Contraception + Breasts Flashcards
1
Q
What are the four most effective contraception methods (TIER 1)
A
- IUD
- Implants
- Vasectomy/Tubal ligation
2
Q
What are tier 2 methods
A
- Pills
- Patches
- Vaginal rings
- Hormonal injections
3
Q
What are tier 3 methods
A
- Condoms (only protection against STIs)
- Diaphragms
- Spermicides
- Sponges
- Periodic abstinences
4
Q
What are the two types of IUDs
A
Hormonal:
Levonorgestrel
Non-Hormonal:
Copper
5
Q
In which population are IUDs recommended for
A
Adolescents and young women who want long-term contraceptives + avoiding oestrogen exposure that could cause TE (smoking)
6
Q
Contraindications for IUDs
A
- Known or suspected pregancny
- Uterine bleeding
- Pelvic infection
- Abnormalities of uterine cavity (fibroids and congenital defects)
Hormonal:
- Liver disease (as hormones are metabolised by liver)
- Breast Cancer (hormonal iud can worsen cancer or increase recurrence)
Copper:
Wilson’s disease or allergies
7
Q
How long does a hormonal IUD last for
A
5 Years
8
Q
How does levonorgestrel work
A
Inhibits LH secretion from pituitary glands - inhibits ovulation
- thickens cervical mucous
- thin endometrial lining.
This causes amenorhhoea
Benefits: Can lessen pain and blood loss during menstruation. Help with endometriosis
9
Q
Side effects of hormonal IUD
A
- Headaches
- Nausea
- Weight gain
- Mood swings
- Breast tenderness
- Acne
10
Q
How long does copper IUD last
A
10 Years
11
Q
When should hormonal IUDs be given (menstrual cycle)
A
- days 1-5. to give immediate contraceptive effect
12
Q
If Hormonal iud is given after day 5, what should be done to minimise risk of preganncy
A
- Back up contraception (condoms) for 7 days.
13
Q
When shoudl copper IUDs be given (menstrual cycle)
A
ANY DAY - effect is immediate.
14
Q
Side effect of IUD insertion
A
Unexpected bleeding or spotting but goes away with time
15
Q
When should IUDs be taken out
A
Can be anytime when pregnancy is desired
HOWEVER,
must use barrier contraception for 1 menstrual cycle after removal to allow endometrium to regenerate normally.
16
Q
What is the contraceptive implant made of
A
Ethylene Vinyl Acetate.
- 68mg Etonogestrel
17
Q
Where is the implant placed
A
Inner side of upper arm, slowly releases etonogestrel into circulation
18
Q
How long does the implant provide contraception for
A
3 years
19
Q
Contraindications of implants
A
- known or suspecte dpregancny
- Liver disease
- Breast cancer
20
Q
How should contraceptive implant be given
A
Inserted by clinician under anesthesia
21
Q
When should impant be given
A
Day 1-5
If after, barrier contraceptives for 7 days.
22
Q
Side effects for implant
A
- Unpredictable menstrual bleeding pattern
- Headaches
- Bloating
- Weight gain
- Acne
- Breast tenderness
23
Q
After removal of implant, how long does it take for ovulation to start again
A
1 month
If contraception is to be continued, can be delivered through same arm or other.
24
Q
What sturcture is occluded in vasectomy
A
Vas Deferens
EFFECT IS NOT IMMEDIATE
25
Contraindicatinons to vasectomy
- Scrotal haematoma
2. GU infections
Must be resolved
26
How long should people with vasectomy's be on barrier contraception for
3 Months, then semen analysis.
Person must have ejaculated 20 times for a valid result (confirmed by azoospermia).
27
What is tubal ligation involve
1. Clips, rubber bands, sutures or cauterisations used to clamp down fallopian tubes
2. OR removal of tubes
28
When is tubal ligation often done
1. Postpartum setting, following birth.
| 2. If unrelated to childbirth - called interval proceedure.
29
Risks with tubal ligation
Ectopic preganncy
30
Two types of hormone contraceptives
1. Oestrogen and progestin (COCP, patches and rings)
| 2. ONLY progestin (injections and pill).
31
How does a combined contraception work
1. Inhibits GnRH hypothalamic
2. Inhibits pituitary FSH and LH.
The higher the dose of oestrogen, the more inhibition - ovarian follicles do not develop and ovulation does not take place.
