NR 602 WEEK 6 STUDY GUIDE
Pelvic Inflammatory Disease necessary for the diagnosis of acute salpingitis, although its
Essentials of Diagnosis absence may indicate other disorders. In one study, only 30%
Inflammation of upper female genital tract of women with laparoscopically confirmed acute salpingitis
Usually polymicrobial had fever.
Often diagnosed clinically based on the presence of Abdominal tenderness is often encountered, usually in both
cervical motion tenderness or uterine or adnexal lower quadrants. The abdomen may be somewhat distended,
tenderness and bowel sounds may be hypoactive or absent. Pelvic
Criteria exist to determine whether to manage examination may demonstrate inflammation of the
patient as an inpatient or outpatient periurethral (Skene) or Bartholin's glands as well as a
May result in pelvic scarring and infertility purulent cervical discharge. Bimanual examination typically
elicits extreme tenderness on movement of the cervix and
Pathogenesis uterus and palpation of the parametria.
Pelvic inflammatory disease (PID) comprises a spectrum of Based on the CDC guidelines, the diagnosis of PID should be
inflammatory disorders of the upper female genital tract, made and empiric treatment initiated in sexually active young
including any combination of endometritis, salpingitis, tubo- women and other women at risk for STDs if they are
ovarian abscess, and pelvic peritonitis. Sexually transmitted experiencing pelvic or lower abdominal pain, if no cause for
organisms, particularly N gonorrhoeae and C trachomatis, are the illness other than PID can be identified, and if 1 or more
implicated in many cases. However, microorganisms that of the following minimum criteria are present on pelvic
comprise the vaginal flora (eg, anaerobes, G examination: cervical motion tenderness, uterine tenderness,
vaginalis, Haemophilus influenzae, enteric gram-negative or adnexal tenderness.
rods, and Streptococcus agalactiae) are also associated with
PID, which is often polymicrobial. More uncommonly, Laboratory Findings
cytomegalovirus, Mycoplasma hominis, Ureaplasma Saline microscopy of vaginal fluid may reveal abundant white
urealyticum, and Mycoplasma genitalium can cause PID. All blood cells. Complete blood count may reveal a leukocytosis
women who have acute PID should be tested for N with a shift to the left. Erythrocyte sedimentation rate and C-
gonorrhoeae and C trachomatis and should be screened for reactive protein may be elevated. Endocervical swabs may be
other STDs. positive for infection with N gonorrhoeae or C trachomatis.
However, all these tests may be normal in a patient with PID;
Prevention therefore, should be used as supportive evidence only, not as
Screening and treating sexually active women and their sex definitive diagnostic tools. Endometrial biopsy is more
partners for chlamydia and gonorrhea reduces their risk for specific and usually shows histopathologic evidence of
PID. Early diagnosis and eradication of minimally symptomatic endometritis. In practice, however, this is often not done,
disease can also prevent salpingitis. Sex partners of women although it may be particularly useful in women who have
with PID should be examined and treated if they had sexual undergone laparoscopy with no visual evidence of salpingitis,
contact with the patient during the 60 days preceding the as endometritis may be the only sign of PID in some cases.
patient's onset of symptoms. If a patient's last sexual
intercourse was >60 days before onset of symptoms or Imaging
diagnosis, the patient's most recent sex partner should be Transvaginal sonography or magnetic resonance imaging
treated. Patients should be instructed to abstain from sexual techniques showing thickened, fluid-filled tubes with or
intercourse until therapy is completed and until they and without free pelvic fluid or tubo-ovarian complex or Doppler
their sex partners no longer have symptoms. studies suggesting pelvic infection (eg, tubal hyperemia) are
quite specific for PID, although in less complicated cases,
Clinical Findings imaging may be normal.
