Gynae + breast Flashcards
Prevalence breast cancer
1 in 8 women diagnosed in their lifetime
6.6% of USC referrals diagnosed with breast cancer
Describe Paget’s disease of the breast
A rare skin condition, sign of a breast cancer under the nipple.
A scaly, raw, vesicular, or ulcerated lesion that begins on the nipple and spreads to the areola.
Pain, burning, or pruritus may be present first
What nipple changes are concerning?
Retraction
New inversion
Ulceration and bleeding
Unilateral nipple discharge
Paget’s disease
Blood stained nipple discharge
Referral criteria for breast
USC ref if:
?Inflammatory breast cancer.
Unexplained breast or subcutaneous axillary lump age>30yrs
Skin changes (dimpling or puckering of the skin, ulcerating lesion from the breast tissue) age>30yrs
Nipple changes with concerning features age>50
Bloodstained nipple discharge
Routine ref if:
Breast or subcutaneous axillary lump<30yrs
Concerning nipple changes<50yrs
Distressing nipple discharge>3m
Causes of breast pain
Never breast cancer!
Cyclical breast pain:
Menstrual cycle
Pregnancy
Perimenopause
Hormone medications
Non‑cyclical breast pain:
Costochondritis
MSK back/shoulder
Medications
Mastitis/breast abscess
Management cyclical breast pain
Altering hormone medication
Evening primrose oil- incr 1g each month, max 4g daily
Exercise more
Reduce saturated fat + caffeine
Vitamin E
Topical NSAIDs
Supportive bra
General preventative strategies for breast cancer
Breastfeeding
Maintain a healthy diet
Normal BMI
Minimal alcohol
Stop smoking
Regular physical activity
Underlying causes of gynaecomastia
Finasteride, spironolactone, anti-androgens
Cannabis
Anabolic steroids
Cirrhosis or malnutrition
Male hypogonadism
Testicular or adrenal neoplasms
Prolactinoma
Hyperthyroidism
Chronic renal failure
Acromegaly
Difference between gynaecomastia and pseudogynaecomastia
Pseudogynaecomastia-obese men, fat deposition without glandular proliferation.
Symptoms corrected by weight loss.
Gynaecomastia-
benign proliferation of glandular tissue of male breast, caused by an increase in the ratio of oestrogen to androgen activity.
Must be differentiated from breast cancer (rare)
Ix for gynaecomastia if new
TFT, prolactin, testosterone, LH, FSH, oestradiol, LFT, U+E
Referral criteria mastitis/abscess
USC if: suspicion of inflammatory breast cancer
SDEC if:
mastitis with signs of sepsis.
breast abscess requiring I+D
Urgent ref if:
severe cellulitis not responding to 48hrs PO antibiotics.
mastitis associated with breast implants.
breast abscess not requiring immediate I+D.
Management mastitis
Keep breastfeeding + massage
If abscess- SDEC for I+D
Flucloxacillin 500mg QDS PO 5-7 days
If penicillin allergy
Clarithromycin 500mg BD PO
If no improvement 48hrs- review
Review 5-7 days to assess progress- can rpt course abx
Can drain simple seb cysts in GP
Nipple discharge referral criteria
USC if:
-nipple retraction, new inversion, ulceration, or bleeding.
-unilateral nipple with or without areola skin changes that fails to improve with 4 weeks of treatment ?Paget’s disease.
-nipple discharge that is bloodstained.
Routine if distressing non‑blood stained nipple discharge>3m
Risk factors for STI or PID
New sexual partner in the last 3m
Recent STI
age<30
bleeding, discharge, rash.
sexual partner with an STI
recent termination of pregnancy or IUD insertion.
pregnant or postpartum.
Referral criteria for cervical polyp
asymptomatic polyp (no bleeding) If:
>1 cm, routine ref for electrocautery or surgical removal.
0.5- 1 cm and
not smooth/uniform, routine ref
0.5-1cm + smooth/uniform, reassure
smaller than 0.5 cm, reassure
If IMB or PMB refer accordingly
Who is eligible for cervical screening?
