To ensure the effectiveness of the contraceptive patch, it should be applied to clean, dry skin on a weekly basis for three weeks, followed by a patch-free week to stimulate a withdrawal bleed. However, if the patch change is delayed for more than 48 hours, it is important to change it immediately and use a barrier method of contraception for the next 7 days. In case of unprotected intercourse, emergency contraceptives should be considered.

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.

To confirm or rule out ectopic pregnancy, the recommended investigation is transvaginal ultrasound. This is because it provides clearer images of the uterus, ovaries, and endometrium, making it more effective in detecting ectopic pregnancies compared to transabdominal scans. While serum Beta-HCG levels are helpful in managing ectopic pregnancies, a single test cannot completely rule out the possibility. Pregnant women are generally advised against undergoing CT scans and abdominal X-rays.

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 salpingotomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy 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.

Investigation is necessary for any ovarian mass found in a woman who has undergone menopause.

Ovarian enlargement is typically diagnosed through ultrasound imaging, which can determine whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and symptoms. Younger women may be treated conservatively if the cyst is small and simple, with a repeat ultrasound scheduled in 8-12 weeks. Postmenopausal women, however, should always be referred to a gynecologist for assessment, as physiological cysts are unlikely in this population. It’s important to note that ovarian cancer can present with vague symptoms, leading to delayed diagnosis.

If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced.

The patient in this case was diagnosed with gestational diabetes during their initial appointment. Despite attempting metformin, their fasting and two-hour post glucose challenge blood glucose levels remain elevated above the normal range. Therefore, insulin should be added to their treatment plan. Choosing to make no changes to their treatment plan is not the correct answer, as this could lead to increased risks for the fetus, such as the development of polyhydramnios or macrosomia. While referral for dietary and exercise regimens may be considered, this is likely to be a first-line intervention, and further escalation of medical therapy is necessary for the health of the fetus. Increasing the dose of metformin is not the correct answer, as the NICE guidelines recommend starting insulin when initial interventions have been unsuccessful. Waiting two weeks to repeat the results would delay necessary treatment intensification, which is required at the current clinic appointment.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis

Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.

To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.

When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.

In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.

The primary way in which Nexplanon works is by preventing ovulation.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. 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.

Oligohydramnios is a condition that occurs during pregnancy when there is a shortage of amniotic fluid. This can result in a smaller symphysiofundal height.

Oligohydramnios is a condition characterized by a decrease in the amount of amniotic fluid present in the womb. The definition of oligohydramnios varies, but it is generally considered to be present when there is less than 500ml of amniotic fluid at 32-36 weeks of gestation or an amniotic fluid index (AFI) that falls below the 5th percentile.

There are several potential causes of oligohydramnios, including premature rupture of membranes, Potter sequence, bilateral renal agenesis with pulmonary hypoplasia, intrauterine growth restriction, post-term gestation, and pre-eclampsia. These conditions can all contribute to a reduction in the amount of amniotic fluid present in the womb, which can have significant implications for fetal development and health. It is important for healthcare providers to monitor amniotic fluid levels and identify any potential causes of oligohydramnios in order to provide appropriate care and support for both the mother and the developing fetus.

Hyperreflexia and clonus are commonly observed in patients with severe pre-eclampsia, while a decrease in platelet count may indicate the onset of HELLP syndrome.

Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

According to NICE guidelines, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, or mefenamic acid should be the first-line treatment for primary dysmenorrhoea, unless contraindicated. Combined oral contraceptives (COCs) containing ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are also recommended for women who do not wish to conceive. However, for a non-sexually active woman, a non-hormonal drug would be more appropriate. Paracetamol can be prescribed if NSAIDs are not tolerated or contraindicated. Tranexamic acid is useful for menorrhagia, not dysmenorrhoea. The diagnosis of primary dysmenorrhoea is likely if menstrual pain starts 6-12 months after menarche, before menstruation, and lasts up to 72 hours, with non-gynaecological symptoms present, and a normal pelvic examination.

Understanding Herpes Simplex Virus

Herpes simplex virus (HSV) is a common viral infection that affects humans. There are two strains of the virus, HSV-1 and HSV-2, which were previously thought to cause oral and genital herpes, respectively. However, there is now considerable overlap between the two strains. The primary infection may present with severe gingivostomatitis, while cold sores and painful genital ulceration are common features.

