Quesmed Flashcards
When does paget’s disease of the breast present?
In older women with an eczma like rash around the nipple and areola
May spread to rest of breast
What are the features of padget’s disease of the breast?
Eczema-like rash on the skin of the nipple and areola. This is may be itchy, red, crusty and inflamed.
Nipple discharge which may be bloody.
Burning sensation, increased sensitivity or pain
Nipple changes such as nipple retraction or inverted
In some cases there may be a palpable breast lump
There may be a skin ulcer which does not heal
What can infection mastitis lead to?
Accumulation of pus in an area of the breast which can lead to the development of a lactational breast absess
What is the cause of a lactational breast absess?
The most common causative agent is staphylococcus aureus, which enters via a crack in the nipple skin or through a milk duct.
What is the managemnet of a lactational breast absess?
Incision and drainage or needle aspiration (with or without diagnostic ultrasound)
The combination of irregular, hard lump which is fixed to the deep tissue (likely her pectorialis major) is very suspicious for what?
Invasive breast cancer
What is a fibroadenoma?
Benign breast lump commonly seen in young women. It typically presents as smooth, firm, highly mobile, painless mass in the breast which is slow growing. It may sometimes be called a “breast mouse” due to its highly mobile nature.
Every patient who have a wide local excision should be offered what?
Adjuvant Rt
Mechanism of action of tamoxifen?
Oestrogen receptor antagonist
Where is tamoxifen metabolised?
pro-drug which is metabolised in the liver into active compounds (afimoxifene and endoxifen). T
Main actions of tamoxifen?
Their main useful actions are as competitive antagonists at the oestrogen receptor. In oestrogen receptor positive tumours this acts to suppress activity or any residual tumour cells.
What is cyclical mastalgia?
Cyclical mastalgia is breast tenderness which comes and goes with the monthly menstrual cycle.
A 60 year old female presents to her general practice. She has noted a patch of dry, thickened and ‘flakey’ skin over her left nipple. She has not noticed any discharge from the nipple.
On examination the breasts are symmetrical, there is no nipple inversion, discharge, swelling or palpable lump. There are no other findings on examination.
Given the likely diagnosis what is the best option?
Refer for a two week wait breast clinic appointment
Suggests paget’s disease
What is the first line mnagamet of uncomplicated mastitis?
continue breast feeding. This helps to stop the milk from building up in the breast. Static milk is prone to ascending infection via the milk ducts. Ensuring a proper latch is crucial as poor latching is a risk factor for mastit
A 56 year old lady undergoes a mastectomy for a T3N0M0 breast cancer. Hormone receptor sensitivities return as oestrogen and progesterone receptor negative but HER2 positive. Which adjuvant therapy is she likely to benefit from?
Trastuzumab (otherwise known as Herceptin) is a monoclonal antibody against the extracellular domain of the HER2 receptor. It improves survival of patients with HER2 positive breast cancer.
What patients as an adjuvant can tamoxifen be used
In patients who have oestrogen receptor positive breast cancer who are pre or peri-menopausal.
A 70 year old female has undergone surgical treatment for an invasive, node negative non-metastatic breast cancer. The surgery was a success and post-operative adjuvant radiotherapy has also been completed. The patient has no other significant past medical history and has no allergies to any medications. The histology results for the tumour show that it is Her2 negative, Oestrogen receptor positive and Progesterone receptor negative.
Given what is known about the patient’s disease what is the best treatment to manage the patient?
Anastrozole
This aromatase inhibitor is used in post-menopausal patents with breast cancer that oestrogen receptor positive. This helps reduce the levels of oestrogen in post-menopausal women, who make the majority of their oestrogen via aromatisation.
Trustuzamab (‘Herceptin’) side effects
Cardiac dysfunction – including heart failure
Teratogenicity
Why is a mammogram difficult in pateitns under 40?
Denser breast tissue
What is fat necrosis?
Fat necrosis is a benign pathology of the breast which is more common in obese patients.
Possible complications of axillary node clearnace
Axillary node clearance related injury
Lymphoedema
Damage to brachial plexus cords or nerves
Axillary artery/vein injury
What is a phyllodes tumour?
breast cancer originating from fibroepithelial tissue and can be difficult to distinguish from a benign fibroadenoma. They commonly present as a smooth, hard, mobile breast mass which can grow rapidly in size over a period of weeks or months
What age group does phyllodes tumour usually present in?
