Breast and genitourinary assessment Flashcards
What is trauma informed care
- Many of us have experienced trauma in our lives and it may not be so obvious
- Everybody brings a different kind of trauma to the table
- We want to provide care that promotes a culture of safety, healing and empowerment
- As practitioners, we see survivors of trauma in settings that too often re-traumatize and marginalize them
- Learning to interact with survivors in ways that encourage their resiliency and growth is important
Keys of trauma informed care
- Trauma is common
- Trauma comes in many forms
- Care for everyone as though we have all experienced trauma
- Practice trauma-informed / trauma-aware care
How to provide trauma informed care
- Always ask for consent; including at each step
- Ask whether the patient would like someone to be with
them - Explain what will be done, how it will be done, and why it is necessary
- Do not assume that any procedure or examination is routine
- Observe body language
- Avoid false reassurances. Offer specific suggestions on how to relax if needed. Discuss in advance. Write things down.
- If the patient is triggered, speak in calm voice and let them know where they are, that they are in a safe place, and encourage them to look at you, focus, and take breaths.
Considerations for trauma informed care
Summary of considerations for physicians when interacting with survivors
- let the patient lead, but avoid having the patient tell very detail of the trauma, unless they want to
- use a non-judgemental approach
- have patient agency
- be sensitive, attentive,
- inform before you perform
- expose one body part at a time
- inclusive care is important; do not discriminate
Inclusive care
- Discrimination against individuals who identify as LGBTQI2S, or any other SOGIE not listed, has been common in many contexts including healthcare
- What are some ways we can make people feel welcome, and understood?
- Don’t assume
- Ask questions in a way that avoids assumptions
Review your:
- Clinic space/unit
- Posters/artwork throughout the clinic
- Washrooms
- Documentation
- Policies & Procedures / Consents / Forms
- Staff orientation program
- Health promotion materials
- Marketing materials / Website
The gingerbread person
Four discrete experiences of every person
- May or may not be the same or related to each other
1) Gender identity
2) Attraction
3) Expression
4) Sex
Female and male breast/chest assessment
- Both females and males have breasts, mammary glands
- But in makes they are rudimentary throughout entire life
Anatomy of breasts
- Breasts are composed of many tissues
- Granular, fibrous, and adipose tissues
- And the proportion changes depending on age, menstrual cycle, pregnancy, lactating, nutritional state, etc.
- Second rib is were breast tissue starts
Breast landmarks: quadrants
- Have to specify where a mass is
- Axillary tail of Spence
- Upper inner quadrant
- Upper outer quadrent
- Lower inner quadrant
- Lower outer quadrant
Breasts and lymphatic drainage
Axillary nodes
- Central
- Pectoral
- Subscapular
- Lateral
- Lymph flows circulatory around breast then up to axillary area then to clavical
- This along with venous drainage is very important in the spread of cancer
Age related changes to breasts: children
Infancy
- Breast structures present, but only nipple (lactifours duct) is active unit puberty
Adolescence
- The onset of breast development, begins between ages 8-10
i. Thelarche (breast development)
ii. Adrenarche/pubarche (axillary/pubic hair development)
iii. Height spurt
iv. Menarche (first period)
Boobs, pubes, grow, flow
Tanner staging: sexual maturity rating in girls
- Good for assessing where someone is in their pubertal development
- Breast development occurs starting at age 8-13
- Pubic hair development from 8-14
- Height spurt from age 9 1/2-14 1/2
- Menarche from age 10-16 1/2
Average age of pubertal changes
Females it beings around 8
Males around age 10-11
Hormones of how puberty works
- The hypothalamus stimulates GnRH, which stimulates the pituitary gland to secrete LH and FSH
- These stimulate either the testes or ovaries to secrete testosterone or oestrogen respectively
- Causes subsequent changes in the body
- We can block puberty with GnRH; fully reversible
Age related breast changes: pregnancy
- Breasts can change quite a bit; can be an early sign of pregnancy
- Breast/nipple increase in size, blue vascular patten can be seen (default is white woman bias)
- Can develop stretch marks
- Nipples become darker and more erect
- Colostrum can be present at 4 months pregnant
Age related breast changes: lactation
- Biological reason for breasts is to nourish offspring; have become very sexualized
- Breasts can be both sexual and biological
- You can incite lactation even if you aren’t the person who just gave birth
Breast/chest feeding
- Trans men can breastfeed depending on top surgery and how much breast tissue has been removed
- Supplemental nursing system can also be use if breastfeeding is difficult
The breastfeed baby
Immune system
- responds better to vaccinations
- human milk helps to mature immune system
- decreased risk of childhood cancer