Symptoms & Signs
Acute PID is difficult to diagnose due to a wide variation in Laparoscopy
symptoms and signs. Many women with PID have subtle or Diagnostic laparoscopy can be used to obtain a more accurate
mild symptoms. Delay in diagnosis and treatment contributes diagnosis of salpingitis and a more complete bacteriologic
to inflammatory sequelae in the upper reproductive tract. diagnosis. However, this tool may not be available at some
Consequently, a diagnosis of PID usually is based on clinical sites, and it may not be appropriate when symptoms are mild
findings, although clinical diagnosis is imprecise, and many or vague. Laparoscopy will not detect endometritis and may
cases of PID go unrecognized. not detect subtle inflammation of the fallopian tubes. It
Patients may complain of insidious or acute onset of lower remains, however, a useful adjunct when the diagnosis is in
abdominal and pelvic pain, which is usually bilateral. There question.
may be a sensation of pelvic pressure or back pain. There is
often an associated purulent vaginal discharge. Differential Diagnosis
Nausea may occur, with or without vomiting. Headache and PID must be differentiated from other acute abdominal
general lassitude are common complaints. Fever is not processes such as acute appendicitis, ectopic pregnancy,
,NR 602 WEEK 6 STUDY GUIDE
ruptured corpus luteum cyst with hemorrhage, diverticulitis, Data on alternative regimens are
infected septic abortion, torsion of an adnexal mass, limited. Amoxicillin/clavulanic acid and doxycycline may be
degeneration of a leiomyoma, endometriosis, acute urinary used, as well as ceftriaxone 250 mg IM single dose
tract infection, regional enteritis, and ulcerative colitis. and azithromycin 1 g orally once a week for 2 weeks. When
considering alternative regimens, the addition
Complications of metronidazole should be considered. As a result of the
Complications of acute salpingitis include pelvic peritonitis or emergence of quinolone-resistant N gonorrhoeae, regimens
generalized peritonitis, prolonged ileus, septic pelvic that include a quinolone agent are no longer recommended
thrombophlebitis, abscess formation with adnexal for the treatment of PID. If parenteral cephalosporin therapy
destruction and subsequent infertility, and intestinal is not feasible, use of fluoroquinolones (levofloxacin 500 mg
adhesions and obstruction. Rarely, dermatitis, gonococcal orally once daily or ofloxacin 400 mg twice daily for 14 days)
arthritis, or bacteremia with septic shock occurs. with or without metronidazole (500 mg orally twice daily for
14 days) can be considered if the community prevalence and
Treatment individual risk for gonorrhea are low.
PID treatment regimens provide empiric, broad spectrum If a response to therapy is not observed after 72 hours, the
coverage of likely pathogens and should be given as soon as a patient should be re-evaluated to confirm the diagnosis and
presumptive diagnosis is made. Several antimicrobial consideration made to admitting the patient for inpatient
regimens have been effective in achieving clinical and therapy.
microbiologic cure in randomized clinical trials with short-
term follow-up. However, the data on long-term outcomes Inpatient Therapy
and frequency of complications such as tubal infertility and RECOMMENDED REGIMEN A
ectopic pregnancy are limited. Cefotetan 2 g IV every 12 hours, or cefoxitin 2 g IV
All regimens used to treat PID should also be effective every 6 hours, plus
against N gonorrhoeae and C trachomatis because negative Doxycycline 100 mg orally or IV every 12 hours
endocervical screening for these organisms does not rule out RECOMMENDED REGIMEN B
upper reproductive tract infection. Clindamycin 900 mg IV every 8 hours, plus
The majority of women with a clinical diagnosis of PID have Gentamicin loading dose IV or IM (2 mg/kg body
symptoms of mild to moderate severity that usually respond weight) followed by a maintenance dose (1.5 mg/kg)
well to outpatient antibiotic therapy. Hospitalization usually is every 8 hours. Single daily dosing (3–5 mg/kg) can be
warranted for women who are more severely ill, as well as substituted.
the following cases: ALTERNATIVE REGIMENS
Patient in whom surgical emergencies (eg, Ampicillin/sulbactam 3 g IV every 6 hours, plus
appendicitis) cannot be excluded Doxycycline 100 mg orally or IV every 12 hours
Patient who are pregnant Oral doxycycline is preferable due to pain associated with IV
Patients who have not responded well to outpatient infusion and similar bioavailability of oral and parenteral
oral therapy preparations.
Patients who are unable to tolerate or comply with Parenteral agents can be discontinued 24 hours after clinical
outpatient therapy improvement is observed, but oral therapy with doxycycline
Patients who have severe illness, nausea and should be continued to complete a course of 14 days of
vomiting, or high fever treatment. When tubo-ovarian abscess is
Patients with tubo-ovarian abscess present, metronidazole or clindamycin should be added to
Outpatient Therapy the inpatient or outpatient regimen to provide adequate
anaerobic coverage.
