Repro wk 5 +6 Flashcards
How do you investigate menstral complaints?
Heavy periods - FBC Intermenstral bleeds/post coital bleeds - chlamydia test Pregnancy test Transvaginal ultrasound Hypsteroscopy
What are the common menstral problems in early teens?
Anovultaory cyts
Coagulation problems
What are the common menstrual problems in teens to 40s?
Chlymadia Contraception related Endometriosis/adenomyosis Fibroids Endometrial/cervical polyps Dysfunctional bleeding
What are the common menstrual problems in 40s-menopause?
As of those below 40 along with: Perimenopausal anovulation Endometrial cancer Warfarin Thyroid dysfunction
What is the PALM-COEIN classification of bleeding?
Polyp Adenomyosis Leiomyoma Malignancy/hyperplasia Coagulation Ovarian (PCOS etc) Endocrine (thyroid) Iatorgenic (warfarin) Not yet classified
What is dysfunctional uterine bleeding?
Abnomral bleeding but no structural/ endocrine/neoplastic /infectious cause found
What is endometriosis?
Where endometrial tissue is found outside the uterine cavity
A chronic condition based on oestrogen
Most often affects ovary, pouch of douglas and peritoneum
What are the theories of the pathogensis of endometriosis?
Retrograde menstruation Colemic metaplasia Coelmic metaplasia Haemtogenous spread Direct transplatation
What are the signs + symtpoms of endometriosis?
Symptoms >Premenstrual pelvic pain >Dysmenorrhoea >Deep dyspareunia >Subfertility
Signs >None >Tender nodules in rectovaginal septum Limited uterine mobility Adnexal masses
How do you diagnose endometriosis?
Laparascopy
>Lesions in varying colours - clear, red, bluish black or white
MRI for deep
US can diagnose chocolate cyst
How do you treat endometriosis?
Medical (hormonal+analgesics)
>Progestogen
>Combined OCP
>GnRH analogues
Surgical
>Excision
>Diathermy/laser ablation of deposits
Removal of ovaries +/- hysteroectomy
What is adenomyosis?
Endometrial tissue in myometrium
What are the signs/symptoms of adenomyosis?
Heavy painful perdios
Bulk tender uterus
Parous women
Co-exists (sometimes) with endometriosis
How do you diagnose adenomyosis?
MRI
Histology of uterine muscles (usually post hysterectomy)
How do you treat adenomyosis?
Treat symptoms of heavy/painful periods with contraception
Mirena coil
Progestogens
combined OCP
What are fibroids?
Smooth muscle growths (leiomyomas)
Common and asymptomatic
How do you diagnose fibroids?
Clinical exam - irregularly enlarged uterus
USS
Hysteroscopy
What are the types of fibroids?
Sub-mucous - uterine cavity
Intramural - within uterine wall
Sub-serous - project into peritoneal cavity
What are the symptoms of fibroids?
May cause pressure symptoms
Menorrhagia
Intermenstural bleeding (in submucosal or fibroid polyps)
Can rapidly increase in size in pregnancy
How do you treat fibroids?
If symptomatic then: GnRH analogues to try and shrink Resection of sumucous fibroids Myomectomy Uterine artery embolisation Hysterectomy
How do you treat dysfunctional uterine bleeding?
Reassure no sinister pathology
Medical:
>Tranexamic acid/mefanamic acid
>Progestogen tablets, Progesterone hormonal contraception (depo provera, minera c-OCP)
Surgical
>Endometrial ablation
Hysterectomy
How do tranexamic acid + mefanamic acid work?
Reduce blood loss
Megenamic also reduces pain
Taken at time of periods and useful for those trying to concieve
Do not regulate cycles
How does hormonal contraception affect dysfunctional uterine bleeding?
Makes periods lighter
More regular
Less painful
Same with progesterone, although may not reduce bleeding
What is endometrial ablation?
