The use of Nexplanon® IMP is not limited by age and is licensed for contraception for a period of 3 years. It contains 68 mg etonogestrel and doesn’t pose an increased risk of VTE, stroke, or MI. Additionally, it has not been found to have a significant impact on bone mineral density (BMD). While the progesterone-only injectable contraceptive may initially decrease BMD, this effect is not exacerbated by menopause.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

There is not enough evidence to recommend any specific treatment for recurrent BV in primary care. However, in women with an intrauterine contraceptive device and persistent BV, it may be advisable to remove the device and suggest an alternative form of contraception.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

The use of combined hormonal contraceptive pills can lead to a decreased risk of ovarian and endometrial cancer that can last for many years even after discontinuation. However, for women under 35 years of age who smoke, the UKMEC category is 2, indicating that the benefits of using the method generally outweigh the potential risks. For women over 35 years of age who smoke, the UKMEC category is 3 if they smoke less than 15 cigarettes a day and 4 if they smoke more than 15 cigarettes a day.

While some meta-analyses have shown a slightly increased risk of breast cancer among women using COCP, there is no significant risk of breast cancer after 10 years of discontinuation. Additionally, COCP can help reduce menstrual bleeding and pain, as well as alleviate menopausal symptoms.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

Management of Asymptomatic Fibroids in Women

The absence of menorrhagia is an important point to note in the management of asymptomatic fibroids in women. According to guidelines, annual follow-up to monitor size and growth is recommended for such cases. However, routine referral to a gynaecologist is not required unless there are symptoms that have not improved despite initial treatments, complications, fertility or obstetric problems associated with fibroids, or a suspicion of malignancy. Treatment options for menorrhagia associated with fibroids are available but have no role in the management of small asymptomatic fibroids. NSAIDs and/or tranexamic acid should be stopped if symptoms have not improved within three menstrual cycles. It is important to consider these factors when managing asymptomatic fibroids in women.

If a woman has symptoms of candidiasis or BV and is unlikely to have an STI or serious illness, vaginal examination may be unnecessary. However, if a woman has vaginal discharge and a history of BV or candidiasis, and is not pregnant or postnatal, and has not recently undergone a gynecological procedure, examination should not be omitted.

Understanding Vaginal Discharge: Common and Less Common Causes

Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a serious health issue. In fact, some amount of discharge is normal and helps to keep the vagina clean and healthy. However, when the discharge is accompanied by other symptoms such as itching, burning, or a foul odor, it may be a sign of an underlying condition.

The most common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. Candida is a fungal infection that can cause a thick, white discharge that resembles cottage cheese. Trichomonas vaginalis is a sexually transmitted infection that can cause a yellow or green, frothy discharge with a strong odor. Bacterial vaginosis is a bacterial infection that can cause a thin, gray or white discharge with a fishy odor.

Less common causes of vaginal discharge include gonorrhea, chlamydia, ectropion, foreign bodies, and cervical cancer.

The addition of progestogen to HRT has been found to increase the risk of breast cancer. However, this risk is dependent on the duration of treatment and decreases after discontinuing HRT. It is important to note that this increased risk doesn’t affect the likelihood of dying from breast cancer. HRT with oestrogen alone may have no or reduced risk of coronary heart disease, while combined HRT has little to no increase in the risk of CHD. It is worth noting that there is no HRT available that contains progestogen only. Although NICE doesn’t provide specific risk analysis for ovarian cancer in women taking HRT, a meta-analysis suggests an increased risk for both oestrogen-only and combined HRT preparations.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

According to NICE, the treatment of premenstrual syndrome should be approached from various angles, taking into account the severity of symptoms and the patient’s preferences. Effective treatment options include non-steroidal anti-inflammatory drugs taken orally, combined oral contraceptive, cognitive behavioural therapy and selective serotonin reuptake inhibitors. However, the copper intrauterine device, tricyclic antidepressants, diazepam and progestogen only pill are not recommended as treatment options.

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

If Bartholin’s cysts are asymptomatic, there is no need for any intervention. However, if they cause symptoms or affect the appearance, they can be treated by incision and drainage. In women over 40, a biopsy may be recommended by some gynaecologists to rule out carcinoma.

If the cyst becomes infected and turns into an abscess, the initial treatment would be marsupialisation. Alternatively, a word catheter can be inserted. Antibiotics are not effective in managing a cyst that is not accompanied by an abscess.

Bartholin’s cyst occurs when the Bartholin duct’s entrance becomes blocked, causing mucous to build up behind the blockage and form a mass. This blockage is usually caused by vulval oedema and is typically sterile. These cysts are often asymptomatic and painless, but if they become large, they may cause discomfort when sitting or superficial dyspareunia. On the other hand, Bartholin’s abscess is extremely painful and can cause erythema and deformity of the affected vulva. Bartholin’s abscess is more common than the cyst, likely due to the asymptomatic nature of the cyst in most cases.

Bartholin’s cysts are usually unilateral and 1-3 cm in diameter, and they should not be palpable in healthy individuals. Limited data suggest that around 3000 in 100,000 asymptomatic women have Bartholin’s cysts, and these cysts account for 2% of all gynaecological appointments. The risk factors for developing Bartholin’s cyst are not well understood, but it is thought to increase in incidence with age up to menopause before decreasing. Having one cyst is a risk factor for developing a second.

Asymptomatic cysts generally do not require intervention, but in older women, some gynaecologists may recommend incision and drainage with biopsy to exclude carcinoma. Symptomatic or disfiguring cysts can be treated with incision and drainage or marsupialisation, which involves creating a new orifice through which glandular secretions can drain. Marsupialisation is more effective at preventing recurrence but is a longer and more invasive procedure. Antibiotics are not necessary for Bartholin’s cyst without evidence of abscess.

References:
1. Berger MB, Betschart C, Khandwala N, et al. Incidental Bartholin gland cysts identified on pelvic magnetic resonance imaging. Obstet Gynecol. 2012 Oct;120(4):798-802.
2. Kaufman RH, Faro S, Brown D. Benign diseases of the vulva and vagina. 5th ed. Philadelphia, PA: Elsevier Mosby; 2005:240-249.
3. Azzan BB. Bartholin’s cyst and abscess: a review of treatment of 53 cases. Br J Clin Pract. 1978 Apr;32(4):101-2.

The progestogen-only pill (POP) is available in different formulations including desogestrel, norethisterone, and levonorgestrel. The DSG pill may be more effective in suppressing ovulation and managing pain associated with endometriosis, menstruation, and ovulation. There is no evidence of increased risks of stroke, MI, VTE, or breast cancer associated with POP use. The traditional POP becomes more effective in older users. The UKMEC category for women over 45 years is 1 if there are no other contraindications.

Pros and Cons of the Progestogen Only Pill

The progestogen only pill, also known as the mini-pill, has its advantages and disadvantages. One of its main advantages is its high effectiveness, with a failure rate of only 1 per 100 woman years. It also doesn’t interfere with sex and its contraceptive effects are reversible upon stopping. Additionally, it can be used while breastfeeding and in situations where the combined oral contraceptive pill is contraindicated, such as in smokers over 35 years of age and women with a history of venous thromboembolic disease.

However, the progestogen only pill also has its disadvantages. One common adverse effect is irregular periods, with some users not having periods while others may experience irregular or light periods. It also doesn’t protect against sexually transmitted infections and has an increased incidence of functional ovarian cysts. Common side-effects include breast tenderness, weight gain, acne, and headaches, although these symptoms generally subside after the first few months. Overall, the progestogen only pill may be a suitable contraceptive option for some women, but it’s important to weigh its pros and cons before deciding to use it.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

Breast cancers can be detected by the presence of the tumour marker CA 15-3.

Understanding Tumour Markers

Tumour markers are substances that can be found in the blood, urine, or tissues of people with cancer. They are used to help diagnose and monitor cancer, as well as to determine the effectiveness of treatment. Tumour markers can be divided into different categories, including monoclonal antibodies against carbohydrate or glycoprotein tumour antigens, tumour antigens, enzymes, and hormones. However, it is important to note that tumour markers usually have a low specificity, meaning that they can also be present in people without cancer.

Monoclonal antibodies are a type of tumour marker that target specific carbohydrate or glycoprotein tumour antigens. Some examples of monoclonal antibodies and their associated cancers include CA 125 for ovarian cancer, CA 19-9 for pancreatic cancer, and CA 15-3 for breast cancer.

Tumour antigens are another type of tumour marker that are produced by cancer cells. Examples of tumour antigens and their associated cancers include prostate specific antigen (PSA) for prostatic carcinoma, alpha-feto protein (AFP) for hepatocellular carcinoma and teratoma, carcinoembryonic antigen (CEA) for colorectal cancer, S-100 for melanoma and schwannomas, and bombesin for small cell lung carcinoma, gastric cancer, and neuroblastoma.

Understanding tumour markers and their associations with different types of cancer can aid in the diagnosis and management of cancer. However, it is important to interpret tumour marker results in conjunction with other diagnostic tests and clinical findings.

The UKMEC provides guidance for healthcare providers when selecting appropriate contraceptives based on a patient’s medical history. For women with an undiagnosed breast mass, starting the combined hormonal contraceptive pill is considered UKMEC 3, while continuing its use is classified as UKMEC 2. It is important to note that hormonal contraceptives may impact the prognosis of women with current or past breast cancer, which is classified as UKMEC 4 and UKMEC 3, respectively. Women with benign breast conditions or a family history of breast cancer are classified as UKMEC 1.

The choice of contraceptive for women may be affected by comorbidities. The FSRH provides UKMEC recommendations for different conditions. Smoking increases the risk of cardiovascular disease, and the COCP is recommended as UKMEC 2 for women under 35 and UKMEC 3 for those over 35 who smoke less than 15 cigarettes/day, but is UKMEC 4 for those who smoke more. Obesity increases the risk of venous thromboembolism, and the COCP is recommended as UKMEC 2 for women with a BMI of 30-34 kg/m² and UKMEC 3 for those with a BMI of 35 kg/m² or more. The COCP is contraindicated for women with a history of migraine with aura, but is UKMEC 3 for those with migraines without aura and UKMEC 2 for initiation. For women with epilepsy, consistent use of condoms is recommended in addition to other forms of contraception. The choice of contraceptive for women taking anti-epileptic medication depends on the specific medication, with the COCP and POP being UKMEC 3 for most medications, while the implant is UKMEC 2 and the Depo-Provera, IUD, and IUS are UKMEC 1. Lamotrigine has different recommendations, with the COCP being UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS being UKMEC 1.

Contraindications for Combined Oral Contraceptive Pill

The decision to prescribe the combined oral contraceptive pill is based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential cautions and contraindications on a four-point scale. UKMEC 1 represents a condition for which there is no restriction for the use of the contraceptive method, while UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, immobility, and a family history of thromboembolic disease in first-degree relatives under 45 years old. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension.

In 2016, the UKMEC was updated to reflect that breastfeeding between 6 weeks and 6 months postpartum is now classified as UKMEC 2 instead of UKMEC 3. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. It is important for healthcare providers to consider these contraindications when deciding whether to prescribe the combined oral contraceptive pill to their patients.

Copper IUD as Emergency Contraception in the UK

A copper-containing intrauterine device (IUD) can be used as emergency contraception in the UK. It can be inserted within 120 hours (five days) of the first episode of unprotected sexual intercourse or up to five days after the earliest expected date of ovulation, regardless of the number of episodes or time since unprotected sex. A negative pregnancy test is not required before insertion of the copper IUD as emergency contraception.

It is important to note that the copper IUD should not be used from 48 hours to four weeks postpartum, as it falls under the UK medical eligibility criteria category 3. This means that it is advised not to be used during this time. Additionally, there is no need for the patient to have taken the progesterone emergency contraception pill beforehand as they will be using the copper device as their emergency contraception. Overall, the copper IUD is a safe and effective option for emergency contraception in the UK.

1. Having First Child at a Young Age

Decreases Risk: Having the first child at a young age is actually associated with a lower risk of breast cancer. Women who have their first child before age 30, especially before age 20, tend to have a reduced risk compared to those who have children later in life or not at all.

Explanation: Early pregnancy reduces the total number of menstrual cycles a woman has over her lifetime, reducing exposure to estrogen and progesterone, which are associated with breast cancer development.

2. Early Menopause

Decreases Risk: Experiencing menopause at an earlier age is associated with a lower risk of breast cancer.

Explanation: Early menopause means fewer menstrual cycles and reduced lifetime exposure to estrogen, which is linked to the development of breast cancer.

3. Multiparity (Having Multiple Pregnancies)

Decreases Risk: Having multiple pregnancies generally reduces the risk of breast cancer.

Explanation: Similar to having a first child at a young age, multiple pregnancies lower the total number of menstrual cycles and thereby reduce lifetime hormone exposure, decreasing breast cancer risk.

4. A Mother Who Has Breast-Fed Her Baby

Decreases Risk: Breastfeeding is associated with a lower risk of breast cancer.

Explanation: Breastfeeding reduces the number of menstrual cycles, which reduces hormone exposure. Additionally, lactation may lead to changes in breast cells that make them more resistant to cancer.

5. Hormone Replacement Therapy (HRT)

Increases Risk: Hormone replacement therapy, particularly combined estrogen-progesterone therapy, is associated with an increased risk of breast cancer.

Explanation: HRT increases the exposure to estrogen and progesterone, which can promote the development and growth of hormone-sensitive breast cancer cells. The risk is higher with longer duration of use and decreases after stopping the therapy.

Suspected Cancer Referral for Breast Cancer

According to NICE guidance on suspected cancer: recognition and referral (NG12), individuals with certain symptoms should be considered for a suspected cancer pathway referral for breast cancer. These symptoms include skin changes that suggest breast cancer or an unexplained lump in the axilla for individuals aged 30 and over.

It is important to note that a suspected cancer pathway referral means that the individual should be seen by a specialist within 2 weeks of referral. This allows for prompt diagnosis and treatment, which can greatly improve outcomes for individuals with breast cancer.

Patients with recurrent vaginal candidiasis, defined as experiencing four or more documented episodes in one year with at least partial symptom resolution between episodes, should be considered for an induction-maintenance regime of oral fluconazole, according to NICE guidance. This involves prescribing an induction course of three doses of oral fluconazole 150 mg taken three days apart or an intravaginal antifungal for 10-14 days, followed by a maintenance regimen of six months of treatment with an oral or intravaginal antifungal.

While topical antifungals can be used for uncomplicated episodes of vaginal thrush, prescribing a course of topical treatment would be inappropriate for patients with recurrent symptoms. Instead, the induction-maintenance regime should be used.

Referral to gynaecology or dermatology may be appropriate for patients aged 12-15 years old, those with doubt about the diagnosis, those with unexplained treatment failure, or those with a non-albicans Candida species identified. Swabbing the discharge to confirm the diagnosis is important, but treatment should not be delayed for symptomatic patients. Therefore, starting treatment with the induction-maintenance protocol is appropriate for patients with recurrent infections.

Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

If simple analgesia with paracetamol and NSAIDs is not effective in treating endometriosis symptoms, hormonal treatment with the combined oral contraceptive pill or a progestogen should be considered.

Although a referral to gynaecology may be necessary due to the recurrence of symptoms and potential pelvic/bowel involvement, primary care can offer further treatment options in the meantime. Hormonal treatment is recommended for this patient, and the combined oral contraceptive pill or any progestogen options can be considered. As the patient plans to start a family soon, a hormonal option that can be quickly reversed is preferred.

Buscopan is not an appropriate treatment for endometriosis. While it may provide some relief for pelvic symptoms during menstruation, it is not a treatment for the condition. It may be used to alleviate cramps associated with irritable bowel syndrome.

Injectable depo-provera is not the best option for this patient as it may delay the return of fertility, which conflicts with her desire to start a family soon.

Opioid analgesia is not recommended for endometriosis treatment as it carries the risk of side effects and dependence. It is not a suitable long-term solution for managing symptoms.

Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

Referral to gynaecology is necessary to rule out endometrial cancer due to the patient’s past experience of intermenstrual bleeding.

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. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. 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 of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be 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.

Breast Lumps and Referral to a Breast Clinic

Breast lumps are a common concern among women, and it is important to know when to seek medical attention. If a woman over the age of 30 has a discrete lump that persists after their next period or presents after menopause, referral to a breast clinic should be considered. However, if the lump is of very recent onset and the patient is premenstrual, referral may not be necessary at this stage.

Benign breast lumps tend to be firm or rubbery, often painful, regular or smooth, mobile, and have no nipple or skin signs. On the other hand, malignant lumps are hard, 90% painless, irregular, fixed, and may have skin dimpling, nipple retraction, or bloody discharge.

It is important to note that evening primrose oil is not a treatment for breast lumps, and there is little evidence to suggest it helps with mastalgia. Despite being marketed as a treatment for this condition, it is not a substitute for medical advice and evaluation.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods. 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 with no 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.

The causes of amenorrhoea vary depending on the type. Primary amenorrhoea may be caused by 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, and thyrotoxicosis. Meanwhile, secondary amenorrhoea may be caused by stress, excessive exercise, PCOS, Sheehan’s syndrome, Asherman’s syndrome, and other underlying medical conditions.

To diagnose amenorrhoea, initial investigations may include pregnancy tests, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels. Management of amenorrhoea involves treating the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause and treat the underlying cause accordingly. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis and other complications.

In conclusion, amenorrhoea is a condition that requires proper diagnosis and management. Understanding the causes and appropriate investigations can help in providing the necessary treatment and care for women experiencing this condition.

Importance of HPV Testing in Cervical Cancer Screening

The presence of high-risk HPV strains, such as 16 and 18, increases the likelihood of malignant changes in the cervical transmission zone. Therefore, a borderline change in this area is significant and should prompt a referral for colposcopy. In the past, before HPV testing was available, the advice would have been to repeat the smear test in six months. However, repeating the smear test after five years, as recommended for women over 50 in England, doesn’t take into account the abnormal result. It is important to understand that there is no antiviral treatment for HPV, so the use of aciclovir would be inappropriate. Currently, vaccination for HPV is only given to 12-13-year-old girls. Regular cervical cancer screening, including HPV testing, is crucial for early detection and prevention of cervical cancer.

If a patient on the combined oral contraceptive pill misses two or more pills and has had unprotected sexual intercourse during the pill-free period or week 1 of the pill packet, emergency contraception should be considered. However, if the patient has only missed one pill, like in this case where the patient missed one pill on day 9, emergency contraception is not necessary. A pregnancy test is also not required at this point. However, if the patient had missed two pills and had a history of erratic pill-taking, a pregnancy test would be recommended before prescribing emergency contraception.

If the patient had missed two pills during days 1-7 of the pill packet and had unprotected sex during this time, emergency contraception should be offered. The choice of emergency contraception depends on various factors such as the timing of the unprotected intercourse event, other medications the patient may be taking, and their preferences. EllaOne (ulipristal acetate) can be used up to 120 hours after unprotected intercourse, while Levonelle (levonorgestrel) can be used up to 96 hours after unprotected intercourse.

Offering to insert a copper coil to prevent pregnancy would be inappropriate in this case as emergency contraception is not required. However, if the patient is having trouble remembering to take their pill correctly and wishes to consider a long-acting contraceptive, options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection can be discussed. It is important to note that the contraceptive injection cannot be used as a form of emergency contraception.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during 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. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she 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 seven days on, seven days off.

Pruritus vulvae can usually be attributed to an underlying cause, which can be determined through a thorough history and physical examination. The most common cause is contact dermatitis, but there are various skin conditions and infections that can also lead to vulval itching, including psoriasis, lichen simplex/planus/sclerosus, candidiasis, trichomoniasis, scabies, pubic lice, and even (pre-)malignant conditions like VIN.

Prescribing medication over the phone, video-link, or online is permitted by the GMC, as long as the healthcare provider is satisfied with the consultation and has taken into account the limitations of the communication medium and the need for examination or access to the patient’s records.

The patient has control over their information and can disclose any relevant details over the phone. Depending on the potential diagnoses, swabs and urine samples may be necessary.

Pruritus vulvae, or vaginal itching, is a common issue that affects approximately 1 in 10 women who may seek medical assistance at some point. Unlike pruritus ani, pruritus vulvae typically has an underlying cause. The most common cause is irritant contact dermatitis, which can be triggered by latex condoms or lubricants. Other potential causes include atopic dermatitis, seborrhoeic dermatitis, lichen planus, lichen sclerosus, and psoriasis, which is seen in around one-third of patients with psoriasis.

To manage pruritus vulvae, women should be advised to take showers instead of baths and clean the vulval area with an emollient such as Epaderm or Diprobase. It is recommended to clean only once a day as repeated cleaning can worsen the symptoms. Most of the underlying conditions can be treated with topical steroids. If seborrhoeic dermatitis is suspected, a combined steroid-antifungal treatment may be attempted. Overall, seeking medical advice is recommended for proper diagnosis and treatment of pruritus vulvae.

Partner notification is not necessary for bacterial vaginosis as it is not considered a sexually transmitted infection.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

If a woman has two consecutive inadequate samples during cervical cancer screening, she should be referred for colposcopy. This is because if the cytology results are abnormal and show high-grade dyskaryosis (moderate or severe), colposcopy should be offered within 2 weeks. For those with inadequate, borderline, or low-grade dyskaryosis (mild) results, they should receive an appointment within 6 weeks. It is not possible for the woman to return to routine recall as her samples were inadequate. Repeat hrHPV tests would only be necessary if the woman had positive hrHPV and normal cytology results.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

The combined oral contraceptive pill (COC) is not recommended for individuals with current gallbladder disease as per the United Kingdom Medical Eligibility Criteria (UKMEC) 3. This is because the risks of using COC outweigh the benefits, as it may increase the risk of gallbladder disease and worsen existing conditions. However, if the patient has undergone cholecystectomy or is asymptomatic, COC may be considered as per UKMEC 2.

The patient’s age is not a factor in determining the suitability of COC in this scenario, as being aged 40 or over is the only age-related UKMEC 3.

The patient’s BMI is within an acceptable range for COC use.

Breastfeeding less than six weeks postpartum is not recommended as per UKMEC 4, as it poses an unacceptable risk to health. From two weeks to six months, it is UKMEC 2, and from six months onwards, it is UKMEC 1.

Smoking ten cigarettes per day is only a UKMEC 3 if the patient is over 35 years of age.

Contraindications for Combined Oral Contraceptive Pill

The decision to prescribe the combined oral contraceptive pill is based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential cautions and contraindications on a four-point scale. UKMEC 1 represents a condition for which there is no restriction for the use of the contraceptive method, while UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, immobility, and a family history of thromboembolic disease in first-degree relatives under 45 years old. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension.

In 2016, the UKMEC was updated to reflect that breastfeeding between 6 weeks and 6 months postpartum is now classified as UKMEC 2 instead of UKMEC 3. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. It is important for healthcare providers to consider these contraindications when deciding whether to prescribe the combined oral contraceptive pill to their patients.

A woman under 30 years old who presents with an unexplained breast lump, with or without pain, may not meet the 2-week-wait referral criteria but can still be referred for further evaluation. The most likely diagnosis is a fibroadenoma, which is a common benign breast lump that often occurs in younger women. These lumps are typically firm, smooth, and highly mobile, and can be described as a breast mouse due to their tendency to move away from the examiner’s hand. While a referral to a breast clinic is necessary, routine referral is appropriate given the low likelihood of cancer. There is no need to arrange mammograms or ultrasounds as these will be done by the breast clinic. Reviewing the patient in one month is unnecessary as the lump has persisted for two months and is not cyclical. Urgent referral to a breast clinic is not necessary given the patient’s age and low likelihood of breast cancer. According to NICE CKS, a 2-week-wait referral is recommended for those over 30 years old with an unexplained breast lump, or over 50 years old with unilateral nipple changes. Consideration of a 2-week-wait referral is also recommended for those over 30 years old with an unexplained lump in the axilla or skin changes suggestive of breast cancer.

In 2015, NICE released guidelines for referring individuals suspected of having breast cancer. If a person is 30 years or older and has an unexplained breast lump with or without pain, they should be referred using a suspected cancer pathway referral for an appointment within two weeks. Similarly, if a person is 50 years or older and experiences discharge, retraction, or other concerning changes in one nipple only, they should also be referred using this pathway. If a person has skin changes that suggest breast cancer or is 30 years or older with an unexplained lump in the axilla, a suspected cancer pathway referral should be considered for an appointment within two weeks. For individuals under 30 years old with an unexplained breast lump with or without pain, a non-urgent referral should be considered.

No additional contraception is needed if an LNG-IUS or Levonorgestrel-IUS is inserted on day 1-7 of the cycle. However, if it is inserted outside this timeframe, 7 days of additional contraception is required. Since the patient is currently on day 6 of her cycle, there is no need for extra precautions.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

The initial treatment for cyclical mastalgia involves wearing a supportive bra and taking simple analgesia, as stated by NICE guidelines. This type of breast pain is linked to hormonal changes during the menstrual cycle. Simple analgesia options include paracetamol and NSAIDs, while codeine is not advised. The use of Cerazette, a progesterone-only contraceptive pill, may exacerbate breast tenderness. NICE guidelines do not recommend the use of vitamin E or primrose oil.

Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

Patients with bacterial vaginosis who have a history of clue cells can be treated with topical clindamycin as an alternative to metronidazole, according to the BNF. This is particularly useful for patients who are allergic to metronidazole.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

According to BASHH, recurrent vaginal candidiasis is characterized by experiencing four or more episodes per year. This criterion is significant as it helps determine the need for prophylactic treatment to prevent future recurrences.

Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

If a patient with primary amenorrhea has elevated FSH/LH levels, it may indicate gonadal dysgenesis, such as Turner’s syndrome.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods. 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 with no 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.

The causes of amenorrhoea vary depending on the type. Primary amenorrhoea may be caused by 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, and thyrotoxicosis. Meanwhile, secondary amenorrhoea may be caused by stress, excessive exercise, PCOS, Sheehan’s syndrome, Asherman’s syndrome, and other underlying medical conditions.

To diagnose amenorrhoea, initial investigations may include pregnancy tests, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels. Management of amenorrhoea involves treating the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause and treat the underlying cause accordingly. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis and other complications.

In conclusion, amenorrhoea is a condition that requires proper diagnosis and management. Understanding the causes and appropriate investigations can help in providing the necessary treatment and care for women experiencing this condition.

HPV Triage in NHS Cervical Cancer Screening Programme

HPV triage is a new addition to the NHS cervical cancer screening programme. It involves testing cytology samples of women with borderline changes or mild dyskaryosis for high-risk HPV types that are linked to cervical cancer development. The aim is to refer only those who need further investigation and treatment, as low-grade abnormalities often resolve on their own.

If a woman tests negative for high-risk HPV, she is simply returned to routine screening recall. However, if she tests positive, she is referred for colposcopy. HPV testing is also used as a ‘test of cure’ for women who have been treated for cervical intraepithelial neoplasia and have returned for follow-up cytology. Those who are HPV negative are returned to 3 yearly recall. This new approach ensures that women receive the appropriate level of care and reduces unnecessary referrals for colposcopy.

Managing Heavy Menstrual Bleeding

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

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

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

The approach to managing secondary dysmenorrhoea varies depending on the root cause.

Understanding Dysmenorrhoea

Dysmenorrhoea is a medical condition that is characterized by excessive pain during the menstrual period. It is classified into two types: primary and secondary dysmenorrhoea. Primary dysmenorrhoea affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. It is caused by excessive endometrial prostaglandin production. The pain typically starts just before or within a few hours of the period starting and is felt as suprapubic cramping pains that may radiate to the back or down the thigh. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, while combined oral contraceptive pills are used second line.

On the other hand, secondary dysmenorrhoea typically develops many years after the menarche and is the result of 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 normal copper coils may worsen the condition.

Diagnosing Menopause According to NICE NG23

According to NICE NG23 guidelines, menopause can be diagnosed without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms. Perimenopause can be diagnosed based on vasomotor symptoms and irregular periods, while menopause can be diagnosed in women who have not had a period for at least 12 months and are not using hormonal contraception. Menopause can also be diagnosed based on symptoms in women without a uterus.

However, in women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle, and in women aged under 40 years in whom menopause is suspected, a FSH test may be considered to diagnose menopause.

In the case of a woman aged over 45 years with amenorrhoea for over 12 months, a clinical diagnosis of menopause can be made without the need for blood tests. It is important to note that premature ovarian failure is not a concern in this case as the woman is aged 48.

It is incorrect to advise the patient that she doesn’t require emergency contraception as she is at risk of pregnancy. Although oral emergency contraception may not be effective if taken after ovulation, the patient’s last menstrual period was only 10 days ago, making it a potential option. The patient has declined an intrauterine device, which is the most effective option, but should not be pressured into using it for emergency contraception. Ulipristal acetate is not recommended for the patient due to her severe asthma and use of oral steroids. It is important to note that patients with a BMI over 26 or weight over 70 kg should be given a double dose of levonorgestrel for emergency contraception. Additionally, it is crucial to discuss ongoing contraception and sexual health with the patient.

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, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

If a woman experiences both deep dyspareunia and lower abdominal pain, it is probable that she has endometriosis. However, if she is trying to conceive, she cannot use initial treatment options like the combined pill. To confirm the diagnosis, a laparoscopy is the preferred method. A pelvic ultrasound is not the most effective way to diagnose endometriosis and may not show any abnormalities in cases of mild to moderate disease.

Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

Endometriosis: A Possible Cause of Chronic Pelvic Pain

Endometriosis is a condition that can cause chronic pelvic pain, period-related pains, gastrointestinal symptoms, urinary symptoms, deep dyspareunia, and subfertility in female patients. Although a normal ultrasound scan is possible in endometriosis, a diagnostic laparoscopy may be required to make the diagnosis. It is important to consider endometriosis in a patient presenting with these symptoms, even in the absence of period-related symptoms. Other possible causes may not explain the period-related urinary symptoms, making endometriosis a likely culprit. Proper diagnosis and treatment can help alleviate the symptoms and improve the patient’s quality of life.

To avoid the need for additional barrier contraception, the woman should begin taking the pill immediately as she is currently menstruating and therefore not at risk of pregnancy. The combined contraceptive pill, except for Qlaira and Zoely, can be started within the first five days of a menstrual cycle without requiring further contraception. If started on day six or later, seven days of barrier contraception or abstinence is recommended. Waiting until day eight or the next menstrual period is unnecessary as the starting rules remain the same.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

According to NICE, women who are at a high risk of developing VTE and are seeking HRT should be referred to haematology before starting any treatment, even if it is transdermal.

While there is no evidence to suggest that transdermal HRT preparations such as patches or gels increase the risk of VTE, it is recommended to seek specialist advice before starting treatment if there are any risk factors present.

For patients with a high risk of VTE, oral HRT, whether it is combined or oestrogen-only, would be risky. Although per vaginal oestrogen would be a safer option, it would only provide local relief and may not alleviate all of the patient’s symptoms.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

The FSRH advises that women who experience problematic bleeding for more than three months after starting the contraceptive implant should undergo a clinical examination, including a speculum, and be screened for sexually transmitted infections if they are at risk. If a woman is experiencing these symptoms, it is not recommended to repeat her smear test outside of the screening program. Instead, if her cervix appears abnormal, she should be referred for colposcopy.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

Suspected Endometrial Cancer in postmenopausal Woman with Abnormal Bleeding

According to the 2015 NICE guidelines, women aged 55 and over with postmenopausal bleeding should be referred for suspected cancer pathway referral within two weeks. This includes women who experience unexplained vaginal bleeding more than 12 months after menstruation has stopped due to menopause.

