Ebook Murtagh''s general practice (5th edition): Part 2
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Part 5
Murtagh - General Practice (5e) Part 5.indd 925
Women's health
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89
Cervical cancer and
Pap smears
If all women have regular Pap smears, one every two years, we can prevent 90% of all cervical cancers.
D R G A B R I E L E M E D L E Y , T I M E , 24 A P R I L 199 5
Facts and figures
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 partners
Early age for first
intercourse
Early age first
pregnancy
Viruses
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
• 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 first intercourse, the greater the
chance of developing cervical cancer.
• Invasive cervical cancer is a disease for which definite
curable premalignant lesions can be identified using a
Papanicolaou (Pap) smear as a screening test.
• The incidence of cervical cancer has been decreased
significantly 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 pathology
The 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
926
Murtagh - General Practice (5e) Part 5.indd 926
22/10/10 2:45:13 PM
Cervical cancer and Pap smears
can extend with progressive metaplasia of columnar
epithelium and so the squamocolumnar junction
may recede into the endocervical canal. This is a
927
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 neoplasia
Cellular 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 modified
Bethesda System.5, 6 These dysplasias have the potential
to become invasive cervical cancer.
Natural history of cervical dysplasia
Figure 89.1 The transformation zone: it is vital that cells
are taken from this zone with Pap smears
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
confirmed moderate to severe dysplasia require a
colposcopic assessment.
89
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to its position
Murtagh - General Practice (5e) Part 5.indd 927
22/10/10 2:45:13 PM
928
Part Five
Women's health
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Figure 89.3 Illustration of the various grades of squamous intraepithelial lesions and CIN (comparison of
nomenclature)
Figure 89.3 and Table 89.2 illustrate the disease
spectrum of cervical neoplasia.
Table 89.2 Squamous cell abnormalities and the
different nomenclatures5, 6
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
flatus, 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 first
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
have symptoms.
• Ideally, practices should have a reminder or a recall
system.
Murtagh - General Practice (5e) Part 5.indd 928
Australian
modified
Bethesda
system
Description
CIN grade
Normal
Normal
Within normal
limits
Atypia
ASCUS
HPV
LSIL
4 Mild dysplasia
CIN 1
LSIL
Moderate
dysplasia
CIN 2
HSIL
6 Severe
dysplasia
CIN 3
HSIL
CIS
HSIL
Invasive
carcinoma
Invasive
carcinoma
1
2 Atypia: reactive
or neoplastic
3
5
7
HPV
Carcinoma in
situ
8 Invasive
carcinoma
ASCUS = Atypical squamous cells of undetermined significance
CIN
= Cervical intraepithelial neoplasia
CIS
= Carcinoma in situ
HSIL
= High-grade squamous intraepithelial lesion
LSIL
= Low-grade squamous intraepithelial lesion
22/10/10 2:45:14 PM
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 benefit
compared with 2-year intervals.
2
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:
• sufficient mature and metaplastic squamous cells
to indicate adequate sampling from the whole of the
transformation zone
• sufficient 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
3
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.
4
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 findings.
The method
1 Education and explanation
Take time to explain the reason for taking the Pap
smear, especially if it is the first. 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
Murtagh - General Practice (5e) Part 5.indd 929
5
6
the patient during the examination with appropriate
explanation. It is advisable for a male doctor to have a
chaperone present.
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 fixative
• 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.
Special notes:
• pregnancy—avoid use of the endocervical brush
and the Cervex-Brush Combi
• eversion—take care to sample the
squamocolumnar junction
Positioning
The supine position is usually best (see Fig. 89.4). The
left lateral position can be used if smears are difficult
to obtain (e.g. older women with lax anterior vaginal
walls, older women with poor hip mobility and the very
embarrassed patient). The Sims exaggerated left lateral
position (see Fig. 89.5) provides better exposure of the
vulva but requires more manipulation of the patient.
Better visualisation of the cervix is obtained if the patient
elevates her buttocks with her hands (best as fists).
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 firm 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).
Visualising the cervix
Good lighting and exposure of the cervix is essential.
Note any significant 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.
Taking the smear
Choose the sampling instrument that best suits the
shape of the cervix and os. Place Ayer’s spatula firmly
929
89
22/10/10 2:45:14 PM
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 (first)
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.
