In Plain Sight

In Plain Sight Normalizing Diverse Clinical Presentations in Obstetrics & Gynecology

A Digital Guidebook

JASMIN EATMAN, HERMES APONTE RIVERA, CHRISTEN JARSHAW, ANGELICA DEMATAS, MANTHI DISSANAYAKE, ALIAH FONTEH, EMILY GHARABEGI, KIMBERLY KAASE, LAUREN OLIVER, ANDREA SÁNCHEZ-VELÁZQUEZ, VALERIA SANTIAGO-PADILLA

fair use disclaimer This document was created for educational and scholarship purposes only.

The information contained in this document is not meant to present complete, exhaustive, or wholistic criteria for the diagnosis, management, or treatment of the included conditions. Nor is this document meant to replace the advice of a competent and licensed medical provider.

U.S. COPYRIGHT OFFICE- FAIR USE DEFINITION http://www.copyright.gov/fls/fl102.html Copyright Disclaimer under Section 107 of the Copyright Act 1976: allowance is made for “fair use” for purposes such as criticism, comment, news reporting, teaching, scholarship, education and research.

Fair use is a use permitted by copyright statute that might otherwise be infringing.

Non-profit, educational, or personal use tips the balance in favor of fair use.

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TABLE OF CONTENTS Chapter 1: Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 2: Reproductive Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Chapter 3: Gynecologic Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Chapter 4: Vulvar Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Chapter 5: Infectious Disease & Other Inflammatory Conditions . . . 36

Chapter 6: Genetic Disorders & Congenital Conditions . . . . . . . . . . . . 43

Chapter 7: Medical Spanish for Obstetrics & Gynecology . . . . . . . . . . . 47

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INTRODUCTION People of color have disproportionately worse gynecologic and gender-based health outcomes than white patients. Today, we see that Black obstetric and gynecologic patients have a significantly increased maternal mortality rate in pregnancy, and proportionally more deaths due to gynecologic and breast cancer despite a lower incidence of these cancers overall, when compared to white patients (Gwan et al. 2022; Jatoi et al. 2022). The cause of these healthcare disparities is multifactorial, and the Institute of Medicine divides them into three broad categories including patient, provider, and systemic factors (Collins et al. 2014; Nelson 2002). Patient factors include education, geographical access to healthcare, financial and insurance status, cultural beliefs and values, and other social factors. Systemic factors are defined by the delivery of healthcare itself.

For example, the type of hospital the patient is evaluated in and the resources the hospital has access to. Provider factors include prior medical knowledge, expectations or beliefs, implicit bias, and the racial or ethnic background of the provider. It is relatively simple to divide causes of healthcare disparities into categories on paper, but these factors have significant interplay and influence on each other through real-world application. Though patient and systemic factors are important to address to mitigate healthcare disparities, this guidebook addresses the need to ensure that medical education provides material that is diverse in its representation of pathology in obstetrics and gynecology.

Racial healthcare disparities dissipate when patients interact with providers who are trained in equitable provision of healthcare, a finding that emphasizes the importance of incorporating principles of anti-racism in medical training (Collins et al. 2014). Recognition and management of medical conditions in people of color is not well embedded in medical curriculum and can delay appropriate care. Prior research has demonstrated a lack of representation of patients of color into educational resources (Nelson 2002; Kaundinya & Kundu 2021). In fact, a 2018 study by Louie and Wilkes (2018) showed that less than 5% of general medicine textbooks have images of dark skin tones. Interestingly, sexually transmitted infections are more frequently shown on dark skin tones as opposed to white skin tones, which are used to depict more common and less stigmatizing diagnoses (Kaundinya & Kundu 2021). A lack of representation of clinical pathology on individuals of darker complexions across educational modalities contributes to disparity in the recognition of various medical conditions on darker skin tones. This disparity contributes to inequity in healthcare and may influence healthcare outcomes amongst non-white patients. In Plain Sight: Normalizing Diverse Clinical Presentations in Obstetrics and Gynecology, is a collaborative resource created by and for medical trainees. Through this digital guidebook, we aim to create the material we want to see in our education and, in turn, advance racial equity in gynecologic and gender-based medicine.

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Dedication This project is dedicated to the patients who allow us to learn from them in their most vulnerable moments. To the medical trainees and providers who dedicate their lives to becoming life-long learners, and to all who are eager to learn how various conditions appear, in plain sight, amongst diverse skin complexions and gender identities. It is our hope that this work will fuel the development of resources in medical education that are representative of the many diverse patient populations we are fortunate enough to serve.

We would also like to dedicate this work to the founding mothers of Obstetrics & Gynecology: Anarcha, Betsey, and Lucy. These womens’ bodies, and those of countless other unnamed enslaved women, were violently subjugated to medical experimentation. Discoveries that were made through their exploitation formed the foundation for the field of Obstetrics and Gynecology. These women endured painful gynecologic procedures and pelvic examinations without consent, without anesthesia, and without pain relief. Their stories are a reminder of the painful history of dehumanization of Black and Brown people - a history of sexual violence, being denied the standards of perinatal care, and enduring painful complications and loss of life due to medical neglect.

As a complication of childbirth, Anarcha, Betsey, and Lucy developed painful vaginal fistulas. They were left untreated, despite being forced to engage in physical labor by their enslavers. In surgical theaters of the time, these women were exposed, restrained, and operated on without anesthesia. James Marion Sims published the results of his unethical exploitation of these women, and was deemed the “Father of Gynecology” for his experimental findings. Though many advances have been made in Obstetrics & Gynecology to advocate for ethical, compassionate, and quality care to patients in the most intimate settings, we must continue to intentionally acknowledge the impact of racism and sexism in medical history and education. In Plain Sight seeks to give voice to the many Black and Brown women throughout history, named and unnamed, to whom we owe our deepest respect and gratitude as future generations of Obstetricians and Gynecologists.

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In Plain Sight Normalizing Diverse Clinical Presentations in Obstetrics & Gynecology

AUTHORSHIP District IV District VII Jasmin Eatman

Emory University School of Medicine

Hermes Aponte-Rivera

University of Puerto Rico School of Medicine

Christen Jarshaw

University of Oklahoma College of Medicine

Manthi Dissanayake ECU Brody School of Medicine

Aliah Fonteh Meharry Medical College

Angelica Dematas Rutgers University

Valeria Santiago-Padilla University of Puerto Rico School of Medicine

Lauren Oliver

University of Oklahoma College of Medicine

Emily Gharabegi

University of Missouri-Kansas City School of Medicine

Andrea Sanchez-Velazquez University of Puerto Rico School of Medicine

Kimberly Kaase

Oklahoma State College of Osteopathic Medicine

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District IV District VII

Chapter 1 Breast

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Chapter1: Breast

breastfeeding

Breastfeeding initiation and retention rates are lowest amongst black women. Breast milk (except for maternal or fetal contradictions) can be one of the best ways to provide nutrients, antibodies, and support to a growing infant. One example of benefit is the reduction of infant infections through maternal immunoglobulins that help provide passive immunity to the infant. The World Health Organization and Center for Disease Control recommends breast milk as the ideal infant nutrition source for at least six months post-delivery. Additional support systems for infant feeding include a variety of online resources, community organizations, lactation consultants, doulas, and making use of protections for "safe and clean sites to pump" at your workplace.