Eyes
- visual acuity is higher in babies fed human milk
Ears
- breastfed babies get fewer ear infections
Throat
- children who are breastfeed are less likely to require tonsilectomies
Skin
- less allergic eczema in breastfed infants
Higher IQ
- cholesterol and other types of fat in human milk support the growth of nerve tissue
Endocrine system
- reduced risk of getting diabetes
Mouth
- less need for orthodontics in children breastfeed more than an year
- improved muscle development of face from suckling at the breast
- subtle changes in the taste of human milk prepare babies to accept a variety of foods
Respiratory system
- breastfeed babies have fewer and less severe upper respiratory infections
- less wheezing, less pneumonia, and less influenza
Heart and circulatory system
- breastfeed children have lower cholesterol as adults
- heart rates are lower in breastfed infants
Kidneys
- with less salt and less protein, human milk is easier on babies kidneys
Digestive system
- less diarrhea, fewer GI infections in babies who are breastfeeding
- 6 months or more of exclusive breastfeeding reduces risk of food allergies
- less risk of Crohn’s disease and UC in adulthood
Appendix
- children with acute appendicitis are less likely to have been breastfed
Urinary tract
- fewer infections in breastfed infants
Bowels
- less constipated
Joints and muscles
- juvenile RA is less common in children who are breastfed
The breastfed toddler
Hair
- have glossier, healthier hair due to protein from milk
Brain
- higher intellectual and cognitive aptitude
Ears
- better hearing due to lower incidence of ear infections
Eyes
- stronger vision due to vitamin A in milk
Teeth
- thumb sucking less likely to occur in breastfed toddlers
- increased duration of breastfeeding improves dental arch
Bones
- calcium requirements met from human milk
Weight
- leaner bodies with less risk of obesity
Limbs
- human milk good painkiller for bruises and bumps
Skin
- smoother and more supple
Hydration
- breastmilk helps keep hydration
Immune system
- antibodies in breastmilk provide protection
Portability
- easier to travel with (with regard to nursing vs carrying bottles)
Taste buds
- less likely to be fussy eaters
- taste buds stimulated by range of flavours in milk
Independence
- breastfeeding helps meet child’s dependancy needs; key to helping them achieve independence
- lets them do so at their own pace
Age related breast changes: pot menopause
- Due to decrease of estrogen and progesterone
- Glandular tissue replaced with fibrous connective tissue
- Fat (adipose tissue) atrophies
- Breast size and elasticity decrease
- Lumps may now be palpable
- Lactiferous duct fibrosis and calcification
- Importance in breast imaging; a young person’s tumour may be obscured due to density, easier to see in less dense (older) tissue
The male breast
- Rudimentary
- Thin disc of underdeveloped tissue underlying the nipple
- Gynecomastia; enlarged breast tissue in males
- Male breast cancer incidence is about 1%
- Males have milk ducts
- Men can produce milk; after extensive stimulation but quality of milk unknown
The 3 most common presenting symptoms of breast issues
- pain
- nipple discharge
- palpable breast lump
Subjective assessment of breasts
History of Present Illness
- Onset
- Chronology
- Current situation
- Location
- Radiation
- Quality
- Timing
Review of System
- Discharge from nipple
- Skin changes
- Pain or swelling
Associated symptoms
- Fever
- Chills
- Rigors
- Malaise
- Nausea
- Vomiting
Medical History
Personal and Social history
Family history
Objective assessment of breasts
General
- State of health,
- Appearance of comfort/distress,
- Colour (flushed, pale),
- Nutritional status
Vital signs
Inspection
Palpation
Subjective data: health history of breasts
PQRSTU-AAA all of the following:
- Discharge
- Lump
- Pain
- Rash
- Swelling
- Trauma
- History of breast disease
- Surgery
- Routine breast health
LACE: breast examination
1) Look
- looking at breast, nipples (retraction, eversion)
- any parts that are stuck down when moving arms
- client seated, breast exposed checking for: symmetry, skin changes, nipple changes, dimpling
2) Arm position
- want to assess while moving arms in different positions
- hands raised above head; check contour
- hands on hips; check for retraction
- breast dangling
3) Check lymph nodes
4) Examine breast tissue
Objective data: inspection
General appearance
- Contour, symmetry
- Masses or fixation
- Dimpling/depression, peau d’orange
- Skin colour, edema, venous pattern
- Lymphatic drainage areas
Nipples
- Size
- Shape
- Direction, inversion
- Scaling, crusting or ulcerations
- Discharge
- Supernumerary
Supernumerary nipples
- A common, minor birth defect
- Consists of an extra nipple (and/or related tissue ) in addition to the two nipples that normally appear on the chest
- Most supernumerary nipples do not cause symptoms or complications
- They often are small and go undetected
Inspect and palpating the axillae: breast examination
- Can be sitting for lymph node assessment but should be supine for rest of assessment
- Want to asses up into the armpit for pumps, bumps, masses, skin changes, etc.
