Breast Pathologies, Complications of Menstruation, and WSW

Breast Abnormalities Requiring Evaluation

Breast Lumps and Masses

• Breast lumps are the most common anomaly found on clinical and self-exam

• Most benign but all need evaluation

• Unilateral, hard, non-tender or fixed lumps suspicious for cancer

Skin Changes

• Erythematous, scaly rash on nipple

• Cyclic breast pain → especially related to menses, is benign and may not require imaging

• Nipple discharge → bloody, persistent, spontaneous, unilateral warrants further wok up (labs and imaging, surgical consult)

 

Breast Imaging Screening

Mammogram for asymptomatic women

• Craniocaudal view and mediolateral oblique view

Begin screening at 40 years old and screen annually

• Women with breast implants should have regular mammographic screening

Dense breast tissue requires U/S

• Only seeing one piece if only do mammogram

BIRADS 3 → probably benign

• Follow up recommended but consider referral to breast specialist

Solid lesions need to be biopsied

Breast Imaging Diagnostic

• Mammography for women with clinical symptoms or previous abnormal mammogram

  • Involves special views

BIRADS

Breast Imaging U/S

• Most common imaging study after mammogram

• Helps differentiate cystic vs solid mass

• Aids in biopsy guidance

• In patients with dense breasts → order both mammogram and U/S

Breast Imaging MRI

• More sensitive for detecting breast cancers in women at high risk (mutation carriers)

• MRI more sensitive than mammography or clinical exam but less specific

• Determines architectural features, shape, margins, distortion, septations, and enhancement patterns

Breast Cancer Non-Modifiable Risk Factors (8)

• Genetic mutations

• Family history of breast cancer

• Age (increases with > 50 y/o)

• Menarche < 12 y/o

• Menopause > 55 y/o

• Dense breast tissue

• Abnormal breast biopsy

• Previous breast cancer

Breast Cancer Modifiable Risk Factors (11)

• Nulliparity

• First live birth > 30 y/o

• Not breastfeeding

• OCP use

• Prolonged post-menopausal HRT

• Obesity

• Alcohol use

• Tobacco

• Sedentary lifestyle

• High fat diet and processed foods

• Radiation exposure

Breast Cancer Screening

Goals

• Detect breast cancer at an early, more treatable stage

• Reduce mortality rates by enabling early intervention

High risk individuals require earlier and more frequent screening

• BRCA1/BRCA2 mutation carriers → start at 25-30 y/o with MRI and mammogram

• Strong family history

• History of chest radiation

Breast Cancer Risk Assessment: Tyrer-Cuzick Model

• Estimates women’s lifetime and 10-year risk of developing breast cancer

• > 20%: should have earlier and frequent screening

  • Gives percentage regardless of testing for genetic component

Breast Cancer Risk Assessment: Gail Model

• Estimate’s 5-year and lifetime risk

• Best for average risk women

Ductal Carcinoma in situ

• Non-invasive

• Abnormal cells confined to the milk ducts

Invasive ductal carcinoma

• Starts in milk ducts but invades surrounding breast tissue

• Most common type of invasive breast cancer

Infiltrating lobular carcinoma

• Starts in lobules and spreads in a single file pattern

• More likely to be bilateral

Inflammatory Breast Cancer

• Instead of lump, causes breast swelling, redness, warmth, and skin dimpling due to lymphatic invasion

• Most aggressive type

Abnormal Uterine Bleeding

Regular cycle length: 24-38 days

• Polymenorrhea: < 21 days apart

• Oligomenorrhea: > 35 days apart or fewer than 8-9 periods per year

• Menorrhagia

  • Heavy menstrual bleeding: > 80 mL of blood loss per cycle or menstruation lasting longer then 7 days

  • Patient reports

    • Soaking through >= 1 pads/tampon every 1-2 hours

    • Needing to change protection during the night

    • Passing clots larger than 1 inch

    • Doubling up on pads or using extra protection

    • Symptoms of anemia

• Metrorrhagia – irregular bleeding

• Menometrorrhagia - heavy and irregular bleeding

Abnormal Uterine Bleeding Classification

Causes of Abnormal Uterine Bleeding

Adolescence

• Most common cause is anovulation → immature HPA

• Coagulopathies

Reproductive Years

• Once pregnancy ruled out:

  • Anovulatory cycles (MCC)

  • Infections

  • Complications of contraception

  • Medications: OCPs, corticosteroids

  • Systemic disease: hyperthyroidism, hypothyroidism, chronic renal failure, leukemia, malignancy

  • Undiagnosed von Willebrand

  • Endometrial polyps and fibroids

Perimenopause

• Usually anovulatory

• Erratic hormone levels

• Malignancy (endometrial cancer)

• Pregnancy: change of life baby

• Medications

• Systemic disease

• Fibroids

Postmenopausal

• Malignancy until proven otherwise (endometrial, cervical, uterine)

