To manage premenstrual syndrome, it is recommended to make specific lifestyle changes such as regular exercise and consuming small, balanced meals rich in complex carbohydrates every 2-3 hours. These changes are advised by the Royal College of Obstetrics and Gynaecology as a first-line management approach. It is also suggested to quit smoking, reduce alcohol intake, maintain regular sleep patterns, and manage stress levels. Contrary to popular belief, reducing dietary fats and carbohydrates is not recommended. Additionally, prescribing diazepam is not a routine management approach and is only used in select cases where anxiety is a significant symptom. Selective serotonin reuptake inhibitors like sertraline can be used for severe premenstrual syndrome, but lifestyle changes are usually sufficient for mild symptoms that do not interfere with daily life.

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 does not 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 common condition.

If the 2nd repeat smear at 24 months shows a negative result for high-risk human papillomavirus (hrHPV), the patient can return to routine recall for cervical cancer screening. Since the patient is over 50 years old, a smear test should be taken every 5 years as part of routine recall. It is not necessary to perform a cytology swab or refer the patient to colposcopy as a negative HPV result does not indicate the presence of cervical cancer. Additionally, repeating the HPV test in 3 years is not necessary for this patient as it is only the routine recall protocol for patients aged 25-49.

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.

Fitz-Hugh-Curtis syndrome is characterized by hepatic adhesions, which are not present in any of the other options. Therefore, the diagnosis is based on the presence of lesions rather than just the symptoms described. This syndrome is a complication of PID that causes inflammation of the liver capsule, known as Glisson’s Capsule.

Gynaecological Causes of Abdominal Pain in Women

Abdominal pain is a common complaint among women, and it can be caused by various gynaecological disorders. To diagnose these disorders, a bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning should be performed in addition to routine diagnostic workup. If diagnostic doubt persists, a laparoscopy can be used to assess suspected tubulo-ovarian pathology.

There are several differential diagnoses of abdominal pain in females, including mittelschmerz, endometriosis, ovarian torsion, ectopic gestation, and pelvic inflammatory disease. Mittelschmerz is characterized by mid-cycle pain that usually settles over 24-48 hours. Endometriosis is a complex disease that may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction. Ovarian torsion is usually sudden onset of deep-seated colicky abdominal pain associated with vomiting and distress. Ectopic gestation presents as an emergency with evidence of rupture or impending rupture. Pelvic inflammatory disease is characterized by bilateral lower abdominal pain associated with vaginal discharge and dysuria.

Each of these disorders requires specific investigations and treatments. For example, endometriosis is usually managed medically, but complex disease may require surgery and some patients may even require formal colonic and rectal resections if these areas are involved. Ovarian torsion is usually diagnosed and treated with laparoscopy. Ectopic gestation requires a salpingectomy if the patient is haemodynamically unstable. Pelvic inflammatory disease is usually managed medically with antibiotics.

If a patient misses 2 pills in the first week of their combined oral contraceptive pill pack and has had unprotected sex during the pill-free interval or week 1, emergency contraception should be considered. The patient should take the missed pills as soon as possible and use condoms for the next 7 days. For patients who have only missed 1 pill, they should take it as soon as possible without needing extra precautions. If extra barrier contraception is needed for patients on the combined oral contraceptive pill, it should be used for at least 7 days. Patients on the progesterone-only pill only need barrier contraception for 2 days. Missing 1 pill at any time throughout a pack or starting a new pack 1 day late generally does not affect protection against pregnancy. Taking more than 2 contraceptive pills in a day is not recommended as it does not provide extra contraceptive effects and may cause side effects.

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.