* Thins endometrial lining
* thickens cervical mucus
32
Non contraceptive benefits for combined contraception
1. Controls menstrual bleeding, pelvic pain, ovarian cysts and PCOS symptoms (hypernadrogenism)
HRT in turner's and slow premature ovarian failure.
33
Contraindications to oestrogen
1. DVT
2. CV events
3. Diabeted, HTN, CAD
Highest risk in over 35, smokers, excess oestrogen (PCOS, medications)
34
Contraindications to progestin
1. Current breast cancer
| 2. Liver disease
35
What medications reduce the contraceptive efficiency of oestrogen and progesterone tablets
1. Antibiotics
2. Anti seizure medications
3. HIV protease inhibitors
4. St John's wart
36
What oestrogen is used in the combined pill
Ethinyl Estradiol
37
What progestins are used in combined pill
Norethindrone and levonorgestrel
Drospirenone and Dienogest (antiandrogenic)
38
Where do norethindrone and levonorgestrel derive from
Testosterone so can alter lipid profiles (lower HDL levels)
So must be monitored regularly
39
When are Drospirenone and dienogest recommended
Hyperandrogenism (pcos)
40
In what amounts can pills be delivered
1. Monophasic (same amount each pill)
2. Multiphasic (different amounts each pill)
Disadvantage of 2 is that they require adherence to the order
41
What should be done before starting COCP
1. Urine pregnancy test
2. Finding the first day of last menstrual period (less than 7 days ago, can be started immediately with barrier contraception)
>7 days, protected sex can be started immediately with barrier
unprotected (<5 days ago) requires emergency contraception, start pills the same day.
unprotected (>5 days ago) requires pregnancy test in 2 weeks and pills started same day.
42
Two start dates for cocp
1. Quick start (> 5 days into menstrual cycle with back up contraception)
2. First sunday (barrier)
3. First day of menstruation (immediate effect, no barrier).
43
How are contraceptives taken (regimen)
21/7 (hormone pills for 21 days, placebo pills for 7 where menstruation happens)
24/4
44
When are placebo periods skipped
Extended Use (7 days of placebo pills after 3 months), or continuous (hormones every day).
* PMDD
* Endometriosis
* Hyperandrogenism
* Premature Ovarian Failure
45
What if you miss a pill (<48 hours)
Take missed pill as soon as remembered with the extra pill - continue as normal
46
What is you miss a pill (>48 hours)
1. Only take most recent missed pill, take rest as usual.
| 2. Barrier until 7 consecutive pills have been taken
47
What if you miss a pill in last week of cycle (15-21)
1. Skip placebo interval and go into another pack
| 2. Barrier contraception until 7 consec plls taken
48
Side effects of COCP
1. Irregular bleeding
2. Nausea
3. Headaches
4. Breast Tenderness
Resolve over time
49
Dangerous complications of cocp
1. DVT
2. PE
3. Strokes
50
HOw often do transdermal patches need to be replaced
Every week for 3 weeks
51
How often do vaginal reings need replacing
1. Kept in for three weeks taken out for fourth week for menstruation
Then replaced
52
Risks with patches and rings
Can slip
But fertility returns quickly
53
Two methods of deliverying progestin only contraceptives
1. Injection
| 2. Pills
54
How do progestin only tablets work
1. Inhibit ovulation
2. Thicken cervical mucus
3. Thin endometrial lining
55
What progestin is used in Progestin injections
1. Depo Medroxyprogesterone acetate
56
How are injections given
IM or SC
57
How long do injections provide contraception for
12 weeks
58
Side effects of injection
1. Amenorrhoea
2. Unpredictable bleeding
3. Headache
4. Abdo pain
5. Decreased libido
6. Decrease in bone mineral density but recovers after stopping injetcions
59
Contraindications of injections
1. Long term corticosteroid use (BMD)
60
How long does it take for fertility to return after injections
1 year
61
What are contained in progesterone only pills
0.35 mg of Norethindrone
62
POP vs COCP
No pill free day (all 28 days are hormonal)
Take same hour daily
63
Side effects of POP
1. Irreular bleeding
2. Headaches
3. Mood swings
4. Breast tenderness
64
Advantage of POP
Fertility comes back after one cycle.
