OBGY Flashcards
When is hormone therapy offered to women with breast cancer? Which drugs are used?
If tumours are positive for hormone receptors:
- Tamoxifen in pre/peri-menopausal women
- Anastrozole in post-menopausal women
When should you refer to the 2WW breast cancer pathway?
> 30 unexplained lump with or without pain
>50 in one nipple: discharge, retraction, other changes of concern
When should you consider a referral to 2WW breast cancer pathway?
Skin changes that suggest breast cancer
>30 lump in axilla
When should you complete a non-urgent referral to breast clinic?
<30 lump with or without pain
Which contraceptive is most associated with weight gain?
Depo-provera injections
What is the management of intrahepatic cholestasis of pregnancy?
- Ursodeoxycholic acid
2. Elective induction from 37 weeks
What is a fibroadenoma?
common benign tumours of stromal/epithelial breast duct tissue
What are the features of a fibroadenoma?
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter
Why are fibroadenomas more common in younger women?
They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.
Which breast lump fluctuates with the menstrual cycle?
Fibrocystic Breast Changes
What are the symptoms of fibrocystic breast changes?
10 days before period, resolve when period ends:
Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size
What is the management of fibrocystic breast changes?
exclude cancer
manage symptoms:
- Wearing a supportive bra
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
- Avoiding caffeine
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What is the most common cause of breast lumps?
Breast cysts
What are the features of breast cysts?
Smooth
Well-circumscribed
Mobile
Possibly fluctuant (change size around period)
What is fat necrosis of the breast?
an oil cyst, containing liquid fat. Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.
What are the features of fat necrosis of the breast?
Painless Firm Irregular Fixed in local structures There may be skin dimpling or nipple inversion
What might look similar to breast cancer on US or mammogram?
Fat necrosis
What is the management for fat necrosis?
- exclude cancer
2. conservative (resection if symptoms)
What are the features of lipoma?
Soft
Painless
Mobile
Do not cause skin changes
What is the management of lipomas?
Reassurance
What is a galactocele?
breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk.
What are the features of a galactocele?
irm, mobile, painless lump, usually beneath the areola
benign - usually resolve without treatment
What is a Phyllodes tumour?
rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50
surgical removal, wide-excision + chemo
What are the two types of mastalgia?
Cyclical
Non-cyclical
Name three causes of non-cyclical breast pain.
Medications (e.g., hormonal contraceptive medications)
Infection (e.g., mastitis)
Pregnancy
Give three differentials for breast pain
Cancer (perform a thorough history and examination)
Infection (mastitis)
Pregnancy (perform a pregnancy test)
What hormonal treatments can be used to treat breast pain?
danazol and tamoxifen (under specialist)
What are the risk factors for breast cancer?
Female (99% of breast cancers)
Increased oestrogen exposure (earlier onset of periods and later menopause)
More dense breast tissue (more glandular tissue)
Obesity
Smoking
Family history (first-degree relatives)
Which genes can predispose to breast cancer?
BRCA1 = CX17 BRCA2 = CX13
TP53
PTEN
Name 5 types of breast cancer
Ductal carcinoma in situ Lobular carcinoma in situ Invasive ductal carcinoma Invasive lobular carcinoma Inflammatory breast cancer Paget's disease of the Nipple
What is the management of lobular carcinoma in situ?
close monitoring (e.g., 6 monthly examination and yearly mammograms)
What is the most common type of invasive breast cancer?
Invasive ductal carcinoma
What should be considered if mastitis does not respond to antibiotics?
Inflammatory breast cancers
How does Paget’s disease of the nipple present?
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Describe the breast cancer screening programme in the UK
offers a mammogram every 3 years to women aged 50 – 70 years.
What are the risk factors for high-risk breast cancer?
A first-degree relative with breast cancer under 40 years
A first-degree male relative with breast cancer
A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
Two first-degree relatives with breast cancer
What should be done before genetic testing for breast cancer?
Counselling
What can be offered to people who are high risk for breast cancer?