People with a cervix age 25- 64 years every 5 years
Yearly if HIV
More often if HPV +ve
Symptoms of ovarian torsion
Sudden onset of severe lower abdominal pain in a female of any age
Nausea + vomiting
May be preceded by occasional cramps for several days or for weeks (intermittent torsion)
More likely if cyst>6cm
Ovarian cyst referral criteria
USC if postmenopausal:
-Simple cyst>5 cm.
-cyst is solid or complex, any size.
USC if premenopausal +cyst solid/complex, any size + CA125>35
(CA125< 35, ref urgent)
Urgent paeds if prepubertal and cyst any size or type
Routine if premenopausal:
-Simple cyst> 5 cm on rpt scan at 8 weeks.
-Haemorrhagic cyst 5-7 cm unchanged or enlarged after rpt scan
-Simple or haemorrhagic cyst<5cm, rpt scan unchanged or increased size,or symptomatic.
-a simple cyst or haemorrhagic cyst<5cm changes into complex cyst.
Postmenopausal and:
-simple cyst 3-5 cm and CA125>35
-simple cyst 3-5 cm, and rpt scan size increased or CA125>35
-simple cyst is 3-5 cm, 3 stable scans + CA125<35 pt concerned
Name 6 causes of secondary dysmenorrhoea
endometriosis/adenomyosis
STI
PID
Fibroids.
Ovarian cysts.
Cervical abnormalities
Primary dysmenorrhoea management
Hot water bottle
TENS machine
NSAIDs
COCP
(if unable to have oestrogens, POP, nexplanon, mirena can be trialed but risk spotting)
Features of endometriosis
Chronic pelvic pain
Secondary dysmenorrhoea and ADLs + QoL
Deep dyspareunia
Period‑related or cyclical painful bowel movements/diarrhoea
Cyclical urinary symptoms (haematuria, dysuria)
Infertility
Management endometriosis
NSAIDs/paracetamol
TENS
Suppress ovulation
-COCP tricycling
-Desogestrel, if still ovulating after 3m can double dose
-Mirena/depo
-SSRI/amtriptyline
If no relief after 6m routine ref gynae for surgical options
Referral criteria for endometriosis
suspected moderate to severe endometriosis.
blue spots in posterior vaginal fornix.
endometriomas on USS
known endometriosis w/exacerbation
subfertility ?endo
not responding to 6m med management, for ?surgery
What is mandatory in FGM?
To report to police if:
-a child<18 years discloses that they have undergone FGM,
or
-they observe physical signs that FGM has been carried out on a child under the age of 18 years.
+ safeguarding ref (MARF)
Which 11 nationalities are higher risk for FGM
Somali
Kenyan
Ethiopian
Sudanese
Sierra Leonean
Egyptian
Nigerian
Eritrean
Yemeni
Kurdish
Indonesian
Name 4 classifications of FGM
Clitoridectomy – partial/total removal of clitoris.
Excision – partial or total removal of clitoris and the labia minora, with or without excision of labia majora.
Infibulation – narrowing of the vaginal orifice with creation of a covering seal by cutting and juxtaposing the labia minora and/or labia majora
Other- piercing, incising or scraping, and cauterisation, introduction of corrosive substances or herbs into the vagina.
Symptoms and signs of fibroids
Pelvic pain
Dyspareunia and dysmenorrhoea
Pelvic organ pressure or obstruction symptoms – difficulty passing urine, urinary frequency, difficulty moving bowels, constipation
Heavy/abnormal periods
Anaemia
Subfertility
Management asymptomatic fibroids
Reassure
Consider routine ref if:
1x fibroid> 6 cm, or multiple fibroids>5 cm.
asymptomatic fibroid prolapse through cervix.
Consider rpt USS in 12 months. If rapid growth of fibroid, routine ref.
Referral criteria symptomatic fibroids
Admit if:
Haemodynamic instability
Urinary obstruction
Symptommatic fibroid prolpasing through cervix
USC if:
rapidly growing fibroid
Unexplained bleeding/weight loss
Routine if:
heavy menstrual bleeding, not improved by medical treatment
compressive symptoms
fibroids palpable abdominally, or uterine length>12 cm
atypical fibroid location
requested surgical intervention.
infertility with fibroid>3 cm or submucosal fibroid>50% within cavity.
