Mastitis: Clinical Guidelines

Mastitis Clinical Guidelines

• Mastitis involves breast tissue inflammation, often due to infection
• Primarily affects lactating women, presenting with tenderness and swelling

Signs & Symptoms of Mastitis

• Localized breast pain and redness is common
• Expect warmth to the touch
• A firm, hardened area or lump may be felt
• Some experience flu-like symptoms such as fever, chills, and malaise
• Purulent or bloody nipple discharge might occur

Physical Examination for Mastitis

• Inspect for erythema, swelling, and nipple abnormalities
• Palpate for induration, warmth, and fluctuance, indicating a possible abscess
• Assess for enlarged axillary lymph nodes

Performing the Exam for Mastitis

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

Mastitis: When to be Concerned (Red Flags)

• Symptoms without improvement after 48 hours of antibiotic treatment
• Monitor for signs of breast abscess, including fluctuant mass and persistent fever
• Severe localized pain is a red flag
• Recurrent mastitis in the same location may indicate underlying pathology
• Bilateral breast involvement can suggest inflammatory breast cancer and requires investigation
• Immunocompromised status such as HIV and diabetes increases risk

Diagnostics for Mastitis

• Diagnosis is typically clinical
• If an abscess is suspected, perform an ultrasound
• Breast milk culture is recommended for recurrent or unresponsive cases
• CBC may show leukocytosis, indicating infection
• Blood cultures are needed if sepsis is suspected
• Biopsy should be performed if malignancy is suspected

The treatment of Mastitis

• First-line antibiotics target Staphylococcus aureus with dicloxacillin or cephalexin (500 mg PO QID x 10-14 days)
• If MRSA is suspected or the patient has a penicillin allergy, use clindamycin or TMP-SMX
• Ibuprofen or acetaminophen helps manage pain and inflammation

Non-pharmacological Treatment

• Continue breastfeeding or pumping to prevent milk stasis
• Apply warm compresses prior to feeding and cold compresses after
• Perform gentle breast massage to facilitate drainage
• Stay hydrated and get enough rest

Abscess Management

• Small abscesses (<3 cm) benefit from antibiotics and ultrasound-guided aspiration
• Large abscesses (>3 cm) or recurrent abscesses need surgical drainage

Educating Patients is Key

• Emphasize frequent and complete breast emptying
• Educate on proper breastfeeding techniques to prevent nipple trauma
• Teach how to recognize signs of worsening infection needing medical attention
• Explain how to perform breast massage and apply heat therapy
• Stress the importance of proper hygiene and handwashing to reduce infection risk

Promoting Health

• Encourage breastfeeding support with referral to a lactation consultant
• Promote adequate hydration and nutrition for lactating mothers
• Screen for postpartum depression
• Encourage smoking cessation

When to Refer a Patient with Mastitis

• Refer to a breast surgeon if an abscess requires drainage or malignancy is suspected
• A lactation consultant is helpful for breastfeeding difficulties or recurrent mastitis
• Consult an infectious disease specialist for persistent, severe, or atypical infections

Mastitis Follow up advice

• Re-evaluate in 48-72 hours to ensure improvement
• If symptoms worsen or don't improve, reassess for abscess or resistant organisms
• Consider long-term follow-up to identify contributing factors in recurrent cases

Recognizing a Breast Mass

• Breast masses can be benign, like fibroadenomas and cysts
• Breast masses can be malignant, such as breast cancer

Signs & Symptoms of Breast Masses

• Palpable lump that is firm, rubbery, or hard
• Changes in breast shape or contour
• Nipple discharge, either bloody or clear
• Skin changes such as dimpling, redness, or thickening
• Pain is often present with benign masses, malignancies are usually painless
• Axillary lymphadenopathy may be present

Performing a Breast Mass Physical Exam

• Inspection should involve assessment for asymmetry, skin dimpling, nipple retraction, or visible lumps
• Palpation involves using the pads of fingers in a circular motion and evaluating size, shape, and consistency
• Fixed versus movable lumps should be noted
• Both breasts should be examined for comparison
• Lymph nodes in the axillary and supraclavicular area should be palpated

When to Be Concerned About a Breast Mass (Red Flags)

• Fixed, hard, or irregular mass
• Skin retraction, nipple inversion, or peau d'orange appearance
• Bloody nipple discharge
• Rapidly growing mass
• Palpable axillary or supraclavicular lymphadenopathy
• Systemic symptoms like unexplained weight loss or fatigue

How to diagnose a breast mass

• Ultrasound is used for women < 30 or to distinguish between cystic and solid masses
• Mammography is first-line for women ≥ 30 or with suspicious masses
• MRI is useful for high-risk patients or inconclusive findings

Doing a breast mass biopsy

• Fine Needle Aspiration (FNA) if cystic lesions are present
• Do a core Needle Biopsy (preferred for solid masses)
• Excisional Biopsy (for definitive diagnosis if uncertain)