65
What are diaphragms made of
Silicone
66
What do diaphragms cover
The cervix. Should be filled with spermicide gel for extra protection.
67
What do spermicides contain
Nonoxynol-9 - impaires sperm motility
68
When shoudl diaphragms and cervical caps be inserted
3 hours before intercourse, if inserted earlier, add more spermicides.
Should be kept in for 6 hours after intercourse.
69
Contraindications for driaphragms and cervical caps
During menstruation - can cause toxic shock syndrome
70
What are sponges
1. Foam discs with spermicides and must be moistuned with water.
71
How should sponges be applied
1. Add water
| 2. Insert less than 24 hours ahead of intercourse and keep for 6 hours afterwards.
72
Side effects of sponges
1. Vaginal dryness and irritation
73
How should spermicides be applied
1. Placed in vagina <10 mins before intercourse.
74
Side effects of spermicides
1. Local irritation ofpenis and vagina (increase HIV infection)
75
Lowest contraception method
1. Fertility based awareness and withdrawal.
76
What is fertility based awareness
1. Sperm viable for less than 5 days
2. Egg viable for less than 24 hours
Max 6 fertile days
Abstain during fertile window or barrier.
77
When does ovulation begin
14 days before menses.
78
Contraindications of PBA
1. Not used in >32 days or <26 day windows (PCOS, irregualr cycles, breast feeding females).
79
What is emergency contraception
1. Copper IUD <5 days after unprotected intercourse or 5 days within likely ovulation date.
80
What is the morning after pill
1. Lovorgestrel (<72 hours) - 1.5mg
| 2. Ulipristal (30 mg) taken up to 5 days after intercourse.
81
SIDE EFFECT OF VOMITING IS PRESENT IN 1% OF ALL LEVORGESTREL USERS (EMERGENCY), WHAT SHOULD BE DONE IF THIS IS REPORTED
1. Vomiting occurs within 3 hours, repeat the dose.
82
When is ulipristal contraindicated
If patient is on oral pills containing levonorgestrel
83
Warning in pregnant women using ulipristal
Delay breast feeding for one week (not needed with levonorgestrel).
84
Whens should levonorgestestrel dose be doubled
1. BMI > 26
85
In which contraception is a history of severe asthma contraindictaed
Ullipristol
86
How long is barrier contraception needed in POP
Only 48 hours
87
Mode of action for COCP
1. Inhibits ovulation
88
Mode of action of POP
Thickens cervical mucous
89
Mod of action of desogestrel only pill
Inhibits ovulation
90
Primary mode of action of inauterine devices
Decreases sperm utility and survival
91
If the patch is delayed at the end of week 1 or 2, what should be done
<48 Hours: changed immediately no other precuations
>48 Hours: Changed immediately, barrier protection
If woman has had UPSI in last 5 days, emergency contraception
92
If the patch is delayed at the end of week 3
1. Patch should be removed as soon as possible, and the new patch applied on the usual cycle start day for the next cycle, no additional contraception
93
If the patch is delayed at the end of a patch free week, what should be done
Additional contraception should be used fro 7 days
94
If a woman misses her 3-hour window for desogestrel, what should be done
For POP, it is actually a 12-hour window, so she can take the pill with no needed further action
95
What is COCP protective against
Ovarian and endometrial cancer
96
What cancers does COCP increase
Breast and cervical
97
If a woman is postmenopausal but under 50, should contraceptives be gven
Yes, current advice is that anyone under 50 should have contraception.
98
When is the injectable Progertone only not recommended
Women after the age of 50 as it reduces BMD
99
If two or more COCP pills are missed in week 1, what should be done
Emergency contraception
100
If two or more COCP pills are missed in week 2, what should be done
Continue as normal, as long as they have taken sevenconsecutive pills
101
If two or more COCP pills are missed in week 3, what should be done
Finish pack, start a new pack and miss out interval
102
What fascia form the breast tissue
2/3 - pectoral fascia
1/3 - Fascia covering serrates anterior
103
What is the retromammary space
The junction between the breast and the pectorals major (separated by the.pectoral fascia
104
Function of the retromammary space
Allows the breast to move a bit on the pectoral fascia
105
Anatomy of the mammary secretion system
Mammary glands have lobules. At the end of each lobule we have alveoli with mammary secretory epithelial cells.