What 4 underlying diagnoses should you think about with heavy menstrual bleeding (+ associated symptoms)
Hypothyroidism – Weight gain, cold intolerance, fatigue, constipation
Androgen excess – Acne, hirsutism
Malignancy – Bloating, weight loss
Bleeding disorders:
Excessive bleeding with invasive procedures or dental work, recurrent epistaxis, excessive bruising, FHx,
Management for heavy menstrual bleeding
FBC (+TFT, coag)
Testosterone, prolactin, if ?PCOS
USS routine if ?fibroids/adenomysosis/endometriosis
Mirena/COCP tricycling/POP/depo
TXA + NSAID
cyclical norithisterone/medroxyprogesterone
Red flags for gynae malignancy
PV bleeding>12m after menopause
Unexplained vulval lump, ulceration, or bleeding
Unexplained palpable mass in or at the entrance to the vagina
Abnormal cervix
USS suggesting ovarian cancer, or CA‑125> 35 + symptoms
Examination identifies ascites, or a pelvic or abdominal mass (which is not obviously a fibroid)
Medical and Surgical management of fibroids
GnRH analogues if approaching menopause.
Selective progesterone receptor modulator ulipristal acetate
Endometrial ablation:
Microwave endometrial ablation — a probe is inserted into the uterus
Thermal balloon endometrial ablation — heated liquid
Uterine artery embolization
Myomectomy-vaginal, laparoscopic, and hysteroscopic.
Hysterectomy
Causes of breakthrough bleeding
Recently started COCP
Recent missed pills, vomiting, or diarrhoea
Continuous COCP
Medicines interact with COCP (St John’s wort, anticonvulsants)
Infection (chlamydia)
Risk factors for endometrial cancer
Obesity/metabolic syndrome
Chronic anovulation, PCOS, infertility
Nulliparity
Exposure to unopposed oestrogen
Exposure to tamoxifen
Endometrial thickness>4 mm in postmenopausal women
USS cystic endometrial changes
FHx endometrial/colon cancer
Causes IMB
Physiological spotting at ovulation
Pregnancy
Breakthrough bleeding
Anovulatory cycle (adolescence, perimenopause, PCOS)
PID
Cervical screening
Bleeding lesion of vulva or vagina
Cervical or endometrial polyp
Cervical cancer
Endometrial cancer
Infection (chlamydia)
Ix and Management IMB
Pregnancy test
Cervical screening if due
STI screen.
TV USS if bleeding persists and no obvious cause.
Bloods if ?PCOS/anaemia/thyroid
If age<40, observe 2-3 cycles, if persistent- urgent ref
If age>40 routine ref, or urgent if persists
COCP/mirena/POP if normal Ix
Menopause symptoms
hot flushes.
night sweats.
vaginal dryness and sexual dysfunction.
mood disturbance
sleep disturbance, headache, joint pains, urinary frequency.
Differential diagnoses for menopausal symptoms
Depression/anxiety (can co-exist)
Anaemia, hypothyroidism, hyperprolactinaemia, pregnancy
SSRIs, tamoxifen, aromatase inhibitors
Phaeochromocytoma, carcinoid syndrome, lymphoma, myeloma
GU infection, lichen sclerosus, prolapse
When do you stop using contraception with menopause?
Age<50, 2yrs no period
Age>50, 1 yr no period
POP, mirena, barrier most suitable
Can keep Mirena in from 45-55yrs for contraception, but only lasts 5 yrs as part of HRT
Stop COCP age 50 (or age 35 is smoke>15cigs)
When can you start COCP after emergency contraception?
Levonorgestrel- start COCP immediately, barrier method 7 days (9 days if taking Qlaira)
Ulipristal acetate, start COCP 5 days after, barrier method 7 days (9 days if taking Qlaira)
What are the UKMEC 4 criteria for COCP?
