How hormone replacement therapy works

Hormone replacement therapy is a method of treatment that involves replacement or substitution of naturally occurring hormones. It is used in instances where there are deficiencies of certain hormones. Examples of commonly used methods of hormone replacement therapy are post menopausal hormone replacement therapy, hormone replacement for transgender gender variant and transsexuals, and androgen replacement therapy. Out of these, post menopausal hormone replacement therapy is the most widely used and well known type of hormone replacement therapy.

Is Mammography equally sensitive to all Women?

Mammography is one of the widely used investigation modality of breast cancer. But is it equally sensitive to all the women. The answer is “No” due to several reasons. That is because the detection rate of a breast cancer depends on so many factors. Some of them are listed below.

·         The size, stage and grade of the tumor.

·         The age of the woman – As a women’s age increases the breast also gets changed. Reduction of the density of the breast tissue is one such change. This is good news for old women because the reduction of the density increases the sensitivity of mammography. However it is a bed news for younger women whose breasts are more denser than the old ones.

Occurrence of breast cancer in young age is very rare and therefore, the risks probably go down. For them ultrasound scan is very useful in investigating any breast apthology.

Diseases of the Nipple

1.      Absence of nipple with or without amazia (Congenital absence of breast)

2.      Supernumerary nipples

3.      Nipple Retraction

4.      Cracked Nipple

·         This usually occurs during lactation and if it occur the breast should be rested for at least 24-48 hours. It should b emptied and breast feeding should be resumed as soon as possible.

5.      Papilloma of nipple

6.      Retraction cysts of the gland of Montgomary

7.      Eczema

8.      Paget’s Disease

9.      Discharge from nipple

                                                              i.      Clear serous discharge –This is can be physiological, due to ductal papilloma or due to mammary dysplasia

                                                            ii.      Blood stained – due to duct ectasia, duct papilloma or carcinoma

                                                          iii.      Black/green – due to duct ectasia

                                                           iv.      Purulent – infection

Treatment – Microdochectomy or cone excision of the major ducts

ANATOMY OF THE BREAST
EXAMINATION OF THE BREAST
INVESTIGATION OF BREAST SYMPTOMS

Investigation of Breast Symptoms

1.      Mammography

a.      Sensitivity of mammography increases with age as the density of the breasts reduces with age.

b.      Digital mammography and tomo mammography are now available with more sensitivity.

2.      Ultrasound

a.      Used in young women with dense breasts

b.      Can be used to identify cysts from solid lesions

c.       Can also be used to impalpable areas of pathology

d.      Used to scan axillary tissues

e.      Useful in guided percutaneous biopsy

3.      MRI (Magnetic Resonant Imaging)

a.      Used to distinguish scar from recurrence

b.       Best modality to investigate women with implants

c.       Useful as screening tool for high risk women

4.      Needle biopsy/Cytology

a.      Biopsy is taken under local anaesthesia

b.      Histology – By taking a spring loaded core needle biopsy device – Core cut biopsy of the Breast

c.       Fine Needle Aspiration Cytology – 21G or 23G needle with 10 ml syringe, sample is taken by passing the needle several times through the lump with negative pressure. Then it is smeared on to slide and air dried or fixed.  

5.      Large needle biopsy with vacuum system

a.      8G or 11G needles are used

b.      Useful in the management of the micro calcification or complete excision of fibroadenomas

Triple Assessment of Breast Symptoms

1.      Clinical Assessment

a.      Age

b.      Examination

2.      Radiological Imaging

a.      Ultrasound Scan

b.      Mammography

3.      Cytology or Histology

a.      Fine Needle Aspiration Cytology

b.      Core cut

ANATOMY OF BREAST

EXAMINATION OF BREAST

Examination of the Breast

·         Inspection

o   Patient sitting

§  Assess – asymmetry

§  Visible masses

§  Distortion or skin tethering

§  Nipple discharge

§  Ulceration

§  Oedema and erythema of skin (Paeu d’orange)

·         Palpation

o   Patient lying in near supine position, or in semi recumbent position if the breast are large

§  Arms raised

§  Hand behind the head

o   Palpate the four quadrants including the axillary tail.