RECOMMENDED REGIMENS
Ceftriaxone 250 mg IM in a single dose (or other Special Circumstances
parenteral third-generation cephalosporin), plus All pregnant women with suspected PID should be
Doxycycline 100 mg orally twice a day for 14 hospitalized and treated with parenteral
days, with or without antibiotics. Doxycycline should not be used in pregnancy.
Metronidazole 500 mg orally twice a day for 14 days Patients with intrauterine devices (IUDs) with suspected PID
or do not necessarily need to have the IUD removed, particularly
Cefoxitin 2 g IM in a single dose and probenecid 1 g if the patient is at high risk of unintended pregnancy.
orally in a single dose administered However, caution should be exercised if the IUD remains in
concurrently, plus place, and close clinical follow-up is required. Re-evaluation
Doxycycline 100 mg orally twice a day for 14 for IUD removal should be considered if the patient is not
days, with or without clinically improving. Of note, the risk of PID is not increased in
Metronidazole 500 mg orally twice a day for 14 days IUD users other than in the first 21 days after insertion, after
which it is uncommon. The levonorgestrel-releasing IUD may
, NR 602 WEEK 6 STUDY GUIDE
have a protective effect against PID due to thickening of which is attributed to better screening and advances in
cervical mucus. If an IUD is removed due to PID, a new one treatment modalities. On average, the breast cancer death
may be reinserted 3 months after resolution of the infection if rate decreased by 2.3% per year from 1990 to 2001. The
the patient is not at ongoing risk of PID. probability of developing the disease increases throughout
Actinomyces israelii is a normal anaerobic commensal of the life. The mean and median age of women with breast cancer
gastrointestinal tract but can be associated with pelvic is 60–61 years, and breast cancer is the main cause of death
infection and abscess. It is present on the Papanicolaou test for women between the ages of 40 and 59.
of approximately 7% of IUD users. Most patients are At the present rate of incidence, a woman's risk of developing
asymptomatically colonized. If actinomyces is present, the invasive breast cancer in her lifetime from birth to death is 1
patient should be examined, and if asymptomatic, there is no in 8. This figure is from the Surveillance, Epidemiology, and
indication to administer antibiotics or remove the IUD. If the End Results Program (SEER) of the National Cancer Institute
patient demonstrates symptoms of PID or tubo-ovarian (NCI) and is often cited but needs clarification. The data
abscess, antibiotics should be commenced and the IUD include all age groups in 5-year intervals with an open-ended
removed, as actinomyces preferentially grow on foreign interval at 85 years and above. When calculating risk, each
bodies. age interval is weighted to account for the increasing risk of
Actinomyces is sensitive to penicillin; a 14-day course of breast cancer with increasing age. A woman's risk of being
penicillin G (500 mg 4 times per day), or doxycycline (100 mg diagnosed with invasive breast cancer by age is as follows:
twice per day) in patients with penicillin allergy, may be By age 30: 1 in 2000
adequate treatment for a very early, local infection, but By age 40: 1 in 233
prolonged IV therapy (weeks to months) is indicated for tubo- By age 50: 1 in 53
ovarian abscess or disseminated infection. Surgical drainage is By age 60: 1 in 22
usually required for actinomycotic abscesses, which are often By age 70: 1 in 13
the result of intestinal infections such as appendicitis but may By age 80: 1 in 9
be associated with IUD use. In a lifetime: 1 in 8
In the United States, breast cancer is the most common
Prognosis cancer among women of all ethnic groups, although the
A favorable outcome is directly related to the promptness incidence of the disease is highest among white patients. In
with which adequate therapy is begun. A single episode of general, rates reported from developing countries are lower
salpingitis has been shown to cause infertility in 12–18% of than those reported from developed countries, with the
women. Follow-up care and education are necessary to notable exception of Japan. Some of the variability may be a
prevent reinfection and complications. In some cases patients result of underreporting, but lifestyle, sociodemographic, and
may experience recurrent or chronic pelvic infection resulting environmental factors such as diet, exercise, parity,
in chronic pelvic pain. breastfeeding, and body weight are implicated as possible
causes for this observed difference.