Annual MMG >30years
Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)
Risk-reducing bilateral mastectomy or bilateral oophorectomy
How does breast cancer present?
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in the axilla
What is the triple assessment?
Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Biopsy (fine needle aspiration or core biopsy)
What are the three types of breast imaging?
US - younger women
MMG - older women
MRI - high risk
What is a sentinel node biopsy?
Sentinel node biopsy is performed during breast surgery for cancer. An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.
Name three breast cancer receptors
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
What is triple-negative breast cancer?
cancer cells do not express any of these three receptors
carries a worse prognosis
Who should receive gene expression profiling?
women with early breast cancers that are ER positive but HER2 and lymph node negative
What mnemonic can be used to remember notable locations of breast cancer mets?
2 Ls and 2 Bs:
L – Lungs
L – Liver
B – Bones
B – Brain
What system is used for staging of breast cancer?
TNM system
T - tumour
N - nodes
M - mets
What are the options for breast surgery in breast cancer?
Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy
Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
What can cause chronic lymphoedema?
Axillary clearance after breast cancer surgery
When should surgical excision be offered for fibroadenomas?
> 3cm
What should be offered after a wide-local excision of breast cancer to reduce recurrence?
Whole breast radiotherapy
What is duct ectasia?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple
How do patients present with duct ectasia?
greenish nipple discharge with a peri-areolar lump
What is indicated by a ‘snowstorm’ sign on breast US?
Implant rupture
What is the purpose of neoadjuvant therapy in breast cancer?
downsize the tumour before surgery
What are the differentials for pelvic pain?
Gynae: PID, ectopic pregnancy, ovarian cyst/torsion/rupture/haemorrhage, endometriosis
Urological: pyelonephritis, appendicitis, diverticulitis, IBD/IBS
What is the definition of a APH?
PV bleeding >24 weeks into pregnancy
Name the causes of APH
Placental abruption Placenta praaevia Genital tract pathology Uterine rupture Vasa praaevia
What are the causes of a PPH?
4Ts
Tone - atonic uterus
Trauma - uterine rupture
Tissue - retained tissue
Thrombin - coagulopathy
What is the definition of a miscarriage?
Loss of pregnancy in the first 24 weeks
What is the most common cause of miscarriage int he 1st trimester?
Chromosomal abnormalities
What is the most common cause of miscarriage in the 2nd trimester?
Cervical incompetence
Also:
Drugs - smoking, alcohol, caffeine
Infection
Name some differentials for PV bleeding during the first 24 weeks of pregnancy
Implantation bleeding
Cervical pathology
UTI
Ectopic pregnancy
What is the general management of a miscarriage?
- ABCDE
- TV US, serum hCG, pelvic examination
- Expectant/medical/surgical management
What are the 5 types of miscarriage?
Threatened Inevitable Incomplete Missed Complete
What might be seen on US in a miscarriage?
POC
Gestational sac >25mm with no yolk sac
Adnexal mass
FHR
What might be seen on serum hCG in a miscarriage?
hCG does not double in 48 hours
What is the medical management of miscarriage?
Misoprostol (vaginal)
What is the surgical management of a miscarriage?
Suction curettage
ERPC (GA)
Who should receive surgical management of miscarriage?
Personal choice
Increased risk: bleeding, infection, unstable
What is a recurrent miscarriage?
> 3 miscarriages in a row
What are the risk factors for recurrent miscarriage?
Obesity
Age
Smoking
What is the most common cause of recurrent miscarriage?
Anti-phospholipid syndrome
How can recurrent miscarriages be investigated?
Bloods - clotting factors
Hypsteroscopy
What are the risk factors for an ectopic pregnancy?
Previous ectopic Endometriosis IUCD POP IVF PID Maternal age (>35) Smoking
When can an ectopic pregnancy be managed medically? What is the management?
Serum hCG <3000
no FHR
unruptured
no pain
IM methotrexate
What are the features of placenta praaevia?
