Possible Diagnoses for Abdominal Pain in Women of Childbearing Age

One of the most likely diagnoses for a woman of childbearing age presenting with abdominal pain is a ruptured ectopic pregnancy. This is especially true if the patient has a history of using an intrauterine device (IUD), has missed a period, and experiences scanty bleeding. However, other possible differential diagnoses include appendicitis, ovarian cysts, and pelvic inflammatory disease.

Appendicitis may cause right iliac fossa pain, but the other symptoms and history suggest an ectopic pregnancy as a more likely cause. A femoral hernia is inconsistent with the clinical findings. Ovarian cysts may also cause right iliac fossa pain, but the other features from the history point to an ectopic pregnancy as a more likely cause. Pelvic inflammatory disease is not consistent with the history described, as there is no offensive discharge and no sexual history provided. Additionally, pelvic inflammatory disease does not cause a delay in the menstrual period.

It is important to always test for pregnancy in any woman of childbearing age presenting with abdominal pain, regardless of contraception use or perceived likelihood of pregnancy. Early diagnosis and treatment of a ruptured ectopic pregnancy can be life-saving.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

Management of Premenstrual Syndrome (PMS)

Premenstrual Syndrome (PMS) is a diagnosis of exclusion, characterized by cyclical psychological, behavioral, and physical symptoms during the luteal phase of the menstrual cycle. The exact causes are not yet identified, but studies suggest that the effects of hormones on serotonin and GABA signaling may have a significant role, in addition to psychological and environmental factors.

For moderate PMS, the National Institute for Health and Care Excellence (NICE) recommends the use of new-generation combined oral contraceptives, which prevent the natural cyclical change in hormones seen in the physiological menstrual cycle. Continuous use, rather than cyclical, showed better improvement. Response is unpredictable, and NICE suggests a trial of three months, and then to review.

Referral to a specialist clinic is reserved for women who have severe PMS, resistant to medication, that cannot be managed in the community. Fluoxetine, a selective serotonin reuptake inhibitor, has been used successfully in the treatment of women with severe PMS symptoms or in women with moderate PMS that fails to respond to other treatments.

Lifestyle modification advice is given to patients with mild PMS, including regular exercise, restriction in alcohol intake, smoking cessation, regular meals, regular sleep, and stress reduction. St John’s wort, an over-the-counter herbal remedy, has shown improvement of symptoms in some studies, but its safety profile is unknown, and it can interact with prescribed medication. Its use is at the discretion of the individual, but the patient needs to be warned of the potential risks.

Management Options for Premenstrual Syndrome (PMS)

Pregnant women with a BMI greater than 30 kg/m2 should be prescribed a high dose of 5mg folic acid instead of the standard 400 micrograms. Therefore, the lifestyle and dietary advice given to this patient is incorrect. Additionally, prescribing 75 mg of aspirin is not appropriate for this patient as it is typically given to women with one high-risk factor or two moderate-risk factors for pre-eclampsia, and a BMI over 35 would only qualify as a single moderate-risk factor. While 150 mg of aspirin is an alternative dose for pre-eclampsia prophylaxis, 75 mg is more commonly used in practice.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

If a woman misses two COCP doses between days 8-14 of her menstrual cycle, emergency contraception is not necessary as long as the previous seven doses were taken correctly. In this case, the woman missed doses on days 8 and 9 but resumed taking the medication on day 10, so emergency contraception is not needed. However, until seven consecutive days of the COCP are taken, using barrier contraception or abstaining from sex is recommended to prevent pregnancy. The intrauterine system is not a form of emergency contraception, and introducing it in this situation is unnecessary. Levonorgestrel is an emergency contraception option that must be taken within 72 hours of unprotected sex, but it is not needed in this case. If the patient had missed more than two COCP doses, levonorgestrel and barrier contraception for seven days would be appropriate. Ulipristal acetate is another emergency contraception option that must be taken within five days of unprotected sex, but it is also not necessary in this situation. If it were indicated, barrier contraception would need to be used for the next seven days until the COCP takes effect.

Missed Pills in Combined Oral Contraceptive Pill

When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

Understanding Hormone Replacement Therapy (HRT) for perimenopausal Symptoms

perimenopausal symptoms can significantly affect a woman’s daily routine, work, and mood. Hormone Replacement Therapy (HRT) is one of the treatment options available for managing these symptoms. However, before commencing HRT, patients need to be consulted and informed of the risks and benefits associated with this treatment.

HRT can be either oestrogen replacement only or combined. Combined HRT is given to women who have a uterus, as oestrogen alone can increase the risk of developing endometrial cancer. Combined HRT can be either cyclical or continuous, depending on the patient’s menopausal status.

For women with irregular menses, a cyclical regime is indicated. This involves taking an oestrogen tablet once daily for a 3-month period, with norethisterone added on the last 14 days. Patients on this regime have a period every three months. Once a woman has completed a year on cyclical therapy or has established menopause, then she can change to combined continuous HRT.

It is important to note that oestrogen-only HRT is only given to women who have had a hysterectomy. Oestrogen therapy alone increases the risk of developing endometrial hyperplasia and endometrial carcinoma. Therefore, in women who have a uterus, combined HRT, with the addition of a progesterone, is preferred to reduce this risk.

In summary, HRT is a treatment option for perimenopausal symptoms. The type of HRT prescribed depends on the patient’s menopausal status and whether they have a uterus. Patients need to be informed of the risks and benefits associated with HRT before commencing treatment.

The Importance of Urine Pregnancy Testing in Females with Abdominal Pain

Any female of childbearing age who presents to the Emergency Department with abdominal pain should have a urinary pregnancy test performed (β-HCG). This is because a negative pregnancy test is necessary to confirm that the patient is not pregnant. It is an easy and inexpensive test to perform.

Shoulder tip pain may indicate diaphragmatic irritation secondary to free intraperitoneal fluid, which can be caused by a ruptured ectopic pregnancy. However, a full blood count (FBC) and urea and electrolytes (U & Es) will not diagnose a potential ruptured ectopic pregnancy and, as such, will not guide subsequent management.

An erect chest X-ray may be requested if perforation is suspected, but a urine pregnancy test would be much more useful in this scenario. An abdominal X-ray is not indicated.

In summary, a urine pregnancy test is crucial in females of childbearing age with abdominal pain to rule out pregnancy and potentially diagnose a ruptured ectopic pregnancy.

Differential diagnosis of abnormal uterine bleeding in a young woman

Abnormal uterine bleeding is a common gynecological complaint that can have various causes. In a young woman presenting with this symptom, the differential diagnosis includes hypothyroidism, submucosal leiomyoma, endometrial hyperplasia and cancer, cervical cancer, and endometrial polyps.

Hypothyroidism is a likely diagnosis if the patient also complains of weight gain, constipation, fatigue, poor concentration, and muscle weakness. Hypothyroidism can affect reproductive functioning and cause irregular and unpredictable uterine bleeding.

Submucosal leiomyoma, although rare in young women, can cause metrorrhagia or menorrhagia. However, it does not explain systemic symptoms.

Endometrial hyperplasia and cancer are more common in postmenopausal women, but can also occur in young women with risk factors such as obesity, hypertension, diabetes mellitus, nulliparity, tamoxifen use, late menopause, and chronic anovulation. Endometrial hyperplasia can lead to abnormal uterine bleeding and uterine enlargement.

Cervical cancer is associated with human papillomavirus infection and other risk factors such as smoking, early intercourse, multiple sexual partners, use of oral contraceptives, and immunosuppression. Early cervical cancer may not cause symptoms, but can present with vaginal spotting, post-coital bleeding, dyspareunia, and vaginal discharge.

Endometrial polyps are more common around the menopausal age and can cause menorrhagia, metrorrhagia, and menometrorrhagia. Although most polyps are benign, some may contain neoplastic foci.

In summary, a thorough evaluation of a young woman with abnormal uterine bleeding should include a thyroid function test and consideration of other potential causes such as leiomyoma, endometrial hyperplasia and cancer, cervical cancer, and endometrial polyps. Treatment depends on the underlying diagnosis and may include hormonal therapy, surgery, or other interventions.

Types of Ectopic Pregnancy in the Fallopian Tube

Ectopic pregnancy, a condition where the fertilized egg implants outside the uterus, can occur in different parts of the Fallopian tube. Here are the different types of ectopic pregnancy in the Fallopian tube and their characteristics:

1. Isthmus – Ectopic pregnancy in the isthmus is rare but can occur. The tube is rigid, making rupture occur earlier than in other parts of the tube.

2. Interstitial part – This is the proximal segment of the tube embedded within the uterine wall. Ectopic pregnancy in this part is very rare and is more likely to occur in women who have had ipsilateral salpingectomy.

3. Ampulla – Ectopic pregnancy occurs most frequently in the ampullary part of the tube, which is relatively wide. Rupture usually occurs about 2 months after the last menstrual period, but it happens later than in the isthmus due to the elasticity of the tube.

4. Fimbrial end – Ectopic pregnancy near the fimbrial end can result in an ovarian pregnancy, which is rare and not associated with pelvic inflammatory disease or an intrauterine device.

5. Cornua – Pregnancy may implant itself in the cornua, which is the opening of the Fallopian tube. Combined with interstitial pregnancies, this represents a small percentage of all ectopic pregnancies.

Knowing the different types of ectopic pregnancy in the Fallopian tube can help in early detection and management of this potentially life-threatening condition.

Expectant management of an ectopic pregnancy is only suitable for an embryo that is unruptured, <35mm in size, has no heartbeat, is asymptomatic, and has a β-hCG level of <1,000 IU/L and declining. In this case, the woman has a small ectopic pregnancy without cardiac activity and a declining β-hCG level. Therefore, expectant management is appropriate, and the woman should be given safety netting advice and asked to return for a follow-up blood test in 48 hours. Admitting her for 12-hourly β-hCG monitoring is unnecessary, and performing a salpingectomy or salpingostomy is not indicated. Prescribing medical management is also inappropriate in this case. Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test. There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility. Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

If a woman misses 2 pills in week 3 of taking the COCP, she should finish the remaining pills in the current pack and start a new pack immediately without taking the pill-free interval. Missing 2 pills means that it has been 72 hours since the last pill was taken, and the standard rule is to take 2 pills on the same day and continue taking one pill each day until the end of the pack. It is important not to take more than 2 pills in one day, and emergency contraception is only necessary if more than 7 consecutive pills are missed. In this case, the woman has not taken the required 7 consecutive pills to be protected during the pill-free interval, so she should start the new pack immediately. However, the chances of pregnancy are low if she has taken 7 pills consecutively the prior week.

Missed Pills in Combined Oral Contraceptive Pill

When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

If one COCP pill is missed, the individual should take the missed pill as soon as possible, but no further action is necessary. They should also take the next pill at the usual time, even if that means taking two pills in one day. Emergency contraception is not required in this situation, as only one pill was missed. However, if two or more pills are missed in week 3 of a packet, it is recommended to omit the pill-free interval and use barrier contraception for 7 days.

Missed Pills in Combined Oral Contraceptive Pill

When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

The most effective form of contraception for young women who desire a low-maintenance option and do not want to remember to take it daily is the implantable contraceptive. This option is particularly suitable for those with busy or unpredictable lifestyles, such as those planning to travel. While the intrauterine device is also effective for 5 years, it is contraindicated for those with active pelvic inflammatory disease. The implantable contraceptive, which lasts for 3 years, is a better option in this case. Injectable contraceptive is less suitable as it only lasts for 12 weeks.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

Ovarian tumours are mostly epithelial in nature, comprising 90% of all cases. Serous tumours are the most common type, accounting for 50% of ovarian cancers and 20% of benign tumours. Although the 5-year survival rate is improving, it remains low at around 40% in the UK. These tumours typically affect postmenopausal women, with over 80% of cases occurring in those over 50 years old. Ovarian tumours can be benign, invasive or malignant, with different pathological subtypes. Mucinous cystadenomas are common in women aged 20-50 years and can be large and multilocular, with a risk of pseudomyxoma peritonei if they rupture. Brenner tumours are rare and often found incidentally, while teratomas are non-seminomatous germ cell tumours that may contain multiple types of tissue. Clear cell carcinomas are rare and have a worse prognosis than serous tumours, growing rapidly and being associated with endometriosis. Surgical removal is the preferred treatment for most ovarian tumours.

Understanding Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects women of reproductive age. It is characterized by menstrual irregularities, signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries. The Rotterdam criteria provide diagnostic criteria for PCOS, which include oligomenorrhoea or amenorrhoea, clinical or biochemical signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries.

Follicle counts and ovarian volume are important ultrasonographic features used to diagnose PCOS. At least 12 follicles in one ovary, measuring 2-9 mm in diameter, and an ovarian volume of >10 ml are diagnostic of PCOS. However, the absence of these features does not exclude the diagnosis if two of the three criteria are met.

Total testosterone levels are usually raised in PCOS, while FSH is usually within the normal range or low, and LH is raised. The ratio of LH:FSH is usually >3:1 in PCOS.

A single complex cyst in one ovary is an abnormal finding and requires referral to a gynaecology team for further assessment.

Understanding the Diagnostic Criteria and Ultrasonographic Features of PCOS

Patients with stress incontinence who do not respond to pelvic floor muscle exercises and decline surgical intervention may be prescribed duloxetine, a serotonin-norepinephrine re-uptake inhibitor. This drug increases sphincter tone during the filling phase of urinary bladder function. However, before starting drug therapy, patients should try pelvic floor exercises and consider surgical intervention. Oxybutynin, an anticholinergic drug, is used to treat urge incontinence or symptoms of detrusor overactivity, but it is not recommended for frail, older women at risk of health deterioration. Desmopressin is the preferred drug treatment for children with nocturnal enuresis and may also be used for women with nocturia. Mirabegron is prescribed for patients with urge incontinence who cannot tolerate antimuscarinic/anticholinergic drugs. It is a beta-3 adrenergic agonist that relaxes the bladder.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

Tumour Markers: An Overview

Tumour markers are substances produced by cancer cells or normal cells in response to cancer. They can be used to aid in the diagnosis, monitoring, and treatment of cancer. Here are some commonly used tumour markers and their applications:

CA125: This marker is used to detect ovarian cancer. It should be tested if a woman has persistent abdominal bloating, early satiety, pelvic or abdominal pain, increased urinary urgency or frequency, or symptoms consistent with irritable bowel syndrome. If CA125 is raised, the patient should be referred for a pelvic/abdominal ultrasound scan.

AFP: Elevated AFP levels are associated with hepatocellular carcinoma, liver metastases, and non-seminomatous germ-cell tumours. It is also measured in pregnant women to screen for neural-tube defects or genetic disorders.

CA15-3: This marker is used to monitor the response to treatment in breast cancer. It should not be used for screening as it is not necessarily raised in early breast cancer. Other causes of raised CA15-3 include liver cirrhosis, hepatitis, autoimmune conditions, and benign disorders of the ovary or breast.

CA19-9: This marker is commonly associated with pancreatic cancer. It may also be seen in other hepatobiliary and gastric malignancies.

CEA: CEA is commonly used as a tumour marker for colorectal cancer. It is not particularly sensitive or specific, so it is usually used to monitor response to treatment or detect disease recurrence.

Common Causes of Abnormal Uterine Bleeding in Women

Abnormal uterine bleeding is a common gynecological problem that can have various underlying causes. Here are some of the most common causes of abnormal uterine bleeding in women:

Endometriosis: This condition occurs when the endometrial tissue grows outside the uterus, usually in the ovaries or pelvic cavity. Symptoms include painful periods, painful intercourse, painful bowel movements, and adnexal tenderness. Endometriosis can also lead to infertility.

Ovulatory dysfunctional uterine bleeding: This condition is caused by excessive production of vasoconstrictive prostaglandins in the endometrium during a menstrual period. Symptoms include heavy and painful periods. Non-steroidal anti-inflammatory drugs are the treatment of choice.

Cervical cancer: This type of cancer is associated with human papillomavirus infection, smoking, early intercourse, multiple sexual partners, use of oral contraceptives, and immunosuppression. Symptoms include vaginal spotting, post-coital bleeding, dyspareunia, and vaginal discharge. Cervical cancer is rare before the age of 25 and is unlikely to cause dysmenorrhea, dyspareunia, dyschezia, or adnexal tenderness.

Submucosal leiomyoma: This is a benign neoplastic mass of myometrial origin that protrudes into the intrauterine cavity. Symptoms include heavy and painful periods, but acute pain is rare.

Endometrial polyps: These are masses of endometrial tissue attached to the inner surface of the uterus. They are more common around menopausal age and can cause heavy or irregular bleeding. They are usually not associated with pain or menstrual cramps and are not pre-malignant.

Understanding the Common Causes of Abnormal Uterine Bleeding in Women

Treatment Options for Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) is a common condition caused by the ascending infection of Chlamydia or gonorrhoeae from the vagina. The symptoms include bilateral lower abdominal pain, deep dyspareunia, and abnormal bleeding or discharge. The recent British Association for Sexual Health and HIV (BASHH) guideline recommends empirical antibiotic treatment for sexually active women under 25 who have these symptoms. The treatment includes stat im ceftriaxone and a 2-week course of doxycycline and metronidazole. Intravenous therapy is indicated in severe cases.

Pelvic ultrasound scan is not necessary for the diagnosis of PID. Blood tests to check inflammatory markers and serum β-HCG are not required if the clinic history and examination suggest PID. Analgesia and observation are not sufficient for the treatment of PID. Oral antibiotics alone are not recommended for the treatment of PID.

In conclusion, PID requires prompt and appropriate treatment with broad-spectrum antibiotics. The recommended treatment options should be followed based on the severity of the disease.

Understanding Polycystic Ovarian Syndrome (PCOS) and Related Conditions

Polycystic ovarian syndrome (PCOS) is a hormonal disorder that affects women of reproductive age. It is characterized by enlarged ovaries with many atretic follicles but no mature antral follicles. This leads to increased production of luteinizing hormone (LH), which stimulates the cells of the theca interna to secrete testosterone. Peripheral aromatase then converts testosterone to estrogen, which suppresses follicle-stimulating hormone (FSH) secretion and upregulates LH secretion from the adenohypophysis. This results in decreased aromatase production in granulosa cells, low levels of estradiol, and failure of follicles to develop normally.

To remember the signs and symptoms of PCOS, use the mnemonic PCOS PAL. PCOS is associated with male pattern balding (alopecia), hirsutism, obesity, hypertension, acanthosis nigricans (thickening and hyperpigmentation of the skin), and menstrual irregularities (oligo- or amenorrhea). It can also cause hypogonadotropic hypogonadism, which is characterized by impaired secretion of gonadotropins from the pituitary, including FSH and LH. This condition can be caused by various factors, such as Kallmann syndrome and GnRH insensitivity. Gonadal dysgenesis, monosomy X variant, is another condition that affects sexually juvenile women with an abnormal karyotype (45, X). It results in complete failure of development of the ovary and therefore no secondary sexual characteristics. Chronic adrenal insufficiency (or Addison’s disease) is another condition that can cause anorexia, weight loss, and hyperpigmentation of the skin in sun-exposed areas.

