Womans Health

Question 1

Risk cancer risk indicators based on family history?

Answer 1

• Two 1^st degree or 2^nd degree relatives on one side of family with Ca
• Individuals with age of onset of ca < 50
• Individuals with bilateral or multifocal breast ca
• Individuals w/ ovarian ca
• Breast Ca in male relative
• Jewish ancestry

Question 2

Breast cancer screening recs for an asymptomatic low risk woman?

Answer 2

• Asymptomatic, low-risk woman
  
  • Screen recommended every 2 yrs between 50-74
  • Screening mammography optional for women 40-49
    
    • Better diagnostic tool in older woman due to less dense/glandular breast tissue
    • Specificity approx. 90%
• Use FRA-BOC (Familial Risk Assessment – Breast and Ovarian Cancer) tool to guide screening for women at increased risk
  
  • Cat 1 – at (or slightly above) average risk, option 2^nd yrly mammograms for 40, routinely recommended from 50
  • Cat 2 – moderately increased risk, annual mammograms from 40 if woman has 1^st-degree relative <50yrs diagnosed with breast cancer; otherwise routine 2 yrly mammograms recommended
  • Cat 3 – potentially high risk – referral to family cancer clinic recommended for possible genetic testing, increased surveillance determined on individual basis

Question 3

Risk factors for cervical cancer?

Answer 3

• Being sexually active (due to HPV exposure)
• Smoking
• COCP use >5yrs
• Immunosuppression
• Exposure to diethylstilboestrol in utero (old drug taken during pregnancy no longer used)

Question 4

Who should have cervical screening?

Answer 4

• All women sexually active from age 25, OR 2 yrs after 1^st sexual intercourse (whichever is later)
• Includes woman who:
  
  • Have had intimate sexual skin on skin contact
  • Have sex with woman
  • Are no longer sexually active
  • Have been HPV vaccinated
  • Are in monogamous relationship
• Should continue every 5 years to age 74
  
  • -ve HPV after age 70 → discontinue screening (i.e. exit test 70-74)
  • Consider >75 if never screened or not done in past 5 yrs, if requested
• Consider earlier testing (20-24) if sexually active <14 OR before receiving HPV vaccine

Question 5

Speculum exam - diagnosis?

Answer 5

Nulliparous cervix

Question 6

Speculum exam - diagnosis?

Answer 6

Eversion / ecropion. Nil further investigation if asymptomatic.

Question 7

Speculum exam - diagnosis?

Answer 7

Nabothian follicles. Nil further investigation if asymptomatic.

Question 8

Speculum exam - diagnosis?

Answer 8

Multiparous. No further ix needed if asymptomatic.

Question 9

Speculum exam - diagnosis?

Answer 9

Atrophy - no further Ix needed if asymptomatic

Question 10

Speculum exam - diagnosis?

Answer 10

Cervical polyp - requires further Ix

Question 11

Speculum exam - diagnosis?

Answer 11

Cervical wart - consider further ix

Question 12

Speculum exam - diagnosis?

Answer 12

Mucopurulent discharge - needs further Ix

Question 13

Speculum exam - diagnosis?

Answer 13

Cervical cancer - needs further Ix

Question 14

Speculum exam - diagnosis?

Answer 14

IUD

Question 15

Speculum exam - diagnosis?

Answer 15

Cervical stenosis - if asymptomatic doesnt need Ix

Question 16

Speculum exam - diagnosis?

Answer 16

Cervix post treatment for ca - no intervention if asymptomatic

Question 17

Information to include on CST request?

Answer 17

• symptomatic?
• age
• hormonal state (i.e. pregnancy, post partum period, post menopausal)
• presence of IUD
• prev abnormal results
• clinical findings

Question 18

Things to consider during CST consult? (also practical things)

Answer 18

• Think about contraception, STI screening, family planning, breast awareness/screening
• Ask about prev CST results, discomfort (i.e. atrophy) etc
• Sample → needs sufficient mature + metaplastic squamous cells to indicate sampling from whole transformation zone, as well as sufficient endocervical cells to indicate upper limit of transformation zone was sampled (to screen for adenocarcinoma)
• Timing → avoid during menstruation, during obvious vaginal infection, within 48 hrs of vaginal creams, pessaries or douching

Question 19

CST result: HPV Not 16/18 detected - further Ix/Mx?

Answer 19

Question 20

CST result: HPV 16/18 - Further management?

Answer 20

All cytology results - refer for colp

Question 21

Post treatment assessment of HSIL?

Answer 21

• After treatment should complete test of cure surveillance to confirm successful
• Co-test (HPV + LBC) 12 months post treatment, and annually until pt receives negative cotest on 2 consecutive occasions → return to 5 yrly screening

Question 22

Risk factors for endometrial cancer/hyperplasia?

Answer 22

• Note: Identifies women at risk for Type I cancer
• Endogenous oestrogen
  
  • ↑ cumulative Oe exposure
    
    • ↑ age
    • Early menarche / Late menopause (>55)
    • Nulliparity → ? linked to anovulation
    • Chronic anovulation
      
      • PCOS
      • Perimenopausal period
  • Other endogenous Oe source
    
    • Obesity
    • Oe-secreting tumour
• Exogenous oestrogen
  
  • Unopposed Oe HRT
  • Tamoxifen therapy
• Other
  
  • HNPCC
  • FmHx of endometrial / ovarian / breast / colon cancer
  • DM
  • HTN
• Protective Factors
  
  • COC
  • Combined HRT
• Essentially unopposed oestrogen stimulation of endometrium

Question 23

Symptoms of endometrial cancer or hyperplasia?

