Benign Breast Disease

Today’s episode suggestion comes to us from Shadae Beale, a resident at Meharry Medical College. Thanks for listening! And be sure to send us your ideas through the website or via email!

We kicked off today’s episode with a vignette:

24 yo F G1P1 with 10 year history of type 1 diabetes presents with right breast mass that she palpated in the shower. She is currently breastfeeding her 9 mo old baby. She states that she has had some pain in her right breast, though no redness or swelling, and that she has always had “lumpy breasts.” She is worried because her 78 yo grandmother was recently diagnosed with breast cancer. No other breast or ovarian cancer in her family. On exam, she has lumpy, cobblestone texture of both breasts, with free-moving tissue throughout. There is one 2x2cm firm, mildly tender, mobile mass in the R breast at the 2 o’clock position, approximately 1 cm from the nipple. No axillary lymphadenopathy. 

Now we imagine that if this isn’t a likely scenario in your clinic time, it is on your test prep questions. What do you do with this patient? Let’s first review a broad differential diagnosis for a likely benign mass:

Nonproliferative Breast Lesions 

  • Breast cysts 

    • Simple cysts - benign, fluid filled mass; usually discrete, compressible, or ballotable solitary mass 

    • Galactocele - milk retention cyst common in women who are breastfeeding 

  • Fibrocystic changes - common, especially in premenopausal women; may cause breast pain 

  • Lipoma - mature fat cells 

  • Fat necrosis - can develop after blunt trauma to the breast; can also occur after surgery (ie. breast reconstruction, radiation therapy); associated generally with skin ecchymosis 

  • Breast abscess - localized collection of inflammatory exudate; can develop alongside mastitis or cellulitis; usually will have all the signs of infection! 

  • Diabetic mastopathy 

    • Usually in women with longstanding T1DM 

    • Suspicious fibrous breast lumps, usually multiple 

    • Need to biopsy for diagnosis

  • Idiopathic granulomatous mastitis 

    • Rare inflammatory disease of the breast - usually presents as a painful, firm and ill-defined mass that can have erythema and edema of the skin 

Proliferative Breast Lesions without Atypia 

  • Intraductal papillomas 

    • Monotonous array of papillary cells that grow from the wall of a cyst into its lumen.

    • Most common cause of bloody nipple discharge (key to any vignette!)

    • Generally not concerning, but CAN harbor DCIS; can be solitary or multiple lesions. If bothersome or concern for atypia, surgical excision is performed.

Intraductal papilloma. (C) WebPathology.

  • Sclerosing adenosis - lobular lesion with increased fibrous tissue; no need to treat.

  • Radial scar - complex sclerosing lesions; usually diagnosed after biopsy. Recommend excision, but no other treatment .

  • Fibroadenoma 

    • Most common benign tumor in the breast, accounting for ½ of all breast biopsies 

    • Glandular and fibrous tissue, presenting as a well defined, mobile mass on exam.

Atypical Hyperplasia 

  • Atypical ductal hyperplasia (ADH)

    • Proliferation of uniform epithelial cells with round nuclei fill part of the duct.

    • Standard of care after biopsy-proven diagnosis is surgical excision, due to risk of upgrade to ductal carcinoma.

  • Atypical lobular hyperplasia (ALH)

    • Monomorphic, evenly spaced dyshesive cells fill part of the lobule; can also involve ducts.

    • Referral to breast onc should occur, as management varies based on other clinical risk factors.

OK, so now you have a differential — what do we still need to do for this patient in front of us?

Always starting off with a history is important. With respect the HPI, it’s important to know not only about the characteristic of the mass, but any changes to the mass and the timiing of changes. For instance, is it painful, but cyclically painful with menses? That would argue more for fibrocystic changes. Has it grown in size over the last 3 months and caused nipple inversion in the meantime? That’s more worrisome for malignancy.

Family history and social history are also exceptionally important. Smoking increases risks of certain breast pathologies. And family history is obviously tantamount to determining a patient’s risk for particularly early-onset breast cancer.

Physical examination should include both breasts, examined in both a sitting and recumbent position. Note asymmetry, skin changes, nipple changes, and the location of masses. Generally using clock face language is most helpful for your referral: i.e., “12:00 position, 3cm from nipple” is highly descriptive. Finally, a regional lymph node exam should also be performed. Generally this includes axillary and supraclavicular nodes.

Imaging is what we will turn to next. For the younger patient, targeted breast ultrasound is an excellent choice, as it’s more sensitive than mammogram in this population with denser breast tissue. It also allows for immediate biopsy should the reading radiologist decide it’s indicated. Diagnostic mammography is also a standard of care in anyone with a palpable breast mass who meets criteria for screening. Definitive diagnosis is achieved with biopsy — core biopsy for solid lesions, fine needle aspiration for cysts, or excisional tissue biopsy as another option.

Abnormal Uterine Bleeding: The Basics

Today we talk through the varied etiologies and a basic workup for a common GYN complaint: abnormal uterine bleeding. ACOG PB 128 makes for good companion reading for women of reproductive age.

