Peopleofcolorhavedisproportionatelyworsegynecologicandgender-basedhealthoutcomes thanwhitepatients.Today,weseethatBlackobstetricandgynecologicpatientshavea significantlyincreasedmaternalmortalityrateinpregnancy,andproportionallymoredeathsdue togynecologicandbreastcancerdespitealowerincidenceofthesecancersoverall,when comparedtowhitepatients(Gwanetal.2022;Jatoietal.2022).Thecauseofthesehealthcare disparitiesismultifactorial,andtheInstituteofMedicinedividesthemintothreebroadcategories includingpatient,provider,andsystemicfactors(Collinsetal.2014;Nelson2002).Patientfactors includeeducation,geographicalaccesstohealthcare,financialandinsurancestatus,culturalbeliefs andvalues,andothersocialfactors.Systemicfactorsaredefinedbythedeliveryofhealthcareitself. Forexample,thetypeofhospitalthepatientisevaluatedinandtheresourcesthehospitalhas accessto.Providerfactorsincludepriormedicalknowledge,expectationsorbeliefs,implicitbias, andtheracialorethnicbackgroundoftheprovider.Itisrelativelysimpletodividecausesof healthcaredisparitiesintocategoriesonpaper,butthesefactorshavesignificantinterplayand influenceoneachotherthroughreal-worldapplication.Thoughpatientandsystemicfactorsare importanttoaddresstomitigatehealthcaredisparities,thisguidebookaddressestheneedtoensure thatmedicaleducationprovidesmaterialthatisdiverseinitsrepresentationofpathologyin obstetricsandgynecology
Racialhealthcaredisparitiesdissipatewhenpatientsinteractwithproviderswhoaretrainedin equitableprovisionofhealthcare,afindingthatemphasizestheimportanceofincorporating principlesofanti-racisminmedicaltraining(Collinsetal2014)Recognitionandmanagementof medicalconditionsinpeopleofcolorisnotwellembeddedinmedicalcurriculumandcandelay appropriatecarePriorresearchhasdemonstratedalackofrepresentationofpatientsofcolorinto educationalresources(Nelson2002;Kaundinya&Kundu2021).Infact,a2018studybyLouie andWilkes(2018)showedthatlessthan5%ofgeneralmedicinetextbookshaveimagesofdark skintones.Interestingly,sexuallytransmittedinfectionsaremorefrequentlyshownondarkskin tonesasopposedtowhiteskintones,whichareusedtodepictmorecommonandless stigmatizingdiagnoses(Kaundinya&Kundu2021).Alackofrepresentationofclinicalpathology onindividualsofdarkercomplexionsacrosseducationalmodalitiescontributestodisparityinthe recognitionofvariousmedicalconditionsondarkerskintones.Thisdisparitycontributesto inequityinhealthcareandmayinfluencehealthcareoutcomesamongstnon-whitepatients In PlainSight:NormalizingDiverseClinicalPresentationsinObstetricsandGynecology,isa collaborativeresourcecreatedbyandformedicaltrainees Throughthisdigitalguidebook,we aimtocreatethematerialwewanttoseeinoureducationand,inturn,advanceracialequityin gynecologicandgender-basedmedicine
Thisprojectisdedicatedtothepatientswhoallowustolearnfromthemintheirmost vulnerablemomentsTothemedicaltraineesandproviderswhodedicatetheirlivestobecoming life-longlearners,andtoallwhoareeagertolearnhowvariousconditionsappear,inplainsight, amongstdiverseskincomplexionsandgenderidentitiesItisourhopethatthisworkwillfuelthe developmentofresourcesinmedicaleducationthatarerepresentativeofthemanydiversepatient populationswearefortunateenoughtoserve
WewouldalsoliketodedicatethisworktothefoundingmothersofObstetrics& Gynecology:Anarcha,Betsey,andLucy.Thesewomens’bodies,andthoseofcountlessother unnamedenslavedwomen,wereviolentlysubjugatedtomedicalexperimentation Discoveries thatweremadethroughtheirexploitationformedthefoundationforthefieldofObstetricsand Gynecology Thesewomenenduredpainfulgynecologicproceduresandpelvicexaminations withoutconsent,withoutanesthesia,andwithoutpainrelief.Theirstoriesareareminderofthe painfulhistoryofdehumanizationofBlackandBrownpeople-ahistoryofsexualviolence,being deniedthestandardsofperinatalcare,andenduringpainfulcomplicationsandlossoflifedueto medicalneglect
Asacomplicationofchildbirth,Anarcha,Betsey,andLucydevelopedpainfulvaginal fistulas.Theywereleftuntreated,despitebeingforcedtoengageinphysicallaborbytheir enslaversInsurgicaltheatersofthetime,thesewomenwereexposed,restrained,andoperatedon withoutanesthesia.JamesMarionSimspublishedtheresultsofhisunethicalexploitationofthese women,andwasdeemedthe“FatherofGynecology”forhisexperimentalfindings Though many advances have been made in Obstetrics & Gynecology to advocate for ethical, compassionate,andqualitycaretopatientsinthemostintimatesettings,wemustcontinueto intentionallyacknowledgetheimpactofracismandsexisminmedicalhistoryandeducation. In Plain Sight seekstogivevoicetothemanyBlackandBrownwomenthroughouthistory,named andunnamed,towhomweoweourdeepestrespectandgratitudeasfuturegenerationsof ObstetriciansandGynecologists.
