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OBGY Flashcards

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1
Q

When is hormone therapy offered to women with breast cancer? Which drugs are used?

A

If tumours are positive for hormone receptors:

  • Tamoxifen in pre/peri-menopausal women
  • Anastrozole in post-menopausal women
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2
Q

When should you refer to the 2WW breast cancer pathway?

A

> 30 unexplained lump with or without pain

>50 in one nipple: discharge, retraction, other changes of concern

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3
Q

When should you consider a referral to 2WW breast cancer pathway?

A

Skin changes that suggest breast cancer

>30 lump in axilla

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4
Q

When should you complete a non-urgent referral to breast clinic?

A

<30 lump with or without pain

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5
Q

Which contraceptive is most associated with weight gain?

A

Depo-provera injections

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6
Q

What is the management of intrahepatic cholestasis of pregnancy?

A
  1. Ursodeoxycholic acid

2. Elective induction from 37 weeks

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7
Q

What is a fibroadenoma?

A

common benign tumours of stromal/epithelial breast duct tissue

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8
Q

What are the features of a fibroadenoma?

A

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

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9
Q

Why are fibroadenomas more common in younger women?

A

They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.

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10
Q

Which breast lump fluctuates with the menstrual cycle?

A

Fibrocystic Breast Changes

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11
Q

What are the symptoms of fibrocystic breast changes?

A

10 days before period, resolve when period ends:

Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size

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12
Q

What is the management of fibrocystic breast changes?

A

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

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13
Q

What is the most common cause of breast lumps?

A

Breast cysts

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14
Q

What are the features of breast cysts?

A

Smooth
Well-circumscribed
Mobile
Possibly fluctuant (change size around period)

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15
Q

What is fat necrosis of the breast?

A

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.

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16
Q

What are the features of fat necrosis of the breast?

A 
Painless
Firm
Irregular
Fixed in local structures
There may be skin dimpling or nipple inversion
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17
Q

What might look similar to breast cancer on US or mammogram?

A

Fat necrosis

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18
Q

What is the management for fat necrosis?

A
  1. exclude cancer

2. conservative (resection if symptoms)

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19
Q

What are the features of lipoma?

A

Soft
Painless
Mobile
Do not cause skin changes

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20
Q

What is the management of lipomas?

A

Reassurance

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21
Q

What is a galactocele?

A

breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk.

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22
Q

What are the features of a galactocele?

A

irm, mobile, painless lump, usually beneath the areola

benign - usually resolve without treatment

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23
Q

What is a Phyllodes tumour?

A

rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50

surgical removal, wide-excision + chemo

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24
Q

What are the two types of mastalgia?

