Breast lump

Key points:

• History needs to include her mentrual and reproductive history, and any known risk factors for breast cancer 
• Approach is clinical examination, U/S and FNA. If all came back negative, then you can re-assure patient. If equivocal, refer to breast surgeon
• Risk factors for breast cancer
• Family history of breast and ovarian cancer
• increasing age
• late childbearing (after the age of 30 years)
• Nulliparity (no children)
• Early menarche (<12 age="" li="" of="" years="">
• Late menopause
• Use of hormone replacement therapy
• Ashkenazi jewish ethnicity
• Obesity (post-menopausal women)
• Lifestyle factors (e.g. high alcohol consumption, high-fat diet)
• Tamoxifen
• it is prescribed to treat early stage oestrogen receptor - positive breast cancer in premenopausal and postmenopausal women
• Tamoxifen is usually taken for up to five years 
• As tamoxifen is an anti oestrogen drug, the common side effects are hot flushes, night sweats and vaginal dryness. Less commonly, tamoxifen increases the risk of blood clots, stroke, cataracts, endometrial cancer, mood swings, depression and loss of libido
• Only about 5% of women have breast cancer due to a genetic predisposition or inherited gene mutation, such as BRCA1 and BRCA2.

Approach to dysmenorrhoea

History

• Pain
• It is important to determine if the pain is actually related to the menstrual cycle or has another underlying cause
• where is the site of the pain ?
• How would you describe the pain ? e.g. continuous or colicky
• How long has it been present 
• Is the pain associated with gastrointestinal function; do you have nausea, vomiting or diarrhoea/loose bowels
• does opening your bowels ease or make the pain worse?
• Do you have pain on urination?
• Menstrual history
• How old were you when you first had your period?
• How often do you have periods and how long does each one last?
• is the period heavy ? if so, on which day of the period?
• What size tampon or pad do you use? do you ever use both?
• how often do you change them?
• do you ever flood through tampon/pad or at night in bed?
• Have your periods caused you to miss school/work/social actives before this period?
• What associated symptoms, including pain and discomfort, do you have?
• What pain relief have taken and does it help?
• Medical and family history 
• do you have any family members with 
• diagnosed endometriosis?
• pelvic pain or pain during menstruation?
• problems getting pregnant or involuntary childlessness?
• Sexual history 
• when the first intercourse occurred
• male or female partners
• route of intercourse
• use of contraception 
• discussion of STIs
• vaccination history including hPV 
• pain or bleeding during sex 
• Examination 
• abdominal examination 
• vaginal examination is often not required esp. in adolescent girls who have never had sexual intercourse before
• Investigation 
• Blood test + STD screen 
• Vaginal or transabdominal ultrasound 
• DDx
• can be broadly classified in primary or secondary dysmenorrhoea 
• for further details about primary dysmenorrhoea, please go to the following link 
•  

• Management
• Analgesia: NSAID
• Suppression of ovarian function: COCP, GnRH agonist, IUD, etonorgestrel implant and oral dienogest
• surgical ablation 
• management of infertility 30-35% of women with endometriosis have infertility
• Prognosis
• Chronic condition 
• recurrence rate of 10-50% one year after surgery

Early pregnancy bleeding

• 20 - 40 % of pregnant women will experience bleeding during the first trimester of pregnancy
• Major causes are miscarriage (10-20%) and ectopic pregnancy (1-2%)
• Establishing the site of the pregnancy is vital, as failure to correctly diagnose an ectopic can have potentially life threatening consequences
• Initial assessment is haemodynamic stability. Unstable patients need to be transferred to the emergency department
• History
• gestational age of the pregnancy
• the amount of blood loss
• any associated pain symptoms 
• the presence of syncope, chest pain and shortness of breath may point to anaemia from significant blood loss, and shoulder tip pain may be associated with intra-abdominal bleeding 
• Examination 
• Assess for haemodynamic instability 
• abdominal examination 
• speculum examination to assess the amount and origin of ongoing bleeding
• bimanual examination allows assessment of uterine size, dilatation of the cervical os, pelvic tenderness and cervical motion tenderness
• Investigation 
• Beta HCG (Serum HCG levels rise exponentially up to six to seven weeks of gestation, increasing by at least 66 % every 48 hours)
• Ultrasound assessment
• Testing for maternal blood group and antibody status will determine the need for RhD immunoglobulin administration 
• On TVS, a gestational sac will usually be visible from 4 weeks and 3 days after the last menstrual period
• Management 
• Rh D immunoglobulin is indicated for the prevention of Rh D sensitisation in Rh D negative women. This should be given within 72 hours of the sensitising event.