Palpating the breasts
- Different patterns; concentric circles, up and down, in to out
Looking at
- Consistency
- Elasticity of tissues
- Tenderness
- Thickening
- Lumps or masses
Describing and documenting a mass in the breast
Location
- Drawing and narrative
- Side (left/right)
- Clock face location
- Distance from areolar edge
Size
- 2 measurements in 2 dimensions
Shape
- Round
- Oval
- Irregular
Consistency
- Soft
- Firm
- Rubbery
Margins
- Well-defined
- Ill-defined
- Fixed or Movable
- Nipple
- Skin over the lump
Tenderness
- Tender or non-tender
Lymphadenopathy
- Disease of the lymph nodes
- They are abnormal in size or consistency
Breast cancer
- Overgrowth of the cells in the breast
- Likely age: 30-80 years
- Irreg, star-shaped
- Hard, dense, fixed
- Often painless
- Grows constantly
- Most common location: upper outer quadrant
- Late stage: dimpling, nipple retraction/ discharge
Breast cancer and pregnancy
- Breast cancer is the most common cancer diagnosis in pregnancy
- Occurs in 1/3000 women
Ductal carcinoma vs invasive ductal carcinoma
- Ductal carcinoma is the most common form of breast cancer
- Ductual carcinoma In situ (DCIS) has not spread out of the mammary ducts; may be a precursor to IDC
- Invasive ductal carcinoma (IDC) breaks out of the ductal walls and into the surrounding tissue; from there it can penetrate into blood vessels or lymph vessels and spread to other organs and tissues
Paget’s disease
- Rare type of cancer
- Involving the skin of the nipple and areola
- Red flag: clustering and ulcers
- Can occur in men, most common in women
Treatment of breast cancer in pregnancy
Modified radical mastectomy: 1st trimester-3rd trimester
Breast conserving surgery or total mastectomy and set lymph node dissection or axillary lymph node dissection: 2nd trimester-3rd trimester
Chemotherapy: 2nd trimester-postpartum
Radiotherapy: postpartum
Endocrine Tx: postpartum
Breast cancer non-modifiable risk factors
- F, age 50-69
- PHx or FHx breast Ca
- Dense breasts
- BRCA gene mutation
- Ashkenazi Jewish ancestry
- Prev breast bx w atyp hyperplasia
- Prev breast irradiation
- Menarche age 55 (longer exposure to estrogen over lifetime)
- Tall adult height
Breast cancer modifiable risk factors
- Nulliparity or first child >age 30 - Hormonal contraceptive use/HRT (hormone replacement therapy, usually the estrogen and progesterone combines for hormones)
- Postmenopausal hormone therapy (esp EP)
- Not breastfeeding
- EtOH of ≥1 drink daily
- Obesity
- High socioeconomic status
Breast cancer possible risk factors
- Some association, not a causal effect
- Physical inactivity
- Adult weight gain
- Smoking and second-hand smoke exposure
- High birth weight
- Night shift work
Breast cancer risk assessment tools
• A number of tools exist
- Some for general public
- Some for health professionals
• Health professional tools
- Gail Model
- Breast Cancer Risk Assessment Tool
- Tyrer-Cuzick Model – computer program
BRCA 1 & BRCA 2
- Tumour suppressor gene
- Mutation lead to increased risk for cancer
- BRCA; breast cancer tumour suppressor gene; we all have it
- It’s people who have the mutation of this gene who are more likely to have breast cancer
- Not a guarantee that they will get cancer but at a higher risk
- Screening more frequently
- Recommended ovaries be removed by 35; breasts removed by 40ish
- Embryos can be tested for gene mutation to ensure it’s not kept in family
Breast cancer in men
- 1% of all breast cancer cases occur in men
- men usually die faster with breast cancer because they don’t realize that can get it too
- usually shows up as a lump under or near the nipple
- signs include: misshaped breasts, non-matching breasts, and nipple discharge
- similarly treated; can get macestomy
OBSP: Be Breast Aware
- Know how your breasts normally look and feel so that you can recognize changes
- A lump or dimpling
- Changes in your nipple or fluid leaking from the nipple
- Skin changes or redness that does not go away
- Any other changes in your breasts