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)
Abnormal cervical cytology
Confirmation 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
• insufficient material
• endocervical cells not being taken in the smear
(i.e. taken from the wrong site)
• a thick film with an inadequate spread of material
• air-drying before fixing
• smear not being fixed 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)
Murtagh - General Practice (5e) Part 5.indd 930
Figure 89.5 The Sims exaggerated left lateral position
22/10/10 2:45:14 PM
Cervical cancer and Pap smears
931
Abnormal Pap smears
B
Follow 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—
inflammatory cells
Repeat smear in 2 years.
Unsatisfactory smear
Repeat smear in
6–12 weeks (allows
regeneration of cells).
C
Low-grade epithelial lesion
Possible LSIL
and
Definite LSIL
D
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.
89
High-grade epithelial lesion
E
Possible HSIL
Definite 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
F
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 fidelity are recommended
for those who can, and condoms for those who cannot’.10
This statement is a succinct recommendation for
prevention and includes the following:
Figure 89.6 Method of smear taking and preparing the
slide
Murtagh - General Practice (5e) Part 5.indd 931
• Ideally, people should have intercourse with only one
partner.
22/10/10 2:45:14 PM
932
Part Five
Women's health
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Figure 89.7 Algorithm for management of low-grade squamous cell abnormalities (based on NHMRC guidelines)
• 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.
• Identification 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.
Murtagh - General Practice (5e) Part 5.indd 932
Medicolegal issues 8
Cervical cancer screening is a potential minefield 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
22/10/10 2:45:15 PM
Cervical cancer and Pap smears
933
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.
Scientific 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: SpringerVerlag, 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 Modified 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,
2004; 5(1): 59–65.
9 Craig S. The smear test. Aust Fam Physician, 1985;
14: 1092–4.
10 Tattersall M. Preventing Cancer. Sydney: Australian
Professorial Publications, 1988: 182–97.
Murtagh - General Practice (5e) Part 5.indd 933
89
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90
Family planning
The Membranous Envelope (condom) is prepared from the bladder of a fish 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.
E D W A R D B L I S S F O O T E 1864, M E D I C A L C O M M O N S E 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, confidentiality 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 contraception
COCs 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.
934
Murtagh - General Practice (5e) Part 5.indd 934
22/10/10 2:45:15 PM
Family planning
935
Table 90.1 Effectiveness of contraceptive methods5, 3
Method
Effectiveness (pregnancies per
100 years of use)
Lowest expected (reliable
consistent user)
Natural rhythm methods
20–30
Billings ovulation (cervical mucus) method
3
2–3
Withdrawal (coitus interruptus)
20–25
18
Spermicides:
• vaginal sponge
• diaphragm (with spermicide)
• condoms
10
15
10–15
–
6
3(O ); 5 (O)
Intra-uterine devices
3–5
0.1–1
Vaginal ring
1–3
0.65
Oral contraceptives:
• combined
• progestogen only
1–3
3
0.1
0.5
Ddepomedroxyprogesterone acetate
0.1
0.3
Implant
0.06
0.09
Female sterilisation
0.02
0.4
Male sterilisation
0.15
0.1
Pearl index
v
90
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 first choice is a monophasic pill containing
30 mcg ethinyloestradiol (EO) with levonorgestrel
Murtagh - General Practice (5e) Part 5.indd 935
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
Specific 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).
22/10/10 2:45:15 PM
936
Part Five
Women's health
Table 90.2 Combined oral contraceptive pill formulations4
Oestrogen
Dose (mcg)
Progestogen
Dose (mcg)
Trade name
Ethinyloestradiol
20
Drospirenone
3000
Yaz
Ethinyloestradiol
20
Levonorgestrel
100
Microgynon 20,
Loette, Microlevlen
Ethinyloestradiol
30
Levonorgestrel
150
Nordette, Levlen
ED, Microgynon 30,
Monofeme
Ethinyloestradiol
30
Dienogest
2000
Valette
Ethinyloestradiol
30
Gestodene
75
Femoden ED,
Minulet
Ethinyloestradiol
30
Desogestrel
150
Marvelon
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
30
Drospirenone
3000
Yasmin
Ethinyloestradiol
50
Levonorgestrel
125
Nordette 50,
Microgynon 50
Mestranol
50
Norethisterone
1000
Norinyl-1
Ethinyloestradiol
30, 40
Levonorgestrel
50, 75, 125
Triphasil, Triquilar/
Trifeme 28, Logynon
ED
Ethinyloestradiol
35, 40
Norethisterone
500, 1000
Synphasic, Improvil
28 day
Monophasic
Triphasic
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 flushes 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 higherdose 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
Murtagh - General Practice (5e) Part 5.indd 936
• concomitant use of enzyme-inducing drugs
• low-dose pill failure
Contraindications to COC usage are shown in
Table 90.3.