In this case, the patient’s periods stopped 18 months ago, making her postmenopausal. Her recent bleeding episode, along with her nulliparity, obesity, menopause after 52, and family history of hereditary nonpolyposis colon cancer, all increase her risk for endometrial cancer. Although bleeding can occur when using HRT, the patient began bleeding six months after initiating HRT, and the bleeding persisted four weeks after stopping HRT, making it less likely that the medication is the cause.

Re-initiating HRT would be contraindicated until endometrial cancer is ruled out. While the patient has not experienced post-coital bleeding and has a normal-looking cervix with normal smear results, referral for colposcopy would not be the most appropriate next step. Inserting a Mirena coil may be useful in managing troublesome bleeding associated with HRT, but it would not be appropriate until the patient is investigated for endometrial cancer.

Endometrial cancer is associated with obesity, while cervical cancer is not.

Understanding Cervical Cancer and its Risk Factors

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

The most significant risk factor for cervical cancer is infection with the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus (HIV), early first intercourse, many sexual partners, high parity, and lower socioeconomic status. The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene.

While the strength of the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet in 2007 confirmed the link. It is important for women to undergo routine cervical cancer screening to detect any abnormalities early on and to discuss any potential risk factors with their healthcare provider.

The hormonal factors are responsible for the risk of ovarian cancer. Women who experience ovulation without suppression are at a higher risk. Therefore, early menarche and late menopause, which increase ovulation, are considered risk factors for ovarian cancer. On the other hand, hormone replacement therapy (HRT) and obesity, not low body weight, are also risk factors.

Pregnancy, which suppresses ovulation, is a protective factor against ovarian cancer. Similarly, the use of combined oral contraceptives is also considered protective.

The media often highlights vague symptoms such as bloating as potential signs of ovarian cancer. However, it is important to reassure patients and conduct a thorough history and examination to identify any risk factors.

Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

Qlaira is taken daily for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and 2 inactive pills. The dose of estradiol decreases gradually while the dose of dienogest increases during the cycle.

Choice of Combined Oral Contraceptive Pill

The combined oral contraceptive pill (COCP) comes in different variations based on the amount of oestrogen and progestogen and the presentation. For first-time users, it is recommended to use a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone. However, two new COCPs have been developed in recent years, namely Qlaira and Yaz, which work differently from traditional pills.

Qlaira is a combination of estradiol valerate and dienogest with a quadriphasic dosage regimen designed to provide optimal cycle control. The pill is taken every day for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and two pills being inactive. The dose of estradiol is gradually reduced, and that of dienogest is increased during the cycle to give women a more natural cycle with constant oestrogen levels. However, Qlaira is more expensive than standard COCPs, and there is limited safety data to date.

On the other hand, Yaz combines 20mcg ethinylestradiol with 3mg drospirenone and has a 24/4 regime, unlike the normal 21/7 cycle. This shorter pill-free interval is better for patients with troublesome premenstrual symptoms and is more effective at preventing ovulation. Studies have shown that Yaz causes less premenstrual syndrome, and blood loss is reduced by 50-60%.

In conclusion, the choice of COCP depends on various factors such as cost, safety data, and missed pill rules. It is essential to consult a healthcare provider to determine the most suitable COCP based on individual needs and medical history.

Cervical Screening Guidelines in the UK

Cervical screening is an important aspect of women’s health in the UK. The age range for screening varies between 25-64 in England and Wales, and 20-60 in Scotland. The screening interval also varies depending on the country. It is important to note that a patient who is too young or has had a normal smear test within the recommended time frame is not overdue for screening.

According to the latest guidance, women who are taking maintenance immunosuppression medication post-transplantation should follow the national guidelines for non-immunosuppressed individuals. This also applies to other special circumstances, such as HIV-positive patients, who should follow the same age range for screening as the general population.

It is important to note that being homosexual and never having had a male partner doesn’t exempt a woman from screening. Women can still be exposed to HPV through a female partner who may have had previous male partners. Therefore, all women with a cervix should be considered as screening candidates and encouraged to attend.

For women who are at high risk of STIs, have recently undergone a gynaecological or obstetric procedure (including delivery), or are pregnant, it is recommended to undergo an examination. In cases of new-onset vaginal discharge, an intimate examination is advised. If the patient has had an intrauterine system inserted recently and is experiencing a recurrence of bacterial vaginosis, an examination should be conducted before determining the next course of action.

Understanding Vaginal Discharge: Common and Less Common Causes

Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a serious health issue. In fact, some amount of discharge is normal and helps to keep the vagina clean and healthy. However, when the discharge is accompanied by other symptoms such as itching, burning, or a foul odor, it may be a sign of an underlying condition.

The most common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. Candida is a fungal infection that can cause a thick, white discharge that resembles cottage cheese. Trichomonas vaginalis is a sexually transmitted infection that can cause a yellow or green, frothy discharge with a strong odor. Bacterial vaginosis is a bacterial infection that can cause a thin, gray or white discharge with a fishy odor.

Less common causes of vaginal discharge include gonorrhea, chlamydia, ectropion, foreign bodies, and cervical cancer.

Consider referral if the cyst remains after 12 weeks.

When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate 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 whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.

For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.

Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.

Recognizing Inflammatory Breast Cancer

Most GPs and patients are familiar with the presentation of a breast lump, but inflammatory breast cancer can present in a more unusual way, making a swift diagnosis difficult. However, simply considering the possibility of this rare form of breast cancer can help pick out relevant information in the patient’s history and examination. Inflammatory breast cancer is not common, accounting for only 1-4% of all breast cancers, which can lead to delayed diagnosis in primary care. Patients with a personal or family history of breast cancer, symptoms of non-lactational mastitis that do not respond to antibiotics, palpable lymphadenopathy, involvement of more than 1/3 of the breast, and an absence of fever should be considered at high risk for inflammatory breast cancer.

It is important for GPs to ask about family history of breast cancer and check and record temperature when seeing patients with mastitis. Blindly prescribing another course of antibiotics, especially when the patient doesn’t have a fever or symptoms of infection, may delay diagnosis. Suggesting milk expression would be reasonable for lactational mastitis, but not for a patient who stopped breastfeeding six months ago. Attempting to aspirate would not be advisable for a generalist in a primary care setting, even if an abscess were suspected. Referring the patient to the Emergency department for assessment by a breast surgeon would be a wiser strategy.

Contraceptive Hormones and Pregnancy

Women who are using contraceptive hormones should not worry about any harm to the fetus if they become pregnant. It is not necessary to terminate the pregnancy for this reason. If the woman chooses to abort the pregnancy, the contraceptive implant can be left in place for ongoing contraception. Referral to an early pregnancy assessment unit or for an anomaly scan is also unnecessary as there is no risk to the fetus.

However, it is important to remove the progesterone-only implant as soon as pregnancy is confirmed. The only exception to this is if an intrauterine device is in place and pregnancy is diagnosed after 12 weeks. In such cases, the contraception should not be removed. Women can be reassured that contraceptive hormones are safe and effective for preventing pregnancy, and should not hesitate to use them if desired.

Norethisterone taken orally is a viable solution for quickly halting heavy menstrual bleeding on a temporary basis.

Managing Heavy Menstrual Bleeding

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

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

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

According to the NICE guidelines on cervical cancer screening, if an individual’s second repeat smear at 24 months is still positive for high-risk human papillomavirus (hrHPV), they should be referred for colposcopy. Prior to this, if an individual is positive for hrHPV but receives a negative cytology report, they should have the HPV test repeated at 12 months. If the HPV test is negative at 12 months, they can return to routine recall. However, if they remain hrHPV positive and cytology negative at 12 months, they should have a repeat HPV test in a further 12 months. If they become hrHPV negative at 24 months, they can safely return to routine recall.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

Breastfeeding Problems and Management

Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.

Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.

Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.

Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.

Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.

To minimize the risk of breast cancer, it is recommended to avoid adding progestogen in hormone replacement therapy (HRT). Therefore, women who have had a hysterectomy are usually prescribed oestrogen-only treatment. According to the British National Formulary (BNF), the risk of stroke remains unchanged regardless of whether the HRT preparation includes progesterone.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

For women over 40, combined hormonal contraception (COCP) can be beneficial in reducing menstrual bleeding and pain, as well as alleviating menopausal symptoms. However, it is important to consider certain factors when prescribing COCP to women over 40. The UKMEC criteria for women over 40 is 2, while for women from menarche until 40, it is 1. The Faculty of Sexual and Reproductive Health recommends the use of COCP until age 50, provided there are no other contraindications. However, women over 50 should be advised to switch to a safer alternative method of contraception, as the risks associated with COCP use outweigh the benefits. Women who smoke should stop using COCP at 35, as smoking increases the risk of mortality. While COCP is associated with a reduced risk of ovarian and endometrial cancer, there is a slightly increased risk of breast cancer among women using COCP, which diminishes after 10 years of cessation. Women using COCP for non-contraceptive benefits after the age of 50 should be considered on an individual basis using clinical judgement and informed choice.

Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

In cases of recurrent vaginal candidiasis, it is important to consider a blood test to rule out diabetes as a potential underlying cause. This is because poorly controlled diabetes can increase the risk of Candida growth. While it is important to treat the symptoms of the infection, it is also crucial to investigate any predisposing factors that may be contributing to the recurrence.

Measuring TSH, free T3 and T4 levels to rule out hyperthyroidism is not necessary as there is no link between an overactive thyroid and Candida infections. Similarly, mid-stream urine to rule out UTI is not necessary unless the patient’s symptoms suggest a urinary tract infection. Referral to a specialist is also not necessary as recurrent vaginal candidiasis can be managed in primary care with an induction-maintenance regimen of antifungals. Specialist referral may only be necessary if the infective organism is resistant to treatment or if it is a non-albicans Candida species.

Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

Mirena® License for Contraception and Endometrial Hyperplasia Protection

At the moment, question stats are not available, but it is likely that many people will choose 5 years as the answer for Mirena®’s duration of use for contraception. However, it is important to note that while Mirena® is licensed for up to 5 years for contraception and idiopathic menorrhagia, it is only licensed for 4 years for protection against endometrial hyperplasia during oestrogen replacement therapy. This means that individuals using Mirena® for this purpose should have it replaced after 4 years to ensure continued protection. It is crucial to follow the recommended duration of use for Mirena® to ensure its effectiveness and safety.

Urgent Referral for Unexplained Vulval Lump or Non-Responsive Ulceration

Any woman who discovers a new, unexplained lump or experiences ulceration that doesn’t respond to treatment should be referred urgently. It is important to note that the term pressure sore should be used with caution, as it may not accurately describe the condition.

If the ulcer appears to be caused by thrush, fluconazole may be considered. However, if the ulcer doesn’t arise from typical intertriginous areas and lacks satellite lesions or white discharge, a fungal infection is unlikely.

While primary syphilis can cause a solitary painless genital ulcer, it tends to resolve within four to eight weeks. Therefore, it is unlikely that this would be the first presentation of a lady with primary syphilis.

If the condition is suspected to be a pressure ulcer on the sacrum or another pressure point, a tissue viability nurse may be consulted. However, based on the given history, this seems unlikely. Referring to dermatology is not appropriate for a strongly suspected case of vulval carcinoma.

Women who have never had sex have a very low risk of cervical cancer and can opt out of screening, but remain eligible if they choose to do so. Screening is not recommended unless the woman develops symptoms, and the age range for screening is 25-64.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

Treatment for Dyspareunia in postmenopausal Women

This postmenopausal woman is experiencing dyspareunia due to atrophic vaginitis caused by a lack of estrogen. While topical or systemic hormone replacement therapy can be effective treatments, this patient specifically doesn’t want hormonal treatment. In this case, the best option is Sylk moisturizer, one of two non-hormonal preparations available for vaginal atrophy. Replens is the other option.

It’s important to note that KY jelly is a lubricant only and doesn’t come with an applicator. Sylk and Replens are classified as vaginal moisturizers, which can be applied every few days and provide long-lasting relief, including relief of itching. KY jelly, on the other hand, is only effective until the water evaporates, which is typically within an hour.

In summary, for postmenopausal women experiencing dyspareunia due to atrophic vaginitis, non-hormonal vaginal moisturizers like Sylk and Replens can be effective treatments.

The primary objective of cervical screening is to identify pre-cancerous alterations rather than detecting cancer.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

Hot flashes are a common side-effect of tamoxifen, as stated in the BNF. Although alopecia and cataracts are also listed as possible side-effects, they are not as frequently observed as hot flashes, particularly in women who have not yet reached menopause.

Tamoxifen and its Adverse Effects

Tamoxifen is a medication used in the treatment of breast cancer that is positive for oestrogen receptors. It is classified as a Selective oEstrogen Receptor Modulator (SERM) and works by acting as an antagonist and partial agonist of the oestrogen receptor. However, the use of tamoxifen can lead to several adverse effects. These include menstrual disturbances such as vaginal bleeding and amenorrhoea, as well as hot flashes which can cause 3% of patients to stop taking the medication due to climacteric side-effects. Additionally, tamoxifen increases the risk of venous thromboembolism and endometrial cancer.

To manage breast cancer, tamoxifen is typically prescribed for a period of 5 years following the removal of the tumour. However, due to the risk of endometrial cancer associated with tamoxifen, an alternative medication called raloxifene may be used. Raloxifene is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer. It is important for patients to discuss the potential risks and benefits of tamoxifen and other medications with their healthcare provider before starting treatment.

Patients should be cautioned that vaginal and topical imidazoles, such as clotrimazole, may harm barrier methods of contraception. However, there is no clear guidance on the duration of abstinence or use of non-barrier methods. According to NICE CKS, patients should avoid using barrier methods during treatment and for several days after stopping antifungal treatment.

Limited evidence suggests that the combined oral contraceptive pill may contribute to the development of genital Candida infection. Patients with recurrent infections may benefit from switching to the progesterone depot injection. While the IUS increases the presence of Candida, it doesn’t increase the rate of symptomatic infection.

Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

If the patient removes her IUD on day 1-5 of her menstrual cycle and switches to the combined oral contraceptive pill (COCP), she doesn’t need any additional contraception. The COCP is effective immediately if started on these days. However, if she starts the COCP from day 6 onwards, she will need to use barrier contraception for 7 days. There is no need to delay starting the COCP after IUD removal unless there is another reason. If the patient had recently taken ulipristal as an emergency contraceptive, she would need to wait for 5 days before starting hormonal contraception, but this is not the case for this patient.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

The appropriate HRT regimen for this patient is a transdermal cyclical one, as she has had a period within the last year. As she has an intact uterus, a combined regimen with both oestrogen and progesterone is necessary. Given her increased risk of venous thromboembolism and cardiovascular disease due to obesity, transdermal preparations are recommended over oral options. Low-dose vaginal oestrogen is not sufficient for her systemic symptoms. An oestrogen-only preparation is not appropriate for women with a uterus. A transdermal continuous combined regimen is not recommended within 12 months of the last menstrual period. If the patient cannot tolerate the transdermal option, an oral cyclical regimen may be considered.

Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

Risk Factors for Uterine Perforation with Intrauterine Contraception

The rate of uterine perforation associated with intrauterine contraception (IUC) is up to 2 per 1000 insertions, with a higher risk in breastfeeding women. According to a recent drug safety update from the medicines and healthcare products regulatory agency, the most significant risk factors for uterine perforation during IUC are insertion during lactation and insertion within 36 weeks after giving birth. Women should be informed of the risks and symptoms to recognize. Age is not a risk factor for uterine perforation. Intrauterine contraception can be inserted at any time during the menstrual cycle if it is reasonably certain that the woman is not pregnant. The Mirena intrauterine system is used to manage menorrhagia, while the copper coil can cause heavy vaginal bleeding, but menorrhagia itself is not a reported risk factor for perforation on insertion.