It is important to note that early pregnancy is not a possibility in women with PCOS who are not ovulating. Additionally, if a woman with PCOS were pregnant, she would have elevated beta human chorionic gonadotropin. Understanding these conditions and their associated symptoms can help healthcare providers diagnose and manage PCOS effectively.

According to the GMC’s good medical practice advice, healthcare professionals can provide contraceptive, abortion, and STI advice and treatment to individuals aged 0-18 years without parental knowledge or consent if certain criteria are met. These include ensuring that the individual fully understands the advice and its implications, not persuading them to tell their parents or allowing you to do so, and determining that their physical or mental health is likely to suffer without such advice or treatment. Confidentiality should be maintained even if advice or treatment is not provided. In this scenario, the correct course of action is to prescribe the pill as the young girl fulfills the Fraser guidelines. Breaking confidentiality, as suggested in answer 4, is not recommended by the GMC guidelines. Therefore, the correct answer is 1.

When it comes to providing contraception to young people, there are legal and ethical considerations to take into account. In the UK, the age of consent for sexual activity is 16 years, but practitioners may still offer advice and contraception to young people they deem competent. The Fraser Guidelines are often used to assess a young person’s competence. Children under the age of 13 are considered unable to consent to sexual intercourse, and consultations regarding this age group should trigger child protection measures automatically.

It’s important to advise young people to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. Long-acting reversible contraceptive methods (LARCs) are often the best choice for young people, as they may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.

If a woman has pelvic inflammatory disease, she cannot have a copper IUD inserted. Women who are at risk of this condition, such as those with multiple sexual partners or symptoms that suggest pelvic inflammatory disease, should be tested for infections like Chlamydia trachomatis and Neisseria gonorrhoeae and treated if necessary. To test for these infections, endocervical swabs are used. While the insertion of a copper IUD does carry a risk of developing pelvic inflammatory disease, this risk is low for women who are at low risk of sexually transmitted infections.

Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucous. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.

Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

For overweight or obese women with polycystic ovarian syndrome (PCOS) who are having difficulty getting pregnant, the initial approach is weight loss. If weight loss is not successful, either due to the woman’s inability to lose weight or failure to conceive despite weight loss, metformin can be used as an additional treatment.

Managing Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

During pregnancy, uterine fibroids may experience growth. These fibroids are common and often do not show any symptoms. However, in non-pregnant women, they can cause menorrhagia. In early pregnancy, they grow due to oestrogen and can cause pelvic pain and pressure. If they grow too quickly and surpass their blood supply, they may undergo ‘red degeneration’. This patient’s symptoms, including pelvic pain and a history of menorrhagia, suggest that the growth of pre-existing fibroids due to oestrogen may be the cause. However, further investigation with ultrasound is necessary to confirm this diagnosis. Ectopic pregnancies are rare in the second trimester and are typically detected during routine ultrasound scans. This patient is unlikely to have an ectopic pregnancy as her first ultrasound scan would have confirmed an intrauterine pregnancy. Pelvic inflammatory disease is not the most likely cause of this patient’s symptoms as it is associated with additional symptoms such as vaginal discharge and dysuria, and the patient would likely be febrile. The growth of pre-existing fibroids due to decreased progesterone is incorrect as progesterone, like oestrogen, is increased during pregnancy. This patient does not exhibit symptoms of dysuria, renal angle tenderness, or pyrexia.

Understanding Fibroid Degeneration

Uterine fibroids are non-cancerous growths that can develop in the uterus. They are sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.

Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days.

Possible Diagnoses for Hirsutism and Menstrual Irregularity in Reproductive-Age Women

Hirsutism and menstrual irregularity in reproductive-age women can be caused by various conditions. Polycystic ovarian syndrome (PCOS) and late-onset (non-classic) congenital adrenal hyperplasia are two possible diagnoses to consider. In this case, the normal 17-hydroxyprogesterone concentration rules out congenital adrenal hyperplasia, while the presence of bilaterally enlarged ovaries with multiple cysts and impaired glucose tolerance suggests PCOS.

An androgen-secreting adrenal tumour can also cause hirsutism, but it typically results in rapid onset and severe symptoms. Ovarian stromal hyperthecosis, which shares some resemblance with PCOS, may occur in premenopausal and postmenopausal women, but PCOS is more likely in this case due to the ultrasound scan findings.

Late-onset congenital adrenal hyperplasia can present with gradual onset of hirsutism without virilisation, but an elevated serum 17-hydroxyprogesterone concentration is a distinguishing feature. Luteoma of pregnancy, a benign solid ovarian tumour associated with excess androgen production, is unlikely in this case as the patient has not been pregnant.

In summary, PCOS is the most likely diagnosis for this patient’s hirsutism and menstrual irregularity, based on the ultrasound appearance and hormone results.

If a patient on the combined oral contraceptive pill missed two or more pills and has had unprotected sexual intercourse during the pill-free period or week 1 of the pill packet, emergency contraception should be considered. However, in this case, the patient has only missed one pill on day 9 and does not require emergency contraception or a pregnancy test. If the patient had missed two pills during days 1-7 of the pill packet and had unprotected sex, emergency contraception would be necessary. The choice of emergency contraception depends on various factors, including the timing of the unprotected intercourse event, other medications the patient may be taking, and her preferences. Offering to insert a copper coil to prevent pregnancy would be inappropriate in this case. However, if the patient was having trouble remembering to take her pill correctly and wished to consider a long-acting contraceptive, options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection could be discussed. It is important to note that the contraceptive injection cannot be used as a form of emergency contraception.

Missed Pills in Combined Oral Contraceptive Pill

When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

The contraceptive patch regime involves wearing one patch per week for three weeks, followed by a patch-free week. This method is gaining popularity due to its flexibility, as the patch can be changed up to 48 hours late without the need for backup contraception. Additionally, the patch’s transdermal absorption eliminates the need for extra precautions during episodes of vomiting or diarrhea. Similar to the pill, this method involves three weeks of contraceptive use followed by a one-week break, during which the woman will experience a withdrawal bleed.

The Evra patch is the only contraceptive patch that is approved for use in the UK. The patch cycle lasts for four weeks, during which the patch is worn every day for the first three weeks and changed weekly. During the fourth week, the patch is not worn, and a withdrawal bleed occurs.

If a woman delays changing the patch at the end of week one or two, she should change it immediately. If the delay is less than 48 hours, no further precautions are necessary. However, if the delay is more than 48 hours, she should change the patch immediately and use a barrier method of contraception for the next seven days. If she has had unprotected sex during this extended patch-free interval or in the last five days, emergency contraception should be considered.

If the patch removal is delayed at the end of week three, the woman should remove the patch as soon as possible and apply a new patch on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.

If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for seven days following any delay at the start of a new patch cycle. For more information, please refer to the NICE Clinical Knowledge Summary on combined hormonal methods of contraception.

In the NHS cervical screening programme, cervical cancer screening involves testing for high-risk HPV (hrHPV) first. If the initial test results in an inadequate sample, it should be repeated after 3 months. If the second test also returns as inadequate, then colposcopy should be performed. This is because without obtaining hr HPV status or performing cytology, the risk of cervical cancer cannot be assessed. It would be unsafe to return the patient to normal recall as this could result in a delayed diagnosis of cervical cancer. Repeating the test after 3, 6 or 12 months is also not recommended as it may lead to a missed diagnosis.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hr HPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

The method of contraception that is commonly linked to weight gain is injectable contraception, which includes Depo-Provera. The combined oral contraceptive pill has been associated with an increased risk of venous thromboembolic disease, breast cancer, and cervical cancer, but there is no evidence to suggest that it causes weight gain. Implantable contraceptives like Implanon are typically associated with irregular or heavy bleeding, but not weight gain. Intrauterine devices, such as the copper coil, are known to cause heavier and more painful periods, but they are not associated with weight gain.

Injectable Contraceptives: Depo Provera

Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150 mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucous thickening and endometrial thinning.

However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

The correct course of action for a patient who had a positive high-risk human papillomavirus (hrHPV) but negative cytology result in their initial smear and a negative hrHPV result in their subsequent 12-month repeat smear is to return to routine recall. This means that the patient should have their next smear in 5 years, as they are in the appropriate age group for this interval. Referring the patient for colposcopy is not necessary in this case, as the cytology result was negative. Repeating the smear in 3 months is also not necessary, as this is only done for inadequate samples. If the hrHPV result is positive again in a further 12-month repeat, then repeating the smear in another 12 months would be appropriate. However, if the hrHPV result is negative in the second repeat, the patient can be returned to routine recall. For younger patients, the appropriate interval for routine recall is 3 years.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Endometrial cancer is more likely to occur in women who have never given birth. One of the warning signs of endometrial cancer is bleeding after menopause. Chronic obstructive pulmonary disease is not a known risk factor for endometrial cancer, but conditions such as type 2 diabetes mellitus and polycystic ovary syndrome are. While late menopause can increase the risk of endometrial cancer, this patient experienced menopause at around age 50, which is slightly earlier than average. Smoking is not a risk factor for endometrial cancer, but it is associated with an increased risk of other types of cancer such as cervical, vulval, and breast cancer. On the other hand, taking the combined oral contraceptive pill can lower the risk of endometrial cancer, but it may increase the risk of breast and cervical cancer.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

Surgical intervention is necessary for the management of ectopic pregnancy.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

If a patient with endometriosis is not experiencing relief from their symptoms with a combination of non-steroidal anti-inflammatories and the combined oral contraceptive pill, they may be prescribed gonadotrophin-releasing hormone agonists (GnRH agonists) as a second-line medical management option. progesterone-only contraception may also be offered in this stage of treatment. GnRH agonists work by down-regulating GnRH receptors, which reduces the production of oestrogen and androgen. This reduction in hormones can alleviate the symptoms of endometriosis, as oestrogen thickens the uterine lining. The copper intrauterine device is not an appropriate treatment option, as it does not contain hormones and may actually worsen symptoms. NICE does not recommend the use of opioids in the management of endometriosis, as there is a high risk of adverse effects and addiction. Amitriptyline may be considered as a treatment option for chronic pain, but it is important to explore other medical and surgical options for endometriosis before prescribing it, as it comes with potential side effects and risks.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

A labial lump and inguinal lymphadenopathy in an older woman may indicate the presence of vulval carcinoma, as these symptoms are concerning and should not be ignored. Although labial lumps are not uncommon, it is important to be vigilant and seek medical attention if a new lump appears.

Understanding Vulval Carcinoma

Vulval carcinoma is a type of cancer that affects the vulva, which is the external female genitalia. It is a relatively rare condition, with only around 1,200 cases diagnosed in the UK each year. The majority of cases occur in women over the age of 65 years, and around 80% of cases are squamous cell carcinomas.

There are several risk factors associated with vulval carcinoma, including human papillomavirus (HPV) infection, vulval intraepithelial neoplasia (VIN), immunosuppression, and lichen sclerosus. Symptoms of vulval carcinoma may include a lump or ulcer on the labia majora, inguinal lymphadenopathy, and itching or irritation.

It is important for women to be aware of the risk factors and symptoms of vulval carcinoma, and to seek medical attention if they experience any concerning symptoms. Early detection and treatment can improve outcomes and increase the chances of a full recovery.

The UK Government implemented legal modifications in October 2015 regarding the response of doctors in England and Wales to instances of female genital mutilation (FGM). As per the guidelines of the General Medical Council (GMC), doctors are required to report all cases of FGM in individuals under the age of 18 to the police. This can be done by contacting 101 or using the established local channels. Reporting is compulsory to align with our responsibilities towards child protection and safeguarding.

Understanding Female Genital Mutilation

Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.

If a patient presents with primary amenorrhoea and raised FSH/LH levels, it is important to consider the possibility of gonadal dysgenesis, such as Turner’s syndrome. This condition is characterized by the presence of only one X chromosome or a deletion of the short arm of one X chromosome, which can result in widely spaced nipples and other physical characteristics. In Turner’s syndrome, the lack of estrogen and progesterone production by the ovaries leads to an increase in FSH/LH levels as a compensatory mechanism. Therefore, an increase in FSH/LH levels is consistent with this diagnosis. Cyclical pain due to an imperforate hymen typically presents with secondary sexual characteristics, while increased prolactin levels are associated with galactosemia, and increased androgen levels are associated with polycystic ovarian syndrome. In the case described, a diagnosis of Turner’s syndrome is likely, and serum estrogen levels would not be expected to be elevated due to gonadal dysgenesis.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls without secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

Hormones Involved in Pregnancy Testing

Pregnancy testing relies on the detection of specific hormones in the body. One such hormone is human chorionic gonadotropin (hCG), which is secreted by the syncytiotrophoblast of a developing embryo after implantation in the uterus. The unique subunit of hCG, β, is targeted by antibodies in blood and urine tests, allowing for early detection of pregnancy. Luteinising hormone (LH) and follicle-stimulating hormone (FSH) also play important roles in female reproductive function, but are not measured in over-the-counter pregnancy tests. Progesterone, while important in pregnancy, is not specific to it and therefore not useful in diagnosis. The hCG subunit α is shared with other hormones and is not specific to pregnancy testing.

If a woman with stage IA cervical cancer desires to preserve her fertility, a cone biopsy with negative margins may be considered as an option. However, for women who do not wish to have children, a hysterectomy with lymph node clearance is recommended. Cisplatin chemotherapy and radiotherapy are not appropriate for this stage of cervical cancer, while laser ablation is only used for cervical intraepithelial dysplasias. Radical trachelectomy is not recommended as it may negatively impact fertility.

Management of Cervical Cancer Based on FIGO Staging

Cervical cancer management is determined by the FIGO staging and the patient’s desire to maintain fertility. The FIGO staging system categorizes cervical cancer into four stages based on the extent of the tumor’s spread. Stage IA and IB tumors are confined to the cervix, with IA tumors only visible under a microscope and less than 7 mm wide. Stage II tumors have spread beyond the cervix but not to the pelvic wall, while stage III tumors have spread to the pelvic wall. Stage IV tumors have spread beyond the pelvis or involve the bladder or rectum.

The management of stage IA tumors involves a hysterectomy with or without lymph node clearance. For patients who want to maintain fertility, a cone biopsy with negative margins can be performed, but close follow-up is necessary. Stage IB tumors are managed with radiotherapy and concurrent chemotherapy for B1 tumors and radical hysterectomy with pelvic lymph node dissection for B2 tumors.

Stage II and III tumors are managed with radiation and concurrent chemotherapy, with consideration for nephrostomy if hydronephrosis is present. Stage IV tumors are treated with radiation and/or chemotherapy, with palliative chemotherapy being the best option for stage IVB. Recurrent disease is managed with either surgical treatment followed by chemoradiation or radiotherapy followed by surgical therapy.

The prognosis of cervical cancer depends on the FIGO staging, with higher survival rates for earlier stages. Complications of treatments include standard surgical risks, increased risk of preterm birth with cone biopsies and radical trachelectomy, and ureteral fistula with radical hysterectomy. Complications of radiotherapy include short-term symptoms such as diarrhea and vaginal bleeding and long-term effects such as ovarian failure and fibrosis of various organs.

Ovarian hyperstimulation syndrome can occur as a possible adverse effect of ovulation induction. The symptoms of this syndrome, such as ascites, vomiting, diarrhea, and high hematocrit, are typical. There are various medications used for ovulation induction, and the risk of ovarian hyperstimulation syndrome is higher with gonadotropin therapy than with clomiphene citrate, raloxifene, letrozole, or anastrozole. Therefore, it is probable that the patient received gonadotropin therapy.

Ovulation induction is often required for couples who have difficulty conceiving naturally due to ovulation disorders. Normal ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. There are three main categories of anovulation: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation to lead to a singleton pregnancy. Forms of ovulation induction include exercise and weight loss, letrozole, clomiphene citrate, and gonadotropin therapy. Ovarian hyperstimulation syndrome is a potential side effect of ovulation induction and can be life-threatening if not managed promptly.

If a patient presents with symptoms highly suggestive of vaginal candidiasis, a high vaginal swab is not necessary for diagnosis and treatment can be initiated with a single oral dose of fluconazole. Symptoms of vaginal candidiasis include vulval soreness, itching, and thick, white vaginal discharge. Prescribing oral metronidazole as a single dose or taking a high vaginal swab would be incorrect as they are used to treat Trichomonas vaginalis infections or bacterial vaginosis, respectively.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

Nerve Damage in Obstetric and Surgical Procedures

During obstetric and surgical procedures, nerve damage can occur in various parts of the body. One such instance is a total vault prolapse, which can occur following a hysterectomy. Two surgical options for management include sacrocolpopexy and sacrospinous fixation. While sacrocolpopexy involves suturing the vaginal vault to the sacrum, sacrospinous fixation requires suturing the top of the vaginal vault to the sacrospinous ligament. However, complications such as damage to the sciatic nerve and pudendal vessels can occur with the latter procedure.

Damage to the common peroneal nerve is most common during total knee arthroplasties when the patient is placed in the lithotomy and lateral positions for extended periods of time. On the other hand, the femoral nerve can be injured during abdomino-pelvic surgery, aortic cross-clamp, invasive procedures to access the femoral vessels, and hip arthroplasty. Inguinal hernia repair is the most common cause of damage to the inguinal nerve.

Lastly, isolated damage to the posterior cutaneous nerve of the thigh is not associated with obstetric surgery. However, damage to the main femoral nerve is commonly seen in abdominal hysterectomies due to compression by retractor blades. It is important for healthcare professionals to be aware of these potential complications and take necessary precautions to prevent nerve damage during procedures.

Common Causes of Vaginal Discharge: Symptoms, Diagnosis, and Treatment

Vaginal discharge is a common symptom experienced by women, and it can be caused by various infections. Here are some of the most common causes of vaginal discharge, along with their symptoms, diagnosis, and treatment options.

Candidiasis: This infection is caused by Candida fungi, particularly Candida albicans. Symptoms include vaginal itch, thick discharge with a consistency similar to cottage cheese, vaginal discomfort, and pain during sexual intercourse. Diagnosis is usually clinical, and treatment includes good hygiene, emollients, loose-fitting underwear, and antifungal cream or pessary, or oral antifungal medication.

Trichomoniasis: This infection is caused by the parasite Trichomonas vaginalis. Symptoms include dysuria, itch, and yellow-green discharge that can have a strong odor. Up to 50% of infected individuals are asymptomatic.

