Ebook Murtagh''s general practice (5th edition): Part 2

(BQ) Part 2 book Murtagh''s general practice presents the following contents: Women''s health, men’s health, sexually related problems, problems of the skin, chronic disorders - continuing management, accident and emergency medicine, health of specific groups.

Part 5 Women's health

89

Cervical cancer

Cervical cancer is a common malignancy in women

worldwide, especially in the developing countries; it

is the sixth most common in Australia1 and seventh

in the US.2 The incidence of invasive cervical cancer

rises steadily from age 20 to 50 and then remains

relatively steady

The most common form of cervical cancer is

squamous cell carcinoma (SCC) 85–90%, with

adenocarcinoma representing 10–15%.2

A striking epidemiological feature about cervical

cancer is that it is a disorder related to sexual activity

It is almost non-existent in virgins but has an increased

incidence in women with multiple partners and

those who began sexual activity at an early age Thus,

epidemiological studies indicate that cervical cancer is

a sexually transmitted disorder (see Table 89.1)

Table 89.1 Cervical cancer and risk factors

Age Increased After 55

Sexuality Increased With multiple and/

or promiscuous sex partnersEarly age for fi rst intercourseEarly age fi rst pregnancyViruses Increased After herpes II or

wart virus infection (probable)

Occupation Increased In prostitutes

(decreased in nuns)Parity Increased Multiparity

Socioeconomic

status

Increased With low

socioeconomic status

Cervical cancer and

Pap smears

If all women have regular Pap smears, one every two years, we can prevent 90% of all cervical cancers.

DR G A B R I E L E M E D L E Y, TI M E, 2 4 AP R I L 1 9 9 5

Facts and fi gures

• Invasive cervical cancer is almost unknown in women under the age of 20, and very rare before age 25

• There are two small peaks of incidence, in the late 30s and late 60s.1

• The lifetime probability of an Australian woman developing cancer is 1 in 90.3

• On average, cervical cancer takes at least a decade

to develop from a focus of a cervical squamous intraepithelial lesion.4

• SCC of the cervix occurs almost exclusively in women who have had coitus

• The earlier the age of fi rst intercourse, the greater the chance of developing cervical cancer

• Invasive cervical cancer is a disease for which defi nite curable premalignant lesions can be identifi ed using a Papanicolaou (Pap) smear as a screening test

• The incidence of cervical cancer has been decreased signifi cantly through the screening procedures of the Pap smear, colposcopy and colposcopically directed cervical biopsy

• Poor Pap smear technique is a common cause of a false negative result

• The GP needs to achieve the best possible cervical cell sample and forward it to the best possible cytology laboratory

• Despite the availability of liquid-based smears, a well-taken conventional Pap smear is still a very good screening test

• New methods of laboratory examination of the smear include PAPNET, which involves computer scanning

of the smear, and ThinPrep, whereby a liquid-based sample is prepared

Basic pathologyThe focus of attention is the transformation zone (see

Fig 89.1) where columnar cells lining the endocervical canal undergo metaplasia to squamous cells—in the region of the squamocolumnar junction It is important clinically to realise that this transformation zone

89

Cervical cancer and Pap smears

Figure 89.1 The transformation zone: it is vital that cells

are taken from this zone with Pap smears

Figure 89.2 Changing position of the transformation zone with age, and a selection of sampling instruments according

to its position

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can extend with progressive metaplasia of columnar

epithelium and so the squamocolumnar junction

may recede into the endocervical canal This is a

feature in postmenopausal women (see Fig 89.2) As squamous cell carcinoma almost always arises in the transformation zone, it is vital that cells are taken from

it when performing a Pap smear

Cervical intraepithelial neoplasiaCellular changes can occur in the transformation zone for a variety of reasons, including invasion with human papillomavirus (HPV) One such important change is cervical dysplasia, previously known as cervical intraepithelial neoplasia (CIN) and squamous intraepithelial lesion in the now adopted modifi ed Bethesda System.5, 6 These dysplasias have the potential

to become invasive cervical cancer

Natural history of cervical dysplasia Dysplasia may return to normal, persist or eventually progress to invasive cervical cancer The reported progression times to cervical cancer range from 1 to

30 years On average it takes at least 10 years, so it is considered that 2-yearly Pap smears are a reasonable safety margin However, women with histologically confi rmed moderate to severe dysplasia require a colposcopic assessment

928 Part Five Women's health

Figure 89.3 and Table 89.2 illustrate the disease

spectrum of cervical neoplasia

Clinical presentation

Many patients with cervical cancer are asymptomatic

and when early symptoms do arise they are often

dismissed as of little consequence

Symptoms, if present, may be:

• vaginal bleeding, especially postcoital bleeding

• vaginal discharge

• symptoms of advanced disease (e.g vaginal urine or

fl atus, weakness)

Screening recommendations

Routine Pap smears

• Perform every 2 years for women 18–70 years of age

with no clinical evidence of cervical pathology and who

have ever had sex

• Perform from beginning of sexual activity up to 70 years

• Begin Pap smears at 18–20 years or 1–2 years after fi rst

sexual intercourse (whichever is later)

• Cease at 70 years in those who have had two normal

Pap smears within the last 5 years

• Perform a Pap smear on women over 70 years if they

request it or if they have never had a smear or if they

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1 Normal Normal Within normal

CIN 2 HSIL

6 Severe dysplasia

CIN 3 HSIL

7 Carcinoma in situ

8 Invasive carcinoma

Invasive carcinoma

Invasive carcinoma

ASCUS = Atypical squamous cells of undetermined signifi cance

CIN = Cervical intraepithelial neoplasia

CIS = Carcinoma in situ

HSIL = High-grade squamous intraepithelial lesion

LSIL = Low-grade squamous intraepithelial lesion

89

Cervical cancer and Pap smears

Women who have never engaged in coitus do not need Pap smears However lesbian women require

Pap testing even if they have never had a male sexual

partner.7 Six-monthly or 12-monthly screening on young,

asymptomatic women provides only minimal benefi t

compared with 2-year intervals

Hysterectomy

Smears are needed if the cervix was not completely

removed However, vaginal vault smears are needed

if there is a history of gynaecological dysplasia or

malignancy, exposure to diethylstilboestrol in utero and

in immunosuppressed women

Taking a Pap smear1, 7

The importance of a good specimen

The optimal Pap smear contains:

• suffi cient mature and metaplastic squamous cells

to indicate adequate sampling from the whole of the transformation zone

• suffi cient endocervical cells to indicate that the upper

limit of the transformation zone was sampled; and to provide a sample for screening of adenocarcinoma and its precursors

Optimal timing of specimens

• The best time is any time after the cessation of the

period

• Avoid smear-taking during menstruation

• Avoid in the presence of obvious vaginal infection

• Avoid within 48 hours of use of vaginal creams or

pessaries or douching

• Avoid within 24 hours of intercourse

• Avoid lubrication or cleaning of cervix with preliminary

pelvic examination

Communicating with the pathologist

Good communication with the pathologist is essential

It is important to provide basic details about the reason

for the Pap smear and the clinical history on the

pathology form sent to the laboratory Include patient

age, LMP, hormone intake, previous treatment and

clinical fi ndings

The method

1 Education and explanation

Take time to explain the reason for taking the Pap smear, especially if it is the fi rst Emphasise that it

is mainly a preventive measure to detect and treat early cell changes that could develop into cancer

Anatomical models, sample instructions or charts are useful in describing the procedure Explain that

it does not hurt and doesn’t take long, that it may

be uncomfortable but slow deep breathing will help relaxation and make it easier It is preferable to talk to

the patient during the examination with appropriate explanation It is advisable for a male doctor to have a chaperone present

2 Equipment

Prepare the following equipment:

• adequate light source

• speculum (preferably bivalve) warmed under lukewarm water

• glass slide labelled in pencil with the woman’s name and date of birth

• spray fi xative

• plastic gloves for both hands

• smear-taking instruments; choose from:

— Ayer’s spatula, wooden or plastic

— Cervex sampler broom

— Cervex-Brush Combi

— endocervical brush Refer Figure 89.2 for recommended choice

Better visualisation of the cervix is obtained if the patient elevates her buttocks with her hands (best as fi sts)

4 Inserting the speculum6

Avoid using lubricating jelly on the speculum blades

Warming the speculum with water should provide adequate lubrication Gently spread the labia with a gloved hand

and introduce the speculum with the blades vertical

or at 45° from the vertical Gently advance the blades with slow fi rm pressure towards the rectum as far as possible Rotate the blades during the process until they are horizontal and exerting gentle pressure against the posterior wall of the vagina Remember that the cervix

is situated in the upper sixth of the anterior vaginal wall (not in the apex of the vagina)

5 Visualising the cervix

Good lighting and exposure of the cervix is essential

Note any signifi cant features or abnormalities of the cervix Reassure the woman if the cervix looks normal with a comment such as ‘Your tissues look very healthy’

A cervical ectropion is normal in most premenopausal women and was formerly incorrectly called an erosion

6 Taking the smear

Choose the sampling instrument that best suits the shape of the cervix and os Place Ayer’s spatula fi rmly

930 Part Five Women's health

on the os and rotate it through 360°, ensuring that

the whole transformation zone is sampled (see Fig

89.6a)

If the squamocolumnar junction is not visible (lying within the endocervical canal), use both spatula (fi rst)

and the cytobrush (see Fig 89.6b) The cytobrush

(tends to cause bleeding) should be advanced until

only the lower bristles are still visible, then rotated for a

quarter of a rotation The cytobrush should be avoided

in pregnant women

After removing the speculum, perform a bimanual pelvic examination if appropriate

7 Preparing the slide

Transfer the cervical cell sample on to a glass slide

with an even spreading motion (see Fig 89.6c, d)

Fix immediately (within 5 seconds from a distance of

20 cm to prevent air drying, which distorts cellular

features) with an aerosol or pump-action alcohol spray

(see Fig 89.6e)

8 The HPV and chlamydia sample

If appropriate after the smear, place the brush and

spatula in the tube with the transport medium (do not

use a wooden spatula for a liquid-based sample) Swirl

it around vigorously to release material The specimen

tube can be forwarded with the slide to the laboratory

with a request to test for HPV and chlamydia

Follow-up

Discuss mutually suitable arrangements to ensure that

the woman obtains the result of the smear whether it is

positive or negative Inform her when her next smear is

likely to be due (special cards are available) and have a

system in place to send a reminder note

The explanation of the results, especially if there is an

abnormality present (a variety of abnormal smear),

should be crystal clear to the patient

Abnormal cervical cytology

Confi rmation of the Pap smear result is by colposcopy

and/or by a biopsy and appropriate referral should be

arranged without delay

Inaccurate results can be caused by:9

• using dirty glass slides

• using lubricants or doing pelvic examinations before

taking the smear

• insuffi cient material

• endocervical cells not being taken in the smear

(i.e taken from the wrong site)

• a thick fi lm with an inadequate spread of material

• air-drying before fi xing

• smear not being fi xed for long enough or the solution

of alcohol being too weak

• the slide not being dry before being placed in

the cardboard container (this encourages fungal

overgrowth)

Figure 89.4 The supine or dorsal position is the best position for the speculum examination and subsequent bimanual palpation (patient should be appropriately clothed and/or draped)

Figure 89.5 The Sims exaggerated left lateral position

89

Cervical cancer and Pap smears

Abnormal Pap smearsFollow the guidelines in Table 89.3 and Figure 89.7 for the abnormal smear result

Table 89.3 Guidelines for abnormal Pap smears7

Pap smear report

Investigation and management

No endocervical cells Repeat in 2 years

Negative smear—

infl ammatory cells

Repeat smear in 2 years

Unsatisfactory smear Repeat smear in

6–12 weeks (allows regeneration of cells)

Low-grade epithelial lesion

Possible LSIL and

Defi nite LSIL

Repeat Pap smear at

12 months If the woman

is 30+ years, and has

no negative cytology in previous 2–3 years, refer for colposcopy or repeat the test in 6 months

High-grade epithelial lesion

Possible HSIL Defi nite HSIL

Refer for colposcopy

Glandular abnormalities including

adenocarcinoma in situ

Refer to a gynaecologist

Invasive squamous cell carcinoma or adenocarcinoma

Refer to appropriate specialist gynaecologist

or unit

Inconclusive—raising possibility of high-grade disease

Refer for colposcopy and possible biopsy

Post-treatment assessment of HSIL

A woman treated for HSIL should have a colposcopy and cervical cytology at 4–6 months after treatment