Who, What, Why: Why do African-American women bresastfeed less? BBC News. Published June 10, 2014. Accessed August 16, 2022. https://www.bbc.com/news/blogs-magazine-monitor-27744391

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Chapter1: Breast

BREAST CANCER SIGNS

While breast self-exams are not a substitute for a breast exam completed by a physician, patients should still be aware of these warning signs of breast cancer. Familiarizing one's self with the look and feel of one's breasts is an important supplement to breast cancer screening

Naraynsingh V, Jarvis JK, Milne DM, Cawich SO, Harnanan D, Singh Y, Islam S. The Pushing Sign for Early Skin Tethering in Breast Cancer. Cureus. 2021 Dec 16;13(12):e20471. doi: 10.7759/cureus.20471. PMID: 34976543; PMCID: PMC8682950.‌

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Chapter1: Breast

breast dimpling ("Pushing sign")

Breast dimpling is seen in breast cancer. This dimpling or pitting is a sign that a mass, likely a tumor, is pulling on breast tissue, skin, or the supportive ligaments of the breast. On exam, it is important to observe the patient through various motions to identify any abnormal changes in the breast tissue. Breast dimpling is usually unilateral (only affecting one breast) and due to inflammatory breast cancer while most cases of bilateral dimpling are non-malignant.

Naraynsingh V, Jarvis JK, Milne DM, Cawich SO, Harnanan D, Singh Y, Islam S. The Pushing Sign for Early Skin Tethering in Breast Cancer. Cureus. 2021 Dec 16;13(12):e20471. doi: 10.7759/cureus.20471. PMID: 34976543; PMCID: PMC8682950.‌

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Chapter1: Breast

inflammatory breast cancer

Inflammatory Breast Cancer (IBC) is a rare type of breast cancer, which is easily misidentified as mastitis on initial presentation. On examination, affected breasts are markedly swollen, red, and tender. IBC is often described as "peau d'orange (orange peel),", which refers to its red/orange appearance on lighter skin tones. Redness may be less apparent in darker skin tones and may present, instead, as hyper-pigmented or purple. Other characteristics (dimpling, swelling) remain similarly identifiable across skin tones. Symptoms include pain, rapid changes in the breast, enlargement of one breast, discoloration (pink, purple, or red), flattening or turning inward of the nipple, and enlarged lymph nodes in the axilla or clavicular areas. IBC develops rapidly due to stromal infiltration and lymphatic obstruction. Diagnosis is made by mammogram and biopsy of breast tissue.

If a patient fails antibiotic treatment for mastitis, work-up for IBC is strongly recommended. This condition can also be confused for Paget's Disease of the Breast; however; IBC is not localized to the nipple alone.

Camazine B. What is the Diagnosis? Earthwide Surgical Foundation. Published Jan 25, 2012. Accessed Sept 4, 2022. http://earthwidesurgicalfoundation.blogspot.com/2012/01/what-is-diagnosis_25.html Nguefack CT, Biwole ME, Massom A, Kamgaing JT, Njamen TN, Halle-Ekane G, Obinchemti TE, Priso EB. Epidemiology and surgical management of breast cancer in gynecological department of Douala General Hospital. The Pan African medical journal. 2012; 13(35).

10.11604/pamj.2012.13.35.1694.

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Chapter1: Breast

PAGET'S DISEASE OF THE BREAST

Paget's Disease of the breast is seen on physical exam as scaly, ulcerated lesions of the nipple that extend to the areola and are normally painful and itchy. These symptoms may be present before the lesion itself manifests.

Underlying breast cancer is present in as much as 88% of cases but does not usually present as a mammary mass. Diagnosis is made by the presence of intraepithelial adenocarcinoma cells in small groups within the epidermis in a full thickness punch or wedge biopsy of the lesion. In comparison to inflammatory breast cancer, Paget's disease is localized to the nipple and has a better prognosis.

Mnikhovich MV, Romanov AV, Mikhaleva LM, et al. Paget's disease of the breast. Differential diagnosis using additional IHC-panel. Literature review and own observations. GJPLM. 2021;1(2):25-49. doi: 10.52402/Pathology205

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Chapter1: Breast

Mastectomy

A mastectomy is a surgery which involves the removal of some or all of the breast tissue. When performed to treat or prevent breast cancer, tissue near the breast such as lymph nodes, chest lining and muscle may also be removed. A total mastectomy is the removal of the whole breast including the nipple, areola, and overlying skin. A modified radical mastectomy removes the entire breast including the nipple, areola, overlying skin, lymph nodes under the arm, and chest muscle lining. A radical mastectomy removes the entire breast including the nipple, areola, overlying skin, lymph nodes under the arm, and chest muscles. Breast reconstruction surgery can be performed after a mastectomy to re-create a "normal" breast structure using an implant, which can address asymmetry between the breasts and otherwise allow the patient to feel more normal in their clothing.

Nall R. What to know about mastectomy scars. Medical News Today. Published August 12, 2019.

Accessed August 19, 2022. https://www.medicalnewstoday.com/articles/320379 ‌

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Chapter1: Breast

FEMALE TO MALE TOP SURGERY

Compared to a partial or total mastectomy performed for the management of breast pathology, subcutaneous mastectomies involve a reduction (not total removal) of breast tissue. This procedure may or may not involve removal of the nipple-areola complex, which is based on the patient's preference. It is important to counsel transgender patients with a family history of breast cancer undergoing a subcutaneous mastectomy as gender affirming surgery to make them aware that screening is still advised per professional medical guidelines. This is because some tissue still remains in place.

Jay T, Segwapa K. The circumareolar approach to gynecomastia and transgender surgery: modifications to provide correct nipple areolar complex position and shape. S Afr J Surg.

2017;55(1):16-20. PMID: 28876553 ‌

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Chapter1: Breast

NIPPLE TATTOO POST-MASTECTOMY

Nipple tattooing post-mastectomy is a method of nipple reconstruction if one or both nipples are removed during a mastectomy. Nipple tattoos use skin-color-pigmented ink to create natural looking areolas, which can be of significant psychosocial benefit to patients. Ideal candidates for nipple tattoos include those who have had breast reconstruction with implants or tissue flaps. Patients with damaged skin due to radiation treatment, very thin breast skin following mastectomy, and lymphedema of the chest may not be ideal candidates for nipple tattooing.

Used with permission of patient and their provider team: Israeli R, Rustemeyer M. DIEP Flap Reconstruction and 3D Nipple Tattooing. NYBRA Plastic Surgery. Accessed September 8, 2022. https://nybra.com/breast-reconstruction/restorative-tattooing/‌

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Chapter1: Breast

idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis is a very rare benign condition. It has the highest prevalence in the third decade of life, and risk factors for this condition include breastfeeding, oral contraception usage, and pregnancy.

On physical exam, a patient will present with a breast mass that is firm and tender. Diagnosis can occur after an analysis of histopathology which should include voids of tissue surrounded by inflamed areas. Therapeutic management of this condition has seen improvement with corticosteroids and alternative immunosuppression therapies. A last resort is surgical management, which is reserved for more severe cases. However, postoperative sequelae to consider include recurrence, improper healing of the surgical site, and scarring.

