some types of stones tend to run in families. Some types may be associated with other conditions such as bowel disease, ileal bypass for obesity, or renal tubule defects. A personal or family history of stones is associated with increased risk of stone formation. Other risk factors include renal tubular acidosis and resultant nephrocalcinosis.

Calcium stones are most common, accounting for 75 to 95% of all stones. They are two to three times more common in men, usually appearing at age 20 to 30. Recurrence is likely. The calcium may combine with other substances such as oxalate (the most common substance), phosphate, or carbonate to form the stone. Oxalate is present in certain foods. Diseases of the small intestine increase the tendency to form calcium oxalate stones.

Uric acid stones are also more common in men. They are associated with gout or chemotherapy. Uric acid stones make up about 8% of all stones.

Cystine stones may form in persons with cystinuria. It is a hereditary disorder affecting both men and women.

Struvite stones are mainly found in women as a result of urinary tract infection. They can grow very large and obstruct the kidney, ureter, or bladder.

Other substances may crystallize, precipitate, and form stones.

Prevention

If there is a history of stones, fluids should be encouraged to produce adequate amounts of dilute urine (usually 6 to 8 glasses of water per day). Depending on the type of stone, medications or other measures may be recommended to prevent recurrence.

Symptoms

• flank pain or back pain
• on one or both sides
• progressive
• severe
• colicky ("spasm-like")
• may radiate or move to lower in flank, pelvis, groin, genitals
• nausea, vomiting
• urinary frequency/urgency, increased (persistent urge to urinate)
• blood in the urine
• abdominal pain
• urination, painful
• urination, excessive at night
• urinary hesitancy
• testicle pain
• groin pain
• fever
• chills
• abnormal urine color

Signs and tests

Pain may be severe enough to require narcotics. There may be tenderness when the abdomen or back is touched. If stones are severe, persistent, or recurrent, there may be signs of kidney failure.

• Straining the urine may capture urinary tract stones when they are excreted. Analysis of the stone shows the type of stone.
• Urinalysis may show crystals and red blood cells in urine.
• Uric acid elevated

Stones or obstruction of the ureter may appear on:

• kidney ultrasound
• IVP (intravenous pyelogram)
• abdominal X-rays
• retrograde pyelogram
• abdominal CT scan
• abdominal/kidney MRI

Overview | Treatment

Definition

A disorder involving sudden blockage of urine flow out of the ureter of 1 kidney, resulting in backup of urine and injury to the kidney (see also reflux nephropathy).

Alternative names

obstructive uropathy - unilateral - acute; ureteral obstruction

Causes, incidence, and risk factors

Unilateral obstructive uropathy occurs when the kidneys produce urine normally, but the urine is unable to drain out of the affected ureter into the bladder. The urine backs up causing distention of the kidney structures, including the renal pelvis and calyces (hydronephrosis).

Sudden blockage of one ureter causes acute unilateral obstructive uropathy, while slow, progressive blockage causes chronic unilateral obstructive uropathy. The most common cause for acute unilateral obstructive uropathy is a kidney stone, although any condition (such as trauma) that suddenly causes obstruction of a single ureter could cause the disorder. In children, stricture of the ureter (congenital) is a common cause.

Hydronephrosis caused by acute unilateral obstructive uropathy may result in permanent damage to the kidney (failure of one kidney) and may be a cause of hypertension. It usually does not cause symptoms of kidney failure unless there is only one functioning kidney because the function of one kidney is sufficient to sustain life.

Acute unilateral obstructive uropathy occurs in 1 out of 1,000 people.

Prevention

If prone to kidney stones, drink plenty of water (6 to 8 glasses per day) to reduce the chances of their formation. If kidney stones are present, seek medical attention if they persist or recur to identify the cause, prevent new stones from forming, and to minimize the risk of developing acute unilateral obstructive uropathy.