Cervical cytology and HPV typing should be done at

12 months and then annually until the woman has tested negative by both tests on two consecutive occasions Return to usual 2-yearly screening when all four tests are negative

Prevention of cervical cancer

‘In other words, chastity and fi delity are recommended for those who can, and condoms for those who cannot’.10This statement is a succinct recommendation for prevention and includes the following:

• Ideally, people should have intercourse with only one partner

Figure 89.6 Method of smear taking and preparing the

slide

932 Part Five Women's health

• The male should use a condom on each occasion if

either sexual partner is unsure of the other’s previous

behaviour

• Those at risk should be counselled accordingly

Other preventive measures include:

• Women should have Pap smears at least 2 yearly

• Identifi cation of high-risk forms of persistent HPV will

aid surveillance If absent, no treatment is needed as

smears become normal

• Use of beta-carotene has a protective effect against

cervical cancer, so ‘both sexes would be well advised

to ensure regular intake of green leaf and orange

vegetables in their diet’.10

• Advise against smoking

HPV vaccination

A new human papillomavirus (types 6, 11, 16, 18)

recombinant vaccine is available for the prevention

of cancer and pre-cancers due to vaccine HPV in

females aged 9–45 years It is given as a course of three

intramuscular injections For maximum effect it should

be given before the onset of sexual activity

Figure 89.7 Algorithm for management of low-grade squamous cell abnormalities (based on NHMRC guidelines)

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Medicolegal issues 8

Cervical cancer screening is a potential minefi eld of litigation, which has increased greatly especially over missed cancers following a false negative Pap smear (a particular dilemma for cytology laboratories)

Common claims made against GPs include:

• failure to offer cervical screening

• failure to adequately investigate abnormal vaginal bleeding (especially postcoital bleeding)

• poor communication including inappropriate use of phone contact

• failure to inform the patient of an abnormal result

• failure to arrange adequate specialist referral for women with abnormal cytological results or a clinically suspicious cervical lesion

Advice and reassurance should be given in a diplomatic way that does not produce guilt feelings

This includes reassurance that not all cervical cancer is sexually transmitted, that women with only one partner may develop cervical cancer and that sexual contact with a male partner who has had the wart virus does not always result in cancer of the cervix.9

89

Cervical cancer and Pap smears

REFERENCES

1 Free A Screening for the Prevention of Cervical Cancer

Canberra: Department of Health, Housing and Community Services, 1991: 1–26.

2 Rakel RE Essentials of Family Practice Philadelphia:

Saunders, 1993: 130–1.

3 Giles G, Armstrong GK, Smith LR (eds) Cancer in Australia

Melbourne: National Cancer Statistics Clearing House

Scientifi c Publications No 1, Australasian Association of Cancer Registries and Australian Institute of Health, 1987.

4 Day NE Screening for cancer of the cervix J Epidemiol

Community Health, 1989; 43: 103–6.

5 Kurman RJ, Solomon D The Bethesda System for Reporting

Cervical/Vaginal Cytologic Diagnoses New York:

Springer-Verlag, 1994.

6 National Health and Medical Research Council Screening

to Prevent Cervical Cancer Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities

The Australian Modifi ed Bethesda System Canberra:

NHMRC, 2005

7 McNair R Lesbian and bisexual women’s sexual health

Australian Fam Physician, 2009; 38: 388–93.

8 Reid R, Hyne S Taking better Pap smears Medicine Today,

The Membranous Envelope (condom) is prepared from the bladder of a fi sh caught in the Rhine Its extreme

thinness does not in the least interfere with the pleasure of the act … [its use] is of the greatest utility because,

while it is a sure preventive of conception, it also prevents either party from contracting disease.

ED W A R D BL I S S FO O T E 1 8 6 4 , ME D I C A L CO M M O N SE N S E

Effective family planning requires a good understanding

of the function of the menstrual cycle, whether it is for

the purpose of conception or contraception

The main consultation is the presentation of a young

woman for contraceptive advice It is a very critical

visit and provides an excellent opportunity to develop

a good rapport with the patient and provide education

and counselling about important health concerns,

such as health promotion, menses regulation, sexual

activity, planned parenthood, fertility and infertility,

pregnancy prevention, STI prevention, immunisation

and cervical smears

In counselling and treating patients, especially

teenagers, confi dentiality is of paramount importance

Keep in mind the Gillick test of competency for females

aged under 16 (see Chapter 88, page 920) The issues

and contraceptive methods can be confusing so careful

education using charts and other aids is recommended

to enhance the therapeutic relationship and facilitate

better compliance

It is worth discussing the patient’s attitude to

pregnancy, including the fear of pregnancy and the

possible reaction to contraceptive failure

Fertility control

The choice of contraceptive methodology will be

determined not only by individual needs, personal

preference and resources but also by its safety and

incidence of side effects

It is worth emphasising that the estimated risk of

death associated with child-bearing (1 in 10 000 in

developed countries) is higher than the risk of death

associated with all methods of contraception, with two

exceptions: women over 35 years of age who smoke

and take the combined oestrogen–progestogen oral

contraceptive, and those over 40 years of age taking

this type of preparation.1 In developed countries of

the Western world the most widely used methods, in

order of preference, are combined oral contraceptives

(COC), condoms, diaphragms, intra-uterine devices, spermicidal agents and rhythm.1

A comparison of the efficacy of the various contraceptive methods is presented in Table 90.1 More than half the pregnancies in the US are unintended and occur because of non-use of contraception, failure of a specific method or discontinuation of contraception.2

For women at risk of acquiring STIs the choice of contraception has to consider methods that protect against both pregnancy and STIs

Steroidal contraception

Methods of steroidal contraception include:3, 4

• combined oral contraceptive pill

• progestogen-only pill (POP)

• injectables

• postcoital contraception

• implants (Implanon)

• levonorgestrel-releasing IUCD (Mirena)

• progestogen-releasing vaginal rings

• oestrogen–progestogen-releasing vaginal rings

• oestrogen–progestogen-releasing skin patch

Combined oral contraceptionCOCs usually contain a low-dose oestrogen and a moderate dose of progestogen The main mode of action

of COC is inhibition of hypothalamic and pituitary function leading to anovulation.1

Which oestrogen to use3

Mestranol and ethinyloestradiol (EO) are about equipotent Mestranol undergoes metabolic conversion

to EO in the liver before it exerts its contraceptive effect

EO is therefore the oestrogen of choice

Which progestogen to use3

All progestogens are nor-testosterone derivatives and exhibit a variety of non-progestogenic actions

Natural rhythm methods 20–30

Billings ovulation (cervical mucus) method 3 2–3

Withdrawal (coitus interruptus) 20–25 18

–63(Ov); 5 (O)

0.10.5Ddepomedroxyprogesterone acetate 0.1 0.3

Pearl Index = (total accidental pregnancies × 1200)/total months of exposure

The norethisterone (NET) group includes norethisterone acetate, ethynodiol acetate and

lynestrenol The last three progestogens are converted

to NET before exerting any contraceptive activity

Levonorgestrel (LNG) is 10 times more potent than NET It has less effect on the coagulation system than

NET and is therefore the preferred progestogen

Gestogens are the ‘third generation’ progestogens and include desogestrel, gestodene, norgestimate

and cyproterone acetate These agents, which are less

androgenic than NET and LNG, have been implicated

with an increased risk of thromboembolism but the data

are of doubtful validity The latest progestogens are the

anti-androgenic drospirenone, which is an analogue of

the diuretic spironolactone, and dienogest

Starting the pill: which COC to use3, 4

The aim is to provide good cycle control and effective

contraception with the least side effects using a pill

of the lowest dose The past menstrual history and

contraceptive use of the patient should be documented

and taken into account in selecting the appropriate

COC Various COC preparations available in Australia

are listed in Table 90.2.5, 6, 7

A suitable fi rst choice is a monophasic pill containing

30 mcg ethinyloestradiol (EO) with levonorgestrel

or norethisterone (e.g Nordette, Microgynon 30, Monofeme, Levlen ED)

The high-dose monophasic (50 mcg oestrogen) should be reserved for the following situations

• breakthrough bleeding on low-dose COCs

• control of menorrhagia

• concomitant use of enzyme-inducing drugs

• low-dose pill failure

Education and counselling is very important for the woman starting the pill Suitable patient education should be given The pill can be used safely up to

50 years of age Cover starts immediately if COC commenced on day 1 of the cycle

Note: A ‘quick start’ technique, described by Westoff,

can be used to start the COC on the day of the consultation.8,9

Specifi c patient groups 1, 6

Adolescents. The COC can be prescribed once menstruation has commenced, with appropriate counselling about safe sex and responsibilities The monophasic low-dose combined preparation should

be selected

Epilepsy. Use a COC with a high dose of oestrogen (e.g 50 mcg)

936 Part Five Women's health

Table 90.2 Combined oral contraceptive pill formulations4

Oestrogen Dose (mcg) Progestogen Dose (mcg) Trade name

Monophasic

Ethinyloestradiol 20 Levonorgestrel 100 Microgynon 20,

Loette, Microlevlen

ED, Microgynon 30, Monofeme

Minulet

Ethinyloestradiol 35 Cyproterone acetate 2000 Brenda-35, Diane-35,

Estelle-35, Juliet-35 Ethinyloestradiol 35 Norethisterone 500 Brevinor, Norimin

Ethinyloestradiol 35 Norethisterone 1000 Brevinor-1, Norimin-1

Ethinyloestradiol 50 Levonorgestrel 125 Nordette 50,

28 day

Women with hirsutism. Use a less androgenic

preparation (e.g Diane-35)

Women over 35 years. Use a low-dose monophasic

COC provided the woman is a non-smoker If

continued until about 50 years, the hot fl ushes of the

perimenopause are controlled It is usual to cease

the pill at around 50–51, wait several weeks and then

measure the serum FSH and oestradiol levels If the

oestradiol levels are low and FSH high, the woman

can be regarded as menopausal and can start HRT

if desired

Menstrual disorders: menorrhagia/dysmenorrhoea Start

with a standard low-dose monophasic COC but a

higher-dose oestrogen (50 mcg) pill may be necessary

Acne. For women with acne (not on COC), commence

with a less androgenic progestogen (e.g Diane-35 ED,

Marvelon)

The high-dose monophasic (50 mcg EO) should be

reserved for the following situations:

• breakthrough bleeding on low-dose COCs

• control of menorrhagia

• concomitant use of enzyme-inducing drugs

• low-dose pill failure

Contraindications to COC usage are shown in

Table 90.3

Effi cacy of COCs

Under ideal circumstances the pregnancy rate in women taking COCs is 1–3 per 100 women years of use, but in practice varies from 2–6 per 100 women years.1 There

is estimated to be 6 million unplanned pregnancies

on COCs per year

Non-contraceptive advantages of COCs

A number of signifi cant benefi cial effects arising from the use of COCs have now been documented:

• Reduction in most menstrual cycle disorders

• Reduction in the incidence of functional ovarian cysts

• 50% reduction in the incidence of PID

• Reduced incidence of ovarian and endometrial cancer

• Benign breast disease reduced

• Fewer sebaceous disorders

• reduced incidence of thyroid disorders

Family planning

90

Serious side effects of COCs

The most serious side effects to be considered are

the effects of COCs on the circulatory system and the

incidence of cancer

Cardiovascular effects3, 6

The following circulatory disorders have been linked

with pill usage

• Venous deep vein thrombosis, pulmonary embolism,

rarely: mesenteric, hepatic and kidney

thrombosis

• Arterial myocardial infarction, thrombotic stroke,

haemorrhagic stroke, rarely: retinal and

mesenteric thrombosis

The risk of circulatory disease has not been related

to duration of use and there is no increased risk in

as occurring predominantly in certain high-risk groups—the ‘at-risk female’, particularly the smoker over 35 years of age

Other risk groups include those with thrombophilia hyperlipid aemia, diabetes, hypertension, and a family history of cardiovascular disease or immobilisation

Provided low-dose COCs are prescribed in low-risk females it would appear safe to use the COC pill up to

50 years of age

COCs and cancer

There appears to be no overall increase in the incidence

of cancer in women using COCs

• Possible effect (not absolutely proven) and possibly very low risk:

— cervix (take regular smears at yearly intervals)

Important advice for the patient

• Periods tend to become shorter, regular and lighter

• No break from the pill is necessary

• Drugs that interact with the pill and affect their effi cacy include antacids, purgatives, vitamin C, antibiotics (especially griseofulvin and

rifampicin) and anticonvulsants (except sodium valproate) With warfarin and oral hypoglycaemics, requirements may change for those starting the pill

