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