Abnormal Bleeding: Anovulation

• No regular ovulation → hormone signals that regulate the menstrual cycle get disrupted → irregular, unpredictable, or heavy bleeding

  • Normal ovulation: ovary releases egg → progesterone produced, which helps stabilize the uterine lining, and without pregnancy progesterone drops and triggers predictable period

  • Anovulation: no ovulation means no progesterone → estrogen may build up the lining excessively and eventually the lining becomes unstable and sheds erratically or heavily

• Causes

Abnormal Bleeding: Diagnosis and Management

Diagnosis

• History

  • Age at menarche

  • Cycle of length

  • Inter-menstrual interval

  • Quantity of bleeding

  • Inter-menstrual bleeding

  • Medications

• Physical → abdominal and pelvic exam

• Labs

  • Serum hCG to r/o pregnancy

  • CBC with reticulocyte and platelet count to determine hemodynamic stability

  • Serum iron, TIBC, and ferritin

  • Coagulation tests

  • Thyroid function tests

  • BUN, creatinine

  • U/A and stool guaiac if source of bleeding is in question

  • Other labs depend on age, ovulatory status, risk of sexually transmitted infection and question of systemic disease

• Pelvic U/S: cheap and easy

• Endometrial biopsy: r/o polyps, hyperplasia, cancer

  • Need to r/o pregnancy first

  • Suction some of the cells with long instrument, pull back on tube, and going in and out and twisting

• D and C: when endometrial biopsy contraindicated or inadequate or if symptoms persist beyond treatment

• Hysteroscopy or direct visualization

• Hysterosalpingography: requires x-ray and contrast dye to visualize the uterus and fallopian tubes

  • Important for patients with fertility issues: can see if fallopian tube is patent or not

• Saline infusion sonohysterography (SIS)

  • Saline infused into uterus through catheter and trans-vaginal ultrasound evaluates

  • Separation of cavity walls → better visualization of endometrium

Abnormal Bleeding: Management

Goals

• Control bleeding

• Prevent further episodes

• Restore synchrony to endometrium

• Replenish iron stores

• Prevent serious long term consequences of anovulation

• Preserve desired fertility

Depends on

• Amount of bleeding

• Cause of bleeding

• Age of patient

• Ovulatory status

• Desire for fertility

Treatment

• PALM-COEIN: treat the underlying cause

• If due to ovarian anovulation

  • Combination estrogen-progesterone or cyclic progestin

  • If peri-menopausal → need to do endometrial biopsy to r/o neoplasia and consider hysterectomy

  • If patient not interested in fertility preservation can consider endometrial ablation

    • This is not a birth control option but causes significant scarring of the endometrium → not sustainable for pregnancy

  • Postmenopausal

    • Precancerous or malignant disease until proven otherwise

    • Benign causes like atrophic endometritis and polyps more common

• All women with menorrhagia should be started on iron

• Mild cases amenable to watchful waiting or treatment with NSAIDs

Abnormal Bleeding: Acute Heavy Bleeding Management

• Check vital signs: may need hospitalization

  • IV fluids, transfusions as needed (hemoglobin < 7)

• OCP pack

  • 1 full pack, double up the first couple days to help stop bleeding

  • Do not put in if have risk of blood clots

• Aygestin (norethisterone) → high dose progesterone

  • Give for 5 days - 1 week

  • Will see withdrawal bleeding

  • May be given to someone going in for a surgery to stop bleeding

• Lysteda (tranexamic acid) → prevents enzymes in the body from breaking down blood clots

  • Taken just on period

• Depo provera injection (medroxyprogesterone)

• If no response to medical treatment within 12-24 hours → surgery

  • D and C

  • Balloon tamponade

  • Uterine artery embolization

  • Hysterectomy is rare and life saving only

Abnormal Bleeding: Chronic Management

• Fix the underlying problem

• Antifibrinolytic therapy

  • Lysteda 650 mg

    • 2, 3, 5: 2 pills 3 times a day for 5 days

    • Contraindication if coagulopathy disorder

• Coordinate endometrial sloughing

  • Best for anovulation

  • Progesterone for withdrawal bleed

  • Combination OCP, patch, or ring: can also provide withdrawal bleed

• Endometrial suppression

  • To lighten bleeding and/or create amenorrhea

  • OCPs, POPs, Nexplanon

  • Extended cycle (seasonal, every 3 months menses, only bleed 4 times a year): OCPs, NuvaRing

  • Depo provera injection (medroxyprogesterone)