Table 90.3 Contraindications for use of the COC 4, 7

Absolute

Pregnancy (known or suspected)

First 2 weeks postpartum

History of thomboembolic disease, including known

thrombophilia

Cerebrovascular disease

Focal migraine

Coronary artery disease

Oestrogen-dependent tumours (e.g breast)

Active liver disease

Polycythaemia

Relative

Heavy smoking

>35 years and smoking or other risks of CAD

Undiagnosed abnormal vaginal bleeding

Breastfeeding

4 weeks before surgery

2 weeks after surgery

Gall bladder or liver disease

938 Part Five Women's health

Table 90.4 Management of common side effects of COC7, 10

Acne Increase oestrogen, reduce or

change progestogen

Triphasil/Triquilar to Diane ED/

MarvelonAmenorrhoea Increase oestrogen or decrease

progestogen

Nordette/Microgynon 30 to Nordette 50/Microgynon 50Breakthrough bleeding:

• early to mid cycle

Try progestogen-only pillAvoid direct sun (use blockout)Depression Decrease or change progestogen Nordette/Microgynon 30 to

Triphasil/Triquilar or BrevinorDysmenorrhoea/menorrhagia Increase progestogen

Decrease oestrogen

Triphasil/Triquilar to Nordette/

MicrogynonLibido loss Increase oestrogen

Change from anti-androgenic progestogen to an alternative

Microgynon 30 etc to Femoden/

stop oestrogen

Use Microgynon 20, etc or progestogen-only pillWeight gain:

Biphasil/Sequilar to Triphasil/

Triquilar or progestogen-only pill

• Diarrhoea and vomiting may reduce the effectiveness

of the pill If a woman vomits within 2 hours of taking

an active pill, she should take an additional ‘active’ pill

• Yearly return visits are recommended to update the

history and examination and repeat the Pap smear

Missed pills

The essential advice is ‘just keep going’ (i.e take a pill

as soon as possible and then resume usual pill- taking

‘Two for twenty’ (i.e if two or more 20 mcg pills are missed)

‘Three for thirty’ (i.e if three or more 30–35 mcg pills

are missed)

• take the most recent missed pill ASAP

• continue taking remaining pills as usual

No additional contraception or emergency contraception needed

If ≥3 × 30–35 mcg EO pills

or

≥2 × 20 mcg EO pills

• take the most recent missed pill ASAP

• continue taking remaining pills

• use condoms or abstinence until pill is taken for 7

There are no serious side effects but compliance is a problem because of cycle irregularity, especially with irregular bleeding The mini-pill often reduces the cycle length to less than 25 days or alters the regularity of the bleeding phase

Indications for the POP include age 45 years or more, smokers aged 45 years or more, contraindications to or intolerance of oestrogens, diabetes mellitus, migraine, chloasma, lactation and well-controlled hypertension

Contraindications include pregnancy, undiagnosed genital tract bleeding, past history of or increased risk

of ectopic pregnancy and concomitant use of inducing drugs (absolute)

enzyme-Injectable contraceptives

Depo-ProveraMedroxyprogesterone acetate (Depo-Provera) is the only injectable intramuscular contraceptive available

in Australia It is very effective for up to 14 weeks

Dose: 150 mg by deep IM injection in fi rst fi ve

days of the menstrual cycle The same dose is given every 12 weeks to maintain contraception

Failure rate: 1 per 1000 women years.1Side effects include a disrupted menstrual cycle (amenorrhoea rate 70% or irregular or prolonged uterine bleeding), excessive weight gain, breast tenderness, depression and a delay in return of fertility (average 6 months).8 There is no effect on cardiovascular disease or the incidence of cancer but long-term use is associated with accelerated bone loss

There are no absolute contraindications Its use is not recommended for >2 years or as a fi rst-line contraceptive

in women <18 and preferably <25 years

Etonogestrel implant (Implanon)This is a subdermal contraceptive implant that is a 3-year system consisting of a single rod containing the progestogen, etonogestrel It inhibits ovulation and has an anti-mucus effect Irregular bleeding is the most common side effect It requires a minor surgical procedure to insert it and also to remove it The pregnancy rate is low at <1/1000 over 3 years of use

• Take the forgotten pill as soon as possible, even if it

means taking two pills in one day Take the next pill

at the usual time and fi nish the course

• If you forget to take it for more than 12 hours

after the usual time there is an increased risk of pregnancy so use another contraceptive method (such as condoms) for 7 days

• If these 7 days run beyond the last hormone pill in

your packet, then miss out on the inactive pills (or 7-day gap) and proceed directly to the fi rst hormone pill in your next packet

• You may miss a period (At least seven hormone

tablets should be taken.)

• continue taking the hormone tablets (skip the

inactive pills) until end of next pack

Progestogen-only contraceptive pill

The POP (mini-pill) is perhaps an underutilised method

of contraception, although it is not as effi cacious as

the COC

The two common formulations are:

• levonorgestrel 30 mcg/day

940 Part Five Women's health

• Yuzpe method: use high oestrogen containing COC,

for example 50 mcg EO + 250 mcg LNG (Nordiol)—

two pills initially, then repeated 12 hours later Failure

Causes of oral contraceptive failure include errors in

administration, decreased absorption, missed pills, drug

interactions and high doses of vitamin C It is possible

that the use of triphasics may be a factor

Management options include using a higher-dose

pill, improved education and compliance and an

alternative method

Intra-uterine contraceptive devices

IUCDs are usually small devices made of an inert

material to which may be added a bioactive substance

such as copper (e.g Multiload-cu375), or a progestogen

(e.g Mirena).11 The mechanism of IUCDs is not well

understood, but copper devices affect sperm motility

— undiagnosed abnormal genital tract bleeding

— previous ectopic pregnancy

— severe uterine cavity distortion

• relative

— menorrhagia

— dysmenorrhoea

— lesser uterine cavity distortion

— very large or very small uterus (>9.0 or <5.5 cm)

— anaemia

— defective immune system

— impaired clotting mechanism

— valvular heart disease

— acutely anteverted or retroverted uterus

— increased risk of PID (multiple sex partners)

Recommended use time: copper IUCD 6–10 years,

Mirena 5 years

Problems associated with IUCD usage1

Pregnancy/ectopic pregnancy

If pregnancy occurs there is a 40–50% increased

risk of abortion and intra-uterine sepsis during the

second trimester There is an increased risk of ectopic

pregnancy (up to 10 times compared with COC usage)

so, if pregnancy occurs, ultrasound examination should

be performed to determine the location

Early removal of the IUCD is essential

Pelvic infl ammatory disease

There is evidence of an increased risk of PID in the fi rst

30 days post-insertion Prophylactic doxycycline reduces this risk.4 As this risk is related to sexual activity and the number of partners, those at risk of STIs should avoid using IUCDs

Extrusion, perforation of uterus and translocation

Spontaneous extrusion is greatest during the fi rst month after insertion and the woman is not always aware of this Perforation of the uterus occurs once in every

1000 insertions and review at 6 weeks post-insertion is essential If translocation is proved by X-ray and pelvic ultrasound, removal is mandatory

Bleeding

Intermenstrual bleeding may follow insertion of an IUCD for 2–3 months and then disappear If menstrual loss is excessive, the device should be removed

However, the Mirena system works to reduce menstrual bleeding

Pain

Lower abdominal cramp-like pains of uterine origin and backache may occur soon after insertion and persist intermittently for several weeks Rarely is the pain severe enough to warrant removal of the IUCD

Checking the IUCDWomen should be taught how to examine themselves vaginally to check if the device remains in situ by palpating the strings or threads which protrude from the cervical canal They should have a medical check 2–3 months after the device has been fi tted and again after 12 months

Vaginal ring 8

The fi rst available contraceptive vaginal ring is NuvaRing,

a fl exible polymer ring with 15 mcg ethinyloestradiol and 120 mcg etonogestrel being released per 24 hours

Metabolic effects and side effects are similar to low-dose COC It is inserted into the vagina once a month (in the

fi rst 5 days after a period) and removed after 21 days with a break of 7 days The cycle control is good with

a low incidence of irregular bleeding

Barrier methods

Barrier methods include condoms, vaginal diaphragms, cervical caps and vaginal vault caps If used correctly, some, particularly condoms, are very effective

Condoms are also very effective in preventing the

spread of STIs, including HIV infection The main

disadvantage is that they are mainly reliant on the

cooperation of the male user

Diaphragms have to be individually fi tted After being liberally coated on both sides with a spermicidal

cream they are inserted at any convenient time before

intercourse and removed after 6 hours have elapsed

since the last act of intercourse

Contraceptive patch 8

This combined ethinyloestradiol progesterone

transdermal delivery system is applied to the skin each

week for 3 weeks, followed by a patch-free week WHO

eligibility for use criteria currently remain the same as

for the COC Widely used in the US and Europe but

not yet available in Australia

Spermicides

These are useful adjuncts to barrier methods of

contraception When used alone they have a pregnancy

rate of less than 10 per 100 women years They

are available as creams, jellies, foams or pessaries

containing nonoxynol 9 or octoxinol

Natural methods

These methods require high motivation and regular

menstrual cycles

Basal body temperature method

Coitus should only occur after there has been a rise in

basal body temperature of 0.2°C for 3 days (72 hours)

above the basal body temperature measurement

during the preceding 6 days, until the onset of the next

menstrual period

Calendar or rhythm method11

The woman reviews and records six cycle lengths and

then selects the shortest and longest cycles She then

subtracts 21 from the shortest cycle and 10 from the

longest cycle to work out fertile and safe days (i.e for

26 to 30-day cycle: fertile days 5–20; for regular 28-day

cycle: fertile days 7–18)

Billings ovulation method 5,11

This method is based on careful observation of the

nature of the mucus so that ovulation can be recognised

and intercourse confi ned to when the vagina is dry

Fertile mucus is wet, clear, stringy, increased in

amount and feels lubricative The peak mucus day is

the last day with this oestrogenised mucus before the

abrupt change to thick tacky mucus associated with the

secretion of progesterone The infertile phase begins

on the fourth day after the peak mucus day Abstinence from intercourse is practised from the fi rst awareness

of increased, clearer wet mucus until 4 days after maximum mucus secretion If taught correctly and followed as directed, the method is most effective, with

a failure rate of only 1–2 (average 3) per 100 women years.4 There is a failure rate of at least 15 if the rules are not followed properly

The main reason for failure is that many women are only able to detect 3 to 4 days of wetness prior to the peak moisture day and still have sex 4 to 6 days prior

to ovulation when sperm survival is still possible

Coitus interruptusMale withdrawal before ejaculation is still a widely used method of contraception and despite theoretical objections will probably continue to have a defi nite place in contraceptive practice

Sterilisation

VasectomyWith vasectomy it is important to confi rm the absence

of spermatozoa in the ejaculate 2–3 months after the operation, before ceasing other contraceptive methods It takes about 12–15 ejaculations to clear all the sperm from the tubes proximal to the surgical division Vasectomy reversal is successful in up to 80% of patients.1 There

is a 1 in 500–1000 chance of recanalisation

Tubal ligationFemale sterilisation is usually performed by minilaparotomy or laparoscopy, at which time clips (Filshie or Hulka) or rings (Falope) are applied to each fallopian tube These are potentially reversible methods

of contraception with a 50–70% success rate of reversal.1 There is a subsequent pregnancy rate of 3–4 per 1000 women sterilised

The Essure procedureThis procedure for permanent female birth control involves the placement of a fl exible titanium micro-insert into each fallopian tube with a hysteroscope

The insert expands and over time (usually 3 months) reactive tissue growth occludes the tubes

Termination of pregnancy

It is estimated that 1 in 4 pregnancies in Australia end

in termination This is higher than in countries such as Belgium and Holland, which have liberal abortion laws but also comprehensive sex education programs.12The main methods used are the traditional surgical methods such as suction curettage and medical abortion using drugs such as the prostaglandin E1 analogue misoprostol alone or with methotrexate or mifepristone (RU486)

942 Part Five Women's health

3 O’Connor V, Kovacs G Obstetrics, Gynaecology and

Women’s Health Cambridge: Cambridge University Press,

2003: 395–413.

4 Moulds R (Chair) Therapeutic Guidelines: Endocrinology

(Version 5) Melbourne: Therapeutic Guidelines Ltd, 2009:

203–17.

5 Billings E, Westmore A The Billings Method Melbourne:

Anne O’Donovan, 1992: 11–49.

