Hormones Involved in Pregnancy Testing

Pregnancy testing relies on the detection of specific hormones in the body. One such hormone is human chorionic gonadotropin (hCG), which is secreted by the syncytiotrophoblast of a developing embryo after implantation in the uterus. The unique subunit of hCG, β, is targeted by antibodies in blood and urine tests, allowing for early detection of pregnancy. Luteinising hormone (LH) and follicle-stimulating hormone (FSH) also play important roles in female reproductive function, but are not measured in over-the-counter pregnancy tests. Progesterone, while important in pregnancy, is not specific to it and therefore not useful in diagnosis. The hCG subunit α is shared with other hormones and is not specific to pregnancy testing.

When it comes to patients with suspected endometriosis, laparoscopy is considered the most reliable investigation method. This is because it enables direct visualization and biopsy of the endometrial deposits. While a CT scan may also be used to detect such deposits, it is less specific compared to MRI scans. Ultrasound can be useful in detecting endometriomas, but it is important to note that a normal scan does not necessarily rule out the possibility of endometriosis.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

For patients with menorrhagia who have completed their family and do not have any underlying pathology, pharmaceutical therapy is recommended. The first-line management for these patients, according to NICE CKS, is the Mirena coil, provided that long-term contraception with an intrauterine device is acceptable.

Managing Heavy Menstrual Bleeding

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

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

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

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The diagnosis of vaginal candidiasis does not require a high vaginal swab if the symptoms are highly suggestive. In fact, the diagnosis can be made clinically based on the patient’s symptoms. For example, if a patient presents with thickened, white discharge that resembles cottage cheese and vaginal itching, along with a normal vaginal pH, it is very likely that they have vaginal candidiasis. It is important to note that glycated haemoglobin (HbA1c) is not necessary for diagnosis unless the patient has recurrent episodes of vaginal candidiasis, which may indicate diabetes mellitus. Additionally, a midstream urine sample is not useful in diagnosing vaginal candidiasis and should only be used if a sexually-transmitted infection is suspected.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

Understanding Ovarian Stromal Hyperthecosis and Differential Diagnosis

Ovarian stromal hyperthecosis is a condition characterized by the proliferation of ovarian stroma and clusters of luteinizing cells throughout the ovarian stroma. This results in increased secretion of androstenedione and testosterone, leading to hirsutism and virilism. In obese patients, the conversion of androgen to estrogen in peripheral adipose tissue can cause a hyperestrogenic state, which may lead to endometrial hyperplasia and abnormal uterine bleeding. Treatment for premenopausal women is similar to that for polycystic ovary syndrome, while bilateral oophorectomy is preferred for postmenopausal women.

Differential diagnosis for virilization symptoms includes adrenal tumor, Sertoli-Leydig cell tumor, polycystic ovary cyst, and theca lutein cyst. Adrenal tumors may present with additional symptoms such as easy bruising, hypertension, and hypokalemia. Sertoli-Leydig cell tumors are unilateral and more common in women in their second and third decades of life. Polycystic ovary syndrome is limited to premenopausal women, while theca lutein cysts do not cause virilization and can be seen on ultrasound.

Depo-provera is linked to an increase in weight.

If this woman is concerned about weight gain, it is best to avoid depo-provera, which is the primary injectable contraceptive in the UK. Depo-provera can cause various adverse effects, including weight gain, irregular bleeding, delayed return to fertility, and an increased risk of osteoporosis.

While some users of the combined oral contraceptive pill have reported weight gain, a Cochrane review does not support a causal relationship. There are no reasons for this woman to avoid the combined oral contraceptive pill.

The progesterone-only pill has not been associated with weight gain and is safe for use in this woman.

The intra-uterine system (IUS) does not cause weight gain in users and is a viable option for this woman.

The subdermal contraceptive implant can cause irregular or heavy bleeding, as well as progesterone-related side effects such as headaches, nausea, and breast pain. However, it is not typically associated with weight gain and is not contraindicated for use in this situation.