OBSP Breast Screening Guidelines
Routine
- Age 40-49: talk to healthcare provider
- Age 50-74: mammogram Q2Y
High risk
- Age 30-69: if high risk, yearly mammogram and breast MRI
OBSP: Screening for those at high risk
Eligible if no acute breast symptoms, are 30-69 years of age and meet of the the following risk criteria:
- Known to be carriers of a deleterious gene mutation (e.g. BRCA 1, BRCA 2)
- Are first degree relative of a mutation carrier, and have declines genetic testing
- Are determined to be at >25% lifetime risk of breast cancer (via IBIS or BOADICEA risk assessment tools, at a genetic clinic)
- Have received chest radiation treatment (not chest x-ray) before age 30 and at least 8 years previously
Canadian Task Force on Preventive Health Care (CTFPHC): recommendations concerning clinical breast exam and breast self exam
- The oppose the OBSP
- State that women not deemed high risk aged 40-74 should be routinely be performing exams
- Say the rate is not high enough to make a significant different
- What about for that one person?
- Use your own judgement in your clinical practice
BREAST Mnemonic
B: breast mass R: retraction E: edema (peau d'orange) A: axillary mass S: skin (scaly nipple, changes) T: tender breasts
Male genitalia structure and function
- External and internal anatomy
- External: penis, glands, urethra, foreskin, scrotum
- Scrotum size controlled by contastor muscle
- Internal: spermatic cord, epididmis, vast deferenes (vacestomy site)
Prostate gland
- Secretes thin milky akaline fluid that helps confirm viability
- Round, heart shaped
- 2.4-4cm diameter
- Grows over time but it always needs to be assessed beyond a certain age
Male genitalia and lymphatic drainage
- Penis and scrotum drain into the inguinal lymph nodes
- Testes drain into abdominal lymph nodes
Subjective assessment of male genitalia
History of Present Illness
- Onset
- Chronology
- Current situation
- Location
- Radiation
- Quality
- Timing
Review of System
- Discharge from penis
- Itching
- Lesions
- Genital pain
- Testicular pain
- Swelling
Associated symptoms
- Fever
- Chills
- Urinary symptoms
- Pain
Medical History
Personal and Social history
Family history
Objective assessment of male genitalia
General
- State of health
- Appearance of comfort/distress
- Colour (flushed, pale)
- Nutritional status
Vital signs
Inspection
Palpation
Subjective data: health history of male genitalia
- Urinary symptoms (frequency, urgency, nocturia, dysuria, hesitancy, straining)
- Past genitourinary history
- Penis; any pain or discharge
- Scrotum; any pain or swelling
- TSE (self care; timing, shower, exam)
- Hernias
- Sexual history
- History of STIs
Objective data: inspection and palpation of male genitalia
Skin
- Colour
- Lesions
- Swelling
Peins
- Glans for smoothness, lesions, discharge
- Urethral meatus for location, discharge
Inguinal lymph nodes
- Horizontal and vertical chains
Scrotum
- Testes firm, oval, smooth, movable, mildly tender
- Shouldn’t be an overt or fixed mass
Spermatic cord
- Palpate up to inguinal ring
Objective data: palpation of the scrotum
1) Cup one testicle at a time
2) Examine by rolling the testicle between your thumb and finger
3) Assess spermatic cord and epididimyis on back side of testes
4) Assess for irregularities between testicles
Describing masses in the testicles
- Size, contour, nodularity
- Tenderness
- Proximal / Distal to testis
- Does it reduce when supine
- Transillumination; use a flashlight to look at it, illuminate whether there is an actual mass there
Inspecting and palpating for hernias
- Inguinal region; stand and strain
- Palpate external inguinal ring
- Palpate in Femoral canal area
- If hernia present, you will feel it against your finger when you are pressing in
Palpating the prostate gland
- Press into gland
- Size: 2.5 - 4 cm
- Heart shape, palpable groove - Smooth
- Rubbery
- Slightly movable
- Non-tender; but exam itself can be uncomfortable
Regional lymphatics: inguinal
- Penis and scrotum drain into the inguinal lymph nodes