References:

http://www.racgp.org.au/afp/2016/may/early-pregnancy-bleeding/

primary dysmenorrhoea

Condition

• Primary dysmenorrhoea

Definition

• Primary dysmenorrhoea is the usual cause of dysmenorrhoea in adolescence

History

• Symptom onset at adolescence
• Duration: first 2-3 days of period
• No pain at other times of menstrual cycle
• No other types of pain 
• Risk factors for primary dysmenorrhoea 
• younger age at menarche
• long duration of menstrual flow 
• smoking 
• obesity 
• ETOH consumption 
• high levels of stress 
• anxiety
• depression 
• disruption of social networks

Management

• NSAIDs
• pain relief is achieved in approximately 70% of women
• Act to prevent pain rather than as an analgesic to treat pain 
• start taking the NSAIDs as soon as you know that period imminent, or as soon as the bleeding starts
• because these tablets prevent pain you need to take them at the correct dose on a regular basis for the first 1-3 days of period
• COCP is highly effective but 30 % users report no relief with use of the COCP

References:

- Check program 2011 

- eTG

Approach to breast pain

Mastalgia: diagnostic strategy model

Probability diagnosis

• Pregnancy
• Cyclical mastalgia
• benign mammary dysplasia 

Serious disorders not to be missed

• Neoplasia
• Inflammatory breast cancer
• Infection:
• mastitis
• abscess
• Myocardial ischaemia

Pitfalls

• pregnancy
• chest wall pain e.g. costochondritis
• Pectoralis muscle spasm
• Referred pain esp. thoracic spine
• Bornholm disease (epidemic pleurodynia)
• Mechanical
• bra problems
• weight change
• trauma
• Rarities
• hyperprolactinaemia
• nerve entrapment
• mammary duct ectasia
• sclerosing adenosis
• ankylosing spondylitis

Mastitis

Condition

• Mastitis

Definition 

• cellulitis of the interlobular connective tissue of the breast
• infection organism is usually S. Aureus, E. Coli or C. Albans

History

• A lump and soreness 
• A red tender area
• possibly fever, tiredness, muscle aches and pains

Management

• prevention: empty breast (keep feeding) and attend to breast engorgement and cracked nipples
• antibiotics: flucloxacillin 500 mg QID 

References:

• John Murtagh's general practice 

Costochondritis

Condition

• Costochondritis

Presentation

• 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 
• pain is acute, intermittent or chronic

Examination

• normal breast examination 
• palpable swelling about 4cm from sternal edge due to enlargement of costochondral cartilage

Management 

• conservative 
• settles on its own 
• can use pain relief

References:

• John Murtagh's General Practice 

Cyclical mastalgia

Condition

• Cyclical Mastalgia

Definition 

• Pain prior to menstruation 

Presentation

• typical age 35
• 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 

Examination

• as per normal breast examination 

Management

• reassurance
• proper bra support
• low fat diet, excluding caffeine
• ideal weight
• analgesia 
• Danazol in severe cases

Reference:

john murtagh general practice 

Intrauterine device

Intrauterine device

Advantages:

• It is in place for approximately 5 years
• It is inexpensive in the long term. The real cost of the levonorgestrel IUCD to the PBS is $246.41. The PBS covers most of the cost so that the user pays only $ 33.30
• Partners cannot usually feel it 
• It has an antiseptic as well as contraceptive effect
• It can be easily removed on request

Disadvantages

•  It is invasive and requires insertion 
•  It can fall out
•  It may be a conduit to infection (however, this not supported by research)
•  There is an increased risk of ectopic pregnancy
•  There is a risk of uterine perforation at insertion 
•  There is a risk of pregnancy, approximately 1-2 pregnancies per 100 women using it
•  Menorrhagia can occur (although reduced menstrual flow usually occurs with the levonorgestrel IUCD and this is used to treat menorrhagia) 
•  If pregnancy occurs, the IUCD should be removed in the first trimester but that carries a risk of miscarriage, however, leaving removal the second trimester increases the risk of sepsis and premature labour. 

The approach to Infertility

Key points:

• Infertility is a complex topic. GPs can start initial investigation and refer appropriately.
• Definition of infertility: absence of conception after a period of 12 months of normal unprotected sexual intercourse.
• In determining the cause of the sub fertility, three basic fertility parameters should be investigated:
• the right number of sperm have to be placed in the right place at the right time
• the woman must be ovulating 
• the tubes must be patent and the pelvis sufficiently healthy to enable fertilisation and implantation 