6 Sexual Health and Family Planning Australia Contraception:

An Australian Clinical Practice Handbook (2nd edn)

11 Harvey C, Read C An update on contraception: Part 3:

IUDs, barriers and natural family planning Medicine Today, 2009; 10(7): 38–48.

12 De Costa C Medical abortion Update Medical Observer,

31 October 2008: 27–9

Breast pain, or mastalgia, is a common problem,

accounting for at least 50% of breast problems

presenting in general practice and 14% of referrals to

an Australian breast clinic.1 As stated in the beginning,

many women suffer breast pain so severe that it affects

their lifestyles, marriages and sexual relationships, and

even prevents them from hugging their children If

no obvious physical cause is found, the problem is all

too often dismissed, without appropriate empathy and

reassurance, as a normal physiological effect

A careful, sympathetic clinical approach, however, followed by reassurance after examination, will be

suffi cient treatment for most patients

Symptoms

Mastalgia usually presents as a heaviness or discomfort

in the breast or as a pricking or stabbing sensation The

pain may radiate down the inner arm when the patient

is carrying heavy objects or when the arm is in constant

use, as in scrubbing fl oors

Key facts and checkpoints

• The typical age span for mastalgia is 30–50 years

• The peak incidence is 35–45 years

• There are four common clinical presentations:

1 diffuse, bilateral cyclical mastalgia

2 diffuse, bilateral non-cyclical mastalgia

3 unilateral diffuse non-cyclical mastalgia

4 localised breast pain

• The specifi c type of mastalgia should be identifi ed

• The commonest type is cyclical mastalgia

• Premenstrual mastalgia (part of type 1) is common

• An underlying malignancy should be excluded

• Less than 10% of breast cancers present with localised

pain

• Only about 1 in 200 women with mastalgia are found

to have breast cancer

• The problems, especially types 2 and 3, are diffi cult to

alleviate

A diagnostic approach

A summary of the safety diagnostic model is presented

in Table 91.1

Breast pain (mastalgia)

Many women suffer breast pain so severe that it affects their lifestyles, marriages and sexual relationships, and

even prevents them from hugging their children.

DR JO H N DAW S O N 1 9 9 0

Probability diagnosis

In the non-pregnant patient, generalised pain, which may be cyclical or non-cyclical, is commonest Typical patterns are illustrated in Figure 91.1

Figure 91.1 Pain patterns for cyclical and non-cyclical mastalgia

DZDMJDBM
NBTUBMHJB OPODZDMJDBM
NBTUBMHJB

Non-cyclical mastalgia is also quite common and the cause is poorly understood It may be associated with duct ectasia and periductal mastitis (see Chapter 93,

page 956)

Serious disorders not to be missedThe three important serious disorders not to be missed with any painful chest condition—neoplasia, infection and myocardial ischaemia—are applicable for breast pain

Neoplasia

We must avoid the trap of considering that breast pain

is not compatible with malignancy Mastalgia can be a presenting symptom (although uncommon) of breast

944 Part Five Women's health

Table 91.1 Mastalgia: diagnostic strategy model

Q Probability diagnosis

A Pregnancy

Cyclical mastalgia:

• benign mammary dysplasia

Q Serious disorders not to be missed

Q Pitfalls (often missed)

✓–

✓––

✓–

Q Is the patient trying to tell me something?

A Yes Fear of malignancy Consider psychogenic

causes

Infection

Mastitis is common among nursing mothers It should

be regarded as a serious and urgent problem because a breast abscess can develop quickly Apart from bacterial

infection, infection with Candida albicans may occur following the use of antibiotics Candida infection

usually causes severe breast pain, producing a feeling like ‘hot cords’, especially during and after feeding

Myocardial ischaemia

A constricting pain under the left breast should be regarded

as myocardial ischaemia until proved otherwise

PitfallsThese include various causes of apparent mastalgia, such as several musculoskeletal chest wall conditions and referred pain from organs such as the heart, oesophagus, lungs and gall bladder and, in particular, from the upper thoracic spine

Musculoskeletal conditions include costochondritis, pectoralis muscle strains or spasm, and entrapment

of the lateral cutaneous branch of the third intercostal nerve Ankylosing spondylitis can affect the chest wall under the breasts Mastalgia may be the fi rst symptom

of pregnancy Pregnancy should be excluded before commencing drug treatment

Seven masquerades checklist

Of these, depression, drugs and spinal dysfunction are probable causes Drugs that can cause breast discomfort include oral contraceptives, HRT and methylxanthine derivatives such as theophylline Drugs that cause tender gynaecomastia (more applicable to men) include digoxin, cimetidine, spironolactone and marijuana

Dysfunction of the upper thoracic spine and even the lower cervical spine can refer pain under a breast

If suspected, these areas of the spine should be examined

Psychogenic considerationsThe symptoms may be exaggerated as a result of an underlying psychogenic disorder, but with a symptom such as breast pain most women fear malignancy and need reassurance

The clinical approach

• Could you be pregnant?

• Is your period on time or overdue?

• Is the pain in both breasts or only one?

cancer ‘Mastitis carcinomatosa’, which is a rare fl orid

form of breast cancer found in young women, often

during lactation, is red and hot but not invariably

painful or tender.2 Pain may also be a symptom in

juvenile fi broadenoma, a soft rapidly growing tumour

in adolescents, and in the fi broadenoma of adult

women

Breast pain (mastalgia)

91

• Do you have pain before your periods or all the time

during your menstrual cycle?

• Do you have pain in your back or where your ribs join

your chest bone?

Examination

The breasts should be systematically palpated to check

for soreness or lumps The underlying chest wall and

thoracic spine should also be examined

Investigations

The following specialised tests could be considered

Mammography should be considered in older women

It is unreliable in young women With few exceptions

it should not be used under 40 years

Ultrasound can be complementary to mammography for it is useful to assess a localised mass or tender area

It is inappropriate to evaluate a diffuse area It is not

so useful for the postmenopausal breast, which is fatty

and looks similar to cancer on ultrasound

Excision biopsy can be useful for an area of localised pain, especially in the presence of a possible mass

Consider a chest X-ray and ECG

Mastalgia in children

Breast pain is uncommon in children, including puberty,

but it may be a presenting problem in the late teens

Pubertal boys may complain of breast lumps under the

nipple (adolescent gynaecomastia) but these are rarely

tender and do not require specifi c treatment

Mastalgia in the elderly

Breast pain is rare after the menopause but is increasing

with increased use of HRT, where it tends to present

as the diffuse bilateral type If the problem is related to

the introduction of HRT, the oestrogen dose should be

reduced or an alternative preparation used

Cyclical mastalgia

The features of cyclical mastalgia are:

• the typical age is 35 years

• discomfort and sometimes pain are present

• usually bilateral but one breast can dominate

• mainly premenstrual

• usually resolves on commencement of menstruation

• breasts diffusely nodular or lumpy

• variable relationship to the pill

Cyclical mastalgia is rare after the menopause

Management

After excluding a diagnosis of cancer and aspirating

palpable cysts, various treatments are possible and can

be given according to severity.3

Acknowledge the condition and its discomfort

Mild

• Reassurance

• Regular review and breast self-examination

• Proper brassiere support

• Proper low-fat diet, excluding caffeine

• Aim at ideal weight

• Adjust oral contraception or HRT (if applicable)

• Analgesia (e.g paracetamol 0.5–1 g (o) 4–6 hourly prn,

or a NSAID e.g ibuprofen)

Moderate

As for mild, plus options (use one or a combination):

• mefenamic acid 500 mg, three times daily

• vitamin B1 (thiamine) 100 mg daily, and

• vitamin B6 (pyridoxine) 100 mg daily

• consider ceasing OCP

If no response

As for mild, plus options (one of the following):

norethisterone 5 mg daily (for second half of cycle)danazol 200 mg daily

Some of these treatments, particularly vitamin therapy, have not been scientifi cally tested but some empirical evidence is favourable The value of diuretics

is not proven, and testosterone or tamoxifen treatment

is generally not favoured

Evening primrose oil contains an essential fatty acid claimed to be lacking in the diet, and replacement allows for the production of prostaglandin E, which counters the effect of oestrogen and prolactin on the breast

However, according to the multi-centred European RCT, it is no more effective than placebo.1

Bromocriptine and danazol have signifi cant side effects but clinical trials have proved their effi cacy for this condition.4, 5

Systemic reviews from RTCs provide limited evi dence to alleviate mastalgia but the suggestions indicate that tamoxifen and a low-fat, high-carbohydrate diet is benefi cial Danazol provides benefi t but has a high incidence of side effects Bromocriptine (also high adverse effect profi le) and HRT are unlikely to be benefi cial The following have unknown effectiveness:

evening primrose oil, pyridoxine, vitamin E and diuretics.6

A summary of a treatment strategy for cyclical mastalgia is presented in Table 91.2

Non-cyclical mastalgia

The features of non-cyclical mastalgia are:

• the typical age is the early 40s (median age 41 years)

• bilateral and diffuse

• pain present throughout the cycle

• no obvious physical or pathological basis

946 Part Five Women's health

Typical pain patterns are presented in Figure 91.1

Management

Non-cyclical mastalgia is very diffi cult to treat, being

less responsive than cyclical mastalgia It is worth a

therapeutic trial of the following agents

First-line treatment

• Exclude caffeine from diet

• Weight reduction if needed

Surgical excision may be required for local lesions

If there is no discrete lesion but a tender trigger

point (including costochondritis), the injection of

local anaesthetic and corticosteroid may relieve the

problem

Costochondritis (Tietze

syndrome)

This is a common cause of referral to a breast pain

clinic The cause is often obscure, but the costochondral

junction may become strained in patients with a

persistent cough The pain can appear to be in the

breast with intermittent radiation round the chest

wall and is initiated or aggravated by deep breathing

and coughing

Features:

• the pain is acute, intermittent or chronic

• the breast is normal to palpation

• palpable swelling about 4 cm from sternal edge due to

enlargement of costochondral cartilage

• X-rays are normal

• it is self-limiting, but may take several months to subside

Treatment. Infi ltration with local anaesthetic and corticosteroid with care Otherwise use NSAIDs or paracetamol

Mastitis

Mastitis is basically cellulitis of the interlobular connective tissue of the breast Mostly restricted to lactating women, it is associated with a cracked nipple

or poor milk drainage The infecting organism is usually

Staphylococcus aureus, or more rarely, Escherichia coli:

C albicans Candida albicans is common in breastfeeding

women Mastitis is a serious problem and requires early treatment Breastfeeding from the affected side can continue as the infection is confi ned to interstitial breast tissue and doesn’t usually affect the milk supply

Clinical features

• A lump and then soreness (at fi rst)

• A red tender area

possibly

• Fever, tiredness, muscle aches and pains

Note: Candida infection usually causes severe breast

pain—a feeling like a hot knife or hot shooting pains, especially during and after feeding It may occur after

a course of antibiotics

Prevention (in lactation)

• Maintain free breast drainage—keep feeding

• Attend to breast engorgement and cracked nipples

Treatment

If systemic symptoms develop:

• antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics7

di/(fl u)cloxacillin 500 mg (o) 6 hourly for 7–10 days

or

cephalexin 500 mg (o) 6 hourly for 7–10 days

If severe cellulitis di/(fl u)cloxacillin 2 g (IV) 6 hourly

• therapeutic ultrasound (2 W/cm2 for 6 minutes) daily for 2–3 days

• ibuprofen or paracetamol for pain

• for Candida albicans infection:

fl uconazole 200–400 mg (o) daily for 2–4 weekssecond line—nystatin 500 000 U (o) tds

Breast abscess

If tenderness and redness persist beyond 48 hours and an area of tense induration develops, then a breast abscess has formed (see Fig 91.2) It requires surgical drainage under general anaesthesia or aspiration with a large bore needle under local anaesthetic every second day (fi rst option) until resolution, antibiotics, rest and complete emptying of the breast

Table 91.2 Management plan for cyclical mastalgia

Progressive stepwise therapy Step 1 Reassurance

Proper brassiere support Diet—exclude/reduce caffeine, low fat Exercises (e.g aerobics for upper trunk) Analgesics (on days of pain)

Step 2 Add (as a trial)Vitamin B1 100 mg daily

Vitamin B6 100 mg daily

Step 3 Add Danazol 200 mg daily

1 Make an incision over the point of maximal tenderness,

preferably in a dependent area of the breast The surgical incision should be placed as far away from the areola and nipple as possible and the dressings kept clear

of the areola to allow breastfeeding to continue The incision needs to be placed in a radial orientation (like the spoke of a wheel) to minimise the risk of severing breast ducts or sensory nerves to the nipple

2 Use artery forceps to separate breast tissue to reach

the pus

3 Take a swab for culture

4 Introduce a gloved fi nger to gently break down the

septa that separate the cavity into loculations

5 Insert a corrugated drainage tube into the cavity

Remove the tube two days after the operation

Change the dressings daily until the wound has

healed Continue antibiotics until resolution of the

inflammation Continue breastfeeding from both

breasts but if breastfeeding is not possible because of

the location of the incisions or drains, milk should be

expressed from that breast

Infl ammatory breast cancer

Also referred to as ‘mastitis carcinomatosa’, this rare

condition develops quickly with fl orid redness, swelling,

dimpling and heaviness of the breast It is not as painful

as it appears and can be confused with mastitis but does

not respond to antibiotics

Refer immediately

When to refer

• Undiagnosed localised breast pain or lump

Figure 91.2 Localised cellulitis and breast abscess in a

• Think of C albicans if mastitis is very severe with hot

shooting pains, especially after antibiotic treatment

• Look for underlying disorders of the chest wall if examination of the breasts is normal

• Consider caffeine intake as a cause of benign diffuse mastalgia

• Mastitis should be treated vigorously—it is a serious condition

• Fibroadenomas and breast cysts are capable of causing localised pain and tenderness

Patient education resources

Hand-out sheets from Murtagh’s Patient Education

2 Ryan P A Very Short Textbook of Surgery (2nd edn)

Canberra: Dennis & Ryan, 1990: 10.