Management of HSV includes oral aciclovir for gingivostomatitis and genital herpes, and topical aciclovir for cold sores, although the evidence base for the latter is modest. Patients with frequent exacerbations may benefit from longer-term aciclovir. In pregnant women, a primary attack of herpes during pregnancy at greater than 28 weeks gestation may require elective caesarean section at term. Women with recurrent herpes who are pregnant should be treated with suppressive therapy and advised that the risk of transmission to their baby is low.

The cytopathic effect of HSV can be seen in Pap smears, which show multinucleated giant cells representing infection by the virus. The 3 M’s – multinucleation, margination of the chromatin, and molding of the nuclei – are characteristic features of HSV infection. Understanding the features and management of HSV is important for effective treatment and prevention of transmission.

Benefits and Risks of Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) is a treatment used to alleviate the symptoms of menopause, such as hot flushes, sweating, and palpitations. It has been proven effective in placebo-controlled randomized studies. HRT can also improve vaginal dryness, superficial dyspareunia, and urinary frequency and urgency. Long-term therapy is required to achieve these benefits, and symptoms may recur after stopping HRT.

HRT is commonly prescribed to prevent osteoporosis, particularly if started within the first five years after menopause onset. Women with decreased bone mineral density and those with a history of osteoporotic fractures also benefit from HRT. However, protection may be lost after stopping the hormones. HRT can reduce the incidence of hip fractures by about one case per 1000 women aged <70 years and by about 8 cases per 1000 women aged 70–79 years. The Women’s Health Initiative (WHI) study revealed an increased annual risk of heart attacks in women who took combined HRT compared to those who took estrogen only. HRT may also prevent and treat dementia and related disorders by enhancing cholinergic neurotransmission and preventing oxidative cell damage, neuronal atrophy, and glucocorticoid-induced neuronal damage. However, studies have failed to provide a consensus on this aspect due to issues of selection bias and extreme heterogeneity in study participants, treatments, cognitive function tests applied, and doses of HRT. In conclusion, HRT can provide relief for menopausal symptoms, improve vaginal health, prevent osteoporosis, and reduce the risk of heart attacks. However, it may increase the risk of dementia, particularly in women aged 65 years who take combination HRT and have relatively low cognitive function at the start of treatment. Therefore, the benefits and risks of HRT should be carefully considered before starting treatment.

The copper intrauterine device is the only suitable method for this patient as it can be used as emergency contraception if inserted within 5 days of unprotected sexual intercourse or within 5 days of the estimated ovulation date, whichever is later. As the patient has a regular 28-day cycle and is currently at day 17, she is within the 5-day window for fitting of the IUD. Levonorgestrel, a tablet used for emergency contraception, would not be suitable as it must be taken within 72 hours of unprotected sexual intercourse. The Mirena intrauterine system is a hormonal device used for regular contraception but cannot be used as emergency contraception. Norethisterone is a drug used for dysfunctional uterine bleeding and period delay but not for emergency contraception.

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.

Despite the absence of symptoms, the patient’s blood pressure remains elevated at a level exceeding 160/100 mmHg, and there is also significant proteinuria, despite receiving labetalol treatment. As a result, emergency admission is necessary to monitor and manage the hypertension in a controlled setting. If there is no improvement, delivery may be considered as an option.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

For women with no other risk factors for infertility, salpingectomy is the first-line treatment for ectopic pregnancy requiring surgical management, rather than salpingotomy. In the case of a patient with acute-onset abdominal pain and vaginal bleeding after 6-8 weeks following her last period, a positive pregnancy test, and ultrasound findings confirming an ectopic pregnancy, laparoscopic salpingectomy and monitoring is the correct course of action. This is especially true if the size of the ectopic pregnancy is greater than 35 mm and the beta-hCG levels are higher than 5000 IU/L. Salpingotomy may require further treatment with methotrexate and may not remove the ectopic pregnancy entirely, making salpingectomy the preferred method. Expectant management and monitoring, laparoscopic salpingotomy and monitoring, and methotrexate and monitoring are all inappropriate for this patient’s 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 salpingotomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy 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.