Schadt S, Schadt ME, Wojda TR, Yanagawa FS, Stawicki SP. Idiopathic granulomatous mastitis: A diagnostic and therapeutic challenge. Int J Acad Med. 2017;3(2):336-9. DOI: 10.4103/IJAM.IJAM_89_17‌

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Chapter1: Breast

breast abscess

A breast abscess is a collection of inflammatory exudate. It usually presents following under-treated or treatment-resistant mastitis or cellulitis, sometimes in the setting of breastfeeding. The most common physical exam findings include redness and tenderness in the breast associated with a fluctuant mass. However, systemic symptoms like fever and malaise can be present. The most common culprit is Staphylococcus aureus.

Ultrasonography can be used to confirm the diagnosis and differentiate this condition from breast malignancy. Treatment consists of drainage and antibiotic therapy. If the patient is lactating, breastfeeding or pumping can continue and will aid in the resolution of the abscess.

Shah BC. Breast Abscess Drainage. bcshah.com. Published 2017. Accessed Sept 7, 2022. https://bcshah.com/breast-abscess-drainage/

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Chapter1: Breast

CANDIDA INFECTION

Candida species are a normal component of the body's flora. When the balance of organisms on our skin or mucosa is disrupted, a candida infection can develop. Most commonly this infection can be found on the mouth, vaginal area, and skin folds. On physical exam, it is seen as a continuous, pruritic, erythematous or hyper-pigmented rash accompanied by satellite lesions. Recovery time may be shortened and recurrence prevented by keeping the area dry.

Usatine RP. Dark rash under breasts. J Fam Pract. 2016;65(9)‌

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Chapter1: Breast

GYNECOMASTIA

Gynecomastia is a benign proliferation of the glandular tissue of the breast in response to increased estrogen activity. On physical exam, gynecomastia is seen as a unilateral or bilateral rubbery, palpable mass of tissue that extends outside the area under the nipple and can be tender. Imaging is not routinely recommended. A full work up includes review of medications, dietary supplements, and herbal supplements. Management ranges from observation to surgical therapy.

Kwekwesa A, Kandionamaso C, Winata N, et al. Breast enlargement in Malawian males on the standard first-line antiretroviral therapy regimen: Case reports and review of the literature. Malawi Med J. 2015; 27(3):115-117. doi:10.4314/mmj.v27i3.11‌

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District IV District VII

Chapter 2

reproductive endocrinology

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Chapter 2: Reproductive Endocrinology

polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is a hormonal disorder in women of reproductive age. Symptoms typically develop at the first menstrual period and include signs of excessive androgenation, irregular periods, and polycystic ovaries. On examination, patients with polycystic ovarian syndrome may show signs of excessive body hair (in a male-pattern distribution), severe acne, and abnormally heavy, infrequent, or long menstrual cycles. Complications of polycystic ovarian syndrome include metabolic syndrome (high blood pressure, high cholesterol, high blood sugar, type 2 diabetes or prediabetes), infertility, and central obesity.

Diagnosis is made by a blood test of hormone levels, an ultrasound for the presence of cysts on ovaries, and a pelvic examination for the presence of abnormal growths or lumps. While PCOS is linked to hyper-adiposity, women of color are substantially more likely to receive poor counseling due to provider weight bias than their white counterparts. @pcos.kicks.my.butt. ACNE. Posted Nov 12, 2020. Accessed Aug 5, 2022. https://www.instagram.com/p/CHf9_rODq8u/ Fite LP, Cohen PR. Polycystic Ovarian Syndrome-associated Confluent and Reticulated Papillomatosis: Report of a Patient Successfully Treated with Azithromycin. J Clin Aesthet Dermatol. 2017;10(9):30-35.‌

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Chapter 2: Reproductive Endocrinology

ACANTHOSIS NIGRICANS

Acanthosis Nigricans is a darkening of body regions- most commonly the axilla or posterior neck. It is associated with a "velvety" appearance and is common in patients with underlying insulin resistance. A patient with acanthosis nigricans and other risk factors for insulin resistance should undergo laboratory screening for diabetes, such as evaluation of their Hemoglobin A1C. Due to underlying endocrine abnormalities, individuals with polycystic ovarian syndrome (PCOS) may also present with acanthosis nigricans. A patient with PCOS, however, will have a history of abnormal menses, excessive acne, hirsutism, elevations in biochemical markers which supporting hyperandrogenism, and/or polycystic ovaries on ultrasound.

Fite LP, Cohen PR. Polycystic Ovarian Syndrome-associated Confluent and Reticulated Papillomatosis: Report of a Patient Successfully Treated with Azithromycin. J Clin Aesthet Dermatol. 2017;10(9):3035.‌

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Chapter 2: Reproductive Endocrinology

reticulated papillomatosis

Reticulated papillomatosis is likely a condition of disordered keratinization. Physical exam demonstrates central plaques which form a reticular pattern at the periphery. These can range from erythematous (red) to dull brown in color and are most commonly seen on the upper body. It's presentation can overlap with other features of Polycystic Ovarian Syndrome (PCOS) due to underlying endocrine abnormalities.

Fite LP, Cohen PR. Polycystic Ovarian Syndrome-associated Confluent and Reticulated Papillomatosis: Report of a Patient Successfully Treated with Azithromycin. J Clin Aesthet Dermatol. 2017;10(9):3035.‌

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Chapter 2: Reproductive Endocrinology

polymorphic eruption of pregnancy

Polymorphic eruption of pregnancy is a skin rash caused by an immune response to the stretching of abdominal skin during the last three months of pregnancy. This phenomenon is more commonly reported in individuals of color. On examination, you may see large, red, hive-like plaques on the abdomen, buttocks, and thighs. Diagnosis is made by the ruling out of other skin conditions causing similar symptoms. Polymorphic eruption of pregnancy resolves within 4-6 weeks after delivery.

Studdiford JS, Georgeo N, Trayes K. Pruritic Rash in Pregnancy. Am Fam Physician.

2017;95(7):453-454.

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District IV District VII

Chapter 3

Gynecologic oncology

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Chapter 3: Gynecologic Oncology

Cervical cancer screening

Preventative gynecological health screening is very important, as it can provide information needed to maintain cervical and full-body health. Early detection of cervical cancer can be made possible with screenings based on your gynecological history. Pap smears are performed during an examination of the cervix and involves the use of two different tools to lightly scrape off cells to be further evaluated under the microscope. It is recommended in all patients ages 21-65 to detect precancerous and cancerous lesions of the cervix. ACOG recommendations include a pap smear with cervical cytology every three years in the average risk patient between 21-29 years old. In patients 30-65 years of age, more cervical cancer screening options are available, including primary high risk HPV (hrHPV) testing every five years, cervical cytology every 3 years, or co-testing (a combination of hrHPV and cervical cytology) every five years. (ACOG April 2021) Behring S. Early detection of cervical cancer: Risk factors and prevention. Healthline. https://www.healthline.com/health/cervical-cancer/early-detection-of-cervical-cancer. Published 2022. Accessed September 7, 2022.‌

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Chapter 3: Gynecologic Oncology

vulvar basal cell carcinoma

Vulvar basal cell carcinoma commonly presents in post-menopausal patients as a locally aggressive disease. It can present as an ulcer with rigged edges and a central ulceration that might be hypo- (pearly) or hyperpigmented. This lesion is usually asymptomatic but can cause pruritus (itchy skin). Treatment is usually radical local excision of the lesion.