Bacterial vaginosis: This infection is caused by an overgrowth of anaerobes in the vagina, most commonly Gardnerella vaginalis. Symptoms include a thin, white discharge, vaginal pH >4.5, and clue cells seen on microscopy. Treatment of choice is oral metronidazole.

Streptococcal infection: Streptococcal vulvovaginitis presents with inflammation, itch, and a strong-smelling vaginal discharge. It is most commonly seen in pre-pubertal girls.

Chlamydia: Although Chlamydia infection can present with urethral purulent discharge and dyspareunia, most infected individuals are asymptomatic. Chlamydia-associated discharge is typically more purulent and yellow-clear in appearance, rather than cheese-like.

In conclusion, proper diagnosis and treatment of vaginal discharge depend on identifying the underlying cause. It is important to seek medical attention if you experience any symptoms of vaginal discharge.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

The effectiveness of different contraceptives varies in terms of the time it takes to become effective if not started on the first day of the menstrual cycle. The intrauterine device is the only method that is instantly effective at any time during the cycle as it reduces sperm motility and survival. The progesterone only pill takes at least 2 days to work if started after day 5 of the cycle and is immediately effective if started prior to day 5. The combined oral contraceptive pill, injection, implant, and intrauterine system take 7 days to become effective and work by inhibiting ovulation, thickening cervical mucous, and preventing endometrial proliferation. Side effects of the progesterone only pill may include menstrual irregularities, breast tenderness, weight gain, and acne.

Counselling for Women Considering the progesterone-Only Pill

Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

Understanding Vaginal Discharge: Common Causes and Key Features

Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a pathological condition. There are various causes of vaginal discharge, including physiological factors and infections. Some of the common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. However, less common causes such as gonorrhea, chlamydia, ectropion, foreign body, and cervical cancer can also lead to vaginal discharge.

It is important to note that the key features of each cause of vaginal discharge can vary. For instance, Candida infection may present with a discharge that resembles cottage cheese, accompanied by vulvitis and itch. On the other hand, Trichomonas vaginalis infection may cause an offensive, yellow/green, frothy discharge, along with vulvovaginitis and a strawberry cervix. Bacterial vaginosis, another common cause of vaginal discharge, may present with an offensive, thin, white/grey, ‘fishy’ discharge.

If there is evidence of infection or an increased risk of haemorrhage, expectant management is not a suitable option for miscarriage. In such cases, NICE recommends either medical management (using oral or vaginal misoprostol) or surgical management (including manual vacuum aspiration). In this particular case, surgical management is the only option as the patient has evidence of infection, possibly due to septic miscarriage. Syntocinon is used for medical management of postpartum haemorrhage, while methotrexate is used for medical management of ectopic pregnancy. Oral mifepristone is used in combination with misoprostol for termination of pregnancy, but it is not recommended by NICE for the management of miscarriage.

Management Options for Miscarriage

Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.

Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.

Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.

It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.

It is safe to insert a contraceptive implant after childbirth. The manufacturer of the most commonly used implant in the UK, Nexplanon®, recommends waiting at least 4 weeks postpartum for breastfeeding women. While there is no evidence of harm to the mother or baby, it is not recommended to insert an implant during pregnancy due to potential complications. It may take some time for fertility to return after pregnancy.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

1: If you are over 35 years old and smoke at least 15 cigarettes a day, smoking is not recommended.
2: A BMI over 35 kg/m² should be evaluated by a medical professional, but it is not considered an absolute contraindication.
3: A history of ectopic pregnancies does not affect the use of COCP.
4: It is not recommended to use COCP within 6 weeks after giving birth.
5: There is no evidence linking the use of COCP to carpal tunnel syndrome.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

The menopause is a natural process that occurs when a woman’s menstrual periods stop due to decreased production of oestradiol and progesterone. While menopause can cause symptoms such as hot flashes, mood changes, and reduced libido, treatment with hormone replacement therapy (HRT) is not necessary and should be based on individual circumstances and patient choice. However, if HRT is used, it is important to note that oestrogen-only therapy can increase the risk of endometrial cancer and should only be given to women without a uterus. This is because oestrogen promotes endometrial growth, which can lead to oncogenesis. Adding progesterone to HRT can prevent this risk. Testosterone may also be used to address libido issues, but it should be prescribed under specialist guidance and can cause virilising side-effects. Selective serotonin reuptake inhibitors (SSRIs) such as venlafaxine can be an alternative to HRT and are effective at managing symptoms without increasing the risk of endometrial cancer. However, SSRIs can cause side-effects such as gastrointestinal disturbances, reduced libido, and potentially life-threatening serotonin syndrome.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

Meig’s syndrome is characterized by the presence of a non-cancerous ovarian tumor, as well as ascites and pleural effusion. This condition is uncommon and typically affects women who are 40 years of age or older, with the ovarian tumor usually being a fibroma. Treatment involves surgical removal of the tumor, although drainage of the ascites and pleural effusion may be necessary beforehand to alleviate symptoms and improve lung function prior to anesthesia. The prognosis for Meig’s syndrome is favorable due to the benign nature of the tumor.

Types of Ovarian Tumours

Ovarian tumours can be classified into four main types: surface derived tumours, germ cell tumours, sex cord-stromal tumours, and metastatic tumours. Surface derived tumours are the most common, accounting for around 65% of ovarian tumours, and include the greatest number of malignant tumours. Examples of surface derived tumours include serous cystadenoma, serous cystadenocarcinoma, mucinous cystadenoma, mucinous cystadenocarcinoma, and Brenner tumour.

Germ cell tumours, which are more common in adolescent girls, account for 15-20% of tumours and have similar cancer types to those seen in the testicle. Examples of germ cell tumours include teratoma, dysgerminoma, yolk sac tumour, and choriocarcinoma.

Sex cord-stromal tumours represent around 3-5% of ovarian tumours and often produce hormones. Examples of sex cord-stromal tumours include granulosa cell tumour, Sertoli-Leydig cell tumour, and fibroma.

Metastatic tumours account for around 5% of tumours and occur when cancer cells from other parts of the body spread to the ovaries. An example of a metastatic tumour is Krukenberg tumour, which is a mucin-secreting signet-ring cell adenocarcinoma that results from metastases from a gastrointestinal tumour.

The most reliable way to confirm ovulation is through the Day 21 progesterone test. This test measures the peak level of progesterone in the serum, which occurs 7 days after ovulation. While the length of the follicular phase can vary, the luteal phase always lasts for 14 days. Therefore, if a woman has a 35-day cycle, she can expect to ovulate on Day 21 and her progesterone level will peak on Day 28. To determine when to take the test, subtract 7 days from the expected start of the next period (Day 21 for a 28-day cycle and Day 28 for a 35-day cycle). Basal body temperature charts and cervical mucous thickness are not reliable predictors of ovulation. Gonadotropins may be used to assess ovarian function in women with irregular menstrual cycles.

Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.

If a patient misses 2 pills in the first week of their combined oral contraceptive pill pack and has had unprotected sex during the pill-free interval or week 1, emergency contraception should be considered. The patient should take the missed pills as soon as possible and use condoms for the next 7 days. For patients who have only missed 1 pill, they should take it as soon as possible without needing extra precautions. If extra barrier contraception is needed for patients on the combined oral contraceptive pill, it should be used for at least 7 days. Patients on the progesterone-only pill only need barrier contraception for 2 days. Missing 1 pill at any time throughout a pack or starting a new pack 1 day late generally does not affect protection against pregnancy. Taking more than 2 contraceptive pills in a day is not recommended as it does not provide extra contraceptive effects and may cause side effects.

Missed Pills in Combined Oral Contraceptive Pill

When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

If the first repeat smear at 12 months is still positive for hrHPV, the next step is to repeat the smear 12 months later (i.e. at 24 months) for cervical cancer screening.

As part of the NHS cervical screening programme, cervical smear tests are initially tested for high-risk HPV (hrHPV). If the test is positive for hrHPV, cytology is performed. If the cytology shows normal cells, the cervical smear test is repeated after 12 months. In cases where the repeat test is still positive for hrHPV but cytology is normal, as in this scenario, the patient should have another repeat test after a further 12 months. Therefore, repeating the test in 12 months is the appropriate course of action.

Colposcopy is not necessary in this case as the cytology showed normal cells. Returning the patient to routine recall is also not appropriate as it would result in a repeat smear in 3 years. Instead, the patient requires a repeat smear in 12 months due to the positive hrHPV result. Repeating the test in 3 or 6 months is too soon and therefore not recommended.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

This individual has reached the postmenopausal stage, indicated by the absence of menstruation for 12 consecutive months. However, despite being postmenopausal, she still requires contraception as she is below the age of 50. According to guidelines, women who use non-hormonal contraception can discontinue after one year of amenorrhea if they are over 50 years old, and after two years if they are under 50 years old. Given her history of breast cancer, a copper coil is the most suitable option as all other hormonal methods are classified as UKMEC Category 3, which may pose an unacceptable risk.

Women over 40 years old still need effective contraception until menopause. All methods of contraception are generally safe for this age group, except for the COCP and Depo-Provera which have some limitations. COCP use may help maintain bone mineral density and reduce menopausal symptoms, but a pill with less than 30 µg ethinylestradiol may be more suitable for women over 40. Depo-Provera use is associated with a small loss in bone mineral density and may cause a delay in the return of fertility for up to 1 year for women over 40. The FSRH provides guidance on how to stop different methods of contraception based on age and amenorrhea status. HRT cannot be relied upon for contraception, and a separate method is needed. The POP may be used with HRT as long as the HRT has a progesterone component, while the IUS is licensed to provide the progesterone component of HRT.

The most effective method of emergency contraception is a copper IUD, and it should be the first option offered to all women who have had unprotected sexual intercourse. This IUD can be used up to 5 days after the UPSI or the earliest estimated date of ovulation. The combined oral contraceptive pill, intrauterine system, and levonorgestrel are not as effective as the copper IUD and should not be the first option offered. Levonorgestrel can only be used within 72 hours of UPSI, and even then, the copper IUD is still more effective.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

Types of Vulval Cancer: Symptoms, Diagnosis, and Treatment

Vulval cancer is a rare type of cancer that affects the external female genitalia. There are different types of vulval cancer, each with its own set of symptoms, risk factors, and treatment options. Here are some of the most common types of vulval cancer:

Squamous cell carcinoma: This is the most common type of vulval cancer, accounting for about 85% of cases. It usually affects women over 60 who smoke or have a weakened immune system. Symptoms include vulval irritation or itching, and as the disease progresses, pain and discharge. Squamous cell carcinoma can be cured if caught early, and treatment usually involves surgical excision.

Basal cell carcinoma: This type of vulval cancer is rare and usually occurs in sun-exposed areas of the skin. It is often treated with surgery.

Sarcoma: Sarcoma is a rare type of vulval cancer that can occur at any age, including childhood. Treatment usually involves surgery and radiation therapy.

Bartholin’s gland carcinoma: This is a rare cause of vulval cancer that affects the Bartholin glands, which are two small mucous-producing glands on either side of the vaginal opening. Risk factors include HPV infection and Paget’s disease of the vulva. It is often diagnosed late, as it is often confused with Bartholin gland cyst, which is a benign condition.

Malignant melanoma: This is a rare type of vulval cancer that accounts for about 5% of cases. Symptoms include itching, bleeding, and an irregular border. Treatment usually involves surgery and chemotherapy.

If you experience any symptoms of vulval cancer, such as itching, pain, or bleeding, it is important to see a doctor as soon as possible. Early diagnosis and treatment can improve your chances of a full recovery.

Common Genital Skin Conditions: Symptoms and Treatment Options

Lichen sclerosus, candidiasis, contact dermatitis, lichen planus, and psoriasis are some of the most common skin conditions that affect the genital area. Each condition has its own set of symptoms and treatment options.

Lichen Sclerosus: This chronic inflammatory condition can affect any part of the body but is most commonly found in the genital area. It presents with pruritus, skin irritation, hypopigmentation, and atrophy. Treatment involves topical steroids and good hygiene.

Candidiasis: This fungal infection is associated with pruritus, burning sensation, erythema, and oedema of the vestibule. The most common characteristic is a thick, curd-like, white vaginal discharge.

Contact Dermatitis: This condition is often caused by changes to shower gel or washing detergent. It presents with pruritus, erythematosus skin, excoriations, and skin breaks, leading to ulceration and superimposed infection. Chronic contact dermatitis can lead to lichenoid changes.

Lichen Planus: This condition presents with purple, red plaques usually on the labia, with central erosion and overlying lacy, white, striated patch. It can cause scarring and narrowing of the introitus and dyspareunia.

Psoriasis: This condition is rare in the genital area but can appear in the inguinal creases and the labia majora. It presents with erythematous plaques with minimal white scale and is associated with itching and excoriations.

It is important to seek medical attention if you suspect you have any of these conditions. Treatment options may include topical or oral medications, good hygiene practices, and lifestyle changes.

Differential Diagnosis for Severe Iliac Fossa Pain in Reproductive-Age Women

Severe, sudden-onset pain in the right or left iliac fossa is a common symptom of ectopic pregnancy in reproductive-age women. This pain may be accompanied by vaginal bleeding, shoulder tip pain, syncopal episodes, and shock. To rule out pregnancy, a urinary beta human chorionic gonadotrophin hormone (b-HCG) test should be performed, followed by a transvaginal ultrasound scan to confirm the diagnosis.

Ovarian torsion may also cause iliac fossa pain, but it is unlikely to cause referred shoulder pain. Appendicitis is not a consideration in this scenario, as the patient does not have an appendix. Irritable bowel syndrome and inflammatory bowel disease are also unlikely diagnoses, as the patient’s tachycardia and right iliac fossa tenderness and guarding are not consistent with these conditions. Overall, a thorough evaluation is necessary to differentiate between these potential causes of severe iliac fossa pain in reproductive-age women.

Common Vaginal Conditions: Symptoms and Management

Cystocele: A weakening of pelvic muscles can cause the bladder to prolapse into the vagina, resulting in stress incontinence, frequent urinary tract infections, and a dragging sensation or lump in the vagina. Management ranges from conservative with pelvic floor exercises to surgery.

Rectocele: Women with a rectocele experience pressure and a lump in the vagina, as well as difficulty with bowel movements. Treatment may involve pelvic floor exercises or surgery.

Bartholin cyst: A blocked Bartholin gland can lead to a cyst that presents as a tender mass in the vaginal wall. Treatment involves incision and drainage, as well as antibiotics.

Vaginal cancer: Symptoms include vaginal or postcoital bleeding, vaginal discharge, and persistent pelvic pain.

Bladder cancer: Painless hematuria is a common symptom, with risk factors including smoking, working in the aniline dye industry, or previous infection with Schistosoma haematobium.

Patients with secondary dysmenorrhoea require referral to gynaecology for further investigation. This is because secondary dysmenorrhoea, which is characterized by painful cramping in the lower abdomen before or after menstruation along with new menorrhagia, suggests an underlying pathology that needs to be addressed. While mefenamic acid can help manage the pain, it is not enough to simply review the patient in two weeks without organizing referrals or investigations. The insertion of an intrauterine progesterone system may be appropriate for primary dysmenorrhoea and some cases of secondary dysmenorrhoea, but this should not be the only course of action. Additional analgesia should be considered if paracetamol is not controlling the pain. An abdominal ultrasound is not suitable for investigating pelvic organs, and a transabdominal or transvaginal pelvic ultrasound is necessary to obtain views of the uterus, ovaries, Fallopian tubes, cervix, and vagina.

Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

Diagnosing Gynaecological Malignancies: Understanding the Differences

When a postmenopausal woman presents with vaginal bleeding, pelvic mass, and pelvic lymphadenopathy, it is important to consider the different types of Gynaecological malignancies that could be causing these symptoms. The most likely diagnosis in this case is cervical squamous cell carcinoma, which typically metastasises to the pelvic lymph nodes along the iliac arteries.

While endometrial carcinoma (adenocarcinoma) is the most common Gynaecological malignancy, it would also be a possibility in this patient. Ovarian cancer, the second most common Gynaecological cancer, typically metastasises to the para-aortic lymph nodes and is not associated with vaginal bleeding.

Vulval cancers tend to metastasise to the superficial inguinal node and are unlikely to present with a pelvic mass or vaginal bleeding. Cervical adenocarcinomas are rare and derived from the endocervix, while uterine leiomyosarcoma often extends beyond the uterine serosa and occasionally metastasises to distant organs through blood vessels. However, neither of these malignancies typically present with vaginal bleeding and pelvic lymphadenopathy.

In summary, understanding the differences between the various types of Gynaecological malignancies is crucial in accurately diagnosing and treating patients with these conditions.

If pelvic floor muscle exercises and surgical intervention are not effective, duloxetine can be used to treat stress incontinence in patients. However, it is important to rule out other potential causes such as infection before starting treatment. Non-pharmacological management should be attempted first, including pelvic floor exercises and reducing caffeine intake. Duloxetine is a medication that works as a serotonin/norepinephrine reuptake inhibitor and may cause side effects such as nausea, dizziness, and insomnia. For urge incontinence, antimuscarinic agents like oxybutynin, tolterodine, and solifenacin are typically used as first-line treatment. If these are not effective, a β3 agonist called mirabegron can be used as a second-line therapy.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

Methotrexate is the preferred medication for treating ectopic pregnancy through medical management, provided the patient is willing to attend follow-up appointments.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Fertility Testing Methods

When it comes to fertility testing, there are several methods available to determine a female’s ovulatory status. One of the easiest tests is the day 21 progesterone level. If the results are greater than 30 nmol/l in two cycles, then the patient is said to be ovulating.

Another method is the cervical fern test, which involves observing the formation of ferns in the cervical mucous under the influence of estrogen. However, measuring progesterone levels is a more accurate test as estrogen levels can vary.

Basal body temperature estimation is also commonly used, as the basal body temperature typically increases after ovulation. However, measuring progesterone levels is still considered the most accurate way to determine ovulation.

It’s important to note that day 2 luteinising hormone (LH) and follicle-stimulating hormone (FSH) are not reliable markers of ovulation. Additionally, endometrial biopsy is not a test used in fertility testing.

In conclusion, there are several methods available for fertility testing, but measuring progesterone levels is the most accurate way to determine ovulatory status.

Differential Diagnosis for Secondary Amenorrhoea: Polycystic Ovary Syndrome, Cushing’s Syndrome, Primary Ovarian Failure, Hypothalamic Disease, and Adrenal Tumour

Secondary amenorrhoea, the cessation of menstruation after previously menstruating, can have various causes. In a patient who is overweight, has acne, and slightly elevated testosterone and LH levels, polycystic ovary syndrome (PCOS) is a likely diagnosis. PCOS is characterized by small cysts in the ovaries and is linked to insulin resistance, hypertension, lipid abnormalities, and increased risk for cardiovascular disease. Hirsutism is also common in PCOS.