Breast Mass Differential Diagnosis

Breast abscesses typically present with localised breast inflammation, pain, and fever. Treatment involves antibiotics and/or incision and drainage. Early breast cancer may be asymptomatic, but may present with changes in breast size or shape, skin dimpling, nipple abnormalities, and axillary lump. Fat necrosis is a benign inflammatory process that can result from trauma or surgery, and presents as a firm, painless mass. Fibroadenoma is the most common cause of breast mass in women aged <35 years, presenting as a singular, firm, rubbery, smooth, mobile, painless mass. Diffuse cystic mastopathy is characterised by cysts of varying sizes due to hormonal changes, but typically presents with multiple lumps and is not associated with inflammation. Clinical examination and biopsy may be needed to differentiate between these conditions.

The use of combined oral contraceptive pills is completely contraindicated in patients with migraine with aura due to an increased risk of ischaemic stroke (UKMEC class 4). However, progestogen-based contraception methods and the levonorgestrel-releasing intrauterine device are considered safe (UKMEC 2) as the benefits of using these methods outweigh the potential risks. The copper intrauterine device is the only form of contraception recommended by UKMEC as having no contraindication in this condition (UKMEC 1).

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 mucus. 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 experienced heavy menstrual bleeding since their first period and have indications of a coagulation disorder in their personal or family medical history should undergo testing for such disorders, including von Willebrand’s disease. This recommendation is made by NICE CG44.

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.

First-line treatment for dysmenorrhoea involves NSAIDs, which work by inhibiting the synthesis of prostaglandins, a major contributor to menstrual pain.

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.

Contraceptives – Time to become effective (if not used on the first day of period):
Immediate: IUD
2 days: Progestin-only pill (POP)
7 days: Combined oral contraceptive (COC), injection, implant, intrauterine system (IUS)

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 mucus. 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.

The patient is suffering from thrush and requires antifungal medication. However, since the patient is pregnant, oral fluconazole cannot be prescribed due to its link with birth defects. Instead, metronidazole can be used to treat bacterial vaginosis and Trichomonas vaginalis.

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.

When a couple is trying to conceive, it is normal for it to take up to one year for them to be successful. Therefore, medical examinations are typically conducted after one year of consistent attempts to conceive. However, it may be wise to address any physical barriers that could be hindering the couple’s ability to conceive, which is why their sexual history is taken into consideration.

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 the COC is initiated on the first day of the menstrual cycle, it becomes effective immediately. However, if it is started on any other day, additional contraception such as condoms should be used for the first 7 days. The injection, implant, IUS, and POP require 7 days to become effective, while the IUD is effective immediately upon insertion.

Counselling for Women Considering the Combined Oral Contraceptive Pill

Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on the potential harms and benefits of the pill. The COC is highly effective if taken correctly, with a success rate of over 99%. However, there is a small risk of blood clots, heart attacks, and strokes, as well as an increased risk of breast and cervical cancer.

In addition to discussing the potential risks and benefits, women should also receive advice on how to take the pill. If the COC is started within the first 5 days of the menstrual cycle, there is no need for additional contraception. However, if it is started at any other point in the cycle, alternative contraception should be used for the first 7 days. Women should take the pill at the same time every day and should be aware that intercourse during the pill-free period is only safe if the next pack is started on time.

There have been recent changes to the guidelines for taking the COC. While it was previously recommended to take the pill for 21 days and then stop for 7 days to mimic menstruation, it is now recommended to discuss tailored regimes with women. This is because there is no medical benefit to having a withdrawal bleed, and options include never having a pill-free interval or taking three 21-day packs back-to-back before having a 4 or 7 day break.

Women should also be informed of situations where the efficacy of the pill may be reduced, such as vomiting within 2 hours of taking the pill, medication that induces diarrhoea or vomiting, or taking liver enzyme-inducing drugs. It is also important to discuss sexually transmitted infections and precautions that should be taken with enzyme-inducing antibiotics such as rifampicin.

Overall, counselling for women considering the COC should cover a range of topics to ensure that they are fully informed and able to make an informed decision about their contraceptive options.

Labetalol is the preferred initial medication for treating hypertension during pregnancy. While methyldopa is an option, it is not recommended as the first choice due to its association with a higher risk of postpartum depression. Ramipril, irbesartan, and bendroflumethiazide should be avoided during pregnancy as they can cause birth defects.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

Cavernosal blood gas analysis is a crucial investigation for patients presenting with priapism. In this case, the patient has a partially erect, non-painful penis that has persisted for over 4 hours, indicating non-ischaemic priapism. This type of priapism is caused by large volume arterial inflow to the penis from trauma or congenital malformation. Confirming whether the priapism is ischaemic or non-ischaemic through cavernosal blood gas analysis is essential for appropriate management. Ischaemic priapism is a medical emergency that requires aspiration of blood from the cavernosa, while non-ischaemic priapism can be managed with observation initially. In paediatric patients, a doppler ultrasound may be a better alternative to cavernosal blood gases due to the potential trauma of the procedure.

