Mastitis: Clinical Guidelines

Mastitis Clinical Guidelines

• Mastitis is an inflammation of breast tissue, common in lactating women

Signs and Symptoms

• Localized breast pain, tenderness, swelling, and redness are common
• Warmth and a firm, hardened area or lump can be present
• Flu-like symptoms (fever, chills, malaise) may occur
• Nipple discharge (purulent or bloody) is possible in infectious

Physical Exam

• Erythema, swelling, and nipple abnormalities should be inspected
• Palpate for induration, warmth, and fluctuance which could suggest an abscess
• Assess for axillary lymphadenopathy

How to Perform the Exam

• Use gentle palpation to check for tenderness and masses
• Examine both breasts for comparison
• Check for nipple trauma or discharge

Red Flags

• Symptoms not improving within 48 hours of antibiotic treatment requires further evaluation
• Fluctuant mass indicates possible abscess
• Severe localized pain indicates possible abscess
• Persistent fever indicate possible abscess
• Recurrent mastitis in the same location may indicate underlying pathology like malignancy
• Bilateral breast involvement may indicate inflammatory breast cancer
• Immunocompromised status (HIV, diabetes) can complicate mastitis

Diagnostics

• Typically a clinical diagnosis, imaging or lab work may be needed
• Ultrasound is used if an abscess is suspected
• Breast milk culture is used for recurrent or unresponsive cases
• CBC may show leukocytosis
• Blood cultures are used if sepsis is suspected
• Biopsy is used if malignancy is suspected, like in persistent, non-lactational mastitis

Pharmacologic Treatment

• First-line antibiotics cover Staphylococcus aureus in lactational mastitis
• Dicloxacillin or Cephalexin at 500 mg PO QID for 10-14 days
• Clindamycin or TMP-SMX is used if MRSA is suspected or in penicillin allergy
• Pain management includes Ibuprofen or Acetaminophen for pain and inflammation

Non-Pharmacologic Treatment

• Breastfeeding or pumping should continue to prevent milk stasis
• Warm compresses should be applied before feeding, and cold compresses after
• Drainage can be facilitated with gentle breast massage
• Hydration and rest is recommended

Abscess Management

• Antibiotics and ultrasound-guided aspiration are used for small abscesses (<3 cm)
• Surgical drainage can be used for large abscesses (>3 cm) or recurrent abscesses

Educational Needs

• Frequent and complete breast emptying is essential
• Proper breastfeeding techniques prevent nipple trauma
• Early medical attention should be sought when there are signs of worsening infection
• Proper hygiene and handwashing reduces infection risk
• Breast massage and heat therapy techniques can be reviewed

Health Promotion

• Breastfeeding support and lactation consultant referrals can be helpful
• Adequate hydration and nutrition should be promoted for lactating mothers
• Screening for postpartum depression should be done as it may be associated with breastfeeding difficulties
• Smoking cessation should be encouraged, as smoking increases the risk of infections

Referral

• Breast surgeon referral is needed if drainage is needed or malignancy is suspected
• A lactation consultant referral is useful for breastfeeding difficulties or recurrent mastitis
• An infectious disease specialist should be consulted for persistent, severe, or atypical infections

Follow-Up

• Re-evaluation should occur in 48-72 hours to ensure improvement
• If worsening or no improvement, reassess for abscess, resistant organisms, or alternative diagnosis
• Long-term follow-up may be needed to investigate contributing factors for recurrent mastitis

Breast Mass Clinical Guidelines

• A breast mass may be benign (fibroadenoma, cyst, fat necrosis) or malignant (breast cancer)
• Recognizing mass characteristics is crucial

Signs and Symptoms

• A palpable lump (firm, rubbery, or hard) is the most common symptom
• Changes in breast shape or contour may be a symptom
• Nipple discharge (bloody or clear)
• Skin changes, which may include skin dimpling, redness, or thickening
• Pain, though masses are often benign; malignancies are usually painless
• Axillary lymphadenopathy may be an indicator

Physical Exam

• Inspection should assess for asymmetry, skin dimpling, nipple retraction, or visible lumps
• Palpation should use the pads of fingers in a circular motion
• Evaluate size, shape, consistency (soft, firm, or hard), and mobility (fixed vs. movable)
• Examine both breasts and compare the features
• Palpate the axillary and supraclavicular lymph nodes

Red Flags

• A fixed, hard, or irregular mass warrants further investigation
• Skin retraction, nipple inversion, and peau d’orange appearance are concerning
• Bloody nipple discharge warrants investigation
• A rapidly growing mass warrants investigation
• Palpable axillary or supraclavicular lymphadenopathy
• Systemic symptoms (unexplained weight loss, fatigue) may be present