Guidelines for Referral of Suspected Breast Cancer

Current NICE guidelines focus on symptoms and signs of breast cancer in individuals aged 30 and over. Referral for an appointment within two weeks is recommended for those with an unexplained breast lump with or without pain, or for those aged 50 and over with nipple discharge, retraction, or other changes of concern. Non-urgent referral may be considered for those under 30 with an unexplained breast lump. However, in cases where the cause of the problem may be an ill-fitting bra, conservative management is recommended. Topical NSAIDs may be given for symptom relief, but evening primrose oil has no evidence to support its use for cyclical mastalgia. Re-examination should be considered if symptoms persist.

Lesbian and bisexual women are at risk of contracting HPV, the virus responsible for causing cervical cancer, through genital contact or oral sex. As a result, it is important for them to undergo regular cervical screening. However, the uptake of screening among lesbian women is significantly lower than that of the general female population, often due to misinformation provided by healthcare providers.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

As per the current NICE CKS guidance, it is recommended to continue iron replacement for 3 months after correcting iron deficiency anaemia, and then discontinue it.

However, in the case of this patient, it is too early to stop the iron tablets as it takes at least 3 months for iron stores to replenish. Once the replacement is adequate, prophylactic iron is not necessary as the patient’s menorrhagia has resolved.

It is important to check haemoglobin levels 2-4 weeks after starting iron tablets, and a rise of approximately 2 g/100 mL over 3-4 weeks is expected. If there is insufficient improvement despite adherence to treatment, specialist referral should be considered. In this patient’s case, the haemoglobin levels have risen adequately, and there is no need for referral.

Iron deficiency anaemia is a prevalent condition worldwide, with preschool-age children being the most affected. The lack of iron in the body leads to a decrease in red blood cells and haemoglobin, resulting in anaemia. The primary causes of iron deficiency anaemia are excessive blood loss, inadequate dietary intake, poor intestinal absorption, and increased iron requirements. Menorrhagia is the most common cause of blood loss in pre-menopausal women, while gastrointestinal bleeding is the most common cause in men and postmenopausal women. Vegans and vegetarians are more likely to develop iron deficiency anaemia due to the lack of meat in their diet. Coeliac disease and other conditions affecting the small intestine can prevent sufficient iron absorption. Children and pregnant women have increased iron demands, and the latter may experience dilution due to an increase in plasma volume.

The symptoms of iron deficiency anaemia include fatigue, shortness of breath on exertion, palpitations, pallor, nail changes, hair loss, atrophic glossitis, post-cricoid webs, and angular stomatitis. To diagnose iron deficiency anaemia, a full blood count, serum ferritin, total iron-binding capacity, transferrin, and blood film tests are performed. Endoscopy may be necessary to rule out malignancy, especially in males and postmenopausal females with unexplained iron-deficiency anaemia.

The management of iron deficiency anaemia involves identifying and treating the underlying cause. Oral ferrous sulfate is commonly prescribed, and patients should continue taking iron supplements for three months after the iron deficiency has been corrected to replenish iron stores. Iron-rich foods such as dark-green leafy vegetables, meat, and iron-fortified bread can also help. It is crucial to exclude malignancy by taking an adequate history and appropriate investigations if warranted.

The failure rate of female sterilisation is 1 in 200.

Understanding Female Sterilisation

Female sterilisation is a common method of permanent contraception for women. It has a low failure rate of 1 per 200 and is usually performed by laparoscopy under general anaesthetic. The procedure is generally done as a day case and involves various techniques such as clips (e.g. Filshie clips), blockage, rings (Falope rings) and salpingectomy. However, there are potential complications such as an increased risk of ectopic pregnancy if sterilisation fails, as well as general risks associated with anaesthesia and laparoscopy.

In the event that a woman wishes to reverse the procedure, the current success rate of female sterilisation reversal is between 50-60%. It is important for women to understand the risks and benefits of female sterilisation before making a decision.

To manage premenstrual syndrome, it is recommended to make specific lifestyle changes such as consuming 2-3 hourly small balanced meals that are rich in complex carbohydrates. This is because complex carbohydrates are more nutrient-dense and higher in fiber compared to simple carbohydrates. Consuming complex carbohydrates in smaller, frequent meals helps to stabilize blood sugar levels and provide the body with essential nutrients throughout the day, which can help control PMS symptoms. Other options have not been proven to improve the severity of symptoms.

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

Contraindications for Progestogen Only Pill

The UK Medical Eligibility Criteria (UKMEC) is used to determine whether a woman is suitable for a particular type of contraceptive. The criteria categorize potential cautions and contraindications into four levels. UKMEC 1 indicates no restriction for the use of the contraceptive method, while UKMEC 2 suggests that the advantages outweigh the disadvantages. UKMEC 3 indicates that the disadvantages generally outweigh the advantages, and UKMEC 4 represents an unacceptable health risk.

Examples of UKMEC 3 conditions that may prevent a woman from taking the progestogen only pill include active liver disease or past tumour, liver enzyme inducers, breast cancer more than 5 years ago, undiagnosed vaginal bleeding, and ischaemic heart disease and stroke (initiation = UKMEC2). On the other hand, UKMEC 4 conditions such as pregnancy and breast cancer within the last 5 years are considered unacceptable health risks and would prevent a woman from taking the progestogen only pill. It is important to consult with a healthcare provider to determine if the progestogen only pill is a suitable contraceptive option.

The diagnosis of vaginal candidiasis doesn’t necessarily require a high vaginal swab if the symptoms are highly indicative of the condition. According to NICE guidelines, if a patient presents with classic symptoms such as thick-white discharge, dysuria, itching, and dyspareunia, objective testing is not necessary to confirm the diagnosis. Therefore, the patient can be prescribed oral fluconazole without the need for a swab.

It is incorrect to assume that a healthcare professional or self-collected high vaginal swab is necessary for diagnosis. As mentioned earlier, the patient’s symptoms are highly suggestive of candidiasis, making a swab unnecessary.

Similarly, a mid-stream urine sample for sensitivities is not appropriate in this case. This type of test would be more suitable if the patient had symptoms indicative of a urinary tract infection. However, since the patient denies urinary urgency and frequency, a UTI is unlikely. The change in discharge consistency, which is characteristic of vaginal candidiasis, further supports this diagnosis. Therefore, a urine sample is not required.

Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

All sexually active individuals with a uterus, including transgender patients, should be offered cervical screening. This patient, who is sexually active and has an intact uterus, requires regular cervical smear tests regardless of their menstrual cycle or symptoms of abnormal vaginal bleeding. Testosterone therapy may affect the patient’s gender characteristics, but gender reassignment allows for legal recognition of their gender identity and rights, such as obtaining a new birth certificate, driving license, passport, and the ability to marry in their new gender. However, neither of these factors exempts the patient from cervical screening.

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

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies. For those engaging in vaginal sex, condoms and dental dams are recommended to prevent sexually transmitted infections. Cervical screening and HPV vaccinations should also be offered. Those at risk of HIV transmission should be advised of pre-exposure prophylaxis and post-exposure prophylaxis.

For individuals assigned female at birth with a uterus, testosterone therapy doesn’t provide protection against pregnancy, and oestrogen-containing regimens are not recommended as they can antagonize the effect of testosterone therapy. Progesterone-only contraceptives are considered safe, and non-hormonal intrauterine devices may also suspend menstruation. Emergency contraception may be required following unprotected vaginal intercourse, and either oral formulation or the non-hormonal intrauterine device may be considered.

In patients assigned male at birth, hormone therapy may reduce or cease sperm production, but the variability of its effects means it cannot be relied upon as a method of contraception. Condoms are recommended for those engaging in vaginal sex to avoid the risk of pregnancy. The guidance stresses the importance of offering individuals options that take into account their personal circumstances and preferences.

Breast cancer treatment often involves hormonal therapy, particularly for those with estrogen receptor-positive tumors (which account for about 80% of all breast cancers). Aromatase inhibitors like anastrozole are commonly used in postmenopausal women to target estrogen production.

However, one of the major concerns with hormonal therapy is the risk of osteoporosis. Women should undergo bone mineral density testing before starting treatment and regularly thereafter.

Tamoxifen, another drug commonly used to treat breast cancer, has been associated with side effects such as deep vein thrombosis, endometrial cancer, and vaginal bleeding. However, urinary incontinence is not a known side effect of anastrozole.

Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen may cause adverse effects such as menstrual disturbance, hot flashes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors may cause adverse effects such as osteoporosis, hot flashes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

The choice of contraceptive for women may be affected by comorbidities. The FSRH provides UKMEC recommendations for different conditions. Smoking increases the risk of cardiovascular disease, and the COCP is recommended as UKMEC 2 for women under 35 and UKMEC 3 for those over 35 who smoke less than 15 cigarettes/day, but is UKMEC 4 for those who smoke more. Obesity increases the risk of venous thromboembolism, and the COCP is recommended as UKMEC 2 for women with a BMI of 30-34 kg/m² and UKMEC 3 for those with a BMI of 35 kg/m² or more. The COCP is contraindicated for women with a history of migraine with aura, but is UKMEC 3 for those with migraines without aura and UKMEC 2 for initiation. For women with epilepsy, consistent use of condoms is recommended in addition to other forms of contraception. The choice of contraceptive for women taking anti-epileptic medication depends on the specific medication, with the COCP and POP being UKMEC 3 for most medications, while the implant is UKMEC 2 and the Depo-Provera, IUD, and IUS are UKMEC 1. Lamotrigine has different recommendations, with the COCP being UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS being UKMEC 1.

To alleviate vaginal symptoms, vaginal topical oestrogen can be used alongside HRT. Compared to systemic treatment, low-dose vaginal topical oestrogen is more effective in providing relief for vaginal symptoms. Patients should be reviewed after 3 months of treatment. It is recommended to consider stopping treatment at least once a year, but in some cases, long-term treatment may be necessary for persistent symptoms. If symptoms persist, increasing the dose or seeking specialist referral may be necessary. Testosterone supplementation is only recommended for sexual dysfunction and should be initiated after consulting a specialist. Sildenafil is not effective in treating menopausal symptoms.

Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

In women aged 50-59 who do not use HRT, the background incidence of VTE is 5 cases per 1,000. The use of oestrogen-only HRT increases the incidence by 2 cases per 1,000, while combined HRT increases it by 7 cases per 1,000. According to the BNF, tibolone doesn’t elevate the risk of VTE when compared to combined HRT.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

Suspected Inflammatory Breast Cancer

This patient’s medical history raises concerns for inflammatory breast cancer, a rare but easily missed subtype of breast cancer. Despite accounting for only 1-5% of cases, inflammatory breast cancer can be difficult to diagnose and is often initially misdiagnosed as mastitis. The patient’s unilateral nipple retraction, which she attributes to breastfeeding, is also a suspicious sign. Therefore, it is crucial to have a high level of suspicion and refer the patient to a breast clinic urgently.

In this scenario, advising the patient to stop breastfeeding, massage the nipple, or use a breast shield would not be appropriate. Referring routinely without considering the severity of the potential diagnosis would also not be appropriate. It is essential to prioritize the patient’s health and well-being by taking swift and appropriate action.

Urgent Action Required for Haemodynamically Unstable Patient

The most appropriate course of action in this case is to call 999 and request an ambulance. This patient may have an ectopic pregnancy or may be miscarrying, and is therefore unstable and requires immediate resuscitation and transfer to hospital. While waiting for the ambulance, an attempt at IV cannulation and fluid resuscitation should be made.

Arranging an assessment at the EPAU within 24 hours is inappropriate, as the patient is haemodynamically unstable and requires urgent admission via ambulance. Conducting a pelvic exam is not appropriate as this patient is haemodynamically unstable and has abdominal tenderness. Similarly, conducting a urine pregnancy test or taking blood for a serum βHCG would only cause unnecessary delay.

It is crucial to prioritize the patient’s immediate medical needs and take urgent action to ensure their safety and well-being.

If a patient has a family history of Jewish ancestry and breast cancer, they should be referred to secondary care. This is one of the criteria that require early referral, as listed below. However, the current presentation doesn’t require an urgent referral. Although the NHS Screening programme is being extended to begin at 47, this patient has valid reasons to be referred earlier.

Breast Cancer Screening and Familial Risk Factors

Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

Polycystic ovarian syndrome (PCOS) is diagnosed based on the Rotterdam criteria, which requires the presence of at least two of the following: oligo/anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovaries on ultrasound scanning. Patients may be asymptomatic or present with menstrual disturbance, infertility, obesity, male pattern hair loss, hirsutism, and acne. Blood tests can support the diagnosis, with elevated LH and testosterone levels being common findings. Mild prolactinaemia and insulin resistance may also be present. Ultrasound scanning is not necessary if the diagnosis is obvious on clinical and biochemical grounds. Confirming the diagnosis is important to rule out other potential causes and to monitor for associated health problems such as diabetes, cardiovascular disease, and endometrial cancer. Women with PCOS should have regular periods or progesterone-induced withdrawal bleeds to reduce the risk of endometrial hyperplasia and cancer.

If a woman aged 50 or above reports symptoms resembling irritable bowel syndrome within the past year, it is important to consider the possibility of ovarian cancer. While IBS is uncommon in this age group, ovarian cancer can present with similar nonspecific symptoms, and it is crucial to rule out any serious conditions.

Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

The patient is likely experiencing genital ulcers and systemic symptoms due to a primary herpes simplex genital infection, which commonly causes painful ulcers. While waiting for swab results, treatment should be initiated with an antiviral such as valaciclovir for a longer course in an initial infection.

If a simple urinary tract infection is suspected, trimethoprim for 3 days may be appropriate. However, dysuria and trace leukocytes can also be indicative of primary herpes simplex infection.

Valaciclovir is the correct treatment for this patient, but a 3-day course is insufficient for a primary infection and would be more appropriate for a recurrence of genital herpes.

If lymphogranuloma venereum is suspected, doxycycline daily for 7 days may be appropriate. However, this is less likely in this case as it typically leads to painless ulceration and is uncommon.

If a complicated urinary tract infection is suspected, trimethoprim for 7 days may be appropriate. However, given the presence of painful ulceration, herpes infection is the most likely cause regardless of urinalysis results and dysuria.

Understanding STI Ulcers

Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most well-known causes is the herpes simplex virus (HSV) type 2, which can cause severe primary attacks with fever and subsequent attacks with multiple painful ulcers. Syphilis, caused by the spirochaete Treponema pallidum, has primary, secondary, and tertiary stages, with a painless ulcer (chancre) appearing in the primary stage. Chancroid, a tropical disease caused by Haemophilus ducreyi, causes painful genital ulcers with a sharply defined, ragged, undermined border and unilateral, painful inguinal lymph node enlargement. Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis, has three stages, with the first stage showing a small painless pustule that later forms an ulcer, followed by painful inguinal lymphadenopathy in the second stage and proctocolitis in the third stage. LGV is treated with doxycycline. Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale (previously called Calymmatobacterium granulomatis). Understanding the different causes of STI ulcers is crucial in diagnosing and treating these infections.

Special Situations for Combined Oral Contraceptive Pill

Concurrent Antibiotic Use:
In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. 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, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

Switching Combined Oral Contraceptive Pills:
The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF.

The only recognized treatment option for premenstrual syndrome among the given choices is a low dose SSRI during the luteal phase. According to the NICE Clinical Knowledge Summary on Premenstrual Syndrome, lifestyle advice should be given to women with severe PMS, and treatment options for moderate PMS include a new-generation combined oral contraceptive, analgesics, or cognitive behavioral therapy. Additionally, an SSRI can be taken continuously or during the luteal phase (days 15-28 of the menstrual cycle, depending on its length).

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

Bartholin’s cysts that are asymptomatic do not need any treatment and can be managed conservatively.

In cases where the cysts are recurrent or causing discomfort, marsupialisation or balloon catheter insertion can be considered as management options. These procedures have been shown to decrease the likelihood of recurrence.