A CT pelvis is not recommended in this case as it would expose the child to unnecessary radiation. Instead, a doppler ultrasound can be used to investigate the arterial/venous blood flow in the penis. A clotting screen may be useful if the patient has a history of bleeding problems or a family history of haemoglobinopathies. However, it should not delay cavernosal blood gas analysis as it is crucial to confirm the type of priapism. Testicular ultrasound is not a useful imaging modality for investigating priapism. If an imaging modality is required to assess penile blood flow, a doppler ultrasound is the preferred option.

Understanding Priapism: Causes, Symptoms, and Management

Priapism is a medical condition characterized by a persistent penile erection that lasts longer than four hours and is not associated with sexual stimulation. There are two types of priapism: ischaemic and non-ischaemic, each with a different pathophysiology. Ischaemic priapism is caused by impaired vasorelaxation, resulting in reduced vascular outflow and trapping of de-oxygenated blood within the corpus cavernosa. Non-ischaemic priapism, on the other hand, is due to high arterial inflow, often caused by fistula formation due to congenital or traumatic mechanisms.

Priapism can affect individuals of all ages, with a bimodal distribution of age at presentation, with peaks between 5-10 years and 20-50 years of age. The incidence of priapism has been estimated at up to 5.34 per 100,000 patient-years. There are various causes of priapism, including idiopathic, sickle cell disease or other haemoglobinopathies, erectile dysfunction medication, trauma, and drug use (both prescribed and recreational).

Patients with priapism typically present acutely with a persistent erection lasting over four hours and pain localized to the penis. A history of haemoglobinopathy or medication use may also be present. Cavernosal blood gas analysis and Doppler or duplex ultrasonography can be used to differentiate between ischaemic and non-ischaemic priapism and assess blood flow within the penis. Treatment for ischaemic priapism is a medical emergency and includes aspiration of blood from the cavernosa, injection of a saline flush, and intracavernosal injection of a vasoconstrictive agent. Non-ischaemic priapism, on the other hand, is not a medical emergency and is usually observed as a first-line option.

Primary dysmenorrhoea is best treated with NSAIDs like mefenamic acid, which are the first line of treatment according to NICE guidelines. Paracetamol can be used if NSAIDs are not suitable, and a combination of both can be tried if NSAIDs alone are not effective. Hormonal options like the combined oral contraceptive pill can also be considered, but contraindications must be ruled out. The intrauterine device or copper coil is not recommended for this patient due to the risk of heavier bleeding. Instead, the intrauterine system or Mirena coil can be offered as an alternative option. While the IUS is the first-line treatment for menorrhagia, NSAIDs are the initial choice for primary dysmenorrhoea. It is important to consider the patient’s plans for conception when deciding on treatment options.

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.

When administering ulipristal acetate to individuals with severe asthma who are using oral steroids to control their condition, caution should be exercised due to the anti-glucocorticoid effect of the medication. The possibility of latex allergy should be considered when recommending barrier contraceptive methods or conducting a physical examination while wearing latex gloves. The failure to use regular contraception is a valid reason to offer emergency contraception following unprotected sexual intercourse. The use of ulipristal as emergency contraception may require caution in individuals with psoriasis, as this condition can be managed with oral steroids. However, it is important to note that oral steroids are only recommended for the individual’s asthma.

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.

When it comes to methotrexate, it is important to discontinue the drug at least six months before attempting to conceive, regardless of gender. This is because methotrexate can potentially harm sperm in males and cause early abortion in females. By allowing for a full wash-out period, the risk of DNA changes in both gametes can be minimized. While some studies suggest that paternal exposure to methotrexate within 90 days before pregnancy may not lead to congenital malformations, stillbirths, or preterm births, current guidelines recommend avoiding the drug for six months to ensure proper folic acid repletion. Therefore, options suggesting stopping methotrexate for only one or three months before conception are incorrect.

Managing Rheumatoid Arthritis During Pregnancy

Rheumatoid arthritis (RA) is a condition that commonly affects women of reproductive age, making issues surrounding conception and pregnancy a concern. While there are no official guidelines for managing RA during pregnancy, expert reviews suggest that patients with early or poorly controlled RA should wait until their disease is more stable before attempting to conceive.