0-6 weeks postpartum + breastfeeding
0-3 weeks postpartum (bottle fed) + VTE risk factors
Age>35 + >15 cigs/day
BP>160/100
Vascular disease + HTN
IHD/stroke
VTE
Major surgery + immobilisation
Thrombotic disease (factor5leiden/proteincdef)
Complicated congenital heart disease
Migraine with aura
Breast cancer
Severe liver cirrhosis/HCC
Lupus w/antibodies
UKMEC 3 criteria COCP
0-3 weeks postpartum no VTE risk factors bottle fed
3-6 weeks bottle fed VTE risk factors
Age>35 smoke<15cigs or quit<1 yr ago
BMI>35
Complicated organ transplant
HTN (even if controlled)
VTE 1st degree relative
Immobility
Migraine no aura to continue COCP
Migraine w/aura>5yrs ago
BRCA+ve
Prev breast cancer
Diabetes w/nephropathy
Gallbladder disease
Prev COCP cholestasis
Viral hepatitis
UKMEC 3+4 for POP, depo + implant
4- current breast cancer
3- IHD +stroke to continue POP, past breast cancer, severe cirrhosis, HCC
UKMEC 3+4 for IUS/IUD
3- postpartum 48hrs-4 weeks, complicated organ transplant, initiate in long QT, distorted uterine cavity, initiate in HIVw/low CD4
continue mirena IHD/stroke, pelvic TB continue, severe cirrhosis/HCC mirena
4- postpartum/post abortion sepsis, initiate in unexplained PV bleeding, gestation trophoblastic disease, cervical cancer untreated, initiate in current PID/STI, pelvic TB initiate
Topical vaginal oestrogen options
Estradiol pessary tablets (Vagifem) – 10 microgram ON 2 weeks then twice weekly
Estriol cream (Ovestin 1 mg/g) – 1 applicator ON 3 weeks, then twice weekly
Estradiol vaginal ring (Estring) – mild prolapse + vaginal atrophy
Get advice if prev breast/ovarian ca
Which SSRI/SNRIs can be used for menopausal symptoms?
Fluoxetine, citalopram, venlafaxine
Relief is rapid, often within a week
Dosage are lower
Avoid using paroxetine or fluoxetine if the patient is taking tamoxifen
Indications for HRT
moderate to severe menopausal symptoms, or
vasomotor symptoms (VMS), and bone preservation in premature (younger than 40 years) or early (younger than 45 years) menopause until 50 years of age.
Contraindications to HRT (absolute + relative) + indications for transdermal route
Absolute contraindications:
Pregnancy
Undiagnosed abnormal PV bleeding
Untreated endometrial hyperplasia
Active breast or endometrial cancer
Hormone‑dependent cancer
Active thromboembolic disorder
Acute-phase MI/stroke
Uncontrolled hypertension
Porphyria
Relative contraindications:
PMHx breast, ovarian, or endometrial cancer
Previous IHD/Stroke
Hypertriglyceridaemia
Can increase the severity of urinary incontinence
Age>60 or menopause>10yrs ago
Indications for transdermal:
VTE risk
Migraine
Gallbladder disease – increased cholecystitis risk
Active liver disease
Benefits HRT
Symptom control
Bone protection
Muscle strength
Risks HRT
Risk of breast cancer:
Increased risk of breast cancer (higher for cont combined than for oestrogen-only HRT)
risk persists for >10 years after stopping HRT.
Increased risk of IHD if started>10 yrs after menopause.
Slightly increased risk of stroke.
Risk VTE with PO HRT so offer transdermal
Smoking, obesity, prolonged immobility, increase the VTE risk more than HRT.
Best HRT regimes
Transdermal oestrogen:
Evorel patch twice weekly
Oestrogel 0.06% 2 measures= 1.5 mg OD)
<12m since last period
Cyclic progestogens:
Utrogestan 200 mg once a day, 14 days of each 28 day oestrogen cycle.