3 Barraclough B The fi brocystic breast—clinical assessment, diagnosis and treatment Modern Medicine Australia, 1990; 33(4): 16–25.

4 Mansel RE et al Controlled trial of the antigonadotrophin danazol in painful nodular benign breast disease Lancet, 1982; 1: 928.

5 Hinton CP et al A double blind controlled trial of danazol and bromocriptine in the management of severe cyclical breast pain Br J Clin Pract, 1986; 40: 326.

6 Barton S (ed) Clinical Evidence London: BMJ Publishing

Group, 2001: 1247–52.

7 Spicer J (Chair) Therapeutic Guidelines: Antibiotic (Version 13)

Melbourne: Therapeutic Guidelines Ltd, 2006: 282.

Neither the cause of breast cancer, one of the most feared and emotion-engendering diseases, nor the means of

preventing it are absolutely known.

AN O N Y M O U S L E C T U R E R O N B R E A S T C A N C E R

Breast lumps are common and their discovery by a

woman provokes considerable anxiety and emotion

(which is often masked during presentation) because, to

many, a ‘breast lump’ means cancer Many of the lumps

are actually areas of thickening of normal breast tissue

Many other lumps are due to mammary dysplasia with

either fi brosis or cyst formation or a combination of the

two producing a dominant (discrete) lump.1 However, a

good working rule is to consider any lump in the breast

as cancer until proved otherwise See Table 92.1 for

causes of breast lumps in a specifi c outpatient study

Table 92.1 Causes of breast lumps (a surgical

Less common

Mammary duct ectasia

Duct papilloma

Lactation cysts (galactocele)

Paget syndrome (disease) of the nipple

Fat necrosis/fi brosis

Sarcoma

Lipoma

Source: Statistics courtesy MA Henderson, PBR Kitchen, PR

Hayes, University of Melbourne Department of Surgery, Breast

Clinic, St Vincent’s Hospital, Melbourne

The genetic predisposition to breast cancer continues

to be delineated with the strong predisposition from

mutations in the genes BRCA1 and BRCA2 Refer to

Chapter 19

Key facts and checkpoints

• The commonest lumps are those associated with mammary dysplasia (32%).2 See Table 92.1

• Mammary dysplasia is also a common cause of cysts, especially in the premenopause phase

• Over 75% of isolated breast lumps prove to be benign but clinical identifi cation of a malignant tumour can only defi nitely be made following aspiration biopsy or histological examination of the tumour.2

• The investigation of a new breast lump requires a very careful history and the triple test

The triple test

1 Clinical examination

2 Imaging—mammography ± ultrasound

3 Fine-needle aspiration ± core biopsy

• Breast cancer is the most common cancer in females, affecting 1 in 11–15 women2 and 1 in 11 in Australia

• Breast cancer is uncommon under the age of 30 but

it then steadily increases to a maximum at the age of about 60 years, being the most common cancer in women over 50 years

• About 25% of all new cancers in women are breast neoplasms

• A ‘dominant’ breast lump in an older woman should

be regarded as malignant

The clinical approach

This is based on following a careful history and examination

HistoryThe history should include a family history of breast disease and the patient’s past history, including trauma, previous breast pain, and details about pregnancies (complications of lactation such as mastitis, nipple problems and milk retention)

• Have you noticed any breast pain or discomfort?

• Do you have any problems such as increased swelling

or tenderness before your periods?

• Have you noticed lumpiness in your breasts before?

• Has the lumpy area been red or hot?

• Have you noticed any discharge from your nipple or

nipples?

• Has there been any change in your nipples?

• Does/did your mother or sisters or any close relatives

have any breast problems?

• Breast asymmetry or skin dimpling (4%)

• Periareolar infl ammation

Important ‘tell-tale’ symptoms are illustrated in

Figure 92.1

Nipple discharge 3

This may be intermittent from one or both nipples It

can be induced by quadrant compression

— intraduct carcinoma (serous)

— breast abscess (pus)

• Milky white (galactorrhoea):

— lactation cysts

— lactation

— hyperprolactinaemia

— drugs (e.g chlorpromazine)

Figure 92.1 Important ‘tell-tale’ symptoms of breast cancer

OJQQMF
JOWFSTJPO CMPPETUBJOFE
OJQQMF
EJTDIBSHF

Red fl ag pointers for breast lumps

• Hard and irregular lump

• Skin dimpling and puckering

• Skin oedema (‘peau d’orange’)

• Nipple discharge

• Nipple distortion

• Nipple eczema

950 Part Five Women's health

Periareolar infl ammation

This presents as pain around the areola with reddening

of the skin, tenderness and swelling Causes may be

inverted nipple or mammary duct ectasia

Paget disease of the nipple

This rare but interesting sign and condition usually

occurs in middle-aged and elderly women (see

Fig 92.2) It starts as an eczematous-looking, dry

scabbing red rash of the nipple and then proceeds to

ulceration of the nipple and areola (see Table 92.2) It

is always due to an underlying malignancy

Method1

1 Inspection: sitting—patient seated upright on side of couch in good light, arms by sides, facing the doctor, undressed to waist

a Note:

• asymmetry of breasts or a visible lump

• localised discolouration of the skin

• nipples:

— for retraction or ulceration

— for variations in the level (e.g elevation on one side)

— or discharge (e.g blood-stained, clear, yellow)

• skin attachment or tethering → dimpling of skin (accentuate this sign by asking patient to raise her arms above her head)

• appearance of small nodules of growth

• visible veins (if unilateral they suggest a cancer)4

• peau d’orange due to dermal oedema

b Raise arms above the head (renders variations

in nipple level and skin tethering more obvious)

Hands are pressed on the hips to contract pectoralis major to note if there is a deep attachment of the lump

2 Examination of lymph glands in sitting position:

patient with hands on hips Examine axillary and supraclavicular glands from behind and front

Note: The draining lymphatic nodes are in the axillae,

supraclavicular fossae and internal mammary chain

3 Palpation:

a Patient still seated: palpate breast with fl at of hand and then palpate the bulk of the breast between both hands

b In supine position:

• patient lies supine on couch with arms above head

• turn body (slight rotation) towards midline so breasts ‘sit’ as fl at as possible on chest wall

Method

• Use the pulps of the fi ngers rather than the tips with the hand laid fl at on the breast

• Move the hand in slow circular movements

• Examine up and down the breast in vertical strips beginning from the axillary tail (see Fig 92.3)

• Systematically cover the six areas of the breast (see Fig 92.4):

— the four quadrants

— the axillary tail

— the region deep to the nipple and areola

4 If a suspicious lump is present, inspect liver, lungs and spine

5 Inspect the bra Note possible pressure on breast tissue from underwiring of the bra, usually on the upper outer quadrant

Note:

• Forty to fi fty per cent of cancers occur in the upper outer quadrant.3

Figure 92.2 Paget disease of the breast: note the

erythematous, eczematous, scaly appearance of the nipple

Table 92.2 Differences between Paget disease and

eczema of the nipple2

Paget disease Eczema

Unilateral Bilateral

Older patients Reproductive years/

lactationPossible nipple discharge No discharge

Not pruritic Pruritic

No pustules Pustules

Deformity of nipple Normal nipple

Possible palpable lump No lump

Examination of the breasts

Objectives

• Identify a dominant lump (one that differs from the

remainder of the breast tissue)

• Identify a lump that may be malignant

• Screen the breasts for early development of cancer

Time of examination: ideally, 4 days after the end

of the period

Lumps in the breast

92Figure 92.3 Systematic examination of the breast

Figure 92.4 The six areas of the breast

3JHIU
CSFBTU

BYJMMBSZ UBJM

 VQQFS
PVUFS

If a solitary lump is present, assess it for:

• position (breast quadrant and proximity to nipple)

• size and shape

• consistency (fi rm, hard, cystic, soft)

• tenderness

• mobility and fi xation

• attachment to skin or underlying muscle

• A useful diagram to record the fi ndings is shown in Figure 92.5

• Lumps that are usually benign and require no immediate action are: tiny (<4 mm) nodules in subcutaneous tissue (usually in the areolar margin);

elongated ridges, usually bilateral and in the lower aspects of the breasts; and rounded soft nodules (usually <6 mm) around the areolar margin.5

• A hard mass is suspicious of malignancy but cancer can be soft because of fat entrapment

• The inframammary ridge, which is usually found in the heavier breast, is often nodular and fi rm to hard

• Lumpiness (if present) is usually most marked in the upper outer quadrant

Figure 92.5 Diagrammatic scheme for recording the features of breast lumps and any lymphadenopathy (axilla and supraclavicular triangles)

Investigations

X-ray mammography

Mammography can be used as a screening procedure and as a diagnostic procedure It is currently the most effective screening tool for breast cancer.6 Positive signs

of malignancy include an irregular infi ltrating mass with focal spotty microcalcifi cation

Screening:

• established benefi t for women over 50 years

• possible benefi t for women in their 40s

• follow-up in those with breast cancer, as 6% develop in the opposite breast

• localisation of the lesion for fi ne-needle aspiration

Breast ultrasound

This is mainly used to elucidate an area of breast density and is the best method of defi ning benign breast disease, especially with cystic changes It is generally most useful in women less than 35 years old (as compared with X-ray mammography)

Useful for:

• pregnant and lactating breast

• differentiating between fl uid-fi lled cysts and solid mass

• palpable masses at periphery of breast tissue (not screened by mammography)

• for more accurate localisation of lump during fi needle aspiration

ne-952 Part Five Women's health

Note: CT and MRI have limited use An age-related

schemata for likely diagnosis and appropriate

investigations is presented in Table 92.3

Table 92.3 Age-related schemata for likely diagnoses

and appropriate investigations (after Hirst)5

1 Very young women—12 to 25 years

Infl amed cysts or ducts, usually close to areola

Fibroadenomata, often giant

Hormonal thickening, not uncommon

• mammography: breasts often very dense

• ultrasound often diagnostic

3 Women—36 to 50 years (premenopausal)

Cysts

Mammary dysplasia, discharges, duct papillomas

Malignancy common

Fibroadenomata occur but cannot assume

Infl ammatory processes not uncommon

Investigations:

• mammography useful

• ultrasound useful

4 Women—over 50 years (postmenopausal)

Any new discrete mass—malignant until proven

otherwise

Any new thickening—regard with suspicion

Infl ammatory lesions—probably duct ectasia

(follow to resolution)

Cysts unlikely

Investigations:

• mammography usually diagnostic

• ultrasound may be useful

5 Women—over 50 years, on hormones

Any new mass—regard with suspicion

Cysts may occur—usually asymptomatic

Hormonal change not uncommon

Investigations:

• mammography usually diagnostic but breast

may become more dense

• ultrasound may be useful

Source: After Hirst.5

Reprinted with permission

Needle aspiration and biopsy techniques

• Cyst aspiration

• Fine-needle aspiration biopsy: this is a very useful diagnostic test in solid lumps, and has an accuracy of 90–95% (better than mammography)3