Efficacy 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 significant beneficial 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
22/10/10 2:45:15 PM
Family planning
Table 90.3 Contraindications for use of the COC 4, 7
Relative
women taking high-oestrogen-content COCs, but now
that the oestrogen content of each pill has been reduced
to as low as 20 mcg EO, these risks of morbidity and
mortality have been reduced.
The progestogen effect on lipid metabolism is not
considered significant in the aetiology of circulatory
disease. Circulatory diseases have now been recognised
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
hyperlipidaemia, 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.
Heavy smoking
COCs and cancer
>35 years and smoking or other risks of CAD
There appears to be no overall increase in the incidence
of cancer in women using COCs.
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
Undiagnosed abnormal vaginal bleeding
Breastfeeding
4 weeks before surgery
2 weeks after surgery
Gall bladder or liver disease
Hypertension
Diabetes mellitus
Long-term immobilisation
Complicated valvular heart disease
Hyperlipidaemia
Chloasma
Severe depression
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
perpetual users.
The oestrogen content of the pill is considered to be
the aetiological factor and the problem is increased in
Murtagh - General Practice (5e) Part 5.indd 937
• Possible effect (not absolutely proven) and possibly
very low risk:
— cervix (take regular smears at yearly intervals)
— breast
• Protective effect:
— endometrial
— epithelial ovarian
• No effect:
— melanoma
— choriocarcinoma
— prolactinomas
937
90
Common side effects
The relatively minor side effects listed in Table
90.4 may discourage women from persisting with
oral contraception in the absence of appropriate
explanation and reassurance. Management of these
side effects is listed in the same table. It is useful in
practice to have this list available as a ready reference
for manipulating the COC if necessary. A common
nuisance side effect is breakthrough bleeding in
the first 2 months. If minor, continue, but if heavy,
stop and start a new COC, usually with 50 mcg
ethinyloestradiol.
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
efficacy 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.
22/10/10 2:45:16 PM
938
Part Five
Women's health
Table 90.4 Management of common side effects of COC7, 10
Symptom change
Change
Examples of pill change
Acne
Increase oestrogen, reduce or
change progestogen
Triphasil/Triquilar to Diane ED/
Marvelon
Amenorrhoea
Increase oestrogen or decrease
progestogen
Nordette/Microgynon 30 to
Nordette 50/Microgynon 50
Breakthrough bleeding:
• early to mid cycle
Increase oestrogen
Triphasil/Triquilar to Biphasil/
Sequilar
• late cycle
Increase progestogen or change type
Triphasil to Nordette
Nordette to Norinyl-1
Breast problems:
• fullness/tenderness
Decrease oestrogen
Biphasil/Sequilar to Triphasil/
Triquilar or progesterone only pill
• mastalgia
Decrease progestogen
Nordette/Microgynon 30 to
Triphasil/Triquilar
Chloasma
Stop oestrogen
Try progestogen-only pill
Avoid direct sun (use blockout)
Depression
Decrease or change progestogen
Nordette/Microgynon 30 to
Triphasil/Triquilar or Brevinor
Dysmenorrhoea/menorrhagia
Increase progestogen
Triphasil/Triquilar to Nordette/
Microgynon
Decrease oestrogen
Libido loss
Increase oestrogen
Change from anti-androgenic
progestogen to an alternative
Headache:
• focal migraine
• in pill-free week
Nausea/vomiting
Microgynon 30 etc. to Femoden/
Minulet
Discontinue pill
Add 10–30 mcg ethinyloestradiol
daily during pill-free week or
50–100 mcg oestradiol patch
Decrease or change oestrogen or
stop oestrogen
Use Microgynon 20, etc. or
progestogen-only pill
Weight gain:
• constant
Decrease or change progestogen
Triphasil/Triquilar to Brevinor or
Marvelon
• cyclic
Decrease oestrogen
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
schedule).
Murtagh - General Practice (5e) Part 5.indd 938
Also
If the missed pills are in week three, she should omit
the pill-free interval.
Also
Condoms or abstinence should be used for 7 days if
the following numbers of pills are missed:
‘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)
22/10/10 2:45:16 PM
Family planning
The seven-day rule for the missed or late pill (more than
12 hours late)
• 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 finish 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 first hormone
pill in your next packet.
• You may miss a period. (At least seven hormone
tablets should be taken.)
Other useful rules for missed pills
If 1 or 2 × 30–35 mcg EO pills
or
1 × 20 mcg EO pill
and
• norethisterone 350 mcg/day
Providing the mini-pill is taken regularly at the
same time each day, the pregnancy rate is 3 per 100
women years.1 The failure rate decreases with age.
