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.

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.

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.

The patient’s symptoms of dysmenorrhoea, dyspareunia, and subfertility are classic signs of endometriosis, a common condition where endometrial tissue grows outside of the uterus. The presence of uterosacral nodularity and tenderness further supports this diagnosis. Some patients with endometriosis may also experience urinary symptoms due to bladder involvement or adhesions. Uterine leiomyoma, or fibroid, is a common pelvic tumor that causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. However, it does not typically present with uterosacral nodularity and tenderness on rectal examination. Interstitial cystitis causes urinary frequency and urgency, with pain relieved upon voiding. Pelvic inflammatory disease presents with fever, nausea, acute pain, malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.

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.

If a cervical smear test performed as part of the NHS cervical screening programme is inadequate, it should be first tested for high-risk HPV (hrHPV) and then repeated within 3 months. Colposcopy should only be performed if the second sample also returns as inadequate. Returning the patient to normal recall would result in a delay of 3 years for a repeat smear test, which is not recommended as it could lead to a missed diagnosis of cervical cancer. Repeating the test in 1 month is too soon, while repeating it in 6 months is not in line with current guidelines.

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.

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.

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.

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.

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 a woman is experiencing fertility issues due to large fibroids, the most effective treatment is myomectomy. In the case of a woman with a large submucosal fibroid that is distorting the shape of her uterus, options such as levonorgestrel-releasing IUS and tranexamic acid may provide symptomatic relief but will not address the underlying fertility issue. Medical treatment may also be ineffective due to the size of the fibroid. Hysterectomy and hysteroscopic endometrial ablation are not appropriate for women who wish to conceive in the future.

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.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

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.

The patient’s symptoms suggest that she may have pelvic inflammatory disease, which is a common diagnosis for women who experience long-term pelvic pain and smelly discharge. It is possible that she has a sexually transmitted infection, as she is not using a barrier method with her intrauterine device. The doctor should take high vaginal swabs and prescribe antibiotics if necessary. It is also recommended to perform a smear test while the patient is there.

While ectopic pregnancy is a possibility, it is less likely due to the patient’s intrauterine device. However, a pregnancy test should still be conducted. Endometriosis is also a possibility, but the patient’s pain does not seem to be related to her menstrual cycle.

Although the patient missed her first cervical smear, cervical cancer is not the most likely diagnosis based on her symptoms and the fact that she has received the human papillomavirus vaccine. However, it is still important for her to have regular smear tests.

Inflammatory bowel disease is another potential cause of pelvic pain, but it is usually accompanied by other symptoms such as weight loss, rectal bleeding, and diarrhea.

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.

Investigation is necessary for any postmenopausal bleeding. The first step is to conduct a transvaginal ultrasound scan to examine the thickness of the endometrium. To diagnose endometrial cancer, a Pipelle biopsy is used to sample the endometrium, which is effective in most cases. Hysteroscopy with directed sampling (dilation and curettage) can be used to detect lesions or when Pipelle has been inconclusive. CT scan is not required as a pre-operative imaging test nor is it used to diagnose endometrial cancer.
Reference: Colombo N, Preti E, Landoni F, Carinelli S, Colombo A, et al. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013; 24 (6): vi33-vi38.

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.

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.

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.

Differential Diagnosis for a Drowsy, Septic Patient with Menstrual Period: A Case Study

A female patient presents with evidence of severe sepsis during her menstrual period. The cause is not immediately apparent on examination or lumbar puncture, but her blood work indicates an infective process with elevated white cell count, reduced platelet count, and acute kidney injury. The differential diagnosis includes toxic shock syndrome, which should prompt an examination for a retained tampon and treatment with a broad-spectrum antibiotic. Bacterial meningitis is ruled out due to a normal lumbar puncture. Gram-negative urinary tract infection is unlikely without a history of urinary symptoms or definitive evidence in the urine. Appendicitis is not consistent with the patient’s history or physical exam. Viral meningitis is also unlikely due to the absence of headache and neck stiffness, as well as a normal lumbar puncture. With increased public awareness of the danger of retained tampons, toxic shock syndrome is becoming a rare occurrence.

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.

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 Options for Sexually Transmitted Infections

Sexually transmitted infections (STIs) can cause a range of symptoms in women, including post-coital bleeding, vaginal discharge, cervicitis, and more. Here are some common treatment options for STIs:

– Metronidazole: This medication is used to treat Trichomonas vaginalis infections. Patients typically take 400-500 mg twice daily for 5-7 days. It’s important to treat the partner simultaneously and abstain from sex for at least one week.
– Referral for colposcopy: If symptoms persist after treatment, patients may be referred for colposcopy to rule out cervical carcinoma.
– Azithromycin or doxycycline: These medications are used to treat uncomplicated genital Chlamydia infections. Most women with a chlamydial infection remain asymptomatic.
– Ceftriaxone and azithromycin: This combination is the treatment of choice for gonorrhoea infections. Symptoms may include increased vaginal discharge, lower abdominal pain, dyspareunia, and dysuria.
– No treatment is required: This is not an option for symptomatic patients with T vaginalis, as it is a sexually transmitted infection that requires treatment.