The terminology of AUB has changed quite a bit, and you may still hear older terms being used. “Dysfunctional uterine bleeding” or DUB has fallen out of favor, as have terms such as metrorrhagia or menorrhagia, yielding instead to simpler terminology such as prolonged menstrual bleeding and heavy menstrual bleeding, respectively. The terms such as oligomenorrhea (bleeding cycles > 35 days apart) and polymenorrhea (cycles < 21 days apart) are also in use to some degree.

Heavy bleeding is difficult to discern, but for research purposes has been described as >80cc blood loss per cycle. In clinical practice, this is obviously impractical, so we rely on subjective descriptions of heavy bleeding to guide care.

The biggest takeaways from this episode include the PALM-COIEN classification of bleeding by FIGO, as well as the common culprits of bleeding by age group. Remember also the criteria for working up for disorders of coagulation, which we’ve put here (though contained in the practice bulletin).

Stay tuned for future episodes about the treatments of these various etiologies, or check out our friends at The OBG Project for excellent summaries of guidelines and new literature!

ACOG PB 128

ACOG PB 128

ACOG PB 128

Cervical Cancer Screening and Prevention

Today we discuss one of the basic screening tools of the OB-GYN office: the Pap smear. Named for Georgios (George) Papanikolau, credited for its creation around 1923, it is a test that has singlehandedly changed the face of cancer screening. With its widespread use, the incidence of cervical cancer in the US has dropped from 14.8 / 100k women in 1975, to 6.7 / 100k women in 2011. The converse also demonstrates the importance of this routine test: 50% of those diagnosed with cervical cancer have never had Pap screening, and 10% have not had screening within the preceding 5 years.

We also now know and can test for the presence of oncogenic strains of human papilloma virus, or HPV. Types 16 and 18 account for over 70% of cervical cancer worldwide, and 12 other strains account for the remaining majority of cases. Ongoing trials are looking at whether HPV screening may ultimately supplant cytology as the preferred 1st test, but HPV screening has added another excellent tool to help OB-GYNs discuss risk and prevent cancer in their patients.

Follow along with ACOG PB 168!

So what are the screening guidelines?
In the immunocompetent patient, they are as follows:

  • < 21 years: Screening should not be performed, even in the presence of behavior-related risk factors.

    • Only 0.1% of cervical cancer cases occur before age 20.

    • Women younger than 21 with no immunocompromising conditions generally clear HPV infection between 8-24 months after exposure. 

    • This population should have discussion about safe sex practices to avoid exposure to STIs including HPV, and strong consideration for HPV vaccination.

  • 21 - 29 years: Screening should be performed using cytology alone every 3 years.

    • Annual screening is discouraged in this group, as it exposes patients to a much more significant number of unnecessary procedures for minimal improvement in outcomes. 

    • HPV co-testing is not recommended in this group; however, HPV reflex testing in the event of an ASC-US Pap smear may be considered to determine need for colposcopy.

  • 30 - 65 years: Screening should be performed with cytology alone every 3 years, or cytology with HPV co-testing every 5 years. 

    • In this population, with a negative cytology and negative HPV test, the risk of developing CIN 2 or 3 in the next 4-6 years is extremely low, based on large database studies (approximately 0.08% risk over 5 years). The risk is higher, but also quite low, with cytology alone (0.26% over 5 years). This is the rationale for the screening interval being extended.

    • RCTs have demonstrated in this population that cotesting has a number of distinct advantages:

      • Cotesting has a higher detection rate of high-grade dysplasia in first round of screening, and decreases risk of CIN3 or cancer in subsequent screening.

      • Cotesting likely has a better pickup rate for cervical adenocarcinomas (vs. squamous cell) than cytology alone.

  • > 65 years, or post-benign hysterectomy: Screening should be discontinued, provided that:

    • There has been no history of CIN2, CIN3, or AIS in the preceding 20 years, and:

    • There are adequate negative prior results:

      • 3 consecutive negative cytology results within last 10 years, or

      • 2 consecutive negative cotest results within the last 10 years, with the most recent test performed within the past 5 years.

    • Women in this age group do get cervical cancer; however, the majority of these cases occur in women who are not screened, or in those who are underscreened.

    • The changes of menopause may also cause false positive Pap tests in this group, leading to likely unnecessary additional and invasive testing and procedures.

Behavioral risks, such as cigarette smoking, new or multiple sexual partners, or early sexual debut, may increase risk of HPV acquisition or persistence, but do not alter screening recommendations.

However, two particular conditions do merit changes to screening:

  • In utero diethylstilbestrol (DES) exposure:

  • DES was an estrogen that was manufactured and prescribed in the US during the 1930s until 1971. It was thought that the medication helped with premature birth or history of miscarriage, though by the 1950s it had been demonstrated to be ineffective.

  • ACOG states that annual cytology is reasonable in women exposed to DES in utero, as cohort studies have demonstrated a much higher incidence of clear cell adenocarcinoma of the vagina in women born to mothers who took DES or similar medications. DES has also been associated with other health problems in both men and women.

  • You can find a list of DES and related medications online at the CDC, and there is an interactive tool for patients to use to determine if they may be at risk.