Permanent destruction of endometrium using energy
Diathermy
Thermal balloon
Radiofrequency
Some will require hysterectomy
What are the pre-requisites to endometrial ablation?
Uterine cavity >11cm
Submucous fibrous <3cm
Previously normal endometrial biopsy
How can a hysterectomy be performed?
Adominaly
Vaginally
Laparascopically
What are the risks of a hysterectomy?
Infection DVT Bladder/bowel/vessel injury Altered bladder function Adhesions
Takes 2-3 months to recover
What is a salpingo-oophorectomy?
Removal of tubes + ovaries
Why are women who have had a hysterectomy at high risk of menopause even if ovaries are left in?
Compromised blood supply
What is the breast?
A highly specialised, modified sweat gland
Has no special capsule or sheath
More developed in females where it is a secondary sexual characteristic
What contributes to breast size/shape?
Genetic
Racial
Dietary factors
How is the breast attached to the dermis?
By suspensory ligament of cooper
Which helps supports the lobules of the gland
How much of the breast lies on the pectoralis major and how much on the serratus anterior?
2/3 on pec major
1/3 on serratus anterior
What are the structures of the breast?
Nipple
Areloa
15-20 lobules of glandular tissue (parenchyme)
How are the parenchyma of the breast drained?
Via the lactiferous duct
What is the lactiferous sinus?
A dilated portion of the lactiferous duct
Where do the lactiferous ducts drain?
Into the nipple
What are the features of the nipple?
Has no fat or hair
Contains collagenous dense connective tissue, elastic fibres and bands of smooth muscle
Tips fissured by lactiferous ducts
What are the features of the areola?
Skin covering nipple/areloa contains numerous sebacous/sweat glands
Enlarges during pregnancy
Oily material secreted provides protective lubricant for nipple and areola
What are the anatomical divisions of the breast?
4 quadrants + axillary tail Superolateral Inferolateral Supermedial Inferomedial
- axillary tail extension of superolateral quadrant
What are the features of the male breast?
Rudimentary throughout life
Formed by small ducts without lobules/alveoli
LIttle supporting fibroadipose tissue
Temporary enlargement in newborn/puberty
How does the breast develop?
Mammary crests or ridges appear during 4th week
Extend from axillary region to inguinal
Usually dissappear everywhere but pectoral region
What is gynaecomastia?
Postnatal development of rudimentary lactiferous ducts in males
During mid puberty about 2/3 develop various hyperplasia in breasts
What is polymastia?
An extra breast
What is polythelia?
An extra nipple
What is athelia/amastia?
Abscence of nipple/breast
What is the blood supply of the breast?
Bracnhes of axillary artery
Internal thoracic
And intercostal arteries
Thoracoacromial artery
Lateral thoracic
Internal mammary artery
WHat is the nerve supply of the breast?
Anterior/lateral cutaneous branches of intercostal nerves 4-6
What do the nerves of the breast innervate?
Convey sensory fibres to skin of breast
Carry sympathetic fibres to blood vessels/smooth muscle around nipple
Why is the lymphatic in the breast of partocilar importance?
Do not contain valves
Metastatic dissemination primarily by these lymphatic routes
Where do the breasts’ lymphatics drain?
Most from lateral quadrants into axillary lymph nodes
Some into supraclavicular/cervical nodes
Medial quadrants into parasternal to opposite breast
How is a sentinel node biopsy done?
Radiolabelled colloid used to locate senitnel node
When surgery is done, a blue dye is injected
Gives an accurate means of localising the node
Used to map and stage patients
What is the histology of the normal breast?
Extensive branching duct system
Surrounded by dense fibrous + interlobular tissue and adipose tissue
Ducts + acini lined by epithelial + myoepithelial cells
What are the prepuberty changes of the breast?
Neonatal breast contain lactiferous ducts but no alveoli
Until puberty little branching of the ducts occurs
Slight breast enlargement reflects growth of fibrous stroma and fat
What are the puberty changes of the breast?
