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Gynae + breast Flashcards

1
Q

Prevalence breast cancer

A

1 in 8 women diagnosed in their lifetime
6.6% of USC referrals diagnosed with breast cancer

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2
Q

Describe Paget’s disease of the breast

A

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

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3
Q

What nipple changes are concerning?

A

Retraction
New inversion
Ulceration and bleeding
Unilateral nipple discharge
Paget’s disease
Blood stained nipple discharge

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4
Q

Referral criteria for breast

A

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

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5
Q

Causes of breast pain

A

Never breast cancer!
Cyclical breast pain:
Menstrual cycle
Pregnancy
Perimenopause
Hormone medications

Non‑cyclical breast pain:
Costochondritis
MSK back/shoulder
Medications
Mastitis/breast abscess

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6
Q

Management cyclical breast pain

A

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

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7
Q

General preventative strategies for breast cancer

A

Breastfeeding
Maintain a healthy diet
Normal BMI
Minimal alcohol
Stop smoking
Regular physical activity

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8
Q

Underlying causes of gynaecomastia

A

Finasteride, spironolactone, anti-androgens
Cannabis
Anabolic steroids
Cirrhosis or malnutrition
Male hypogonadism
Testicular or adrenal neoplasms
Prolactinoma
Hyperthyroidism
Chronic renal failure
Acromegaly

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9
Q

Difference between gynaecomastia and pseudogynaecomastia

A

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)

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10
Q

Ix for gynaecomastia if new

A

TFT, prolactin, testosterone, LH, FSH, oestradiol, LFT, U+E

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11
Q

Referral criteria mastitis/abscess

A

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.

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12
Q

Management mastitis

A

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

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13
Q

Nipple discharge referral criteria

A

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

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14
Q

Risk factors for STI or PID

A

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.

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15
Q

Referral criteria for cervical polyp

A

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

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16
Q

Who is eligible for cervical screening?

A

People with a cervix age 25- 64 years every 5 years
Yearly if HIV
More often if HPV +ve

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17
Q

Symptoms of ovarian torsion

A

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

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18
Q

Ovarian cyst referral criteria

A

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

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19
Q

Name 6 causes of secondary dysmenorrhoea

A

endometriosis/adenomyosis
STI
PID
Fibroids.
Ovarian cysts.
Cervical abnormalities

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20
Q

Primary dysmenorrhoea management

A

Hot water bottle
TENS machine
NSAIDs
COCP
(if unable to have oestrogens, POP, nexplanon, mirena can be trialed but risk spotting)

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21
Q

Features of endometriosis

A

Chronic pelvic pain
Secondary dysmenorrhoea and ADLs + QoL
Deep dyspareunia
Period‑related or cyclical painful bowel movements/diarrhoea
Cyclical urinary symptoms (haematuria, dysuria)
Infertility

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22
Q

Management endometriosis

A

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

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23
Q

Referral criteria for endometriosis

A

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

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24
Q

What is mandatory in FGM?

A

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)

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25
Which 11 nationalities are higher risk for FGM
Somali Kenyan Ethiopian Sudanese Sierra Leonean Egyptian Nigerian Eritrean Yemeni Kurdish Indonesian
26
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.
27
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
28
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.
29
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.
30
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,
31
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
32
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)
33
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
34
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)
35
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
36
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)
37
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
38
Menopause symptoms
hot flushes. night sweats. vaginal dryness and sexual dysfunction. mood disturbance sleep disturbance, headache, joint pains, urinary frequency.
39
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
40
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)
41
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)
42
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
43
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
44
UKMEC 3+4 for POP, depo + implant
4- current breast cancer 3- IHD +stroke to continue POP, past breast cancer, severe cirrhosis, HCC
45
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
46
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
47
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
48
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.
49
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
50
Benefits HRT
Symptom control Bone protection Muscle strength
51
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.
52
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
53
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
54
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
55
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
56
Causes of raised CA125
Ovarian cancer Physiological: Ovulation, Pregnancy, Menstruation PID, Endometriosis, Ovarian cysts, Fibroids Autoimmune disease: Sjogren's syndrome, Polyarteritis nodosa, SLE
57
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
58
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
59
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)
60
Features concerning for androgen secreting tumour
Testosterone> 5 Clitoromegaly Deepening of voice Increased musculature Balding -> urgent endo ref
61
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
62
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.
63
Management PMB
If no HRT, USC ref Abdo + gynae exam + STI screen
64
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
65
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
66
Ix subfertility woman
FBC, ferritin, B12, bone profile, vitamin D, TFTs Luteal-phase progesterone(Day 21 of a 28‑day cycle, 7 days before bleed) FSH, LH)- Day 2 or 3 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
67
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
68
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

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