If an abscess is suspected, antibiotics may be necessary. Symptoms of an abscess include pain, swelling, redness, and fever.

Women who are 40 years old or older should be referred for a biopsy to rule out the possibility of carcinoma.

Bartholin’s cyst occurs when the Bartholin duct’s entrance becomes blocked, causing mucous to build up behind the blockage and form a mass. This blockage is usually caused by vulval oedema and is typically sterile. These cysts are often asymptomatic and painless, but if they become large, they may cause discomfort when sitting or superficial dyspareunia. On the other hand, Bartholin’s abscess is extremely painful and can cause erythema and deformity of the affected vulva. Bartholin’s abscess is more common than the cyst, likely due to the asymptomatic nature of the cyst in most cases.

Bartholin’s cysts are usually unilateral and 1-3 cm in diameter, and they should not be palpable in healthy individuals. Limited data suggest that around 3000 in 100,000 asymptomatic women have Bartholin’s cysts, and these cysts account for 2% of all gynaecological appointments. The risk factors for developing Bartholin’s cyst are not well understood, but it is thought to increase in incidence with age up to menopause before decreasing. Having one cyst is a risk factor for developing a second.

Asymptomatic cysts generally do not require intervention, but in older women, some gynaecologists may recommend incision and drainage with biopsy to exclude carcinoma. Symptomatic or disfiguring cysts can be treated with incision and drainage or marsupialisation, which involves creating a new orifice through which glandular secretions can drain. Marsupialisation is more effective at preventing recurrence but is a longer and more invasive procedure. Antibiotics are not necessary for Bartholin’s cyst without evidence of abscess.

References:
1. Berger MB, Betschart C, Khandwala N, et al. Incidental Bartholin gland cysts identified on pelvic magnetic resonance imaging. Obstet Gynecol. 2012 Oct;120(4):798-802.
2. Kaufman RH, Faro S, Brown D. Benign diseases of the vulva and vagina. 5th ed. Philadelphia, PA: Elsevier Mosby; 2005:240-249.
3. Azzan BB. Bartholin’s cyst and abscess: a review of treatment of 53 cases. Br J Clin Pract. 1978 Apr;32(4):101-2.

Surgical Referral for Faecal and Urinary Incontinence

NICE guidelines recommend surgical referral for patients with faecal incontinence. Female patients with urinary incontinence should be referred to a urological expert with specific training and experience in treating stress incontinence. Surgical techniques for stress incontinence include mid-urethral tape and mesh suspension procedures, slings, intramural bulking agents, and traditional repair techniques. Other reasons for surgical referral include persistent bladder or urethral pain, pelvic masses, neurological disease, previous pelvic cancer surgery, and previous pelvic irradiation. It is important for healthcare professionals to be aware of these guidelines and refer patients appropriately for surgical intervention.

If a patient refuses a chaperone for an intimate examination and you are not comfortable performing the examination without one, it is necessary to make alternative arrangements for the patient to be examined.

As per the current guidelines of the Faculty of Sexual and Reproductive Healthcare, a speculum examination is necessary for a patient who has been experiencing problematic per vaginal bleeding with hormonal contraception for more than three months. It is crucial to examine and visualize the cervix. However, in this case, the patient has declined a male chaperone, making it a challenging situation.

While referring the patient to another service for the examination is an option, it is not appropriate for an urgent same-day admission as this is a longstanding problem. Additionally, some accident and emergency departments may not be comfortable performing speculum examinations and would refer the patient to the gynaecology department if necessary.

Referring the patient to the two-week wait clinic without examining is not appropriate as the referral may not be necessary.

Continuing with the examination without a chaperone is not advisable, especially if the clinician is uncomfortable doing so, as there is no indication of an emergency presentation.

Proceeding with the examination with a female receptionist chaperoning is not recommended as the patient has declined this and has the capacity to do so. This would be without her consent.

The most appropriate course of action would be to arrange for a suitable colleague to examine the patient the following day. As there is no indication of an acute emergency or evidence of ectopic pregnancy, deferring the examination to the following day is entirely appropriate.

GMC Guidelines on Intimate Examinations and Chaperones

The General Medical Council (GMC) has provided comprehensive guidance on how to conduct intimate examinations and the role of chaperones in the process. Intimate examinations refer to any procedure that a patient may consider intrusive or intimate, such as examinations of the genitalia, rectum, and breasts. Before performing such an examination, doctors must obtain informed consent from the patient, explaining the procedure, its purpose, and the extent of exposure required. During the examination, doctors should only speak if necessary, and patients have the right to stop the examination at any point.

Chaperones are impartial individuals who offer support to patients during intimate examinations and observe the procedure to ensure that it is conducted professionally. They should be healthcare workers who have no relation to the patient or doctor, and their full name and role should be documented in the medical records. Patients may also wish to have family members present for support, but they cannot act as chaperones as they are not impartial. Doctors should not feel pressured to perform an examination without a chaperone if they are uncomfortable doing so. In such cases, they should refer the patient to a colleague who is comfortable with the examination.

It is not mandatory to have a chaperone present during an intimate examination, and patients may refuse one. However, the offer and refusal of a chaperone should be documented in the medical records. If a patient makes any allegations against the doctor regarding the examination, the chaperone can be called upon as a witness. In cases where a patient refuses a chaperone, doctors should explain the reasons for offering one and refer the patient to another service if necessary. The GMC guidelines aim to ensure that intimate examinations are conducted with sensitivity, respect, and professionalism, while also protecting the interests of both patients and doctors.

HPV Testing in Cervical Screening

The use of HPV testing in cervical screening has been studied to determine if it can improve the accuracy of identifying women who need further investigation and treatment. Currently, only a small percentage of women referred for colposcopy actually require treatment as low-grade abnormalities often resolve on their own. By incorporating HPV testing, women with borderline or mild dyskaryosis who test negative for high-risk HPV can simply return to routine screening recall, while those who test positive are referred for colposcopy.

HPV testing is also used as a test of cure for women who have been treated for cervical intraepithelial neoplasia. Those with normal, borderline, or mild dyskaryosis smear results who are HPV negative can return to three-yearly recall. This approach ensures that women receive appropriate follow-up care while minimizing unnecessary referrals and treatments. Overall, the use of HPV testing in cervical screening has the potential to improve the accuracy and efficiency of the screening process.

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

Understanding Vulval Carcinoma

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

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

Bacterial Vaginosis: Symptoms, Risk Factors, and Treatment

Bacterial vaginosis is a common condition among women of childbearing age. It is characterized by a thin, milky white discharge with a malodorous fishy smell. The discharge is not itchy, but the fishy odor can be detected by adding 10% potassium hydroxide to the vaginal discharge. The vaginal pH is usually greater than 4.5.

Risk factors for bacterial vaginosis include the use of intrauterine coil devices, vaginal douching, and having multiple sexual partners. If left untreated, bacterial vaginosis can lead to pelvic inflammatory diseases. Some patients may not experience any symptoms, but those who do should seek treatment, especially if they are pregnant.

In the UK, the first line treatment for bacterial vaginosis is metronidazole 400 mg twice daily for seven days. Alternatively, a single dose of oral metronidazole 2 g may be given if patient adherence is an issue. Azithromycin is used to treat Chlamydia, and ceftriaxone is used to treat gonorrhea.

In the US, the CDC has updated treatment recommendations for bacterial vaginosis. Metronidazole 500 mg orally twice a day for seven days is the recommended therapy, with alternatives including several tinidazole regimens or clindamycin (oral or intravaginal). Additional regimens include metronidazole (750 mg extended release tablets once daily for seven days) or a single dose of clindamycin intravaginal cream, although data on the performance of these alternative regimens are limited.

Prior to initiating tamoxifen treatment, women should be informed about the elevated risk of VTE, which is one of the most significant side effects of the medication. Additionally, tamoxifen has been linked to an increased risk of endometrial cancer.

Risk Factors for Venous Thromboembolism

Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While some common predisposing factors include malignancy, pregnancy, and the period following an operation, there are many other factors that can increase the risk of VTE. These include underlying conditions such as heart failure, thrombophilia, and nephrotic syndrome, as well as medication use such as the combined oral contraceptive pill and antipsychotics. It is important to note that around 40% of patients diagnosed with a PE have no major risk factors. Therefore, it is crucial to be aware of all potential risk factors and take appropriate measures to prevent VTE.

The initial approach to treating cyclical mastalgia involves a supportive bra and basic pain relief measures like paracetamol, ibuprofen, or topical NSAIDs. Codeine is not the preferred first-line option. The evidence is inadequate to suggest reducing caffeine intake or using the progestogen-only pill. A systematic review revealed that evening primrose oil is not superior to placebo.

Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

If a patient’s cervical cancer screening sample is positive for high-risk HPV and shows cytological abnormalities, the next step according to guidelines is to refer the patient for a colposcopy. During this procedure, the cervix is closely examined to identify any disease. If significant abnormalities are found, loop excision of the transformation zone may be necessary.

Returning the patient to normal recall is not appropriate as further investigation is required. Repeating the sample in 3 months is also not necessary as the patient has high-risk HPV and needs specialist assessment. However, repeating the sample in 12 months could be considered if the patient has high-risk HPV with normal cytological findings after colposcopy.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

Tumour Markers in Clinical Contexts

Tumour markers can be a useful tool in certain clinical contexts, but they are not a routine primary care investigation. One example of a valuable tumour marker is CA125, which is associated with ovarian cancer. Ovarian cancer often presents with vague symptoms that can be easily attributed to more benign pathology, so a high index of suspicion is needed. The use of the CA125 tumour marker can be helpful in the diagnosis of ovarian cancer during initial primary care investigations.

NICE recommends that women over the age of 50 who have one or more symptoms associated with ovarian cancer that occur more than 12 times a month or for more than a month are offered CA125 testing. These symptoms include bloating, appetite loss, early satiety, abdominal pain, pelvic pain, urinary frequency/urgency, lethargy, weight loss, and change in bowel habit.

Other tumour markers are typically specialist tests that would rarely, if at all, be requested in primary care. These markers are associated with other types of cancer, such as α fetoprotein for hepatocellular carcinoma, CEA for colonic carcinoma, CA19-9 for pancreatic cancer, and Chromogranin A for neuroendocrine tumours.

Transdermal HRT is a safer option than oral HRT for women at risk of VTE, according to NICE guidelines. Sharon’s BMI puts her at risk of VTE, so prescribing oral HRT would not be appropriate. Recommending lifestyle changes would not be effective as Sharon has already tried this. Seeking specialist advice is unnecessary as starting transdermal HRT in primary care is safe and reasonable. While antidepressants can be considered for menopausal symptoms, it is not necessary in this case as HRT is a viable option for Sharon.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

Suspected Cervical Cancer

This patient should be suspected to have cervical cancer until proven otherwise, due to inflammation of the cervix that has been shown to be non-infective and no documented smear history, which puts her at higher risk. Empirical treatment for Chlamydia or gonorrhoea would not usually be suggested in general practice unless the patient has symptoms and signs of PID. Referring to an STD clinic is incorrect, as urgent investigation for cancer is necessary. Referring routinely to gynaecology is an option, but it doesn’t fully take into account the urgency of ruling out cervical cancer. Arranging a smear test for a lady with suspected cervical cancer would be inappropriate, as smear tests do not diagnose cancer, they only assess the likelihood of cancer occurring in the future.

Detecting Ovarian Cancer: Symptoms and Testing

The symptoms of ovarian cancer can be vague, making it difficult to detect in its early stages. Patients may present with persistent bloating, abdominal or pelvic pain, and difficulty eating. Women over the age of 50 who experience these symptoms more than 12 times a month or for more than a month should be offered CA125 testing. If the CA125 level is 35 IU/mL or greater, an urgent ultrasound scan of the pelvis should be arranged.

It is important to note that symptoms of ovarian cancer can overlap with less serious conditions, such as irritable bowel syndrome (IBS). However, IBS rarely arises for the first time in women over 50, so persistent symptoms should be investigated further.

Patients who suspect they may have Coeliac disease should be tested before starting a gluten-free diet. The tTG antibody test will produce a negative result if the patient is not consuming gluten, so a daily gluten-containing diet should be followed for at least 6 weeks prior to testing. By being aware of these symptoms and testing options, healthcare professionals can help detect ovarian cancer early and improve patient outcomes.

The NHS is extending its breast screening initiative to cover women between the ages of 47 and 73. Women over this age can still undergo screening by making their own arrangements.

Breast Cancer Screening and Familial Risk Factors

Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

The recommended duration for using Mirena as the progestogen component of HRT is 4 years, according to the British National Formulary and NICE guidelines. However, for contraception purposes, the license allows for use up to 5 years.

For women using the levonorgestrel-releasing intrauterine device solely for contraception or heavy menstrual bleeding, it can be retained for a longer period. If the patient is 45 years or older and no longer menstruating, the device can be kept until menopause (confirmed by FSH testing), even if it exceeds the recommended duration (off-label use).

If the patient is still menstruating, the levonorgestrel intrauterine device can be left in place for up to 7 years (off-label use) if the bleeding pattern is satisfactory.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Referral for Colposcopy in HPV Positive and Abnormal Cytology Cases

According to national guidelines and summarised in NICE Clinical Knowledge Summaries, individuals who test positive for high-risk human papillomavirus (hrHPV) and have abnormal cytology should be referred for colposcopy. This means that if a woman has a borderline smear and is also HPV positive, she should be referred for colposcopy.

In this case, we have a 45-year-old female who would normally have cervical smears every 3 years. However, due to the presence of HPV positive and borderline smear, she requires further investigation through colposcopy. It is important to follow these guidelines to ensure early detection and treatment of any potential cervical abnormalities.

The initial treatment for cyclical mastalgia is a supportive bra and basic pain relief.

Cyclical breast pain is a common condition that affects up to two-thirds of women, typically beginning two weeks before their menstrual cycle. Breast pain, in the absence of other breast cancer symptoms such as a lump or changes in the nipple or skin, is not linked to breast cancer. Referral to a breast specialist may be considered if the pain is severe enough to impact quality of life or sleep and doesn’t respond to first-line treatment after three months, but there is no need for referral in this case.

Antibiotics are not recommended for the treatment of cyclical breast pain, as there is no evidence to support their use.

According to current NICE CKS guidelines, the combined oral contraceptive pill or progesterone-only pill should not be used to treat cyclical breast pain, as there is limited evidence of their effectiveness compared to a placebo.

The first-line approach to managing cyclical breast pain involves advising patients to wear a supportive bra and take basic pain relief. This is based on expert consensus, which suggests that most cases of cyclical breast pain can be managed conservatively with a watchful-waiting approach, as long as malignancy has been ruled out as a cause.

Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

Letrozole and its Side Effects

Letrozole is a medication used to treat postmenopausal women with oestrogen-receptor positive breast cancer. However, it is not recommended for premenopausal women. The British National Formulary (BNF) lists the frequency of side effects as very common, common, uncommon, rare, and very rare. Letrozole’s less common side effects include cough and leucopenia, while vulvovaginal disorders are listed as uncommon. Pulmonary embolism is a rare side effect. On the other hand, osteoporosis and bone fractures are more common side effects, and patients should have their bone mineral density assessed before treatment and at regular intervals. The BNF also cautions that patients may be susceptible to osteoporosis. It is important to be aware of these potential side effects when prescribing Letrozole.

Ovarian hyperstimulation syndrome can occur as a result of ovulation induction, as seen in this case with symptoms such as ascites, vomiting, diarrhea, and high hematocrit. Different medications can be used for ovulation induction, with gonadotrophin therapy carrying a higher risk of ovarian hyperstimulation syndrome compared to other options like clomiphene citrate, raloxifene, letrozole, or anastrozole. It is likely that the patient in question was given gonadotrophin therapy.

Understanding Ovulation Induction and Its Categories

Ovulation induction is a common treatment for couples who have difficulty conceiving naturally due to ovulation disorders. The process of ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. Anovulation can occur due to alterations in this balance, which can be classified into three categories: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation, leading to a singleton pregnancy.