Jasmin Eatman
EmoryUniversitySchoolofMedicine
Hermes Aponte-Rivera
UniversityofPuertoRicoSchoolofMedicine
Christen Jarshaw
UniversityofOklahomaCollegeofMedicine
Manthi Dissanayake
ECUBrodySchoolofMedicine
Aliah Fonteh
MeharryMedicalCollege
Angelica Dematas RutgersUniversity
Valeria Santiago-Padilla
UniversityofPuertoRicoSchoolofMedicine
Lauren Oliver
UniversityofOklahomaCollegeofMedicine
Emily Gharabegi
UniversityofMissouri-KansasCitySchoolofMedicine
Andrea Sanchez-Velazquez
UniversityofPuertoRicoSchoolofMedicine
Kimberly Kaase
OklahomaStateCollegeofOsteopathicMedicine
initiationandretentionratesarelowestamongstblack women.Breastmilk(exceptformaternalorfetalcontradictions)canbe oneofthebestwaystoprovidenutrients,antibodies,andsupporttoa growing infant. One example of benefit is the reduction of infant infectionsthroughmaternalimmunoglobulinsthathelpprovidepassive immunitytotheinfant.TheWorldHealthOrganizationandCenterfor DiseaseControlrecommendsbreastmilkastheidealinfantnutrition sourceforatleastsixmonthspost-delivery.Additionalsupportsystemsfor infant feeding include a variety of online resources, community organizations,lactationconsultants,doulas,andmakinguseofprotections for"safeandcleansitestopump"atyourworkplace.
Who,What,Why:WhydoAfrican-Americanwomenbresastfeedless?BBCNews.PublishedJune 10,2014.AccessedAugust16,2022.https://www.bbc.com/news/blogs-magazine-monitor-27744391
While breast self-exams arenotasubstituteforabreastexamcompleted byaphysician,patientsshouldstillbeawareofthesewarningsignsof breastcancer.Familiarizingone'sselfwiththelookandfeelofone'sbreasts isanimportantsupplementtobreastcancerscreening
Breast dimpling isseeninbreastcancer.Thisdimplingorpittingisasign thatamass,likelyatumor,ispullingonbreasttissue,skin,orthe supportiveligamentsofthebreast.Onexam,itisimportanttoobservethe patientthroughvariousmotionstoidentifyanyabnormalchangesinthe breasttissue.Breastdimplingisusuallyunilateral(onlyaffectingonebreast) and due to inflammatory breast cancer while most casesof bilateral dimplingarenon-malignant.
NaraynsinghV,JarvisJK,MilneDM,CawichSO,HarnananD,SinghY,IslamS.ThePushing SignforEarlySkinTetheringinBreastCancerCureus2021Dec16;13(12):e20471doi: 10.7759/cureus.20471.PMID:34976543;PMCID:PMC8682950.
Inflammatory Breast Cancer (IBC) isararetypeofbreastcancer,which iseasilymisidentifiedasmastitisoninitialpresentation.Onexamination, affected breasts are markedly swollen, red, and tender. IBC is often describedas"peaud'orange(orangepeel),",whichreferstoitsred/orange appearanceonlighterskintones.Rednessmaybelessapparentindarker skintonesandmaypresent,instead,ashyper-pigmentedorpurple.Other characteristics(dimpling,swelling)remainsimilarlyidentifiableacrossskin tones.Symptomsincludepain,rapidchangesinthebreast,enlargementof onebreast,discoloration(pink,purple,orred),flatteningorturning inwardofthenipple,andenlargedlymphnodesintheaxillaorclavicular areas.IBCdevelopsrapidlyduetostromalinfiltrationandlymphatic obstruction.Diagnosisismadebymammogramandbiopsyofbreasttissue. Ifapatientfailsantibiotictreatmentformastitis,work-upforIBCis stronglyrecommended.ThisconditioncanalsobeconfusedforPaget's DiseaseoftheBreast;however;IBCisnotlocalizedtothenipplealone.
Paget's Disease ofthebreastisseenonphysicalexamasscaly,ulcerated lesionsofthenipplethatextendtotheareolaandarenormallypainfuland itchy.Thesesymptomsmaybepresentbeforethelesionitselfmanifests. Underlyingbreastcancerispresentinasmuchas88%ofcasesbutdoesnot usuallypresentasamammarymass.Diagnosisismadebythepresenceof intraepithelialadenocarcinomacellsinsmallgroupswithintheepidermisin afullthicknesspunchorwedgebiopsyofthelesion.Incomparisonto inflammatorybreastcancer,Paget'sdiseaseislocalizedtothenippleandhas abetterprognosis.
MnikhovichMV,RomanovAV,MikhalevaLM,etal.Paget'sdiseaseofthebreast.Differential diagnosisusingadditionalIHC-panelLiteraturereviewandownobservationsGJPLM 2021;1(2):25-49.doi:10.52402/Pathology205
A mastectomy isasurgerywhichinvolvestheremovalofsomeorallof thebreasttissue.Whenperformedtotreatorpreventbreastcancer,tissue nearthebreastsuchaslymphnodes,chestliningandmusclemayalsobe removed.Atotalmastectomyistheremovalofthewholebreastincluding thenipple,areola,andoverlyingskin.Amodifiedradicalmastectomy removestheentirebreastincludingthenipple,areola,overlyingskin, lymphnodesunderthearm,andchestmusclelining.Aradicalmastectomy removestheentirebreastincludingthenipple,areola,overlyingskin, lymphnodesunderthearm,andchestmuscles.Breastreconstruction surgerycanbeperformedafteramastectomytore-createa"normal"breast structureusinganimplant,whichcanaddressasymmetrybetweenthe breastsandotherwiseallowthepatienttofeelmorenormalintheir clothing.