106
How are all the lobules in the mammary gland connected
Lactiferous ducts, these join together from each mammary gland at the areola
107
What is the lactiferous sinus
It is a tunnel at the end of the lactiferous duct where milk accunmulates (think like a hand pump - similar action)
108
What is contained in the storm of breast tissue
Adipose tissue and fibrous connective tissue
109
What are the suspensory ligaments of Cooper
Formed by fibrous connective tissues to attach mammary glands to the dermis (support)
110
Anatomical location of the nipple
Along the 4th rib and lateral to the midclavicular line
111
Blood supply of the breast
Medial Mammary branches from the internal thoracic which branches from the subclavian
Lateral thoracic artery
Thoracoacromial artery off the axillary artery
Posterior intercostal off the axillary artery
112
Venous drainage of the breast
Axillary vein
113
Lymphatic drainage of the breast
All structures connect to the subareolar lymphatic plexus.
Drains into the anterior nodes then into the axillary lymph nodes.
Other lymph drainage goes through the parasternal nodes or sometimes even to the opposite breast.
114
Nerve supply of the breast
1. Lateral and anterior cuteaneous branches of the 4th to 6th intercostal nerves.
2. These move through the pectoral fascia to supply the breast
115
Onset for breast cancer
Typically postmenopausal women (>50)
116
Most common form of breast cancer
Adenocarcinomas from the. terminal duct lobular units
117
Most common location for a breast mass
Upper lateral quadrant of the breast
118
What genetic over expression can lead to breast cancer
Oestrogen receptors
Progesterone Receptors
HER2 receptors (most aggressive)
119
What is the clinical significance for oestrogen and progesterone receptor caused breast cancer
More susceptible to anti oestrogen medications (tamoxifen)
120
What gene causes HER2 receptor overexpression
erbB2
121
In what other cancers are HER2 receptors overexpressed
Ovaries
Lungs
Stomache
Oral adenocarcniomas
122
Role of HER2
Facilitates epithelial growth and differentiation by accelerating tyrosine kinase activity
123
Treatment for HER2 receptor cancers
Anti-HER2 monoclonal antibodies - trastuzumab
124
Most aggressive form of breast cancer
Osterogen negative, progesterone negative and HER2 negative - triple negative
125
Where do breast cancers first metastasise to
Axillary lymph nodes
126
Common sites for breast metastases
Lungs
Bone
Liver
127
RF for breast cancer
1. Age
2. Family History (strongest risk factor) of breast, ovarian cancer (BRCA1 and BRCA2)
3. Increased oestrogen exposure (nulliparity, early menarche, late menopause and late first pregnancy)
4. Alcohol
5. No breast feeding
6. Obesity after menopause
8. Caucasians
128
What factor increases the risk of breast cancer in YOUNG women
Multiple people in immediate family with premenopausal breast cancer
129
Role of BRCA1 and BRCA2 genes
Tumour supressors to control cell cycle, they are 70% more likely to have breast cancer!
130
What ethnicity is at the highest risk of developing triple negative breast cancer
African descent
131
How often are breast cancer screens and who are they offered to
Women 50 to 70 every 3 years
Yearly mammogram screens to women with previous breast cancer for 5 years
132
Diagnosis for breast cancer
Mammography
| Needle Biopsy - GOLD
133
Surgery of Breast Cancer
Sugery:
Radical Mastectomy
Breast-Conserving: Removal of cancerous breast tissue only
Chemotherapy:
Trastuzumab for HER-2 positive invasive cancers
134
Complications of trastuzumab
Cardiovascular issues
135
Treatment of HER-2 cancer
Trastuzumab
136
Treatment for Oestrogen receptor positive invasive breast cancers
Aromatase Inhibitors (anastrozole) or Ovarian Function suppressions
137
Pharmacology of tamoxifen
Oestrogen modulator, competes with estradiol at receptor site and blocks them off
138
What are non-invasive breast cancers
Cancers that have not crossed the basement membrane of the ducts and stay in the breasts
139
Name three non invasive breast cancers
1. Ductal Carcinoma in situ
Paget Disease of the Brerast
Lobular Carcnioma in situ
140
What is ductal carcinoma in situ
Where neoplastic epithelial cells form a mass growing INTO the terminal duct lobular unit
Usually only affects one ductal system
141
Two subtypes of SCIS
1. Comedo and Non-Comedo
142
What are comedocarcinomas of the breast
High grade malignant cells under go central necrosis and then calcify
This causes chronic inflammation and periductal concentric fibrosis. Eventually this can penetrate basement membranes
As they do not penetrate, comedocarcinomas do not produce a MASS LESION unless invaded.