Diagnostics

• Imaging may be needed
• Ultrasound is used for women < 30 or to distinguish cystic vs. solid masses
• Mammography is first-line for women ≥ 30 or with suspicious masses
• MRI is good for high-risk patients or inconclusive findings
• Biopsy is used if suspicious features are present
• Fine Needle Aspiration (FNA) for cystic lesions
• Core Needle Biopsy is preferred for solid masses
• Excisional Biopsy is for definitive diagnosis if uncertain
• Additional tests may be done
• Hormone receptor testing (ER/PR, HER2) is done for malignancy
• Genetic testing (BRCA1/2) is done if there is a strong family history

Treatment

• Fibroadenoma typically undergoes observation or surgical removal when symptomatic or large
• Cysts may be aspirated if painful, or excised if recurrent
• Fat necrosis typically resolves, but a biopsy may be performed if uncertain

Malignant Masses (Breast Cancer)

• Surgical options include Lumpectomy vs. mastectomy
• Radiation therapy may be used post-surgery for localized control
• Systemic therapy may be used
• Hormonal therapy (tamoxifen, aromatase inhibitors) if ER/PR positive
• Chemotherapy is used for aggressive tumors, triple-negative, or HER2 positive
• Targeted therapy uses trastuzumab for HER2 positive

Educational Needs

• Breast self-exam techniques should be taught
• Adherence to follow-up imaging and biopsy should be encouraged
• Address emotional and psychological concerns, especially with malignancy
• Treatment options and potential side effects should be explained

Health Promotion

• Routine breast cancer screening should be encouraged based on age and risk factors
• Healthy lifestyle changes, like diet, exercise, and limiting alcohol, should be promoted
• Smoking cessation should be advised
• Genetic counseling should be available if family history suggests increased risk

Referral

• Oncologist referral is needed if malignancy is confirmed
• Breast surgeon referral is needed if biopsy indicates malignancy or if a mass requires excision
• Genetic counselor referral is needed with a high-risk family history (BRCA mutations)

Follow-Up

• For benign findings, re-examine every 6 months or based on imaging recommendations
• For suspicious findings, biopsy and close monitoring
• For cancer treatment, ongoing oncology follow-up

Menstrual Cycle and Related Disorders: Clinical Guidelines

• The menstrual cycle has four key phases: follicular, ovulatory, luteal, and menstruation
• Disorders include amenorrhea, heavy menstrual bleeding (HMB), and anemia secondary to menstrual irregularities

Recognition: Normal Menstrual Cycle Phases

• Follicular Phase (Days 1-13) begins on the first day of menstruation where estrogen rises and endometrium thickens
• Ovulatory Phase is day 14 which causes sudden LH surge triggers ovulation, releasing the egg from the dominant follicle
• Luteal Phase (Days 15-28) is when corpus luteum secretes progesterone, and if no pregnancy occurs, progesterone drops, triggering menstruation
• Menstruation (Days 1-7 of next cycle) involves endometrial lining shedding and bleeding lasting 3-7 days, with average blood loss is 30-40 mL

Common Disorders and Symptoms

• Amenorrhea is an absence of menstruation
• Primary amenorrhea means no menses by age 15
• Secondary amenorrhea means absence for >3 months in previously regular cycles
• Causes of secondary amenorrhea include PCOS, pregnancy, thyroid disorders, low body weight
• Heavy Menstrual Bleeding (HMB) means bleeding is >7 days or >80 mL blood loss
• Causes of Heavy Menstrual Bleeding include Fibroids, adenomyosis, endometrial hyperplasia
• HNB causes Anemia characterized by fatigue, pallor, dizziness, tachycardia

Physical Exam

• General exam includes assessing pallor, signs of anemia
• Abdominal exam involves palpating for masses like fibroids or ovarian cysts
• Pelvic exam should: -Inspect for cervical abnormalities, such as polyps or lesions
• Bimanual exam is used to assess uterine size and tenderness.

Red Flags

• Sudden cessation of periods after regular cycles consider pregnancy, PCOS, or hypothalamic dysfunction
• Postmenopausal bleeding possibly indicates endometrial cancer
• Severe anemia presents with symptoms such as shortness of breath, syncope, tachycardia, and Hgb <7 g/dL
• Severe pelvic pain possibly indicates ovarian torsion, endometriosis, or PID
• Unresponsive heavy bleeding may require urgent intervention or transfusion

Diagnostics: Female Infertility Workup

• Serum progesterone should be done on day 21 that confirms ovulation
• An LH and FSH should be done on day 3 to assess if there is diminished ovarian reserve
• Should assess for thyroid disorder or hyperprolactinemia
• Evaluate ovarian reserve
• Should consider if there is blockage or uterine abnormalities
• Endometrial pathology should assessed
• Should detect if there are PCOS, fibroids, and ovarian masses

Diagnostics: Male Infertility Workup

• Sperm count, testostrone, and scrotal ultrasound are performed to check the male

Conditions for women <15

• Progestin-only methods
• IUD
• Barrier method

Conditions for menopausal women

• Hormonal IUD
• Progestin therapy

Complications with hormonal birth control(contraception)

• Hypertension-should get tested to prevent future issues

Followup

• Asses if birth control is the right choice
• Check for risks
• Follow up in 3-6 months