• Large needle (core needle) biopsy

• Incision biopsy

Tumour markers

Oestrogen receptors are uncommon in normal breasts but are found in two-thirds of breast cancers, although the incidence varies with age They are good prognostic indicators Progesterone receptors can also

be estimated

Fine-needle aspiration of breast lump

This simple technique is very useful, especially if the lump is a cyst, and will have no adverse effects if the lump is not malignant If it is, the needle biopsy will help with the preoperative cytological diagnosis

Method of aspiration and needle biopsy:

1 Use an aqueous skin preparation without local anaesthesia

2 Use a 23 gauge needle and 5 mL sterile syringe

3 Identify the mass accurately and fi x it by placing three

fi ngers of the non-dominant hand fi rmly on the three sides of the mass (see Fig 92.6)

4 Introduce the needle directly into the area of the swelling Once in subcutaneous tissue, apply gentle suction as the needle is being advanced (see Fig 92.7)

If a cyst is involved it can be felt to ‘give’ suddenly

5 If fl uid is obtained (usually yellowish-green), aspirate

8 Release suction before exit from the skin to keep cells

in the needle (not in the syringe)

9 After withdrawal, remove syringe from needle, fi ll with

2 mL of air, reattach needle and produce a fi ne spray

on one or two prepared slides

10 Fix to one slide (in Cytofi x or similar) and allow one to air dry, and forward to a reputable pathology laboratory

to be examined by a skilled cytologist

Follow-up: the plan for aspiration is outlined in

Figure 92.8

Summary: investigation of a breast lump

If the patient presenting with a breast lump is younger than 35, perform an ultrasound;7 if older than 35 perform a mammogram and an ultrasound If the lump is cystic—aspirate; if solid—perform a fi ne-needle

Lumps in the breast

92

biopsy and then manage according to outcomes If

it is suspicious, an excisional biopsy is the preferred option

Breast cancer

Breast cancer is uncommon under the age of 30 but it then steadily increases to a maximum at the age of about 60 years.3 About one-third of women who develop breast cancer are premenopausal and two-thirds postmenopausal About 1 in 11–15 women (1 in 11 in Australia) develop breast cancer Ninety per cent of breast cancers are invasive duct carcinomas, the remainder being lobular carcinoma, papillary carcinomas, medullary carcinomas and colloid or mucoid carcinomas.2

Risk factors include increasing age (>40 years), Caucasian race, pre-existing benign breast lumps, alcohol, HRT >5 years, personal history of breast cancer, family history in a fi rst-degree relative (raises risk about threefold), nulliparity, late menopause (after 53), obesity, childless until after 30 years of age, early menarche,6ionising radiation exposure

Familial breast cancer

Up to 5% of cases are familial, with most being autosomal dominant Refer to Chapter 19

• Usually the lump is hard and irregular

• Nipple changes, discharge, retraction or distortion

• Rarely cancer can present with Paget disease of breast (nipple eczema) or infl ammatory breast cancer (see Chapter 91, page 947)

• Rarely it can present with bony secondaries (e.g back pain, dyspnoea, weight loss, headache)

Note: There are basically three presentations of the

disease:

• the vast majority present with a local breast lump2 (see Fig 92.10)

• ductal carcinoma in situ

• some present with metastatic disease

Figure 92.6 Aspiration of breast lump: fi xation of cyst

GPVSUI
GJOHFS UIJSE
GJOHFS

TFDPOE
GJOHFS EJSFDUJPO
PG
TZSJOHF

Figure 92.7 Aspiration of breast lump: position of the

hand—second (index) fi nger and thumb steady the

syringe while the third (middle) fi nger slides out the

plunger to create suction

MVNQ

BTQJSBUJPO

CMPPETUBJOFE BTQJSBUF

OP BTQJSBUF

DZUPMPHZ PG
GMVJE OFHBUJWF

OP
SFTJEVBM

SFTJEVBM MVNQ

QPTJUJWF

FYDJTJPO CJPQTZ

Indications for biopsy or excision of lump

• The cyst fl uid is bloodstained

• The lump does not disappear completely with aspiration

• The swelling recurs within 1 month

954 Part Five Women's health

radiotherapy, surgery and/or endocrine therapy if applicable (level IV evidence)

Most relapses8 after surgery occur in the first

3 years

Ductal carcinoma in situ

DCIS is a non-invasive abnormal proliferation of milk duct epithelial cells within the ductal–lobular system and is a precursor lesion for invasive breast cancer Since mammography screening it is readily detected and now comprises about 20% of breast cancer It may present clinically with a palpable mass or nipple discharge or Paget disease of the nipple with or without a mass

Management

Management decisions are challenging, with options being total mastectomy or breast-conserving therapy with or without radiotherapy Patients usually have an excellent outcome with low local recurrence rates and

a survival of at least 98%.9

Adjuvant therapy for breast cancerThe consultant will choose the most appropriate surgical and adjuvant treatments for the individual patient

The National Breast Cancer Consensus report emphasised that ‘continuing care should be coordinated through the patient’s GP as the impact of treatment may last longer than therapy and support must continue’

The report made the following recommendations:10

• Tumour excision followed by whole breast irradiation was the most preferred local therapy for most women with stage I or II cancer

• Total mastectomy and breast-conservation surgery had

an equivalent effect on survival

• Total mastectomy is preferred for a large tumour, multifocal disease, previous irradiation and extensive tumour on mammography

• Current recommendations for radiotherapy after mastectomy are:11

— tumours >4 cm in diameter

— axillary node involvement of >3 nodes

— the presence of positive or close tumour margins

• Intraoperative radiotherapy following tumour excision is one of several techniques for partial breast irradiation.12

• Cytotoxic chemotherapy has an important place in management Newer regimens containing anthracyclines (e.g epirubicin) and a taxane (e.g docetaxel) have largely replaced the traditional CMF (cyclophosphamide, methotrexate and fl uorouracil) regimen.12

• Adjuvant hormonal therapy by the anti-oestrogen agent tamoxifen 20 mg (o) daily, which is a specifi c modulating agent, is widely used and is most suitable

in postmenopausal women

Figure 92.9 Advanced adenocarcinoma of breast in

patient showing denial for a problem of 2 years duration

Figure 92.10 Relative frequencies of breast cancer at

various anatomical segments







Of those who present with local disease, approximately

50% will develop metastatic disease

Management

Immediate referral to an expert surgeon on suspicion

or proof of breast cancer is essential The treatment

has to be individualised according to the nature of the

lump, age of the patient and staging Accurate staging

requires knowledge of whether the draining lymph

nodes are involved with the tumour, as this is the single

most powerful predictor of subsequent metastases and

death Staging for systemic disease also requires full

blood examination and liver function tests (including

alkaline phosphatase) A bone scan may be used as

a valuable baseline Size and histological grading of

tumour plus nodal status and receptor status are the

most important prognostic factors

Optimal management of locally advanced breast

cancer is a combined approach that uses chemotherapy,

Lumps in the breast

92

Adjunct agents available for treatment include:13

• anti-oestrogens: tamoxifen, toremifene

• aromatase inhibitors: anastrozole, letrozole,

exemestane

• monoclonal antibodies: trastuzumab (Herceptin)

• progesterones (e.g medroxyprogesterone acetate)

Guidelines for adjuvant treatments are presented

in Table 92.4, which is a general guide only as other

adjunct agents may be added or substituted

Mammary dysplasia

Synonyms: fi broadenosis, chronic mastitis, fi brocystic

disease, cystic hyperplasia

Clinical features

• Most common in women between 30 and 50 years

• Hormone-related (between menarche and menopause)

• Pain and tenderness and swelling

• Premenstrual discomfort or pain and increased swelling

• Fluctuation in the size of the mass

• Usually settles after the period

• Unilateral or bilateral

• Nodularity ± a discrete mass

• Ache may extend down inner aspect of upper arm

• Nipple discharge may occur (various colours, mainly

green–grey)

• Most cysts are premenopausal (fi nal 5 years before

menopause)

Table 92.4 Adjuvant treatment favoured by trial meta-analyses11

Menopausal status Node status Oestrogen receptor Other factors Treatment

Premenopausal Positive

PositiveNegativeNegative

PositiveNegativePositiveNegative

Poor prognosis*

Poor prognosis

Chemotherapy† + tamoxifenChemotherapyChemotherapy and/or tamoxifen

ChemotherapyPostmenopausal Positive Positive

NegativeNegative

<60, poor prognosis

>60

TamoxifenChemotherapy

?

*Poor prognostic features are defi ned as tumours >20 mm, or tumours 11–20 mm with additional poor prognostic features such as

oestrogen and progesterone receptor negativity, or high histological grade For patients with good prognostic features (e.g those

with tumours <10 mm diameter) there has been no demonstrated benefi t of adjuvant therapy.

† Adapted from National Health and Medical Research Council Recommendations for the Selection of Adjuvant Systemic Therapy

after Surgical Treatment for Breast Cancer Clinical Practice Guidelines 1995 Canberra: NHMRC 1995

Examination Look for lumpiness in one or both

breasts, usually upper outer quadrant

• Reassure patient that there is no cancer

• Give medication to alleviate mastalgia (see treatment for cyclical mastalgia in Chapter 91)

• Use analgesics as necessary

• Surgically remove undiagnosed mass lesions

Breast cyst

• Common in women aged 40–50 years (perimenopausal)

• Rare under 30 years

• Associated with mammary dysplasia

• Tends to regress after the menopause

• Pain and tenderness variable

• Has a 1 in 1000 incidence of cancer

• Usually lined by duct epithelium

Examination. Look for a discrete mass, fi rm, relatively mobile, that is rarely fl uctuant

Diagnosis

• Mammography

• Ultrasound (investigation of choice)

• Cytology of aspirate

956 Part Five Women's health

Lactation cysts (galactoceles)

• These milk-containing cysts arise during pregnancy

and present postpartum with similar signs to

perimenopausal cysts

• They vary from 1–5 cm in diameter

• Treat by aspiration: fl uid may be clear or milky

Fibroadenoma

Clinical features

• A discrete, asymptomatic lump

• Usually in 20s (range: second to sixth decade,

commonly 15–35 years)

• Firm, smooth and mobile (the ‘breast mouse’)

• Usually rounded

• Usually in upper outer quadrant

• They double in size about every 12 months7

Management

Ultrasound and fi ne-needle aspiration or core biopsy

with cytology is recommended plus mammography

in older women If needle aspiration or core biopsy is

negative the patient can be reassured The lump may be

left in those in the late teens but as a rule it is removed

to be certain of the diagnosis in all patients

These are giant fi broadenoma-like tumours that are

usually benign but 25% are malignant and metastasise

They are completely excised with a rim of normal

breast tissue

Fat necrosis

Fat necrosis is usually the end result of a large bruise

or trauma that may be subtle, such as protracted

breastfeeding The mass that results is often accompanied

by skin or nipple retraction and thus closely resembles

cancer If untreated it usually disappears but the

diagnosis can only be made on excision biopsy

Duct papillomas

These are benign hyperplastic lesions within large

mammary ducts and are not premalignant (nor usually

palpable) They present with nipple bleeding or a

bloodstained discharge and must be differentiated from

infi ltrating carcinoma Mammography and ductography

are usually of limited value The involved duct and

affected breast segment should be excised.14

Mammary duct ectasia

Synonyms: plasma cell mastitis, periductal mastitis

In this benign condition a whole breast quadrant

may be indurated and tender The larger breast ducts

are dilated The lump is usually located near the margin of the areola and is a fi rm or hard, tender, poorly defi ned swelling There may be a toothpaste-like nipple discharge It is a troublesome condition with a tendency to repeated episodes of periareolar infl ammation with recurrent abscesses and fi stula formation Many cases settle but often surgical intervention is necessary to make the diagnosis The condition is most common in the decade around the menopause

The problem of mammary prostheses5

Clinical examination is still necessary and fortunately the residual mammary tissue is usually spread over the prosthesis in a thin, easily palpable layer The areas of clinical diffi culty lie at the margin of the prosthesis, especially in the upper outer quadrant where most

of the breast tissue is displaced It should be noted that mammography may be of limited value in the presence of prostheses, especially if a fi brous capsule exists around the prosthesis Ultrasound examination may be helpful

Skin changes can occur from long-term lymphoedema without treatment, and cellulitis from abrasions and wounds is a concern

Management

• Encourage movement; elevation of the arm on a pillow

at night; avoid slings

• Physiotherapy: a reduction phase with non-elasticised bandages then maintenance with graduated pressure support sleeves