There are various forms of ovulation induction, starting with the least invasive and simplest management option first. Exercise and weight loss are typically the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss. Letrozole is now considered the first-line medical therapy for patients with PCOS due to its reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate. Clomiphene citrate is a selective estrogen receptor modulator that acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. Gonadotropin therapy tends to be the treatment used mostly for women with hypogonadotropic hypogonadism.

One potential side effect of ovulation induction is ovarian hyperstimulation syndrome (OHSS), which can be life-threatening if not identified and managed promptly. OHSS occurs when ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space. The severity of OHSS varies, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction. Management includes fluid and electrolyte replacement, anticoagulation therapy, abdominal ascitic paracentesis, and pregnancy termination to prevent further hormonal imbalances.

Polycystic ovarian syndrome is among the risk factors for endometrial cancer.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. 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 of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be 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.

First-Line Treatment for Menorrhagia

When it comes to treating menorrhagia, the levonorgestrel-releasing intrauterine system (LNG-IUS) is considered the first-line option by NICE. This is especially true for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis. While the combined oral contraceptive pill is also an option, it is not the preferred choice.

It is important to note that a repeat ultrasound may not be the next step in management, as the history of menorrhagia is the crucial point to consider. If menorrhagia is not present, the treatment plan may differ. Ulipristal acetate may be used for larger fibroids, but it is typically started in secondary care. Referral for surgical treatment should not be the first-line option, as more conservative measures should be tried initially.

Management of Suspicious Bleeding in a High-Risk Patient

This patient has several risk factors for endometrial dysplasia and cancer, including obesity, polycystic ovarian syndrome, and long-term amenorrhea. Recently, she has experienced a change in her bleeding pattern from amenorrhea to spotting, which requires ruling out any suspicious causes. According to NICE guidelines, women aged 55 years and over with postmenopausal bleeding should be referred for an appointment within 2 weeks for endometrial cancer. For women under 55 years, a suspected cancer pathway referral should be considered. A direct access ultrasound scan may also be considered for women aged 55 years and over with unexplained symptoms of vaginal discharge, thrombocytosis, haematuria, low haemoglobin levels, thrombocytosis, or high blood glucose levels.

In this case, checking a day 21 progesterone is not useful as the patient is amenorrheic. The FSH:LH ratio may be helpful in diagnosing polycystic ovarian syndrome, but it will not guide management in this case. The use of a coil may be considered after a TVUS to measure endometrial thickness if the patient is deemed low risk. Overall, it is important to promptly investigate any suspicious bleeding in high-risk patients to ensure early detection and management of any potential malignancies.

Marsupialisation is the definitive treatment for Bartholin’s abscess, which presents with sudden pain and difficulty urinating. On examination, a hard mass with surrounding cellulitis is found at the site of the Bartholin’s glands in the vulvar vestibule. The abscess is caused by infection of the Bartholin’s cyst. Bartholin’s cyst, on the other hand, is caused by a buildup of mucous secretions from the Bartholin’s glands and is typically asymptomatic unless it grows larger. Inclusion cysts, which are caused by vaginal wall trauma, are usually small and found on the posterior vaginal wall. Skene’s gland cysts, which form when the duct is obstructed, may cause dyspareunia or urinary tract infection symptoms. Vesicovaginal fistulas, which allow urine to continuously discharge into the vaginal tract, require surgical treatment.

Understanding Bartholin’s Abscess

Bartholin’s glands are two small glands situated near the opening of the vagina. They are typically the size of a pea, but they can become infected and swell, resulting in a Bartholin’s abscess. This condition can be treated in a variety of ways, including antibiotics, the insertion of a word catheter, or a surgical procedure called marsupialization.

Patients who experience a change in bleeding after being on the combined contraceptive pill for 3 months should undergo a speculum examination. It is common to experience problematic bleeding in the first 3 months after starting a new combined hormonal contraceptive pill, but if bleeding starts after 3 months or is accompanied by symptoms such as abdominal pain, dyspareunia, abnormal vaginal discharge, heavy bleeding, or postcoital bleeding, a per vaginal examination and speculum examination should be considered to identify any underlying causes. Although the irregular bleeding may not be serious, it is important to offer an examination as it has started 3 months after starting the combined hormonal contraceptive pill. There is no need to refer the patient to a gynaecology clinic at this stage before further investigation. If problematic bleeding persists, a higher dose of ethinylestradiol can be tried, up to a maximum of 35 micrograms. Changing the dose of progestogen doesn’t appear to improve cycle control, although it may be helpful on an individual basis. There is no reason to discontinue the combined hormonal contraceptive pill and switch to the progestogen-only pill.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

Topical Oestrogens for Genitourinary Symptoms of Menopause

Topical oestrogens can be used alongside transdermal/oral HRT to treat genitourinary symptoms of menopause. In fact, systemic HRT doesn’t improve these symptoms in 10-15% of women. Topical oestrogens are effective in these cases and can be combined with systemic HRT.

Combined HRT is not better than oestrogen-only therapy for treating genitourinary symptoms, and progestogens are only used for endometrial protection. If a patient already has protection via an IUS, combination therapy would not be beneficial. Topical oestrogen preparations have been shown to improve vaginal symptoms, including vaginal atrophy and pH decrease, and to increase epithelial maturation compared to placebo or non-hormonal gels.

It is important to note that systemic absorption of vaginal oestrogen is very low. Therefore, topical oestrogens work better for genitourinary symptoms of menopause compared to oral HRT and can be used in combination. According to NICE NG23, vaginal oestrogen should be offered to women with urogenital atrophy, including those on systemic HRT, and treatment should continue for as long as needed to relieve symptoms.

If vaginal oestrogen doesn’t relieve symptoms, the dose can be increased after seeking advice from a healthcare professional with expertise in menopause. Women should be informed that symptoms often return when treatment is stopped, but adverse effects from vaginal oestrogen are very rare. They should report any unscheduled vaginal bleeding to their GP. Additionally, moisturisers and lubricants can be used alone or in addition to vaginal oestrogen for vaginal dryness. Routine monitoring of endometrial thickness during treatment for urogenital atrophy is not necessary.

Contraceptive Methods and Their Associated Risks of Unintended Pregnancy

When it comes to preventing unintended pregnancy, not all contraceptive methods are created equal. The risk of unintended pregnancy in the first year of typical use of the combined oral contraceptive pill (COCP) is 9%, but with perfect use, it drops to 0.3%. However, the risk of unintended pregnancy is even lower with other methods such as the progestogen implant (0.05%), the LNG-IUD (0.2%), and the copper IUD (0.8%) for typical use. The highest risk of unintended pregnancy is associated with the typical use of DMPA, which has a 6% failure rate. It’s important to consider these risks when choosing a contraceptive method that works best for you.

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

When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate 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 whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.

For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.

Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.

The intensity of cyclical mastalgia changes depending on the menstrual cycle phase. It is most severe during menstruation and starts during the luteal phase, gradually worsening until menstruation. However, it improves during the follicular phase. This type of mastalgia is linked to hormonal fluctuations and is not influenced by seasonal changes.

Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

For women over 40, it is recommended to consider a COC pill containing less than 30 µg ethinylestradiol as the first-line option due to the potentially lower risks of VTE, cardiovascular disease, and stroke compared to formulations with higher doses of estrogen. COCP can also help reduce menstrual bleeding and pain, which may be beneficial for women in this age group. However, it is important to consider special considerations when prescribing COCP to women over 40.

Levonorgestrel or norethisterone-containing COCP preparations should be considered as the first-line option for women over 40 due to the potentially lower risk of VTE compared to formulations containing other progestogens. The UKMEC criteria for women over 40 is 2, while for women from menarche until 40, it is 1. The faculty of sexual and reproductive health recommends the use of COCP until age 50 if there are no other contraindications. Women aged 50 and over should be advised to use an alternative, safer method for contraception.

Extended or continuous COCP regimens can be offered to women for contraception and to control menstrual or menopausal symptoms. COCP is associated with a reduced risk of ovarian and endometrial cancer that lasts for several decades after cessation. It may also help maintain bone mineral density compared to non-use of hormones in the perimenopause.

Although meta-analyses have found a slightly increased risk of breast cancer among women using COCP, there is no significant risk of breast cancer ten years after cessation. Women who smoke should be advised to stop COCP at 35 as this is the age at which excess risk of mortality associated with smoking becomes clinically significant.

Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

Cervical screening is only available to women between the ages of 25 and 64, and cannot be offered to those outside of this age range. However, if a patient has never had a screening test or has not had one since age 50, they can have a one-off test. Unlike breast and bowel screening, patients cannot self-refer for cervical screening outside of the routine age range. This is because cervical cancer is unlikely to develop after this age if previous tests have been normal. Patients with symptoms of cervical cancer should be referred for colposcopy, while asymptomatic patients should not be referred as screening is designed to detect asymptomatic cases.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

Protection against genital warts is an advantage offered by Gardasil, as opposed to Cervarix.

The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with strains 6 and 11 causing genital warts and strains 16 and 18 linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for developing cervical cancer, such as smoking and contraceptive pill use, HPV vaccination is an effective preventative measure.

The UK introduced an HPV vaccine in 2008, initially using Cervarix, which protected against HPV 16 and 18 but not 6 and 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16, and 18. Initially given only to girls, boys were also offered the vaccine from September 2019. The vaccine is offered to all 12- and 13-year-olds in school Year 8, with the option for girls to receive a second dose between 6-24 months after the first. Men who have sex with men under the age of 45 are also recommended to receive the vaccine to protect against anal, throat, and penile cancers.

Injection site reactions are common with HPV vaccines. It should be noted that parents may not be able to prevent their daughter from receiving the vaccine, as information given to parents and available on the NHS website makes it clear that the vaccine may be administered against parental wishes.

The use of SSRI medications, either continuously or during the luteal phase, may be beneficial in managing premenstrual syndrome (PMS). This is especially true for patients who have not seen improvement with first-line treatments such as combined oral contraceptive pills. Co-cyprindiol, levonorgestrel-releasing intrauterine systems, mirtazapine, and copper coils are not indicated for the management of PMS.

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

Treatment Options for Menorrhagia

Menorrhagia, or heavy menstrual bleeding, can be effectively treated with the Mirena intrauterine device. It is important to note that the Mirena also serves as a long-term contraceptive, making it a suitable option for many women. The copper coil, on the other hand, can actually increase vaginal bleeding and should be avoided in cases of menorrhagia. While the combined oral contraceptive pill is a viable option, it may not be the best choice for women with busy or unpredictable lifestyles. The progesterone-only pill is a third-line option, but there is no reason not to use the Mirena as a first-line treatment. Non-steroidal anti-inflammatory drugs like mefenamic acid may be helpful for dysmenorrhoea, but are not typically used for menorrhagia. For more information on treatment options for menorrhagia, visit http://cks.nice.org.uk/menorrhagia#!scenario.

Treatment options for hypoactive sexual desire disorder in women

Hypoactive sexual desire disorder is a common issue among postmenopausal women and those who have undergone ovarian failure. While counselling and lifestyle changes may be effective in cases where the primary cause is stress or relationship issues, they may not be enough in cases where hormonal imbalances are the root cause.

If depression is the primary cause, it may need to be treated, but some antidepressants can actually worsen the problem by reducing libido. In cases where hormones are inadequate, hormone replacement therapy (HRT) may be necessary, but caution should be exercised, and an opinion from a specialist may be wise.

Androgen patches are sometimes used to treat hormone-deficient women, but their effectiveness is controversial, and they may have negative effects on the liver and cholesterol. Progestogens are not necessary for women who have had a hysterectomy and may actually make symptoms worse. Overall, treatment options for hypoactive sexual desire disorder should be tailored to the individual and their specific needs.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

Strangulation of inguinal hernias is a rare occurrence.

Understanding Inguinal Hernias

Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main symptom is a lump in the groin area, which disappears when pressure is applied or when the patient lies down. Discomfort and aching are also common, especially during physical activity. However, severe pain is rare, and strangulation is even rarer.

The traditional classification of inguinal hernias into indirect and direct types is no longer relevant in clinical management. Instead, the current consensus is to treat medically fit patients, even if they are asymptomatic. A hernia truss may be an option for those who are not fit for surgery, but it has limited use in other patients. Mesh repair is the preferred method, as it has the lowest recurrence rate. Unilateral hernias are usually repaired through an open approach, while bilateral and recurrent hernias are repaired laparoscopically.

After surgery, patients are advised to return to non-manual work after 2-3 weeks for open repair and 1-2 weeks for laparoscopic repair. Complications may include early bruising and wound infection, as well as late chronic pain and recurrence. It is important to seek medical attention if any of these symptoms occur.

Recognizing Risk Factors for Ovarian Cancer in Primary Care

It can be challenging to diagnose ovarian cancer in primary care, as patients often present with vague abdominal symptoms. However, early detection is crucial for improving outcomes. One way to increase early detection rates is to recognize the risk factors for ovarian cancer. The Macmillan organization has compiled a list of possible risk factors, including family history, age, early menarche, late menopause, HRT use, endometriosis, and ovarian cysts before the age of 30. Protective factors include pregnancy, increased numbers of children, combined oral contraceptive use, and hysterectomy. By asking a few questions about risk factors and family history, primary care providers can better assess the risk of ovarian cancer in their patients. It is important to consider ovarian cancer as a possibility, particularly in women with predominantly gastrointestinal symptoms. By recognizing the risk factors and being alert to the possibility of ovarian cancer, primary care providers can improve early detection rates and ultimately improve patient outcomes.

To ensure reliable contraception, it is recommended to take a two-month course of Cerazette (desogestrel) as Nexplanon may not be dependable.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

Injectable progesterone contraceptives are not recommended for individuals with current breast cancer due to contraindications. This applies to all hormonal contraceptive options, including Depo-Provera, which are classified as UKMEC 4. As a result, the copper intrauterine device is the only suitable contraception option available.

Injectable Contraceptives: Depo Provera

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

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

It is important to note that Noristerat, another injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks. The BNF gives different advice regarding the interval between injections, stating that a pregnancy test should be done if the interval is greater than 12 weeks and 5 days. However, this is not commonly adhered to in the family planning community.

Although cervical cancer screening is effective in detecting squamous cell cancer, it may not be as effective in detecting adenocarcinomas. Even with the switch to liquid based cytology, the detection rate for adenocarcinomas has not improved.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

If the patient has missed two pills between days 8-14 of her cycle but has taken the previous 7 days of COCP correctly, emergency contraception is not necessary according to the Faculty of Sexual and Reproductive Health. Since the patient is not in need of emergency contraception, offering a hormonal-based option would be inappropriate. However, if emergency contraception is required, options include EllaOne (ulipristal acetate) up to 120 hours after unprotected intercourse or Levonelle (levonorgestrel) up to 96 hours after unprotected intercourse.

Inserting a copper IUD to prevent pregnancy would also be inappropriate in this case. If the patient is having difficulty remembering to take her pill correctly and is interested in long-acting contraception, counseling her on options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection would be appropriate.

It is important to note that emergency contraception can be prescribed up to 120 hours after unprotected sexual intercourse, but its effectiveness decreases over time. Therefore, advising a patient to take emergency contraception within 12 hours would be incorrect.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during 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. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she 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 seven days on, seven days off.

Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation. Recent discontinuation of breastfeeding is a common risk factor for both conditions. However, galactoceles are typically painless and non-tender on examination, with no signs of infection, while breast abscesses are usually associated with local or systemic signs of infection. Although the patient’s history of mastitis raises suspicion for a breast abscess, the absence of tenderness, erythema, and fever strongly suggests a galactocele in this case.

Understanding Galactocele

Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and doesn’t cause any local or systemic signs of infection.

In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and doesn’t require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.