Banda JEA, Mendes SHF, Fernandes SS, Chaves R. Basal Cell Carcinoma of the Vulva: A Case Report. Obstet Gynecol Int J. 2016;5(3):00158. doi:10.15406/ogij.2016.05.00158

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Chapter 3: Gynecologic Oncology

vulvar squamous cell carcinoma

Squamous Cell Carcinoma (SCC) is the most common subtype of vulvar cancer. Risk factors include HPV infection, vulvar lichen sclerosis, cervical intraepithelial neoplasia (CIN), tobacco use, and immunodeficiency. Most patients present first with a vulvar lesion desribed as an ulcer, plaque or mass in the labia majora, labia minora, perineum, clitoris or mons pubis. Symptoms associated with this pathology include persistent itching, pain and tenderness, skin color and texture changes (tissue thickening), and bleeding. A biopsy is performed for diagnostic purposes and treatment depends on the extent of the lesion and lymph node involvement.

Rogers LJ. Management of Advanced Squamous Cell Carcinoma of the Vulva. Cancers. 2022;14(1):167.

Chokoeva AA, Tchernev G, Castelli E, Orlando E, Shyam BV, Grebe M, Wollina U. Vulvar cancer: a review for dermatologists. WMW. 2015;165 (7-8):164-177. doi: 10.1007/s10354-015-0354-9‌

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Chapter 3: Gynecologic Oncology

malignant vulvar melanoma

This image depicts a malignant vulvar melanoma, which, though rare, is the second most common type of vulvar malignancy. It is more common in post-menopausal women.

Unfortunately, when this form of melanoma is identified, it is typically late in presentation with a poor prognosis. Patient may have complaints of severe labial pruritus and white discharge for several months. Pelvic exam at late stages may reveal a growth originating from the labia minora with features such as irregularity of shape, hyperpigmentation, and ulceration. Internal examination with a speculum may reveal hyperpigmented lesions on the vaginal wall and/or parts of the cervix. Histopathology is necessary to differentiate melanoma from other gynecologic lesions. Management is through complete excision. In cases with metastasis, adjuvant chemotherapy, immunotherapy, or radiotherapy may be recommended. The main considerations for the prognosis of a patient diagnosed with vulvar melanoma include tumor size, depth, presence of ulceration, and whether or not lymph node involvement is present. ul Ain Q, Rao B. A Rare Case Report: Malignant Vulvar Melanoma. Indian J Gynecol Oncolog.

2020;18:23. doi: 10.1007/s40944-020-0368-0

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District IV District VII

Chapter 4

vulvar pathology

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Chapter 4: Vulvar Pathology

lichen sclerosus

Lichen sclerosus exists on a spectrum and may progress to more serious vulvar pathologies if left untreated. A pelvic exam may reveal erosions, fissures, and the narrowing of the introitus (which may limit a speculum exam).

Additionally, shrinkage of the labia minora and clitoris to the point that these structures are difficult to distinguish between may also be evident upon examination. The skin loses pigmentation and may be described as being "smooth" and like "porcelain-white/ivory." This pathology also has a characteristic shape which can be described as a figure-of-eight, keyhole, hourglass, or lotus flower. Patients with this disorder may report other symptoms such as diffuse irritation and soreness, urinary obstruction, painful urination, pain with intercourse, or pain with defecation. Notably, prepubertal girls are more likely than other age demographics to report bowel or bladder incontinence and bleeding. This diagnosis is clinical.

Marfatia Y, Surani A, Baxi R. Genital lichen sclerosus et atrophicus in females: An update. Indian J Sex Transm Dis AIDS. 2019;40(1):6-12. doi: 10.4103/ijstd.IJSTD_23_19. PMID: 31143853; PMCID: PMC6532494.

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Chapter 4: Vulvar Pathology

lichen simplex chronicus

Lichen simplex chronicus of the vulva is a skin condition created by excessive and chronic scratching or rubbing leading to inflammation and lichenification (thickening of skin). On examination, lichen simplex chronicus is seen as swelling of the vulva or clitoris, discoloration of the vulva, tears or fissures on the vulva, and thickened appearance of vulva or clitoris. Symptoms include burning, itching, hyperpigmentation of the vulva, and swelling of the vulva.

Diagnosis is made by ruling out skin conditions with similar symptoms. A skin swab may be used to identify the presence of a bacterial or fungal infection. A skin biopsy may be needed to rule out squamous cell carcinoma or extramammary Paget disease.

Verma SB. Scrotal labia - An uncommon presentation of vulvar lichen simplex chronicus. Indian Dermatol Online J. 2021;12(4):590-592. doi: 10.4103/idoj.IDOJ_896_20 PMID: 34430467 Sanchez A, Gandhi K, Lee B, Gomez Garcia J, Ventolini G. Vulvar neurodermatitis in a postmenopausal African-American patient: a case report. J Menopausal Med. 2022;28(1):42-45. doi: 10.6118/jmm.21032 PMID: 35534430‌

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Chapter 4: Vulvar Pathology

lichen planus

Lichen planus is a common inflammatory disease characterized by swelling and irritation of the skin or mouth. Lichen planus of the vulva may be associated with pain, burning, and reddish-brown patches that can be found on the inner vulva. On examination, vulvar lichen planus is seen as generalized atrophy and scarring on the vulva, flattened labia minora, and shrinking of the vaginal opening. Diagnosis is made by physical examination and biopsy of vulvar skin.

Kharkar V, Sunkwad A. Good response to metronidazole in a case of erosive genital lichen planus.

Indian J Drugs Dermatol. 2019;5(2):110-112. DOI: 10.4103/ijdd.ijdd_46_19

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Chapter 4: Vulvar Pathology

extramammary paget's disease

Extramammary Paget's Disease is intraepithelial adenocarcinoma of the vulva. It presents as a pruritic, raised, eczematous lession with poor demarcation in an red-purple background with scatered hyperkeratosis. This lesion persists even with appropiate treatment of eczema. Diagnosis is made by vulvar biopsy.

Gonçalves Amorim A, Batista Fraga Mendes B, Neves Ferreira R, Chambô Filho A. Paget Disease of the Vulva: Diagnosis by Immunohistochemistry. Case Rep Dermatol Med. 2015;2015:162483. doi:10.1155/2015/162483

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Chapter 4: Vulvar Pathology

seborrheic keratosis of the genitalia

Seborrheic Keratosis (SK) of the genital region is rare. On physical exam of the skin, it can manifest as macules, papules, or plaques which are sharply demarcated with a "stuck on" appearance. Polypoidal masses are especially rare but are much more likely to occur in the genital region than other parts of the body. Though benign, SK can still be physically debilitating or be a source of social stigma.

Nath AK, Kumari R, Rajesh G, Thappa DM, Basu D. Giant seborrheic keratosis of the genitalia.