Injectable Contraceptives: Depo Provera

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

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

It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

When a woman with risk factors for infertility, such as damage to the contralateral tube, has an ectopic pregnancy requiring surgical management, it is recommended to consider salpingostomy instead of salpingectomy. In this case, the woman has a left-sided ectopic pregnancy and a damaged right tube, making salpingostomy a more appropriate option to preserve her fertility. Methotrexate is not suitable for this case due to the severity of pain, and monitoring for 48 hours is not appropriate either. Expectant management is only recommended for small, asymptomatic ectopic pregnancies without cardiac activity.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

The addition of progesterone to hormone replacement therapy (HRT) has been found to raise the risk of breast cancer. It is worth noting that taking low doses of progesterone alone, without oestrogen, does not seem to have the same effect on breast cancer risk. If used for less than 10 years, oestrogen-only HRT does not appear to increase the likelihood of developing breast cancer. However, it does increase the risk of endometrial cancer and should be avoided unless the patient has had a hysterectomy.

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 progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

When dealing with patients who have urinary incontinence, it is crucial to eliminate the possibility of a UTI and diabetes mellitus as underlying causes. The first step in investigating urinary incontinence would be to conduct a urine dipstick and culture test, which can be easily done in a GP’s office. Other initial investigations include keeping a bladder diary for at least three days and undergoing urodynamic studies. It is important to note that the reliability of urine dip tests is questionable in women over 65 years of age and those who have catheters. A three-day bladder diary is necessary for initial investigations, and a one-day diary would not suffice. CT scans are not typically used to investigate urinary incontinence but are useful in detecting renal pathology such as ureteric calculi. Cystoscopy is not appropriate for this patient and is usually reserved for cases where bladder cancer is suspected.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

When a cervical cancer screening smear is inadequate, the recommended course of action is to repeat the smear within 3 months. It is not necessary to consider any previous inadequate smears from a decade ago. Therefore, repeating the smear in 1 month or 3 years is not appropriate. Referral for colposcopy or gynaecology is also not necessary at this stage, as it should only be considered if the second smear in 3 months’ time is also inadequate.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Condoms act as a barrier contraceptive and do not have any impact on ovulation, therefore they do not cause any delay in fertility. The intrauterine system (IUS) functions by thickening cervical mucous and may prevent ovulation in some women, but most women still ovulate. Once the IUS is removed, most women regain their fertility immediately.

The combined oral contraceptive pill may postpone the return to a normal menstrual cycle in some women, but the majority of them can conceive within a month of discontinuing it. The progesterone-only pill is less likely to delay the return to a normal cycle as it does not contain oestrogen.

Depo-Provera can last up to 12 weeks, and it may take several months for the body to return to a normal menstrual cycle, which can delay fertility. As a result, it is not the most suitable method for a woman who wants to resume ovulatory cycles immediately.

Injectable Contraceptives: Depo Provera

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

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

It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

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.

The patient needs a fast-acting contraceptive method. The intrauterine device (IUD) is the quickest, but it’s not recommended due to the patient’s history of menorrhagia. The patient also prefers not to have intrauterine contraception, making the IUS and IUD less suitable. The next fastest option is the progesterone-only pill (POP), which becomes effective within 2 days if started mid-cycle. Therefore, the POP is the best choice for this patient. The combined oral contraceptive pill (COC) is not recommended due to the patient’s wheelchair use, and the IUS, contraceptive injection, and implant all take 7 days to become effective.

Counselling for Women Considering the progesterone-Only Pill

Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

A rupture endometrioma can result in a sudden and severe pain, given the patient’s medical history of endometriosis, acute abdomen, and fluid accumulation in the pelvis. Diverticular disease is an improbable diagnosis in this age group and does not match the symptoms described. Additionally, the patient’s current menstrual cycle rules out endometriosis pain as a possible cause.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

If the patient has missed two pills between days 8-14 of her cycle but has taken the previous 7 days of COCP correctly, emergency contraception is not necessary according to the Faculty of Sexual and Reproductive Health. Since the patient is not in need of emergency contraception, offering her a hormonal-based emergency contraceptive would be inappropriate. However, if emergency contraception is required, options include EllaOne (ulipristal acetate) up to 120 hours after unprotected intercourse or Levonelle (levonorgestrel) up to 96 hours after unprotected intercourse. Inserting a copper IUD to prevent pregnancy would also be inappropriate in this case. If the patient is having difficulty remembering to take her pill correctly and is interested in long-acting contraception, counseling her on options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection would be appropriate. It should be noted that contraceptive injections are not used as a form of emergency contraception and advising a patient to take emergency contraception within 12 hours would be incorrect.