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

Missed Pills in Combined Oral Contraceptive Pill

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

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

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

The patient is likely suffering from endometriosis, which is the presence of endometrial tissue outside of the uterus. This condition can cause subfertility, chronic pelvic pain, dysmenorrhoea, and dyspareunia. It may also lead to an increase in serum CA-125 levels and the development of ovarian deposits known as chocolate cysts. Acute appendicitis and ovarian neoplasms are unlikely causes of the patient’s symptoms, while mittelschmerz only causes mid-cycle pain and does not explain the elevated CA-125 levels. Granulosa cell tumors of the ovary typically secrete inhibin and estrogen, making endometriosis a more likely diagnosis. Symptoms of ovarian cancer are often vague and include abdominal discomfort, bloating, back and pelvic pain, irregular menstruation, loss of appetite, fatigue, and weight loss. Risk factors for ovarian cancer include not having children, early first menstruation and last menopause, hormone replacement therapy, endometriosis, and the BRCA genes. In this age group, germ cell tumors are the most likely ovarian carcinoma.

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.

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.

According to Good Medical Practice (2013), if you have a conscientious objection to a particular procedure, it is your responsibility to inform your patients and explain their right to see another doctor. You must provide them with sufficient information to exercise this right without expressing any disapproval of their lifestyle, choices, or beliefs. It is important to ensure that your personal views do not unfairly discriminate against patients or colleagues and do not affect the treatment you provide or arrange.

Termination of Pregnancy in the UK

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

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

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

Diagnostic Tests and Imaging for Lower Abdominal Pain in Women

Lower abdominal pain in women can have various causes, including appendicitis, urinary tract infection, ovarian or tubal pathology, pelvic inflammatory disease, ruptured ectopic pregnancy, mesenteric adenitis, and other less common pathologies. To determine the cause of the pain, several diagnostic tests and imaging techniques can be used.

Beta human choriogonadotropin (β-hCG) test is essential for every woman of reproductive age admitted with lower abdominal pain. This test helps determine the pregnancy status, which can guide further investigations. An abdominal/pelvic ultrasound can detect acute ovarian and other gynecological pathology. It is also useful in assessing biliary pathology and involvement in pancreatitis. However, it is not very sensitive in detecting appendicitis.

If the diagnosis is uncertain, admitting the patient for observation and review in 12 hours can help determine if any other signs or symptoms develop or change. A CT scan would be inappropriate without checking the patient’s pregnancy status, as it could be harmful to the fetus. However, it can be useful in delineating acute intestinal pathology such as inflammatory bowel disease, bowel obstruction, and renal calculi.

Finally, an erect chest X-ray can help determine if there is bowel perforation by assessing for air under the diaphragm. This investigation is critical in the presence of a peritonitic abdomen.

In conclusion, a combination of diagnostic tests and imaging techniques can help determine the cause of lower abdominal pain in women and guide appropriate treatment.

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

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

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

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

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

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

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

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

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.

The effectiveness of different contraceptives varies in terms of the time it takes to become effective if not started on the first day of the menstrual cycle. The intrauterine device is the only method that is instantly effective at any time during the cycle as it reduces sperm motility and survival. The progesterone only pill takes at least 2 days to work if started after day 5 of the cycle and is immediately effective if started prior to day 5. The combined oral contraceptive pill, injection, implant, and intrauterine system take 7 days to become effective and work by inhibiting ovulation, thickening cervical mucous, and preventing endometrial proliferation. Side effects of the progesterone only pill may include menstrual irregularities, breast tenderness, weight gain, and acne.

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.

Not all hormonal contraceptives are contraindicated for patients assigned female at birth undergoing testosterone therapy. The combined oral contraceptive pill, which contains oestrogen, should be avoided as it may interfere with the effects of testosterone therapy. However, the copper intrauterine device and progesterone-only pill are acceptable options as they do not have any adverse effects on testosterone therapy. The vaginal ring, which also contains oestrogen, should also be avoided.

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

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies.

For individuals engaging in vaginal sex where there may be a risk of pregnancy and/or sexually transmitted infections, condoms and dental dams are recommended. Cervical screening and human papillomavirus vaccinations should also be offered to sexually active individuals with a uterus. Those engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations. Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.