Cushing’s syndrome is a potential differential diagnosis for this patient, but blood results would show suppression of LH and FSH, not elevation. Primary ovarian failure is much rarer than PCOS and would show elevated serum FSH levels. Hypothalamic disease is less likely in this patient with multiple risk factors for PCOS, as it would result in decreased production of gonadotropin-releasing hormone and lower than normal detectable serum levels of LH and FSH. An adrenal tumour, particularly an adenoma, could rarely lead to amenorrhoea, but would also present with other symptoms such as palpitations and weight loss. Other adrenal tumours that secrete sex hormones are even rarer and would also be associated with weight loss.

The current guidelines for cervical cancer screening recommend using hrHPV as the first screening test. If the result is negative, the patient can return to routine recall. However, if the result is positive, the sample is examined for cytology. If the cytology is normal, the patient is asked to return for screening in 12 months instead of the usual 3 years. If the hrHPV result is negative at the 12-month follow-up, the patient can return to routine recall. But if the result is positive again, as in this scenario, and the cytology is normal, the patient should attend another screening in 12 months. If the cytology is abnormal at any point, the patient should be referred for colposcopy. If the patient attends a third screening in another 12 months and the hrHPV result is still positive, she should be referred for colposcopy regardless of the cytology result.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

When an ovarian cyst ruptures, it can cause sudden and severe pain on one side of the pelvis, especially after sexual activity or strenuous exercise. During a physical exam, the lower abdomen may be tender, but there may not be any other noticeable abnormalities. An ultrasound can reveal the presence of fluid in the pelvic area. It’s important to note that ovarian or adnexal torsion can also cause similar symptoms, including sharp pain on one side, nausea, and vomiting. However, in this case, a palpable mass may be felt during a physical exam, and an ultrasound may show an enlarged ovary with reduced blood flow.

Gynaecological Causes of Abdominal Pain in Women

Abdominal pain is a common complaint among women, and it can be caused by various gynaecological disorders. To diagnose these disorders, a bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning should be performed in addition to routine diagnostic workup. If diagnostic doubt persists, a laparoscopy can be used to assess suspected tubulo-ovarian pathology.

There are several differential diagnoses of abdominal pain in females, including mittelschmerz, endometriosis, ovarian torsion, ectopic gestation, and pelvic inflammatory disease. Mittelschmerz is characterized by mid-cycle pain that usually settles over 24-48 hours. Endometriosis is a complex disease that may result in pelvic adhesion formation with episodes of intermittent small bowel obstruction. Ovarian torsion is usually sudden onset of deep-seated colicky abdominal pain associated with vomiting and distress. Ectopic gestation presents as an emergency with evidence of rupture or impending rupture. Pelvic inflammatory disease is characterized by bilateral lower abdominal pain associated with vaginal discharge and dysuria.

Each of these disorders requires specific investigations and treatments. For example, endometriosis is usually managed medically, but complex disease may require surgery and some patients may even require formal colonic and rectal resections if these areas are involved. Ovarian torsion is usually diagnosed and treated with laparoscopy. Ectopic gestation requires a salpingectomy if the patient is haemodynamically unstable. Pelvic inflammatory disease is usually managed medically with antibiotics.

Fitz-Hugh-Curtis syndrome is characterized by hepatic adhesions, which are not present in any of the other options. Therefore, the diagnosis is based on the presence of lesions rather than just the symptoms described. This syndrome is a complication of PID that causes inflammation of the liver capsule, known as Glisson’s Capsule.

Gynaecological Causes of Abdominal Pain in Women

Abdominal pain is a common complaint among women, and it can be caused by various gynaecological disorders. To diagnose these disorders, a bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning should be performed in addition to routine diagnostic workup. If diagnostic doubt persists, a laparoscopy can be used to assess suspected tubulo-ovarian pathology.

There are several differential diagnoses of abdominal pain in females, including mittelschmerz, endometriosis, ovarian torsion, ectopic gestation, and pelvic inflammatory disease. Mittelschmerz is characterized by mid-cycle pain that usually settles over 24-48 hours. Endometriosis is a complex disease that may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction. Ovarian torsion is usually sudden onset of deep-seated colicky abdominal pain associated with vomiting and distress. Ectopic gestation presents as an emergency with evidence of rupture or impending rupture. Pelvic inflammatory disease is characterized by bilateral lower abdominal pain associated with vaginal discharge and dysuria.

Each of these disorders requires specific investigations and treatments. For example, endometriosis is usually managed medically, but complex disease may require surgery and some patients may even require formal colonic and rectal resections if these areas are involved. Ovarian torsion is usually diagnosed and treated with laparoscopy. Ectopic gestation requires a salpingectomy if the patient is haemodynamically unstable. Pelvic inflammatory disease is usually managed medically with antibiotics.

Endometriosis is characterized by pelvic pain, dysmenorrhoea, dyspareunia, and subfertility. The symptoms experienced by the patient in this case suggest the presence of intra-pelvic pathology, including a retroverted uterus and age-related factors. Chlamydia infection is often asymptomatic and does not typically cause dysmenorrhoea, although dyspareunia may occur. Lower abdominal pain may be caused by ovarian cysts, while ectopic pregnancy is associated with amenorrhoea and lower abdominal pain.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

Pelvic inflammatory disease is primarily caused by Chlamydia trachomatis.

Understanding Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a condition that occurs when the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. The most common cause of PID is an ascending infection from the endocervix, often caused by Chlamydia trachomatis. Other causative organisms include Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and gonorrhoeae. However, these tests are often negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves a combination of antibiotics, such as oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis. PID can also lead to infertility, with the risk as high as 10-20% after a single episode, chronic pelvic pain, and ectopic pregnancy. In mild cases of PID, intrauterine contraceptive devices may be left in, but recent guidelines suggest that removal of the IUD should be considered for better short-term clinical outcomes. Understanding PID and its potential complications is crucial for early diagnosis and effective management.

The definition of menorrhagia has been updated to focus on a woman’s personal experience rather than attempting to measure the amount of blood loss. Previously, heavy bleeding was defined as a total blood loss of over 80 ml during the menstrual cycle. However, due to challenges in accurately measuring blood loss and the fact that treatment for heavy bleeding can improve quality of life regardless of the amount of blood lost, the definition has shifted to a more subjective approach.

Understanding Menorrhagia: Causes and Definition

Menorrhagia is a condition characterized by heavy menstrual bleeding. While it was previously defined as total blood loss exceeding 80 ml per menstrual cycle, the assessment and management of the condition now focuses on the woman’s perception of excessive bleeding and its impact on her quality of life. Dysfunctional uterine bleeding, which occurs in the absence of underlying pathology, is the most common cause of menorrhagia, accounting for about half of all cases. Anovulatory cycles, uterine fibroids, hypothyroidism, pelvic inflammatory disease, and bleeding disorders such as von Willebrand disease are other potential causes of menorrhagia. It is important to note that the use of intrauterine devices, specifically copper coils, may also contribute to heavy menstrual bleeding. However, the intrauterine system (Mirena) is a treatment option for menorrhagia.

The correct course of action for an individual who tests positive for high-risk human papillomavirus (hrHPV) but receives a negative cytology report during routine primary HPV screening is to repeat the HPV test after 12 months. If the HPV test is negative at this point, the individual can return to routine recall. However, if the individual remains hrHPV positive and cytology negative, another HPV test should be conducted after a further 12 months. If the individual is still hrHPV positive after 24 months, they should be referred to colposcopy. It is incorrect to repeat the cervical smear in 3 months, wait 3 years for a repeat smear, or refer the individual to colposcopy without abnormal cytology.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

According to the BNF, the copper intra-uterine device is the most efficient option for emergency contraception and should be offered to all eligible women seeking such services. Unlike other medications, its effectiveness is not influenced by BMI. Additionally, it provides long-term contraception, which is an added advantage for the patient. If the copper intra-uterine device is not appropriate or acceptable to the patient, oral hormonal emergency contraception should be offered. However, the effectiveness of these contraceptives is reduced in patients with a high BMI. A double dose of levonorgestrel is recommended for patients with a BMI of over 26 kg/m² or body weight greater than 70kg. It is unclear which of the two oral hormonal contraceptives is more effective for patients with a raised BMI. The levonorgestrel intrauterine system and ethinylestradiol with levonorgestrel are not suitable for emergency contraception. In conclusion, the copper intrauterine device is the most effective method for this patient because it is not affected by BMI, unlike oral hormonal emergency contraceptives.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

Smoking doubles the risk of cervical cancer in women compared to non-smokers. Other risk factors include increased parity, use of oral contraceptives, early first intercourse, and HPV vaccination does not eliminate the need for cervical screening.

Understanding Cervical Cancer: Risk Factors and Mechanism of HPV

Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.

The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.

The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.

Importance of Pregnancy Test in Women with Acute Abdominal Pain

When a young woman presents with an acute abdomen and pain in the left iliac fossa, it is important to consider the possibility of an ectopic pregnancy, even if there is a lack of menstrual history. Therefore, the most appropriate investigation would be a urinary beta-hCG, which is a pregnancy test. It is crucial to rule out a potentially life-threatening ectopic pregnancy as the first line of investigation for any woman of childbearing age who presents with acute onset abdominal pain.

In summary, a pregnancy test should be performed in women with acute abdominal pain to rule out an ectopic pregnancy, which can be life-threatening if left untreated. This simple and quick test can provide valuable information for prompt and appropriate management of the patient.

The likelihood of cervical ectropion is higher in individuals who take the COCP due to increased levels of oestrogen. Based on the patient’s medical history and examination results, cervical ectropion appears to be the most probable diagnosis. This condition is more prevalent during puberty, pregnancy, and while taking the pill. Endometrial cancer is improbable in a young person, and the presence of cervical ectropion on examination supports this straightforward diagnosis. Although chlamydia infection can cause cervicitis, the patient’s sexual history does not suggest this diagnosis, and the pill remains the most likely cause. It is recommended to undergo STI screenings annually.

Understanding Cervical Ectropion

Cervical ectropion is a condition that occurs when the columnar epithelium of the cervical canal extends onto the ectocervix, where the stratified squamous epithelium is located. This happens due to elevated levels of estrogen, which can occur during the ovulatory phase, pregnancy, or with the use of combined oral contraceptive pills. The term cervical erosion is no longer commonly used to describe this condition.

Cervical ectropion can cause symptoms such as vaginal discharge and post-coital bleeding. However, ablative treatments such as cold coagulation are only recommended for those experiencing troublesome symptoms. It is important to understand this condition and its symptoms in order to seek appropriate medical attention if necessary.

How the Copper IUD Affects Different Parts of Sperm

The copper IUD is a popular form of birth control that works by preventing fertilization. It does this by affecting different parts of the sperm. The Golgi apparatus, which contributes to the acrosome of the sperm, is inhibited by the IUD, preventing capacitation. The mitochondria, which form the middle piece of the sperm, are not affected. The nucleus is also unaffected. Sperm do not have cell walls, so this is not a factor. Finally, the centrioles contribute to the flagellum of the sperm, but the copper IUD does not target this part of the sperm. Understanding how the copper IUD affects different parts of the sperm can help individuals make informed decisions about their birth control options.

When a teenage girl experiences regular painful cycles but has not yet started menstruating, an imperforate hymen is a likely cause. This condition blocks the flow of menstrual blood, leading to primary amenorrhoea while allowing for normal development of secondary sexual characteristics like pubic hair and breast growth. The accumulation of menstrual blood in the vagina can cause discomfort and bloating due to pressure. Other potential causes of amenorrhoea include chemotherapy during childhood, Turner’s syndrome, and polycystic ovary syndrome, which can all interfere with the production of estrogen and the development of secondary sexual characteristics.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls without secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

Causes and Precipitants of Urge Incontinence: A Brief Overview

Urge incontinence, characterized by involuntary leakage of urine associated with or following urgency, is a common condition in women. It is caused by overactivity of the detrusor muscle in the bladder wall, leading to irregular contractions during the filling phase and subsequent leakage of urine. While there are many causes and precipitants of urge incontinence, it is often difficult to identify a single factor in the presence of multiple contributing factors.

Some of the common causes of urge incontinence include poorly controlled diabetes, excess caffeine and alcohol intake, neurological dysfunction, urinary infection or faecal impaction, and adverse medication effects. In the case of a patient presenting with a short history of symptoms, urinary tract infection is the most likely cause, and prompt treatment is necessary to prevent complications.

It is important to rule out developing cauda equina, a medical emergency that can lead to paralysis, in patients presenting with short-term urinary incontinence. Normal anal tone and perineal sensation can help exclude this condition.

Excess alcohol and caffeine intake can precipitate symptoms of urge incontinence by inducing diuresis, causing frequency and polyuria. Chronic constipation, particularly in patients with diverticular disease, can also compress the bladder and lead to urge incontinence symptoms. Systemic illnesses such as diabetes mellitus can cause glycosuria and polyuria, leading to bladder irritation and detrusor instability. Finally, oestrogen deficiency associated with postmenopausal status can cause vaginitis and urethritis, both of which can precipitate urge incontinence symptoms.

In conclusion, urge incontinence is a complex condition with multiple contributing factors. Identifying and addressing these factors can help manage symptoms and improve quality of life for affected patients.

If a woman is 55 years old or older and experiences postmenopausal bleeding (which occurs after 12 months of no menstruation), she should be referred for further evaluation within 2 weeks using the suspected cancer pathway to rule out endometrial cancer.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

Hormone Replacement Therapy (HRT) Options for Women with a History of DVT

Women with a history of deep vein thrombosis (DVT) need to be cautious when considering Hormone Replacement Therapy (HRT) options. Here are some options:

1. Transdermal Combined HRT Patches: This option is the best as it bypasses the enterohepatic circulation, reducing the effect on the hepatic clotting system.

2. Oral Continuous Combined HRT: This option is only suitable for postmenopausal women who have not had a period for over a year.

3. Oral Sequential Combined HRT: This option is suitable for perimenopausal women who are still having periods. However, oral preparations increase the risk of clots, compared to transdermal preparations.

4. Raloxifene: This is a selective oestrogen receptor modulator (SERM) that reduces osteoporosis in postmenopausal women. It has effects on lipids and bone but does not stimulate the endometrium or breast.

5. Tibolone: This synthetic steroid has oestrogenic, progestational, and androgenic properties. It is only suitable for postmenopausal women who had their last period more than a year ago.

In conclusion, women with a history of DVT should consult their healthcare provider before starting any HRT option. Transdermal combined HRT patches may be the safest option for these women.

Ectopic Pregnancy: A Gynaecological Emergency

Ectopic pregnancy is a serious condition that requires immediate medical attention. It occurs when a fertilized egg implants outside the uterus, usually in the fallopian tube. This can lead to life-threatening complications if left untreated. Risk factors for ectopic pregnancy include a history of pelvic inflammatory disease (PID), previous terminations, and a positive pregnancy test.

Understanding the Different Types of Urinary Incontinence in Women

Urinary incontinence is a common condition that affects many women. There are different types of urinary incontinence, each with its own causes and treatment options. The most common type of incontinence in women is genuine stress incontinence, which is caused by sphincter incompetence and leads to leakage of small amounts of urine on stress, such as sneezing, standing, laughing, and coughing.

To diagnose incontinence, common investigations include a midstream urine specimen, frequency volume chart, filling urodynamic assessment, and voiding urodynamic assessment. Treatment options vary depending on the patient’s wishes, desire for future children, and severity of symptoms. Conservative treatment involves pelvic floor exercises, vaginal cones, and drugs such as estrogen. Surgery is the most effective way of restoring continence, with a cure rate of 80-90%. Procedures include burch colposuspension, anterior repair and bladder buttress, tension-free vaginal tape, and suburethral sling.

Other types of urinary incontinence in women include fistula, which is a rare cause of incontinence caused by pelvic surgery, overactive bladder, which is the second most common type of incontinence, retention with overflow, which is a rare cause of incontinence more common in men, and congenital abnormalities, which is a rare cause of incontinence that is often apparent since early life.

It is important for women to understand the different types of urinary incontinence and seek medical advice if they experience any symptoms. With proper diagnosis and treatment, urinary incontinence can be effectively managed, improving quality of life and overall health.

The combined oral contraceptive pill (COCP) has been found to have a slight increase in the risk of breast cancer, but this risk returns to normal after 10 years of stopping the pill. Additionally, the COCP may increase the risk of cervical cancer, but this could be due to a lack of barrier contraception use and increased exposure to HPV. While the COCP is associated with an increased risk of benign and malignant tumors, there is no evidence of an increased risk of lung cancer. On the other hand, the COCP has been shown to reduce the risk of ovarian cancer, endometrial cancer, and bowel cancer.

Pros and Cons of the Combined Oral Contraceptive Pill

The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than 1 per 100 woman years. It does not interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.

However, there are also some disadvantages to the combined oral contraceptive pill. One of the main issues is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side-effects such as headache, nausea, and breast tenderness may also be experienced.

It is important to weigh the pros and cons of the combined oral contraceptive pill before deciding if it is the right method of birth control for you. While some users report weight gain while taking the pill, a Cochrane review did not support a causal relationship. Overall, the combined oral contraceptive pill can be an effective and convenient method of birth control, but it is important to discuss any concerns or potential risks with a healthcare provider.

The GMC has issued new guidance stating that all instances of female genital mutilation (FGM) must be reported to the police if the victim is under 18 years old. Failure to do so could result in a breach of GMC guidelines and put a doctor’s registration at risk. However, this mandatory duty does not apply to victims over 18 years old, or if another doctor has already reported the same act of FGM to the police. It is not recommended to involve the patient’s family in discussions about FGM, as this may cause further distress. Instead, doctors should focus on making a police report and may also need to contact child protection services. Referring the patient to secondary care for treatment of FGM symptoms may be helpful, but a police report must still be made.

Understanding Female Genital Mutilation

Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

During laparoscopy, carbon dioxide gas is used to inflate the abdomen for better visibility and access to abdominal organs. However, after surgery, the remaining gas can cause referred pain in the C3-5 nerve distribution by pressing on the diaphragm. While pulmonary embolus is a potential side effect of any surgery, it is unlikely in a young patient who is not immobilized for long periods. Incontinence is also unlikely in a young, nulliparous woman, even with the risk of urinary tract infection from the catheter used during surgery. Flatulence is not a common side effect as the gas is not passed into the colon. Finally, sciatic nerve damage is not a concern during abdominal surgery as it is a common side effect of hip arthroplasty, which involves a posterior approach to the hip.

Common Causes of Abdominal Mass in Women

One of the common symptoms that women may experience is an abdominal mass that is painful on palpation. This can be caused by various conditions, including ovarian serous cystadenomas, polycystic ovarian syndrome, fibroids, cystocele, and rectocele.