o   If a mass is detected examine it further with the thumb and the forefinger

§  Site

§  Size

§  Surface

§  Shape

§  Mobility

§  Consistency

§  Tenderness

§  Transilluminating or not

§   Enlargement of the lymph nodes

·         Examine axillary and cervical draining nodes

·         Examine abdominal organs for metastatic involvement 

 ANATOMY OF THE BREASTS

The Breast

The Anatomy

General borders-

·         Upper border – second rib

·         Lower border – sixth rib

·         Medial border – lateral border of the sternum

·         Lateral border – anterior axillary line

Actual borders –

o   Upper border – clavicle

o   Lower border – seventh or eighth rib

o   Medial border – midline

o   Lateral border – edge of latissimus dorsi

Important parts of the breasts

·         Breast lobe

·         Ductile

·         Lactiferous duct and ampulla

·         Areola

·         Cooper ligament

·         Axillary tail

·         Lobule – structural unit of the mammary gland

1.      Lobule à Ductules à lactiferous duct à terminal papilla

·         Ligaments of Cooper

o   Apices are attached to the superficial facial

o   Account for the dimpling of skin overlying carcinoma

·         Areola

o   Contain involuntary muscles

o   Epithelium contains sweat glands and sebaceous glands

o   Sebaceous glands enlarge during lactation. Then it is called “Montgomary tubercle”

·         Nipple

o   An erectile structure pointing upwards

·         Lymphatics

o   To axillary and internal mammary lymph nodes

o   Axillary lymph nodes have six groups

1.      Lateral – along the axillary vein

2.      Anterior – along lateral thoracic vessels

3.      Posterior – along the sub capsular vessels

4.      Central

5.      Interpectoral

6.      Apical à Supraclavicular nodes à Subclavian lymph trunk à Thoracic duct or Jugular trunk

·         Sentinel node is the first node draining the tumour bearing area of the breast

EXAMINATION OF BREAST

Do you have Leukaemia? Diagnose Yourself

Even though the exact diagnosis of any disease is done by proper investigation, one can assume the disease they have only by concentrating on the symptoms he/she has. Considering leukaemias, there are many subtypes. The 2 major broad categories of leukaemias are acute and chronic leukaemias.

What are the symptoms of acute leukaemia? What are things that you will or experience if you have acute leukaemia?

The symptoms that patient have are the same regardless of the subtype of the disease. They all are attributing to the inadequate blood cell production in the bone marrow. The blood cell production becomes less as the abnormally proliferating cells infiltrate the surrounding bone marrow.

1.      Symptoms of anaemia – Red blood cells are produce by the bone marrow. In leukaemia red blood cell production is reduced giving rise to anaemia(less haemoglobin in blood).

a.      Feeling of weakness

b.      Becoming breathless on effort

c.       Exercise tiredness

2.      Symptoms of leucopenia (reduced white blood cells in blood) –

a.      Recurrent infection – If you are getting more diseases than usual that means your immunity has reduced. The major cells that are involved in immunity are white blood cells. In leukaemia the number of normally functioning white blood cells reduces giving rise to leucopenia. So, you may have cold, fever and other infectious diseases more often than usual.

3.      Thrombocytopenia (reduced thrombocytes in the blood)- Thrombocytes or the platelets are another constituent of blood. They are also produced in the bone marrow. These are important in blood clotting. They are also reduced in leukaemia and cause bleeding disorders. So, you may have gum bleeding, etc.   

4.      Symptoms due to marrow infiltration – The proliferating cells infiltrate in to the marrow. This causes bone pain. The patient may feel pain in their limbs and joints.

Above are the symptoms you may have. But there are more signs, you may have indicting leukaemia, but you should observe carefully to detect these symptoms. They are listed below.

1.      Pallor – This is seen in the eyes. To see it you have to pull the lower eyelid downwards and see the conjunctiva. It should be bright pinkish closer to red in colour. It becomes pallor when the colour becomes pale and closer to whitish colour.

2.      Fever – You can measure your temperature by a thermometer. There are thermometers in most of the houses these days. If the reading is higher than 37⁰  C, your are having fever. This is due to increase activity of the abnormally proliferating cells. This results in increased basal metabolic rate in leukaemic individuals.

3.      Petechiaea, purpura, bruises – look carefully in your skin and look for bruises which may result from bleeding in to the skin.

4.      Lymphadenopathy (enlargement of the lymph nodes) – to detect these you should know where the lymph nodes are and how to palpate for them. I will discuss about the method in a later article.

5.      Hepatosplenomegally – the method of observing will be discussed later.