Indian J Dermatol. 2012 Jul;57(4):310-2. doi: 10.4103/0019-5154.97681. PMID: 22837573; PMCID: PMC3401854.‌

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District IV District VII

Chapter 5

infectious disease and other inflammatory conditions

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Chapter 5: Infectious Diseases and Other Inflammatory Conditions

Varicella zoster "shingles"

Shingles is caused by an infection of the varicella-zoster virus (VZV) commonly known for causing the primary infection of chicken pox. Patients who have previously been infected with the varicella-zoster virus and recovered from chicken pox may develop shingles . Physical examination of the skin is most notable for a single stripe of fluid-filled blisters (or "dew-drops on roses") that affect only a small section on one side of the body (dermatomal distribution). While these blisters are very painful to the touch (often described as a "lightning shock" nerve pain), they are often still itchy. Even in darkerpigmented skin, a red hue can be characteristic. In severely immunocompromised patients, the blisters may impact more than one area of the body.

Seladi-Schulman J. How to identify shingles on black and brown skin. Healthline. Last updated July 1, 2021. Accessed August 19, 2022. https://www.healthline.com/health/skin/shingles-on-black-skin

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Chapter 5: Infectious Diseases and Other Inflammatory Conditions

Condyloma Acuminata "HPV Warts"

Condyloma acuminata is a manifestation of Human Papilloma Virus (HPV), the most common sexually transmitted disease in the world. The most common strains that cause genital warts are 6 and 11. HPV is transmitted through contact with infected skin and warts, and puts individuals at greater risk for cervical cancer over time. On physical exam, these lesions are seen as flat, dome, cauliflower-shaped, fungating, lobulated, or verrucous lesions.

They are often clumped together and can be skin colored, gray, brown, or hyperpigmented and are commonly found on the vulva, penis, perineum, perianal area and in the groin region.

Sonnex C, Vrotsou K. Treatment of ano-genital warts: the effect of an educational event on practitioner choice. Int J STD AIDS. 2007;18(8):531-537.

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Chapter 5: Infectious Diseases and Other Inflammatory Conditions

Herpes simplex virus (HSV-2) vesicles

Herpes simplex virus is a very common infection worldwide. Both HSV-1 and HSV-2 can cause genital herpes, although HSV-2 is the more common culprit. It presents as clustered, exquisitely tender vesicles on an erythematous base ("dew drops on roses"). Definitive diagnosis requires laboratory testing, although empiric treatment if often reasonable. Recurrence is expected and is commonly seen in immunocompromised patients or times of stress. Routine screening of asymptomatic patients is not recommended.

Mathew J, Sapra A. Herpes Simplex Type 2. StatePearls [Internet]. June 12, 2022. https://www.ncbi.nlm.nih.gov/books/NBK554427/

39

Chapter 5: Infectious Diseases and Other Inflammatory Conditions

Bartholin's gland abscess

This is a Bartholin cyst/abscess. These glands are located near the 4 o'clock or 8 o'clock position of the vaginal introitus. Bartholin abscesses can be extremely painful and exquisitely tender on exam, even limiting a patient's ability to sit in a chair or tolerate a pelvic exam. Compared with cysts, abscesses are more likely to appear indurated with fluctuance and/or purulent drainage; erythema may be less easily visualized compared to pale skin tones.

For symptomatic patients, incision and drainage is the recommended management. Cysts may be palpated on exam as a fluctuant mass in an asymptomatic patient. Asymptomatic patients do not require intervention.

Radhakrishna V, Goel R, Parashar G, Santhanakrishnan R. Bartholin's gland abscess in a prepubertal female: A case report. Ann Med Surg (Lond). 2017;24:1-2. doi: 10.1016/j.amsu.2017.09.017. PMID: 29062477

40

Chapter 5: Infectious Diseases and Other Inflammatory Conditions

Hives

Hives represent an inflammatory reaction by the body to some trigger, most commonly and allergen. On exam, the skin will display round, oval or worm-like welts which are raised and incredibly itchy. With lighter skin pigmentation, the welts are likely to be pink or red in color; however, in darker skin the welt is likely to be the same color as the surrounding skin.

How to Identify Hives on Brown and Black Skin. Healthline. Published February 8, 2021. Accessed Auggust 26, 2022. https://www.healthline.com/health/skin/hives-on-black-skin

41

Chapter 5: Infectious Diseases and Other Inflammatory Conditions

Contact Dermatitis

Contact dermatitis is a hypersensitivity reaction of the skin to any irritant and is the most common cause of vulvar pruritus. Patients will most likely note symptoms of severe pruritus, although bilateral and symmetric patches without sensory changes are also possible. On exam, skin is often notably dry with red patches on lighter skin or with dark brown, purple, or gray patches on darker skin. Darker pigmented skin is also much more likely to present with lichenification. The affected site may have associated blisters, oozing, crusting, or flaking.

Cohen PR. Follicular contact dermatitis revisited: A review emphasizing neomycin-associated follicular contact dermatitis.

World J Clin Cases. 2014 Dec 16;2(12):815-21. doi: 10.12998/wjcc.v2.i12.815. PMID: 25516854; PMCID: PMC4266827.

Sangha AM. Dermatological Conditions in skin of color--: Managing Atopic Dermatitis. J Clin Aesthet Dermatol. 2021; 14(3):S20-S22. PMID: 34188741

42

District IV District VII

Chapter 6

genetic disoRders and congenital conditions

43

Chapter 6: Genetic Disorders and Congenital Conditions

Turner Syndrome

This is Turner syndrome sometimes referred to as congenital ovarian hypoplasia syndrome. Turner syndrome is a genetic disorder effecting females and occurs when one of the two X chromosomes is missing partially or completely. Symptoms of Turner syndrome during infancy include a wide or weblike neck, swelling of hands and feet at birth, cardiac defects, low set ears, and broad breast with widely spaced nipples. In adolescence, these individuals can exhibit failure to begin puberty or notable "stalling" of sexual development. Common adulthood symptoms include short stature, infertility, development of hypothyroidism, and cardiovascular problems.

Abdalla AM, Nabil KM. Axenfeld-Rieger spectrum in a patient with 45,X Turner syndrome.

Opthalmic Genet. 2012;33(2):111-115. DOI:10.3109/13816810.2011.634880

44

Chapter 6: Genetic Disorders and Congenital Conditions

Complete androgen insensitivty

This patient has complete androgen insensitivity syndrome due to a defect in the androgen receptors. In utero, this defect prevents the body from recognizing available testosterone to initiate male external genitalia development, leading to an individual who is genotypically male and phenotypically female. On exam, these patients have female external genitalia but minimal pubic and axillary hair. Other exam findings include a "rudimentary vagina" and absent uterus and fallopian tubes. The absence of the latter two organs is due to anti-Mullerian hormone from the normal testes these patients have. Surgical removal of the testies is part of management to reduce the risk for future malignancy. Laboratory studies in these patients include elevated testosterone, estrogen, and luteinizing hormone. When counseling these patients on inital diagnosis, it is important to validate their gender identity and provide supportive services if desired.

Rema NV, Bhavana S. XY Female with Complete Androgen Insensitivity Syndrome with Bilateral Inguinal Hernia. J Obstet Gynecol India. 2013. DOI 10.1007/s13224-013-0379-1.

45

Chapter 6: Genetic Disorders and Congenital Conditions

Fetal alcohol syndrome disorder

Fetal Alcohol Syndrome Disorder (FASD) encompasses a range of neurodevelopmental, physical, and behavioral characteristics in an individual that was exposed to alcohol in utero. Short palpebral fissures, wide-set eyes, a smooth philtrum, and a thin upper lip can aid in the identification and diagnosis. Because FASD can present differently in every patient, the management and interventions must be individualized to their needs.

