Gynaecology and Breast Flashcards
2ww referral criteria for breast cancer?
-aged 30 and over with unexplained breast lump with/without pain
-aged 50 and over with any 1 of the following sx in 1 nipple only:
discharge
retraction
other changes of concern
consider 2ww referral if 30 and over with unexplained lump in axilla or any age with skin changes that suggest breast cancer
consider non-urgent referral if age under 30 with unexplained breast lump
When to measure CA-125 in primary care?
sx that suggest ovarian cancer-women that report any of the below sx on a persistent or frequent basis, especially more than 12 times per month and if age 50 and over:
persistent abdo bloating
early satiety and/or reduced appetite
increased urinary urgency and/or frequency
pelvic or abdo pain
consider if woman reports unexplained weight loss, change in bowel habit or fatigue.
also if woman 50 and over with new sx suggesting IBS in the last 1 year
Level of CA-125 that necessitates US scan of abdo and pelvis?
35 and above (IU/ml)
if US findings suggestive of ovarian cancer make urgent referral to gynae
2ww referral for suspected endometrial Ca?
if age 55 and over with post-menopausal bleeding
consider if post-menopausal bleeding under age of 55
When should direct access US scan be offered to women to assess for endometrial cancer?
if age 55 and over with:
- unexplained sx of vaginal d/c who are presenting with these sx for first time OR raised PLT OR report haematuria
- visible haematuria and low Hb OR raised PLT OR high blood glucose levels.
How often should women with a gene mutation for breast cancer receive breast cancer screening?
if TP53 gene mutation women should have annual MRI scans from the age of 20.
if BRCA 1 or 2 mutation women should have annual MRI from age of 30.
NICE guidance on referral of patients with cyclical breast pain to secondary care?
if persistent cyclical breast pain for more than 3 months which is affecting QOL or sleep and which has not responded to 1st line treatment e.g. topical NSAIDs-diclofenac, piroxicam. Also dopamine agonists e.g. bromocriptine.
In the presentation of menorrhagia, which women should be examined?
if any abnormal features in hx e.g. abnormal pattern to the bleeding or hx of pelvic pain or pressure e.g. frequent urination, pt should then have abdo exam, speculum and bimanual
If a woman with menorrhagia is at risk of endometrial pathology based on the hx e.g. persistent intermenstrual bleeding, or RFs e.g. PCOS, what is the 1st line investigation?
hysteroscopy +/- endometrial biopsy
she should also have FBC- investigation recommended for all women with menorrhagia
Biggest modifiable risk factor for endometrial cancer?
obesity
When would a hysterectomy usually be advised for a women with endometrial hyperplasia?
if hyperplasia with atypia
Which type of fibroids are most likely to cause abnormal uterine bleeding?
submucosal (affect the endometrium)
if <3cm diameter may be controlled using LNG-IUS or other medical management
Most common cause of infertility in young women?
PCOS
Management of oligomenorrhoea or amenorrhoea in women with PCOS?
cyclical progesterone e.g. medroxyprogesterone 10mg daily for 14/7, to induce a WD bleed, then r/f for TV US to assess for endometrial thickness-if normal, need to ensure tx given to prevent endometrial hyperplasia:
cyclical progesterone for 14/7 every 1-3 months
COCP
mirena
1st line tx of acne in PCOS?
COCP
How should bladder diaries be used in the assessment of urinary incontinence in women?
used for initial assessment in incontinence or overactive bladder
should be kept for minimum of 3 days covering variations in usual activities
1st line tx for stress or mixed urinary incontinence?
supervised pelvic floor muscle training for at least 3 months
at least 8 contractions performed 3 times a day
1st line tx for women with urgency or mixed urinary incontinence?
bladder training lasting at least 6 weeks
if satisfactory result not achieved and frequency is a troublesome sx consider combining training with an overactive bladder medicine
Next step if women taking medication for overactive bladder have not found it successful/tolerated?
refer to secondary care
1st line tx of women with symptomatic pelvic organ prolapse stage 1 or 2?
supervised pelvic floor muscle training for at least 16 weeks
When to refer couples for earlier assessment of infertility (prior to 1 yr of unsuccessful conception)?
woman aged 36 or over (r/f at 6 months of UPSI) predisposing factors to infertility: oligomenorrhoea amenorrhoea PID, previous STI endometriosis previous abdo/pelvic surgery
testicular trauma, mumps orchitis or varicocele, previous urogenital surgery, significant systemic illness
approx 25% of couples will have unexplained infertility
Initial investigations for infertility in women?