NallR.Whattoknowaboutmastectomyscars.MedicalNewsToday.PublishedAugust12,2019. AccessedAugust19,2022.https://www.medicalnewstoday.com/articles/320379
Compared management of (not totalremoval) proceduremay may involve removalofthenipple-areolacomplex,whichisbasedonthepatient's preference.Itisimportanttocounseltransgenderpatientswithafamily historyofbreastcancerundergoingasubcutaneousmastectomyasgender affirmingsurgerytomakethemawarethatscreeningisstilladvisedper professionalmedicalguidelines.Thisisbecausesometissuestillremainsin place.
Nipple tattooing post-mastectomy isamethodofnipplereconstruction ifoneorbothnipplesareremovedduringamastectomy.Nippletattoos useskin-color-pigmentedinktocreatenaturallookingareolas,whichcan beofsignificantpsychosocialbenefittopatients.Idealcandidatesfornipple tattoosincludethosewhohavehadbreastreconstructionwithimplantsor tissueflaps.Patientswithdamagedskinduetoradiationtreatment,very thinbreastskinfollowingmastectomy,andlymphedemaofthechestmay notbeidealcandidatesfornippletattooing.
Used with permission of patient and their provider team: IsraeliR,RustemeyerM.DIEPFlapReconstructionand3DNippleTattooing.NYBRAPlastic Surgery.AccessedSeptember8,2022.https://nybra.com/breast-reconstruction/restorative-tattooing/
Idiopathic granulomatous mastitis isaveryrarebenigncondition.Ithas thehighestprevalenceinthethirddecadeoflife,andriskfactorsforthis conditionincludebreastfeeding,oralcontraceptionusage,andpregnancy. Onphysicalexam,apatientwillpresentwithabreastmassthatisfirmand tender.Diagnosiscanoccurafterananalysisofhistopathologywhich shouldincludevoidsoftissuesurroundedbyinflamedareas.Therapeutic managementofthisconditionhasseenimprovementwithcorticosteroids and alternative immunosuppression therapies. A last resort is surgical management, which is reserved for more severe cases. However, postoperativesequelaetoconsiderincluderecurrence,improperhealingof thesurgicalsite,andscarring.
A breast abscess isacollectionofinflammatoryexudate.Itusuallypresents following under-treated or treatment-resistant mastitis or cellulitis, sometimesinthesettingofbreastfeeding.Themostcommonphysical examfindingsincluderednessandtendernessinthebreastassociatedwith afluctuantmass.However,systemicsymptomslikefeverandmalaisecan be present. The most common culprit is Staphylococcus aureus. Ultrasonographycanbeusedtoconfirmthediagnosisanddifferentiatethis conditionfrombreastmalignancy.Treatmentconsistsofdrainageand antibiotictherapy.Ifthepatientislactating,breastfeedingorpumpingcan continueandwillaidintheresolutionoftheabscess.
ShahBC.BreastAbscessDrainage.bcshah.com.Published2017.AccessedSept7,2022. https://bcshah.com/breast-abscess-drainage/
Candida speciesareanormalcomponentofthebody'sflora.Whenthe balanceoforganismsonourskinormucosaisdisrupted,acandida infectioncandevelop.Mostcommonlythisinfectioncanbefoundonthe mouth,vaginalarea,andskinfolds.Onphysicalexam,itisseenasa continuous,pruritic,erythematousorhyper-pigmentedrashaccompanied by satellite lesions. Recovery time may be shortened and recurrence preventedbykeepingtheareadry.
Gynecomastia isabenignproliferationoftheglandulartissueofthebreast inresponsetoincreasedestrogenactivity.Onphysicalexam,gynecomastia isseenasaunilateralorbilateralrubbery,palpablemassoftissuethat extendsoutsidetheareaunderthenippleandcanbetender.Imagingisnot routinelyrecommended.Afullworkupincludesreviewofmedications, dietarysupplements,andherbalsupplements.Managementrangesfrom observationtosurgicaltherapy.
KwekwesaA,KandionamasoC,WinataN,etal.BreastenlargementinMalawianmalesonthe standardfirst-lineantiretroviraltherapyregimen:CasereportsandreviewoftheliteratureMalawi MedJ.2015;27(3):115-117.doi:10.4314/mmj.v27i3.11
Polycystic ovarian syndrome (PCOS) isahormonaldisorderinwomen ofreproductiveage.Symptomstypicallydevelopatthefirstmenstrual periodandincludesignsofexcessiveandrogenation,irregularperiods,and polycystic ovaries. On examination, patients with polycystic ovarian syndromemayshowsignsofexcessivebodyhair(inamale-pattern distribution), severeacne,andabnormallyheavy,infrequent,orlong menstrualcycles.Complicationsofpolycysticovariansyndromeinclude metabolicsyndrome(highbloodpressure,highcholesterol,highblood sugar,type2diabetesorprediabetes),infertility,andcentralobesity. Diagnosisismadebyabloodtestofhormonelevels,anultrasoundforthe presenceofcystsonovaries,andapelvicexaminationforthepresenceof abnormalgrowthsorlumps.WhilePCOSislinkedtohyper-adiposity, womenofcoloraresubstantiallymorelikelytoreceivepoorcounseling duetoproviderweightbiasthantheirwhitecounterparts.
@pcos.kicks.my.butt.ACNE.PostedNov12,2020.AccessedAug5,2022.https://www.instagram.com/p/CHf9rODq8u/ FiteLP,CohenPRPolycysticOvarianSyndrome-associatedConfluentandReticulatedPapillomatosis:ReportofaPatient SuccessfullyTreatedwithAzithromycin.JClinAesthetDermatol.2017;10(9):30-35.