Symptoms

• flank pain or pain in the side
• severe
• may travel or radiate to the groin, genitals, thigh
• periodic and changing intensity over minutes (colicky), or spasmodic
• on one side
• severe enough to require narcotics
• radiating to groin
• with nausea or vomiting
• back pain, may be on only one side
• abdominal pain
• right lower quadrant or
• left lower quadrant
• blood in the urine
• abnormal urine color (tan, cola colored, tea colored)
• high blood pressure that his increased recently (within 2 weeks)

Signs and tests

A history of acute ureteric colic may indicate nephrolithiasis or unilateral obstructive uropathy. Palpation of the abdomen reveals an enlarged or tender kidney. Blood pressure may be elevated. Fever may or may not be present (infection).

• Urinalysis may reveal blood in the urine and pyorrhea.

Hydronephrosis and/or obstruction of the ureter may appear on:

• IVP
• abdominal ultrasound
• abdominal CT scan

Overview | Treatment

Overview | Treatment

Definition

A disorder characterized by high blood pressure; generally this includes systolic blood pressure (the "top" number, which represents the pressure generated when the heart beats) consistently higher than 140, or diastolic blood pressure (the "bottom" number, which represents the pressure in the vessels when the heart is at rest) consistently over 90.

Causes, incidence, and risk factors

Blood pressure is determined by the amount of blood pumped by the heart, and the size and condition of the arteries. Many other factors can affect blood pressure, including volume of water in the body; salt content of the body; condition of the kidneys, nervous system, or blood vessels; and levels of various hormones in the body. Caucasian men and African-Americans of both sexes have a higher incidence of significant hypertension.

"Essential" hypertension has no identifiable cause. It may have genetic factors and environmental factors, such as salt intake or others. Essential hypertension comprises over 95% of all hypertension.

"Secondary" hypertension is hypertension caused by another disorder. This may include:

• adrenal gland tumors
• Cushing's syndrome
• kidney disorders
• glomerulonephritis
• renal vein thrombosis
• renal artery occlusion (renal artery stenosis)
• renal artery embolism
• renal failure
• use of medications, drugs, or other chemicals
• pregnancy or use of oral contraceptives
• hemolytic-uremic syndrome
• Henoch-Schonlein purpura
• periarteritis nodosa
• radiation enteritis
• retroperitoneal fibrosis
• Wilms' tumor
• other disorders

Prevention

Lifestyle changes may be helpful to control high blood pressure. Lose weight, if overweight. Excess weight adds to strain on the heart. In some cases, weight loss may be the only treatment needed. Exercise to improve cardiac fitness. Dietary adjustments may be beneficial, especially a decrease of sodium in diet. Modify intake (sodium intake may have little effect in persons without hypertension but may have a profound effect in those with hypertension). Salt, MSG, and baking soda all contain sodium.

Follow the health care provider's recommendations to modify, treat, or control possible causes of secondary hypertension.

Symptoms

• headache (occasionally)

If hypertension is severe, may have:

• tiredness
• confusion
• vision changes
• nausea, vomiting
• anxiety
• excessive perspiration
• pale skin, or redness of the face or other areas
• muscle tremors
• angina-like pain: crushing substernal chest pain
• splenomegaly

Note: Often no symptoms are present.

Additional symptoms that may be associated with this disease:

• nosebleed - symptom
• heartbeat sensations
• ear noise/buzzing

Signs and tests

Hypertension may be suspected when the blood pressure is high. It is confirmed through blood pressure measurements that are repeated over time. Blood pressure consistently elevated over 140 systolic (which indicates the pressure generated when the heart beats) or 90 diastolic (which indicates the pressure when the heart is at rest), or consistently over the person's "normal" blood pressure, is considered hypertension. The person may show signs of complications.

Tests for suspected causes and complications may be performed. These are guided by the symptoms presented, history, and results of examination.

This disease may also alter the results of the following tests:

• visual field
• a RBC count
• a ophthalmoscopy
• a liver scan
• alpha-1 antitrypsin

Overview | Treatment

Definition

Loss of brain function that occurs when the blood supply to any part of the brain is interrupted, resulting in tissue death.