Essentials of Diagnosis
Early findings: Single, nontender, firm to hard mass Women with a family history of breast cancer are more likely
with ill-defined margins; mammographic to develop the disease than controls. The risk of being
abnormalities and no palpable mass. diagnosed with breast cancer for a patient with 1 affected
Later findings: Skin or nipple retraction; axillary first-degree relative (mother or sister) is increased by almost
lymphadenopathy; breast enlargement, redness, 2-fold. With 2 affected first-degree relatives, the increased
edema, brawny induration, peau d'orange, pain, risk is almost 3-fold. The risk is even higher if those relatives
fixation of mass to skin or chest wall. were diagnosed at a young age. A family history of breast
Late findings: Ulceration; supraclavicular cancer is, however, only reported by 15–20% of patients with
lymphadenopathy; edema of arm; bone, lung, liver, breast cancer. Inherited specific genetic mutations that
brain, or other distant metastases. predispose patients to breast cancer such as, BRCA1 and
BRCA2 gene mutations, are rare, accounting for
General Considerations approximately 5% of all breast cancers. BRCA mutations place
Cancer of the breast is the most common cancer in women, affected women at a significantly increased lifetime risk, up to
excluding nonmelanoma skin cancers. After lung cancer, it is a 70%, of being diagnosed with breast cancer.
the second most common cause of cancer death for women.
The American Cancer Society estimates that over 210,000 Nulliparous women and women whose first full-term
new cases of cancer of the breast will be diagnosed in 2010, pregnancy was after age 30 years have a slightly higher
resulting in over 40,000 deaths. These figures include male incidence of breast cancer than multiparous women. Late
breast cancer, which accounts for less than 1% of annual menarche and artificial menopause are associated with a
breast cancer incidence. The yearly breast cancer incidence lower incidence of breast cancer, whereas early menarche
has steadily decreased from 1999 to 2006. Similarly, the (before age 12 years) and late natural menopause (after age
mortality from breast cancer has been decreasing since 1975, 50 years) are associated with a slight increase in risk of
Pelvic Inflammatory Disease necessary for the diagnosis of acute salpingitis, although its
Essentials of Diagnosis absence may indicate other disorders. In one study, only 30%
Inflammation of upper female genital tract of women with laparoscopically confirmed acute salpingitis
Usually polymicrobial had fever.
Often diagnosed clinically based on the presence of Abdominal tenderness is often encountered, usually in both
cervical motion tenderness or uterine or adnexal lower quadrants. The abdomen may be somewhat distended,
tenderness and bowel sounds may be hypoactive or absent. Pelvic
Criteria exist to determine whether to manage examination may demonstrate inflammation of the
patient as an inpatient or outpatient periurethral (Skene) or Bartholin's glands as well as a
May result in pelvic scarring and infertility purulent cervical discharge. Bimanual examination typically
elicits extreme tenderness on movement of the cervix and
Pathogenesis uterus and palpation of the parametria.
Pelvic inflammatory disease (PID) comprises a spectrum of Based on the CDC guidelines, the diagnosis of PID should be
inflammatory disorders of the upper female genital tract, made and empiric treatment initiated in sexually active young
including any combination of endometritis, salpingitis, tubo- women and other women at risk for STDs if they are
ovarian abscess, and pelvic peritonitis. Sexually transmitted experiencing pelvic or lower abdominal pain, if no cause for
organisms, particularly N gonorrhoeae and C trachomatis, are the illness other than PID can be identified, and if 1 or more
implicated in many cases. However, microorganisms that of the following minimum criteria are present on pelvic
comprise the vaginal flora (eg, anaerobes, G examination: cervical motion tenderness, uterine tenderness,
vaginalis, Haemophilus influenzae, enteric gram-negative or adnexal tenderness.
rods, and Streptococcus agalactiae) are also associated with
PID, which is often polymicrobial. More uncommonly, Laboratory Findings
cytomegalovirus, Mycoplasma hominis, Ureaplasma Saline microscopy of vaginal fluid may reveal abundant white
urealyticum, and Mycoplasma genitalium can cause PID. All blood cells. Complete blood count may reveal a leukocytosis
women who have acute PID should be tested for N with a shift to the left. Erythrocyte sedimentation rate and C-
gonorrhoeae and C trachomatis and should be screened for reactive protein may be elevated. Endocervical swabs may be
other STDs. positive for infection with N gonorrhoeae or C trachomatis.