Acanthosis Nigricans isadarkeningofbodyregions-mostcommonly theaxillaorposteriorneck.Itisassociatedwitha"velvety"appearanceand iscommoninpatientswithunderlyinginsulinresistance.Apatientwith acanthosisnigricansandotherriskfactorsforinsulinresistanceshould undergolaboratoryscreeningfordiabetes,suchasevaluationoftheir HemoglobinA1C.Duetounderlyingendocrineabnormalities,individuals with polycystic ovarian syndrome (PCOS) may also present with acanthosisnigricans.ApatientwithPCOS,however,willhaveahistoryof abnormalmenses,excessiveacne,hirsutism,elevationsinbiochemical markerswhichsupportinghyperandrogenism,and/orpolycysticovarieson ultrasound.
FiteLP,CohenPR.PolycysticOvarianSyndrome-associatedConfluentandReticulatedPapillomatosis: ReportofaPatientSuccessfullyTreatedwithAzithromycinJClinAesthetDermatol2017;10(9):30-
Reticulated papillomatosis is likely a condition of disordered keratinization.Physicalexamdemonstratescentralplaqueswhichforma reticularpatternattheperiphery.Thesecanrangefromerythematous(red) todullbrownincolorandaremostcommonlyseenontheupperbody.It's presentation can overlap with other features of Polycystic Ovarian Syndrome(PCOS)duetounderlyingendocrineabnormalities.
Polymorphic eruption of pregnancy isaskinrashcausedbyanimmune responsetothestretchingofabdominalskinduringthelastthreemonths of pregnancy. This phenomenon is more commonly reported in individualsofcolor.Onexamination,youmayseelarge,red,hive-like plaquesontheabdomen,buttocks,andthighs.Diagnosisismadebythe rulingoutofotherskinconditionscausingsimilarsymptoms.Polymorphic eruptionofpregnancyresolveswithin4-6weeksafterdelivery.
StuddifordJS,GeorgeoN,TrayesK.PruriticRashinPregnancy.AmFamPhysician. 2017;95(7):453-454.
Preventativegynecologicalhealthscreeningisveryimportant,asitcanprovide informationneededtomaintaincervicalandfull-bodyhealth. Early detection of cervical cancer canbemadepossiblewithscreeningsbasedonyourgynecological history.Papsmearsareperformedduringanexaminationofthecervixandinvolves theuseoftwodifferenttoolstolightlyscrapeoffcellstobefurtherevaluatedunder themicroscope.Itisrecommendedinallpatientsages21-65todetectprecancerousandcancerouslesionsofthecervix.ACOGrecommendationsincludea papsmearwithcervicalcytologyeverythreeyearsintheaverageriskpatient between21-29yearsold.Inpatients30-65yearsofage,morecervicalcancer screeningoptionsareavailable,includingprimaryhighriskHPV(hrHPV)testing everyfiveyears,cervicalcytologyevery3years,orco-testing(acombinationof hrHPVandcervicalcytology)everyfiveyears.(ACOGApril2021)
BehringS.Earlydetectionofcervicalcancer:Riskfactorsandprevention.Healthline. https://www.healthline.com/health/cervical-cancer/early-detection-of-cervical-cancer.Published 2022.AccessedSeptember7,2022.
Vulvar basal cell carcinoma commonlypresentsinpost-menopausal patientsasalocallyaggressivedisease.Itcanpresentasanulcerwithrigged edges and a central ulceration that might be hypo- (pearly) or hyperpigmented.Thislesionisusuallyasymptomaticbutcancausepruritus (itchyskin).Treatmentisusuallyradicallocalexcisionofthelesion.
Squamous Cell Carcinoma (SCC) isthemostcommonsubtypeofvulvar cancer.RiskfactorsincludeHPVinfection,vulvarlichensclerosis,cervical intraepithelial neoplasia (CIN), tobacco use, and immunodeficiency. Most patientspresentfirstwithavulvarlesiondesribedasanulcer,plaqueormassin thelabiamajora,labiaminora,perineum,clitorisormonspubis.Symptoms associatedwiththispathologyincludepersistentitching,painandtenderness, skincolorandtexturechanges(tissuethickening),andbleeding.Abiopsyis performedfordiagnosticpurposesandtreatmentdependsontheextentofthe lesionandlymphnodeinvolvement.
RogersLJManagementofAdvancedSquamousCellCarcinomaoftheVulvaCancers2022;14(1):167 ChokoevaAA,TchernevG,CastelliE,OrlandoE,ShyamBV,GrebeM,WollinaU.Vulvarcancer:areview fordermatologists.WMW.2015;165(7-8):164-177.doi:10.1007/s10354-015-0354-9
Thisimagedepictsa malignant vulvar melanoma,which,thoughrare,isthesecondmost common type of vulvar malignancy. It is more common in post-menopausal women. Unfortunately,whenthisformofmelanomaisidentified,itistypicallylateinpresentationwith apoorprognosis.Patientmayhavecomplaintsofseverelabialpruritusandwhitedischargefor severalmonths.Pelvicexamatlatestagesmayrevealagrowthoriginatingfromthelabiaminora with features such as irregularity of shape, hyperpigmentation, and ulceration. Internal examinationwithaspeculummayrevealhyperpigmentedlesionsonthevaginalwalland/or parts of the cervix. Histopathology is necessary to differentiate melanoma from other gynecologiclesions.Managementisthroughcompleteexcision.Incaseswithmetastasis, adjuvantchemotherapy,immunotherapy,orradiotherapymayberecommended.Themain considerationsfortheprognosisofapatientdiagnosedwithvulvarmelanomaincludetumor size,depth,presenceofulceration,andwhetherornotlymphnodeinvolvementispresent.