For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy. Testosterone therapy does not provide protection against pregnancy, and oestrogen-containing regimes are not recommended in patients undergoing testosterone therapy. Progesterone-only contraceptives are considered safe, and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding.

In patients assigned male at birth, there may be a reduction or cessation of sperm production with certain therapies, but the variability of effects means they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients engaging in vaginal sex wishing to avoid the risk of pregnancy. Emergency contraception may be required in patients assigned female at birth following unprotected vaginal intercourse, and either of the available oral emergency contraceptive options may be considered. The non-hormonal intrauterine device may also be an option, but it may have unacceptable side effects in some patients.

Overall, the guidance stresses the importance of individualized care and communication in contraceptive and sexual health decisions for transgender and non-binary individuals.

Understanding Amenorrhoea: Causes and Symptoms

Amenorrhoea, the absence of menstrual periods, can be caused by a variety of factors. One common cause is polycystic ovary syndrome (PCOS), which is characterized by hyperandrogenisation and chronic anovulation. PCOS is diagnosed when a patient has at least two of the following: oligo-ovulation or anovulation, excess androgen activity, and polycystic ovaries. Elevated plasma LH is a relatively specific sign of PCOS, which can lead to symptoms such as hirsutism, acne, menstrual disturbances, and obesity.

Other common causes of amenorrhoea include pregnancy, Turner syndrome, primary ovarian failure, anorexia nervosa, and hyperprolactinaemia. Pregnancy is a cause of amenorrhoea that should not be ignored, but elevated testosterone levels are not consistent with this. Turner syndrome is due to a karyotypic abnormality (XO), which results in primary ovarian failure. Anorexia nervosa often results in hypopituitarism, which causes amenorrhoea, but FSH and LH levels would be low and testosterone normal. Hyperprolactinaemia inhibits gonadotropin-releasing hormone (GnRH), causing lowered LH and FSH levels, but testosterone levels are unlikely to change in women.

In summary, understanding the causes and symptoms of amenorrhoea can help with diagnosis and treatment. PCOS, pregnancy, Turner syndrome, primary ovarian failure, anorexia nervosa, and hyperprolactinaemia are all potential causes to consider.

Levonorgestrel emergency contraception (Levonelle) does not affect the effectiveness of hormonal contraception, so it can be started immediately after use. However, ulipristal acetate emergency contraception (EllaOne) should not be used concurrently with hormonal contraception, and patients should wait 5 days after taking it before starting a COCP regimen. The COCP must be taken within a 24-hour window each day to ensure effectiveness, while levonorgestrel emergency contraception must be taken within 72 hours of unprotected sexual intercourse. The interval to wait before starting or restarting hormonal contraception after using ulipristal acetate emergency contraception is 5 days. Day 1 of the menstrual cycle is the preferred day to start a COCP regimen for immediate protection against pregnancy, but it is not the earliest option in this scenario.

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.

Ectopic Pregnancy: Sites and Symptoms

Ectopic pregnancy is a condition where the fertilized egg implants outside the uterine cavity. The most common site for ectopic implantation is the Fallopian tube, particularly the ampullary region, accounting for 97% of cases. Symptoms include 4-8 weeks of amenorrhea, abdominal pain, vaginal bleeding, and signs of shock associated with rupture. Shoulder tip pain may also occur due to irritation of the phrenic nerve. Diagnosis is made through measurement of β-human chorionic gonadotrophin and ultrasound scan of the abdomen, with laparoscopic investigation as the definitive method. Treatment involves removal of the pregnancy and often the affected tube via laparoscopy or laparotomy.

Other sites for ectopic pregnancy include the peritoneum or abdominal cavity, which accounts for 1.4% of cases and may proceed to term. Cervical pregnancy is rare, accounting for less than 1% of cases. Ovarian pregnancy occurs in 1 in 7000 pregnancies and accounts for 0.5-3% of all ectopic pregnancies. The broad ligament is an uncommon site for ectopic pregnancies due to its poor vascularity.

