유방의구조(breast structure 1/2) -...
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유방의구조(Breast Structure 1/2)• 유방: 젖을분비하는변형된땀선조직• 20 개엽(lobe)의실질선조직과섬유와지방조직으로구성된간질로구성- 엽(lobe), 소엽(lobule), 관(duct)
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유방의구조(Breast Structure 2 of 2)• 풍부한혈액양과림프배출기능을가지고있음.
- 림프통로들은각유방에서겨드랑림프절(axillary nodes), 쇄골윗부분림프절(supraclavicular nodes), 그리고중격동림프절( mediastinal nodes)로배출된다.
- 유방암의전이와관련하여이곳림프절로전이가가능.• 유방크기의차이는간질인지방과섬유조직에따른다.• 호르몬자극에민감하게반응한다.
– 생리주기: 주기적증식과퇴화가일어난다.– 임신시수유시: 선조직의비대(hypertrophy)가일어난다– 폐경시: 유방의크기가작아진다.
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(정상) (임신시증식) (폐경)유방발달이상 (Abnormalities in Breast Development)- 태생학적으로겨드랑이에서위쪽넙다리까지체벽앞쪽을따라늘어선유방능선(mammary ridges)의세포에서유래. 발달과정에서대부분의정상적인위치이외의것은소실.
Tissue Changes Secondary to Hormone Levels
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Common sites of accessory breasts
Extra nipple below and medial to left breast and nipple
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유방의 양성 낭성변화(Benign Cystic Change in the Breast)
• 유방에발생하는매우흔하게발생되는질환;- 양성섬유낭병(Fibrocystic disease)으로불린다.- 형태적으로보면관(duct)들의확장과더불어선조직과섬유조직의증식이관찰된다.
- 정상생리주기적변화에대한유방조직의불규칙으로발생.• 치료: 액체흡인, 또는외과적절제
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- 섬유선종(Fibroadenoma) • 경계가 뚜렷한 종양. 배란기에 촉진 시 경미한 압통• 젋은 여성에서 호발.
• 원인은 불명이나 호르몬 불균형으로 발생• 외과적 절제로 치유
- 관내유두종(intraductal papilloma). 중년여성에서흔히발생
혈성유즙분비
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유방암(Breast Carcinoma)
• 위험인자들- 가족력(여성의어머니또는자매의가족력)- 30세이상의나이에아이를처음가진여성- 생리를일찍한여성- 늦은폐경기- 폐경기증상완화를위한호르몬치료
* Estrogen alone: increase 1% risk Estrogen + progestin: increase 8% risk
- 발생율: 1 in every 10 women- 유방암종감수성유전자들: BRCA1/ BRCA2 돌연변이유방암과난소암에대한발병위험율이높다.
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유방암의 진단(Diagnosis of Breast cancer)- 3 가지접근:
1) 임상소견:- 통증없는덩어리촉진(mass detection)- 피부당김과피부의오렌지껍질모양: 침투성암종의미- 유두함몰(retracted nipple)- 혈성분비물(bloody nipple discharge)- 유륜(areola)부위색조변화
2) 유방촬영(Mammography)3) 조직검사:
- FNAB, needle biopsy
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제자리관상암종(ductal carcinoma In situ) 미세석회( microcalcifications): 유방촬영술
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유방암의예후인자(Prognostic Factors)- TNM 병기- 조직학적분화도- 에스트로겐/프로게스테론수용체유무- HER-2(human epidermal growth factor receptor, ErbB-2) 유전자 : 수용체결합항체치료시재발위험도감소
유방암의 치료1. 외과적절제2. 보조요법:
-화학요법-호르몬요법: Tamoxifen, aromatase inhibitors
3. 방사선요법: 종양재발억제위해사용
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유방자가진단(Breast Self Examination)
생리중인여성:생리후 3 – 5일폐경기여성: -매월같은날- 1 회시간 20분-유두를중심으로동심원적촉지-유두분비물확인
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여성생식계(Female Genital Tract) Infections
• 질염(Vaginitis): 흔한질환으로질분비물, 소양감유발1. 칸디다알비킨스(Candida albicans)
- 흔한 곰팡이 감염증, 보균자 10%
- 성적인 접촉에 의해 발생되지 않는다.