- Testes drain into the abdominal lymph nodes
Torsion
- Testicle twisted on itself
- Usually around the spermatic cord
Inguinal hernia
- Contents of abdominal cavity protruding into the scrotum
- Can be uncomfortable
Varicocele
- Gross dilation of the veins draining into the testes
- Left testicle more commonly affected
- Feels like “a bag of worms”
Epididymitis
- Inflammation of the coiled tube (epididmyis) at the back of the testicle that stores and carries sperm
- Treated with antibotics
Age related male genital changes: children
Infant
- Testes descend along inguinal canal to scrotum before birth
- When testes have not descended; called cryptorchidism
- Associated with infertility and lower sperm parameters
- Important to ask about during assessment
- Uncircumcised/circumcised (choice)
Adolescent
- Tanner Staging
Tanner staging: sexual maturity rating in boys
- The brain determines when puberty starts; usually around age 11 for boys
- Pituitary gland releases LH and PSH
- Affects the respective sex glands
- Testes secrete testosterone (they grow in size)
- Penis grows at age 12
- Followed by growth spurt
Age related male genital changes: aging
- No definite end to fertility; spermatogenesis decreased over time with aging
- Amount of pubic hair decreases
- Penis size decreases; and scrotum can becomes more penedulant over time
- Testes decrease in size, less firm
- Slower less intense sexual response; erection takes longer, ejaculation less forceful, less seminal volume
Testicular cancer risk factors
- Incidence highest 15-49 y
- Undescended testicles (late correction)
- Family history
Early symptoms of testicular cancer
- Lump or swelling +/- pain
- ‘Heaviness’ abdomen/ scrotum
TSE self exam of testicles
T: timing
S: shower
E: examine changes
- Self exam for testicular cancer
- Examine entire scrotal content for any changes
- Encouraged to asses consistently and same pattern each time
- Monthly ideal
- Any changes should be reported to HCP
Risk factors of prostate cancer
- Age>65
- Family history of prostate Ca
- African ancestry
- Diet high in fat
Signs and symptoms of prostate cancer
- Urinary symptoms; because prostate can block the urethra if enlarged due to tumour
- Frequency, nocturia, hesitiancy, incomplete emptying, pain
- Painful ejaculation
Subjective assessment of female genitalia
History of Present Illness
- Onset
- Chronology
- Current situation
- Location
- Radiation
- Quality
- Timing
Review of System
- Discharge
- Skin changes
- Irritation
- Bleeding
- Pain
- Swelling
Associated symptoms
- Fever
- Urinary symptoms
- Pain (abdominal, back, flank)
- Constipation
Medical History
Personal and Social history
Family history
Objective assessment of female genitalia
General
- State of health
- Appearance of comfort/distress
- Colour (flushed, pale)
- Nutritional status
Vital signs
Inspection
Palpation
External genitalia: vulva
- Internal and external anatomy
- External: vulva
- Labia majoria (rounded folds of tissue that extends from the mons pubis to the perineum)
- Labia minora (inside the labia majoria, darker folds of skin)
When we are looking at the vulva, we are looking for:
- Skin changes
- Notible discharge
- Swelling of glands (Barlolin’s gland)
- Skene’s gland doesn’t usually swell (found underneath clitoral hood)
Internal genitalia: vagina
- Just the inside part
- Lots of people confuse the vulva for vagina and call the overall thing vagina
Subjective data: health history for female genitalia
- Menstrual history
- Obstetric history
- Menopause
- Urinary symptoms
- Vaginal discharge
- GU history (surgery, treatments)
- Sexual activity
- Contraceptive use (still ovulating if exposed to sperm need to consider)
- STI contact
- STI risk reduction
Objective data: physical exam of female genitalia
- Lithotomy position; easiest position to do a pap smear
- Maintain respect; be careful you aren’t triggering people as you speak to them
- Communicate; give them an out, they don’t need to do it that day; let them be a feel ready
- Involve them in the process