Alternative names

cerebrovascular disease; CVA; cerebrovascular accident

Causes, incidence, and risk factors

The brain requires about 20% of the circulation of blood in the body.A primary blood supply to the brain is through 2 arteries in the neck (the carotid arteries), which then branch off within the brain to multiple arteries that each supply a specific area of the brain. The posterior part of the brain and brainstem are supplied through the vertebral arteries. Even a brief interruption to the blood flow can cause decreases in brain function (neurologic deficit).

The symptoms vary with the area of the brain affected and commonly include such problems as changes in vision, speech and comprehension changes, weakness, vertigo, loss of sensation in a part of the body, or changes in the level of consciousness. If the blood flow is decreased for longer than a few seconds, brain cells in the area die (infarct) -- causing permanent damage to that area of the brain (or even death), and resulting in loss of function corresponding to the area that part of the brain controls.

A stroke affects about 4 out of 1,000 people. It is the 3rd leading cause of death in most developed countries, including the U.S., and the leading cause of disability in adults. The incidence of stroke rises dramatically with age, with the risk doubling with each decade after age 35. About 5% of people over age 65 have had at least one stroke. The disorder occurs in men more often than women.

People who smoke cigarettes or who have hypertension, diabetes, hyperlipidemia or heart disease, have an increased risk of stroke. Rarely, strokes may happen in women on birth control pills. The risk is increased if a woman also smokes and is older than 35. Pregnancy and the puerperium also put women at an increased risk of stroke. Other illnesses such as vasculitis, lupus or high blood viscosity that predispose to stroke.

A stroke involves loss of brain functions (neurologic deficits) caused by a loss of blood circulation to areas of the brain. The specific neurologic deficits may vary depending on the location, extent of the damage, and cause of the disorder.

A stroke may be caused by reduced blood flow (ischemia) that results in deficient blood supply and death of tissues in that area (infarction). Causes of ischemic strokes are blood clots that form in the brain (thrombus) and blood clots or pieces of atherosclerotic plaque or other material that travel to the brain from another location (emboli). Bleeding (hemorrhage) within the brain can rarely cause symptoms that mimic stroke.

The most common cause of a stroke is stroke secondary to atherosclerosis (cerebral thrombosis). Atherosclerosis ("hardening of the arteries") is a condition in which fatty deposits occur on the inner lining of the arteries, and atherosclerotic plaque (a mass consisting of fatty deposits and blood platelets) develops. The occlusion of the artery develops slowly. Atherosclerotic plaque does not necessarily cause a stroke. There are many small connections between the various brain arteries. If the blood flow gradually decreases, these small connections will increase in size and "by-pass" the obstructed area (collateral circulation). If there is enough collateral circulation, even a totally blocked artery may not cause neurologic deficits. A second safety mechanism within the brain is that the arteries are large enough that 75% of the blood vessel can be occluded, and there will still be adequate blood flow to that area of the brain.

A thrombotic stroke (stroke caused by thrombosis) is most common in older people, and often there is underlying atherosclerotic heart disease or diabetes mellitus. This type of stroke may occur at any time, including at rest. The person may or may not lose consciousness.

Strokes caused by embolism (moving blood clot) are most commonly strokes secondary to a cardiac source. Clots that develop because of heart disorders may then travel to the brain. An embolism may also originate in other areas, such as the aortic arch, especially where there is atherosclerotic plaque. The embolus travels through the bloodstream and becomes stuck in a small artery in the brain. This stroke occurs suddenly with immediate maximum neurologic deficit. It is not associated with activity levels and can occur at any time. Arrhythmias of the heart, such as atrial fibrillation, are commonly seen with this disorder and often are the cause of the embolus. Other causes of embolic stroke include endocarditis (an infection of the heart valves), or a mechanical heart valve which may have a clot attached to it. A heart attack puts people at greater risk for having an embolic stroke. Damage to the brain is often more severe than with a stroke caused by cerebral thrombosis. Consciousness may or may not be lost.

