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MD3 > GP - Women's health > Flashcards

GP - Women's health Flashcards

1
Q

Risk factors for breast cancer

A

Increasing age
Female (significantly higher risk than men)
Early age of menarche and late age of menopause
OCP - risk returns to normal after 10 years of cessation
Prolonged HRT
Family hx
Previous BCa (increased risk of contralateral BCa)
Overweight/obesity
Increased alcohol consumption

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2
Q

Protective factors for breast cancer

A

Parity and childbirth
Breast feeding - at least 12 months total
Younger age of first parity (esp.

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3
Q

Key features of malignancy vs. cyst on U/S

A

Malignancy - poorly circumscribed hypoechoic lesion with posterior acoustic shadowing and taller than it is wide

Cyst - well circumscribed anechoic lesion with posterior acoustic enhancement and wider than that it is tall

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4
Q

Features suggestive that breast lump is malignant on examination

A

Larger, hard, irregular and fixed nodule
Breast distortion esp. on movement
Tethering of nipple or skin
Dimpling or peau d’orange
Bleeding, ulceration or fungation of lesion
Palpable axillary LNs
Non-tender
Nipple discharge and areola redness and bleeding
Asymmetrical nodularity

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5
Q

What are the main Rx options for breast cancer?

A
  1. Surgery - WLE + RTx or mastectomy
  2. Medical adjuvant Rx
    - Endocrine Rx - if ER/PR +
    - Chemo - if advanced disease, high risk of reoccurrence
    - Targeted Rx - if HER2 receptor +

Endocrine - Oestrogen receptor antagonist (Tamoxifen) pre- and post-menopausal women (5-10 yr course, increased risk of VTE, uterine Ca) or aromatase inhibitors (post-menopausal women only)

Targeted - Transtuzumab (Herceptin), 5 year course

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6
Q

What are the likely DDx of breast lump

A

Fibroadenoma (most common)

  • Well circumscribed, firm, mobile, non-tender lump
  • Smooth, rubbery
  • Hormone dependent - change with cycle
  • Requires core or excision biopsy

Fibrocystic changes

  • Usually symmetrical (bilateral), commonly upper outer quadrant
  • Tender, mobile
  • Varies with menstrual cycle
  • Nipple discharge - straw-like, brown or green
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7
Q

What is the diagnostic criteria for PCOS (Rotterdam criteria)?

A
  1. Irregular or absent ovulation (cycle 35 days)
  2. Clinical or biochemical evidence of hyperandrogegism (Raised Free testosterone or free androgen index, low SHBG, acne, hirsutism, alopecia)
  3. PCO seen on US (>12 antral follicles seen)
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8
Q

What are DDx for PCOS?

A 
Cushing's syndrome
Hypothyroidism 
Hyperprolactinaemia 
Late-onset CAH
Androgen secreting tumour
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9
Q

What are clinical features of PCOS?

A 
Acne 
Hirsutism
Weight gain
Alopecia 
Sub-fertility/infertility 
High rate of associated depression & anxiety 
Insulin resistance, 'pre-diabetes' 
HTN
Irregular menstrual cycle
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10
Q

What are important Rx issues to screen for/Rx in PCOS?

A 
Subfertility/infertility 
Depression, anxiety, eating disorders, body dysmorphia
Cardiometabolic risk 
Weight control
Cosmetic issues - acne, hirsutism
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11
Q

What are the key initial Ix in suspected PCOS?

A

Confirm diagnosis - U/S, free testosterone level, SHBG
Exclude DDx - TFT, prolactin
Risk factor ax - Lipid profile, glucose tolerance test

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12
Q

What are general Rx principles in PCOS?

A 
Menstrual regulation
Clinical hypoandrogenism symptoms 
Fertility 
Emotional health 
Cardiometabolic health 
Emotional health 
Lifestyle management

Managed in primary care but with endocrinology referral if complex or fertility specialist if >35 or ongoing issues after 6mths wt loss +/- metformin

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13
Q

How can menstrual regulation be Rx in PCOS?

A
  1. Lifestyle factors - weight loss 5-10% can restore ovulatory cycles
  2. Metformin - can improve cycles
  3. Contraception - COCP (+endometrial Ca protection as increased risk with amenorrhoea), progesterone only

Aim for >4 periods/year (unless on contraception)

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14
Q

How can hyperandrogenism in PCOS be Rx?

A

1st line - cosmetic options
2nd line - COCP - increases SHBG, decreasing testosterone
3rd line - antiandrogen (spirnolactone, finasteride)

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15
Q

What Ix for cardiometabolic risk should be performed in PCOS and how frequently?

A

2nd yearly - lipids, OGTT

Annual - BP, smoking status

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16
Q

How can fertility be Rx in PCOS?