  • HIV or immunocompromising conditions:

    • Women infected with HIV or with other immunocompromising conditions are less readily able to clear HPV infections. Thus, the recommendations in this population differ:

  • Screening should begin within 1 year of sexual activity, and no later than age 21.

  • In women less than 30, If the first screen is negative, it should be repeated in 12 months. If three consecutive annual screens are normal, screening may be spaced to regular intervals (i.e., q3 year cytology). HPV cotesting is not recommended.

  • In women older than 30, three annual tests should be normal, before moving to cytology alone or co-testing. Screening intervals should be every 3 years in this population, regardless of the method chosen. 

  • Screening should continue for the lifetime of the woman, and not stop at age 65.

What about HPV vaccination?

HPV vaccination has been an incredible advance for primary prevention of cancer. Currently available include a bivalent vaccine, a quadrivalent vaccine, and a 9-valent vaccine. All of these cover HPV types 16 and 18. The 9-valent vaccine covers up to 50% additional cases of cervical cancer versus the bivalent vaccine. The 9-valent vaccine should be given to boys and girls ages 9-26. 

  • For those receiving their first dose before age 15, only two doses given 6 months apart are needed. 

  • For those receiving it after age 15, 3 doses given at 0, 1-2, and 6 months apart are recommended. 

HPV vaccination is not recommended during pregnancy, but also hCG screening is not necessary prior to initiating the dose. If pregnancy interrupts the schedule, it should be resumed postpartum without need for redosing. Studies are ongoing to determine the safety of HPV vaccination during pregnancy. 

In June 2019, the CDC’s advisory council on immunization practices (ACIP) updated its HPV vaccination recommendations, to extend recommendation for vaccination for all persons up through age 45, after the FDA approved this in October 2018. While this hasn’t made it into official ACOG practice guidance yet, it’s safe to say that this is forthcoming!

Further Reading from the OBG Project:

USPSTF Releases Final Cervical Cancer Screening Guidelines – Including ‘HPV Only’ Option
Screening for Cervical Cancer in the Woman at Average Risk
What is the Most Efficient Method for Cervical Cancer Screening?
Cervical Cytology and HPV Screening in the HIV Positive Woman

Cervical Cancer Screening Strategies and Cost-Effectiveness: Which is the Best?

Care of the Transgender Patient

Today we sit down with Dr. Beth Cronin, clinical associate professor and assistant program director at Brown / Women and Infants of Rhode Island. Dr. Cronin has become a national expert in the care of LGBTQ patients, and is a fixture at ACOG and other venues, and we are lucky enough today to have her break down the need-to-know essentials for the OB/Gyn.

Definitions are an excellent place to start, and set the stage for this conversation:

  • Sex is what we do in the delivery room - defining “male” or “female” based on the presence of external genitalia.

  • Gender is a social construct, comprising attitudes, feelings, or behaviors associated to “male” or “female” by a culture.

  • Gender identity is a person’s internal sense of their gender:

    • Cisgender the biological sex and gender identity align

    • Transgender the biological sex and gender identity are opposite:

      • Transgender woman biological sex male, identity female

      • Transgender man biological sex female, identify male

    • Gender should be viewed along a spectrum, with varying definitions for terms such as gender fluid, gender queer, or nonbinary.

About 1.4 million adults and 150,000 youth aged 13-17 are estimated to identify as transgender or gender non-binary in the United States. This population has much higher risks of experiencing discrimination, violence, and sexual assault. Additionally, these patients are likely to have poor experiences in healthcare settings. These patients really need access to care, and OB/Gyns are in perfect position to be safe and welcoming environments for the transgender/gender non-binary community.

For your office and daily practice, it is important to be inclusive, and there are myriad resources to get this started. Staff training and education to promote inclusivity is also important. Inclusive forms and medical record systems that elicit gender identity are important to make available, including documentation of preferred pronouns.

Dr. Cronin also took time today to discuss some clinical care aspects. UCSF and WPATH each have excellent protocols and guidelines for clinical care, including for initiating or maintaining transition care. Modifications of usual care, and care in the midst of hormonal transition, is discussed in great detail at these resources. ACOG also has excellent online modules for OB/Gyns for transgender healthcare, in addition to more primary reading at CO 512, CO 685, and additional ACOG-approved resources for clinicians.

Dr. Cronin easily explains it as “screen the parts that are present” per usual care guidelines, including with respect to things such as breast and cervical cancer screening, contraceptive methods, and pregnancy and abortion care.

Intimate Partner Violence and Gun Violence

Today we are spending some time on IPV/DV and gun violence. These are topics every OB/GYN should be familiar with; IPV accounts for 250,000 hospital visits, 2,000 deaths, and $8 billion in direct care costs annually on a conservative estimate. 1 in 3 American women is victimized by IPV during their lifetimes, and 1 in 5 report being the victim of sexual assault.

ACOG CO 518 serves as essential reading for our conversation today. Important points from the reading and today’s episode include:

Finally, check out ACOG’s stance and legislative priority list surrounding gun violence. Be active and get involved today — this is our lane!