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S2 E013 Contraception, Infertility and Breast Issues

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depositphotos_6033866_originalContraceptive methods

  • Couitus interurrutpus
  • Lactational amenorrhea
  • Calendar methods
  • Basal body temperature method
    • A slight drop in temperature occurs 24-36 hours after ovulation
    • Secondary to progesterone body temp then rises about 0.5 degrees F until the end of the cycle
  • Mucus evaluation method
  • Cervical mucus resembles egg whites when patient most fertile
  • Oral Contraceptives (OCP)
    • Perfect use results in 0.3% failure rate. Typical failure rate is 8%.
    • Synthetic steroids similar to estrogen and progestins are used to suppress ovulation
    • Combination pills are typically started either the first day of the menstrual cycle or the first Sunday after the menstrual cycle begins.
    • If a pill is missed then two pills should be taken and a backup method should be used for 7 days
    • If a missed pill was preceded by intercourse at any point during the previous 5 days then, if desired emergency contraception should be used. Pills should be restarted and a backup method used.
  • Minipills are progesterone only and are not as effective as combination pills but have different side effect profiles
  • Non contraceptive benefits of OCPs
    • Improvement of benign breast disease
    • Decreased anemia
    • Improved dysmenorrhea, acne and hirsutism
    • Decreased in development of fibroids
    • Decreased risk of endometrial cancer and ovarian cysts
  • Disadvantages of OCPs
    • Increased risk of thromboembolic events especially in smokers
    • Increased risk of breast cancer
  • Intrauterine Devices
    • IUD’s have have a less than 1% failure rate
    • Uterine perforation, migrated IUD or misplacement
    • Increased risk of ectopic
    • Increased risk of pelvic infection
  • Intramuscular injection of progesterone or a combination of estrogen and progesterone
    • Depo Provera (medroxyprogesterone acetate) is most common
    • There are 90 day and 30 day formulations
    • 0.3% failure rate
    • Fertility returns within 18 months of discontinuing medication
  • Transdermal patches
  • Hormone-impregnated vaginal ring
  • Hormone releasing rod implant

Infertility

  • Infertility is the inability to conceive after one year of sexual activity without the use of contraception.

Possible Causes: Female

  • Problems with ovulation
  • Cervical Problem
  • Infection (Chlamydia)
  • Scarring of tubes or uterus
  • Endometriosis

Possible Causes: Male

  • Smoking
  • Recreational or prescription drug use including alcohol
  • Scrotal hyperthermia
  • Abnormal spermatogenesis

Labs & studies

  • Semen analysis
  • Pelvic U/S
  • FSH, LH, TSH, progesterone and estrogen levels
  • Ovulation prediction tests
  • Hysterosalpingography
  • Laparoscopy

Treatment

  • Clomiphene citrate 50-100mg to promote ovulation
  • Antibiotics for infectious problems
  • Resolution of endocrine disorders
  • Laparoscopic
    • Lysis of adhesions
    • Fulguration of endometriosis
  • Artificial insemination – introducing concentrated sperm into the uterus
  • In Vitro fertilization – creating an embryo outside of the body then placing that embryo into the uterus

Breast Disorders

Fibrocystic Disease

  • The most common breast lesion.
  • Includes: cysts, fibrosis and ductal epithelial hyperplasia
  • Typically age 30-50 (think slightly older)

I came in today to see my physician assistant because of…

  • My breasts hurt
    • Typically painful but may not be (usually changes with menstrual cycle)
    • Frequently changes in size (usually changes with menstrual cycle)
    • Usually multiple masses and bilateral
  • Nipple discharge

Physical exam

  • Palpable mass(es) on physical exam on both breasts
  • Lumpy, Bumpy Breasts
  • Rope like

Labs & Studies

  • Breast U/S may be useful
  • Mammography
  • Biopsy
  • Fine-needle aspiration cytology
  • Gram stain and culture of any discharge

Treatment

  • Monitor
  • Aspiration of cysts reduce pain and for cytology
  • Anecdotal evidence supports reduction of caffeine to improve symptoms
  • Supportive bra will help with symptoms

Fibroadenoma

  • Benign breast tumor
  • Ages 14-40 most common (think slightly younger)
  • African Americans have an increased risk

I came in today to see my physician assistant because of…

  • A lump in my breast

Physical exam

  • Breast mass
    • Rubbery
    • Movable
    • Non tender
    • 1-5 cm

Labs & studies

  • Mammography
  • Breast U/S may be useful
  • Biopsy
  • Fine-needle aspiration cytology
  • Excision with pathology if diagnosis is necessary

Treatment

  • Reassurance
  • Cryoablation

Breast Carcinoma

  • The most common cancer in women. Affects 12% of women.
  • Lung cancer is the only cancer with higher death rates among women.