Lichen sclerosus existsonaspectrumandmayprogresstomoreseriousvulvar pathologiesifleftuntreated.Apelvicexammayrevealerosions,fissures,and the narrowing of the introitus (which may limit a speculum exam). Additionally,shrinkageofthelabiaminoraandclitoristothepointthatthese structures aredifficulttodistinguishbetweenmayalsobeevidentupon examination.Theskinlosespigmentationandmaybedescribedasbeing "smooth" and like "porcelain-white/ivory." This pathology also has a characteristicshapewhichcanbedescribedasafigure-of-eight,keyhole, hourglass, or lotus flower. Patients with this disorder may report other symptomssuchasdiffuseirritationandsoreness,urinaryobstruction,painful urination,painwithintercourse,orpainwithdefecation.Notably,prepubertal girlsaremorelikelythanotheragedemographicstoreportbowelorbladder incontinenceandbleeding.Thisdiagnosisisclinical.
MarfatiaY,SuraniA,BaxiR.Genitallichensclerosusetatrophicusinfemales:Anupdate.IndianJ SexTransmDisAIDS.2019;40(1):6-12.doi:10.4103/ijstd.IJSTD2319.PMID:31143853;PMCID: PMC6532494.
Lichen simplex chronicus ofthevulvaisaskinconditioncreatedbyexcessive andchronicscratchingorrubbingleadingtoinflammationandlichenification (thickeningofskin).Onexamination,lichensimplexchronicusisseenas swellingofthevulvaorclitoris,discolorationofthevulva,tearsorfissureson thevulva,andthickenedappearanceofvulvaorclitoris.Symptomsinclude burning,itching,hyperpigmentationofthevulva,andswellingofthevulva. Diagnosisismadebyrulingoutskinconditionswithsimilarsymptoms.Askin swabmaybeusedtoidentifythepresenceofabacterialorfungalinfection.A skin biopsy may be needed to rule out squamous cell carcinoma or extramammaryPagetdisease.
VermaSBScrotallabia-AnuncommonpresentationofvulvarlichensimplexchronicusIndianDermatolOnlineJ 2021;12(4):590-592.doi:10.4103/idoj.IDOJ89620PMID:34430467
SanchezA,GandhiK,LeeB,GomezGarciaJ,VentoliniGVulvarneurodermatitisinapostmenopausalAfrican-American patient:acasereport.JMenopausalMed.2022;28(1):42-45.doi:10.6118/jmm.21032PMID:35534430
Lichen planus isacommoninflammatorydiseasecharacterizedbyswelling andirritationoftheskinormouth.Lichenplanusofthevulvamaybe associatedwithpain,burning,andreddish-brownpatchesthatcanbefound on the inner vulva. On examination, vulvar lichen planus is seen as generalizedatrophyandscarringonthevulva,flattenedlabiaminora,and shrinkingofthevaginalopening.Diagnosisismadebyphysicalexamination andbiopsyofvulvarskin.
KharkarV,SunkwadA.Goodresponsetometronidazoleinacaseoferosivegenitallichenplanus.
IndianJDrugsDermatol.2019;5(2):110-112.DOI:10.4103/ijdd.ijdd4619
Extramammary Paget's Disease isintraepithelialadenocarcinomaofthe vulva.Itpresentsasapruritic,raised,eczematouslessionwithpoordemarcation inanred-purplebackgroundwithscateredhyperkeratosis.Thislesionpersists evenwithappropiatetreatmentofeczema.Diagnosisismadebyvulvarbiopsy.
GonçalvesAmorimA,BatistaFragaMendesB,NevesFerreiraR,ChambôFilhoA.PagetDiseaseof theVulva:DiagnosisbyImmunohistochemistry.CaseRepDermatolMed.2015;2015:162483.
Seborrheic Keratosis (SK) ofthegenitalregionisrare.Onphysicalexamof theskin,itcanmanifestasmacules,papules,orplaqueswhicharesharply demarcatedwitha"stuckon"appearance.Polypoidalmassesareespeciallyrare butaremuchmorelikelytooccurinthegenitalregionthanotherpartsofthe body.Thoughbenign,SKcanstillbephysicallydebilitatingorbeasourceof socialstigma.
NathAK,KumariR,RajeshG,ThappaDM,BasuD.Giantseborrheickeratosisofthegenitalia.
IndianJDermatol.2012Jul;57(4):310-2.doi:10.4103/0019-5154.97681.PMID:22837573;PMCID: PMC3401854.
Shingles is caused by an infection of the varicella-zoster virus (VZV) commonlyknownforcausingtheprimaryinfectionofchickenpox.Patients whohavepreviouslybeeninfectedwiththevaricella-zostervirusandrecovered fromchickenpoxmaydevelopshingles.Physicalexaminationoftheskinis mostnotableforasinglestripeoffluid-filledblisters(or"dew-dropsonroses") that affect only a small section on one side of the body (dermatomal distribution).Whiletheseblistersareverypainfultothetouch(oftendescribed asa"lightningshock"nervepain),theyareoftenstillitchy.Evenindarkerpigmented skin, a red hue can be characteristic. In severely immunocompromisedpatients,theblistersmayimpactmorethanoneareaof thebody.
Seladi-SchulmanJ.Howtoidentifyshinglesonblackandbrownskin.Healthline.LastupdatedJuly 1,2021.AccessedAugust19,2022.https://www.healthline.com/health/skin/shingles-on-black-skin
Condyloma acuminata isamanifestationofHumanPapillomaVirus(HPV), themostcommonsexuallytransmitteddiseaseintheworld.Themost commonstrainsthatcausegenitalwartsare6and11.HPVistransmitted throughcontactwithinfectedskinandwarts,andputsindividualsatgreater riskforcervicalcancerovertime.Onphysicalexam,theselesionsareseenas flat,dome,cauliflower-shaped,fungating,lobulated,orverrucouslesions. Theyareoftenclumpedtogetherandcanbeskincolored,gray,brown,or hyperpigmentedandarecommonlyfoundonthevulva,penis,perineum, perianalareaandinthegroinregion.