Non-tender
Painless
Shock consistent with bleeding
Normal FHR
Breach/transverse lie
Red blood
What are the features of placental abruption?
‘woody’ hard uterus
Painful
Shock inconsistent with bleeding
Foetal distress
Normal lie
Dark blood
What are the risk factors for placenta praaevia?
More common in twins, high parity, age and scarred uterus
What are the risk factors for placental abruption?
Pre-eclampsia
Smoking/cocaine
Previous abruption
Intrauterine growth restriction
What is the general management of an APH?
- Maternal welfare (ABCDE)
- Monitor foetal condition (CTG, US)
- Early delivery (section/induce labour
What is the definitive management of placental abruption?
<37 weeks: foetal distress = c-section, no distress = corticosteroids (< 34 weeks)
> 37 weeks: foetal distress = c-section, no distress = vaginal delivery
What should be given to rhesus negative women in APH?
Anti-D
What is the definition of a PPH?
Loss of >500ml of blood <24 hours after delivery
What are the risk factors for PPH?
Previous Hx/caesarean Clotting disorder/anti-coagulant therapy Retained placenta Instrumental delivery APH (placenta praevia) Uterine malformation/fibroids Maternal age Prolonged/induced labour Large BMI Anaemia Shoulder dystocia
What is the most common cause of PPH?
Atonic uterus
What is the management of PPH?
ABCDE
RESUSITATE (crystalloid, fluids)
STOP BLEEDING:
- Ergometrine (not with HTN), oxytocin
- Uterus contraction (fundal massage, bi-manual compression)
- catheter (empty bladder)
INVESTIGATE CAUSE:
- Examination
- Bloods: FBC, G&S, U&E, clotting
PERSISTENT BLEEDING/MAJOR HAEMORRHAGE: = major haemorrhage protocol
What is included in booking bloods at 10 weeks?
Infectious disease: HIB, Hep B, syphilis
Blood disorders: sickle cell, thalassaemia
Hb
Blood group: ABO, rhesus status
What is included in booking bloods at 10 weeks?
Infectious disease: HIB, Hep B, syphilis
Blood disorders: sickle cell, thalassaemia
Hb
Blood group: ABO, rhesus status
How is anaemia of pregnancy treated?
Fe
Folic acid
When should anti-D be given to pregnant women?
give anti-D @ 28 and 34 and within 72 hours of a sensitizing event
What is the purpose of the 12 week scan?
- Due date (depending on crown-rump length)
- Diagnose multiple pregnancies
- Offer screening: trisomy 21 (down’s syndrome), 18 (Edward’s) and 13 (Patau’s)
Describe the testing for Down’s syndrome
- Combined screening - maternal blood test (hCG/PAPP-A); nuchal translucency; maternal risk factors
- Quadruple test - maternal blood test for 4 hormones: oestriol; hCG; AFP; inhibit A
What is offered if antenatal screening is deemed high risk?
Further testing is offered:
- Chorionic villous sampling
- Amniocentesis
What is looked for on the anomaly scan at 20 weeks?
11 physical conditions e.g. spina bifida, cleft lip, diaphragmatic hernia
Congenital visceral malformation: gastroschisis, exophalos
What are the options for a termination of pregnancy?
<9 weeks = mifepristone
<13 weeks = surgical D&C
> 15 weeks = D&C or late medical abortion
What are the risk factors for cervical cancer?
HPV - sexual partners, risky sexual behaviours, no vaccine
OCP
Smoking
Family history
What are the risk factors for endometrial cancer?
Increased age Earlier onset of menstruation Late menopause Oestrogen only hormone replacement therapy No or fewer pregnancies Obesity Polycystic ovarian syndrome Tamoxifen
What are the risk factors for ovarian cancer?
Early menarche Late menopause No pregnancies Obesity Age Smoking BRCA genes Clomifene
Vulval cancer risk factors?
Age
Lichen sclerosis
Immunosuppressioin
HPV
What is the tumour marker for ovarian cancer?
CA125