Objective data: inspection and palpation of female genitalia
External Genitalia
- Skin colour, hair distribution
- Pubic area for colour, irritation
- Labia, clitoris, urethral opening and vaginal opening for colour, lesions, masses, discharge
- Perineum for colour, lesions, masses, scars (episiotomy)
Palpation of the female genitalia
- Pubic area; mass, tender
- Labia; mass, tender
- Skene’s glands; swelling discharge, pain
- Bartholin’s glands; swelling, discharge, pain
Pelvic Musculature:
- Perineum
- Tone of vaginal opening
- Vaginal wall for bulging, prolapse, urinary incontinence
Speculum exams
- Proper size speculum
- Options and explain to them why you’re using the speculum that you ate
Normal variations of the cervix
- There are many variations of normal
- Nulliparous; never has pregnancy or delivery
- Parous; after childbirth
- Unilateral transverse
- Bilateral transverse
- Stellate
- Cervical eversion; sometimes seen on patient who has been on hormonal birth control for a long time
- Nabothian cysts; yellow cysts present on cervix, normal variation
Bimanual exam
- Both hands; one on top to feel uterus/ovaries and other hand in vagina
- Is it ever necessary?
Looking at:
1) Cervix
- Consistency
- Contour
- Mobility
2) Uterus
- Position
3) Adnexa
- Fallopian area; fullness, tenderness, masses
Uterine position
- Variety of normal
- Anteverted
- Midposition
- Anteflexed
- Retroflexed
- Retroverted; not a risk factor for infertility, but can cause painful vaginal-penile sex
Contraceptive options
- Approaching it; how effective do you need it be be and how often do you have to think about it
- Also think about what their drug plan can afford
Age related female genital changes: children
Infant
- Engorgement of external genitalia; due to maternal or parental providing estrogen
Adolescent
- Tanner Staging
- Boobs, pubes, grow, flow
Age related female genital changes: pregnancy
- Paps are safe in pregnancy; wouldn’t use the broom though, find the right tool for the test that’s right for them
- Goodell’s sign; cervix softens at 4-6 weeks pregnant
- Chadwick’s sign; vaginal mucosa and cervix looks a but cynaotic (blue) at 8-12 weeks
- Hegar’s sign; istmus of uterus softens at 6-8 weeks
- Uterus increases in size and capacity; 500-1000x it’s non-pregnant state
Age related female genital changes: aging
- Menses – irreg then cease; perimenupasual, can be unpredictable or irratic
- Uterus and cervix shrink
- Ovaries atrophy
- Ovulation becomes sporadic
- Pelvic musculature weakens; sacral ligaments relax, potential for prolapse
- Vagina shortens, narrows, epithelium atrophies; sexual activity can become uncomfortable due to lack of estrogen
Risk factors for cervical cancer
- Sexual intercourse at an early age; cervix still maturing and more susceptible
- Multiple sexual partners; potential for for HPV exposure
- History of STIs
- Increasing age; as we age, can’t fight off HPV as well
- Compromised immunity (e.g. HIV)
- Infection with HPV
- Smoking; increases risk of not clearing HPV from our system
- Low socioeconomic status; due to not screening as often? Screened too late?
Ontario Cervical Screening Program
- Found that a lot of people can clear HPV on their own
- Screening starts at 21 if you are sexually active
- Includes digital, oral sexual activity with partner of any sex
- Screen Q3Yr unless abnormal reading
- Until age 70; not high rate after that
Risk factors of ovarian cancer
- Age >50
- Personal history of Ca (breast, uterine or colorectal)
- Family history of ovarian Ca or breast cancer (esp 1 degree, BRCA1 or BRCA2 genes) and a family hx of colon, uterine or pancreatic cancer
- Nulliparous
- Fx of ovarian cancer
- BRCA gene mutation
- Lynch syndrome; gene mutation that exposed people to colorectal and uterine cancer
- Never being pregnant
- Px history of breast cancer
- Fx of certain cancers
- Ashkenazi Jewish ancestry
- Hormone replacement therapy
- Smoking
- Asbestos
Possible risk factors of ovarian cancer
- Obesity
- Using talc on genitals
- Endometriosis
- Tall adult height