• Significant causes of infertility 
• Female factors
• Ovulation factors 
• Hypothalamic/pituitary disorders
• hyperprolactinaemia 
• other endocrine disorders
• ovarian failure (e.g. oocyte ageing)
• stress
• PCOS
• weight-related ovulation disorders
• idiopathic eugonadotropic anovulation 
• Tubal disease:
• PID
• endometriosis 
• previous ectopic pregnancy
• previous tubal ligation 
• previous peritonitis
• Uterine and cervical abnormalities
• congenital 
• acquired
• Endometriosis 
• Male factors
• Reduced sperm production 
• congenital cryptorchidism 
• inflammation (e.g. mumps orchitis)
• antispermatogenic agents
• chemotherapy 
• drugs
• irradiation 
• heat
• Idiopathic
• Klinefelter syndrome (46XXY)
• Sperm autoimmunity
• Hypothalamic pituitary disease
• hypogonadotropic disorder
• Disorders of coitus
• Erectile dysfunction 
• psychosexual ejaculatory failure
• retrograde ejaculation 
• genitourinary surgery 
• autonomic disorders (e.g. diabetes)
• congenital abnormalities
• Ductal obstruction 
• Couple factors
• joint sub fertility
• psychosexual dysfunction 

History to cover:

Female factors

Ovulatory function 

- Are her period regular? Cycles from 28-35 days are considered regular. Irregular cycles may indicate involution, with possible underlying causes including polycystic ovarian syndrome, hyperprolactinaemia, thyroid dysfunction and premature ovarian failure. 

- Is there inter menstrual bleeding?

Tubal function 

- Previous STD?

- Pelvic surgery for treatment of conditions such as ovarian cysts, fibroids or endometriosis

- Ruptured appendix

- IUD use

- Infection after previous termination pregnancy

- Severe dysmenorrhoea, dyspareunia or pelvic pain ? Clinical findings of suggestive of endometriosis include a fixed retrieved uterus, thickening of the uteros aural ligaments, cup-de-sac modularity or pelvic tenderness during examination

Male Factors

- Previous infertility, for example, in a previous relationship 

- Testicular injury, torsion, surgery or infection 

- Undescended testes 

- Varicocele

- Hernia or urinary tract surgery including vasectomy reversal 

- Sexually transmitted disease

- Impotence 

- Ejaculatory problems, for example, no ejaculation or retrograde ejaculation

- History of disease or illness that my affect fertility such as diabetes, cystic fibrosis or testicular involvement in mumps

- Drug therapy that may affect fertility such as chemotherapy and hormonal therapy including ETOH

• Medications that could affect fertility
• ETOH
• Chemotherapy
• Anabolic steroids
• Aminoglycoside abx
• Sulphasalazine
• Cimetidine/ranitidine
• Colchicine
• Spironolactone 
• Antihypertensive agents
• Narcotics
• Phenytoin
• Nitrofurantoin
• Nicotine
• Marijuana

Physical examination 

- Female: breast, abdominal and pelvic examination, pay particular attention of fibroids or ovarian cysts

- Male: if the sperm count is abnormal or there is a history of sexual problems

Investigations:

- Female: Pelvic ultrasound +/- hysterosalpingogram (HSG), ovulation may be confirmed by measurement of the serum progesterone level in the mid-luteal phase. If periods are irregular, 2-3 blood samples should be taken over two-week period. A high level of progesterone indicates the woman is ovulating.

- If not ovulating, measure LF, FSH and prolactin. Rubella immunity may be checked with the same blood sample. 

- High LH: FHS ratio may indicate polycystic ovarian syndrome. Elevated FSH may be a sign of approaching or premature menopause. A high prolactin level may be associated with pituitary micro adenoma. Marginally elevated prolactin may warrant a repeat test.

- Investigation of free androgen index may be of benefit if polycystic ovary syndrome is suspected

- TSH measurement may help. 

- urine specimen should be taken to exclude chlamydia 

Sperm assessment:

- A sperm count sample should be collected in a clean, non sterile jar, kept warm and taken to the pathologist within 1-2 hours 

- Semen analysis is normal if the count is more than 20 million/ml, motility is greater than 50 % and there are adequate normal forms. If the sperm count is abnormal, it should be repeated before conclusions are made. 

Advice to patients:

- Have sex at least every second day around the time of ovulation 

- Stop smmoking 

- Limit ETOH intake

- Avoid unnecessary medications; for example : NSAIDs may interfere with ovulation by blocking oocyte release 

- Eat a healthy diet

- Weight loss may increase chances of conception in obese people 

- Commence preconception folate therapy in the female  partner 

Referral:

- Women under 35 years in whom there is a lack of obvious pathology may be advised to keep trying of up to 12 months. Refer if conception has not occurred after 12 months. 

- Couples where the woman is over 35 years may be advised to persevere for no more than six months if investigations reveal correctable factors that can be managed in general practice, such as lifestyle changes. 

- Early referral is appropriate in women over 35 years with no apparent abnormalities because the influence of age of fertility; and in couples with abnormal results of investigations or whose history reveals risk factors for infertility

References: 

- John Murtagh General Practice 5th edition The subfertile couple 

- http://www.australiandoctor.com.au/clinical/therapy-update/investigating-infertility

- http://www.australiandoctor.com.au/cmspages/getfile.aspx?guid=0fd498f2-572c-4484-ac6f-16da37f733a9

Approach to Dyspareunia

Key points:

- Painful intercourse is a source of considerable distress both physically and psychologically for the sufferer and also for her partner.