Present in women in their 40s or 50s (in contrast to fibroadenomas, which tend to appear in younger women).
Epidimology of fibrocytic disease?
Fibrocystic disease is the most common benign disease of the breast.
It occurs most commonly in the 20-50 year old age group.
It is caused by the cumulative effect of cyclical hormones such as oestrogen and progesterone (among many others) which leads to chronic changes in the breast including multiple small cysts and proliferative changes.§
Clinical features of fibrocystic disease?
Bilateral “lumpy” breasts – more commonly in upper outer quadrant
Breast pain
Symptoms which worsen with the menstrual cycle – normally peaking 1 week before menstruation
Management of fibrocystic disease?
Treatment is essentially supportive although there is some question as to whether oral contraceptives or hormone replacement therapy may work.
Most cases will resolve after menopause.
A 35 year old woman presents to the GP after noticing a breast lump in the shower 2 weeks ago. She is generally well, is not taking any regular medication and has no family history of breast cancer. She does not smoke or drink alcohol.
On examination, there is a small, solid 1cm mass in the right breast which is non-tender. There are no visible skin or nipple changes and the patient reports no discharge. No lymphadenopathy is felt on palpation of the axilla.
What is the most appropriate management in regards to referral to secondary care?
Urgent referral as the patient as over the age of 30 with an unexplained breast lump.
What are the clinical featrures of periductal mastitis?
The smoking history is a strong risk factor for periductal mastitis. The mammary duct fistula is a feature associated with periductal mastitis. This condition occurs when the ducts behind the nipple become infected.
Risk factors for breast carcinoma?
Increased hormone exposure; Early menarche or late menopause, Nulliparity or late first pregnancy, Oral contraceptives or Hormonal Replacement Therapy Susceptibility gene mutations: Most commonly BRCA mutations (BRCA1/BRCA2) Advancing age Caucasian ethnicity Obesity and lack of physical activity Alcohol and tobacco use Past history of breast cancer Previous radiotherapy treatment
First line medication for mastitis?
Flucloaxcillin
First steps of management for shoulder dystocia?
Once shoulder dystocia has been recognised, management is as follows:
Immediately call for help - further midwifery assistance, senior obstetrician, paediatrician and anaesthetist may be required
Do not apply fundal pressure as this may lead to uterine rupture and discourage maternal pushing as this may exacerbate shoulder impaction
First line procedure is McRoberts manoeuvre
Hyperflexion and abduction of the mother’s legs tightly to the abdomen
This may be accompanied with applied suprapubic pressure
Routine traction (as applied during normal delivery) in an axial direction should be applied to assess whether the shoulders have been released.
What should be done iif McRobert’s manoeuvre fails?
All-fours position
Internal rotational manoeuvres:
Woods’ screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest.
If both first and second line manoeuvres have failed, the following may be considered (but carry increased risk of morbidity and mortality and success rates are unknown):
Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section
Causes of polyhydramions?
Excess production can be due to increased foetal urination:
Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome
Insufficient removal can be due to reduced foetal swallowing:
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
What is the defenition of acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is a rare condition which occurs in the third trimester of pregnancy.
The cause for this fatty liver is unclear but it is believed that it may be part of a spectrum of pregnancy conditions with HELLP syndrome and pre-eclampsia.
What are the clinical features of acute fatty liver of pregnancy?
Jaundice Abdominal pain (commonly in right upper quadrant) Disseminated Intravascular Coagulation Nausea and/or vomiting Malaise Fatigue Oliguria Tachycardia Fever
safest anti-epileptic medications to use during pregnancy.
Carbamazepine
Iamotrigine
What is cabergoline?
Dopamine receptor agonist
Inhibits prolactin production leading to suppression of lactation
What is frank breech?
Legs are fully extended up to the shoulders and the presenting part is the buttocks.
Certain circumstances call for addition or subtraction of points (Bishops score modifiers):
1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
The components of the bishop score can be remembered with the following mnemonic:
Pregnancy Can Enlarge Dainty Stomachs! (Position, Consistency, Effacement, Dilation, Station).
What can prostaglandin E2 PV do?
Encourage cervical ripening and increase the likelihood of a vaginal delivery
Management of hyperemesis gravidarum?