During pregnancy, RA symptoms tend to improve for most patients, but only a small minority experience complete resolution. After delivery, patients often experience a flare-up of symptoms. It’s important to note that certain medications used to treat RA are not safe during pregnancy, such as methotrexate and leflunomide. However, sulfasalazine and hydroxychloroquine are considered safe.

Interestingly, studies have shown that the use of TNF-α blockers during pregnancy does not significantly increase adverse outcomes. However, many patients in these studies stopped taking the medication once they found out they were pregnant. Low-dose corticosteroids may also be used to control symptoms during pregnancy.

NSAIDs can be used until 32 weeks, but should be withdrawn after that due to the risk of early closure of the ductus arteriosus. Patients with RA should also be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation. Overall, managing RA during pregnancy requires careful consideration and consultation with healthcare professionals.

Antenatal care guidelines were issued by NICE in March 2008, which included specific points for the care of healthy pregnant women. Nausea and vomiting can be treated with natural remedies such as ginger and acupuncture on the ‘p6’ point, as recommended by NICE. Antihistamines, with promethazine as the first-line option according to the BNF, can also be used. Adequate vitamin D intake is crucial for the health of both the mother and baby, and women should be informed about this at their booking appointment. The Chief Medical Officer advises all pregnant and breastfeeding women to take a daily supplement containing 10 micrograms of vitamin D, with particular care taken for those at risk. In 2016, new guidelines were proposed by the Chief Medical Officer regarding alcohol consumption during pregnancy. The government now advises pregnant women not to drink any alcohol to minimize the risk of harm to the baby.

Investigations for Male Infertility: Which Tests are Necessary?

Testing for chlamydia is an important part of the initial screening investigations for primary infertility, according to The National Institute for Health and Care Excellence (NICE) guidance. This test should be carried out in primary care prior to referring the couple to secondary care fertility services. On the other hand, screening for gonorrhoea does not form part of these investigations, as it does not tend to affect a patient’s ability to conceive and does not usually remain asymptomatic in affected individuals. Anti-sperm antibodies can be used in secondary care as part of the investigation for couples who are struggling to conceive. However, it would not usually be done in primary care. The NICE guidance on fertility management in men advises that couples who have been trying to conceive after one year of regular intercourse should be referred to fertility services. Watching and waiting would not be appropriate in this situation, as the couple has been trying to conceive for 24 months. Finally, a testicular biopsy is indicated for investigation of potential testicular carcinoma or for sperm retrieval for in-vitro fertilisation procedures. This patient has a normal testicular examination and there is no indication for a testicular biopsy at this point.

If enzyme-inducing drugs are taken at the same time as the combined oral contraceptive pill, its effectiveness is decreased. Out of the given choices, only St John’s wort is an enzyme inducer, while the rest are enzyme inhibitors.

Counselling for Women Considering the Combined Oral Contraceptive Pill

Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on the potential harms and benefits of the pill. The COC is highly effective if taken correctly, with a success rate of over 99%. However, there is a small risk of blood clots, heart attacks, and strokes, as well as an increased risk of breast and cervical cancer.

In addition to discussing the potential risks and benefits, women should also receive advice on how to take the pill. If the COC is started within the first 5 days of the menstrual cycle, there is no need for additional contraception. However, if it is started at any other point in the cycle, alternative contraception should be used for the first 7 days. Women should take the pill at the same time every day and should be aware that intercourse during the pill-free period is only safe if the next pack is started on time.

There have been recent changes to the guidelines for taking the COC. While it was previously recommended to take the pill for 21 days and then stop for 7 days to mimic menstruation, it is now recommended to discuss tailored regimes with women. This is because there is no medical benefit to having a withdrawal bleed, and options include never having a pill-free interval or taking three 21-day packs back-to-back before having a 4 or 7 day break.

Women should also be informed of situations where the efficacy of the pill may be reduced, such as vomiting within 2 hours of taking the pill, medication that induces diarrhoea or vomiting, or taking liver enzyme-inducing drugs. It is also important to discuss sexually transmitted infections and precautions that should be taken with enzyme-inducing antibiotics such as rifampicin.

Overall, counselling for women considering the COC should cover a range of topics to ensure that they are fully informed and able to make an informed decision about their contraceptive options.