A

Risk of infertility in PCOS increases >30 yo & BMI > 30
1st line = weight loss & lifestyle intervention
2nd line = pharmacological - metformin (if primary setting), clomiphene (if specialist setting) - increased fertility if used together

If 35 yo and if BMI >30

17
Q

What is the clinical presentation of ectopic pregnancy?

A
  1. Amenorrhoea (6-8 wks - longer suggests other cause)
  2. Pelvic pain - often first symptom, can be unilateral

Abnormal pelvic bleeding in 1st trimester
Adnexal tenderness and cervical excitation

18
Q

What are signs of ruptured ectopic pregnancy?

A

Signs of peritonitis
Shoulder tip pain
Haemodynamically unstable, LOC, dizziness
Dysuria, painful defaecation (due to haemperitonium)

19
Q

What Ix would be ordered in suspected ectopic pregnancy?

A
  1. BhCG
  2. Transvaginal U/S - intrauterine sac not seen in +B-hCG, blood in pouch of douglas, may see ovarian/fallopian mass
  3. Serum progesteron - decreased level sensitive indicator
  4. Diagnostic laparoscopy (gold standard diagnosis)
20
Q

What is the Rx of ectopic pregnancy?

A
  1. Surgical most common due to risk of rupture and haemorrphage - if adnexal mass >3.5cm, haemodynamically unstable, foetal heart activity, b-hCG high, moderate-severe pelvic pain, intraperitoneal bleeding
  2. Medical
    - Large single dose of methotrexate - rupture/haemorrphage must be less likely, willing for regular follow-up, stable, mild-no pelvic pain or tenderness, adnexal mass
21
Q

What HRT consideration must be made in female with hysterectomy vs. intact uterus?

A

Must provide cyclical progesterone with oestrogen if intact uterus to reduce risk of endometrial cancer

If hysterectomy oestrogen alone is fine

22
Q

What are the C/I for HRT?

A 
VTE
IHD/CVD or high risk 
Unexplained vaginal bleeding - needs Ix 
Hx breast cancer, endometrial cancer
Active liver disease 
>60 yo or >10 yrs since menopause
23
Q

What considerations, assessments & discussions with patient do you make before prescribing HRT?

A
  1. Confirm menopause and that they are experiencing symptoms
  2. Age - generally avoid commencing >60 yo
  3. Consider if any C/I to HRT and if so consider other symptomatic agents
  4. Mammogram - before or 3/12 after commencement
  5. Assessment of CV risk (lipids, HbA1c, examination)
  6. Discussion of risks vs. benefits
  7. Side effects
24
Q

What are the current general recommendations for HRT?

A

All women with premature or early menopause should be prescribed HRT unless C/I

Appropriate for women with osteoporosis but should not be prescribed solely for Rx or prevention

Not appropriate for cardioprotection and avoid in those with established or high risk

Generally don’t commence >60 yo

Avoid therapy > 4 - 5 yrs

Review patient risk/benefit annually

25
Q

What are the risks & benefits of HRT?

A

Benefits

  • Reduced symptoms - improved QOL
  • Reduced risk of osteoporosis & related #
  • Reduced risk of CRC, diabetes

Risks

  • Increased risk of VTE but does not increase CVD risk in healthy women
  • Small increased risk of ovarian Ca
  • Risk of endometrial Ca but eliminated if cyclic progesterone used
26
Q

What are the indications for HRT?

A

Peri- or post-menopausal women who are experiencing menopausal symptoms (within 5 yrs of last period)

All women with premature or early menopause to prevent osteoporosis

27
Q

What are HRT alternatives for symptom Rx?

A

Clonidine
SNRI, SSRI (venlafexine, paroxetine)
Gabapentin

Mainly useful at reducing hot flushes, takes ~1-2 weeks to be effective

28
Q

What is the Rx of atrophic vaginitis & its symptoms?

A

Topical oestrogens or other local oestrogen (pessaries, hormone releasing rings) - use daily for 2 weeks then reduce to 1-2 week

Vaginal moisturisers

Lubricants during sex

HRT

29
Q

What are non-pharm strategies of managing menopausal Rx?

A

Identify personal triggers of hot flushes & avoid - i.e. caffeine, alcohol, cigarettes, hot baths

Wear light cotton PJs with light bed covers

Cooling gels, cold face washers, ice blocks under pillow

Increase physical activity
Diet - increase phytoestrogen foods (i.e. tofu, sesame)
Stress Rx techniques

30
Q

How is prolapse associated with menopause & whats the Rx?

A

Oestrogen maintains muscle tone - withdrawal decreases tone

  1. Lifestyle - weight loss, pelvic floor exercises, reduce lifting, avoid constipation
  2. Pessary - physical support
  3. Surgery - red flags (i.e. bleeding), symptomatic & not responding to conservative rx

MD3 (21 decks)

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