According to NICE guidelines for cervical cancer screening, if a person’s first repeat smear at 12 months is still positive for high-risk human papillomavirus (hrHPV), they should have another smear test 12 months later (i.e. at 24 months after the initial test). If the person remains hrHPV positive but has negative cytology results at 12 and 24 months, they should be referred to colposcopy. However, if they become hrHPV negative at 24 months, they can return to routine recall.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

The Kyleena® is a newly licensed levonorgestrel (LNG) intrauterine system (IUS) that is designed for contraceptive use for up to 5 years. Unlike the Mirena® IUS, it is not approved for managing heavy menstrual bleeding or providing endometrial protection as part of hormonal replacement therapy. The Kyleena® IUS is smaller in size than the Mirena® coil and contains 19.5mg of LNG, which is less than the 52mg found in the Mirena®. The Jaydess IUS contains the least amount of LNG at 13.5mg, but it is only licensed for 3 years. The Kyleena® releases a lower amount of systemic LNG than the Mirena® IUS, which may result in lower rates of amenorrhea and a higher number of bleeding or spotting days.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Management of Unilateral Spontaneous Bloody Nipple Discharge

When a patient presents with unilateral spontaneous bloody nipple discharge, it is important to rule out breast cancer before assuming it is duct ectasia. Reassuring the patient without proper investigation is inappropriate. Prescribing antibiotics or sending a sample for culture without evidence of cellulitis can delay a diagnosis and is not the correct management. Advising the patient to express the discharge again is also inappropriate.

If a non-lactational abscess is suspected, it is best to refer the patient to the emergency department for proper drainage. However, if infection is less likely, an urgent referral for suspected cancer is appropriate. According to NICE guidelines, patients aged 50 and over with any symptoms in one nipple only, such as discharge, retraction, or other changes of concern, should be referred for an appointment within 2 weeks. However, regardless of age, a patient presenting with unilateral spontaneous bloody discharge should have an urgent referral.

In summary, proper investigation and referral are crucial in managing unilateral spontaneous bloody nipple discharge to ensure timely diagnosis and appropriate management.

Management of Unscheduled Bleeding in a Young Lady on Depo-Provera Injection

This patient is a young lady who has been experiencing unscheduled bleeding after being put on the Depo-Provera injection. However, she has no red flag symptoms and is up-to-date with her cervical smears, which provides reassurance to her history. At this stage, blood tests and a pelvic ultrasound scan are not necessary, but may be considered later on. Referral to a gynaecologist is not indicated as there are no alarming symptoms present.

It is important to follow advice from the cervical screening hub regarding cervical smears and not order one sooner than indicated. If any alarming symptoms arise, referral to a gynaecologist is recommended. For women experiencing unscheduled bleeding while on a progesterone-only injectable and who are medically eligible, a combined oral contraceptive can be offered for three months in the usual cyclic manner. The longer-term use of the combined contraceptive pill with the injectable progesterone is a matter of clinical judgement.

If a woman is not starting her contraceptive method on the first day of her period, the only option that will be effective immediately is an intrauterine device (IUD). This device is a T-shaped plastic device that contains copper and is inserted into the uterus to provide contraception immediately.

Other methods, such as the contraceptive injection, implant, and combined oral contraceptive (COC), as well as the intrauterine system (IUS), require 7 days to become effective if not started on the first day of menstruation. The progesterone-only pill (POP) is also not the best choice as it requires 2 days before becoming effective and must be taken every day. It is important to consider the effectiveness and convenience of each method when choosing a contraceptive.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

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

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

For individuals who test positive for high-risk human papillomavirus (hrHPV) but receive a negative cytology report during routine primary HPV screening, the recommended course of action is to repeat the HPV test after 12 months. If the HPV test is negative at this point, the individual can return to routine recall. However, if the individual remains hrHPV positive and cytology negative, another HPV test should be conducted after a further 12 months. If the individual is still hrHPV positive after 24 months, they should be referred to colposcopy. It is important to note that repeating the cervical smear in 3 months or waiting 3 years for a repeat smear would not be appropriate in this scenario. Additionally, routine referral to colposcopy is not necessary unless there is abnormal cytology.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

Trichomonas Vaginalis: The Most Common Non-Viral STI Worldwide

Trichomonas vaginalis is a prevalent non-viral sexually transmitted infection that affects individuals worldwide. It is estimated that up to 20% of cases may be asymptomatic and can only be detected through routine cervical smear tests. However, typical symptoms include a copious frothy green/yellow vaginal discharge accompanied by pruritus. Symptoms tend to peak just after menses.

Multiple sexual partners are a significant risk factor for contracting Trichomonas vaginalis. Pregnant women who contract the infection are at risk of delivering low birth weight babies and preterm delivery.

The pathognomonic feature of Trichomonas vaginalis is the presence of fusiform protozoa on cytology. Treatment for this infection is with oral metronidazole. While other conditions can cause vaginitis, the presence of these protozoa is a clear indication of Trichomonas vaginalis.

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

NICE advises against examining an adnexal mass as it may lead to rupture.

Understanding Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is a medical emergency that requires immediate attention. Women with ectopic pregnancy typically experience lower abdominal pain, which is often the first symptom. The pain is usually constant and may be felt on one side of the abdomen. Vaginal bleeding is another common symptom, which is usually less than a normal period and may be dark brown in color. Women with ectopic pregnancy may also experience dizziness, fainting, or syncope.

During a physical examination, doctors may find abdominal tenderness and cervical excitation, also known as cervical motion tenderness. However, they are advised not to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels above 1,500 suggest an ectopic pregnancy.

In summary, ectopic pregnancy is a serious condition that requires prompt medical attention. Women who experience lower abdominal pain and vaginal bleeding should seek medical help immediately. Early diagnosis and treatment can prevent complications and improve outcomes.

Women under the age of 25 years cannot receive cervical screening. Before considering referral to colposcopy, other possible causes should be ruled out first.

As she is currently on day 2 of her menstrual period, pregnancy is unlikely. Given her new boyfriend and symptoms of increased vaginal discharge and occasional post-coital bleeding, a speculum examination and STI screening would be the most appropriate course of action.

While cervical screening is not typically offered to women under 25, if the patient’s history strongly suggests cervical cancer and other possibilities have been eliminated, referral to colposcopy may be necessary.

Although cervical cancer is rare in young women, it is still important to investigate the cause of her symptoms.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

NICE Guidance on Referral for Breast Cancer

According to the NICE guidance on suspected cancer, individuals aged 30 and over with an unexplained breast lump with or without pain, or aged 50 and over with nipple discharge, retraction, or other changes of concern in one nipple only, should be referred using a suspected cancer pathway referral for an appointment within 2 weeks. Additionally, individuals with skin changes that suggest breast cancer or aged 30 and over with an unexplained lump in the axilla should also be considered for a suspected cancer pathway referral.

For individuals under 30 with an unexplained breast lump with or without pain, a non-urgent referral should be considered. However, the NICE 2015 GDG recommends that urgent referral should not be precluded in individuals under 30 where the suspicion of breast cancer is high. It is important to seek specialist advice and follow the referral and safety netting pathway for further information.

Contraception and Pregnancy

When a woman becomes pregnant while using contraception, it is usually recommended to stop or remove the method. However, it is important to note that contraceptive hormones do not typically harm the fetus.

If an intrauterine method is in place when pregnancy is diagnosed, the woman should be informed of the potential risks of leaving it in-situ, such as second-trimester miscarriage, preterm delivery, and infection. While removal in the first trimester carries a small risk of miscarriage, it may reduce the risk of adverse outcomes. If the threads of the intrauterine contraceptive are visible or can be retrieved, it should be removed up to 12 weeks gestation, but not after this point.

Overall, it is important for women to discuss their contraceptive options with their healthcare provider and to inform them if they suspect they may be pregnant.

Women and men who are taking leflunomide must use effective contraception for a minimum of 2 years and 3 months respectively after discontinuing the medication, similar to the requirements for thalidomide.

Leflunomide: A DMARD for Rheumatoid Arthritis

Leflunomide is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage rheumatoid arthritis. It is important to note that this medication has a very long half-life, which means that its teratogenic potential should be taken into consideration. As such, it is contraindicated in pregnant women, and effective contraception is essential during treatment and for at least two years after treatment in women, and at least three months after treatment in men. Caution should also be exercised in patients with pre-existing lung and liver disease.

Like any medication, leflunomide can cause adverse effects. Some of the most common side effects include gastrointestinal issues such as diarrhea, hypertension, weight loss or anorexia, peripheral neuropathy, myelosuppression, and pneumonitis. To monitor for any potential complications, patients taking leflunomide should have their full blood count (FBC), liver function tests (LFT), and blood pressure checked regularly.

If a patient needs to stop taking leflunomide, it is important to note that the medication has a very long wash-out period of up to a year. To help speed up the process, co-administration of cholestyramine may be necessary. Overall, leflunomide can be an effective treatment option for rheumatoid arthritis, but it is important to carefully consider its potential risks and benefits before starting treatment.

The cause of endometrial hyperplasia is the lack of opposition to oestrogen by progesterone. This condition is linked to various factors such as taking unopposed oestrogen, obesity, late menopause, early menarche, being over 35 years old, smoking, nulliparity, and the use of tamoxifen. Tamoxifen is a risk factor because it has a pro-oestrogen effect on the uterus and bones, but it also has an anti-oestrogen effect on the breast.

Understanding Endometrial Hyperplasia

Endometrial hyperplasia is a condition characterized by the abnormal growth of the endometrium, which is the lining of the uterus. This growth is excessive compared to the normal proliferation that occurs during the menstrual cycle. There are different types of endometrial hyperplasia, including simple, complex, simple atypical, and complex atypical. Patients with this condition may experience abnormal vaginal bleeding, such as intermenstrual bleeding.

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

In summary, endometrial hyperplasia is a condition that requires proper diagnosis and management to prevent the development of endometrial cancer. Patients experiencing abnormal vaginal bleeding should seek medical attention to determine the underlying cause of their symptoms.

If the results of the 2nd repeat smear at 24 months show that the patient is now negative for high-risk human papillomavirus (hrHPV), the appropriate action is to return to routine recall in 3 years. This is based on the assumption that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but with normal cytology. The patient then had a repeat test at 12 months, which also showed hrHPV positive but with normal cytology. If the patient had still been hrHPV positive, she would have been referred for colposcopy. However, since she is now negative, there is no need for further testing or repeat smear in 4 weeks or 12 months. It is also not necessary to check cytology on the sample as the latest cervical screening programme doesn’t require it if hrHPV is negative. It is important to note that transient hrHPV infection is common and doesn’t necessarily indicate a high risk of cervical cancer.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

Cervical Screening in the UK

Cervical screening is recommended for all women in England aged 25-64, and from 20 onwards in Wales and Scotland. This screening is important because certain human papillomavirus (HPV) subtypes underlie the development of almost all cases of cervical cancer. HPV is transmitted during sexual intercourse and intimate sexual contact, and even homosexual women can still pass the virus on to female partners.

Women who have been vaccinated as part of the national HPV programme will be protected against the main two HPV subtypes that cause the majority of cervical cancers, but there are other less common subtypes that can lead to cervical cancer that they are not vaccinated against. Women with a previously abnormal smear require follow up either with further smears or referral for colposcopy/treatment depending on the exact abnormalities detected.

Women who have never been sexually active would be very low risk so following discussion with their GP often may decide not to participate in cervical screening. However, they are eligible to be screened routinely and would be offered screening. The only group above who are not eligible for routine cervical screening are women over the age of 65. Routine screening runs up to the age of 64. However, if a woman has abnormalities that require further follow up smears then this would of course be done beyond the age of 65 if clinically indicated.

In summary, cervical screening is an important part of women’s health in the UK, and all women should consider participating in routine screening to help prevent cervical cancer.

Management of Endometriosis-Related Pain and Pelvic Inflammatory Disease

When it comes to managing endometriosis-related pain, a trial of paracetamol or an NSAID (alone or in combination) is recommended as first-line treatment. If this proves ineffective, other forms of pain management, including neuropathic pain treatment, should be considered. Hormonal treatment, such as COCP and POP, is also a sensible first-line option for women with suspected or confirmed endometriosis.

For pelvic inflammatory disease (PID), metronidazole + ofloxacin is often used as first-line treatment. However, there is no indication of this from the patient’s history. Referral to gynaecology would not add much at this stage, as they would likely offer the same options. Additionally, the patient is not keen on any surgical intervention at this point, which would include laparoscopy.

It’s important to note that GnRH agonists are not routinely started in primary care. They are sometimes started by gynaecology as an adjunct to surgery for deep endometriosis. Overall, a tailored approach to management is necessary for both endometriosis-related pain and PID, taking into account the individual patient’s needs and preferences.

Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite called Trichomonas vaginalis. It is more common in women than men, and many women with the infection do not experience any symptoms. In order to diagnose trichomoniasis, a sample of vaginal discharge is collected and examined under a microscope for the presence of motile trophozoites. Confirmation of the diagnosis can be done through molecular testing. Treatment typically involves taking oral metronidazole for a specified period of time. Other sexually transmitted infections, such as Chlamydia, gonorrhea, and candidiasis, require different treatments.

Comparison of Bacterial Vaginosis and Trichomonas Vaginalis

Bacterial vaginosis and Trichomonas vaginalis are two common sexually transmitted infections that affect women. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while Trichomonas vaginalis is caused by a protozoan parasite. Both infections can cause vaginal discharge and vulvovaginitis, but Trichomonas vaginalis may also cause urethritis in men.

The vaginal discharge in bacterial vaginosis is typically thin and grayish-white, with a fishy odor. The pH of the vagina is usually higher than 4.5. In contrast, the discharge in Trichomonas vaginalis is offensive, yellow/green, and frothy. The cervix may also appear like a strawberry. The pH of the vagina is also higher than 4.5.

To diagnose bacterial vaginosis, a doctor may perform a pelvic exam and take a sample of the vaginal discharge for testing. The presence of clue cells, which are vaginal cells covered in bacteria, is a hallmark of bacterial vaginosis. On the other hand, Trichomonas vaginalis can be diagnosed by examining a wet mount under a microscope. The motile trophozoites of the parasite can be seen in the sample.

Both bacterial vaginosis and Trichomonas vaginalis can be treated with antibiotics. Metronidazole is the drug of choice for both infections. For bacterial vaginosis, a course of oral metronidazole for 5-7 days is recommended. For Trichomonas vaginalis, a one-off dose of 2g metronidazole may also be used. It is important to complete the full course of antibiotics to ensure that the infection is fully treated.

It is now recommended to use both levonorgestrel and ulipristal more than once in the same menstrual cycle. According to the current guidelines from the Faculty of Sexual and Reproductive Healthcare (FSRH), if a woman has already taken either medication once or more in a cycle, she can be offered it again after further unprotected sexual intercourse in the same cycle. However, if she has already taken one medication, the other should not be taken within a certain timeframe. It is important to note that the intrauterine copper device is the most effective form of contraception and should be offered to eligible patients. Advising that no emergency contraception is needed when a woman is at risk of pregnancy is incorrect.

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, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

Mild cases of pelvic inflammatory disease do not require removal of intrauterine contraceptive devices.

Pelvic inflammatory disease (PID) is a condition where the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. It is typically caused by an infection that spreads from the endocervix. The most common causative organism is Chlamydia trachomatis, followed by 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 Gonorrhoea. However, these tests may often be negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole. In mild cases of PID, intrauterine contraceptive devices may be left in, but the evidence is limited, and removal of the IUD may be associated with better short-term clinical outcomes according to recent guidelines.

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, infertility (with a risk as high as 10-20% after a single episode), chronic pelvic pain, and ectopic pregnancy.

Screening for ovarian cancer in asymptomatic women should not be done using Ca-125 due to its poor sensitivity and specificity. Even when used in symptomatic patients, there is a high false negative rate, so an ultrasound scan should be considered if symptoms persist. CEA is a tumour marker for colorectal cancer, but it is not recommended for screening and is only used to monitor disease activity. Ultrasound is also not advised for screening for ovarian cancer in asymptomatic patients. Private whole-body scans for the worried well are available, but they carry the risk of incidental findings, and CT scans have a significant radiation risk.

Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

Chlamydia is best diagnosed using nucleic acid amplification tests (NAATs), which are highly sensitive and specific. In clinical practice, NAATs are the preferred method of testing. For females, vulvo-vaginal swabs are the most effective, while urethral swabs are typically used for men. Although cultures are also highly sensitive and specific, they can be less effective due to various factors such as inadequate specimen collection and overgrowth of cell cultures. Additionally, cell culture is expensive and requires experienced technicians. Patients who test positive for chlamydia should also be advised on the risks associated with unprotected sex and offered long-acting contraceptives. A pregnancy test may also be necessary.

Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

According to NICE guidelines, laparoscopy is the most reliable method of diagnosing endometriosis in patients.

To confirm the presence of endometriosis, it is necessary to perform a laparoscopic examination of the pelvis, regardless of whether a transvaginal or transabdominal ultrasound appears normal.

If a thorough laparoscopy is conducted and no signs of endometriosis are found, the patient should be informed that she doesn’t have the condition and offered alternative treatment options.

Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

If a patient experiences reddening and thickening of the nipple and areola, it is important to consider the possibility of Paget’s disease of the breast. However, it is also possible that the symptoms are caused by nipple eczema, especially if the patient has a history of atopy and no personal or family history of breast disease. It is important to rule out Paget’s disease, as it typically presents unilaterally and may be accompanied by bloody nipple discharge and an underlying breast lump.

Understanding Paget’s Disease of the Nipple

Paget’s disease of the nipple is a condition that affects the nipple and is associated with an underlying breast cancer. It is present in only 1-2% of patients with breast cancer, but it is important to note that half of these patients have an underlying mass lesion, and 90% of them will have an invasive carcinoma. Even patients without a mass lesion may still have an underlying carcinoma, which is found in 30% of cases. The remaining patients will have carcinoma in situ.

Unlike eczema of the nipple, Paget’s disease primarily affects the nipple and later spreads to the areolar. Diagnosis is made through a combination of punch biopsy, mammography, and ultrasound of the breast. Treatment options will depend on the underlying lesion.

Breast Cancer Screening and Familial Risk Factors

Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

If the cervical cancer screening sample is negative for hrHPV, the patient can return to routine recall and should have a repeat cervical smear in 3 years. It is important for individuals, even if they are not sexually active, to attend routine cervical smear tests. No further cervical smears are required if the patient has no previous relevant history. A repeat cervical smear in 12 months is not necessary as the routine recall for this age group is every 3 years. Similarly, a repeat cervical smear in 5 years is not appropriate for this patient as routine cervical smear tests are every 5 years for individuals between the ages of 50 and 64 years.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

Elevated Ca125 and Normal Examination: What to Do Next?

This patient has an elevated Ca125 but a normal examination. Although the elevated result was detected during screening, she admits to experiencing bloating, which can be an early symptom of ovarian cancer. However, it’s important to note that Ca125 can be elevated for non-malignancy reasons, and if the ovarian cancer is not epithelial in origin, the Ca125 can be normal.

According to NICE guidelines, if a woman has symptoms that suggest ovarian cancer, serum CA125 should be measured in primary care. If the serum CA125 is 35 IU/ml or greater, an ultrasound scan of the abdomen and pelvis should be arranged. If the ultrasound suggests ovarian cancer, the woman should be referred urgently for further investigation.

If a woman has a normal serum CA125 (less than 35 IU/ml) or a CA125 of 35 IU/ml or greater but a normal ultrasound, she should be assessed carefully for other clinical causes of her symptoms and investigated if appropriate. If no other clinical cause is apparent, she should be advised to return to her GP if her symptoms become more frequent and/or persistent.

Understanding Mastitis: Symptoms, Management, and Risks

Mastitis is a condition that occurs when the breast tissue becomes inflamed, and it is commonly associated with breastfeeding. It affects approximately 1 in 10 women and is characterized by symptoms such as a painful, tender, and red hot breast, as well as fever and general malaise.

The first-line management of mastitis is to continue breastfeeding, and simple measures such as analgesia and warm compresses can also be helpful. However, if a woman is systemically unwell, has a nipple fissure, or if symptoms do not improve after 12-24 hours of effective milk removal, treatment with antibiotics may be necessary. The most common organism causing infective mastitis is Staphylococcus aureus, and the first-line antibiotic is oral flucloxacillin for 10-14 days. It is important to note that breastfeeding or expressing should continue during antibiotic treatment.

If left untreated, mastitis can lead to the development of a breast abscess, which may require incision and drainage. Therefore, it is crucial to seek medical attention if symptoms persist or worsen. By understanding the symptoms, management, and risks associated with mastitis, women can take proactive steps to address this condition and ensure their overall health and well-being.

Breastfeeding mothers may experience nipple damage due to poor latch, which can cause pain and fissuring. This is often caused by incorrect positioning and attachment of the baby to the breast. It is important to seek help from a breastfeeding expert to improve positioning and address any underlying issues, such as tongue tie.

Nipple candidiasis can cause burning pain, itching, and hypersensitivity in both nipples, as well as deep breast pain. A bacterial infection may result in purulent nipple discharge, crusting, redness, and fissuring. Vasospasm, also known as Raynaud’s disease of the nipple, can cause intermittent pain during and after feeding, as well as blanching, cyanosis, and/or erythema.

If a breastfeeding mother experiences itching and a dry, scaly rash on both nipples, it may be a sign of eczema. For more information and guidance on breastfeeding problems, consult the NICE clinical knowledge summary and the GP infant feeding network.

Breastfeeding Problems and Management

Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.

Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.

Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.

Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.

Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.

When starting the combined oral contraceptive pill, it is important to inform women that there is a slight increase in the risk of breast and cervical cancer. However, it is also important to note that the pill is protective against ovarian and endometrial cancer.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

The most common cause of brown-green nipple discharge is duct ectasia. This condition is often found in women around menopause and is caused by the dilation of the milk duct due to aging. It may or may not be accompanied by a small lump under the nipple.

While breast cancer can also cause nipple discharge, it is usually bloody and only comes from one nipple. A prolactinoma, a benign pituitary tumor that produces prolactin, can cause bilateral lactation and a cream-colored discharge.

Fat necrosis of the breast is typically caused by blunt trauma to the breast, resulting in a hard lump, but no nipple discharge. Paget’s disease of the nipple is characterized by a change in the skin of the nipple and areola, but there is usually no associated nipple discharge.

Understanding Nipple Discharge: Causes and Assessment

Nipple discharge is a common concern among women, and it can be caused by various factors. Physiological discharge may occur during breastfeeding, while galactorrhea may be triggered by emotional events or certain medications. Hyperprolactinemia, pituitary tumors, mammary duct ectasia, and intraductal papilloma are other possible causes of nipple discharge.

To assess patients with nipple discharge, a breast examination should be conducted to determine the presence of a mass lesion. If a mass is detected, triple assessment is recommended to evaluate the condition. Reporting of investigations should follow a system that uses a prefix denoting the type of investigation, such as M for mammography, followed by a numerical code indicating the findings.

For non-malignant nipple discharge, endocrine disease should be excluded, and smoking cessation advice may be given for duct ectasia. In severe cases of duct ectasia, total duct excision may be necessary. Nipple cytology is generally unhelpful in diagnosing the cause of nipple discharge.

Understanding the causes and assessment of nipple discharge is crucial in providing appropriate management and treatment for patients. Proper evaluation and reporting of investigations can help in identifying any underlying conditions and determining the best course of action.

Breakthrough Bleeding and the Combined Pill

Breakthrough bleeding is a common issue that can occur when taking the combined pill. It is important to first check compliance with pill usage, as missed pills or erratic usage can lead to bleeding problems. Other factors such as intercurrent illness or the use of other medications should also be considered. Pregnancy should be ruled out with a test, especially if any pills have been missed or pill efficacy has been compromised. Additionally, sexually transmitted infections should be considered and appropriate tests performed.

For women who have recently started using the combined pill, breakthrough bleeding is a common occurrence in the first few months of use. It is important to discuss this with a healthcare provider and be reassured that it usually settles with time. If breakthrough bleeding persists, a change in approach may be necessary. Lower dose pills (20 mcg ethinyloestradiol) are more likely to cause breakthrough bleeding, and switching to a higher dose pill (30 mcg) may be an option. Overall, it is important to address breakthrough bleeding promptly to ensure the effectiveness and safety of the combined pill.

The patient has vaginal candidiasis, indicated by itching, reddening, and ‘curdy’ discharge with pH <4.5. Treatment with vaginal clotrimazole is appropriate. Other treatments are used for bacterial vaginosis, Trichomonas vaginalis, Chlamydia, and gonorrhoea infections. Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions. Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

Blood stained discharge from the nipple is most commonly associated with an intraductal papilloma, which is a benign tumor that develops within the milk ducts of the breast. Surgical excision is the recommended treatment for papillomas, with histology performed to rule out any signs of breast cancer.

Breast fat necrosis, on the other hand, is typically caused by trauma and presents as a firm lump in the breast tissue. It is not associated with nipple discharge and usually resolves on its own.

Fibroadenomas are another type of benign breast lump that are small, non-tender, and mobile. They do not cause nipple discharge and do not require treatment.

Mammary duct ectasia is a condition where the breast ducts become dilated, often leading to blockage. It is most common in menopausal women and can cause nipple discharge, although this is typically thick, non-bloody, and green in color. Surgery may be necessary in some cases.

While pituitary prolactinoma is a possible cause of nipple discharge, it typically presents as bilateral and non-bloodstained. Larger prolactinomas can also cause vision problems due to pressure on the optic chiasm.

Understanding Nipple Discharge: Causes and Assessment

Nipple discharge is a common concern among women, and it can be caused by various factors. Physiological discharge may occur during breastfeeding, while galactorrhea may be triggered by emotional events or certain medications. Hyperprolactinemia, pituitary tumors, mammary duct ectasia, and intraductal papilloma are other possible causes of nipple discharge.

To assess patients with nipple discharge, a breast examination should be conducted to determine the presence of a mass lesion. If a mass is detected, triple assessment is recommended to evaluate the condition. Reporting of investigations should follow a system that uses a prefix denoting the type of investigation, such as M for mammography, followed by a numerical code indicating the findings.

For non-malignant nipple discharge, endocrine disease should be excluded, and smoking cessation advice may be given for duct ectasia. In severe cases of duct ectasia, total duct excision may be necessary. Nipple cytology is generally unhelpful in diagnosing the cause of nipple discharge.

Understanding the causes and assessment of nipple discharge is crucial in providing appropriate management and treatment for patients. Proper evaluation and reporting of investigations can help in identifying any underlying conditions and determining the best course of action.

HPV Triage in NHS Cervical Cancer Screening Programme

HPV triage is a new addition to the NHS cervical cancer screening programme. It involves testing cytology samples of women with borderline changes or mild dyskaryosis for high-risk HPV types that are linked to cervical cancer development. The aim is to refer women with abnormalities for colposcopy and further investigation, and if necessary, treatment. However, only a small percentage of women referred for colposcopy actually require treatment as low-grade abnormalities often resolve on their own. HPV testing provides additional information to help determine who needs onward referral for colposcopy and who doesn’t. Women who test negative for high-risk HPV are simply returned to routine screening recall, while those who test positive are referred for colposcopy. HPV testing is also used as a ‘test of cure’ for women who have been treated for cervical intraepithelial neoplasia and have returned for follow-up cytology. Those with ‘normal’, ‘borderline’, or ‘mild dyskaryosis’ smear results who are HPV negative are returned to 3 yearly recall.

Due to the presence of positive antiphospholipid antibodies in systemic lupus erythematosus (SLE), the use of the combined oral contraceptive pill (COCP) is classified as UK Medical Eligibility Criteria for Contraceptive Use UKMEC 4, which is an absolute contraindication. The risk of arterial and venous thrombosis is unacceptably high, and alternative contraceptive options should be considered. It should be noted that the isolated presence of antiphospholipid antibodies, but not the diagnosis of antiphospholipid syndrome, is also classified as UKMEC 4. If the patient had SLE without antiphospholipid antibodies or did not test positive again after 12 weeks, the use of the COCP would be classified as UKMEC 2. The statement that the advantages of using the pill generally outweigh the risks is not correct, as this is equivalent to UKMEC 2. The statement that the risks usually outweigh the advantages of using the COCP is also not correct, as this is equivalent to UKMEC 3. Finally, the statement that there is no risk or contraindication to restarting the COCP is not correct, as this is equivalent to UKMEC 1.

Contraindications for Combined Oral Contraceptive Pill

The decision to prescribe the combined oral contraceptive pill is based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential cautions and contraindications on a four-point scale. UKMEC 1 represents a condition for which there is no restriction for the use of the contraceptive method, while UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, immobility, and a family history of thromboembolic disease in first-degree relatives under 45 years old. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension.

In 2016, the UKMEC was updated to reflect that breastfeeding between 6 weeks and 6 months postpartum is now classified as UKMEC 2 instead of UKMEC 3. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. It is important for healthcare providers to consider these contraindications when deciding whether to prescribe the combined oral contraceptive pill to their patients.

If a woman is 55 years or older and experiences postmenopausal bleeding (i.e. bleeding occurring more than 12 months after her last menstrual cycle), she should be referred through the suspected cancer pathway within 2 weeks to rule out endometrial cancer. As this woman is over 50 years old and has not had a menstrual cycle for over a year, she has reached menopause and doesn’t require blood tests to confirm it. The recent vaginal bleeding she has experienced is considered postmenopausal bleeding and requires further investigation to eliminate the possibility of endometrial cancer.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. 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 of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

For women, the appropriate location to take swabs for chlamydia and gonorrhoea is the vulvo-vaginal area, specifically the introitus.

Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

The appropriate HRT for Annie, who is postmenopausal and at risk of venous thromboembolism due to her smoking and obesity, is a continuous combined transdermal preparation. This is because she requires the progestogen component for endometrial protection and oral preparations should be avoided in her case. Cyclical preparations, both oral and transdermal, are not indicated as she has been amenorrhoeic for over 12 months.

Hormone Replacement Therapy: Uses and Varieties

Hormone replacement therapy (HRT) is a treatment that involves administering a small amount of estrogen, combined with a progestogen (in women with a uterus), to alleviate menopausal symptoms. The indications for HRT have changed significantly over the past decade due to the long-term risks that have become apparent, primarily as a result of the Women’s Health Initiative (WHI) study.

The most common indication for HRT is vasomotor symptoms such as flushing, insomnia, and headaches. Other indications, such as reversal of vaginal atrophy, should be treated with other agents as first-line therapies. HRT is also recommended for women who experience premature menopause, which should be continued until the age of 50 years. The most important reason for giving HRT to younger women is to prevent the development of osteoporosis. Additionally, HRT has been shown to reduce the incidence of colorectal cancer.

HRT generally consists of an oestrogenic compound, which replaces the diminished levels that occur in the perimenopausal period. This is normally combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer. The choice of hormone includes natural oestrogens such as estradiol, estrone, and conjugated oestrogen, which are generally used rather than synthetic oestrogens such as ethinylestradiol (which is used in the combined oral contraceptive pill). Synthetic progestogens such as medroxyprogesterone, norethisterone, levonorgestrel, and drospirenone are usually used. A levonorgestrel-releasing intrauterine system (e.g. Mirena) may be used as the progestogen component of HRT, i.e. a woman could take an oral oestrogen and have endometrial protection using a Mirena coil. Tibolone, a synthetic compound with both oestrogenic, progestogenic, and androgenic activity, is another option.

HRT can be taken orally or transdermally (via a patch or gel). Transdermal is preferred if the woman is at risk of venous thromboembolism (VTE), as the rates of VTE do not appear to rise with transdermal preparations.