The patient did not respond to methotrexate treatment for ectopic pregnancy, as indicated by the βhCG levels. Additionally, there is no history of increased infertility risk. According to NICE guidelines, salpingectomy is recommended for women with tubal ectopic unless they have other infertility risk factors, such as damage to the contralateral tube. Alternatively, salpingostomy may be offered. Women who undergo salpingostomy should be informed that up to 20% may require further treatment, which could include methotrexate and/or salpingectomy.

Understanding Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended 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 >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

Differential diagnosis of abnormal uterine bleeding in a young woman

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

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

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

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

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

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

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

Understanding Pelvic Conditions: Endometriosis, Adenomyosis, Fibroids, PCOS, and Chronic Pelvic Infection

Pelvic conditions can cause discomfort and pain for many women. Endometriosis is a common condition where tissue resembling the endometrium grows outside the endometrial cavity, often in the pelvis. Laparoscopy may reveal chocolate cysts and a thickened uterosacral ligament. Symptoms include continuous pelvic pain, colicky dysmenorrhoea, heavy menstrual loss, and clotting.

Adenomyosis occurs when endometrial tissue infiltrates the uterus muscle. Symptoms include dysmenorrhoea and menorrhagia. Laparoscopy may reveal subserosal endometrium, but no chocolate cysts or thickened uterosacral ligament.

Fibroids cause a bulky uterus on bimanual examination and menorrhagia, but not chocolate cysts or a bulky uterine ligament.

Polycystic ovarian syndrome (PCOS) symptoms include oligomenorrhoea, hirsutism, weight gain, and polycystic ovaries on ultrasound. Chocolate cysts and a thickened uterosacral ligament are not associated with PCOS.

Chronic pelvic infection presents with deep dyspareunia and chronic discharge, but not chocolate cysts or a thickened uterosacral ligament. Understanding these conditions can help women seek appropriate treatment and manage their symptoms.

Understanding Cervical Ectropion

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

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

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

Termination of Pregnancy in the UK

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

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

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

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

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

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

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

The development of atypical hyperplasia of the endometrium is caused by excessive stimulation of the endometrium by oestrogen, and it is classified as a premalignant condition. Hormone production is increased in sex cord stromal tumours such as Thecomas, Fibromas, Sertoli cell and granulosa cell tumours, which are associated with this condition.

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

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

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

Missed Pills in Combined Oral Contraceptive Pill

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

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

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

The use of the levonorgestrel IUS as a contraceptive or treatment for menorrhagia is not recommended in women with a distorted fibroid uterus due to the complexity and difficulty of the procedure. Other contraindications include current pregnancy, pelvic inflammatory disease, trophoblastic disease, breast/endometrial/ovarian/cervical cancer, postpartum endometritis, septic abortion/miscarriage in the last three months, and cervical intra-epithelial neoplasia. Migraine with aura is an absolute contraindication to the use of the combined oral contraceptive pill, but the levonorgestrel IUS can be safely used. It is safe to use the levonorgestrel IUS during breastfeeding, and it can be used by women of all ages, regardless of parity. A history of venous thromboembolism is a contraindication to the use of the combined oral contraceptive pill, but the levonorgestrel IUS is safe to use according to NICE guidance.

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

Understanding Amenorrhoea: Causes, Investigations, and Management

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

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

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

Management Options for Stress Incontinence: A Case-Based Discussion

Stress incontinence is a common condition that can significantly impact a patient’s quality of life. In this scenario, a female patient has attempted lifestyle changes and pelvic floor exercises for three months with little effect. What are the next steps in management?

Duloxetine is a second-line management option for stress incontinence when conservative measures fail. It works by inhibiting the reuptake of serotonin and noradrenaline, leading to continuous stimulation of the nerves in Onuf’s nucleus and preventing involuntary urine loss. However, caution should be exercised in patients with certain medical conditions.

Continuing pelvic floor exercises for another three months is unlikely to yield significant improvements, and referral is indicated at this stage.

Intramural urethral-bulking agents can be used when conservative management has failed, but they are not as effective as other surgical options and symptoms can recur.

The use of a ring pessary is not recommended as a first-line treatment option for stress incontinence.

A retropubic mid-urethral tape procedure is a successful surgical option, but it may not be appropriate for high-risk patients who wish to avoid surgery.

In conclusion, the management of stress incontinence requires a tailored approach based on the patient’s individual circumstances and preferences.

Common Causes of Vaginal Discharge: Symptoms and Treatment

Bacterial vaginosis, Trichomonas vaginalis, Candidiasis, gonorrhoeae, and Pelvic inflammatory disease are some of the most common causes of vaginal discharge in women.

Bacterial vaginosis is caused by an overgrowth of anaerobic bacteria and loss of lactobacilli in the vagina. It presents with a grey-white, thin discharge with a fishy odour and an increased vaginal pH. Metronidazole is the treatment of choice.

Trichomonas vaginalis is a sexually transmitted infection that presents with a yellow-green discharge and an erythematosus cervix with a punctate exudate.

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

gonorrhoeae can be asymptomatic or present with abdominal pain, mucopurulent discharge, cervicitis, dyspareunia, or abnormal bleeding.

Pelvic inflammatory disease is the result of an ascending infection and presents with dyspareunia, lower abdominal pain, menstrual irregularities, irregular bleeding, and a blood stained, purulent vaginal discharge. Cervicitis and cervical excitation are also present.

Proper diagnosis and treatment are essential to prevent complications and improve the quality of life of affected women.

Understanding Cervical Screening: Guidelines and Options

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

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

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

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

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

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

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

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

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

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

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

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

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

Surgical Manoeuvre for Safe Access to the Gravid Uterus

During Gynaecological surgery, a specific manoeuvre is used to safely access the gravid uterus. The bladder is reflected downwards with the peritoneum, which also displaces the distal ureters and uterine tubes. This displacement renders these structures less vulnerable to damage during the procedure. The ovarian arteries, which are branches of the aorta, are not affected by this manoeuvre. However, the uterine artery needs to be pushed down for safe ligation as the ureters typically run superior to it. The sigmoid colon is also displaced out of the operating field using this manoeuvre, reducing the risk of injury. While the ovarian arteries are unlikely to be injured during surgery as they are more lateral, the incidence of ureteric injury is 1-2% in Gynaecological surgery, with 70% of these injuries occurring during the tying off of the uterine pedicle.

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

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

Common Causes of Delayed Puberty

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

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

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

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

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

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

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

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

Treatment Options for Cervical Carcinoma: A Comparison

Cervical carcinoma is a type of cancer that primarily affects the squamous cells of the cervix. Its main symptoms include abnormal bleeding or watery discharge, especially after sexual intercourse. The risk of developing cervical cancer increases with sexual activity.

The disease is staged based on the extent of its spread, with stages 0 to 4 indicating increasing severity. For stage 1b cervical cancer, the recommended treatment is a Wertheim’s radical abdominal hysterectomy. This procedure involves removing the uterus, tubes, ovaries, broad ligaments, parametrium, upper half or two-thirds of the vagina, and regional lymph glands. However, in older patients, the surgeon may try to preserve the ovaries to avoid premature menopause.

Other treatment options include simple hysterectomy, which is not suitable for cervical cancer that has spread beyond the cervix, and radical trachelectomy, which is appropriate for stage 1 cancers in women who wish to preserve their fertility. Close cytological follow-up is not recommended for confirmed cases of cervical cancer, while platinum-based chemotherapy is typically used only when surgery is not possible.

In summary, the choice of treatment for cervical carcinoma depends on the stage of the disease, the patient’s age and fertility preferences, and the feasibility of surgical intervention.

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

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