Branching of lactiferous ducts
Solid spherhoidal masses of granular polyhedral cells (alveoli)
Accumulation of lipids in adipocytes
How does the breast change during pregnancy?
Lobules enlarge
Acini dilate
Epithelium vary from cubuoudal to low columnar
Colostrum - protein reich fluid available few days after birth
Rich in maternal antibodies
How does the breast change with lactation?
Acini distend with milk
Thin septa between lobules
At higher magnification - can see acini with eosinophillic material containing clear vaculoes
Milk production through suckling
What are the diagnostic methods used on the breast?
Mammography
USS
FNA
Core biopsy
What is the chance of devloping breast cancer?
1 in 9
What are the types of benign breast tumours?
Fibroadenomas Duct papiloomas Ademonas Connective tissue tumours Pajects disease of the nipple
What is pagets disease?
Erosion of the nipple - resembles eczema
Asociated with ductal or invasive carcinoma
How can you take a cytology from the breast?
FNA
Direct smear from nipple discharge
Scrape of nipple with scapel
What palpable abnormalities would you use an FNA for in the breast?
Discrete masses (either cystic/solid) Diffuse thickening Nipple Lesion (either discharge or eczmatous skin)
What are the features of benign cystology?
Low/moderate cellularity Cohesive groups of cells Flat sheets of cells Bipolar nuclei in background Cells of uniform size Uniform chromatin pattern
What are the features of malignant cytology?
High cellularity Loss of cohesion Crowding/overlapping of cells Nuclear pleomorphism Hyperchromasia Absence of bipolar nuclei
What is the cytology scoring system?
Unsatisfactory - C1 Benign - C2 Atypia - C3 Suspicious - C4 Malignant - C5
When do you not discard cystic fluid?
When it is blood stained
Or residual mass
What are the advantages of cytology?
Simple procedure
Well tolerated
Inexpensive
Get immediate results
What are the limitations of cytology?
Not 100% accuracy Invasion cannot be assessed Nor can grading Can miss small lesions Difficult to examine cells Differing interpretation
What are the complications of FNA?
Pain
Haematoma
Faiting
Infection, pneumothorax
What can be diagnosed from a nipple scrape?
Paget’s disease (squamous + malgnant cells)
Eczema (squamous cells from epidermis only)
When would you perform a nipple discharge cytology?
Bloody discharge from a single duct
What can be diagnosed by a nipple discharge cystology?
Duct ectasia (only macrophages) Intraduct papilloma (benign cells in papillary groups) Intraduct carcinoma (malignant cells)
When is a core biospy performed?
All cases with
Clinical
radiological
Or cytological suspicion
Breast screening
Or pre-op classification
What is performed on a core biopsy?
Confirm invasion
Tumour grading/typing
Imminohistochemistry
What is the pre-puberty breast like?
No lobules with varying degrees of branching
15-25 lactiferous ducts
Ducts start from nipple and branch outwards forming terminal ductal lobular units
What are the histological changes in menopause?
Lobular size decreases and is replaced by fibrous/adipose tissue
Increasing adipose as time does on
What are the two linings of the breast ducts?
Internal
Peripheral (myoepithelial)
What determines if a breast neoplastic condition is in situ?
If the myoepithelial cells are still present
What determines if a breast neoplastic condition is invasive?
If the myoepithelial lining has been lost
What are the benign breast conditions?
Fibrocycstic change Fibroadenoma Intraduct papilloma Fat necrosis Duct ectasia
What are some examples of fibrocystic change?
Fibrosis Adenosis Cysts Apocrine metaplasia Ductal epithelial hyperplasia
What is the most common cause od fat necrosis?
Traumatic
What is duct ectasia?
Diltation of the duct
Most often due to blockage of duct
Can rupture - resulting in nipple discharge
What does fibrocystic change look like?
Enlarged ducts (white) with pink fibrous tissue
What is fibroadenoma?