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.

Methotrexate is the preferred medication for treating ectopic pregnancy through medical management, provided the patient is willing to attend follow-up appointments.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

Myoma: Common Benign Tumor in Women

Myoma, also known as uterine fibroids, is a benign tumor commonly found in women. It is characterized by histological features and symptoms such as menorrhagia and pressure. Although it may occur in teenagers, it is most commonly seen in women in their fourth and fifth decades of life. Black women are more likely to develop myomas and become symptomatic earlier. Having fewer pregnancies and early menarche are reported to increase the risk.

Myomas are benign tumors and do not metastasize to other organs. However, they may cause obstetric complications such as red degeneration, malpresentation, and the requirement for a Caesarean section. Surgical complications or intervention-related infections may lead to mortality, but associated deaths are rare. The 5-year survival rate is not applicable in this case.

This woman is displaying symptoms that are commonly associated with endometrial cancer, such as abdominal pain and bloating. She also has several risk factors for this type of cancer, including a history of PCOS, being nulliparous, and experiencing menopause after the age of 52. Other risk factors include obesity, endometrial hyperplasia, diabetes, tamoxifen, and unopposed estrogen. Interestingly, the risk associated with unopposed estrogen can be eliminated if progesterone is given concurrently.

While this woman has risk factors for breast cancer, her current symptoms are not indicative of this type of cancer. She does not have any risk factors for cervical cancer. It is important to note that abdominal pain and bloating are not normal symptoms of menopause. Normal menopausal symptoms include hot flashes, mood changes, musculoskeletal symptoms, vaginal dryness/itching, sexual dysfunction, and sleep disturbance.

Vaginal cancer typically presents with symptoms such as a vaginal mass, vaginal itching, discharge and pain, and vulval bleeding. Risk factors for this type of cancer include advancing age, infection with human papillomavirus, previous or current cervical cancer, smoking, and alcohol consumption.

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.

Fertility Testing Methods

When it comes to fertility testing, there are several methods available to determine a female’s ovulatory status. One of the easiest tests is the day 21 progesterone level. If the results are greater than 30 nmol/l in two cycles, then the patient is said to be ovulating.

Another method is the cervical fern test, which involves observing the formation of ferns in the cervical mucous under the influence of estrogen. However, measuring progesterone levels is a more accurate test as estrogen levels can vary.

Basal body temperature estimation is also commonly used, as the basal body temperature typically increases after ovulation. However, measuring progesterone levels is still considered the most accurate way to determine ovulation.

It’s important to note that day 2 luteinising hormone (LH) and follicle-stimulating hormone (FSH) are not reliable markers of ovulation. Additionally, endometrial biopsy is not a test used in fertility testing.

In conclusion, there are several methods available for fertility testing, but measuring progesterone levels is the most accurate way to determine ovulatory status.

The risk of breast cancer is increased when progesterone is added to HRT. However, it is important to note that the risk is minimal and patients should be informed of this. According to the Women Health Institute, if 1000 women on HRT for 5 years were compared to 1000 women not on HRT for 5 years, there would only be 4 more cases of breast cancer. Women who start HRT under the age of 60 are not at an increased risk of dying from cardiovascular disease. Norethisterone, a progesterone, reduces the risk of endometrial carcinoma, so women with a uterus are always started on combined HRT. Women without a uterus are started on unopposed oestrogen. While HRT may increase the risk of headaches, this is less important to mention compared to the risk of breast cancer.