Ovarian serous cystadenomas are benign tumors composed of cysts suspended within fibrotic stroma. They are usually asymptomatic but can cause pain and mass symptoms when they grow to a size greater than 10 cm. These tumors are prone to torsion and can present as an acute abdomen. Removal of the mass is curative, and histological examination is essential to ensure there are no malignant features.

Polycystic ovarian syndrome is associated with irregular periods, skin acne, and weight gain. Fibroids, on the other hand, are hormone-driven and can cause menorrhagia, dysmenorrhea, constipation, and urinary symptoms. Subserosal, pedunculated, or ovarian fibroids can also present as an abdominal mass.

Cystocele and rectocele are conditions that present with a lump or dragging sensation in the vagina. Cystocele is associated with urinary frequency, incontinence, and frequent urinary tract infections, while rectocele is associated with incomplete emptying following a bowel motion and pressure in the lower pelvis.

In conclusion, an abdominal mass in women can be caused by various conditions, and it is important to seek medical attention for proper diagnosis and treatment.

If analgesia is ineffective in treating endometriosis, the first-line option to try is the combined oral contraceptive pill or a progesterone.

The patient’s chronic cyclical pelvic pain, dyspareunia, secondary dysmenorrhoea, and pain with bowel movements are consistent with endometriosis. The examination findings also support this diagnosis. Paracetamol with or without an NSAID (such as mefenamic acid or ibuprofen) is the initial treatment for endometriosis. If these medications do not work, hormonal therapy (such as the combined oral contraceptive pill or medroxyprogesterone acetate) is the second-line option.

Since the patient plans to start a family within the next year, the combined oral contraceptive pill is the more appropriate choice as it does not delay fertility. Medroxyprogesterone acetate, also known as Depo Provera, provides contraception for up to 12 weeks but can delay fertility for up to 12 months and is irreversible once given. Additionally, the patient’s BMI of 34 kg/m² is a known risk factor for weight gain, which is a potential side effect of the injectable contraceptive.

Offering mefenamic acid is not recommended as analgesia has already been tried without success. If analgesia is ineffective in treating endometriosis, the combined oral contraceptive pill or a progesterone should be considered.

Referring the patient for consideration of GnRH analogue is not appropriate at this stage. This option is only considered if hormonal therapy is ineffective. It is important to trial the combined oral contraceptive pill before considering a referral.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

Treatment and Management of Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a serious condition resulting from an ascending sexually transmitted infection, commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Patients with PID may present with symptoms such as chronic lower abdominal pain, dyspareunia, irregular bleeding, dysmenorrhoea, and purulent vaginal discharge. It is important to identify and treat PID promptly, as it can lead to complications such as infertility, ectopic pregnancy, and pelvic adhesion formation.

The management of PID depends on the severity of the presentation. Patients who are haemodynamically stable can be treated in the primary care setting with a single dose of ceftriaxone IM, followed by metronidazole and doxycycline for 14 days. However, patients with pyrexia, nausea and vomiting, or suspicion of a tubo-ovarian abscess or pelvic peritonitis should be admitted to hospital for IV antibiotics.

It is important to note that NICE recommends treating patients who are likely to have PID without waiting for swab results. In patients considered high-risk for gonococcal infection, who have no indication for admission to hospital for parenteral antimicrobial treatment, a single dose of ceftriaxone 1 g IM, followed by 14 days of metronidazole and doxycycline is recommended. Ofloxacin, moxifloxacin, or azithromycin should be avoided in women at high risk of a gonococcal infection due to increased resistance against quinolones.

In conclusion, early identification and prompt treatment of PID is crucial to prevent complications. Treatment should be tailored to the severity of the presentation and the patient’s risk factors.

Postcoital Bleeding

Postcoital bleeding is a condition that occurs when there is trauma to superficial lesions within the vaginal tract. This can be caused by a variety of factors, including cervical trauma, cervical polyps, endometrial and cervical carcinoma, cervicitis, and vaginitis. In some cases, invasive cervical carcinoma may be found in those who are referred to the hospital, accounting for 3.8% of cases.

Vaginitis is also a possibility, but it is more common in elderly patients with low estrogen levels. On the other hand, salpingo-oophoritis, which is usually caused by pelvic inflammatory disease from sexually transmitted infections, typically presents with deep dyspareunia and purulent vaginal discharge. However, post-coital bleeding is highly unlikely to be caused by salpingo-oophoritis.

If a patient was assigned male at birth and is undergoing treatment with oestradiol, GNRH analogs, finasteride or cyproterone, there may be a decrease or cessation of sperm production. However, this cannot be considered a reliable method of contraception. In the case of a trans female patient, who was assigned male at birth, hormonal treatments cannot be relied upon for contraception. There is a possibility of her female partner becoming pregnant, and therefore, barrier methods are recommended. Hormonal contraceptives are not suitable for this patient, and the copper IUD is not an option as she does not have a uterus.

Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies.

For individuals engaging in vaginal sex where there may be a risk of pregnancy and/or sexually transmitted infections, condoms and dental dams are recommended. Cervical screening and human papillomavirus vaccinations should also be offered to sexually active individuals with a uterus. Those engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations. Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.

For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy. Testosterone therapy does not provide protection against pregnancy, and oestrogen-containing regimes are not recommended in patients undergoing testosterone therapy. Progesterone-only contraceptives are considered safe, and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding.

In patients assigned male at birth, there may be a reduction or cessation of sperm production with certain therapies, but the variability of effects means they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients engaging in vaginal sex wishing to avoid the risk of pregnancy. Emergency contraception may be required in patients assigned female at birth following unprotected vaginal intercourse, and either of the available oral emergency contraceptive options may be considered. The non-hormonal intrauterine device may also be an option, but it may have unacceptable side effects in some patients.

Overall, the guidance stresses the importance of individualized care and communication in contraceptive and sexual health decisions for transgender and non-binary individuals.

If a woman of reproductive age has been having unprotected vaginal sexual intercourse for a year without conceiving and there is no known cause of infertility, NICE guidance recommends that she and her partner undergo further clinical assessment and investigation. The most appropriate initial investigation for this patient is a day 21 progesterone test, which is non-invasive and can determine if the patient is ovulating. Serum prolactin and thyroid function tests are not recommended unless there is a specific reason for testing, such as a pituitary tumor or overt thyroid disease. Transvaginal or abdominal ultrasounds are unlikely to reveal the cause of subfertility and are therefore not necessary. As part of the initial assessment, the male partner should also undergo a semen analysis.

Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.

Understanding Different Stages of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a common condition among women, especially those who have given birth or gone through menopause. It occurs when the pelvic organs, such as the uterus, bladder, or rectum, descend from their normal position and bulge into the vaginal canal. The severity of POP is classified into four stages based on the distance of the prolapse from the hymen.

Stage 1 prolapse is the mildest form, where the cervix descends more than 1 cm above the hymen. Stage 2 prolapse is when the most distal prolapse is between 1 cm above and 1 cm below the level of the hymen. Stage 3 prolapse is when the prolapse extends more than 1 cm below the hymen but not completely outside the vaginal opening. Finally, stage 4 prolapse is the most severe form, where there is complete eversion of the vagina.

Another type of POP is called enterocoele or enterocele, which occurs when the small intestine descends into the lower pelvic cavity and pushes into the upper vaginal wall. This can cause discomfort, pain, and difficulty with bowel movements.

In rare cases, a condition called procidentia can occur, where the uterus and cervix protrude from the introitus, resulting in thickened vaginal mucous and ulceration. This is a severe form of POP that requires immediate medical attention.

It is important for women to be aware of the different stages of POP and seek medical advice if they experience any symptoms, such as pelvic pressure, discomfort, or difficulty with urination or bowel movements. Treatment options may include pelvic floor exercises, pessaries, or surgery, depending on the severity of the prolapse.

The most common reason for delayed puberty in women is constitutional delay, which is a normal variation where puberty starts later than usual. This may be due to a family history of late menarche. However, it is important to refer the patient to a specialist for further investigation. Hypogonadotrophic hypogonadism is another cause, which is a result of a deficiency in gonadotrophin-releasing hormone secretion. This can be managed by restoring weight in cases such as athletes, dancers, or anorexia sufferers. Primary gonadal failure is rare and may occur in isolation or as part of chromosomal anomalies. Hormone replacement therapy is the treatment for this condition. Hyperprolactinaemia is a rare cause of primary amenorrhoea, which is caused by high levels of prolactin from a tumour. However, it is unlikely to affect normal development. Hypothyroidism can also cause amenorrhoea, but it is usually accompanied by other symptoms such as cold intolerance, mood changes, and weight gain.

Understanding Mittelschmerz: Mid-Cycle Pain in Women

Mittelschmerz, which translates to middle pain in German, is a common experience for approximately 20% of women during mid-cycle. This pain or discomfort occurs when the membrane covering the ovary stretches to release the egg, resulting in pressure and pain. While the amount of pain varies from person to person, some may experience intense pain that can last for days. In severe cases, the pain may be mistaken for appendicitis.

However, other conditions such as acute appendicitis, ruptured ectopic pregnancy, incarcerated hernia, and pelvic inflammatory disease should also be considered and ruled out through physical examination and investigations. It is important to note that a ruptured ectopic pregnancy is a medical emergency and can present with profuse internal bleeding and hypovolaemic shock.

In this case, the patient’s physical examination and investigations suggest recent ovulation and fluid in the pouch of Douglas, making Mittelschmerz the most likely diagnosis. It is important for women to understand and recognize this common experience to differentiate it from other potential conditions.

Stages of Endometrial Carcinoma: TNM Classification Explained

Endometrial carcinoma is a type of cancer that affects the lining of the uterus. The TNM classification system is used to describe the extent of the cancer and guide treatment decisions. Here are some common stages of endometrial carcinoma:

T3a N0 M0: This stage describes endometrial carcinoma that involves the uterine serosa or adnexae, but has not spread to lymph nodes or other organs.

T3b N0 M0: This stage describes endometrial carcinoma that involves the vagina or parametrial tissues, but has not spread to lymph nodes or other organs.

T1a N0 M0: This stage describes endometrial carcinoma that is confined to the endometrium or has invaded less than half of the myometrium, without lymph node or distal metastases.

T1b N0 M0: This stage describes endometrial carcinoma that is confined to the uterus but has invaded more than half of the myometrium, without lymph node or distal metastases.

T2 N0 M0: This stage describes endometrial carcinoma that involves the cervix but has not spread beyond the uterus, without lymph node or distal metastases.

Understanding the stage of endometrial carcinoma is important for determining the best treatment options and predicting outcomes.

Due to a weakened immune response and reduced clearance of the human papillomavirus, women who are HIV positive face an elevated risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer. If HIV positive women have low-grade lesions (CIN1), these lesions may not clear and could progress to high-grade CIN or cervical cancer. Even with effective antiretroviral treatment, these women still have a high risk of abnormal cytology and an increased risk of false-negative results. Therefore, it is recommended that women with HIV receive cervical cytology at the time of diagnosis and annually thereafter for screening purposes.

Understanding Cervical Cancer: Risk Factors and Mechanism of HPV

Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.

The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.

The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.

Treatment Options for Menopausal Symptoms in Breast Cancer Patients

Breast cancer patients experiencing mood disturbance, anxiety, and depression related to menopausal symptoms can benefit from cognitive behavioural therapy (CBT) and lifestyle modifications. A 2-week trial of fluoxetine may be an option, but it is contraindicated in patients receiving tamoxifen therapy. Combined cyclic hormonal replacement therapy (HRT) is not routinely offered due to the increased risk of breast cancer recurrence, but can be prescribed in exceptional circumstances. Over-the-counter herbal products like black cohosh are not recommended due to safety concerns and potential interactions with medications. Lifestyle changes such as reducing caffeine and alcohol consumption, using a handheld fan, and regular exercise can also help alleviate symptoms.

The addition of progesterone to hormone replacement therapy (HRT) has been linked to an increased risk of breast cancer, as well as venous thromboembolism and cardiovascular disease. HRT may be recommended for menopausal patients experiencing vasomotor symptoms such as hot flashes, night sweats, and palpitations. However, if a patient only presents with urogenital symptoms, topical oestrogens such as oestradiol creams or pessaries may be more appropriate. These act locally to alleviate vaginal dryness, reduce UTI recurrence, and ease dyspareunia. For patients with vasomotor symptoms, HRT preparations with systemic effects (such as oral medications, topical patches, and implants) may be considered. If the patient has not undergone a hysterectomy, their HRT regime must include both oestrogen and progesterone to prevent hypertrophy of the uterus and a 5-10x increased risk of endometrial carcinoma associated with unopposed oestrogen therapy.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

The patient is likely suffering from endometriosis, which is the presence of endometrial tissue outside of the uterus. This condition can cause subfertility, chronic pelvic pain, dysmenorrhoea, and dyspareunia. It may also lead to an increase in serum CA-125 levels and the development of ovarian deposits known as chocolate cysts. Acute appendicitis and ovarian neoplasms are unlikely causes of the patient’s symptoms, while mittelschmerz only causes mid-cycle pain and does not explain the elevated CA-125 levels. Granulosa cell tumors of the ovary typically secrete inhibin and estrogen, making endometriosis a more likely diagnosis. Symptoms of ovarian cancer are often vague and include abdominal discomfort, bloating, back and pelvic pain, irregular menstruation, loss of appetite, fatigue, and weight loss. Risk factors for ovarian cancer include not having children, early first menstruation and last menopause, hormone replacement therapy, endometriosis, and the BRCA genes. In this age group, germ cell tumors are the most likely ovarian carcinoma.

Types of Epithelial Cells in the Female Reproductive System

The female reproductive system is composed of various types of epithelial cells that serve different functions. Here are some of the most common types of epithelial cells found in the female reproductive system:

1. Simple columnar cells – These cells are found in the endometrial lining and have a pseudostratified columnar appearance. They are often associated with endometrial carcinoma.

2. Glycogen-containing stratified squamous cells – These cells are found in the vagina and are responsible for producing glycogen, which helps maintain a healthy vaginal pH.

3. Cuboidal cells – These cells are found in the ovary and are responsible for producing and releasing eggs.

4. Stratified squamous cells – These cells are found in the cervix and provide protection against infections.

5. Columnar ciliated cells – These cells are located in the Fallopian tubes and are responsible for moving the egg from the ovary to the uterus.

Understanding the different types of epithelial cells in the female reproductive system can help in the diagnosis and treatment of various reproductive disorders.

Even if a child is Gillick competent, they are still unable to consent to sexual intercourse if they are under the age of 13. Therefore, any interaction with this age group should prompt child protection measures to be taken. Simply prescribing medication or ignoring the situation would not be in compliance with this protocol.

When it comes to providing contraception to young people, there are legal and ethical considerations to take into account. In the UK, the age of consent for sexual activity is 16 years, but practitioners may still offer advice and contraception to young people they deem competent. The Fraser Guidelines are often used to assess a young person’s competence. Children under the age of 13 are considered unable to consent to sexual intercourse, and consultations regarding this age group should trigger child protection measures automatically.

It’s important to advise young people to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. Long-acting reversible contraceptive methods (LARCs) are often the best choice for young people, as they may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.

When a woman experiences postmenopausal bleeding (PMB), the primary concern is the possibility of endometrial cancer. This is because endometrial adenocarcinoma is strongly linked to PMB and early detection is crucial for better prognosis. The patient in this scenario has two risk factors for endometrial adenocarcinoma – obesity and hypertension. Other risk factors include high levels of oestrogen, late menopause, polycystic ovarian syndrome, diabetes mellitus, and tamoxifen use.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

The topic of primary amenorrhoea is being discussed, where the patient is experiencing cyclical pain but has not had any evidence of menstruation. This eliminates certain possibilities such as mullerian agenesis and constitutional delay, which are typically painless. Turner syndrome is also unlikely as it is often accompanied by distinct physical features and health issues. Pregnancy cannot be ruled out entirely, but it is improbable given the patient’s lack of menarche and cyclical pain. Therefore, imperforate hymen is the most probable diagnosis.

Amenorrhoea refers to the absence of menstruation, which can be primary (when menarche has never occurred) or secondary (when the patient has not had periods for more than six months despite having had them in the past). Primary amenorrhoea is diagnosed if the patient has not had a period by the age of 14 without any secondary sexual characteristics, or over the age of 16 if such characteristics are present. The causes of primary amenorrhoea can include constitutional delay (when the patient is a late bloomer but has secondary sexual characteristics) or anatomical issues such as mullerian agenesis (where the patient has varying degrees of absence of female sexual organs despite developing secondary sexual characteristics).

Common Causes of Delayed Puberty

Delayed puberty is a condition where the onset of puberty is later than the normal age range. This can be caused by various factors such as genetic disorders, hormonal imbalances, and chronic illnesses. Delayed puberty with short stature is often associated with Turner’s syndrome, Prader-Willi syndrome, and Noonan’s syndrome. These conditions affect the growth and development of the body, resulting in a shorter stature.

On the other hand, delayed puberty with normal stature can be caused by polycystic ovarian syndrome, androgen insensitivity, Kallmann syndrome, and Klinefelter’s syndrome. These conditions affect the production and regulation of hormones, which can lead to delayed puberty.

It is important to note that delayed puberty does not necessarily mean there is a serious underlying condition. However, it is recommended to consult a healthcare professional if there are concerns about delayed puberty. Treatment options may include hormone therapy or addressing any underlying medical conditions.

In summary, delayed puberty can be caused by various factors and can be associated with different genetic disorders. It is important to seek medical advice if there are concerns about delayed puberty.

On ultrasound imaging, the presence of a whirlpool sign and free fluid may indicate ovarian torsion. This sign occurs when a structure twists upon itself. It is important to note that appendicitis and ectopic pregnancy do not show this sign on imaging. Additionally, the pain associated with Mittelschmerz is typically less severe and would not be accompanied by the ultrasound finding.

Understanding Ovarian Torsion

Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.

When experiencing atrophic vaginitis, the dryness of the vaginal mucosa can cause pain, itching, and dyspareunia. The first-line treatment for this condition is topical oestrogen cream, which helps to restore the vaginal mucosa. However, lubricants and moisturisers can also provide short-term relief while waiting for the topical oestrogen cream to take effect. Oestrogen secreting pessaries are an alternative to topical oestrogen cream, but using them together would result in an excessive dose of oestrogen. Sitz baths are useful for irritation and itching of the perineum, but they do not address internal vaginal symptoms. Warm or cold compresses may provide temporary relief, but they are not a long-term solution.

Atrophic vaginitis is a condition that commonly affects women who have gone through menopause. Its symptoms include vaginal dryness, pain during sexual intercourse, and occasional spotting. Upon examination, the vagina may appear dry and pale. The recommended treatment for this condition is the use of vaginal lubricants and moisturizers. If these do not provide relief, a topical estrogen cream may be prescribed.