Capizano T. Fetal alcohol syndrome. AAPOS. Updated December 9, 2021. Accessed August 29, 2022. www.aapos.org. https://www.aapos.org/glossary/fetal-alcohol-syndrome

46

District IV District VII

Chapter 7

medical spanish for OBSTETRICS & GYNECOLOGY

47

Medical Spanish for Obstetrics & gynecology Introductions:

Past Medical History:

Hello, my name is Dr. Jane Doe and I am a medical student/resident/attending.

Hola, mi nombre es _____ y soy estudiante de medicina/residente/médico supervisor.

Do you have any chronic illnesses? ¿Padece alguna condición crónica?

I will be gathering your medical history today, if that is okay with you.

Voy a estar tomando su historial médico en el día de hoy, si está bien con usted.

What is your name? ¿Cuál es su nombre?

When is your birthdate? ¿Cuándo es su fecha de nacimiento?

Do you take any medications? This includes prescribed and not prescribed medications. ¿Usted toma algún medicamento? Esto incluye medicamentos recetados y no recetados.

Do you have any allergies to foods, medications, or materials? ¿Es alérgico a alguna comida, medicamento o material?

Have you had any previous surgeries? ¿Ha tenido alguna cirugía en el pasado?

Are your immunizations up to date? ¿Sus vacunas están al día?

History of Present Illness: What is the reason for your visit? ¿Cuál es la razón de su visita?

How long ago did the symptoms start? ¿Hace cuánto comenzaron los síntomas?

What were you doing when the symptoms started? ¿Qué estaba haciendo cuando los síntomas comenzaron?

Have the symptoms gotten worse since they started? ¿Los síntomas han empeorado desde que comenzaron?

Can you describe your pain/discomfort? ¿Cómo describiría su dolor/incomodidad?

48

Medical Spanish for Obstetrics & gynecology Gynecologic History: When was your first menstrual period? ¿Cuándo fue su primera menstruación?

Are you sexually active? ¿Está teniendo relaciones sexuales al momento?

How long does your period last? ¿Cuánto dura su periodo?

When was your last sexual encounter? ¿Cuándo fue su última relación sexual?

Have you been having any pain associated with your period? ¿Ha tenido dolor asociado a su menstruación?

When was your first sexual encounter? ¿Cuándo fue su primera relación sexual?

Does this pain interfere with your daily living? ¿Este dolor interfiere con su diario vivir?

Do you have bleeding between periods? ¿Usted tiene sangrado entre periodos?

When was your last menstrual period? ¿Cuándo fue su último periodo menstrual?

Do you use contraception? ¿Utiliza algún método contraceptivo?

Have you had any sexually transmitted disease? ¿Ha tenido alguna enfermedad de transmisión sexual?

Have you had cervical cancer screening recently? ¿Ha tenido cernimiento para cáncer cervical recientemente?

How many partners do you currently have? ¿Cuántas parejas tiene en estos momentos?

Do you practice oral sex? ¿Usted practica sexo oral?

Do you practice anal sex? ¿Usted practica sexo anal?

Have you noticed loss of sexual interest? ¿Ha notado pérdida en su interés sexual?

Do you have pain with sex? ¿Usted tiene dolor durante el acto sexual?

Are you able to reach orgasm? ¿Usted es capaz de llegar al orgasmo?

Have you had breast cancer screening recently? ¿Ha tenido cernimiento para cáncer de seno recientemente?

49

Medical Spanish for Obstetrics & gynecology Obstetric History:

Pregnancy Visit:

How many pregnancies have you had? ¿Cuántos embarazos ha tenido?

How do you feel today? ¿Cómo se siente en el día de hoy?

Have you had any abortions? ¿Ha tenido algún aborto?

How have you felt this past week? ¿Cómo se ha sentido en la última semana?

How many children do you have? ¿Cuántos hijos tiene?

What is your estimated due date (EDD)? ¿Cuál es su fecha estimada de parto?

If patient had previous pregnancies:

How many sonograms have you had in this pregnancy? ¿Cuántos sonogramas se ha realizado en este embarazo?

Were they vaginal or cesarean deliveries? ¿Los partos fueron vaginal o cesárea?

Any complications during past pregnancies? ¿Alguna complicación en alguno de los embarazos?

When was your last pregnancy? ¿Cuándo fue su último embarazo?

Have you been previously diagnosed with hypertension or gestational diabetes in previous pregnancies? ¿Fue diagnosticada con hipertensión o diabetes gestacional en embarazos previos?

Do any of your children have a genetic condition or a condition present since birth? ¿Alguno de sus hijos padece alguna condición de nacimiento o genética?

Have you had any pain in the abdominal or pelvic area? ¿Ha tenido algún dolor en el área de la barriga o pelvis?

Have you had any malodorous or purulent vaginal secretions? ¿Ha tenido secreciones vaginales mal olientes o purulentas?

Have you had any vaginal bleeding? ¿Ha tenido sangrado vaginal?

Have you had any unusual leakage, watery discharge or fluid from the vagina? ¿Ha sentido alguna fuga de agua o fluido inodoro inusual por el área de la vagina?

Have you felt the baby moving? ¿Ha sentido al bebé moverse?

Do you have any concerns you want to discuss today? ¿Tiene alguna preocupación que quisiera discutir con más detalle en esta visita?

50

Medical Spanish for Obstetrics & gynecology Preeclampsia Screening:

Labor Precautions:

Have you had any changes in vision? Do you see blurry? ¿Ha tenido cambios en visión? ¿Ve borroso?

Have you had any severe headaches? ¿Ha tenido dolor de cabeza intenso?

If any of the following things happens to you, you must contact your obstetrician or go to the nearest ER/LR as soon as possible: Si le ocurre alguna de las siguientes cosas, debe contactarse con su obstetra o ir a la sala de emergencia/sala de parto lo antes posible:

How are the at-home blood pressure readings? ¿Cómo han estado las presiones arteriales en su casa?

Vaginal Bleeding.

Sangrado Vaginal You haven't felt your baby move how it normally does.

No ha sentido a bebé moverse como normalmente lo hace.

You have felt a gush of fluid coming out of your vagina.

Siente expulsión intensa de líquido por su vagina.

You have intense pain that is increasing in frequency and magnitude.

Tiene un dolor intenso que aumenta en frecuencia y magnitud.

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Medical Spanish for Obstetrics & gynecology Instructions for the Pelvic Exam: Please move down to the end of the table, until your bottom hits my hand.

Por favor si puede acercarse más al borde de la cama, hasta que su trasero toque mi mano.

Okay, good. I am about to remove the speculum.

One more deep breath.

Muy bien. Ahora removeré el espéculo. Por favor, respire hondo.

Just a little more (down the table)/another scoot.

Solo un poco más hacia abajo.

Last thing - I will perform the bimanual exam.

Por último, voy a estar realizando el examen bimanual.

When you are ready, please relax your knees to about where my hands are.

Cuando esté lista, por favor deja caer las rodillas hasta donde están mis manos.

I will be palpating for your ovaries and uterus with one hand in the vagina and the other on your abdomen.