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 progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

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.

The correct course of action for an individual who tests positive for high-risk human papillomavirus (hrHPV) but receives a negative cytology report during routine primary HPV screening is to repeat the HPV test after 12 months. If the HPV test is negative at this point, the individual can return to routine recall. However, if the individual remains hrHPV positive and cytology negative, another HPV test should be conducted after a further 12 months. If the individual is still hrHPV positive after 24 months, they should be referred to colposcopy. It is incorrect to repeat the cervical smear in 3 months, wait 3 years for a repeat smear, or refer the individual to colposcopy without abnormal cytology.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

The correct statement is that unopposed oestrogen increases the risk of endometrial cancer. Combined oestrogen and progesterone HRT can reduce the risk of endometrial cancer in patients with a uterus, while patients without a uterus should be prescribed oestrogen-only HRT as combined HRT is less well tolerated. The statement that unopposed oestrogen increases the risk of breast cancer is incorrect, as both types of HRT can increase the risk of breast cancer, with combined HRT potentially increasing the risk more than oestrogen-only. Additionally, the statement that unopposed oestrogen increases the risk of heart disease is incorrect, as oestrogen has a protective role in inhibiting the development of atherosclerosis, which can reduce the risk of heart disease. Finally, the statement that unopposed oestrogen increases the risk of osteoporosis is also incorrect, as HRT can be prescribed to prevent or treat osteoporosis in some patients and can reduce the risk of fracture instead of increasing it.

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 progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

If a cervical smear test performed as part of the NHS cervical screening programme returns as hr HPV positive, cytology is performed. If the cytology shows normal cells, the test is repeated in 12 months. If the second repeat test is still hr HPV positive and cytology normal, the test should be repeated in a further 12 months. However, if the third test at 24 months is still hr HPV positive, colposcopy should be performed instead of returning the patient to routine recall. Repeating the test in 3, 6 or 12 months is not appropriate in this case.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hr HPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Ultrasound imaging may reveal a whirlpool sign in cases of ovarian torsion, which is strongly indicated by the patient’s history and examination. The beads-on-a-string sign is typically associated with chronic salpingitis, while hypoechoic masses are often indicative of fibroids. A snow-storm appearance is a characteristic finding in complete hydatidiform mole.

Understanding Ovarian Torsion

Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.

The definition of menorrhagia has been updated to focus on a woman’s personal experience rather than attempting to measure the amount of blood loss. Previously, heavy bleeding was defined as a total blood loss of over 80 ml during the menstrual cycle. However, due to challenges in accurately measuring blood loss and the fact that treatment for heavy bleeding can improve quality of life regardless of the amount of blood lost, the definition has shifted to a more subjective approach.

Understanding Menorrhagia: Causes and Definition

Menorrhagia is a condition characterized by heavy menstrual bleeding. While it was previously defined as total blood loss exceeding 80 ml per menstrual cycle, the assessment and management of the condition now focuses on the woman’s perception of excessive bleeding and its impact on her quality of life. Dysfunctional uterine bleeding, which occurs in the absence of underlying pathology, is the most common cause of menorrhagia, accounting for about half of all cases. Anovulatory cycles, uterine fibroids, hypothyroidism, pelvic inflammatory disease, and bleeding disorders such as von Willebrand disease are other potential causes of menorrhagia. It is important to note that the use of intrauterine devices, specifically copper coils, may also contribute to heavy menstrual bleeding. However, the intrauterine system (Mirena) is a treatment option for menorrhagia.

The appropriate technique to treat cervical intraepithelial neoplasia (CIN2 or CIN3) is urgent large loop excision of the transformation zone (LLETZ). Cryotherapy may also be considered as an alternative. Offering the HPV vaccination is not a suitable option for individuals who have already been diagnosed with CIN2 or CIN3. A repeat cervical smear within 3 months may be offered if the high-risk human papillomavirus (hrHPV) test result is unavailable or cytology is inadequate. Routine referral to gynaecology is not necessary as the patient would already be under the care of the colposcopy service.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.