Proliferation of pithelial and stromal elements
Most common breast cancer in adolescent /young women
May regress with age if untreated
Well circumscribed non painful mass, freely mobile
What are the types of fibroadenoma?
Ducts being distorted/elongated = intracanalicular pattern (slit like)
Ducts not compresssed = pericanalicular growth pattern (normal appearance)
What is tubular adeoma?
Less common
Young women, discrete, freely moveable
Uniform sized ducts
What is lactating adeoma?
Enlarging mass during lactation/pregnancy
Prominent secretory change
Who is affected by intraduct papilloma? What is it?
Usually middle aged women
Present with nipple discharge
Epithelial hyperplasia
A papillary infiltration that occurs within a duct
What is fat necrosis?
History of trauma
Can simulate carcinoma both clinically and in mamogram
Has histocytes with foarmy cytoplasm
Lipid filled cysts
Fibrosis, calcifications on mamography (egg shel
What is phyllodes tumour?
A fleshy tumour (fibroepithelial lesion)
Has leaf-like pattern + cysts on cut surface
Circumscribed connective tissue + epithelial elements
Can be borderline, malignant or benign
Metasteses travel by haematogenous spread
It is the stromal component that is proliferative
Who is affected by breast carcinoma?
1/8 women
1 in 870 men
Commonest cause of female cancer death (1/3 from disease)
How does breast carcinoma appear on a mamogram?
Soft tissue opacity
Microcalcification
How does breast carcinoma present macroscopically?
Hard lumps fixed in place
Tethered to skin
Dimpling of skin
What are the risk factors for breast cancer?
Female Inc age Delayed age of first pregnancy Early menarch/late menopause Family /personal history HRT Obesity Alcohol Lack of physical activity Radiation
What is LCIS?
Lobular carcinoma in situ
What is DCIS?
Ductus carcinoma in situ
How much do the BRACA genes incrweas your risk of cancer?
BRACA1 - 20-40%
BRACA2 - 1–30%
What are the histological classification of breast cancer?
Non invasive (DCIS/LCIS) Invasive: Invasive ductal carcinoma (75%) Invasive lobular carcinoma (5-15%) Special types
What is in situ carcinoma?
Preinvasive - does not form palapble tumour
No lump - not detected clinically
Multicentricity (multiple parts of same breast) + bilaterality
No metastatic spread
What is the difference between atypical lobular displasia and LCIS?
LCIS affects the whole lobule
Atypical lobular dysplasia ia not whole lobule
What is the characteristic abnormality of lobular carcinoma?
The loss of the transmembrane molcule
What types of procedures are diagnostic for breast cancer?
Clinical exam
Radiology (mamogram etc)
FNA
Needle core biopsy
When is breast screening carried out?
Ever 3 years
From age 50-70
What are microcalcifications?
Tiny depostis of calcium appearing anywhere in the breast
Mostly harmless however small percentage precancerous or cancerous
What are the two main indicators for breast cancer picked up on a mammography?
Masses
Microcalcifications
What do cancers does anti-oestrogen therapy work on?
Oestrogen receptive tumours
What does transonimab work on?
HER-2 positive tumours
How do breast cancers spread?
Local (skin/pectoral muscles)
Lymphatic (axillary/internal mammary nodes)
Blood (bone, lungs, liver, brain)
What is the prognosis of breast cancer dependant on?
Node status (if no nodes good prognosis, if positive depends on nodes amount) Younger = more aggressive cancers HER-2 + ER/PR good prognosis now with treatment (ER best)
What is pagets disease of the nipple?
Result of intraepithelial spread of intraductal carcinoma
Large pale-staining cells within epidermis of nipple
Pain, itching, scaling + redness
Can be mistaken for ecezma
Ulceration, crusting + serous/bloody discharge possible
What is gynaecomastia?
Most common clinical/patholigcal abnormality in male breast
Increasein subareolar tissue
30-40% of males
Associated with cirrhosis, chronic renal failure, hypothyroidism, COPD + drugs