More tests may be needed

• Hormone receptor testing looks for ER/PR and HER2 for malignancy
• Genetic testing for BRCA1/2 should be performed if there is a strong family history

Treating benign breast masses

• Fibroadenoma: Observation or surgical removal if large or symptomatic
• Cyst: Aspiration if painful, excision if recurrent
• Fat Necrosis: Typically resolves; biopsy if uncertain

Treating malignant breast masses

• Surgical options include lumpectomy and mastectomy
• Radiation therapy is indicated post-surgery for localized control
• Systemic therapy options include hormone therapy, chemotherapy, and targeted therapy

Educating Your Patient about Breast Masses

• Teach breast self-exam techniques
• Encourage adherence to follow-up imaging and biopsy if needed
• Explain treatment options and potential side effects
• Address emotional and psychological concerns, especially with malignancy

Promoting breast health

• Encourage routine breast cancer screening based on age and risk factors
• Promote healthy lifestyle changes like diet, exercise, and limiting alcohol
• Advise on smoking cessation
• Offer genetic counseling if family history suggests increased risk

Referral guidelines after breast mass diagnosis

• A breast surgeon should be consulted if biopsy indicates malignancy or mass requires excision
• An oncologist should be consulted if malignancy is confirmed
• A genetic counselor should be consulted if there is a high-risk family history (BRCA mutations)

Performing adequate follow up is important for Breast Masses

• Re-examine benign findings in 6 months or per imaging recommendations
• Suspicious findings need biopsy and close monitoring
• Ongoing oncology follow-up should be scheduled if for cancer treatment

Menstrual Cycle Phases

• The menstrual cycle's four key phases include:

  • Follicular
  • Ovulatory
  • Luteal
  • Menstruation

• Some disorders include:

  • Amenorrhea
  • Heavy menstrual bleeding (HMB)
  • Anemia secondary to menstrual irregularities

Normal Menstrual Cycle Phases

• Follicular Phase (Days 1-13):
  • Begins on the first day of menstruation
  • Estrogen rises, stimulating follicle growth
  • Endometrial lining thickens
• Ovulatory Phase (Day 14, mid-cycle):
  • A sudden LH surge triggers ovulation
  • The egg is released from the dominant follicle
• Luteal Phase (Days 15-28):
  • The corpus luteum secretes progesterone to support implantation
  • Progesterone levels drop, triggering menstruation if no pregnancy occurs
• Menstruation (Days 1-7 of next cycle):
  • Shedding of the endometrial lining
  • Bleeding typically lasts 3-7 days, with an average blood loss of 30-40 mL

Common Disorders & Symptoms

• Amenorrhea (Absence of Menstruation):
  • Primary: No menses by age 15
  • Secondary: Absence for >3 months in previously regular cycles
  • Causes: PCOS, pregnancy, thyroid disorders, and low body weight
• Heavy Menstrual Bleeding (HMB):
  • Bleeding >7 days or >80 mL blood loss
  • Causes: Fibroids, adenomyosis, and endometrial hyperplasia
• Anemia (from HMB):
  • Presents with fatigue, pallor, dizziness, and tachycardia

Physical Exam

• General exam: Assess pallor and signs of anemia
• Abdominal exam: Palpate for masses, such as fibroids or ovarian cysts
• Pelvic exam:
  • Inspect for cervical abnormalities like polyps and lesions
  • Bimanual exam to assess uterine size and tenderness

Red Flags

• Sudden cessation of periods after regular cycles indicates pregnancy, PCOS, or hypothalamic dysfunction
• Postmenopausal bleeding suggests possible endometrial cancer
• Severe anemia symptoms include shortness of breath, syncope, tachycardia, and Hgb <7 g/dL
• Consider pregnancy, PCOS, or hypothalamic dysfunction if a patient presents with sudden cessation of cycles after regular cycles
• Evaluate for possible endometrial cancer if a patient presents with postmenopausal bleeding
• Evaluate for ovarian torsion, endometriosis, and PID if complaining of severe pelvic pain

Contraception: Efficacy and Duration

• COCs (Combined Estrogen-Progestin): 91% typical use, daily
• POP (Progestin-only): 91% efficacy, daily
• Injection (Depo-Provera): 94% efficacy, every 3 months
• Implant (Nexplanon): 99.9% effective, lasts 3-5 years
• Hormonal IUD: 99.8% effective, lasts 3-8 years
• Copper IUD: 99.2% effective, lasts 10 years
• Barrier Methods (Condoms, Diaphragm, Spermicide): 72-88% efficacy, per use
• Sterilization (Tubal ligation, Vasectomy): 99.9% effective, permanent