  • Levonorgestrel: IUD

    • Prevents ½ of women from hysterectomy

    • Very effective

Abnormal Bleeding: Refractory Prolonged Heavy Bleeding Management

Medical agents

• GnRH antagonist: Danazol

• GnRH agonists: Leuprolide

• Last resort: produce medical menopause

May require surgery

• D and C

• Endometrial ablation

• Hysterectomy

Abnormal Bleeding: Polyp

• See inter-menstrual bleeding

• Can often not be seen on exam: need pelvic exam or hysterectomy

  • Can use sonohysterography: separates endometrium to better see structural issues (may be difficult to see on U/S)

  • Endometrial biopsy may return fragments of polyp

• Needs to be removed

Abnormal Bleeding: Adenomyosis

• Endometrial cells from the lining of the uterus grow into the muscle wall

• Causes

  • Painful cramps

  • Heavy, prolonged menses

  • Dyspareunia

  • Boggy appearance/texture

• Treatment

  • Depends on severity

  • Conservative

  • Hormonal methods

  • Hysterectomy

Abnormal Bleeding: Leiomyoma

• Fibroids: tumors of uterine wall

  • Worry about submucosal: won’t be able to compress vessels well post-partum, which can lead to post-partum hemorrhage

• Causes:

  • Heavy vaginal bleeding

  • Prolonged bleeding

  • Often asymptomatic

• Treatment

  • Depends on severity

  • Hormonal methods

  • Myomectomy (removal of fibroids)

  • Uterine fibroid embolization

  • Hysterectomy

Abnormal Bleeding: Malignancy and Hyperplasia

• Hyperplasia is precursor to uterine cancer

• Any post-menopausal bleeding is a red flag

  • Should not see thickened lining (> 4 mm) on U/S in post-menopausal women

Abnormal Bleeding: Coagulopathy

• Abnormal bleeding caused by a bleeding disorder

• Von Willebrand Disease

  • The most common inherited bleeding disorder worldwide

  • Inadequate platelet adhesion and thrombus formation → easy bruising, frequent nose bleeds, bleeding gums, heavy menstrual periods, prolonged bleeding after cuts or surgery

  • Diagnostic labs

    • Decreased plasma vWD factor

    • Decreased VIII activity

    • Prolonged bleeding time

  • Treat with vasopressin (single infusion effective for minor bleeding episodes like menorrhagia)

  • OCPs effective for repeated, severe menorrhagia due to vWD

WSW Statistics

• Lesbian and bisexual women report higher rates or certain diagnoses

• Sexual minority of women have higher rates of forgoing or delaying medical care than heterosexual women

• WSW are often under-screened for pap smears due to provider assumptions regarding lower risk of cervical cancer

• Some are rarely asked about sexual orientation

• Many fear negative experiences when disclosing sexual orientation

Five P’s

Sexual History Questions for All Patients

• Are you sexually active with women, men, or both

• How many sexual partners have you had in the past 5 years

• Does your current partner have sex with women, men, or both

• Describe your sexual contact

• Is your sexual contact with someone who shared needed for injection drug use

• During sexual contact do you use barrier methods

• If active with men, what is your method of birth control

• Do you or your partners have any history of STIs

• Do you have any further concerns about sex or STIs

STI Transmission

Can occur through

• Skin to skin contact

• Mucosal contact

• Digital/vaginal/anal contact

• Shared penetrative sex toys

• Oral-anal contact

• Exchange of vaginal secretions or blood

Common STIs

• HPV: most common STI

  • Transmitted skin to skin

  • Cervical cancer risk

• HSV 1 and 2

• Bacterial vaginosis

  • Very common

  • Not an STD but sexually associated due to disruption of normal vaginal flora

• Trichomonas

• Chlamydia and gonorrhea → less common via female to female transmission

• Syphylis: increasing rates in women via oral/genital contact

• HIV rare in female to female transmission

STI Predisposing Factors

• Multiple sexual partners

• Shared sex toys without cleaning/barrier use

• Inconsistent barrier protection

• History of male sexual partners

• Substance use

• History of sexual trauma

• Misperception of low risk

• Under screening by providers

STI Screening Recommendations

• Screen based on behavior, not identity

• Routine screenings

  • PAP/HPV

  • HPV vaccination

  • Chlamydia and gonorrhea

  • HIV screening at least once

  • Syphylis based on risk

  • Trichomonas

STI Prevention

Safe sex practices, as with any sexual contact between any gender

• Use condoms on shared sex toys

• Clean toys between use

• Use dental dams for oral genital contact

• Avoid sharing toys without barriers

• Wash hands between genital contact

Cancer in WSW

Increased risk of

• Ovarian cancer

  • They may not use hormonal contraceptives

  • Using OCPs for 5 years reduces ovarian cancer by 50%

• Endometrial cancer

  • Nulliparity is a recognized risk factor for endometrial cancer

• Breast cancer

  • Nulliparity, birth to only once child, and no history of breast feeding

  • Hormones released during pregnancy and breast feeding are thought to be cancer protective