Voy a estar palpando los ovarios y el útero con una mano en la vagina y la otra sobre su abdomen.

First, I am just inspecting your external anatomy.

You will feel my touch.

Primero voy a examinar la anatomía externa. Va a sentir mis manos.

That part of the exam was normal.

Esta parte de la examinación fue normal.

Now, we will move on to the speculum exam.

Ahora realizaré el examen vaginal con el espéculo.

You’re going to feel my hand on your thigh. Take a big deep breath; you’ll feel the cool gel and the pressure as I insert the speculum.

Sentirá mi mano en su muslo. Respire hondo; sentirá el gel frío y un poco de presión mientras inserto el espéculo.

You will feel my hand on your thigh, cool gel as I insert my hand. Lots of pressure on your belly.

Sentirá mi mano en su muslo, además del gel frío mientras inserto mi mano. Va a sentir presión en el abdomen.

Okay, we are done. When you are ready, you are welcome to move back up the table to a more comfortable position.

Bien, ya terminamos. Cuando esté lista, puede moverse hacia arriba de la camilla a una posición más cómoda.

I am now going to obtain your PAP smear/test.

Ahora obtendré la muestra del Papanicolaou.

52

Medical Spanish for Obstetrics & gynecology Instructions for the Pelvic Exam: Big deep breath.

Respire hondo Relax your legs.

Relaje las piernas.

Try to relax your pelvis -- move the tension to your lower back by pushing it into the table.

Trate de relajar la pelvis; mueva la tensión hacia la espalda baja como si estuviese haciendo fuerza sobre la camilla.

I am so sorry - we are almost done. Just a few more seconds.

Disculpe, estamos acabando. Solo algunos segundos más.

I’m sorry, I know this is really uncomfortable.

Lo siento, sé que esto es incómodo para usted.

If patient remarks discomfort:

on

pain

or

significant

Does it feel like pinching, stinging, or tearing?” ¿Esto se siente como un pinchazo, punzadas o como un desgarre?

53

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Introduction 1. Gwan, A., Tanner-Sanders, L. N., Nair, N., Chapple, A. G., & Jernigan, A. (2022). Equity in visual representation of vulvar conditions in major gynecology textbooks. Journal of the National Medical Association, 114(3), 314–323. https://doi.org/10.1016/j.jnma.2022.02.005 2. Jatoi, I., Sung, H., & Jemal, A. (2022). The Emergence of the Racial Disparity in U.S. Breast-Cancer Mortality. The New England journal of medicine, 386(25), 2349–2352. https://doi.org/10.1056/NEJMp2200244 3.Collins, Y., Holcomb, K., Chapman-Davis, E., Khabele, D., & Farley, J. H. (2014). Gynecologic cancer disparities: a report from the Health Disparities Taskforce of the Society of Gynecologic Oncology. Gynecologic oncology, 133(2), 353–361. https://doi.org/10.1016/j.ygyno.2013.12.039 4. Nelson A. (2002). Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the National Medical Association, 94(8), 666–668.

5. Kaundinya, T., & Kundu, R. V. (2021). Diversity of Skin Images in Medical Texts: Recommendations for Student Advocacy in Medical Education. Journal of medical education and curricular development, 8, 23821205211025855. https://doi.org/10.1177/23821205211025855 6. Louie, P., & Wilkes, R. (2018). Representations of race and skin tone in medical textbook imagery. Social science & medicine (1982), 202, 38–42. https://doi.org/10.1016/j.socscimed.2018.02.023

Dedication Kuta, Sarah. (2022). “Subjected to Painful Experiments and Forgotten, Enslaved 'Mothers of Gynecology' Are Honored with New Monument.” Smithsonian.com, Smithsonian Institution.

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Chapter 1: Breast Who, What, Why: Why do African-American women bresastfeed less? BBC News. Published June 10, 2014. Accessed August 16, 2022. https://www.bbc.com/news/blogs-magazine-monitor-27744391 Naraynsingh V, Jarvis JK, Milne DM, Cawich SO, Harnanan D, Singh Y, Islam S. The Pushing Sign for Early Skin Tethering in Breast Cancer. Cureus. 2021 Dec 16;13(12):e20471. doi: 10.7759/cureus.20471. PMID: 34976543; PMCID: PMC8682950.

Naraynsingh V, Jarvis JK, Milne DM, Cawich SO, Harnanan D, Singh Y, Islam S. The Pushing Sign for Early Skin Tethering in Breast Cancer. Cureus. 2021 Dec 16;13(12):e20471. doi: 10.7759/cureus.20471. PMID: 34976543; PMCID: PMC8682950.

Camazine B. What is the Diagnosis? Earthwide Surgical Foundation. Published Jan 25, 2012. Accessed Sept 4, 2022. http://earthwidesurgicalfoundation.blogspot.com/2012/01/what-is-diagnosis_25.html Nguefack CT, Biwole ME, Massom A, Kamgaing JT, Njamen TN, Halle-Ekane G, Obinchemti TE, Priso EB. Epidemiology and surgical management of breast cancer in gynecological department of Douala General Hospital. The Pan African medical journal. 2012; 13(35). 10.11604/pamj.2012.13.35.1694.

Mnikhovich MV, Romanov AV, Mikhaleva LM, et al. Paget's disease of the breast. Differential diagnosis using additional IHC-panel. Literature review and own observations. GJPLM. 2021;1(2):25-49. doi: 10.52402/Pathology205 Nall R. What to know about mastectomy scars. Medical News Today. Published August 12, 2019. Accessed August 19, 2022. https://www.medicalnewstoday.com/articles/320379 ‌ Jay T, Segwapa K. The circumareolar approach to gynecomastia and transgender surgery: modifications to provide correct nipple areolar complex position and shape. S Afr J Surg. 2017;55(1):16-20. PMID: 28876553 Israeli R, Rustemeyer M. DIEP Flap Reconstruction and 3D Nipple Tattooing. NYBRA Plastic Surgery. Accessed September 8, 2022. https://nybra.com/breast-reconstruction/restorative-tattooing/ Schadt S, Schadt ME, Wojda TR, Yanagawa FS, Stawicki SP. Idiopathic granulomatous mastitis: A diagnostic and therapeutic challenge. Int J Acad Med. 2017;3(2):336-9. DOI: 10.4103/IJAM.IJAM_89_17 Shah BC. Breast Abscess Drainage. bcshah.com. Published 2017. Accessed Sept 7, 2022. https://bcshah.com/breastabscess-drainage/ Usatine RP. Dark rash under breasts. J Fam Pract. 2016.65(9) Kwekwesa A, Kandionamaso C, Winata N, et al. Breast enlargement in Malawian males on the standard first-line antiretroviral therapy regimen: Case reports and review of the literature. Malawi Med J. 2015; 27(3):115-117. doi:10.4314/mmj.v27i3.11 Chapter 2: Reproductive Endocrinology @pcos.kicks.my.butt. ACNE. Posted Nov 12, 2020. Accessed Aug 5, 2022. https://www.instagram.com/p/CHf9_rODq8u/ Fite LP, Cohen PR. Polycystic Ovarian Syndrome-associated Confluent and Reticulated Papillomatosis: Report of a Patient Successfully Treated with Azithromycin. J Clin Aesthet Dermatol. 2017;10(9):30-35.