Disorders of Sexual Development: An Overview

Disorders of sexual development (DSD) are a group of conditions that affect the development of the reproductive system. Here are some of the most common DSDs:

Androgen Insensitivity Syndrome (AIS)
AIS is a condition where cells cannot respond to androgens, resulting in disrupted sexual development. Patients with complete AIS have a female phenotype with male internal genitalia, while those with partial or mild AIS may have a mix of male and female characteristics. Treatment involves careful gender assignment and hormone replacement therapy.

Turner Syndrome
Turner syndrome is a condition where patients are missing all or part of an X chromosome, resulting in premature ovarian failure and delayed puberty. Patients are phenotypically female with normal external genitalia.

Klinefelter’s Syndrome
Klinefelter’s syndrome is a chromosomal aneuploidy where patients have an extra copy of an X chromosome, resulting in hypogonadism and infertility. Patients are phenotypically male with normal external genitalia.

Congenital Adrenal Hyperplasia
Congenital adrenal hyperplasia is a group of conditions associated with abnormal enzymes involved in the production of hormones from the adrenals. Patients may have ambiguous genitalia at birth and later present with symptoms of polycystic ovary syndrome or hyperpigmentation.

5-α Reductase Deficiency
5-α reductase deficiency is a condition where patients have a mutation in the SDR5A2 gene, resulting in disrupted formation of external genitalia before birth. Patients may have ambiguous genitalia at birth and later show virilisation during puberty. Patients are infertile.

Treatment for DSDs involves hormone replacement therapy and supportive care. It is important to provide psychosocial support for patients and their families.

The contraceptive patch regime involves wearing one patch per week for three weeks, followed by a patch-free week. This method is gaining popularity due to its flexibility, as the patch can be changed up to 48 hours late without the need for backup contraception. Additionally, the patch’s transdermal absorption eliminates the need for extra precautions during episodes of vomiting or diarrhea. Similar to the pill, this method involves three weeks of contraceptive use followed by a one-week break, during which the woman will experience a withdrawal bleed.

The Evra patch is the only contraceptive patch that is approved for use in the UK. The patch cycle lasts for four weeks, during which the patch is worn every day for the first three weeks and changed weekly. During the fourth week, the patch is not worn, and a withdrawal bleed occurs.

If a woman delays changing the patch at the end of week one or two, she should change it immediately. If the delay is less than 48 hours, no further precautions are necessary. However, if the delay is more than 48 hours, she should change the patch immediately and use a barrier method of contraception for the next seven days. If she has had unprotected sex during this extended patch-free interval or in the last five days, emergency contraception should be considered.

If the patch removal is delayed at the end of week three, the woman should remove the patch as soon as possible and apply a new patch on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.

If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for seven days following any delay at the start of a new patch cycle. For more information, please refer to the NICE Clinical Knowledge Summary on combined hormonal methods of contraception.

If a patient on the combined oral contraceptive pill missed two or more pills and has had unprotected sexual intercourse during the pill-free period or week 1 of the pill packet, emergency contraception should be considered. However, in this case, the patient has only missed one pill on day 9 and does not require emergency contraception or a pregnancy test. If the patient had missed two pills during days 1-7 of the pill packet and had unprotected sex, emergency contraception would be necessary. The choice of emergency contraception depends on various factors, including the timing of the unprotected intercourse event, other medications the patient may be taking, and her preferences. Offering to insert a copper coil to prevent pregnancy would be inappropriate in this case. However, if the patient was having trouble remembering to take her pill correctly and wished to consider a long-acting contraceptive, options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection could be discussed. It is important to note that the contraceptive injection cannot be used as a form of emergency contraception.

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.

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 does not 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 common condition.

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.

Common Vaginal Infections and Their Symptoms

Vaginal infections can be caused by various organisms and can present with different symptoms. Here are some common vaginal infections and their symptoms:

1. Candida albicans: This fungal infection can cause candidiasis, which presents with a thick, cottage-cheese yellowish discharge and pain upon urination. Treatment involves antifungal medication.