Fluid replacement therapy with normal saline
Potassium chloride as excessive vomiting usually causes hypokalaemia
Anti-emetic medications such as cyclizine (first line), metoclopramide or prochlorperazine. Ondansetron or domperidone may be used in severe cases.
Thiamine and folic acid to prevent development of Wernicke’s encephalopathy
Antacids to relieve epigastric pain
Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration.
Selective screening for gestational diabetes is based on risk factors. Patients with any of the following risk factors can be offered an OGTT at 26-28 weeks gestation:
BMI above 30kg/m2.
Previous macrosomic baby (weighing 4.5kg or above).
Previous gestational diabetes.
First degree relative with diabetes.
Ethnic origin with a high prevalence of diabetes (South Asian, black Carribbean, Middle Eastern)
Antepartum haemorrhage is what?
Vaginal bleeding occurring between 24 weeks of pregnancy and birth.
What is the management of placental abruption?
Admit to hospital, obtain IV access and crossmatch blood, monitor fetus with cardiotocography and consider delivery
Antepartum haemorrhage may be concealed in some cases and thus she may be losing a lot of blood disproportionate to the visible blood loss.
What does milk ejection come from
Oxytocin
Where is oxytocin produced from?
Posterior pituitary gland
Side effects of progestrone
premenstrual syndrome-like symptoms, mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain
Where are follicle stimulating hormone (FSH) and luteinising hormone (LH) produced in males?
Anterior pituitary
What is human placental lactogen
has metabolic effects on the mother, including stimulating an increase in the plasma level of glucose, amino acids and free fatty acids. This ensures that there is a constant supply of energy substrates for the foetus to use.
Which hormone acts on the endometrium during the proliferative phase of the uterine cycle?
Oestrogen
Which of the following is a function of luteinising hormone (LH) in males?
LH acts on the Leydig cells in the testes to stimulate androgen production.
What nerve causes male erection?
The pelvic splanchnic nerve carries PARASYMPATHETIC fibres from S2-4, responsible for the male erection but not ejaculation. Remember, ‘Point’.
What nerve causes ejaulation
Pudendal
What is shed during the menstrual phase of the uterine cycle?
The stratum functionalis of the endometrium
What is the cortical reaction
Reaction with prevents more than one sperm cell entering the same oocyte.
Which of the following is an action of oestrogen in the female reproductive cycle?
Promotes endometrial proliferation during the proliferative stage of the uterine cycle
What is the role of follicle stimulating hormone (FSH) in the male reproductive system?
FSH acts on Sertoli cells in the testes to stimulate spermatogenesis and to support spermiogenesi
action of luteinising hormone (LH) in females?
The LH surge induces ovulation.
Transforms the empty Graafian follicle into the corpus luteum after ovulation.
Stimulates the production of androgens by the theca cells, which then undergo FSH-stimulated aromatisation in the granulosa cells.
Which type of cell does follicle stimulating hormone (FSH) act on in males?
Sertoli cells
What happens to HR during pregnancy and why
Between week 6 and week 28 of gestation a woman’s cardiac output will increase by 30 to 50%. This is a necessary development to support a growing pregnancy; supplying the uterus and placenta with adequate blood and removing waste products from the fetal circulation.
What is prolactin secretion regulated by
Tonic dopamine secretion
Steps in spermatogenesis
Spermatogonia (diploid stem germ cells) lie on the basement membrane of the seminiferous tubules in the testes.
The stem cells multiply using the process of mitosis inside the testes. Half of the new cells from this go onto become the future sperm cells (type B spermatogonia), and the other half remain as stem cells so that there is a constant source of germ cells (A1 spermatogonia).
The spermatogonia that will undergo spermatogenesis cross the membrane into the sertoli cells. They become enlarged and are called primary sperm cells.
The primary sperm cells undergo meiosis which produces two secondary spermatocytes.
The secondary spermatocytes undergo a second division of meiosis which produces a total of four haploid spermatids.
The spermatids are released into the seminiferous tubules (a process called spermination).
The spermatids mature into spermatozoa in a process called spermiogenesis as they travel along the seminiferous tubule.
Once they reach the epididymus, the spermatids undergo the final stages of maturation. This can take up to a week.
A sustained erection, in the absence of physical and psychological stimuli, beyond 4 hours is called what
Priapism
A 31 year old woman delivered her first baby 4 weeks ago. After a good start with breastfeeding, the mother is now having difficulty producing milk. Which of the following may be implicated?