Types of Urinary Incontinence and Their Causes

Urinary incontinence is a common condition that affects many people, particularly women. There are different types of urinary incontinence, each with its own causes and management options.

Stress incontinence is the most common form of urinary incontinence in women. It occurs when there is either loss of muscle tension of the pelvic floor muscles or damage to the urethral sphincter, leading to leakage of urine with stress. Risk factors include vaginal delivery, obesity, previous pelvic surgery, increasing age, family history, and use of certain medications.

Functional incontinence occurs when one cannot make it to the toilet in time due to physical or environmental problems. This is not applicable to the patient in the scenario.

Overflow incontinence occurs in the presence of a physical obstruction to bladder outflow, which may be caused by a pelvic tumour, faecal impaction, or prostatic hyperplasia. The patient in the scenario has no known obstructive pathology.

True incontinence is a rare form of urinary incontinence and is associated with the formation of a fistula between the bladder or the ureter and the vagina, resulting in leakage of urine through the vagina. It is associated with cases of trauma following surgery or the presence of a pelvic cancer that has invaded through the wall resulting in damage to adjacent organs.

Urge incontinence is the second most common form of urinary incontinence in women. It is defined as urinary leakage that is preceded by a strong desire to pass urine, a symptom referred to as urgency. It can be the result of detrusor instability or an overactive bladder. Management options include lifestyle modifications, bladder training, medications, and referral to secondary care for more advanced options.

Patients experiencing secondary dysmenorrhoea should be referred to gynaecology for further investigation as it is often associated with underlying pathologies such as endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease. While the combined oral contraceptive pill may provide relief, it is important to determine the root cause first. Fluoxetine is not appropriate for managing secondary dysmenorrhoea, as it is used for premenstrual dysphoric disorder. Intra-uterine devices may actually cause secondary dysmenorrhoea and should not be used. Tranexamic acid is not indicated for the management of secondary dysmenorrhoea, but rather for menorrhagia.

Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

Treatment Options for Stress Urinary Incontinence

Stress urinary incontinence is a common condition in women, especially those who have had vaginal deliveries and are getting older. It is caused by weak sphincter muscles, leading to leakage during activities such as coughing, sneezing, laughing, or exercising. The first-line treatment for this condition is pelvic floor muscle training, which involves a minimum of eight contractions three times per day for 12 weeks.

However, it is important to note that other treatment options, such as oxybutynin, pelvic ultrasound scans, urodynamic studies, and bladder training, are not recommended for stress urinary incontinence. Oxybutynin is used for overactive bladder or mixed urinary incontinence, while pelvic ultrasound scans are not indicated for urinary incontinence. Urodynamic studies are not recommended for women with simple stress incontinence on history and examination, and bladder training is used for urgency or mixed urinary incontinence, not stress incontinence. Therefore, pelvic floor muscle training remains the most effective treatment option for stress urinary incontinence.

When choosing a contraceptive method, individual preferences and any cautions or contraindications must be taken into account. In this case, the priority is to find a method that won’t be affected by carbamazepine’s enzyme-inducing effect, such as the intrauterine system. While the combined oral contraceptive pill (COCP) could help with heavy bleeding, its failure rate would be high due to enzyme induction. Nexplanon may cause heavy bleeding and its low progesterone dose would also be affected by enzyme induction. Depo-Provera is an option, but prolonged use in young individuals could lead to reduced bone density. The Mirena intrauterine system would be effective in reducing heavy bleeding and providing reliable contraception alongside the anti-epileptic medication.

Contraception for Women with Epilepsy

Women with epilepsy need to consider several factors when choosing a contraceptive method. Firstly, they need to consider how the contraceptive may affect the effectiveness of their anti-epileptic medication. Secondly, they need to consider how their anti-epileptic medication may affect the effectiveness of the contraceptive. Lastly, they need to consider the potential teratogenic effects of their anti-epileptic medication if they become pregnant.

To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends that women with epilepsy consistently use condoms in addition to other forms of contraception. For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends the use of the COCP and POP as UKMEC 3, the implant as UKMEC 2, and the Depo-Provera, IUD, and IUS as UKMEC 1.

For women taking lamotrigine, the FSRH recommends the use of the COCP as UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS as UKMEC 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol. By considering these recommendations, women with epilepsy can make informed decisions about their contraceptive options and ensure the safety and effectiveness of their chosen method.

Management of Women after Treatment for Cervical Intra-epithelial Neoplasia

After treatment for cervical intra-epithelial neoplasia (CIN) at colposcopy, women undergo a repeat smear six months later to check for any residual disease. The management plan following this test of cure depends on the results.

HPV Test of Cure in Six Months, If Negative Recall in Three Years

If the test is negative for dyskaryosis and high-risk HPV (HR HPV), the woman is recalled in three years, regardless of her age. If the test remains negative at the three-year mark, she can return to routine screening based on her age group.

HPV Test of Cure in Six Months, If Negative Recall in Five Years

Even if the patient is 54 years old, women who have a negative HPV test of cure at six months are recalled for a smear three years later. If this is negative, she will then be returned to routine recall every five years.

HPV Test of Cure in Three Months, If Negative Recall in Five Years

The screening test should not be repeated at three months, as this is not enough time for the cervical tissue to heal. Reactive/healing changes in the cytological sample may give a false impression of dyskaryosis. Instead, a HPV test of cure is performed at six months, and if negative, the woman is recalled for routine screening every five years.

Refer Back to Routine Screening, Repeat in Three/Five Years

If the HPV test of cure is positive for HPV or there is evidence of moderate/severe dyskaryosis, the woman is referred back to colposcopy for further investigation. If the test is negative, she is referred back to routine screening and recalled in three or five years, depending on the scenario.

Treatment Options for Menorrhagia

Menorrhagia, or heavy menstrual bleeding, can be a distressing condition for women. Current guidelines recommend the use of Mirena (IUS) as the first line of treatment, even for women who do not require contraception. Patient preference is important in the decision-making process, but IUS is still the preferred option.

If IUS is not suitable or preferred, there are several other treatment options available. Tranexamic acid, a medication that prevents the breakdown of blood clots, is a second-line option. Non-steroidal anti-inflammatory drugs (NSAIDs) and combined oral contraceptive pills can also be used to prevent the proliferation of the endometrium.

If these options are not effective, oral or injected progestogens can be used to prevent endometrial proliferation. Gonadotrophin-releasing hormone (GnRH) agonists, such as Goserelin, are also available as a last resort.

It is important for women to discuss their options with their healthcare provider and choose the treatment that is best for them. With the variety of options available, there is likely a treatment that can effectively manage menorrhagia and improve quality of life.

Understanding Cervical Screening: Guidelines and Options

Cervical screening, also known as a smear test, is a vital tool in detecting precancerous cell changes in the cervix and preventing cervical cancer. Here are some important guidelines and options to keep in mind:

Age and Frequency: In the UK, women aged 25-64 are invited for screening, with those aged 25-49 screened every three years and those aged 50-64 screened every five years. In Scotland, screening is recommended every five years for women aged 25-65.

Hysterectomy: Women who have had a total hysterectomy (removal of the uterus and cervix) do not require cervical screening. However, those who have had a partial hysterectomy (removal of the uterus but not the cervix) should continue to be screened according to age guidelines.

Age Limit: Women over the age of 65 may still be eligible for screening if they have had recent abnormal results or have not been screened since the age of 50.

Opting Out: While cervical screening is not obligatory, it is highly recommended. Patients can opt out by speaking to their doctor and signing an ‘opting out’ form, but this decision can be reversed at any time. It is important to understand the benefits and risks associated with screening before making a decision.

After a termination of pregnancy, a urine pregnancy test can still show positive results for up to 4 weeks. However, if the test remains positive beyond this time frame, it could indicate an incomplete abortion or a persistent trophoblast, which requires further examination. Therefore, any other options suggesting otherwise are incorrect.

Termination of Pregnancy in the UK

The UK’s current abortion law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for termination from 28 weeks to 24 weeks gestation. To perform an abortion, two registered medical practitioners must sign a legal document, except in emergencies where only one is needed. The procedure must be carried out by a registered medical practitioner in an NHS hospital or licensed premise.

The method used to terminate a pregnancy depends on the gestation period. For pregnancies less than nine weeks, mifepristone (an anti-progesterone) is administered, followed by prostaglandins 48 hours later to stimulate uterine contractions. For pregnancies less than 13 weeks, surgical dilation and suction of uterine contents is used. For pregnancies more than 15 weeks, surgical dilation and evacuation of uterine contents or late medical abortion (inducing ‘mini-labour’) is used.

The 1967 Abortion Act outlines the circumstances under which a person shall not be guilty of an offence under the law relating to abortion. These include if two registered medical practitioners are of the opinion, formed in good faith, that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family. The limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is a risk of serious physical or mental injury to the woman.

Appropriate Treatment Options for Vaginal Infections

Bacterial vaginosis is a common vaginal infection that results in a decrease in lactobacilli and an increase in anaerobic bacteria. The typical symptoms include a white, milky, non-viscous discharge with a fishy odor and a pH greater than 4.5. The recommended treatment for bacterial vaginosis is metronidazole 400 mg twice a day for a week.

Azithromycin is the treatment of choice for Chlamydia, but it is not appropriate for bacterial vaginosis. acyclovir is used to treat herpes infections, which is not the cause of this patient’s symptoms. Fluconazole is a treatment option for vaginal candidiasis, but it is unlikely to be the cause of this patient’s symptoms. Pivmecillinam is used to treat urinary tract infections, which is not the cause of this patient’s symptoms.

In conclusion, the appropriate treatment for bacterial vaginosis is metronidazole, and other treatments should be considered based on the specific diagnosis.

The risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

Understanding Ectopic Pregnancy: The Pathophysiology

Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

If the 2nd repeat smear at 24 months shows a negative result for high-risk human papillomavirus (hrHPV), the patient can return to routine recall for cervical cancer screening. Since the patient is over 50 years old, a smear test should be taken every 5 years as part of routine recall. It is not necessary to perform a cytology swab or refer the patient to colposcopy as a negative HPV result does not indicate the presence of cervical cancer. Additionally, repeating the HPV test in 3 years is not necessary for this patient as it is only the routine recall protocol for patients aged 25-49.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.

Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.

When managing a miscarriage, medical treatment typically involves administering vaginal misoprostol alone. According to the NICE miscarriage Clinical Knowledge Summary, medical management is recommended if expectant management is not suitable or if a woman continues to experience symptoms after 14 days of expectant management. Misoprostol can be given orally or vaginally. If products of conception are not expelled after medical treatment or if symptoms persist after 14 days of expectant management, manual vacuum aspiration or surgical management may be considered. However, hospitalization and observation are not usually necessary unless the patient is experiencing hemodynamic instability. In most cases, women can take misoprostol and complete the miscarriage at home. Oral methotrexate is used for medical management of ectopic pregnancy.

Management Options for Miscarriage

Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.

Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.

Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.

It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.

Treatment Options for Primary Dysmenorrhoea: A Guide for Healthcare Professionals

Primary dysmenorrhoea is a common condition that affects many women of reproductive age. When treating this condition, healthcare professionals have several options to consider. Here, we will discuss the most common treatments and their appropriateness for different patients.

Paracetamol is a suitable first-line treatment for patients with primary dysmenorrhoea who cannot take NSAIDs. If the patient does not wish to conceive, a hormonal contraceptive may also be considered as a first-line treatment.

Gabapentin is not recommended for the treatment of dysmenorrhoea, as it is primarily used for epilepsy and neuropathic pain.

Mefenamic acid and naproxen are both NSAIDs and are recommended as first-line treatments for primary dysmenorrhoea. However, they are contraindicated in patients with a history of asthma triggered by NSAID use.

Oral morphine is not typically used as a first-line treatment for dysmenorrhoea. If NSAIDs and paracetamol are not effective, transelectrical nerve stimulation (TENS) may be trialled. If none of these treatments are effective within 3-6 months, the patient should be referred to a gynaecologist for further assessment.

In summary, healthcare professionals should consider the patient’s medical history and preferences when selecting a treatment for primary dysmenorrhoea. Paracetamol and hormonal contraceptives are suitable first-line treatments, while NSAIDs and TENS may also be effective in some patients. Referral to a specialist may be necessary if initial treatments are not effective.

Starting hormonal contraception immediately after using levonorgestrel emergency contraceptive pill is safe. However, if ulipristal was used, hormonal contraception should be started or restarted after 5 days, and barrier methods should be used during this time. Waiting for 7 or 30 days before starting hormonal contraception is unnecessary as levonorgestrel does not affect its efficacy. A pregnancy test is only recommended if the patient’s next period is more than 5-7 days late or lighter than usual, not routinely after taking levonorgestrel.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

If there is suspicion of ovarian cancer and an abdominal or pelvic mass is present, it is not necessary to perform a CA125 and US test. Instead, the patient should be immediately referred to gynaecology. Prescribing loperamide and buscopan for symptoms of irritable bowel syndrome in women over 50 years old is not appropriate as these symptoms could indicate ovarian cancer and require investigation. While waiting for the results of CA125 and ultrasound tests is usually recommended for suspected ovarian cancer patients, urgent referral to gynaecology is necessary in this case due to the presence of an abdominal mass. Although CA125 measurement should still be performed, waiting for test results to determine the need for urgent referral is not appropriate as guidelines already recommend it.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

Management of Menopausal Symptoms: Lifestyle Changes and Medication Options

Menopausal symptoms, such as hot flashes and mood disturbance, can significantly impact a woman’s quality of life. The first step in managing these symptoms should involve lifestyle changes, such as reducing caffeine and alcohol intake, regular exercise, and weight loss. If symptoms persist or worsen, medication options such as hormone replacement therapy (HRT) or selective serotonin reuptake inhibitors (SSRIs) can be considered.

Cognitive behavioral therapy (CBT) is also an option for women experiencing mood disturbance, anxiety, or depression. However, it is important to note that SSRIs should only be used for severe symptoms that have not improved with lifestyle changes. When starting SSRIs, patients should be reviewed after two weeks and then again after three months if symptoms have improved.

While over-the-counter herbal products like St John’s wort, isoflavones, and black cohosh have been associated with symptom improvement, their safety and efficacy are unknown. It is not recommended for doctors to suggest these products, and patients should be warned of potential risks and interactions with other medications.

Overall, the management of menopausal symptoms should involve a combination of lifestyle changes and medication options, with regular review of symptoms to ensure the best possible outcome for the patient.

Tranexamic acid is the recommended first-line non-hormonal treatment for menorrhagia, particularly for this patient who is trying to conceive. The contraceptive pill and IUS are not suitable options, and endometrial ablation is not recommended for those who wish to have children in the future. As the patient’s periods are painless, mefenamic acid is not necessary. Tranexamic acid is an anti-fibrinolytic that prevents heavy menstrual bleeding by inhibiting plasminogen activators. This treatment aligns with the guidelines set by NICE for managing heavy menstrual bleeding.

Managing Heavy Menstrual Bleeding

Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

[Insert flowchart here]

Pelvic inflammatory disease can raise the likelihood of an ectopic pregnancy occurring.

If a patient has a history of Chlamydia, it may have caused pelvic inflammatory disease before being diagnosed. Chlamydia can cause scarring of the fallopian tubes, subfertility, and an increased risk of ectopic pregnancy. Any condition that slows the egg’s movement to the uterus can lead to a higher risk of ectopic pregnancy.

While drinking excessively during pregnancy is not recommended due to the risk of neural tube defects and foetal alcohol syndrome, it is not linked to ectopic pregnancy. However, smoking is believed to increase the risk of ectopic pregnancy, highlighting the importance of asking about social history when advising patients who want to conceive.

A history of cervical ectropion is not a risk factor for ectopic pregnancy, but it can make a patient more prone to bleeding during pregnancy.

The previous use of an IUS will not increase the risk of an ectopic pregnancy. However, conceiving while an IUS is in place will raise the risk of this happening. This is due to the effect of slowing the ovum’s transit to the uterus.

A simple ovarian cyst will not increase the risk of an ectopic pregnancy. Large ovarian cysts can cause ovarian torsion, but a 3 cm cyst is not a cause for concern, and the patient does not have any signs or symptoms of ovarian torsion or ectopic pregnancy.

Understanding Ectopic Pregnancy: Incidence and Risk Factors

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. This condition is a serious medical emergency that requires immediate attention. According to epidemiological studies, ectopic pregnancy occurs in approximately 0.5% of all pregnancies.

Several risk factors can increase the likelihood of ectopic pregnancy. These include damage to the fallopian tubes due to pelvic inflammatory disease or surgery, a history of previous ectopic pregnancy, endometriosis, the use of intrauterine contraceptive devices (IUCDs), and the progesterone-only pill. In vitro fertilization (IVF) also increases the risk of ectopic pregnancy, with approximately 3% of IVF pregnancies resulting in ectopic implantation.

It is important to note that any factor that slows down the passage of the fertilized egg to the uterus can increase the risk of ectopic pregnancy. Early detection and prompt treatment are crucial in managing this condition and preventing serious complications.

postmenopausal Bleeding: Common Causes and Investigations

postmenopausal bleeding can be caused by various factors, including atrophic vaginitis, endometrial atrophy, cervical or endometrial polyps, and endometrial hyperplasia/cancer. Among these causes, endometrial cancer is the most likely. Therefore, investigation for patients with postmenopausal bleeding is typically done in a specialist clinic, with transvaginal ultrasound, hysteroscopy, and biopsy.

However, submucosal fibroids become quiescent following menopause and usually calcify, and there is no evidence of increased risk of endometrial cancer in women with fibroids. On the other hand, ovarian cancer rarely, if ever, presents with postmenopausal bleeding. Cervical ectropion is a condition of young women, and vaginal cancer is very rare and usually presents with vaginal discharge.

In summary, postmenopausal bleeding should be investigated thoroughly to rule out any underlying serious conditions, such as endometrial cancer.

Diagnosis of Hydatidiform Mole in Early Pregnancy: Clinical Features and Treatment Options

Hydatidiform mole is a type of gestational trophoblastic disease that occurs due to abnormal fertilization of an ovum, resulting in a non-viable pregnancy. The condition presents with clinical features such as vaginal bleeding, excessive vomiting, a large-for-dates uterus, and a very high hCG level. Pelvic ultrasound may reveal a ‘snowstorm’ appearance from the intrauterine mass and cystic components.

The diagnosis of hydatidiform mole is crucial as it determines the treatment options. If the patient wishes to retain her fertility, dilation and evacuation are offered. However, if fertility is not desired, a hysterectomy is recommended. The former has fewer post-operative complications but carries a higher risk of post-operative gestational trophoblastic neoplasia. Antiemetics are prescribed to manage nausea and vomiting.