143
Three types of non-comedo DCIS
No central necrosis
Pappillary (finger liike projections into the ducts)
Cribriform (gaps between the malignant cells)
SOlid (no gaps and fingers, completely full duct
144
What is Paget disease of the breast
Ductal carcinomas spread through the lactiferous ducts to the nipple and areola
145
Clinical Features of pagets
Because of spread to the areola and nipple, eczematous skin lesions or persistent dermatitis
146
Diagnosis fo pagets
Biopsy and Mammography to check for underlying breast cancer
147
What would be seen under a microscope for pagest
Intraepitehlial adenocarcinomas in the lactiferous ducts
148
Treatment of pagets
Tamoxifen
149
Why are lobular carcinomas in situ found incidentally
Not associated with normal presentation of breast cancers (no palpable lesions) and sometimes can be found in both breasts
150
Where can breast masses invade
Pectoral muscles and deep fascia
Infiltration to surrounding structures near the nipple causes retraction (inversion)(
151
What structure causes skin dimpling in breast cancer
Invasion into the suspensory Cooper ligaments
152
Clinical features of breast cancer
Peu d'orange finding
153
Four types of invasive breast cancer
1. Invasive ductal, invasive lobular, medullary and inflammatory
154
Two histological presentations of invasive ductal carcinomas
Tubular (well differentiated tubular structures) or mutinous (lots of extracellular mucin) - more common in older women
155
Differentiating symptoms of lobular breast carcnioma
OFTEN BILATERAL WITH MULTIPLE LESIONS
and has low E-Cadherin expressions
Cancer cells arranges into strands on histology and there are no duct formations
156
What is dangerous about medullary carcniomas
They are well circumscribed so they mimic benign lesions of the breast (fibroadenoma)
157
RF for medullary carcnioma
Younger women
BRCA1
Triple negative phenotype
158
Histolgy for medullary carcnioma
Cells Grow in sheets
159
What can inflammatory breast carcnioma be mistaken for
Mastitis or Paget's diseases due to erythema and paeu d'orange appearance
No palpable mass
160
Indications for annual mammography under the age of 50
Atypical duct hyperplasia
Lobular carcinoma in situ
Follow up for previous breast cancer
161
Contraindications to mammography
1. Breast pain but no lump
2. Symmetrical thickening
3. Before HRT
4. Women under 40 (usually stick to ultrasound)
162
Indications for MRI scanning
1. Between 30 and 50 with a high risk family history of BRCA1 or 2
2. 20-70 years of age if li fraumeni tp53 mutation carrier)
163
What does P1 - 5 mean
1. Normal
2. Benign
3. Indeterminate
4. Suspicious
5. Malignant
164
What is the FNAC score for cancers
1. Insufficient
2. benign
3. Atypical, possibly benign
4. Atypical, probably malignant
5. Malignant
165
What is the core biopsy score
1. Insufficient
2. Benign
3. Atypical, probably benign
4. Atypical, probably malignant
5. Malignant, in situ
6. Malignant, invasive
166
What is a triple assessment
1. Clinical
2. Radiological (US/MMG)
3. Pathological (FNA, core biopsy)
167
What scoring system is used for breast cancer prognostics
Nottingham Prognostic Index
168
First line treatment of Oestrogen-receptor breast cancer in premenopausal women
Tamoxifen
169
First line treatment of oestrogen positive breast cancer in post menopausal women
Anastrozole (need to have SEXA scans every 2 years)
170
Role of bisphosphonates in breast cancer
Reduces bone metastases
171
From what part of the body is skin and fat taken from for breast reconstruction
Lattisimus Dorsi
172
What is duct erctasia
Milk duct in the breast widens and walls thicken causing it to block and fluid build up
173
What are papillomas
Single tumours that grow in the common milk duct straight behind the nipple (felt as a mass pretty much next to. the nipple)
174
What conditions is a bloody nipple discharge commonly seen in
Paget's, Duct erctasia and papillomas
175
First line treatment for lactational breast infection
Flucloxacillin
176
In what women are fibroadenomas common
<35
177
What is Li Fraumeni syndrome
TP53 mutation, needed for tumour suppression. Quite general and causes many differnet types of cancers including breast cancer.