• Elastic sleeves worn all day but not at night

• Lymphoedema massage at home

• Skin hygiene: regular use of non-perfumed emollients, prevention of infection and injury Avoid sunburn and insect bites

• Avoid BP measurement, venesection and IV therapy in that arm

• Consider diuretics to relieve pressure

Breast lumps in children

There are several benign conditions that can cause

a breast lump in children, although the commonest presentation is a diffuse breast enlargement

Lumps in the breast

92

Neonatal enlargement15

Newborn babies of either sex can present with breast

hyperplasia and secretion of breast milk (see page 863)

This is due to transplacental passage of lactogenic

hormones The swelling usually lasts 7–10 days if

left alone Any attempts to manipulate the breasts to

facilitate emptying will prolong the problem

Premature hyperplasia15

The usual presentation is the development of one breast

in girls commonly 7–9 years of age but sometimes

younger The feature is a fi rm discoid lump 1–2 cm in

diameter, situated deep to the nipple The same change

may follow in the other breast within 3–12 months

Reassurance and explanation is the management and

biopsy must be avoided at all costs

Counselling of patients

‘Treat the whole woman, not merely her breasts.’5

Extreme anxiety is generated by the discovery of a breast

lump and it is important that women are encouraged

to visit their doctor early, especially as they can learn

that there is a 90% chance of their lump being benign

It is possible that denial may be a factor or there is a

hidden agenda to the consultation The decision to

perform a lumpectomy or a mastectomy should take

the patient’s feelings into consideration—many do

fear that a breast remnant may be a focus for cancer

Long-standing doctor–patient relationships are the ideal

basis for coping with the diffi culties

Screening

Screening mammography should be encouraged for

women between 50 and 70 years, and performed at

least every 2 years Technically it is a better diagnostic

tool in older women because of the less dense and

glandular breast tissue It has a specifi city of around

90% A management program for women at high risk

of breast cancer is presented in Table 92.5

Breast self-examination is a controversial issue and has no proven benefi t in reducing morbidity and

mortality The false positive rate is high, especially

in those under 40 years However, regular BSE is

recommended for all women 35 years and over

When to refer

• Patients with a solitary breast mass

• Following cyst aspiration:

— blood in aspirate

— palpable residual lump

— recurrence of the cyst

• Patients given antineoplastic drugs, whether for adjuvant therapy or for advanced disease, require skilled supervision

Lumps that require investigation and referral are presented in Table 92.6

Table 92.6 Lumps that require investigation and referral5

A stony, hard lump or area, regardless of size, history

or position

A new palpable ‘anything’ in a postmenopausal woman

A persisting painless asymmetrical thickening

An enlarging mass—cyclic or not

A ‘slow-to-resolve’ or recurrent infl ammation

A bloodstained or serous nipple dischargeSkin dimpling, of even a minor degree, or retraction of the nipple

A new thickening or mass in the vicinity of a scar

Source: After Hirst5

Table 92.5 Management program for women at high risk of breast cancer6

Monthly breast self-examination

At least an annual consultation with GP—if aged 40

or older Aspiration of cystsMammography, ultrasound and/or fi ne-needle biopsy

to diagnose any localised mass Ultrasound alone for further assessment of young, dense breasts

Regular screening mammography after 50 years of age—every 2 years

Source: After Barraclough6

958 Part Five Women's health

Practice tips

• Any doubtful breast lump should be removed

• Fibroadenomas commonly occur in women in their

late teens and 20s, benign breast cysts between 35

years and the menopause, and cancer is the most

common cause of a lump in women over 50 years.3

• Never assume a palpable mass is a fi broadenoma in

any woman over 30 years of age.5

• Gentle palpation is required Squeezing breast

tissue between fi nger and thumb tends to produce

‘pseudolumps’

• Any eczematous rash appearing on the nipple or

areola indicates underlying breast cancer

• Mammary duct ectasia and fat necrosis can be

clinically indistinguishable from breast cancer

• Nine out of 10 women who get breast cancer do not

have a strong family history

• The oral contraceptive pill has been generally shown

not to alter the risk of breast cancer.

• Never assume that a lump is due to trauma unless

you have seen the bruising and can observe the

lump decrease in size.5

• Never assume a lesion is a cyst—prove it with

ultrasound or successful aspiration.5

• Never ignore skin dimpling even if no underlying

mass is palpable.5

• Never ignore a woman’s insistence that an area of

her breast is different or has changed.5

• Mammography can detect breast cancers which are

too small to feel

• Mammography is not a diagnostic tool

• Recommended mammography screening for

women 50–69 years and those aged 40–49 who

request it

Patient education resources

Hand-out sheets from Murtagh’s Patient Education

5 th edition:

• Breast Cancer, page 72

• Breast Lumps, page 73

• Breast Self-Examination, page 74

REFERENCES

1 Davis A, Bolin T, Ham J Symptom Analysis and Physical

Diagnosis (2nd edn) Sydney: Pergamon Press, 1990: 118.

2 Green M Breast cancer In: MIMS Disease Index (2nd edn)

Sydney: IMS Publishing, 1996: 83–5.

3 Hunt P, Marshall V Clinical Problems in General Surgery

Sydney: Butterworths, 1991: 63–71.

4 Talley N, O’Connor S Clinical Examination (3rd edn)

Sydney: MacLennan & Petty, 1996: 113–35.

5 Hirst C Managing the breast lump Solving the dilemma—

reassurance versus investigation Aust Fam Physician, 1989; 18: 121–6.

6 Barraclough B The fi brocystic breast—clinical assessment, diagnosis and treatment Modern Medicine Australia, 1990; April: 16–25.

7 Crea P Benign breast diseases: a management guide for GPs Modern Medicine Australia, 1995; 38(8): 74–88.

8 National Health and Medical Research Council

Management of Advanced Breast Cancer: Clinical Practice Guidelines NHMRC Clinical Practice Guidelines 2001

Canberra: NHMRC, 2001

9 Stuart K, Boyages J, Brennan, M, Ung O Ductal carcinoma

in situ Aust Fam Physician, 2005: 949–53.

10 Coates A Breast Cancer Consensus report Med J Aust, 1994; 161: 510–13.

11 Wetzig NR Breast cancer: how to treat Australian Doctor,

19 October 2001: I–VIII.

12 Buglar L, James T et al Breast cancer for GPs Australian Doctor (Suppl), March 2008: 10–13.

13 Bochner F (Chair) Australian Medicines Handbook

Adelaide: Australian Medicines Handbook Pty Ltd, 2006:

559–63.

14 Burkitt H, Quick C, Gatt D Essential Surgery (2nd edn)

Edinburgh: Churchill Livingstone, 1996: 542.

15 Hutson JM, Beasley SW, Woodward AA Jones Clinical

Paediatric Surgery Melbourne: Blackwell Scientifi c

Publications, 1992: 266–7.

Abnormal uterine bleeding is a common problem

encountered in general practice Heavy menstrual

bleeding is the commonest cause of iron-defi ciency

anaemia in the Western world A classifi cation of

abnormal uterine bleeding is presented in Table 93.1

Table 93.1 Classifi cation of abnormal uterine bleeding

Increased amount = menorrhagia

Decreased amount = hypomenorrhoea

Combination (rhythm and amount)

Irregular and heavy periods = metromenorrhagia

Irregular and light periods = oligomenorrhoea

Key facts and checkpoints

• Up to 20% of women in the reproductive age group

complain of increased menstrual loss.1

• At least 4% of consultations in general practice deal

with abnormal uterine bleeding

• Up to 50% of patients who present with perceived

menorrhagia (or excessive blood loss) have a normal blood loss when investigated.2 Their perception is unreliable

• The possibility of pregnancy and its complications,

such as ectopic pregnancy, abortion (threatened, complete or incomplete), hydatidiform mole or choriocarcinoma should be kept in mind

• The mean blood loss in a menstrual cycle is

30–40 mL

• A menstrual record is a useful way to calculate blood

loss

• Blood loss is normally less than 80 mL

• Menorrhagia is a menstrual loss of more than 80 mL

per menstruation

• Menorrhagia disposes women to iron defi ciency anaemia

Abnormal uterine bleeding

It is advisable that menstruation begin before the individual ceases to be a virgin.

SO R A M U S O F EP H E S U S ( 2N D C E N T U R Y) , T E X T O N D I S E A S E S O F W O M E N

• Two common organic causes of menorrhagia are

fi broids and adenomyosis (presence of endometrium

in the uterine myometrium).3

• Various drugs can alter menstrual bleeding (e.g anticoagulants, cannabis, steroids)

Defi ning what is normal and what is abnormal

This feature is based on a meticulous history, an understanding of the physiology and physiopathology

of the menstrual cycle and a clear understanding

of what is normal Most girls reach menarche by the age of 13 (range 10–16 years).1 Dysfunctional bleeding is common in the fi rst 2–3 years after menarche due to many anovulatory cycles resulting

in irregular periods, heavy menses and probably dysmenorrhoea

Once ovulation and regular menstruation are established the cycle usually follows a predictable pattern and any deviation can be considered as abnormal uterine bleeding (see Table 93.2) It is abnormal if the cycle

is less than 21 days, the duration of loss is more than

8 days, or the volume of loss is such that menstrual pads of adequate absorbency cannot cope with the

fl ow or clots.4

Table 93.2 Normal menstruation in the reproductive age group

Length of cycle 26–28 days 21–35 days

Menstrual fl ow 3–4 days 2–7 days

Normal blood loss

30–40 mL 20–80 mL

Source: After Fung1

A normal endometrial thickness, as measured by ultrasound, is between 6 and 12 mm The menstrual cycle is confi rmed as being ovulatory (biochemically)

if the serum progesterone (produced by the corpus luteum) is >20 nmol/L during the mid-luteal phase (5–10 days before menses).5

960 Part Five Women's health

Relationship of bleeding to age

Dysfunctional uterine bleeding (DUB) is more common

at the extremes of the reproductive era (see Fig 93.1).4

The incidence of malignant disease as a cause of

bleeding increases with age, being greatest after the age

of 45, while endometrial cancer is predicted to be less

than 1 in 100 000 in women under the age of 35.1

Figure 93.1 The relationship between age and various

causes of abnormal uterine bleeding Dysfunctional

uterine bleeding is more common in the extremes of

the reproductive era, while the incidence of cancer as a

cause of bleeding is greatest in the perimenopausal and

Menorrhagia, which is excessive blood loss (>80

mL per period),6 is essentially caused by hormonal

dysfunction (e.g anovulation), excessive local

production of prostaglandins in the endometrium,

excessive local fi brinolysis of clot, local pathology (e.g

fi broids) or medical disorder (e.g blood dyscrasias)

Heavy bleeding, possibly with clots, is the major

symptom of menorrhagia Dysmenorrhoea may

accompany the bleeding and, if it does, endometriosis

or PID should be suspected With care a 60–80%

accuracy can be achieved in clinical assessment.6 A

summary of the diagnostic strategy model is presented

in Table 93.3

By far the most common single ‘cause’ of menorrhagia

is ovulatory dysfunctional uterine bleeding The most

common organic causes are fi bromyomatas (fi broids),

endometriosis, adenomyosis (‘endometriosis’ of the

myometrium), endometrial polyps and PID.4

Acute heavy bleeding or ‘flooding’ most often

occurs in pubertal girls before regular ovulation is

• PID

Q Pitfalls (often missed)

A Genital tract traumaIUCD

Adenomyosis/endometriosisPelvic congestion syndromeSLE

association

✓

✓association

✓ hypothyroidism–

–

Q Is the patient trying to tell me something?