Twin pregnancy and complete miscarriage are differential diagnoses, but the absence of fetal parts and the grossly elevated hCG level point towards hydatidiform mole. Pre-eclampsia cannot be diagnosed before the second trimester, and endometrial carcinoma is unlikely to cause a uterine mass or elevated hCG levels.

In conclusion, early diagnosis of hydatidiform mole is crucial for appropriate management and prevention of complications.

Endometrial cancer is strongly linked to HNPCC/Lynch syndrome, while the use of combined oral contraceptives can help reduce the risk. Other factors that increase the risk of endometrial cancer include obesity, a higher number of ovulations (due to factors such as early menarche, late menopause, and fewer pregnancies), certain medications like tamoxifen, and medical conditions like diabetes and polycystic ovarian syndrome. Anorexia, the Mirena coil, and familial adenomatous polyposis are not considered risk factors for endometrial cancer.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

progesterone Only Pill: What to Do When You Miss a Pill

The progesterone only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to note that the rules for the two types of pills should not be confused. The traditional POPs (Micronor, Noriday, Norgeston, Femulen) and Cerazette (desogestrel) have the following guidelines for missed pills:

– If the pill is less than 3 hours late, no action is required, and you can continue taking the pill as normal.
– If the pill is more than 3 hours late (i.e., more than 27 hours since the last pill was taken), action is needed.
– If the pill is less than 12 hours late, no action is required, and you can continue taking the pill as normal.
– If the pill is more than 12 hours late (i.e., more than 36 hours since the last pill was taken), action is needed.

Diagnosis of Androgen Insensitivity Syndrome: A Case Study

The presented case strongly suggests the presence of androgen insensitivity syndrome, a condition where a patient’s phenotype and secondary sexual characteristics differ from their karyotype and gonads. In this case, the patient is likely to have a karyotype of 46,XY and be a male pseudohermaphrodite. Androgen insensitivity syndrome is associated with mutations in the AR gene, which codes for the androgen receptor. In complete androgen insensitivity, the body cannot respond to androgens at all, resulting in a female phenotype, female secondary sexual characteristics, no uterus, and undescended testes.

Karyotyping is the key diagnostic investigation to confirm the diagnosis of androgen insensitivity syndrome. Serum oestradiol levels may vary according to the type of androgen insensitivity disorder and are unlikely to aid the diagnosis. Pituitary MRI may be a second diagnostic investigation if karyotype abnormalities are ruled out. Transvaginal ultrasound is not necessary if an abdominal ultrasound has already been performed and showed an absent uterus.

Surgical management is recommended for all ectopic pregnancies with a foetal sac larger than 35mm or a serum B-hCG level exceeding 5,000 IU/L, as per NICE guidelines. Foetal sacs larger than 35mm are at a higher risk of spontaneous rupture, making expectant or medical management unsuitable. The size of the foetal sac is measured using transvaginal ultrasound. Detection of a foetal heartbeat on transvaginal ultrasound requires urgent surgical management. A history of pelvic inflammatory disease is not an indication for surgical management, although it is a risk factor for ectopic pregnancy. Serum HCG levels between 1,500IU/L and 5,000 IU/L may be managed medically if the patient can return for follow-up and has no significant abdominal pain or haemodynamic instability. A septate uterus is not an indication for surgical management of ectopic pregnancy, but it may increase the risk of miscarriage.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Differential diagnosis for a woman with typical PCOS phenotype and biochemical markers

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that affects reproductive-aged women. Its diagnosis is based on the presence of at least two of the following criteria: oligo-ovulation or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. However, other conditions can mimic or coexist with PCOS, making the differential diagnosis challenging. Here are some possible explanations for a woman who presents with the typical PCOS phenotype and biochemical markers:

– Cushing syndrome: This rare disorder results from chronic exposure to high levels of cortisol, either endogenously (e.g., due to a pituitary or adrenal tumour) or exogenously (e.g., due to long-term glucocorticoid therapy). Cushing syndrome can cause weight gain, central obesity, moon face, buffalo hump, purple striae, hypertension, glucose intolerance, and osteoporosis. However, it is not associated with a high LH: FSH ratio, which is a hallmark of PCOS.
– Androgen-secreting tumour: This is a rare cause of hyperandrogenism that can arise from the ovary, adrenal gland, or other tissues. The excess production of androgens can lead to virilization, hirsutism, acne, alopecia, menstrual irregularities, and infertility. However, the testosterone level in this case would be expected to be higher than 3.5 nmol/l, which is the upper limit of the normal range for most assays.
– Simple obesity: This is a common condition that can affect women of any age and ethnicity. Obesity can cause insulin resistance, hyperinsulinemia, dyslipidemia, inflammation, and oxidative stress, which can contribute to the development of PCOS. However, the abnormal testosterone and LH: FSH ratio suggest an underlying pathology that is not solely related to excess adiposity. Moreover, at a BMI of 28, the patient’s weight is not within the range for a clinical diagnosis of obesity (BMI ≥ 30).
– Complete androgen insensitivity syndrome: This is a rare genetic disorder that affects the androgen receptor, leading to a lack of response to androgens in target tissues. As a result, affected individuals have a female phenotype despite having XY chromosomes. They typically present with primary amenorrhea

It is common for HCG levels to remain positive for several weeks after a termination of pregnancy. HCG levels are typically measured every two days, and a positive result beyond four weeks may indicate a continuing pregnancy. However, in most cases, HCG levels will return to normal within four weeks.

In this scenario, the appropriate course of action is to repeat the urine pregnancy test in one week, as the patient is currently only three weeks post-termination. There is no need for further referrals or imaging at this time, as a positive test result is unlikely to indicate a continuing pregnancy, and the patient does not exhibit any urgent symptoms such as infection or hemorrhage.

Termination of Pregnancy in the UK

The UK’s current abortion law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for termination from 28 weeks to 24 weeks gestation. To perform an abortion, two registered medical practitioners must sign a legal document, except in emergencies where only one is needed. The procedure must be carried out by a registered medical practitioner in an NHS hospital or licensed premise.

The method used to terminate a pregnancy depends on the gestation period. For pregnancies less than nine weeks, mifepristone (an anti-progesterone) is administered, followed by prostaglandins 48 hours later to stimulate uterine contractions. For pregnancies less than 13 weeks, surgical dilation and suction of uterine contents is used. For pregnancies more than 15 weeks, surgical dilation and evacuation of uterine contents or late medical abortion (inducing ‘mini-labour’) is used.

The 1967 Abortion Act outlines the circumstances under which a person shall not be guilty of an offence under the law relating to abortion. These include if two registered medical practitioners are of the opinion, formed in good faith, that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family. The limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is a risk of serious physical or mental injury to the woman.

Treatment Options for Vulval Cancer: Simple Vulvectomy and Bilateral Inguinal Lymphadenectomy

Vulval cancer is a rare form of cancer that accounts for less than 1% of cancer diagnoses. The labia majora are the most common site, followed by labia minora. Squamous cell carcinoma is the most common type of vulval cancer, with carcinoma-in-situ being a precursor lesion that does not invade through the basement membrane. Risk factors for developing vulval cancer include increasing age, exposure to HPV, vulval lichen sclerosus et atrophicus, smoking, and immunosuppression.

Patients may present with symptoms such as itching, pain, easy-contact bleeding of the vulva, changes in vulval skin, or frank ulcers/masses. The first lymph node station for metastases is the inguinal group. Surgery is the primary treatment for vulval cancer, with a simple vulvectomy and bilateral inguinal lymphadenectomy being the usual surgery performed, even in the absence of clinically palpable groin lymph nodes.

Radiotherapy is commonly used before and/or after surgery depending on the stage of the disease, but it is not curative and would not be offered in isolation to an otherwise healthy patient. Chemotherapy is not usually used as a primary treatment but is offered in disseminated malignancy. Wide local excision is only used for lesions less than 2 cm in diameter with a depth of less than 1 mm. Lesions larger than this require vulvectomy and lymph node clearance due to the risk of metastasis.

In conclusion, a simple vulvectomy and bilateral inguinal lymphadenectomy are the mainstay of treatment for vulval cancer, with radiotherapy and chemotherapy being used in certain cases. Early detection and treatment are crucial for improving outcomes in patients with vulval cancer.

Pelvic floor muscle training is the most effective and cost-efficient treatment for stress urinary incontinence in women. Ring pessaries can also be used as a non-surgical option for pelvic organ prolapse. Oxybutynin is typically used for urge incontinence, but in this scenario, the woman only experiences stress incontinence. While a referral to urogynaecology may be considered for further investigation or surgery, it is not necessary to do so urgently. Pelvic floor exercises should be attempted for at least 3 months under the guidance of a continence adviser, specialist nurse, or women’s health physiotherapist. As the woman’s symptoms persist despite 6 months of trying this approach, it would be inappropriate to suggest continuing with the same strategy.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

The diagnosis of vaginal candidiasis does not require a high vaginal swab if the symptoms are highly suggestive. In fact, the diagnosis can be made clinically based on the patient’s symptoms. For example, if a patient presents with thickened, white discharge that resembles cottage cheese and vaginal itching, along with a normal vaginal pH, it is very likely that they have vaginal candidiasis. It is important to note that glycated haemoglobin (HbA1c) is not necessary for diagnosis unless the patient has recurrent episodes of vaginal candidiasis, which may indicate diabetes mellitus. Additionally, a midstream urine sample is not useful in diagnosing vaginal candidiasis and should only be used if a sexually-transmitted infection is suspected.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

According to the NICE guidelines for cervical cancer screening, if an individual tests positive for high-risk human papillomavirus (hrHPV) but receives a negative cytology report during routine primary HPV screening, they should undergo a repeat HPV test after 12 months. If the HPV test is negative at this point, they can return to routine recall. However, if they remain hrHPV positive and cytology negative after 12 months, they should undergo another HPV test after a further 12 months. If they are still hrHPV positive after 24 months, they should be referred for colposcopy if their cytology report is negative or inadequate. Therefore, the appropriate course of action in this scenario is to refer the individual for colposcopy.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Treatment Options for Vulval Cancer: Surgery, Radiation Therapy, and Chemotherapy

Vulval cancer is a type of cancer that affects the external female genitalia. The lymphatic drainage of the vulva is to the inguinal nodes, which means that even if there is no clinical evidence of lymphatic involvement, the inguinal nodes should be removed. This is done through a simple vulvectomy and bilateral inguinal lymphadenectomy. Radiation therapy can also be used for T2 or greater lesions, when combined with surgery. The role of radiation is often to shrink tumours to make a surgical excision more likely to succeed or to increase the chance of remission.

It is important to note that vulvectomy without lymph node surgery or biopsy is inappropriate. Only in stage 1a cancer with a depth of invasion of <1 mm can lymph nodes safely not be biopsied or removed. Chemotherapy largely plays a role as neoadjuvant or adjuvant therapy in vulval cancer. This is particularly important for tumours which extend within 1 cm of structures that would not be surgically removed such as the urethra, clitoris and anus. It can also be used where repeat surgery in positive margins may not be feasible. Wide local excision, also termed radical local excision, is appropriate, depending on the staging of the lesion. If the tumour is localised, ie T1 staging, then a radical local excision is a viable option, regardless of the location. As the tumour is described as invasive, it must be T2 or greater in staging and therefore needs more invasive surgery. In summary, treatment options for vulval cancer include surgery, radiation therapy, and chemotherapy, depending on the staging and location of the tumour.

If pelvic floor muscle exercises are ineffective and surgical intervention is not desired, duloxetine may be used to manage stress incontinence, as per NICE guidance from 2019. It should be noted that bladder retraining is not recommended for this type of incontinence, and oxybutynin is only indicated for urge incontinence if bladder retraining has failed. Referral for urodynamics testing is also not recommended, with urogynaecology being the preferred option for secondary care. Additionally, NICE does not recommend continuing pelvic floor exercises for an additional 3 months.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

For women with atypical endometrial hyperplasia who are postmenopausal, it is recommended to undergo a total hysterectomy with bilateral salpingo-oophorectomy to prevent malignant progression. A total hysterectomy alone is not sufficient for postmenopausal women. It is also not recommended to undergo a bilateral salpingo-oophorectomy without removing the endometrium. A watch and wait approach is not advisable due to the potential for malignancy, and radiotherapy is not recommended as the condition is not yet malignant.

Endometrial hyperplasia is a condition where the endometrium, the lining of the uterus, grows excessively beyond what is considered normal during the menstrual cycle. This abnormal proliferation can lead to endometrial cancer in some cases. There are four types of endometrial hyperplasia: simple, complex, simple atypical, and complex atypical. Symptoms of this condition include abnormal vaginal bleeding, such as intermenstrual bleeding.

The management of endometrial hyperplasia depends on the type and severity of the condition. For simple endometrial hyperplasia without atypia, high dose progestogens may be prescribed, and repeat sampling is recommended after 3-4 months. The levonorgestrel intra-uterine system may also be used. However, if atypia is present, hysterectomy is usually advised.

For non-pregnant women with vaginal thrush, the recommended first-line treatment is a single-dose of oral fluconazole. This is based on NICE guidelines for the diagnosis of vaginal candidiasis. The use of clotrimazole intravaginal pessary is only recommended if the patient is unable to take oral treatment due to safety concerns. Oral nystatin is not appropriate for this condition as it is used for oral candidiasis. While topical clotrimazole can be used to treat vaginal candidiasis, it is not the preferred first-line treatment and should only be used if fluconazole is not effective or contraindicated.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

Clomiphene is the recommended first-line treatment for infertility in patients with PCOS. While there is ongoing debate about the use of metformin, current evidence does not support it as a first-line option. In vitro fertilisation is also not typically used as a first-line treatment for PCOS-related infertility.

Managing Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

Understanding Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS) is a potential complication that can occur during infertility treatment. This condition is believed to be caused by the presence of multiple luteinized cysts in the ovaries, which can lead to high levels of hormones and vasoactive substances. As a result, the permeability of the membranes increases, leading to fluid loss from the intravascular compartment.

OHSS is more commonly seen following gonadotropin or hCG treatment, and it is rare with Clomiphene therapy. Approximately one-third of women undergoing in vitro fertilization (IVF) may experience a mild form of OHSS. The Royal College of Obstetricians and Gynaecologists (RCOG) has classified OHSS into four categories: mild, moderate, severe, and critical.

Symptoms of OHSS can range from abdominal pain and bloating to more severe symptoms such as thromboembolism and acute respiratory distress syndrome. It is important to monitor patients closely during infertility treatment to detect any signs of OHSS and manage the condition appropriately. By understanding OHSS and its potential risks, healthcare providers can work to minimize the occurrence of this complication and ensure the safety of their patients.

Management Options for Menorrhagia Secondary to Fibroids

Menorrhagia secondary to fibroids is a common gynecological problem that can significantly impact a woman’s quality of life. There are several management options available, depending on the severity of symptoms, the patient’s desire for fertility preservation, and the presence of other medical conditions.

Tranexamic acid is the first-line medical management option for women with menorrhagia secondary to fibroids who do not want contraception. It is an antifibrinolytic agent that reduces bleeding by inhibiting the conversion of plasminogen to plasmin. Hormonal therapies, such as combined oral contraceptives, are not indicated in this scenario.

Surgical options, such as myomectomy, endometrial ablation, or hysterectomy, may be considered if medical management fails or the patient declines medication. Myomectomy is a surgical procedure that removes fibroids while preserving the uterus and fertility. However, fibroids can recur following myomectomy. Hysterectomy is the only definitive method of management, but it is only recommended for women who have completed their family.

Iron supplementation with ferrous sulfate is appropriate for patients with iron deficiency anemia secondary to menorrhagia. Mefenamic acid, an NSAID, is contraindicated in patients with inflammatory bowel disease due to the increased risk of gastrointestinal bleeding. The levonorgestrel intrauterine system (Mirena® coil) is recommended as the first-line treatment for menorrhagia without underlying pathology, suspected or diagnosed adenomyosis, or small fibroids that do not cause uterine distortion, but it is not appropriate for women who want to conceive.

In conclusion, the management of menorrhagia secondary to fibroids requires a tailored approach that takes into account the patient’s symptoms, desire for fertility preservation, and medical history. A multidisciplinary team approach involving gynecologists, hematologists, and other specialists may be necessary to provide optimal care.

The UK Medical Eligibility Criteria (UKMEC) offer guidance on the contraindications for using contraception, including the combined oral contraceptive pill (COCP). The UKMEC categorizes the use of COCP as follows: no restriction (UKMEC1), advantages outweigh disadvantages (UKMEC2), disadvantages outweigh advantages (UKMEC3), and unacceptable risk (UKMEC4).

According to UKMEC3, COCP use may have more disadvantages than advantages for individuals who are over 35 years old and smoke less than 15 cigarettes per day, have a BMI over 35, experience migraines without aura, have a family history of deep vein thrombosis or pulmonary embolism in a first-degree relative under 45 years old, have controlled hypertension, are immobile (e.g., use a wheelchair), or are breastfeeding and between 6 weeks to 6 months postpartum.

On the other hand, UKMEC4 indicates that COCP use poses an unacceptable risk for individuals who are over 35 years old and smoke more than 15 cigarettes per day, experience migraines with aura, have a personal history of deep vein thrombosis or pulmonary embolism, have a personal history of stroke or ischemic heart disease, have uncontrolled hypertension, have breast cancer, have recently undergone major surgery with prolonged immobilization, or are breastfeeding and less than 6 weeks postpartum.

Source: FSRH UKMEC for contraceptive use.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

If there has been a delay in changing the patch for over 48 hours but no sexual activity has occurred within the past 10 days, emergency contraception is not necessary. However, the individual must use barrier contraception for the next 7 days and replace the patch immediately. If there is no sexual activity planned for the next 7 days, no further action is required, but it is important to advise the individual to use barrier contraception during this time. It is crucial to replace the patch as soon as possible to ensure effective contraceptive coverage.

The Evra patch is the only contraceptive patch that is approved for use in the UK. The patch cycle lasts for four weeks, during which the patch is worn every day for the first three weeks and changed weekly. During the fourth week, the patch is not worn, and a withdrawal bleed occurs.

If a woman delays changing the patch at the end of week one or two, she should change it immediately. If the delay is less than 48 hours, no further precautions are necessary. However, if the delay is more than 48 hours, she should change the patch immediately and use a barrier method of contraception for the next seven days. If she has had unprotected sex during this extended patch-free interval or in the last five days, emergency contraception should be considered.

If the patch removal is delayed at the end of week three, the woman should remove the patch as soon as possible and apply a new patch on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.

If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for seven days following any delay at the start of a new patch cycle. For more information, please refer to the NICE Clinical Knowledge Summary on combined hormonal methods of contraception.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

Teratomas, also known as dermoid cysts, are non-cancerous tumors that originate from multiple germ cell layers. These tumors can produce a variety of tissues, including skin, hair, blood, fat, bone, nails, teeth, cartilage, and thyroid tissue, due to their germ cell origin.