Answer 23

• Abnormal uterine bleeding → >90%!, ESP perimenopausal
  
  • Irregular
  • Menorrhagia
• Vaginal discharge (leucorrhoea)

Question 24

Investigations for suspected endometrial cancer/hyperplasia?

Answer 24

• US -> determine endometrial thickness, however won’t necessarily detect hyperplasia
• Requires biopsy
  
  • Pipelle (endometrial sampling), can miss due to not seeing lesions
  • Hysteroscopy, D&C -> required to fully evaluate any abnormalities on sampling

Question 25

Risk factors for ovarian cancer?

Answer 25

* Increase no. of ovulations * nulligravidity/infertility * Early menarche/late menopause * Endometriosis * PCOS * Obesity * SMoking * Family hx of breast/ovarian/colorectal ca * BRCA1&2 -\> 10-15% of ovarian ca * HNPCC -\> ~1% ovarian ca * Protective factors * OCP * Multiparity * Tubal ligation/hysterectomy * Breast feeding * Progesterone

Question 26

Clinical features of ovarian cancer?

Answer 26

* Symptoms usually vague * Abdo distension * Nausea * Anorexia * Early satiety -\> ascites, bowel mets * Dyspnoea -\> pleural effusion * Pressure Sx (mass effect?) * Feeling of pelvic pressure * GI complaints - constipation etc * Urinary frequency * Lower limb oedema * Examination * Distended abdomen * Adnexal/pelvic mass * Ascites

Question 27

Where does ovarian ca metastasize to?

Answer 27

* Peritoneal cavity / surfaces * Lymphatics → pleural cavity, nodes * Organs → lung, liver, GI, brain (uncommon)

Question 28

Investigations for suspected ovarian cancer/tumour?

Answer 28

* **USS** → adnexal mass * USS features suggestive of malignancy: * Solid component → nodular, papillary * Doppler flow in the solid compartment * Septations * Presence of ascites * Peritoneal masses, enlarged nodes etc. * More accurate in postmenopausal age group: have higher incidence of malignancy. * **Bloods** * **CA 125** → not specific for epithelial tumour(endometrial Ca, pancreatic Ca, endometriosis, fibroids, PID, 1% normal women! etc. etc.) * More useful in postmenopausal women: high incidence of malignancy * Indications: * Suspicious features on US * Postmenopausal woman * Persistent ovarian cyst on 2 pelvic US 6 weeks apart AND * Simple cyst \>5cm (premenopausal) * Cyst \<5cm if complex (haemorrhagic, endometrial, dermoid, cystadenoma * Pelvic pain * **AFP** → largely germ cell tumours * **Β-hCG** → largely germ cell tumours * Indications for AFP, LDH, B-hCG, HE4 (Human epididymis protein 4) * Pre-pubertal pts w/ ovarian cyst or mass * Pt aged \<40 with complex cyst * \>3cm at diagnosis * \<3cm persistent at 6 wk US f/u * **Other imaging**: * abdo / pelvic CT → look for sites of metastasis * look at endometrium → 10% have synchronous primaries! * Gastroscopy / colonoscopy if suspected GI primary * Breast imaging if suspected breast primary * **Surgery** → histology = definitive Dx

Question 29

Post treatment surveillance for ovarian ca?

Answer 29

* Posttreatment Surveillance * Every 3/12 for 2 years, then 6/12 for 3 years, then annually * Tumour markers every visit * Pelvic examination as clinically indicated * Imaging as clinically indicated

Question 30

Risk factors for breast cancer?

Answer 30

* Age \>40 * Western * Pre-existing benign lumps * Alcohol intake \>2SDs/day * Use of MHT \>5 yrs (combined) * PHx of breast ca * FHx in 1^st degree relative (x3 rr) * Genetic mutation BRCA1 or BRCA2 * Nulliparity * Late menopause (\>53) * Obesity * Childless \>30 yrs * Early menarche * Ionising radiation exposure * Ashkenazi Jewish Ancestry

Question 31

Symptoms/signs of breast ca?

Answer 31

* **Clinical features** * 75% present w/ a lump * Usually painless, hard & irregular * Nipple changes, discharge, retraction, or distortion * Rarely -\> Paget disease of breast (nipple eczema) or inflammatory B.C. * Rarely bone secondaries (i.e. back pain, dyspnoea, weight loss, headache) * Symptoms/red flags * Lump * Skin dimpling * Peau d’orange * Nipple inversion * Bloodstained nipple discharge * Eczema of nipple

Question 32

DDx of breast lump?

Answer 32

* High probability * Fibrocystic disease (32%) * Fibroadenoma (23%) * Cancer (22%) * Cysts (10%) * Breast abscess/periareolar inflammation * Lactation cyst (galactocele) * Serious disorders (don’t miss) * Vascular -\> thrombophlebitis (mondors disease) * Infection -\> mastitis, breast abscess, tuberculosis * Cancer * Carcinoma * DCIS * Pagets disease of nipple * Sarcoma * Lymphoma * Mastitis carcinomatosa * Other -\> phyllodes tumour * Pitfalls (often missed) * Duct papilloma * Lipoma * Mammary duct ectasia * Fat necrosis/fibrosis