It’s important to seek medical attention if you suspect you have an STI, as early treatment can prevent complications and transmission to others.

Contraception for Obese Patients

Obesity is a risk factor for venous thromboembolism in women taking the combined oral contraceptive pill (COCP). To minimize this risk, the UK Medical Eligibility Criteria (UKMEC) recommends that women with a body mass index (BMI) of 30-34 kg/m² should use the COCP with caution (UKMEC 2), while those with a BMI of 35 kg/m² or higher should avoid it altogether (UKMEC 3). Additionally, the effectiveness of the combined contraceptive transdermal patch may be reduced in patients weighing over 90kg.

Fortunately, there are other contraceptive options available for obese patients. All other methods of contraception have a UKMEC of 1, meaning they are considered safe and effective for most women, regardless of their weight. However, it’s important to note that patients who have undergone gastric sleeve, bypass, or duodenal switch surgery cannot use oral contraception, including emergency contraception, due to the lack of efficacy.

In summary, obese patients should be aware of the increased risk of venous thromboembolism associated with the COCP and consider alternative contraceptive options. It’s important to discuss these options with a healthcare provider to determine the best choice for each individual patient.

To ensure maximum safety when switching from a traditional POP to COCP, it is recommended to use barrier contraception for 7 days while starting the combined oral contraceptive. This is the standard duration of protection required when starting this medication outside of menstruation. It is not necessary to use barrier contraception for 10 or 14 days, as the standard recommendation is 7 days. Using barrier contraception for only 3 days is too short, as it is the duration recommended for starting a traditional progesterone-only pill. While there may be some protection, it is still advisable to use additional contraception for 7 days to prevent unwanted pregnancy.

Special Situations for Combined Oral Contraceptive Pill

Concurrent antibiotic use has been a concern for many years in the UK, as doctors have advised that it may interfere with the effectiveness of the combined oral contraceptive pill. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines to abandon the extra precautions previously advised during antibiotic treatment and for 7 days afterwards. The latest edition of the British National Formulary (BNF) has also been updated to reflect this guidance, although precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

When it comes to switching combined oral contraceptive pills, the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The FSRH’s Combined Oral Contraception guidelines state that the pill-free interval does not need to be omitted, while the BNF advises missing the pill-free interval if the progesterone changes. Given this uncertainty, it is best to follow the BNF’s advice.

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.

In the case of an inadequate smear test result, the patient will be advised to undergo a repeat test within 3 months. If the second test also yields an inadequate result, the patient will need to undergo colposcopy 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.

The Most Appropriate Initial Investigation for Amenorrhoea: Urine Pregnancy Test

When a patient presents with amenorrhoea, the most appropriate initial investigation is always a pregnancy test. If pregnancy is excluded, further investigations may be necessary to determine the underlying cause. For example, a diagnosis of polycystic ovary syndrome (PCOS) may be supported by high levels of free testosterone with low levels of sex-hormone binding globulin, which can be tested after excluding pregnancy. A pelvic ultrasound is also a useful investigation for PCOS and should be done following β-HCG estimation. While a raised LH: FSH ratio may be suggestive of PCOS, it is not diagnostic and not the initial investigation of choice here. Similarly, an oral glucose tolerance test might be useful in patients diagnosed with PCOS, but it would not be an appropriate initial investigation. Therefore, a urine pregnancy test is the most important first step in investigating amenorrhoea.

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.

Diagnostic Tests and Imaging for Lower Abdominal Pain in Women

Lower abdominal pain in women can have various causes, including appendicitis, urinary tract infection, ovarian or tubal pathology, pelvic inflammatory disease, ruptured ectopic pregnancy, mesenteric adenitis, and other less common pathologies. To determine the cause of the pain, several diagnostic tests and imaging techniques can be used.

Beta human choriogonadotropin (β-hCG) test is essential for every woman of reproductive age admitted with lower abdominal pain. This test helps determine the pregnancy status, which can guide further investigations. An abdominal/pelvic ultrasound can detect acute ovarian and other gynecological pathology. It is also useful in assessing biliary pathology and involvement in pancreatitis. However, it is not very sensitive in detecting appendicitis.

If the diagnosis is uncertain, admitting the patient for observation and review in 12 hours can help determine if any other signs or symptoms develop or change. A CT scan would be inappropriate without checking the patient’s pregnancy status, as it could be harmful to the fetus. However, it can be useful in delineating acute intestinal pathology such as inflammatory bowel disease, bowel obstruction, and renal calculi.

Finally, an erect chest X-ray can help determine if there is bowel perforation by assessing for air under the diaphragm. This investigation is critical in the presence of a peritonitic abdomen.

In conclusion, a combination of diagnostic tests and imaging techniques can help determine the cause of lower abdominal pain in women and guide appropriate treatment.

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.

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.

After undergoing treatment for cervical intraepithelial neoplasia (CIN) during her colposcopy appointment, this woman needs to undergo follow-up cervical screening to ensure that the lesion has been effectively treated. Women who have received treatment for CIN II should be provided with cervical screening and an HPV test of cure after 6 months. If the test results are positive, the woman should go back 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.