The probable outcome is worsened if blood vessels damaged by stroke rupture and bleed (hemorrhagic stroke).

See also:

• stroke secondary to carotid dissection (bleeding from the carotid arteries)
• stroke secondary to carotid stenosis (narrowing of the carotid arteries)
• stroke secondary to cocaine
• stroke secondary to FMD (fibromuscular dysplasia)
• stroke secondary to syphilis

Prevention

The prevention of a stroke includes control of risk factors. Hypertension, diabetes, heart disease, and other associated disorders should be treated as appropriate. Smoking should be minimized or, preferably, stopped. A low-cholesterol, low-salt diet may be appropriate if the risk factors include atherosclerosis or hypertension. Increased physical activity may be advised.

The treatment of TIA can prevent some strokes.

Symptoms

• loss of movement (paralysis) of any body area
• weakness
• decreased sensation
• numbness
• tingling or other sensation changes
• decreased vision
• language difficulties (aphasia):
• slurred, thick, difficult speech
• inability to speak
• inability to understand speech
• may have difficulty with reading or writing
• inability to recognize or identify sensory stimuli (agnosia) resulting in "neglect" of one side of the body
• loss of memory
• vertigo (abnormal sensation of movement)
• loss of coordination
• swallowing difficulties
• personality changes
• mood/emotion changes (such as depression or apathy)
• consciousness changes:
• sleepy
• stuporous/somnolent/lethargic
• comatose/unconscious
• urinary incontinence (lack of control over bladder)
• lack of control over the bowels
• cognitive decline
• dementia
• easily distracted
• impaired judgment
• limited attention

Additional symptoms that may be associated with this disease:

• tongue problems
• seizures
• movement, unpredictable - jerky
• movement, uncontrollable
• movement, dysfunctional
• incontinence
• fatigue
• fainting
• facial paralysis
• eye movements, uncontrollable
• eye lid drooping
• drooling
• breathing, absent temporarily
• behavior, unusual or strange
• abnormal lack of sweating

Note: Specific changes in brain function (neurologic deficits) depend on the location and amount of injury to the brain. The symptoms are typically on one side of the body but may be isolated to specific functions, may involve one side of the body and the opposite side of the face, or may involve the face only.

Signs and tests

A history of the pattern of symptom development is important in the diagnosis of a stroke. Maximum neurologic deficits may be present at the beginning (onset) of the stroke, or symptoms may progress or fluctuate for the first day or two (stroke in evolution). Once there is no further deterioration, the stroke is considered a complete stroke.

Examination may include neurologic, motor, and sensory examination to determine the specific deficits present, because they often correspond closely to the location of the injury to the brain. An examination may show changes in vision or visual fields, changes in reflexes including abnormal reflexes or abnormal extent of "normal" reflexes, abnormal eye movements, muscle weakness, decreased sensation, and other changes. A bruit (an abnormal sound heard with the stethoscope) may be heard over the carotid arteries of the neck. There may be signs of atrial fibrillation.

Tests may be used to determine underlying disorders, the location and cause of the stroke, and to rule out other disorders that may cause the symptoms.

• a head CT or MRI of head may be used to rule out bleeding (hemorrhage) or other lesions and to define the location and extent of the stroke
• an ECG (electrocardiogram) may be used to determine underlying heart disorders
• an echocardiogram may be used if the cause is suspected to be cardiac embolus
• a carotid duplex (ultrasound) may be used if the cause is suspected to be carotid artery stenosis
• a cerebral (head) arteriography may be used if disorder involving the blood vessels is suspected

This disease may also alter the results of the following tests:

• platelet aggregation test
• osmolality
• LDH isoenzymes
• LDH
• cytometric study
• CSF collection
• CPK isoenzymes
• BERA (brainstem evoked response audiometry)

Overview | Treatment