Studdiford JS, Georgeo N, Trayes K. Pruritic Rash in Pregnancy. Am Fam Physician. 2017;95(7):453-454.

Chapter 3: Gynecologic Oncology Behring S. Early detection of cervical cancer: Risk factors and prevention. Healthline. https://www.healthline.com/health /cervical-cancer/early-detection-of-cervical-cancer. Published 2022. Accessed September 7, 2022.‌ Banda JEA, Mendes SHF, Fernandes SS, Chaves R. Basal Cell Carcinoma of the Vulva: A Case Report. Obstet Gynecol Int J. 2016;5(3):00158. doi:10.15406/ogij.2016.05.00158 Rogers LJ. Management of Advanced Squamous Cell Carcinoma of the Vulva. Cancers. 2022;14(1):167.

Chokoeva AA, Tchernev G, Castelli E, Orlando E, Shyam BV, Grebe M, Wollina U. Vulvar cancer: a review for dermatologists. WMW. 2015;165 (7-8):164-177. doi: 10.1007/s10354-015-0354-9‌ ul Ain Q, Rao B. A Rare Case Report: Malignant Vulvar Melanoma. Indian J Gynecol Oncolog. 2020;18:23. doi: 10.1007/s40944-020-0368-0

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Chapter 4: Vulvar Pathology Marfatia Y, Surani A, Baxi R. Genital lichen sclerosus et atrophicus in females: An update. Indian J Sex Transm Dis AIDS. 2019;40(1):6-12. doi: 10.4103/ijstd.IJSTD_23_19. PMID: 31143853; PMCID: PMC6532494.

Verma SB. Scrotal labia - An uncommon presentation of vulvar lichen simplex chronicus. Indian Dermatol Online J. 2021;12(4):590-592. doi: 10.4103/idoj.IDOJ_896_20 PMID: 34430467 Sanchez A, Gandhi K, Lee B, Gomez Garcia J, Ventolini G. Vulvar neurodermatitis in a postmenopausal African-American patient: a case report. J Menopausal Med. 2022;28(1):42-45. doi: 10.6118/jmm.21032 PMID: 35534430 Kharkar V, Sunkwad A. Good response to metronidazole in a case of erosive genital lichen planus. Indian J Drugs Dermatol. 2019;5(2):110-112. DOI: 10.4103/ijdd.ijdd_46_19 Gonçalves Amorim A, Batista Fraga Mendes B, Neves Ferreira R, Chambô Filho A. Paget Disease of the Vulva: Diagnosis

by Immunohistochemistry. Case Rep Dermatol Med. 2015;2015:162483. doi:10.1155/2015/162483 Nath AK, Kumari R, Rajesh G, Thappa DM, Basu D. Giant seborrheic keratosis of the genitalia. Indian J Dermatol. 2012 Jul;57(4):310-2. doi: 10.4103/0019-5154.97681. PMID: 22837573; PMCID: PMC3401854.‌ Chapter 5: Infectious Disease and Other Inflammatory Conditions Seladi-Schulman J. How to identify shingles on black and brown skin. Healthline. Last updated July 1, 2021.

Accessed August 19, 2022. https://www.healthline.com/health/skin/shingles-on-black-skin Sonnex C, Vrotsou K. Treatment of ano-genital warts: the effect of an educational event on practitioner choice.

Int J STD AIDS. 2007;18(8):531-537.

Mathew J, Sapra A. Herpes Simplex Type 2. StatePearls [Internet]. June 12, 2022. https://www.ncbi.nlm.nih.gov/books/NBK554427/ Radhakrishna V, Goel R, Parashar G, Santhanakrishnan R. Bartholin's gland abscess in a prepubertal female: A case report. Ann Med Surg (Lond). 2017;24:1-2. doi: 10.1016/j.amsu.2017.09.017. PMID: 29062477 How to Identify Hives on Brown and Black Skin. Healthline. Published February 8, 2021. Accessed Auggust 26, 202.2 https://www.healthline.com/health/skin/hives-on-black-skin Cohen PR. Follicular contact dermatitis revisited: A review emphasizing neomycin-associated follicular contact dermatitis. World J Clin Cases. 2014 Dec 16;2(12):815-21. doi: 10.12998/wjcc.v2.i12.815.

PMID: 25516854; PMCID: PMC4266827.

Sangha AM. Dermatological Conditions in skin of color--: Managing Atopic Dermatitis. J Clin Aesthet Dermatol. 2021; 14(3):S20-S22. PMID: 34188741 Chapter 6: Genetic Conditions and Congenital Abnormalities Abdalla AM, Nabil KM. Axenfeld-Rieger spectrum in a patient with 45,X Turner syndrome. Opthalmic Genet. 2012;33(2):111-115. DOI:10.3109/13816810.2011.634880 Rema NV, Bhavana S. XY Female with Complete Androgen Insensitivity Syndrome with Bilateral Inguinal Hernia.

J Obstet Gynecol India. 2013. DOI 10.1007/s13224-013-0379-1.

Capizano T. Fetal alcohol syndrome. AAPOS. Updated December 9, 2021. Accessed August 29, 2022. www.aapos.org. https://www.aapos.org/glossary/fetal-alcohol-syndrome Chapter 7: Medical Spanish for the Gynecologic Exam Translations provided by Hermes Aponte-Rivera, Valeria Santiago-Padilla, and Andrea Sanchez-Velazquez.

56

Index Abscess, Breast, 17 Acanthosis Nigricans, 22 Androgen Insensitivity, XY Phenotype, 45 Bartholin abscess/cyst, 40 Basal Cell Carcinoma, Vulvar, 27 Breastfeeding, 8 Breast Abscess, 17 Breast Cancer Inflammatory, 11 Peau d'orange, 11 Signs, 9 Breast Dimpling, "Pushing Sign," 10 Candida, Breast, 18 Cervical Cancer, Screening, 26 Condylomata acuminata, HPV warts, 38 Contact dermatitis, 42 Extramammary Paget's Disease, 34 Fetal Alcohol Syndrome Disorder (FASD), 46 Gynecomastia, 19 Herpes Simplex Virus-2 (HSV-2) vesicles, 39 Hives, 41 Humanpappiloma Virus (HPV) warts, condyloma acuminata, 38 Idiopathic Granulomatous Mastitis, 16 Inflammatory Breast Cancer, 11

57

Index Lichen Planus, 33 Lichen Sclerosus, 31 Lichen Simplex Chronicus, 32 Mastectomy, 13-15 Nipple tattoo, 15 Subcutaneous mastectomy, 14 Melanoma, Vulvar, 29 Nipple tattoo, post-mastectomy, 15 Paget's Disease Extramammary, 34 Of the Breast, 12 Peau d'orange, 11 Polycystic Ovarian Syndrome (PCOS), 21-23 Acanthosis Nigicans, 22 Polymorphic eruption of pregnancy, 24 Pushing Sign, Breast Dimpling, 10 Reticulated Papillomatosis in PCOS, 23 Seborrheic Keratosis, 35 Shingles, VZV, 37 Squamous Cell Carcinoma, Vulvar, 28 Transgender, 14 Turner Syndrome, 44 Varicella Zoster (VZV), Shingles, 37 Vulvar, 31-35 BCC, 27 SCC, 28 XY genotype, androgen insensitivity, 45

58