The mother is taking the OCCP
Which of the following best describes the acrosome reaction?
The release of hydrolytic enzymes from the head of the sperm which softens the zona pellucida to enable fertilisation to occur.
oestrogen-receptor-positive (ER +ve), early-stage breast cancer in postmenopausal women treatment
Aromatase inhibitors
anastrozole, exemestane and letrozole.
What does HCG do?
Produced by foetal trophoblast cells.
It is structurally similar to luteinising hormone (LH) so it is able to bind to LH receptors on the corpus luteum. This prevents the regression of the corpus luteum so that progesterone production continues for the first 8-10 weeks of pregnancy. After this, the placenta takes over the production of progesterone.
During pregnancy, oxytocin and oxytocin receptors in the myometrium are down-regulated to reduce myometrial excitability. Which hormone is responsible for this?
Progestrone
What triggers menstruation if fertilisation does not occur?
Degeneration of the corpus luteum leading to a fall in the level of progesterone
Which hormone in the combined oral contraceptive pill (COCP) is primarily responsible for preventing pregnancy?
Progestrone
Site of sperm maturation
Epididymis
Fluid that is released from the ducts of the seminal vesicles protects and supports the sperm. It has the following properties:
It is alkaline to neutralise the acidic environment of the male urethra and the female reproductive tract which would otherwise inactivate and harm the sperm cells.
It contains fructose, which the sperm use for ATP production.
It contains prostaglandins, which contributes to sperm mobility and may stimulate smooth muscle contraction within the female reproductive tract.
It contains clotting proteins, which help the semen to coagulate after ejaculation.
Which hormone acts on the endometrium during the secretory phase of the uterine cycle?
Progestrone
Criteria known as the UK Medical Eligibility Criteria (UKMEC) is used to guide decisions about when to start the COCP. There are four categories:
UKMEC1: a condition for which there is no restriction for the use of the COCP
UKMEC2: a condition where the advantages of using the COCP generally outweigh the theoretical or proven risks
UKMEC3: a condition where the theoretical or proven risks usually outweigh the advantages of using the COCP. The provision of a method requires excellent clinical judgment and referral to a specialist contraceptive provider. Not usually recommended unless other more appropriate methods are not available or not acceptable
UKMEC4: a condition which represents an unacceptable health risk if the COCP is used
UKMEC3 conditions include:
BMI more than 35
Family history of VTE
More than 35 years old and smoking, but less than 15 cigarettes per day
Immobility e.g. wheelchair use
Carrier of known gene mutations associated with breast cancer e.g. BRCA1/BRCA2
Controlled hypertension
Diabetes mellitus diagnosed more than 20 years ago but is not very severe
UKMEC4 conditions include:
Migraine with aura
More than 35 years old and smoking more than 15 cigarettes per day
History of VTE
History of stroke or heart disease
Breastfeeding less than 6 weeks post-partum
Uncontrolled hypertension
Major surgery with prolonged immobilisation
Severe diabetes mellitus diagnosed more than 20 years ago
What does an ovulation test measure
LH levels
Diagnosis of PCOS requires two out of the following:
infrequent or no periods, high levels of androgen hormones (such as testosterone) or the physical characteristics of androgen excess (such as hirsutism), and evidence of ovarian cysts on pelvic ultrasound. There is also an association with obesity and high levels of insulin and development of type II diabetes mellitus, which is why PCOS is often considered a metabolic syndrome. It is a common cause of fertility problems for females, as ovulation is impaired.
The ovarian ‘cysts’ described in the name PCOS are actually what
ovarian follicles which have arrested in their development, and can be seen around the periphery of the ovary on ultrasound. They are not the cause of the disease, and not all sufferers of PCOS actually have ‘polycystic ovaries’. The underlying aetiology of PCOS is as of yet unclear, although a combination of genetic and environmental factors has been implicated.
What is progestrone
released following ovulation. A blood test for the level of progesterone can be taken on day 21 of a regular menstrual cycle. A high progesterone level indicates that ovulation has occurred, whereas a low level indicates that the cycle was anovulatory.
What happens during the proliferative phase
Occurs from around day 6 to day 13.
Oestrogen secreted by growing ovarian follicles stimulates the repair of the endometrium. As the stratum basale remains, it is able to undergo mitosis to form a new stratum functionalis.
As the endometrium thickens, the endometrial glands become larger and more densely packed and the spiral arterioles coil and lengthen.