Physical Exam Prior to Contraception Initiation

• BP Measurement: Estrogen-containing methods are contraindicated if BP ≥ 140/90
• BMI Check: Obesity may reduce the effectiveness of some methods
• Pelvic Exam & STI Screening: Necessary for IUD insertion
• Breast Exam: COCs are contraindicated in active breast cancer

Contraception: Red Flags

• Unexplained vaginal bleeding requires ruling out malignancy
• Severe headaches/migraines with aura contraindicate estrogen-containing contraceptives
• Avoid estrogen-containing methods in patients with DVT/PE history, thrombophilia, or stroke
• Avoid hormonal methods with severe liver disease or hepatic adenoma
• Avoid all hormonal methods in patients with current or a history of breast cancer
• Rule out pregnancy if pregnancy is suspected

Contraception: Initial Diagnostics

• An initial pregnancy test is needed before IUD insertion or hormonal initiation of contraception
• Blood pressure check is needed before prescribing COCs
• Sexually transmitted infection testing is needed before IUD insertion
• Pap Smear is not required before contraception but recommended for cervical cancer screening

Oral Contraceptives (COCs & POPs)

• COCs (Estrogen + Progestin)
  • Suppress ovulation and thicken cervical mucus
  • Contraindications: Hypertension, migraine with aura, thromboembolism, and smoking >35 y/o
• Progestin-Only Pill (POP, "Mini-Pill"):
  • Thickens mucus, suppressing ovulation in some women
  • Ideal for breastfeeding women or those with estrogen contraindications
  • Requires strict timing and must be taken at the same time daily (3-hour window)

Contraception: Other Pharmacologic Options

• Injectable (Depo-Provera):
  • Advantages: No daily adherence and reduces dysmenorrhea
  • Disadvantages: Irregular bleeding, weight gain, and long-term bone loss
• Implant (Nexplanon):
  • Highly effective (99.9%), long-acting, and reversible
  • Side effects are irregular bleeding but there is minimal weight gain
• IUDs (Hormonal & Copper):
  • Hormonal IUDs lighten periods and reduce cramps
  • Copper IUDs are non-hormonal but may increase menstrual bleeding/cramping

Contraception: Health Promotion

• Annually screen for cervical cancer and STIs if sexually active
• Encourage smoking cessation due to increased thromboembolism risk with estrogen
• Discuss fertility return timeline and monitor blood pressure regularly if using COCs

Contraception: Education and Referral

• Explain proper use, adherence, and potential side effects of the chosen method
• Patients should be aware of breakthrough bleeding commonly seen in COC use in the first 3-6 months of use
• Referral needed for those with post-contraception amenorrhea lasting over 6 months
• Referral needed for those with pelvic pain or abnormal bleeding:
• Refer for those with complex medical history or have had multiple contraceptive failures

Adolescent Contraception

• Long-acting reversible contraception (LARC) is the highest recommended option
• Depo-Provera is good for privacy no daily pill-taking
• Combined oral contraceptives (COC’s) are a good option if adherence is not an issue

Perimenopausal Contraception (40+)

• Declining fertility but still ovulating
• High dose estrogen increases the risk of stroke, MI, DVT
• A copper IUD can worsen the bleeding if a patient is experiencing heavy periods

Recognizing Menopause

• The permanent cessation of menstruation with 12 consecutive months of no periods
• Signs & Symptoms of Menopause include Vasomotor Symptoms, menstrual Irregularity, and Skin and Hair Changes

Diagnosing Menopause

• Clinically diagnosed in women 45+ years with menopause symptoms
• FSH will be high if a patient is in menopause
• Estradiol will be low in menopause

Treating and Managing Menopause

• Hormone therapy is now safe for severe symptoms of menopause
• Vaginal estrogen can help improve the genitourinary syndrome of menopause (GSM)
• Exercise weight-bearing activities can help improve bone and cardiovascular health

Treatment goals for treatment and management of bacterial vaginosis

• To balance out the normal flora
• Avoid scented soaps and douches since it disrupt the normal flora and also educate them on the connection of sexual contact
• Consider the use of probiotics to help the vaginal flora

HIV (Human Immunodeficiency Virus)

• Acute HIV is often presented as a flu-like illness known as acute retroviral syndrome (ARS) which includes having a fever, fatigue, and a rash
• Lymphatic exam is often done for HIV for the palpitation of cervical, axillary, and inguinal lymph nodes
• HIV drugs often require adherence support, vaccinations and Mental Health Support

STI (Sexually Transmitted Infections)

• Chlamydia can have symptoms such as discharge, dysuria, abdominal pain or pelvic pain
• HIV is often first discovered with flu-like symptoms Early on, progressing to more severe immune system dysfunction over time
• Pelvic exam can also be done, including the visual inspection of cervix and vagina to check for discharge.
• A STI treatment is to make sure a provider advices on the HIV vaccine