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 enzymeinducing drugs (absolute).
Injectable contraceptives
Depo-Provera
• take the most recent missed pill ASAP
• continue taking remaining pills as usual
Medroxyprogesterone acetate (Depo-Provera) is the
only injectable intramuscular contraceptive available
in Australia. It is very effective for up to 14 weeks.
No additional contraception or emergency
contraception needed.
Dose:
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
consecutive days
Practice tip
Delaying a period
Prescribe norethisterone 5 mg bd or tds for 3 days prior
to expected period.
Period resumes 2–3 days after stopping tablets.
If taking COC:
• 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 efficacious as
the COC.
The two common formulations are:
• levonorgestrel 30 mcg/day
Murtagh - General Practice (5e) Part 5.indd 939
939
90
150 mg by deep IM injection in first five
days of the menstrual cycle. The same
dose is given every 12 weeks to maintain
contraception.
Failure rate: 1 per 1000 women years.1
Side 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 first-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.
Emergency contraception
• Postinor-2 [Plan B (USA)]: one 750 mcg levonorgestrel
tablet followed by another tablet 12 hours later. Limited
to first 72 hours.
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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
rate: 2.6%.1
• Danazol 200 mg tablets (e.g. two initially and repeated
12 hours later).
• A copper IUCD within 5 days.
Pill 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
and transport.
Efficacy: IUCDs give 96–99% protection against
pregnancy.2
Contraindications for IUCD use:4, 11
• absolute
— known or suspected pregnancy
— active PID
— 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)
Murtagh - General Practice (5e) Part 5.indd 940
so, if pregnancy occurs, ultrasound examination should
be performed to determine the location.
Early removal of the IUCD is essential.
Pelvic inflammatory disease
There is evidence of an increased risk of PID in the first
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 first 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 IUCD
Women 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 fitted and again
after 12 months.
Vaginal ring 8
The first available contraceptive vaginal ring is NuvaRing,
a flexible 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
first 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
22/10/10 2:45:16 PM
Family planning
contraceptives, with pregnancy rates of 5 or less per
100 women years.1, 2
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 fitted. 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.
on the fourth day after the peak mucus day. Abstinence
from intercourse is practised from the first 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 interruptus
Male withdrawal before ejaculation is still a widely
used method of contraception and despite theoretical
objections will probably continue to have a definite
place in contraceptive practice.
Sterilisation
Vasectomy
With vasectomy it is important to confirm 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.
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 Essure procedure
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).
This procedure for permanent female birth control
involves the placement of a flexible titanium microinsert into each fallopian tube with a hysteroscope.
The insert expands and over time (usually 3 months)
reactive tissue growth occludes the tubes.
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 confined 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
Murtagh - General Practice (5e) Part 5.indd 941
90
Tubal ligation
Female 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.
Basal body temperature method
941
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.12
The 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).
22/10/10 2:45:16 PM
942
Part Five
Women's health
REFERENCES
1 Walters W. Fertility control. In: MIMS Disease Index. Sydney:
IMS Publishing, 1991–92: 185–90.
2 Stovall TG. Clinical Manual of Gynaecology. New York:
McGraw-Hill, 1992: 263–6.
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).
Canberra: SHFPA, 2008.
Murtagh - General Practice (5e) Part 5.indd 942
7 Weisberg E. Choosing an oral contraceptive. Modern
Medicine Australia, 1997; 40(1): 18–26.
8 Moore P. Recent developments in contraception: how to
treat. Australian Doctor, 3 April 2009: 25–32.
9 Westoff C, et al. Quick start: a novel oral contraceptive
initiation method. Contraception, 2002, 66: 141-8.
10 Miller C. The combined oral contraceptive: a practical
guide. Aust Fam Physician, 1990; 19: 897–905.
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.
22/10/10 2:45:16 PM
Breast pain (mastalgia)
91
Many women suffer breast pain so severe that it affects their lifestyles, marriages and sexual relationships, and
even prevents them from hugging their children.
D R J O H N D AW S O N 1 9 9 0
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 floors.
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 specific type of mastalgia should be identified.
• 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 difficult to
alleviate.
A diagnostic approach
A summary of the safety diagnostic model is presented
in Table 91.1.
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.
DZDMJDBMNBTUBMHJB
OPODZDMJDBMNBTUBMHJB
1BJO
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
sufficient treatment for most patients.