Evorel sequi patches
> 12m since last period
Continuous progesterone:
Mirena
Evorel conti patches
Utrogestan 100 mg OD
Referral criteria PMB on HRT
USC if:
unscheduled bleeding after 1st 6m HRT with risk factors for endometrial cancer
Urgent gynae if:
Endometrial thickness on HRT is 5 mm or over on continuous combined, 7 mm or over on sequential combined, or irregular endometrium
Risk factors for endometrial cancer
BMI > 40
Strong FHx breast, bowel, or colon cancer
Oestrogen only HRT for longer than 6m with uterus
Tricycling HRT> 6m
Sequential HRT >5 years use if age>50
Tamoxifen
PCOS
Diabetes,
Nulliparity
Late menopause
Ovarian cancer symptoms
> 12x per month
Abdominal distension or bloating
Early satiety or loss of appetite
Pelvic/abdominal pain unknown cause
Increased urinary urgency or frequency
IBS symptoms, new onset age>50
Unexplained weight loss or fatigue
Causes of raised CA125
Ovarian cancer
Physiological: Ovulation, Pregnancy, Menstruation
PID, Endometriosis, Ovarian cysts, Fibroids
Autoimmune disease: Sjogren’s syndrome, Polyarteritis nodosa, SLE
Ix for ovarian cancer symptoms
CA125, LFT, FBC, CRP, calcium, U+E
USC USS if:
Pelvic mass
CA125<35 but symptoms persist
If CA125>35
Diagnostic criteria for PCOS
2 out of 3 of:
Oligomenorrhoea or amenorrhoea.
Clinical (hirsutism, acne, scalp hair loss) or biochemical (raised testosterone or free androgen index) features of hyperandrogenism.
USS shows polycystic ovaries
Management PCOS
HbA1c, lipids, LFT
Screen for psycho impact + sleep apnoea
Encourage exercise/healthy eating
Weight loss 5% will regulate cycles, improve fertility, reduce risk T2DM
COCP for acne, hirsutism
Medroxyprogesterone 10 mg for 14 days to induce a bleed 4x a year if amenorrhoeic (+ routine USS) or mirena
Metformin for fertility (secondary care initiated)
Features concerning for androgen secreting tumour
Testosterone> 5
Clitoromegaly
Deepening of voice
Increased musculature
Balding
-> urgent endo ref
Causes of post coital bleeding
Cervical cancer or dysplasia
STI (most commonly chlamydia)
Endometrial pathology
Cervical polyps
Cervical ectropion
Atrophic vaginitis
Pregnancy-related bleeding
Vaginal or vulval cancer
Trauma
Referral criteria for post coital bleeding
USC if
>1 episode and unexplained or persistent postcoital bleeding
high suspicion of malignancy from history or examination
concern regarding appearance of cervix
Consider USS if:
no cause seen for bleeding on speculum examination.
abnormal findings on abdominal or pelvic examination.
Management PMB
If no HRT, USC ref
Abdo + gynae exam + STI screen
Management of PMS/PMDD
COCP tricycling
SSRIs as a daily therapy or luteal phase-only treatment, starting on cycle day 14.
Lifestyle modification, talking therapy
Subfertility Hx
Length of time trying to conceive
Previous children/pregnancies
Freq timing intercourse
Diet, smoking, alcohol
Menstrual hx, gynae STI hx
Contraception hx
Cervical screening
Medications
FHx menopause/miscarriage
Ix subfertility woman
FBC, ferritin, B12, bone profile, vitamin D, TFTs
Luteal-phase progesterone(Day21 of a 28‑day cycle, 7 days before bleed)
FSH, LH)- Day2 or3 of period if possible
If irregular cycle arrange:prolactin., testosterone, SHBG
HbA1c and LFTs if the patient is obese, particularly if irregular cycle.
HIV, Hep B, Hep C
STI + HVS swabs
Management subfertility
vitamin D OTC
Folic acid 400 microgram OTC
Prescribe folic acid 5 mg daily if:
BMI>30.
Epilepsy medication, incl neuropathic pain, mood stabilisation, or migraine prophylaxis.
Diabetes or sickle cell disease.
FHx neural tube defect
sex every 2 to 3 days, sperm can survive up to 7 days and an egg lives for 24hrs
Refer if:
failure to achieve pregnancy after 12 months or more in the absence of a known cause.
Female partner> 35 years and trying 6 months.
male and female sub‑fertility factors are identified (amenorrhoea or tubal damage) Ensure both names are on the referral form+ male results
Management uterovaginal prolapse
Treat constipation/chronic cough
Pelvic floor physio
Topical oestrogen for 2w then vaginal ring pessary (cont oestrogen twice weekly)
Routine gynae ref if:
no experience initiating pessary treatment
failure of conservative treatment 3 months.
stage 3 or 4 prolapse.
voiding problems or obstructed defecation.
recurrent prolapse after reconstructive surgery.
For surgical management