Mature cystic teratomas have a white shiny mass or masses projecting from the wall towards the center of the cyst. This protuberance is called the Rokitansky protuberance and is where hair, bone, teeth, and other dermal appendages usually arise from.

While ovarian malignancy is rare in young females, suspicion can be assessed using the risk of malignancy index (RMI), which takes into account serum CA-125 levels, ultrasound findings, and menopausal status.

Understanding the Different Types of Ovarian Cysts

Ovarian cysts are a common occurrence in women, and they can be classified into different types. The most common type of ovarian cyst is the physiological cyst, which includes follicular cysts and corpus luteum cysts. Follicular cysts occur when the dominant follicle fails to rupture or when a non-dominant follicle fails to undergo atresia. These cysts usually regress after a few menstrual cycles. Corpus luteum cysts, on the other hand, occur when the corpus luteum fails to break down and disappear after the menstrual cycle. These cysts may fill with blood or fluid and are more likely to cause intraperitoneal bleeding than follicular cysts.

Another type of ovarian cyst is the benign germ cell tumour, which includes dermoid cysts. Dermoid cysts are also known as mature cystic teratomas and are usually lined with epithelial tissue. They may contain skin appendages, hair, and teeth. Dermoid cysts are the most common benign ovarian tumour in women under the age of 30, and they are usually asymptomatic. However, torsion is more likely to occur with dermoid cysts than with other ovarian tumours.

Lastly, there are benign epithelial tumours, which arise from the ovarian surface epithelium. The most common benign epithelial tumour is the serous cystadenoma, which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Serous cystadenomas are bilateral in around 20% of cases. The second most common benign epithelial tumour is the mucinous cystadenoma, which is typically large and may become massive. If it ruptures, it may cause pseudomyxoma peritonei.

In conclusion, understanding the different types of ovarian cysts is important for proper diagnosis and treatment. Complex ovarian cysts should be biopsied to exclude malignancy, while benign cysts may require monitoring or surgical removal depending on their size and symptoms.

Diagnosis and Testing for Trichomoniasis: A Common STD

Trichomoniasis is a sexually transmitted disease caused by the protozoan parasite T. vaginalis. While both men and women can be affected, women are more likely to experience symptoms. Diagnosis of trichomoniasis is typically made through wet mount microscopy and direct visualisation, with DNA amplification techniques offering higher sensitivity. Urine testing is not considered the gold standard, and cervical swabs are not sensitive enough. Treatment involves a single dose of metronidazole, and sexual partners should be treated simultaneously. Trichomoniasis may increase susceptibility to HIV infection and transmission. Symptoms in women include a yellow-green vaginal discharge with a strong odour, dysuria, pain on intercourse, and vaginal itching. Men may experience penile irritation, mild discharge, dysuria, or pain after ejaculation.

Polycystic ovarian syndrome patients commonly experience insulin resistance, which can result in complex alterations in the hypothalamic-pituitary-ovarian axis.

Managing Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

Understanding Cervical Ectropion

Cervical ectropion is a condition that occurs when the columnar epithelium of the cervical canal extends onto the ectocervix, where the stratified squamous epithelium is located. This happens due to elevated levels of estrogen, which can occur during the ovulatory phase, pregnancy, or with the use of combined oral contraceptive pills. The term cervical erosion is no longer commonly used to describe this condition.

Cervical ectropion can cause symptoms such as vaginal discharge and post-coital bleeding. However, ablative treatments such as cold coagulation are only recommended for those experiencing troublesome symptoms. It is important to understand this condition and its symptoms in order to seek appropriate medical attention if necessary.

When dealing with patients who have urinary incontinence, it is crucial to eliminate the possibility of a UTI and diabetes mellitus as underlying causes. The first step in investigating urinary incontinence would be to conduct a urine dipstick and culture test, which can be easily done in a GP’s office. Other initial investigations include keeping a bladder diary for at least three days and undergoing urodynamic studies. It is important to note that the reliability of urine dip tests is questionable in women over 65 years of age and those who have catheters. A three-day bladder diary is necessary for initial investigations, and a one-day diary would not suffice. CT scans are not typically used to investigate urinary incontinence but are useful in detecting renal pathology such as ureteric calculi. Cystoscopy is not appropriate for this patient and is usually reserved for cases where bladder cancer is suspected.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

According to NICE CG44, when heavy menstrual bleeding is not caused by any structural or histological abnormality, the first recommended treatment is the intrauterine system, also known as Mirena.

Managing Heavy Menstrual Bleeding

Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

[Insert flowchart here]

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

To follow up on a positive hrHPV result with a cytologically normal sample, it is recommended to repeat the smear after 12 months as HPV can be naturally cleared by the immune system within this timeframe.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

To address the patient’s condition, it is recommended to refer her to the postmenopausal bleeding clinic for an endometrial biopsy. According to the Faculty of Sexual and Reproductive Health, women aged 45 years who use hormonal contraception and experience persistent problematic bleeding or a change in bleeding pattern should undergo endometrial biopsy. Given that the patient is obese and has type two diabetes, both of which are risk factors for endometrial malignancy, watchful waiting and reassurance are not appropriate responses. While the Mirena may be nearing the end of its lifespan after 4 years of insertion, bleeding cannot be attributed to this without ruling out underlying pathology. Hormone replacement therapy is not recommended for this patient at this time.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

For patients with stress incontinence who do not respond to pelvic floor muscle exercises and decline surgery, duloxetine may be a suitable option. However, if urge incontinence is the main issue, antimuscarinic (oxybutynin) or beta-3 agonist (mirabegron) medications may be more appropriate. In this case, since the patient has not seen improvement with pelvic floor muscle training and has declined surgery, duloxetine would be the best choice.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

In cases of recurrent vaginal candidiasis, it is recommended to consider a blood test to rule out diabetes as a potential underlying condition. Other predisposing factors such as immunosuppression, pregnancy, and antibiotic or steroid usage should also be evaluated. While HIV testing is important, a CD4+ T-cell count is not the first line investigation and HIV testing is typically done using antibody, antigen, or nucleotide testing. A full blood count may be useful to assess the patient’s general health, but it is not the most likely cause of recurrent vaginal candidiasis. HbA1c testing should be done to assess for diabetes mellitus, and a pregnancy test and HIV test may also be indicated. While a high vaginal swab can confirm the diagnosis, it will not provide information about any underlying diseases.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

The appropriate management for urgency urinary incontinence (UUI) is to refer the patient for bladder training. UUI is characterized by uncontrollable bladder leakage that occurs shortly after the patient experiences a sudden urge to urinate, and is often associated with an overactive bladder that causes symptoms such as increased urinary frequency and nocturia. Advising the patient to reduce fluid intake and use continence products is not the correct approach, as both too much and too little fluid can contribute to lower urinary tract symptoms. Instead, patients should be advised to make lifestyle changes such as reducing caffeine intake, losing weight, and quitting smoking. Referring the patient for pelvic floor muscle training is the appropriate management for stress incontinence, which causes urine leakage during exertion, sneezing, or coughing. However, this is not applicable in this case as the patient denies these symptoms. If conservative management is unsuccessful and the patient does not wish to explore surgical options, a trial treatment with duloxetine may be considered for stress incontinence.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

Annual Monitoring for Diabetes in Women with Polycystic Ovary Syndrome

Women with polycystic ovary syndrome (PCOS) are at an increased risk of developing type 2 diabetes mellitus. Therefore, it is important to monitor these patients for diabetes. The monitoring approach depends on the patient’s risk stratification, which is determined by factors such as BMI, family history of diabetes, and personal history of gestational diabetes.

For patients with evidence of impaired glucose tolerance, defined as a fasting glucose of < 7.0 mmol/l and a 2-hour OGTT of ≥ 7.8 but < 11.1 mmol/l, dietary and weight loss advice should be given, and a repeat glucose tolerance test is indicated annually. For patients with a normal glucose tolerance test, with a BMI of < 30 kg/m2, no family history of diabetes, and no personal history of gestational diabetes, annual random fasting glucose testing is appropriate. If the result is ≥ 5.6 mmol/l, then a glucose tolerance test should be performed. For patients with a BMI of ≥ 30 kg/m2, annual glucose tolerance testing is recommended. If diabetes is suspected based on symptoms such as polyuria, polydipsia, and weight loss, a random serum glucose of ≥ 11.0 mmol/l or a fasting glucose of ≥ 7.0 mmol/l is diagnostic. In asymptomatic patients, two samples of fasting glucose of ≥ 7.0 mmol/l are adequate for diagnosis. In conclusion, annual monitoring for diabetes is important in women with PCOS to prevent complications and morbidity associated with type 2 diabetes mellitus. The monitoring approach should be tailored to the patient’s risk stratification.

Levonorgestrel emergency contraception (Levonelle) does not affect the effectiveness of hormonal contraception, so it can be started immediately after use. However, ulipristal acetate emergency contraception (EllaOne) should not be used concurrently with hormonal contraception, and patients should wait 5 days after taking it before starting a COCP regimen. The COCP must be taken within a 24-hour window each day to ensure effectiveness, while levonorgestrel emergency contraception must be taken within 72 hours of unprotected sexual intercourse. The interval to wait before starting or restarting hormonal contraception after using ulipristal acetate emergency contraception is 5 days. Day 1 of the menstrual cycle is the preferred day to start a COCP regimen for immediate protection against pregnancy, but it is not the earliest option in this scenario.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

The contraceptive implant primarily works by inhibiting ovulation through the slow release of progesterone hormone. While it also increases cervical mucous thickness, this is not its main mode of action. The progesterone-only pill also increases cervical mucous thickness, while the intrauterine copper device decreases sperm viability. The intrauterine system prevents implantation of the ovum by exerting local progesterone onto the uterine lining.

Understanding the Mode of Action of Contraceptives

Contraceptives are used to prevent unwanted pregnancies. They work by different mechanisms depending on the type of contraceptive used. The Faculty for Sexual and Reproductive Health (FSRH) has provided a table that outlines the mode of action of standard contraceptives and emergency contraception.

Standard contraceptives include the combined oral contraceptive pill, progesterone-only pill, injectable contraceptive, implantable contraceptive, and intrauterine contraceptive device/system. The combined oral contraceptive pill and injectable/implantable contraceptives primarily work by inhibiting ovulation, while the progesterone-only pill and some injectable/implantable contraceptives thicken cervical mucous to prevent sperm from reaching the egg. The intrauterine contraceptive device/system decreases sperm motility and survival and prevents endometrial proliferation.

Emergency contraception, which is used after unprotected sex or contraceptive failure, also works by different mechanisms. Levonorgestrel and ulipristal inhibit ovulation, while the intrauterine contraceptive device is toxic to sperm and ovum and inhibits implantation.

Understanding the mode of action of contraceptives is important in choosing the most appropriate method for an individual’s needs and preferences. It is also important to note that no contraceptive method is 100% effective, and the use of condoms can provide additional protection against sexually transmitted infections.

Ultrasound imaging may reveal a whirlpool sign in cases of ovarian torsion, which is strongly indicated by the patient’s history and examination. The beads-on-a-string sign is typically associated with chronic salpingitis, while hypoechoic masses are often indicative of fibroids. A snow-storm appearance is a characteristic finding in complete hydatidiform mole.

Understanding Ovarian Torsion

Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.

If two consecutive samples are deemed inadequate during cervical cancer screening, the correct course of action is to refer the patient for colposcopy. Repeating the smear in 1 or 3 months is not appropriate as two inadequate samples have already been taken. Requesting hrHPV testing from the laboratory is also not useful if the sample is inadequate. Referring the patient to gynaecology is not necessary, and instead, a referral for colposcopy should be made.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Surgical management is recommended for ectopic pregnancies that are larger than 35mm or have a serum B-hCG level greater than 5,000 IU/L. In this case, the patient is experiencing typical symptoms of an ectopic pregnancy, including vaginal bleeding and referred shoulder tip pain. The ultrasound confirms the presence of a tubal ectopic, with a mass exceeding 35mm and tubal ring sign. Therefore, a laparoscopic salpingectomy is the appropriate surgical intervention.
Adrenalectomy is not relevant in this case, as the complex adnexal mass refers to the ectopic pregnancy located near the ovaries, uterus, and fallopian tubes, not the adrenal glands.
Expectant management is not suitable for this patient, as her serum b-hCG is significantly elevated, and the mass exceeds 35mm in size.
Medical management with methotrexate is an option for ectopic pregnancies that are smaller than 35mm or have a serum B-hCG level below 5,000 IU/L.
Ultrasound-guided potassium chloride injection is an alternative to methotrexate for medical management, but it is not currently standard practice in the UK.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Possible Causes of Sudden Pelvic Pain: A Differential Diagnosis

Sudden pelvic pain can be a sign of various medical conditions. In this case, the patient’s symptoms suggest ovarian torsion, a condition that occurs when the ovary twists on its blood supply, causing ischemia and infarction. The resulting pain is severe, sharp, and sudden, often accompanied by tenderness and internal bleeding. However, other possible causes of sudden pelvic pain should also be considered.

Rectal diseases or trauma are unlikely to explain the patient’s current presentation. Similarly, while appendicitis can cause abdominal pain, fever, nausea, and anorexia, the pattern of pain is different, starting as dull pain around the belly button and becoming sharp and localized to the right lower quadrant over time. Rovsing’s sign, which is pain in the right lower quadrant when pressure is applied to the left lower quadrant, is often positive in appendicitis.

A ureteral stone can also cause sudden-onset pelvic and flank pain, but it is not associated with pelvic bleeding. Urinary tract stones typically cause colicky pain, which comes and goes in waves, rather than the unrelenting pain described by the patient.

Finally, a ruptured Fallopian tube can be a complication of an ectopic pregnancy, but the patient’s recent normal menstrual periods make this diagnosis less likely. In ectopic tubal pregnancy, the patient usually complains of amenorrhea, abnormal uterine bleeding, and pelvic pain of several days to weeks’ duration.

In summary, while ovarian torsion is a possible cause of the patient’s sudden pelvic pain, other conditions should also be considered and ruled out through further evaluation and testing.

Cytological examination of a cervical smear sample is only conducted if it tests positive for high risk HPV (hrHPV). If the sample is negative for hrHPV, there is no need for cytology testing.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

If the result of the first repeat smear for cervical cancer screening at 12 months is negative for high-risk human papillomavirus (hrHPV), the patient can resume routine recall. This means they should undergo screening every 3 years from age 25-49 years or every 5 years from age 50-64 years. However, if the repeat test is positive again, the patient should undergo another HPV test in 12 months. If there is dyskaryosis on a cytology sample, the patient should be referred for colposcopy.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Investigating Postcoital Bleeding: The Role of Speculum Examination and Other Tests

Postcoital bleeding can be caused by various abnormalities of the cervix, including cervical ectropion, polyps, infection, or cervical cancer. In women presenting with postcoital bleeding, cervical cancer should be suspected if there are other symptoms such as vaginal discharge, pelvic pain, or dyspareunia. Risk factors for cervical cancer include smoking, oral contraceptive use, HPV infection, HIV infection, immunosuppression, and family history.

The primary screening tool for cervical cancer is a cervical smear, which should be done every three years for women aged 25-49. If a patient presents with postcoital bleeding, the first step is to perform a speculum examination to visualize the cervix, which can detect over 80% of cervical cancers. If the cervix appears normal, a smear may be taken if it is due, and swabs can be taken for STI testing and pregnancy testing. If symptoms persist, referral to colposcopy may be necessary.

Other tests such as blood tests, urine dipstick, and high vaginal swab may be useful in certain cases, but they are not the primary investigation for postcoital bleeding. Blood tests may be indicated later, while urine dipstick and high vaginal swab are secondary investigations following visualisation of the cervix.

In summary, speculum examination is the key initial investigation for postcoital bleeding, and cervical smear is the primary screening tool for cervical cancer. Other tests may be useful in specific situations, but they should not replace the essential role of speculum examination and cervical smear in the evaluation of postcoital bleeding.

The most probable diagnosis for this patient is ovarian torsion, which is common in women of reproductive age. Symptoms include pain in the iliac fossa that can spread to the loin, groin, or back, as well as nausea and vomiting. An adnexal mass may be present on examination, which is often caused by an ovarian cyst or neoplasm that has disrupted the ovary’s normal position and caused torsion. In some cases, a low-grade fever may also be present if ovarian necrosis has occurred.

It is important to rule out ectopic pregnancy as a differential diagnosis, which can be done with a pregnancy test regardless of reported contraception. Vaginal bleeding may help differentiate between the two conditions. However, since the patient’s menstrual period started 7 days ago and she uses condoms for contraception, ectopic pregnancy is less likely than ovarian torsion.

Appendicitis is also a possible cause of this presentation, but it typically presents with diffuse abdominal pain that later localizes to the right iliac fossa. In appendicitis, pain can be reproduced in the right iliac fossa by palpating the left iliac fossa (Rovsing’s sign), but left iliac fossa pain would not be the presenting symptom.

Mittelschmerz, which is mild pain in the right iliac fossa, could also be a possible cause, but it would not be associated with nausea and vomiting.

Causes of Pelvic Pain in Women

Pelvic pain is a common complaint among women, with primary dysmenorrhoea being the most frequent cause. Mittelschmerz, or pain during ovulation, may also occur. However, there are other conditions that can cause pelvic pain, which can be acute or chronic in nature.

Acute pelvic pain can be caused by conditions such as ectopic pregnancy, urinary tract infection, appendicitis, pelvic inflammatory disease, and ovarian torsion. Ectopic pregnancy is characterized by lower abdominal pain and vaginal bleeding in women with a history of 6-8 weeks of amenorrhoea. Urinary tract infection may cause dysuria and frequency, while appendicitis may present with pain in the central abdomen before localizing to the right iliac fossa. Pelvic inflammatory disease may cause pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria, and menstrual irregularities. Ovarian torsion, on the other hand, may cause sudden onset unilateral lower abdominal pain, nausea, vomiting, and a tender adnexal mass on examination.

Chronic pelvic pain, on the other hand, may be caused by conditions such as endometriosis, irritable bowel syndrome, ovarian cysts, and urogenital prolapse. Endometriosis is characterized by chronic pelvic pain, dysmenorrhoea, deep dyspareunia, and subfertility. Irritable bowel syndrome is a common condition that presents with abdominal pain, bloating, and change in bowel habit. Ovarian cysts may cause a dull ache that is intermittent or only occurs during intercourse, while urogenital prolapse may cause a sensation of pressure, heaviness, and urinary symptoms such as incontinence, frequency, and urgency.

In summary, pelvic pain in women can be caused by various conditions, both acute and chronic. It is important to seek medical attention if the pain is severe or persistent, or if there are other concerning symptoms present.