A

Cyclical

Non-cyclical

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25
Name three causes of non-cyclical breast pain.
Medications (e.g., hormonal contraceptive medications) Infection (e.g., mastitis) Pregnancy
26
Give three differentials for breast pain
Cancer (perform a thorough history and examination) Infection (mastitis) Pregnancy (perform a pregnancy test)
27
What hormonal treatments can be used to treat breast pain?
danazol and tamoxifen (under specialist)
28
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)
29
Which genes can predispose to breast cancer?
``` BRCA1 = CX17 BRCA2 = CX13 ``` TP53 PTEN
30
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 ```
31
What is the management of lobular carcinoma in situ?
close monitoring (e.g., 6 monthly examination and yearly mammograms)
32
What is the most common type of invasive breast cancer?
Invasive ductal carcinoma
33
What should be considered if mastitis does not respond to antibiotics?
Inflammatory breast cancers
34
How does Paget's disease of the nipple present?
Looks like eczema of the nipple/areolar | Erythematous, scaly rash
35
Describe the breast cancer screening programme in the UK
offers a mammogram every 3 years to women aged 50 – 70 years.
36
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
37
What should be done before genetic testing for breast cancer?
Counselling
38
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
39
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
40
What is the triple assessment?
Clinical assessment (history and examination) Imaging (ultrasound or mammography) Biopsy (fine needle aspiration or core biopsy)
41
What are the three types of breast imaging?
US - younger women MMG - older women MRI - high risk
42
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.
43
Name three breast cancer receptors
Oestrogen receptors (ER) Progesterone receptors (PR) Human epidermal growth factor (HER2)
44
What is triple-negative breast cancer?
cancer cells do not express any of these three receptors carries a worse prognosis
45
Who should receive gene expression profiling?
women with early breast cancers that are ER positive but HER2 and lymph node negative
46
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
47
What system is used for staging of breast cancer?
TNM system T - tumour N - nodes M - mets
48
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
49
What can cause chronic lymphoedema?
Axillary clearance after breast cancer surgery
50
When should surgical excision be offered for fibroadenomas?
>3cm
51
What should be offered after a wide-local excision of breast cancer to reduce recurrence?
Whole breast radiotherapy
52
What is duct ectasia?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple
53
How do patients present with duct ectasia?
greenish nipple discharge with a peri-areolar lump
54
What is indicated by a 'snowstorm' sign on breast US?
Implant rupture
55
What is the purpose of neoadjuvant therapy in breast cancer?
downsize the tumour before surgery
56
What are the differentials for pelvic pain?
Gynae: PID, ectopic pregnancy, ovarian cyst/torsion/rupture/haemorrhage, endometriosis Urological: pyelonephritis, appendicitis, diverticulitis, IBD/IBS
57
What is the definition of a APH?
PV bleeding >24 weeks into pregnancy
58
Name the causes of APH
``` Placental abruption Placenta praaevia Genital tract pathology Uterine rupture Vasa praaevia ```
59
What are the causes of a PPH?
4Ts Tone - atonic uterus Trauma - uterine rupture Tissue - retained tissue Thrombin - coagulopathy
60
What is the definition of a miscarriage?
Loss of pregnancy in the first 24 weeks
61
What is the most common cause of miscarriage int he 1st trimester?
Chromosomal abnormalities
62
What is the most common cause of miscarriage in the 2nd trimester?
Cervical incompetence Also: Drugs - smoking, alcohol, caffeine Infection
63
Name some differentials for PV bleeding during the first 24 weeks of pregnancy
Implantation bleeding Cervical pathology UTI Ectopic pregnancy
64
What is the general management of a miscarriage?
1. ABCDE 2. TV US, serum hCG, pelvic examination 3. Expectant/medical/surgical management
65
What are the 5 types of miscarriage?
``` Threatened Inevitable Incomplete Missed Complete ```
66
What might be seen on US in a miscarriage?
POC Gestational sac >25mm with no yolk sac Adnexal mass FHR
67
What might be seen on serum hCG in a miscarriage?
hCG does not double in 48 hours
68
What is the medical management of miscarriage?
Misoprostol (vaginal)
69
What is the surgical management of a miscarriage?
Suction curettage | ERPC (GA)
70
Who should receive surgical management of miscarriage?
Personal choice | Increased risk: bleeding, infection, unstable
71
What is a recurrent miscarriage?
>3 miscarriages in a row
72
What are the risk factors for recurrent miscarriage?
Obesity Age Smoking
73
What is the most common cause of recurrent miscarriage?
Anti-phospholipid syndrome
74
How can recurrent miscarriages be investigated?
Bloods - clotting factors | Hypsteroscopy
75
What are the risk factors for an ectopic pregnancy?
``` Previous ectopic Endometriosis IUCD POP IVF PID Maternal age (>35) Smoking ```
76
When can an ectopic pregnancy be managed medically? What is the management?
Serum hCG <3000 no FHR unruptured no pain IM methotrexate
77
What are the features of placenta praaevia?
Non-tender Painless Shock consistent with bleeding Normal FHR Breach/transverse lie Red blood
78
What are the features of placental abruption?
‘woody’ hard uterus Painful Shock inconsistent with bleeding Foetal distress Normal lie Dark blood
79
What are the risk factors for placenta praaevia?
More common in twins, high parity, age and scarred uterus
80
What are the risk factors for placental abruption?
Pre-eclampsia Smoking/cocaine Previous abruption Intrauterine growth restriction
81
What is the general management of an APH?
1. Maternal welfare (ABCDE) 2. Monitor foetal condition (CTG, US) 3. Early delivery (section/induce labour
82
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
83
What should be given to rhesus negative women in APH?
Anti-D
84
What is the definition of a PPH?
Loss of >500ml of blood <24 hours after delivery
85
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 ```
86
What is the most common cause of PPH?
Atonic uterus
87
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
88
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
88
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
89
How is anaemia of pregnancy treated?
Fe | Folic acid
90
When should anti-D be given to pregnant women?
give anti-D @ 28 and 34 and within 72 hours of a sensitizing event
91
What is the purpose of the 12 week scan?
1. Due date (depending on crown-rump length) 2. Diagnose multiple pregnancies 3. Offer screening: trisomy 21 (down’s syndrome), 18 (Edward’s) and 13 (Patau’s)
92
Describe the testing for Down's syndrome
1. Combined screening - maternal blood test (hCG/PAPP-A); nuchal translucency; maternal risk factors 2. Quadruple test - maternal blood test for 4 hormones: oestriol; hCG; AFP; inhibit A
93
What is offered if antenatal screening is deemed high risk?
Further testing is offered: - Chorionic villous sampling - Amniocentesis
94
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
95
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
96
What are the risk factors for cervical cancer?
HPV - sexual partners, risky sexual behaviours, no vaccine OCP Smoking Family history
97
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 ```
98
What are the risk factors for ovarian cancer?
``` Early menarche Late menopause No pregnancies Obesity Age Smoking BRCA genes Clomifene ```
99
Vulval cancer risk factors?
Age Lichen sclerosis Immunosuppressioin HPV
100
What is the tumour marker for ovarian cancer?
CA125

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