- Some authors claim that most cases (80%) of dyspareunia have a physical cause and careful physical examination is mandatory


- History is the key

- Causes of dyspareunia

• Pain worse on insertion 
• physiological inadequate lubrication
• Vaginitis in chronic candidiasis
• Vulvar dermatoses 
• Postnatal perineal scarring 
• Incompletely ruptured hymen 
• Vulvar vestibular sydrome (vestibulitis): well defined entry pain, painful inflammation of vulvar vestibular area, dull ache, burning or pruritus. Tenderness on touch of cotton tipped applicator
• Vulvovaginal atrophy 
• Vaginismus: well defined entry, involuntary spasm of muscles, difficulty of insertion of penis, tampons or digit. Palpable spasm and difficult inserting speculum. 
• Pain worse on deep penetration 
• Endometriosis: Deep pain; cyclic pain with menses, complained of something being bumped into. Enlarged adnexa and tender to touch. 
• PID
• Pelvic adhesions
• Ovarian and uterine tumours
• Postnatal

- Questions to ask

• Where is the located?
• When is the onset of the pain ? (before, entry, vaginal, deep or after)
• Is it pruritic, burning or aching in quality?
• What is the chronologic history? If multiple pain sites, which came first?
• Is it situational or positional ?
• Has it been lifelong or acquired?
• Are there other sexual dysfunctions such as arousal, lubrication or orgasmic difficulties ?
• What treatments have been attempted?
• Explore potential gynecologic causes
• Are there vaginal symptoms including discharge, burning or itching?
• Does patient have a history of STDs, especially HSV or HPV?
• Is there an obstetric delivery history of lacerations, episiotomies or other trauma?
• Is there an obstetric delivery history of lacerations, episiotomies or other trauma?
• Is there an abdominal of genitourinary surgical or radiation history?
• Has the patient had prior pgynecologic diagnoses, including endometriosis, fibroids or chronic pelvic pain?
• What is the patient's current contraception method and its here any history of intrauterine device use?

References:

aafp : http://www.aafp.org/afp/2001/0415/p1535.html

John murtagh 8th edition

Quick start of contraception

Quick start of contraception

Traditionally, contraception methods are started within the first 5 days of menstrual cycle. It becomes a problem when a woman comes to you for contraception during mid cycle. If you tell her to wait, she may become pregnant before she gets her next period. Quick start of contraception tries to tackle that.

Essentially, the process can be summarised in 3 steps:
1. Establish pregnancy status
2. Choose contraception method
3. Follow up

1. Establish pregnancy status 

• Pregnancy can be excluded if :
• -ve pregnancy test + no sex in the last 3 wks
• no sex since last period
• using contraception correctly and reliably
• within the first 5 days of menstrual period 
• < 21 days post part
• < 5 days post abortion or post miscarriage 
• Pregnancy cannot be excluded:
• needs follow up pregnancy testing, the current Australian guideline is in 4 weeks time

2. Choose contraception method 

• If pregnancy can be excluded: can choose any contraceptive method. Don't forget COCP, Vaginal ring, DMPA, LNG IUD and Levonorgestrel take 7 days to work. POP takes 3 days. Copper IUD effective immediately
• If pregnancy cannot be excluded
• tell her that there is a chance she could be pregnant, if it is appropriate, offer her emergency contraception 
• inform choices available for contraceptions: 
• Vaginal ring, COCP, POP, levonorgestrel have not shown to have teratogenic effects in babies. 
• DMPA injection is long acting, so it is less perferrable but also no evidence of teratogenicity
• IUD and Copper IUD not preferred as can cause miscarriage

3. Follow up 

• Women in whom the pregnancy status cannot be excluded: needs pregnancy test in 4 weeks. (This is the current Australian recommendation. Other guidelines have different timeframe)

Resources:

1. Flow chart for quick start contraception(American version, follow up testing time frame different)

2. Family planning victoria quick start guideline

Perinatal depression 101

Key facts about perinatal depression

1.  "It takes a village to raise a baby" Explore helps which are available (husband, mother and friends)
2. Edinburgh postnatal depression scale (EPDS) can be used to screen for postnatal depression. A score > 10 is suggestive of possible depression.
3. Don't forget risk assessment and physical problems such as mastitis, urinary tract infection and thyroid dysfunction.
4. beyondblue postnatal depression screening program reported that 16% of women have depression in the postnatal period. (Postnatal depression is common)
5. SSRI (sertraline) is reported to be present in low concentrations in breast milk, has little transfer to the infant and poses few risks of side effects in the child.
6. Paroxetine should be avoided in women of child-bearing age.
7. When stopping antidepressants, reduce it over a period of time (6 months)