2. Normal discharge: A normal vaginal discharge is clear and mucoid, without smell or other concerning symptoms.

3. gonorrhoeae: This sexually transmitted infection caused by Neisseria gonorrhoeae can cause a thick green-yellow discharge, painful urination, and bleeding between periods.

4. Chlamydia: This common sexually transmitted infection is often asymptomatic but can eventually cause pain upon urination, vaginal/penile discharge, and bleeding between periods.

5. Bacterial vaginosis: This infection is caused by an overgrowth of bacteria in the vagina and presents with a grey, watery discharge with a fishy odor. Treatment involves antibiotics and topical gels or creams.

It is important to seek medical attention if you experience any concerning symptoms or suspect a vaginal infection.

If a woman requests it, the combined oral contraceptive pill can be prescribed 6 weeks after giving birth, even if she is breastfeeding. However, it is important to note that she can still become pregnant as early as day 21 postpartum. Therefore, if she has had unprotected sex during this time, a pregnancy test should be conducted before prescribing the pill.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

If a woman is 55 years old or older and experiences postmenopausal bleeding (which occurs after 12 months of no menstruation), she should be referred for further evaluation within 2 weeks using the suspected cancer pathway to rule out 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. 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.

Levonorgestrel can still be taken within 72 hours of unprotected sexual intercourse (UPSI) in this case. Ulipristal acetate can also be taken up to 120 hours later, but the efficacy of oral options may have decreased after 61 hours. The copper coil is not a suitable option as the patient has declined any form of birth control. Therefore, the correct answer is that levonorgestrel can still be taken within 72 hours of UPSI.

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.

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

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

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

Secondary amenorrhoea is a common issue in highly athletic women, often caused by hypothalamic hypogonadism. This is the case for a young woman who is training for a marathon and has experienced oligomenorrhoea in the past. When a woman’s body has low levels of fat, the hypothalamus releases less gonadotrophin-releasing hormone, leading to hypogonadism. This is believed to occur because very low-fat levels are not conducive to successful pregnancy in females.

While an ultrasound may reveal many cysts on the ovaries, this woman does not meet the Rotterdam criteria for a diagnosis of polycystic ovary syndrome (PCOS). Although she experiences oligomenorrhoea, she does not exhibit signs of hyperandrogenism and has a lower-normal weight. It is also possible that she is pregnant, and a urine or serum pregnancy test should be conducted to rule out this possibility, even if she claims not to be sexually active.

While primary ovarian failure is a potential cause, it is not the most likely explanation in this case. However, it should still be investigated with gonadotrophins. If ovarian failure is present, gonadotrophin levels will be elevated, indicating that the hypothalamus and pituitary gland are not providing negative feedback on hormone release.

Understanding Amenorrhoea: Causes, Investigations, and Management

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

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

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

Different Types of Ovarian Tumours and their Histological Features

Ovarian tumours can be classified into various types based on their histological features. Here are some examples:

Krukenberg tumours:
These are secondary tumours that originate from the gastrointestinal tract and metastasize to the ovaries. They are characterized by the presence of signet ring cells.

Fibromas:
These are benign ovarian tumours that can cause Meigs’ syndrome. They contain spindle-shaped fibroblasts.

Granulosa cell tumours:
These are ovarian tumours that are most commonly seen in the first few decades of life. They contain Call-Exner bodies, which are follicles containing eosinophils.

Brenner tumours:
These are benign ovarian tumours that contain transitional cells.

Mucinous cystadenomas:
These are benign ovarian tumours that contain cells that resemble endocervical cells. However, if the tumour is malignant, it may not have this characteristic feature.

In conclusion, the histological features of ovarian tumours can provide important clues about their origin and potential malignancy.

Polycystic ovarian syndrome patients commonly experience insulin resistance, which can result in complex alterations in the hypothalamic-pituitary-ovarian axis.

Managing Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.