178
A woman smokes heavily and gets recurrent episodes of infection in her right breast with induration, what condition is most associated with smokers
Periductal mastitis
179
What should be done with women with no palpable axillary lymphadenopathy at presentation
Pre operative axillary uSS
If positive = sentinel node biopsy
180
What indicates a mastectomy over a local excision
1. Multifocal tumour
2. Central tumour (not peripheral, so not as easy to take out)
3. Large lesion
4. DCIS < 4cm
181
When is a radiotherapy offered in breast cancer
T3-T4 tumours or four or more positive axillary nodes
182
What adjuvant hormonal therapy is used for pre and perimenopausal women
Tamoxifen
183
In post menopausal women, what adjuvant therapy is used
Anastrozole
184
What chemotherapy is used for breast cancer
FEC-D
185
What disease produces a halo sign on a mammogram
Breast cysts
186
After initial excision surgery, what is the recommended course of treatment to prevent recurrence
Whole breast radiotherapy
187
What is the colour of discharge in mammary duct ectasia
Green
188
When is a fibroadenoma eligible for excision
>3cm
189
Diagnosis of Paget's disease of the nipple
Punch Biopsy
190
What is the likelihood of someone's daughter and son receiving the BRCA1 gene if one parent is positive
50%
191
What is the first line management for any breast cnacer
Surgery
192
What endocrine therapy can be used in elderly patients who want non invasive management of breast cnacer
Letrozole therapy
193
Onset of duct ectasia
Menopause.
194
What does a snowstorm sign in a USS axillary lymph node indicate
Implant rupture.
195
What is the most common gynaecological cancer in the UK
Endometrial!
196
When can the POP be started in pregnant, breastfeeding women
Immediately
197
When can COCP be taken in breastfeeding women
After 6 weeks
Or, if not breastfeeding, after 3 weeks.
198
When should Mastitis be treated with flucoxacillin
Infective/ Systemic symptoms
199
What BP is an absolute contraindication to COCP
160/95
200
What age is considered an absolute contraindication to COCP
35 AND smoking 15 a day or more
201
What contraceptive should be given if a patient is taking enzyme inducing drugs
Depo-Provera
OR
Copper IUD
Rifampicin
Anti-epileptics
Phenytoin
Barbiturates
Topiramate
Lamotrigine
202
What medications are contraindicated with COCP
Anti-epileptics: Carbamazepine, Phenytoin and other epileptic drugs
203
LGV vs Syphilis
LGV has an unindurated lesion vs indurated lesion
Both painless
LGV has tender, inguinal lymph nodes
Syphilis has non-tender, inguinal lymph nodes
204
What is the GOLD STANDARD for testing for HSV
NAAT not PCR
205
If a smear displays 5 or more polymorphs per high power field, what empirical treatment is given before diagnosis can be confirmed
Doxycycline
206
Under what HIV load can a normal vaginal delivery be recommended
Under 50
207
What should the baby be given if th emoter has a viral load of <50
PEP
>50: cART
208
Treatment of LGV
Doxycycline
209
GOLD Standrad diagnostic for trichomoniasis
High vaginal swab from the posterior fornix
210
Differential for mastitis
Breast Abscess, if not improving on flucloxacillin, suspect an abscess as they both have systemic features.
211
First line investigation for women under 40 years old
USS, not a mammogram.
Because a mammogram is not as sensitive under 35 years of age.
212
What scan is used to check for metastasis
PET scan
213
What is fibroadenosis
Painful, lumpy breast that becomes worse around menstruation
214
What neoadjuvant chemotherapy is used for Breast Disease and when is it indicated
To downstage a tumour (e.g., axillary node metastasise), FEC-D
215
What blood test antigen can be used as a marker for breast cnacer
CA 15-3
216
How do we calculate the Nottingham Prognostic Index
Tumour size x 0.2 + Nodes + Grade
217
What is the prognosis of NPI > 5.0
50%
218
What two drugs cannot be used after the age of 50 for contraception
Depo-Provera
| COCP
