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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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.

When switching from a traditional POP to COCP, 7 days of barrier contraception is needed. The safest option is to recommend 7 days of barrier contraception while commencing the combined oral contraceptive to prevent unwanted pregnancy. 10 or 14 days of additional barrier contraception is not required, and 3 days is too short. It is safest to recommend 7 days of additional contraception.

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.

Factors affecting breast cancer risk

Breast cancer risk is influenced by various factors. Women who experience late menopause, early menarche, and use combined oral contraceptive pills are at an increased risk of developing breast cancer. Additionally, older first-time mothers are also at a higher risk. However, childbearing can reduce the risk of breast cancer. According to Cancer Research UK, women who have had children have a 30% lower risk of developing breast cancer compared to those who have not.

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.

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.

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.

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.

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.

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.

Clonidine is the only option listed above that is recognized as a non-hormonal treatment for hot flashes during menopause. Amitriptyline is an antidepressant, Tibolone is a synthetic compound with estrogenic, progestogenic, and androgenic activity, Danazol is a synthetic steroid that suppresses gonadotropin production, and Clomiphene is a selective estrogen receptor modulator used in fertility treatments. According to the NICE Clinical Knowledge Summaries article on treating menopause symptoms, non-hormonal therapies for hot flashes include lifestyle changes, a trial of certain medications such as paroxetine, fluoxetine, citalopram, or venlafaxine, a 24-week trial of clonidine, or a progestogen like norethisterone or megestrol (with specialist advice).

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.

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.

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.

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.

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.

If you experience ovarian hyperstimulation syndrome, your chances of developing ovarian torsion are higher. This is because the ovary becomes enlarged, which increases the risk of torsion. If you experience sudden pelvic pain and vomiting on one side, it may be a sign of ovarian torsion.

While an ovarian cyst can cause pelvic pain, the sudden onset of pain suggests a cyst accident, such as rupture, haemorrhage, or torsion.

Pelvic inflammatory disease typically causes pelvic pain, fever, and abnormal vaginal bleeding.

Appendicitis usually causes pain in the right iliac fossa.

Understanding Ovarian Torsion

Ovarian torsion is a condition where the ovary twists on its supporting ligaments, leading to a compromised blood supply. This can result in partial or complete torsion of the ovary. When the fallopian tube is also affected, it is referred to as adnexal torsion. The condition is commonly associated with ovarian masses, pregnancy, and ovarian hyperstimulation syndrome. Women of reproductive age are also at risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is often colicky in nature. Other symptoms include vomiting, distress, and in some cases, fever. Adnexal tenderness may be detected during a vaginal examination. Ultrasound may reveal free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for ovarian torsion.

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.

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.

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.

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.

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®.

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.

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.

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.

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 FSRH has issued UKMEC recommendations for the combined oral contraceptive pill (COCP) due to the heightened risk of cardiovascular disease. According to these guidelines, the COCP is classified as UKMEC 2 for individuals under the age of 35. For those over the age of 35 who smoke less than 15 cigarettes per day, the COCP is classified as UKMEC 3. However, for those over the age of 35 who smoke more than 15 cigarettes per day, the COCP is classified as UKMEC 4. Progestogen-only contraceptives, on the other hand, are not associated with an increased risk of cardiovascular disease and are therefore classified as UKMEC 1, regardless of the patient’s age or cigarette intake.

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.

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.

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.

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.

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®.

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 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.

The patient has breast engorgement and should be advised to feed the infant with no restrictions on frequency and length of feeds. Analgesia with opioids is not recommended, and support measures such as breast massage and cold gel packs are the mainstay of treatment. Mastitis is a differential diagnosis, but hospital admission is not necessary unless there are signs of sepsis or rapidly progressing infection. Other causes of breast pain or discomfort in breastfeeding women include a full breast, a blocked duct, mastitis, or a breast abscess. Deep breast pain may also be caused by ductal infection, spasm of the ducts, persistent reaction to nerve trauma, or prolactin-induced mastalgia.

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.

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.

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.

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.

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.

The correct answer is to double the dose of levonorgestrel to 3 mg by mouth for this patient, as she has a weight of over 70kg, despite having a healthy BMI. This information is based on the BNF guidelines.

Inserting a copper intrauterine device would not be the best option for this patient, as she already has plans for levonorgestrel device insertion and may be using it for additional hormonal benefits, such as reducing the heaviness of her bleeding.

Inserting the levonorgestrel uterine system would not provide the emergency contraception required for this patient, as it takes about 7 days to become effective. Therefore, it is not appropriate in this situation.

The standard dose of levonorgestrel 1.5mg would be given to females who weigh less than 70 kg or have a BMI less than 26. However, in this case, it would be inappropriate due to the patient’s weight being over 70kg.

It would be risky to suggest to this patient that she doesn’t need to take another form of emergency contraception, as the initial pill may not have prevented ovulation during this cycle.

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.

Compared to the Mirena IUS, the Kyleena IUS has a lower rate of amenorrhoea. The Kyleena IUS is a newly licensed contraceptive that contains 19.5mg of levonorgestrel and can be used for up to 5 years. However, it is not licensed for managing heavy menstrual bleeding or providing endometrial protection as part of hormonal replacement therapy, unlike the Mirena IUS. The Kyleena IUS is smaller in size than the Mirena coil, and the Jaydess IUS contains the least amount of LNG at 13.5mg but is only licensed for 3 years. While the lower LNG in the Kyleena IUS may result in a higher number of bleeding/spotting days, overall, the number of such days is likely to be lower than other doses of LNG-IUS. Women may prefer the Kyleena IUS over the Mirena IUS due to its lower systemic levonorgestrel levels.

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®.