However, all these tests may be normal in a patient with PID;
Prevention therefore, should be used as supportive evidence only, not as
Screening and treating sexually active women and their sex definitive diagnostic tools. Endometrial biopsy is more
partners for chlamydia and gonorrhea reduces their risk for specific and usually shows histopathologic evidence of
PID. Early diagnosis and eradication of minimally symptomatic endometritis. In practice, however, this is often not done,
disease can also prevent salpingitis. Sex partners of women although it may be particularly useful in women who have
with PID should be examined and treated if they had sexual undergone laparoscopy with no visual evidence of salpingitis,
contact with the patient during the 60 days preceding the as endometritis may be the only sign of PID in some cases.
patient's onset of symptoms. If a patient's last sexual
intercourse was >60 days before onset of symptoms or Imaging
diagnosis, the patient's most recent sex partner should be Transvaginal sonography or magnetic resonance imaging
treated. Patients should be instructed to abstain from sexual techniques showing thickened, fluid-filled tubes with or
intercourse until therapy is completed and until they and without free pelvic fluid or tubo-ovarian complex or Doppler
their sex partners no longer have symptoms. studies suggesting pelvic infection (eg, tubal hyperemia) are
quite specific for PID, although in less complicated cases,
Clinical Findings imaging may be normal.
Symptoms & Signs
Acute PID is difficult to diagnose due to a wide variation in Laparoscopy
symptoms and signs. Many women with PID have subtle or Diagnostic laparoscopy can be used to obtain a more accurate
mild symptoms. Delay in diagnosis and treatment contributes diagnosis of salpingitis and a more complete bacteriologic
to inflammatory sequelae in the upper reproductive tract. diagnosis. However, this tool may not be available at some
Consequently, a diagnosis of PID usually is based on clinical sites, and it may not be appropriate when symptoms are mild
findings, although clinical diagnosis is imprecise, and many or vague. Laparoscopy will not detect endometritis and may
cases of PID go unrecognized. not detect subtle inflammation of the fallopian tubes. It
Patients may complain of insidious or acute onset of lower remains, however, a useful adjunct when the diagnosis is in
abdominal and pelvic pain, which is usually bilateral. There question.
may be a sensation of pelvic pressure or back pain. There is
often an associated purulent vaginal discharge. Differential Diagnosis
Nausea may occur, with or without vomiting. Headache and PID must be differentiated from other acute abdominal
general lassitude are common complaints. Fever is not processes such as acute appendicitis, ectopic pregnancy,
,NR 602 WEEK 6 STUDY GUIDE
ruptured corpus luteum cyst with hemorrhage, diverticulitis, Data on alternative regimens are
infected septic abortion, torsion of an adnexal mass, limited. Amoxicillin/clavulanic acid and doxycycline may be
degeneration of a leiomyoma, endometriosis, acute urinary used, as well as ceftriaxone 250 mg IM single dose
tract infection, regional enteritis, and ulcerative colitis. and azithromycin 1 g orally once a week for 2 weeks. When
considering alternative regimens, the addition
Complications of metronidazole should be considered. As a result of the
Complications of acute salpingitis include pelvic peritonitis or emergence of quinolone-resistant N gonorrhoeae, regimens
generalized peritonitis, prolonged ileus, septic pelvic that include a quinolone agent are no longer recommended
thrombophlebitis, abscess formation with adnexal for the treatment of PID. If parenteral cephalosporin therapy
destruction and subsequent infertility, and intestinal is not feasible, use of fluoroquinolones (levofloxacin 500 mg
adhesions and obstruction. Rarely, dermatitis, gonococcal orally once daily or ofloxacin 400 mg twice daily for 14 days)
arthritis, or bacteremia with septic shock occurs. with or without metronidazole (500 mg orally twice daily for
14 days) can be considered if the community prevalence and
Treatment individual risk for gonorrhea are low.