- 소인 요인:임신, 당뇨병, 비만- 하얀색의 질분비물
2. 질편모충(Trichomonas vaginalis)- 성적접촉에의해감염(protozoa)- 증상없는보균자: 10%- 녹색조의거품모양질분비물(생선냄새)
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3. 콘딜로마(Condylomas):
- 사람유두종바이러스(Human Papilloma Virus:HPV) 감염- 생식기에 성병에 의한 사마귀 모양 (크기 1mm-1cm 이상)
- 바이러스감염에 의한 편평상피세포의 과증식- 호발부위:
. 자궁경부, 질 점막
. 질구 주위
. 항문 주위
- 치료:
– 화학물질(podophylin)
– 전기응고술– 동결지짐– 외과적 절제
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자궁내막증(Endometriosis)• 정의: 자궁내막이자궁이외의다른부위에존재하는것
– 자궁이외의장소:난소, 골반, 충수, 직장등– 여성의 10% - 15%에서발생, 가족내에발생빈도증가– 불임, 골반통증, 불규칙한생리가있는경우흔히발생– 호르몬주기에따라변화, 이차적인난관협착초래: 불임
• 진단:복강경검사• 치료:
– 외과적제거– 자궁내막증의진행을막는호르몬요법
. 생리주기억제약, 생식선자극호르몬분비억제제
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자궁내막증(ENDOMETRIOSIS)
• 발생 가설- 역행성 생리/ 정착- 혈행/림프관 전파
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자궁경부 질환(Disease of the Cervix)1. 사람유두종 바이러스감염(HPV infection)2. 자궁경부상피내종양(Cervical Intraepithelial Neoplasm, CIN)3. 편평상피세포암(Squamous cell carcinoma)
1. HPV 감염: 성적 접촉에 의해, 80종 중 40종이 생식기 감염- 40 종 중 8종(고위험바이러스)이 암을 유발- HPV 6 and 11: HPV 유두종 원인의 90%- HPV 31, 33, 35- HPV 16 and 18: 자궁 경부 이형성과 자궁 암의 70%* HPV 백신: Type 6, 11, 16, 18에 대한 면역력 제공 백신
2. 자궁경부상피내종양- 자궁경부의 편평상피가 비정상적으로 증식하는 것을 의미- 자궁경부 이형성증과 동일시 취급
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CIN(Cervical Intraepithelial Neoplasm):
CIN I: 1/3 경증 이형성증; CIN II: 중등도 1/2
CIN III: 심한 이형성증과 제자리암종, 진행성 암종으로 이행CIN의 일반적 경과:
- 50% with CIN I: 자연적 소실- 30% with CIN I: 경증 이형성증으로 지속- 20% CIN I: 10년 이후 CIN II 과 III 으로 진행- 20% of CIN III: 10년 내 암종으로 진행
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자궁경부 질환
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세포 진 검사(PAP SMEAR SCREEN)
NORMAL LSIL
HSIL HSIL
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자궁내막질환(Endometrial )Disorders
• 자궁내막증식증(Endometrial hyperplasia)
– 자궁의 부정출혈과 관련• 자궁내막 용종(Benign endometrial polyps)
– 흔한 국소적 내막 증식– 표면에 염증이나 궤양이 생기면 출혈
• 자궁내막암종(Endometrial adenocarcinoma)
– 지속적인 에스트로겐에 의한 자궁내막의 자극과 관련– 폐경 후 자궁의 부정 출혈– 비만한 여성– 불임여성에 호발
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자궁근종(Uterine leiomyoma): 양성평활근종양- 30세이상여자의 30%에서발견- 자궁출혈, 방광, 직장의압력증가, 자연유산등
자궁육종(Uterine leiomyosarcoma): 악성평활근종양- 40세 - 60세 (peak age), 유사분열수가진단에중요
- 재발과혈행성으로폐, 뇌에전이가능
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부정자궁출혈(Irregular Uterine Bleeding)• 기능성자궁출혈(Dysfunctional uterine bleeding):
– 난포(follicle)가성숙되지않아, 그결과황체가형성되지않기때문에발생. 결국지속적인자궁내막의에스트로겐자극에의해비주기적인자궁출혈발생. 무배란성출혈(anovulatory bleeding)
– 정상생리주기가시작되는사춘기나폐경기에흔히발생
• 자궁출혈의다른원인들:– 양성자궁내막증(Benign endometrial hyperplasia)– 자궁내막,경부용종(Endometrial and cervical polyps)– 자궁근종(Uterine myomas)– 자궁암(Uterine carcinoma)
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정상생리주기(Normal Cycle)• 월경주기첫 ½ 기간(14일) : 자궁내막선조직과간질이난포에서분비되는에스트로겐영향으로증식.증식기(Proliferative phase)
• 월경주기중간(14일- 15일): 배란이일어난다– 난포(Follicle)에서난자를배출하고, 황체(Corpus luteum)로되어에스트로겐과프로게스테론분비
– 프로게스테론: 자궁내막을수정된난자를수용하기위해분비기로변화시킨다.
• 임신이되지않을경우:– 황체퇴화– 에스트로겐-프로게스테론농도저하– 분비기자궁내막탈락(생리, menstruation)
• 새로운생리주기시작
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월경통(Dysmenorrhea
일차적 월경통(Primary dysmenorrhea)– 가장흔한유형으로골반내장기는정상– 생리시작후 1-2년동안은생리기에대부분은통증이없다(무배란성생리)
– 월경통은규칙적생리주기인경우발생. 생리시작후 1-2일동안발생
– 기전: 난소에서생성된프로게스테론에의해분비기의자궁내막에서생성된프로스타그란딘(Prostaglandin)이생리가시작되면서방출되어자궁근육의경련성수축을유도하여발생
– 치료: 생리시작전아스피린투여, 또는경구피임제
이차적 월경통(Secondary dysmenorrhea):- Endometriosis 등 기질적 원인에 의한 월경 통
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난소 종양(OVARIAN TUMORS)- 대부분 양성 (80%) :
- 젋은 여성에서 호발 (20 to 45-years-old)
- 처음 임상 양상은 대부분 복수(ascites) 발생- 난소암의 위험인자:
- 미분만성(Nulliparity)
- 가족력, 유전인자(BRCA genes)
- 종양표지인자: CA-125
- 난소종양의 기원– 상피성(Epithelial): 장액성(Serous), 점액성(Mucinous tumor)– 생식세포(Germ Cell): 기형종(Teratoma )– 성기삭-간질(Sex Cord/Stromal): – 전이성(Metastatic tumors): 위암
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Benign Cystic Ovarian Tumors
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독성쇼크 증후군(Toxic Shock Syndrome)
• 대부분높은흡수성의탐폰사용시발생• 질에서자라는황색포도구균(Staphylococci)에서생산된독소에의해발생
• 임상양상: 열, 구토, 근육통, 피부발진• 생리혈이황색포도균의독소생산할수있는배지역활• 치료:
– 탐폰사용금지– 항생제처방과대중적치료