-Note initial investigations should be arranged if a couple has not conceived after 1 year of regular UPSI, Ix may be offered earlier if at risk of infertility.
-Mid-luteal phase progesterone to confirm ovulation (Day 21 of 28 day cycle)->30 consistent with ovulation
Chlamydia screen
-Additional tests:
FSH and LH-in women with irregular menstrual cycles, should be taken D2-5 of cycle
Weekly serum progesterone from day 21 until start of menstruation may be needed if irregular cycles
TFTs if sx of thyroid disease
Prolactin if sx of an ovulatory disorder e.g. PCOS
rubella status should also be checked
Men-semen analysis and chlamydia screen
What duration can clomifene citrate be used for to try and achieve ovulation in women with PCOS?
6 months due to theoretical risk of ovarian cancer
What are the NICE recommendations on IVF treatment for infertility?
- Unexplained infertility with failure to conceive after 2 years and under age of 40-offer 3 cycles, if age 40-42 offer 1 full cycle
- donor sperm-if failure to conceive after 12 cycles of IUI
- oocyte donation-premature ovarian insufficency
- tubal disease-if failure to conceive after surgical correction or not correctable surgically
- anovulation-failure to conceive with ovulation induction
- male factor-moderate/severe, may be indication for intracytoplasmic sperm injection
Management of endometriosis?
- r/f to gynae/US if severe, recurrent or persistent sx, or pelvic signs of endometriosis
- primary care: -analgesia-PO paracetamol and/or NSAIDs, 3 month trial 1st line
- hormonal tx e.g. COCP, POP, mirena, implant, NOT if trying to conceive
- review after 3-6 months
Symptoms suggestive of an underlying pathology in presentation of menorrhagia?
dysmenorrhoea dyspareunia intermenstrual or post coital bleeding vaginal discharge pelvic pain and/or pressure sx e.g. urinary
When to offer a pelvic US scan in presentation of menorrhagia?
- uterus palpable abdominally
- Hx or examination suggests a pelvic mass
- examination inconclusive or difficult e.g. due to obesity
Preliminary investigations in primary care for secondary amenorrhoea?
serum prolactin-if mildly elevated e.g. 500-1000, should be repeated before referral FSH and LH total testosterone TSH US scan (if PCOS suspected)
Definition of polycystic ovaries on US scan?
presence of 12 or more follicles (2-9mm in diameter) in 1 or both ovaries and/or increased ovarian volume (>10cm^3)
What tx does NICE advise can be considered for women with amenorrhoea for more than 1 year to help prevent osteoporosis?
COCP or combined cyclical HRT
tx should be reviewed annually
if amenorrhoea due to reversible causes e.g. low body weight, periodically stop oestrogen tx for 6 months to see if menses resumes
When can PCOS be diagnosed in primary care after investigations?
if 2 of following 3 criteria are present:
- infrequent or no ovulation (oligomenorrhoea or amenorrhoea)
- clinical and/or biochemical evidence of hyperandrogenism e.g. hirsutism, acne, raised free or total testosterone
- 12 or more follicles in 1 or both ovaries and/or increased ovarian volume (>10) on US scan.
in adolescent girls both irregular menstrual cycles and hyperandrogenism are required for PCOS diagnosis
If suspect bartholins cyst when should a women be referred to gyne for biospy to r/o malignancy?
if age over 40
UKMEC for continuing a COCP in patient with an undiagnosed breast mass?
2
initiating in this patient would be UKMEC 3
UKMEC for COCP if previous breast cancer?
3
(same for all methods of hormonal contraception, UKMEC 1=copper coil)
if current breast cancer-4
Most common ovarian cyst?
follicular cyst
type of physiological cyst
Most common benign ovarian tumour in women under age of 30?
dermoid cyst (mature cystic teratoma)
torsion more likely than with other ovarian tumours
Most common benign epithelial cell tumour of ovary?
serous cystadenoma
note most common ovarian cancer=serous carcinoma
Management of patients under age of 35 where US reports a simple ovarian cyst which is less than 5cm?
rpt ultrasound in 8-12 weeks
any postmenopausal women with an ovarian cyst should be referred to gynae