NFOTFT
NFOTFT
POFNFOTUSVBMDZDMF
Figure 91.1 Pain patterns for cyclical and non-cyclical
mastalgia
Cyclical mastalgia is the commonest diffuse breast
pain (see Chapter 93, page 969). It occurs in the
latter half of the menstrual cycle, especially in the
premenstrual days, and subsides with the onset of
menstruation. It obviously has a hormonal basis, which
may be an abnormality in prolactin secretion. The main
underlying disorder is benign mammary dysplasia, also
referred to as fibroadenosis, chronic mastitis, cystic
hyperplasia or fibrocystic breast disease.
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 missed
The 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
943
Murtagh - General Practice (5e) Part 5.indd 943
22/10/10 2:45:16 PM
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
A.
Neoplasia
Inflammatory breast cancer
Infection:
• mastitis
• abscess
Pitfalls (often missed)
A.
Pregnancy
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.
Pitfalls
Myocardial ischaemia
Q.
Infection
Chest wall pain (e.g. costochondritis)
Costochondritis
Pectoralis muscle spasm
Referred pain, esp. thoracic spine
Bornholm disease (epidemic pleurodynia)
Mechanical:
• bra problems
• weight change
• trauma
These 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 first symptom
of pregnancy. Pregnancy should be excluded before
commencing drug treatment.
Seven masquerades checklist
Rarities:
• hyperprolactinaemia
• nerve entrapment
• mammary duct ectasia
• sclerosing adenosis
• ankylosing spondylitis
Q.
Seven masquerades checklist
A.
Depression
✓
Diabetes
–
Drugs
✓
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.
Anaemia
–
Psychogenic considerations
Thyroid disorder
–
Spinal dysfunction
✓
UTI
–
The 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.
Q.
Is the patient trying to tell me something?
A.
Yes. Fear of malignancy. Consider psychogenic
causes.
cancer. ‘Mastitis carcinomatosa’, which is a rare florid
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 fibroadenoma, a soft rapidly growing tumour
in adolescents, and in the fibroadenoma of adult
women.
Murtagh - General Practice (5e) Part 5.indd 944
The clinical approach
History
It is important to relate the pain to the menstrual
cycle and determine whether the patient is pregnant
or not.
Key questions
• Could you be pregnant?
• Is your period on time or overdue?
• Is the pain in both breasts or only one?
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Breast pain (mastalgia)
• 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.
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)
Investigations
Moderate
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.
As for mild, plus options (use one or a combination):
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 specific 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
•
•
•
•
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 scientifically 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 significant side
effects but clinical trials have proved their efficacy for
this condition.4, 5
Systemic reviews from RTCs provide limited
evidence to alleviate mastalgia but the suggestions
indicate that tamoxifen and a low-fat, high-carbohydrate
diet is beneficial. Danazol provides benefit but has a
high incidence of side effects. Bromocriptine (also
high adverse effect profile) and HRT are unlikely to be
beneficial. 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.
91
Non-cyclical mastalgia
Cyclical mastalgia is rare after the menopause.
Management
The features of non-cyclical mastalgia are:
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.
•
•
•
•
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945
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
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946
Part Five
Women's health
Table 91.2 Management plan for cyclical mastalgia
Progressive stepwise therapy
Step 1
Treatment. Infiltration with local anaesthetic and
corticosteroid with care. Otherwise use NSAIDs or
paracetamol.
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
Typical pain patterns are presented in Figure 91.1.
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 confined to interstitial breast
tissue and doesn’t usually affect the milk supply.
Management
Clinical features
Non-cyclical mastalgia is very difficult to treat, being
less responsive than cyclical mastalgia. It is worth a
therapeutic trial of the following agents.
• A lump and then soreness (at first)
• A red tender area
possibly
• Fever, tiredness, muscle aches and pains
First-line treatment
•
•
•
•
Exclude caffeine from diet
Weight reduction if needed
Vitamin B1 100 mg daily
Vitamin B6 100 mg daily
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.
Second-line treatment
Prevention (in lactation)
• norethisterone 5 mg daily
• Analgesia: treat as for cyclical mastalgia
• Maintain free breast drainage—keep feeding
• Attend to breast engorgement and cracked nipples
Local lesions
Treatment
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.
If systemic symptoms develop:
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
Murtagh - General Practice (5e) Part 5.indd 946
• antibiotics: resolution without progression to an
abscess will usually be prevented by antibiotics7
di/(flu)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/(flu)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:
fluconazole 200–400 mg (o) daily for 2–4 weeks
second 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 (first option) until resolution, antibiotics, rest and
complete emptying of the breast.
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