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General lnternal Medicine Breast Mass Diagnosis Most breast lumps are benign, but clinical examination cannot distinguish between benign and malignant. STUDY TABLE: Evaluation of Breast Mass Breast Finding Diagnostic Testing Palpable lump or mass and age <30 years Choose ultrasonography lf simple cyst on ultrasound, aspirate and repeat clinical breast examination in 4-6 weeks lf complex cyst on ultrasound, biopsy lf solid on ultrasound, biopsy or excise Palpable lump or mass and age >30 years Mammography: if BI-RADS category 1-3 (benign or close follow-up recommended), obtain ultrasonography and follow protocol above; if BI-RADS category 4-5 (suspicious or highly suspicious), obtain tissue diagnosis Nipple discharge, no mass, any age Bilateral, milky: pregnancy test (if negative, choose endocrine evaluation) Persistent, spontaneous, unilateral, one duct, or serous/bloody: choose mammography and surgical referral for duct exploration Skin changes (erythema, peau d'orange, scaling, Consider mastitis and treat with antibiotics if appropriate and reevaluate in nipple excoriation, eczema)and age <30 years 2 weeks; otherwise, evaluate as below Skin changes (erythema, peau d'orange, scaling, Perform bilateral mammography: if normal, obtain skin biopsy; if abnormal or nipple excoriation, eczema) and age >30 years indeterminate, obtain needle biopsy or excision Bl-RADS = Breast lmaging Reporting and Data System.

STUDY TABLE: Evaluation of Breast Mass Breast Finding Diagnostic Testing Palpable lump or mass and age <30 years Choose ultrasonography lf simple cyst on ultrasound, aspirate and repeat clinical breast examination in 4-6 weeks lf complex cyst on ultrasound, biopsy lf solid on ultrasound, biopsy or excise Palpable lump or mass and age >30 years Mammography: if BI-RADS category 1-3 (benign or close follow-up recommended), obtain ultrasonography and follow protocol above; if BI-RADS category 4-5 (suspicious or highly suspicious), obtain tissue diagnosis Nipple discharge, no mass, any age Bilateral, milky: pregnancy test (if negative, choose endocrine evaluation) Persistent, spontaneous, unilateral, one duct, or serous/bloody: choose mammography and surgical referral for duct exploration Skin changes (erythema, peau d'orange, scaling, Consider mastitis and treat with antibiotics if appropriate and reevaluate in nipple excoriation, eczema)and age <30 years 2 weeks; otherwise, evaluate as below Skin changes (erythema, peau d'orange, scaling, Perform bilateral mammography: if normal, obtain skin biopsy; if abnormal or nipple excoriation, eczema) and age >30 years indeterminate, obtain needle biopsy or excision Bl-RADS = Breast lmaging Reporting and Data System. DOil'T BE TRICKED o Do not stop the evaluation of a breast mass if mammogram is normal. . On mammography, an irregular mass with microcalcifications or spiculation is suspicious for malignant disease, and biopsy is mandatory. o Evidence is lacking that breast self-examination offers benefit in screening for breast cancer in average-risk asymptomatic women; self-examination may be associated with a higher rate of breast biopsy.

DOil'T BE TRICKED o Do not stop the evaluation of a breast mass if mammogram is normal. . On mammography, an irregular mass with microcalcifications or spiculation is suspicious for malignant disease, and biopsy is mandatory. o Evidence is lacking that breast self-examination offers benefit in screening for breast cancer in average-risk asymptomatic women; self-examination may be associated with a higher rate of breast biopsy. Contraception Most common contraceptive methods include: r hormonal contraception, including intrauterine devices . barriercontraceptives o sterilization STUDY ?ABtEr Comparison of Contraceptive Options Agent Advantages Disadvantages Hormonal Agents Combined (estrogen-progesterone) methods Oral contraceptive pill Easy to use Daily oral pill Transdermal patch Single patch changed weekly Higher levels of estrogen, increased WE risk Vaginal ring Ring changed every 3 weeks (Continued on the next page) 154

General lnternal Medicine STUDY TABLE: Comparison of Contraceptive Options (Continued) Agent Advantages Disadvantages Progesterone-only methods Oral contraceptive pill Safe when estrogen is contraindicated lrregular bleeding, breakthrough bleeding Must maintain a daily schedule Depot medroxyprogesterone acetate Administered every 3 months lrregular bleeding Decreases menstrual frequency Delayed return to fertility (up to 10 months) Weight gain, decreased bone mineral density Long-Acting Reyersible Contraception lntrauterine devices Bleeding and pain with insertion Requires office visit for insertion and removal Copper Nonhormonal Effective up to 1 0 years Levonorgestrel Effective3to5years Decreased menstrual bleeding Progesterone subdermal implant Effective up to 3 years lrregular bleeding Topical Sperm I nhibitors Nonoxynol-9 (spermicide) On-demand use Vaginal irritation No systemic effects Lactic acid, citric acid, and potassium bitartrate On-demand use Vaginal irritation vaginal gel (sperm mobility inhibitor) Non-hormonal UTI

STUDY TABLE: Comparison of Contraceptive Options (Continued) Agent Advantages Disadvantages Progesterone-only methods Oral contraceptive pill Safe when estrogen is contraindicated lrregular bleeding, breakthrough bleeding Must maintain a daily schedule Depot medroxyprogesterone acetate Administered every 3 months lrregular bleeding Decreases menstrual frequency Delayed return to fertility (up to 10 months) Weight gain, decreased bone mineral density Long-Acting Reyersible Contraception lntrauterine devices Bleeding and pain with insertion Requires office visit for insertion and removal Copper Nonhormonal Effective up to 1 0 years Levonorgestrel Effective3to5years Decreased menstrual bleeding Progesterone subdermal implant Effective up to 3 years lrregular bleeding Topical Sperm I nhibitors Nonoxynol-9 (spermicide) On-demand use Vaginal irritation No systemic effects Lactic acid, citric acid, and potassium bitartrate On-demand use Vaginal irritation vaginal gel (sperm mobility inhibitor) Non-hormonal UTI Barrier Methods Cervical cap User dependent Vaginal sponge Diaphragm Requires spermicide Male condom Protection from STls Female condom Protection from STls furmanent Methods Sterilization Female (tubal occlusion) Salpingectomy reduces ovarian lncreased risk of ectopic pregnancy cancer risk Procedural complication (rare) Male (vasectomy) Lower cost, fewer complications, and Procedural complication (rare) more effective than female sterilization

Barrier Methods Cervical cap User dependent Vaginal sponge Diaphragm Requires spermicide Male condom Protection from STls Female condom Protection from STls furmanent Methods Sterilization Female (tubal occlusion) Salpingectomy reduces ovarian lncreased risk of ectopic pregnancy cancer risk Procedural complication (rare) Male (vasectomy) Lower cost, fewer complications, and Procedural complication (rare) more effective than female sterilization Contraindications to combination hormonal products include: o uncontrolled hypertension . breast cancer r VTE o liver disease . migraine with aura Estrogen containing preparations are contiaindicated in women >35 years who smoke more than 15 cigarettes per day. Emergency contraception is postcoital hormonal contraception used to prevent pregnancy after inadequately protected coitus. Options include: . over-the-counter levonorgestrel o prescription ulipristal 155