SonnexC,VrotsouK.Treatmentofano-genitalwarts:theeffectofaneducationaleventon practitionerchoice.IntJSTDAIDS.2007;18(8):531-537.
Herpes simplex virus isaverycommoninfectionworldwide.BothHSV-1 andHSV-2cancausegenitalherpes,althoughHSV-2isthemorecommon culprit.Itpresentsasclustered,exquisitelytendervesiclesonanerythematous base("dewdropsonroses").Definitivediagnosisrequireslaboratorytesting, althoughempirictreatmentifoftenreasonable.Recurrenceisexpectedandis commonlyseeninimmunocompromisedpatientsortimesofstress.Routine screeningofasymptomaticpatientsisnotrecommended.
MathewJ,SapraA.HerpesSimplexType2.StatePearls[Internet].June12,2022. https://www.ncbi.nlm.nih.gov/books/NBK554427/
Thisisa Bartholin cyst/abscess.Theseglandsarelocatednearthe4o'clock or8o'clockpositionofthevaginalintroitus.Bartholinabscessescanbe extremelypainfulandexquisitelytenderonexam,evenlimitingapatient's abilitytositinachairortolerateapelvicexam.Comparedwithcysts, abscessesaremorelikelytoappearinduratedwithfluctuanceand/orpurulent drainage;erythemamaybelesseasilyvisualizedcomparedtopaleskintones.
For symptomatic patients, incision and drainage is the recommended management.Cystsmaybepalpatedonexamasafluctuantmassinan asymptomaticpatient.Asymptomaticpatientsdonotrequireintervention.
RadhakrishnaV,GoelR,ParasharG,SanthanakrishnanR.Bartholin'sglandabscessina prepubertalfemale:Acasereport.AnnMedSurg(Lond).2017;24:1-2.doi: 10.1016/j.amsu.2017.09.017.PMID:29062477
Hives representaninflammatoryreactionbythebodytosometrigger, mostcommonlyandallergen.Onexam,theskinwilldisplayround,ovalor worm-likeweltswhichareraisedandincrediblyitchy.Withlighterskin pigmentation,theweltsarelikelytobepinkorredincolor;however,in darkerskintheweltislikelytobethesamecolorasthesurroundingskin. HowtoIdentifyHivesonBrownandBlackSkin.Healthline.PublishedFebruary8,2021.Accessed Auggust26,2022.https://www.healthline.com/health/skin/hives-on-black-skin
Contact dermatitis isahypersensitivityreactionoftheskintoanyirritantand isthemostcommoncauseofvulvarpruritus.Patientswillmostlikelynote symptomsofseverepruritus,althoughbilateralandsymmetricpatcheswithout sensorychangesarealsopossible.Onexam,skinisoftennotablydrywithred patchesonlighterskinorwithdarkbrown,purple,orgraypatchesondarker skin. Darker pigmented skin is also much more likely to present with lichenification.Theaffectedsitemayhaveassociatedblisters,oozing,crusting, orflaking.
CohenPR.Follicularcontactdermatitisrevisited:Areviewemphasizingneomycin-associatedfollicularcontactdermatitis. WorldJClinCases2014Dec16;2(12):815-21doi:1012998/wjccv2i12815PMID:25516854;PMCID:PMC4266827 SanghaAM.DermatologicalConditionsinskinofcolor--:ManagingAtopicDermatitis.JClinAesthetDermatol.2021; 14(3):S20-S22PMID:34188741
Thisis Turner syndrome sometimesreferredtoascongenitalovarian hypoplasiasyndrome.Turnersyndromeisageneticdisordereffecting femalesandoccurswhenoneofthetwoXchromosomesismissing partiallyorcompletely.SymptomsofTurnersyndromeduringinfancy includeawideorweblikeneck,swellingofhandsandfeetatbirth,cardiac defects,lowsetears,andbroadbreastwithwidelyspacednipples.In adolescence,theseindividualscanexhibitfailuretobeginpubertyor notable"stalling"ofsexualdevelopment.Commonadulthoodsymptoms include short stature, infertility, development of hypothyroidism, and cardiovascularproblems.
AbdallaAM,NabilKM.Axenfeld-Riegerspectruminapatientwith45,XTurnersyndrome. OpthalmicGenet.2012;33(2):111-115.DOI:10.3109/13816810.2011.634880
Thispatienthas complete androgen insensitivity syndromeduetoadefect intheandrogenreceptors.Inutero,thisdefectpreventsthebodyfrom recognizing available testosterone to initiate male external genitalia development, leading to an individual who is genotypically male and phenotypicallyfemale.Onexam,thesepatientshavefemaleexternalgenitalia but minimal pubic and axillary hair. Other exam findings include a "rudimentaryvagina"andabsentuterusandfallopiantubes.Theabsenceofthe lattertwoorgansisduetoanti-Mullerianhormonefromthenormaltestes thesepatientshave.Surgicalremovalofthetestiesispartofmanagementto reducetheriskforfuturemalignancy.Laboratorystudiesinthesepatients include elevated testosterone, estrogen, and luteinizing hormone. When counselingthesepatientsoninitaldiagnosis,itisimportanttovalidatetheir genderidentityandprovidesupportiveservicesifdesired. RemaNV,BhavanaSXYFemalewithCompleteAndrogenInsensitivitySyndromewith
Fetal Alcohol Syndrome Disorder (FASD)encompassesarangeof neurodevelopmental, physical, and behavioral characteristics in an individualthatwasexposedtoalcoholinutero.Shortpalpebralfissures, wide-seteyes,asmoothphiltrum,andathinupperlipcanaidinthe identificationanddiagnosis.BecauseFASDcanpresentdifferentlyinevery patient,themanagementandinterventionsmustbeindividualizedtotheir needs.