Ductal carcinomas

  • 85% of breast cancer

Ductal Carcinoma in situ (DCIS)

  • Possibly malignant, cancerous cells within the milk the ducts
  • DCIS puts the patient at increased risk of invasive disease

Invasive Ductal Carcinoma (IDC)

  • Malignant and invasive neoplastic cells which have broken out of the milk ducts

Lobular Carcinomas

  • 15% of breast cancer
  • Lobule is the gland within the breast that makes milk

Lobular carcinoma in situ (LCIS)

  • Abnormal cells within the lobule. This is not considered cancer though does place the patient at an increased risk of developing cancer.

Invasive lobular cancer

  • Cancer cells have broken out of the lobule

Paget’s Disease

  • Cancer of the nipple and areola
  • Often DCIS or IDC underneath
  • Paget’s accounts for about 1% of breast cancer.

Risk factors for breast cancer

  • Most cases of breast cancer do not have any risk factors
  • Estrogen exposure
    • Advancing Age – with an average age of 60
    • Nulliparity
    • Advanced age at first pregnancy
    • Early menarche < 12 years old
    • Late menopause > 50 years old
  • 5%-10% of cases have a genetic susceptibility with a BRCA1 or BRCA2 gene
  • Family history of breast cancer
  • Caucasian

I came in to see my physician assistant today because of…

  • Routine screening
  • Lump in breast
    • First presentation in the majority of cases is a self detected, firm, immobile, painless mass.
  • Peau d’orange – orange peel skin
  • Breast pain
  • Nipple discharge
  • Nipple retraction
  • Enlargement or shrinkage of the breast
  • Metastatic symptoms – bone pain, weight loss etc

Physical Exam

  • Mass on breast exam
    • Firm
    • Poorly defined
    • Immobile
    • Non tender
    • Most commonly found in the upper outer quadrant

Labs & Studies

  • Mammography
    • Screening recommendations from the American Cancer Society
      • Average risk patients should be screened annually from age 45-54
      • Average risk patients 55 should be screened every other year
  • U/S
  • MRI
  • Excisional biopsy
  • Imaging for metastatic disease
    • CT
    • PET scan

Treatment

  • Lumpectomy
  • Mastectomy
  • Chemotherapy
  • Radiation
  • Tamoxifen is an estrogen receptor antagonist, can be used to treat estrogen-receptor positive cancer as well as postmenopausal women.

Galactorrhea

  • Often caused by a pituitary prolactinoma.

I came in to see my physician assistant because of…

  • Milk discharge from the breast in women, men and infants unrelated to childbirth
  • Amenorrhea, oligomenorrhea, infertility

Labs & Studies

  • Elevated prolactin
  • Beta hCG
  • MRI of the pituitary and hypothalamus

Treatment

  • Reassurance if patient has had children or if prolactin is normal
  • If prolactin is elevated correct underlying cause
  • Dopamine agonist may lower prolactin
    • Cabergoline
    • Bromocriptine

Gynecomastia

  • Often seen in elderly men, obese men, and taller, heavier boys during puberty.

I came in today to see my physician assistant because of…

  • Male developing female breasts

Possible causes

  • Endocrine issues
  • Chronic liver disease
  • Chronic kidney disease
  • Neoplasm
  • Drugs
  • Puberty

Labs & Studies

  • Prolactin may be elevated
  • Low serum testosterone
  • Estradiol may be increased
  • Karyotype – Klinefelter’s syndrome
  • Consider biopsy for suspicious mass

Treatment

  • Typically self limited
  • Treat underlying condition
  • Stop offending medication
  • Surgical removal

Mastitis and Breast Abscess

  • Most commonly occurs within three months of delivery and women nursing for the first time

I came in today to see my physician assistant because of…

  • Engorged breast
  • Sore, cracked nipples
  • Warm, tender, red breast
  • Erythema

Labs and Studies

  • Culture nipple discharge. Staph Aureus is the most common pathogen
  • Incision and biopsy

Treatment

  • Antibiotic therapy
    • Augmentin
    • Dicloxacillin
  • Mechanical emptying of the breast
  • Continue to breastfeed
  • An abscess may be drained with a needle
  • I&D

Study tip

Talk with those around you about when your study schedule.

 


<< Click here to get 26 ObGyn questions straight from my book, The Final Step >>