PID treatment regimens provide empiric, broad spectrum If a response to therapy is not observed after 72 hours, the
coverage of likely pathogens and should be given as soon as a patient should be re-evaluated to confirm the diagnosis and
presumptive diagnosis is made. Several antimicrobial consideration made to admitting the patient for inpatient
regimens have been effective in achieving clinical and therapy.
microbiologic cure in randomized clinical trials with short-
term follow-up. However, the data on long-term outcomes Inpatient Therapy
and frequency of complications such as tubal infertility and RECOMMENDED REGIMEN A
ectopic pregnancy are limited. Cefotetan 2 g IV every 12 hours, or cefoxitin 2 g IV
All regimens used to treat PID should also be effective every 6 hours, plus
against N gonorrhoeae and C trachomatis because negative Doxycycline 100 mg orally or IV every 12 hours
endocervical screening for these organisms does not rule out RECOMMENDED REGIMEN B
upper reproductive tract infection. Clindamycin 900 mg IV every 8 hours, plus
The majority of women with a clinical diagnosis of PID have Gentamicin loading dose IV or IM (2 mg/kg body
symptoms of mild to moderate severity that usually respond weight) followed by a maintenance dose (1.5 mg/kg)
well to outpatient antibiotic therapy. Hospitalization usually is every 8 hours. Single daily dosing (3–5 mg/kg) can be
warranted for women who are more severely ill, as well as substituted.
the following cases: ALTERNATIVE REGIMENS
Patient in whom surgical emergencies (eg, Ampicillin/sulbactam 3 g IV every 6 hours, plus
appendicitis) cannot be excluded Doxycycline 100 mg orally or IV every 12 hours
Patient who are pregnant Oral doxycycline is preferable due to pain associated with IV
Patients who have not responded well to outpatient infusion and similar bioavailability of oral and parenteral
oral therapy preparations.
Patients who are unable to tolerate or comply with Parenteral agents can be discontinued 24 hours after clinical
outpatient therapy improvement is observed, but oral therapy with doxycycline
Patients who have severe illness, nausea and should be continued to complete a course of 14 days of
vomiting, or high fever treatment. When tubo-ovarian abscess is
Patients with tubo-ovarian abscess present, metronidazole or clindamycin should be added to
Outpatient Therapy the inpatient or outpatient regimen to provide adequate
anaerobic coverage.
RECOMMENDED REGIMENS
Ceftriaxone 250 mg IM in a single dose (or other Special Circumstances
parenteral third-generation cephalosporin), plus All pregnant women with suspected PID should be
Doxycycline 100 mg orally twice a day for 14 hospitalized and treated with parenteral
days, with or without antibiotics. Doxycycline should not be used in pregnancy.
Metronidazole 500 mg orally twice a day for 14 days Patients with intrauterine devices (IUDs) with suspected PID
or do not necessarily need to have the IUD removed, particularly
Cefoxitin 2 g IM in a single dose and probenecid 1 g if the patient is at high risk of unintended pregnancy.
orally in a single dose administered However, caution should be exercised if the IUD remains in
concurrently, plus place, and close clinical follow-up is required. Re-evaluation
Doxycycline 100 mg orally twice a day for 14 for IUD removal should be considered if the patient is not
days, with or without clinically improving. Of note, the risk of PID is not increased in
Metronidazole 500 mg orally twice a day for 14 days IUD users other than in the first 21 days after insertion, after
which it is uncommon. The levonorgestrel-releasing IUD may
, NR 602 WEEK 6 STUDY GUIDE
have a protective effect against PID due to thickening of which is attributed to better screening and advances in
cervical mucus. If an IUD is removed due to PID, a new one treatment modalities. On average, the breast cancer death
may be reinserted 3 months after resolution of the infection if rate decreased by 2.3% per year from 1990 to 2001. The
the patient is not at ongoing risk of PID. probability of developing the disease increases throughout
Actinomyces israelii is a normal anaerobic commensal of the life. The mean and median age of women with breast cancer
gastrointestinal tract but can be associated with pelvic is 60–61 years, and breast cancer is the main cause of death
infection and abscess. It is present on the Papanicolaou test for women between the ages of 40 and 59.