CapizanoT.Fetalalcoholsyndrome.AAPOS.UpdatedDecember9,2021.AccessedAugust29, 2022.www.aapos.org.https://www.aapos.org/glossary/fetal-alcohol-syndrome
Introductions:
Hello,mynameisDr.JaneDoeandIamamedical student/resident/attending Hola, mi nombre es y soy estudiante de medicina/residente/médico supervisor.
Iwillbegatheringyourmedicalhistorytoday,if thatisokaywithyou.
Voy a estar tomando su historial médico en el día de hoy, si está bien con usted
Whatisyourname?
¿Cuál es su nombre?
Whenisyourbirthdate?
¿Cuándo es su fecha de nacimiento?
History of Present Illness:
Whatisthereasonforyourvisit?
¿Cuál es la razón de su visita?
Howlongagodidthesymptomsstart?
¿Hace cuánto comenzaron los síntomas?
Whatwereyoudoingwhenthesymptomsstarted?
¿Qué estaba haciendo cuando los síntomas comenzaron?
Havethesymptomsgottenworsesincetheystarted?
¿Los síntomas han empeorado desde que comenzaron?
Canyoudescribeyourpain/discomfort?
¿Cómo describiría su dolor/incomodidad?
Past Medical History:
Doyouhaveanychronicillnesses?
¿Padece alguna condición crónica?
Do you take any medications? This includes prescribedandnotprescribedmedications.
¿Usted toma algún medicamento? Esto incluye medicamentos recetados y no recetados.
Doyouhaveanyallergiestofoods,medications,or materials?
¿Es alérgico a alguna comida, medicamento o material?
Haveyouhadanyprevioussurgeries?
¿Ha tenido alguna cirugía en el pasado?
Areyourimmunizationsuptodate?
¿Sus vacunas están al día?
Whenwasyourfirstmenstrualperiod?
¿Cuándo fue su primera menstruación?
Howlongdoesyourperiodlast? ¿Cuánto dura su periodo?
Haveyoubeenhavinganypainassociatedwithyour period?
¿Ha tenido dolor asociado a su menstruación?
Doesthispaininterferewithyourdailyliving? ¿Este dolor interfiere con su diario vivir?
Doyouhavebleedingbetweenperiods? ¿Usted tiene sangrado entre periodos?
Whenwasyourlastmenstrualperiod?
¿Cuándo fue su último periodo menstrual?
Doyouusecontraception? ¿Utiliza algún método contraceptivo?
Haveyouhadanysexuallytransmitteddisease? ¿Ha tenido alguna enfermedad de transmisión sexual?
Haveyouhadcervicalcancerscreeningrecently? ¿Ha tenido cernimiento para cáncer cervical recientemente?
Haveyouhadbreastcancerscreeningrecently?
¿Ha tenido cernimiento para cáncer de seno recientemente?
Areyousexuallyactive? ¿Está teniendo relaciones sexuales al momento?
Whenwasyourlastsexualencounter? ¿Cuándo fue su última relación sexual?
Whenwasyourfirstsexualencounter? ¿Cuándo fue su primera relación sexual?
Howmanypartnersdoyoucurrentlyhave? ¿Cuántas parejas tiene en estos momentos?
Doyoupracticeoralsex? ¿Usted practica sexo oral?
Doyoupracticeanalsex? ¿Usted practica sexo anal?
Haveyounoticedlossofsexualinterest? ¿Ha notado pérdida en su interés sexual?
Doyouhavepainwithsex? ¿Usted tiene dolor durante el acto sexual?
Areyouabletoreachorgasm? ¿Usted es capaz de llegar al orgasmo?
Obstetric History:
Howmanypregnancieshaveyouhad?
¿Cuántos embarazos ha tenido?
Haveyouhadanyabortions?
¿Ha tenido algún aborto?
Howmanychildrendoyouhave? ¿Cuántos hijos tiene?
Ifpatienthadpreviouspregnancies:
Weretheyvaginalorcesareandeliveries?
¿Los partos fueron vaginal o cesárea?
Anycomplicationsduringpastpregnancies?
¿Alguna complicación en alguno de los embarazos?
Whenwasyourlastpregnancy?
¿Cuándo fue su último embarazo?
Have you been previously diagnosed with hypertensionorgestationaldiabetesinprevious pregnancies?
¿Fue diagnosticada con hipertensión o diabetes gestacional en embarazos previos?
Doanyofyourchildrenhaveageneticcondition oraconditionpresentsincebirth?
¿Alguno de sus hijos padece alguna condición de nacimiento o genética?
Pregnancy Visit:
Howdoyoufeeltoday?
¿Cómo se siente en el día de hoy?
Howhaveyoufeltthispastweek? ¿Cómo se ha sentido en la última semana?
Whatisyourestimatedduedate(EDD)? ¿Cuál es su fecha estimada de parto?
How many sonograms have you had in this pregnancy?
¿Cuántos sonogramas se ha realizado en este embarazo?
Haveyouhadanypainintheabdominalorpelvicarea?
¿Ha tenido algún dolor en el área de la barriga o pelvis?
Haveyouhadanymalodorousorpurulentvaginal secretions?
¿Ha tenido secreciones vaginales mal olientes o purulentas?
Haveyouhadanyvaginalbleeding?
¿Ha tenido sangrado vaginal?
Haveyouhadanyunusualleakage,waterydischargeor fluidfromthevagina?
¿Ha sentido alguna fuga de agua o fluido inodoro inusual por el área de la vagina?
Haveyoufeltthebabymoving?
¿Ha sentido al bebé moverse?
Doyouhaveanyconcernsyouwanttodiscusstoday?
¿Tiene alguna preocupación que quisiera discutir con más detalle en esta visita?