A Consider exaggerated perception Note association with anxiety and depression

History

Bearing in mind that abnormal uterine bleeding is

a subjective complaint, a detailed history is the key initial step in management The patient’s perception

of abnormal bleeding may be quite misleading and education about normality is all that is necessary in her

Abnormal uterine bleeding

93

management A meticulous history should include details

of the number of tampons or pads used and their degree

of saturation A menstrual calendar (over 3+ months) can

be a very useful guide A history of smoking and other

psychosocial factors should be checked For unknown

reasons, cigarette smokers are fi ve times more likely to

have abnormal menstrual function.3

Questions need to be directed to rule out:1

• pregnancy or pregnancy complications (e.g ectopic

pregnancy)

• trauma of the genital tract

• medical disorders (e.g bleeding disorder)

• endocrine disorders

• cancer of the genital tract

• complications of the pill

Examination1

A general physical examination should aim at ruling out

anaemia, evidence of a bleeding disorder and any other

stigmata of relevant medical or endocrine disease

Specifi c examinations include:

• speculum examination: ?ulcers (cervical cancer) or

polyps

• Pap smear

• bimanual pelvic examination: ?uterine or adnexal

tenderness, size and regularity of uterus

It is prudent to avoid vaginal examination in selected patients, such as a young virgin girl, as the procedure

is unhelpful and unnecessarily traumatic

Investigations

Investigations, especially vaginal ultrasound scans,

should be selected very carefully and only when really

indicated Abnormal pelvic examination fi ndings,

persistent symptoms, older patients and other

suspicions of disease indicate further investigation to

confi rm symptoms of menorrhagia and exclude pelvic

or systemic pathology

Consider foremost:

• full blood count (to exclude anaemia and

thrombocytopenia)

• iron studies: serum ferritin

• hysteroscopy and endometrial sampling (use directed

endometrial biopsy with an instrument such as a Pipelle or Gynoscann, or curettage under general anaesthetic)

Special investigations (only if indicated):

• thyroid function tests

• tests for SLE: antinuclear antibodies

• ultrasound

Note: Hysteroscopy and D&C remain the gold

standard for abnormal uterine bleeding In some women,

a transvaginal ultrasound, Pipelle endometrial sampling

or hysteroscopy and D&C will be indicated.7

Dysfunctional uterine bleeding

DUB, which is a diagnosis of exclusion, is defi ned

as ‘excessive bleeding, whether heavy, prolonged or frequent, of uterine origin, which is not associated with recognisable pelvic disease, complications of pregnancy

or systemic disease’.4

Clinical features

• It is a working clinical diagnosis based on the initial detailed history, normal physical examination and normal initial investigation

• Very common: 10–20% incidence of women at some stage

• Peak incidence of ovulatory DUB in late 30s and 40s (35–45 years)

• Anovulatory DUB has two peaks: 12–16 years and 45–55 years The bleeding is typically irregular with spotting and variable menorrhagia

• The majority complain of menorrhagia

• The serum progesterone and the pituitary hormones (LH and FSH) will confi rm anovulation

• Up to 40% with the initial diagnosis of DUB will have other pathology (e.g fi broids, endometrial polyps)

if detailed pelvic endoscopic investigations are undertaken

Symptoms

• Heavy bleeding: saturated pads, frequent changing,

‘accidents’, ‘fl ooding’, ‘clots’

• Prolonged bleeding:

— menstruation >8 days

or

— heavy bleeding >4 days

• Frequent bleeding—periods occur more than once every 21 days

• Pelvic pain and tenderness are not usually prominent features

a menstrual calendar

• Conservative management is usually employed if the uterus is of normal size and there is no evidence of anaemia

962 Part Five Women's health

• Drug therapy is indicated if symptoms are

persistently troublesome and surgery is

contraindicated or not desired by the patient and

D&C doesn’t alleviate

• Provide reassurance about the absence of pathology,

especially cancer, and give counselling to maximise

compliance with treatment

• Consider surgical management if fertility is no longer

important and symptoms cannot be controlled by at

least 3–4 months of hormone therapy

• General rule:

<35 years—medical treatment

>35 years—hysteroscopy and direct endometrial

sample (diagnostic—sometimes therapeutic)

Treatment (drug therapy)5,6

Treatment regimens are presented in Tables 93.4 and

93.5 First-line treatment is with fi brinolytic inhibitors

or antiprostaglandin agents, given as soon as possible

and throughout the menses These agents are simple

to use, generally very safe and can be used over long

periods of time About 60–80% of patients with

ovulatory menorrhagia will respond if compliance is

good.5 Such agents include tranexamic acid, mefenamic

acid, naproxen, ibuprofen and indomethacin The agent

of fi rst choice is usually mefenamic acid, which reduces

blood loss by 20–25% as well as helping dysmenorrhoea

Ideally, it should be started at least 4 days before the

menses Evidence-based reviews confi rm the benefi t

of NSAIDs and tranexamic acid for menorrhagia over

the other agents.8

Hormonal agents include progestogens, combined

oestrogen–progestogen oral contraceptives and

danazol Oestrogens can be used but generally are not

recommended except in the occasional patient with

very heavy bleeding, when intravenous conjugated

oestrogens 25 mg can be used (repeated in 2 hours if no

response) and always followed by a 14-day course of oral

progestogen The COC constitutes important fi rst-line

therapy in both ovulatory and anovulatory patients, but

at least 20% of patients do not respond It is preferable to

use a pill with a higher oestrogen dose, which works better

(50 mcg rather than 30 mcg or 35 mcg of oestrogen),

and one that contains norethisterone (e.g Norinyl-1)

Progestogens can be given via several routes Oral

use is usually of no benefit in ovulatory DUB In

the adolescent with anovulatory DUB, cyclical oral

progestogens may be required for 6 months until

spontaneous regular ovulation eventuates.9 Intramuscular

medroxyprogesterone acetate (Depo-Provera) will induce

amenorrhoea in 50% of users in 1 year

The most effective agent for both ovulatory and

anovulatory DUB is tranexamic acid, which inhibits

endometrial plasminogen activation The dose is 1 g

(up to 1.5 g if necessary) orally qid for the fi rst 4 days

of the menstrual cycle commencing at the onset of visible bleeding.10, 11

The intra-uterine progesterone implant system (Mirena) releasing 20 mcg of levonorgestrel/day has shown considerable effectiveness.12 It is regarded as the most effi cacious of the hormone treatments with a mean blood loss of 94% of women with menorrhagia.7

Treatment (surgical options)

Surgical treatment for menorrhagia is more appropriate

if the uterus is enlarged, especially if greater than the size

of a 12-week gestation (grapefruit size) or if the patient

is anaemic.1 It is indicated if menorrhagia interferes with lifestyle despite medical (drug) treatment The surgical options are:

Table 93.4 Regimens used in management of menorrhagia

NSAIDs (prostaglandin inhibitors)*

Mefenamic acid 500 mg tds (4 days before menses due to end of menses)

This is an important fi rst-line therapy

For example: 50 mcg oestrogen + 1 mg norethisterone (Norinyl-1)

Progestogens (especially for anovulatory patients)

Norethisterone 5–15 mg/day for 14 days (days 15–28)

Approved for short-term treatment (6 months or less)

of severe menorrhagia—dosage 100–200 mg daily

Stops menstruation

Antifi brinolytic agents*

Tranexamic acid 1 g (o) qid, days 1–4 of menstruation

GnRH agonists

Administer by nasal spray (Synarel) or monthly SC implant of goserelin 3.6 mg (Zoladex) to induce medical ‘menopause’ for 3–6 months or 1–2 months before surgery

Progestogen-releasing IUDs (levonorgestrel)

For example: Mirena → amenorrhoea in 20–50% after

1 year

*Effectiveness supported by EBM 8 A trade-off between benefi ts and harms applies to danazol.

Abnormal uterine bleeding

93

Table 93.5 Typical treatment options for acute and

chronic heavy bleeding6, 10

Acute heavy bleeding

Curettage/hysteroscopy

• IV oestrogen (Premarin 25 mg) then oral

or

• oral high-dose progestogens (e.g norethisterone

5–10 mg 2 hourly until bleeding stops then 5 mg bd

or tds for 14 days3)

Chronic bleeding

For anovulatory women:

• cyclical oral progestogens for 14 days

• tranexamic acid

For ovulatory women:

• cyclical prostaglandin inhibitor (e.g mefenamic

Practice tipsEmergency menorrhagia (acute fl ooding)5

norethisterone 5–10 mg 2 hourly till bleeding stops, then 5 mg bd or tds (or 10 mg daily) for 14 days

or

medroxyprogesterone acetate 20 mg (o) 8 hourly for

7 days then 20 mg daily for 21 days

or

COCP (ethinyloestradiol 35 mcg + norethisterone

1 mg) 8 hourly for 7 days then one daily for 21 days

• endometrial ablation or electrodiathermy excision—to

produce amenorrhoea

• hysterectomy (up to 25% of Australian women will

have this before age 50); it requires a very carefully planned approach

Cycle irregularity 13

For practical purposes patients with irregular menstrual

cycles can be divided into those under 35 and those

over 35 years

Patients under 35 years:

• the cause is usually hormonal, rarely organic, but keep

malignancy in mind

• management options:1

— explanation and reassurance (if slight irregularity)

— COC pill for better cycle control—any pill can be used

— progestogen-only pill (especially anovulatory cycles) norethisterone (Primolut N) 5–15 mg/day from day 5–25 of cycle

Patients over 35 years should be referred for investigation for organic pathology, usually by endometrial sampling and/or hysteroscopy If normal, the above regimens can be instituted

Intermenstrual bleeding and postcoital bleeding

These bleeding problems are due to factors such as cervical ectropion (often termed cervical ‘erosion’), cervical polyps, the presence of an IUCD and the oral contraceptive pill Cervical cancer and intra-uterine cancer must be ruled out, hence the importance of a Pap smear in all age groups and endometrial sampling, especially in the over-35 age group Mismanagement of these presentations is a legal ‘minefi eld’ A Pap smear should be taken, using the speculum carefully so as not

to provoke bleeding, if one has not been taken within the previous 3 months, and sent to a laboratory that uses appropriate quality control procedures with notation of the bleeding on the smear request form Remember that it is only a screening test Refer women with these bleeding problems with an abnormal smear or even without any unusual features Those with a friable ectropion that is causing persistent symptoms should also be referred.14 Thus, intermenstrual bleeding (IMB) should always be investigated Order a pregnancy test

if appropriate

Cervical ectropion, which is commonly found

in women on the pill and postpartum, can be left untreated unless intolerable discharge or moderate postcoital bleeding (PCB)1 is present An IUCD should be removed if causing signifi cant symptoms and the causative pill should be changed to one with

a higher oestrogen dose (e.g from 30 mcg oestrogen

to 50 mcg oestrogen)

Uterine fi broids (leiomyoma)

Fibroids are benign tumours of smooth muscle of the myometrium They are classifi ed according to their location: subserosal, intramural, subendometrial or intra-uterine They are oestrogen-dependent and shrink with onset of menopause

964 Part Five Women's health

• Pelvic discomfort ± pain (pressure)

• Bladder dysfunction

• Pain with torsion of pedunculated fi broid

• Pain with ‘red degeneration’—only in pregnancy (pain,

fever, local tenderness)

• GnRH analogues—especially if >42 years can shrink

fi broids (maximum 6 months)

This should be the diagnosis until proved otherwise

for postcoital, intermenstrual or postmenopausal

bleeding

Clinical features

• Peak incidence in sixth decade

• 80% due to squamous cell carcinoma

• Risk factors (refer Chapter 91, page 926)

Symptoms

• Postcoital bleeding

• Intermenstrual bleeding

• Vaginal discharge—may be offensive

Mainly diagnosed on routine screening

Examination

• Ulceration or mass on cervix

• Bleeds readily on contact—may be friable

Management

• Urgent gynaecological referral

Endometrial cancer

This is the diagnosis until proved otherwise in any

woman presenting with postmenopausal bleeding

— drugs (e.g unopposed oestrogen, tamoxifen)

— family history—breast, ovarian, colon cancer

Amenorrhoea and oligomenorrhoea

Amenorrhoea is classifi ed as primary or secondary

Primary amenorrhoea is the failure of the menses

to start by 16 years of age.3 Secondary amenorrhoea is the absence of menses for over 6 months in a woman who has had established menstruation

The main approach in the patient with primary amenorrhoea is to differentiate it from delayed puberty,

in which there are no signs of sexual maturation by age 13 It is important to keep in mind the possibility

of an imperforate hymen and also excessive exercise, which can suppress hypothalamic GnRH production

A good rule is to note the presence of secondary sex characteristics.4 If absent it implies that the ovaries are non-functional Causes of primary amenorrhoea include genital malformations, ovarian disease, pituitary tumours, hypothalamic disorder and Turner syndrome

Diagnostic tests include serum FSH, LH, prolactin, oestradiol and also chromosome analysis Early referral

is appropriate

In secondary amenorrhoea, consider a physiological cause such as pregnancy, or the menopause, failure

of some part of the hypothalamic–pituitary– ovarian–

uterine axis (e.g PCOS), or a metabolic disturbance

... pathological basis

946 Part Five Women''s health

Typical pain patterns...

Melbourne: Therapeutic Guidelines Ltd, 20 06: 28 2.

Neither the cause of breast... class="text_page_counter">Trang 27

Lumps in the breast

92< /h3>Figure 92. 3 Systematic examination of the breast

Figure 92. 4 The six areas