of approximately 7% of IUD users. Most patients are At the present rate of incidence, a woman's risk of developing
asymptomatically colonized. If actinomyces is present, the invasive breast cancer in her lifetime from birth to death is 1
patient should be examined, and if asymptomatic, there is no in 8. This figure is from the Surveillance, Epidemiology, and
indication to administer antibiotics or remove the IUD. If the End Results Program (SEER) of the National Cancer Institute
patient demonstrates symptoms of PID or tubo-ovarian (NCI) and is often cited but needs clarification. The data
abscess, antibiotics should be commenced and the IUD include all age groups in 5-year intervals with an open-ended
removed, as actinomyces preferentially grow on foreign interval at 85 years and above. When calculating risk, each
bodies. age interval is weighted to account for the increasing risk of
Actinomyces is sensitive to penicillin; a 14-day course of breast cancer with increasing age. A woman's risk of being
penicillin G (500 mg 4 times per day), or doxycycline (100 mg diagnosed with invasive breast cancer by age is as follows:
twice per day) in patients with penicillin allergy, may be By age 30: 1 in 2000
adequate treatment for a very early, local infection, but By age 40: 1 in 233
prolonged IV therapy (weeks to months) is indicated for tubo- By age 50: 1 in 53
ovarian abscess or disseminated infection. Surgical drainage is By age 60: 1 in 22
usually required for actinomycotic abscesses, which are often By age 70: 1 in 13
the result of intestinal infections such as appendicitis but may By age 80: 1 in 9
be associated with IUD use. In a lifetime: 1 in 8
In the United States, breast cancer is the most common
Prognosis cancer among women of all ethnic groups, although the
A favorable outcome is directly related to the promptness incidence of the disease is highest among white patients. In
with which adequate therapy is begun. A single episode of general, rates reported from developing countries are lower
salpingitis has been shown to cause infertility in 12–18% of than those reported from developed countries, with the
women. Follow-up care and education are necessary to notable exception of Japan. Some of the variability may be a
prevent reinfection and complications. In some cases patients result of underreporting, but lifestyle, sociodemographic, and
may experience recurrent or chronic pelvic infection resulting environmental factors such as diet, exercise, parity,
in chronic pelvic pain. breastfeeding, and body weight are implicated as possible
causes for this observed difference.
Essentials of Diagnosis
Early findings: Single, nontender, firm to hard mass Women with a family history of breast cancer are more likely
with ill-defined margins; mammographic to develop the disease than controls. The risk of being
abnormalities and no palpable mass. diagnosed with breast cancer for a patient with 1 affected
Later findings: Skin or nipple retraction; axillary first-degree relative (mother or sister) is increased by almost
lymphadenopathy; breast enlargement, redness, 2-fold. With 2 affected first-degree relatives, the increased
edema, brawny induration, peau d'orange, pain, risk is almost 3-fold. The risk is even higher if those relatives
fixation of mass to skin or chest wall. were diagnosed at a young age. A family history of breast
Late findings: Ulceration; supraclavicular cancer is, however, only reported by 15–20% of patients with
lymphadenopathy; edema of arm; bone, lung, liver, breast cancer. Inherited specific genetic mutations that
brain, or other distant metastases. predispose patients to breast cancer such as, BRCA1 and
BRCA2 gene mutations, are rare, accounting for
General Considerations approximately 5% of all breast cancers. BRCA mutations place
Cancer of the breast is the most common cancer in women, affected women at a significantly increased lifetime risk, up to
excluding nonmelanoma skin cancers. After lung cancer, it is a 70%, of being diagnosed with breast cancer.
the second most common cause of cancer death for women.
The American Cancer Society estimates that over 210,000 Nulliparous women and women whose first full-term
new cases of cancer of the breast will be diagnosed in 2010, pregnancy was after age 30 years have a slightly higher
resulting in over 40,000 deaths. These figures include male incidence of breast cancer than multiparous women. Late
breast cancer, which accounts for less than 1% of annual menarche and artificial menopause are associated with a
breast cancer incidence. The yearly breast cancer incidence lower incidence of breast cancer, whereas early menarche
has steadily decreased from 1999 to 2006. Similarly, the (before age 12 years) and late natural menopause (after age
mortality from breast cancer has been decreasing since 1975, 50 years) are associated with a slight increase in risk of