Preeclampsia Screening:
Haveyouhadanychangesinvision?Doyousee blurry?
¿Ha tenido cambios en visión? ¿Ve borroso?
Haveyouhadanysevereheadaches?
¿Ha tenido dolor de cabeza intenso?
Howaretheat-homebloodpressurereadings?
¿Cómo han estado las presiones arteriales en su casa?
Labor Precautions:
Ifanyofthefollowingthingshappenstoyou,youmust contactyourobstetricianorgotothenearestER/LRas soonaspossible:
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:
VaginalBleeding Sangrado Vaginal
Youhaven'tfeltyourbabymovehowitnormallydoes No ha sentido a bebé moverse como normalmente lo hace
Youhavefeltagushoffluidcomingoutofyourvagina. Siente expulsión intensa de líquido por su vagina
Youhaveintensepainthatisincreasinginfrequency andmagnitude.
Tiene un dolor intenso que aumenta en frecuencia y magnitud.
Instructions for the Pelvic Exam:
Pleasemovedowntotheendofthetable,until yourbottomhitsmyhand.
Por favor si puede acercarse más al borde de la cama, hasta que su trasero toque mi mano.
Justalittlemore(downthetable)/anotherscoot. Solo un poco más hacia abajo
Whenyouareready,pleaserelaxyourkneesto aboutwheremyhandsare. Cuando esté lista, por favor deja caer las rodillas hasta donde están mis manos.
First,Iamjustinspectingyourexternalanatomy. Youwillfeelmytouch Primero voy a examinar la anatomía externa. Va a sentir mis manos
Thatpartoftheexamwasnormal Esta parte de la examinación fue normal.
Now,wewillmoveontothespeculumexam Ahora realizaré el examen vaginal con el espéculo.
You’regoingtofeelmyhandonyourthigh.Take abigdeepbreath;you’llfeelthecoolgelandthe pressureasIinsertthespeculum. Sentirá mi mano en su muslo. Respire hondo; sentirá el gel frío y un poco de presión mientras inserto el espéculo
IamnowgoingtoobtainyourPAPsmear/test. Ahora obtendré la muestra del Papanicolaou
Okay,good.Iamabouttoremovethespeculum. Onemoredeepbreath. Muy bien Ahora removeré el espéculo Por favor, respire hondo.
Lastthing-Iwillperformthebimanualexam. Por último, voy a estar realizando el examen bimanual
Iwillbepalpatingforyourovariesanduteruswith onehandinthevaginaandtheotheronyour abdomen
Voy a estar palpando los ovarios y el útero con una mano en la vagina y la otra sobre su abdomen.
Youwillfeelmyhandonyourthigh,coolgelasI insertmyhand.Lotsofpressureonyourbelly.
Sentirá mi mano en su muslo, además del gel frío mientras inserto mi mano Va a sentir presión en el abdomen
Okay,wearedone.Whenyouareready,youare welcometomovebackupthetabletoamore comfortableposition.
Bien, ya terminamos. Cuando esté lista, puede moverse hacia arriba de la camilla a una posición más cómoda
Instructions for the Pelvic Exam:
Bigdeepbreath. Respire hondo
Relaxyourlegs. Relaje las piernas.
Trytorelaxyourpelvis--movethetensionto yourlowerbackbypushingitintothetable.
Trate de relajar la pelvis; mueva la tensión hacia la espalda baja como si estuviese haciendo fuerza sobre la camilla
Iamsosorry-wearealmostdone.Justafew moreseconds.
Disculpe, estamos acabando Solo algunos segundos más.
I’msorry,Iknowthisisreallyuncomfortable Lo siento, sé que esto es incómodo para usted
If patient remarks on pain or significant discomfort:
Doesitfeellikepinching,stinging,ortearing?” ¿Esto se siente como un pinchazo, punzadas o como un desgarre?
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TranslationsprovidedbyHermesAponte-Rivera,ValeriaSantiago-Padilla,andAndreaSanchez-Velazquez.
Abscess,Breast,17 AcanthosisNigricans,22 AndrogenInsensitivity,XYPhenotype,45
Bartholinabscess/cyst,40
BasalCellCarcinoma,Vulvar,27 Breastfeeding,8 BreastAbscess,17 BreastCancer Inflammatory,11 Peaud'orange,11 Signs,9
BreastDimpling,"PushingSign,"10
Candida,Breast,18 CervicalCancer, Screening,26
Condylomataacuminata,HPVwarts,38 Contactdermatitis,42
ExtramammaryPaget'sDisease,34
FetalAlcoholSyndromeDisorder(FASD),46
Gynecomastia,19
HerpesSimplexVirus-2(HSV-2)vesicles,39 Hives,41
HumanpappilomaVirus(HPV)warts,condylomaacuminata,38
IdiopathicGranulomatousMastitis,16 InflammatoryBreastCancer,11
LichenPlanus,33 LichenSclerosus,31 LichenSimplexChronicus,32
Mastectomy,13-15 Nippletattoo,15
Subcutaneousmastectomy,14 Melanoma,Vulvar,29
Nippletattoo,post-mastectomy,15
Paget'sDisease Extramammary,34 OftheBreast,12 Peaud'orange,11
PolycysticOvarianSyndrome(PCOS),21-23 AcanthosisNigicans,22 Polymorphiceruptionofpregnancy,24 PushingSign,BreastDimpling,10
ReticulatedPapillomatosisinPCOS,23
SeborrheicKeratosis,35 Shingles,VZV,37 SquamousCellCarcinoma,Vulvar,28
Transgender,14 TurnerSyndrome,44
VaricellaZoster(VZV),Shingles,37 Vulvar,31-35 BCC,27 SCC,28
XYgenotype,androgeninsensitivity,45