A 14 year old boy visits his GP because he is concerned that he hasn’t had any growth of secondary sexual hair. What hormonal mechanism underpins this physiological change?
Activation of pulsatile GnRH secretion
Which of the following best describes the process of capacitation?
The physiological changes that spermatozoa undergo once in the female reproductive tract in order to gain the ability to penetrate and fertilise an oocyte.
What is the primary source of progesterone after 8-10 weeks of pregnancy?
The placenta
Approximately how long does spermatogenesis take?
74 days
If pregnancy does not occur, the corpus luteum will degenerate. What structure does this form?
Corpus albicans
Which of the following underpins the onset of menstrual bleeding in the normal cycle?
Following ovulation the corpus luteum maintains the lining of the womb. If the oocyte is not fertilised then the fall in lutenising hormone (LH) levels will result in the degeneration of the corpus luteum, and the womb lining will break down and be lost from the womb in vaginal bleeding.
Oestrogen is produced in the ovaries, and to a lesser degree, in the adrenal glands and adipose tissue. It is responsible for:
Development of the female reproductive structures.
Development of female secondary sexual characteristics. These include: distribution of adipose tissues in the breasts, abdomen, mons pubis and hips, pigmentation of the nipples, change in voice pitch, broadening of the pelvis, and changes to the pattern of hair growth on the body.
Increased protein anabolism (synergistic with growth hormone).
Maintenance of bone mineral density.
Reduction in cholesterol concentrations and increase in serum triglyceride concentrations.
During the ovarian cycle, oestrogen promotes endometrial proliferation, and triggers the LH surge which leads to ovulation. It also stimulates the muscles in the uterus to develop and contract, which helps to expel the dead tissue during menstruation.
Which type of cell does luteinising hormone (LH) act on in males?
Leydig cells
Management of PCOS
symptom control, including diet and exercise, and the use of medications such as metformin (an anti-diabetic drug) and the oral contraceptive pill to regulate bleeding and counteract the excess of androgens. Medication may also be used induce ovulation in women hoping to become pregnant.
A 21 year old female has been prescribed the combined oral contraceptive pill by her GP. Which of the following describes its effect on gonadotrophin releasing hormone (GnRH)?
Decreases the GnRH pulse frequency through negative feedback
What does the COOP contain
oestradiol (the most active of the oestrogens) plus a progestin (a progesterone analogue, such as Levonorgestrel, Desogestrel or Drospirenone). It is usually taken daily for 21 days, with a 7-day break before starting again. This allows a ‘break-through bleed’ or shedding of the endometrial lining, which will not occur if the pill is taken continuously. Monophasic formulations contain the same concentrations of hormones in each pill, whilst phasic formulations vary the concentrations to reflect a more natural cycle.
Hormonal methods of contraception often thicken the cervical mucus to prevent the passage of sperm into the uterus. Which hormone is responsible for this?
Progestrone
Once oestrogen production falls beyond a critical value what happens to LH and FSH
Less negative feedback so more FSH and LH
Where does oxytocin act
It acts via cell-surface G-protein coupled receptors to stimulate intracellular changes in myometrial cells, causing an increase in contractility.
Site of spermatogenesis
Seminiferous tubules
What happens during the menstral phase of the uterine cycle
Occurs from day 1 to around day 5. Declining levels of progesterone and oestrogen stimulate the release of prostaglandins that cause the uterine spiral arteries to constrict. As a result, the endometrial tissue becomes ischaemic. This causes cell death within the stratum functionalis of the endometrium and so it sloughs off.
Around 50-150 ml of blood, tissue fluid, mucus and epithelial cells are shed through the vagina
Once a spermatozoon reaches a secondary oocyte, it releases hydrolytic enzymes that break down the zona pellucida to enable it to reach the membrane of the oocyte for fertilisation. Which term describes this process?
The acrosome reaction
How many primordial follicles are stimulated each cycle
Multiple primordial follicles are stimulated each cycle to grow and develop, however usually only one follicle is allowed to reach full maturation and release its oocyte. In the case of dizygotic twins, two oocytes have been released during ovulation and fertilised by two sperm cells. This results in twins which are genetically equivalent to siblings, (and are sometimes called ‘fraternal twins’).
Correct order for spermatogenesis
Spermatogonia -> primary spermatocytes -> secondary spermatocytes -> spermatids -> sperm.
