Types of Ectopic Pregnancy in the Fallopian Tube

Ectopic pregnancy, a condition where the fertilized egg implants outside the uterus, can occur in different parts of the Fallopian tube. Here are the different types of ectopic pregnancy in the Fallopian tube and their characteristics:

1. Isthmus – Ectopic pregnancy in the isthmus is rare but can occur. The tube is rigid, making rupture occur earlier than in other parts of the tube.

2. Interstitial part – This is the proximal segment of the tube embedded within the uterine wall. Ectopic pregnancy in this part is very rare and is more likely to occur in women who have had ipsilateral salpingectomy.

3. Ampulla – Ectopic pregnancy occurs most frequently in the ampullary part of the tube, which is relatively wide. Rupture usually occurs about 2 months after the last menstrual period, but it happens later than in the isthmus due to the elasticity of the tube.

4. Fimbrial end – Ectopic pregnancy near the fimbrial end can result in an ovarian pregnancy, which is rare and not associated with pelvic inflammatory disease or an intrauterine device.

5. Cornua – Pregnancy may implant itself in the cornua, which is the opening of the Fallopian tube. Combined with interstitial pregnancies, this represents a small percentage of all ectopic pregnancies.

Knowing the different types of ectopic pregnancy in the Fallopian tube can help in early detection and management of this potentially life-threatening condition.

Long-Term Complications of Vaginal Hysterectomy

Vaginal hysterectomy with antero-posterior repair is a common surgical procedure for women. However, it may lead to long-term complications such as enterocoele and vaginal vault prolapse. These conditions occur when the pelvic organs shift and push against the vaginal wall, causing discomfort and pain. While urinary retention may occur immediately after the surgery, it is not typically a chronic complication.

It is important for women who undergo vaginal hysterectomy to be aware of these potential complications and to discuss them with their healthcare provider. Regular check-ups and pelvic exams can help detect any issues early on and prevent further complications. Additionally, women can take steps to reduce their risk of developing these conditions by maintaining a healthy weight, avoiding heavy lifting, and practicing pelvic floor exercises. By being proactive and informed, women can minimize the impact of long-term complications and enjoy a better quality of life after surgery.

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.

To ensure maximum safety when switching from a traditional POP to COCP, it is recommended to use barrier contraception for 7 days while starting the combined oral contraceptive. This is the standard duration of protection required when starting this medication outside of menstruation. It is not necessary to use barrier contraception for 10 or 14 days, as the standard recommendation is 7 days. Using barrier contraception for only 3 days is too short, as it is the duration recommended for starting a traditional progesterone-only pill. While there may be some protection, it is still advisable to use additional contraception for 7 days to prevent unwanted pregnancy.

Special Situations for Combined Oral Contraceptive Pill

Concurrent antibiotic use has been a concern for many years in the UK, as doctors have advised that it may interfere with the effectiveness of the combined oral contraceptive pill. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines to abandon the extra precautions previously advised during antibiotic treatment and for 7 days afterwards. The latest edition of the British National Formulary (BNF) has also been updated to reflect this guidance, although precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

When it comes to switching combined oral contraceptive pills, the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The FSRH’s Combined Oral Contraception guidelines state that the pill-free interval does not need to be omitted, while the BNF advises missing the pill-free interval if the progesterone changes. Given this uncertainty, it is best to follow the BNF’s advice.

Pregnant women with a BMI greater than 30 kg/m2 should be prescribed a high dose of 5mg folic acid instead of the standard 400 micrograms. Therefore, the lifestyle and dietary advice given to this patient is incorrect. Additionally, prescribing 75 mg of aspirin is not appropriate for this patient as it is typically given to women with one high-risk factor or two moderate-risk factors for pre-eclampsia, and a BMI over 35 would only qualify as a single moderate-risk factor. While 150 mg of aspirin is an alternative dose for pre-eclampsia prophylaxis, 75 mg is more commonly used in practice.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

Annual Monitoring for Diabetes in Women with Polycystic Ovary Syndrome

Women with polycystic ovary syndrome (PCOS) are at an increased risk of developing type 2 diabetes mellitus. Therefore, it is important to monitor these patients for diabetes. The monitoring approach depends on the patient’s risk stratification, which is determined by factors such as BMI, family history of diabetes, and personal history of gestational diabetes.

For patients with evidence of impaired glucose tolerance, defined as a fasting glucose of < 7.0 mmol/l and a 2-hour OGTT of ≥ 7.8 but < 11.1 mmol/l, dietary and weight loss advice should be given, and a repeat glucose tolerance test is indicated annually. For patients with a normal glucose tolerance test, with a BMI of < 30 kg/m2, no family history of diabetes, and no personal history of gestational diabetes, annual random fasting glucose testing is appropriate. If the result is ≥ 5.6 mmol/l, then a glucose tolerance test should be performed. For patients with a BMI of ≥ 30 kg/m2, annual glucose tolerance testing is recommended. If diabetes is suspected based on symptoms such as polyuria, polydipsia, and weight loss, a random serum glucose of ≥ 11.0 mmol/l or a fasting glucose of ≥ 7.0 mmol/l is diagnostic. In asymptomatic patients, two samples of fasting glucose of ≥ 7.0 mmol/l are adequate for diagnosis. In conclusion, annual monitoring for diabetes is important in women with PCOS to prevent complications and morbidity associated with type 2 diabetes mellitus. The monitoring approach should be tailored to the patient’s risk stratification.

Premenstrual syndrome can be treated with a combination of oral contraceptives and SSRIs, along with cognitive behavioral therapy. While the copper intrauterine device is effective for long-term contraception, it does not address the hormonal changes that cause PMS symptoms. The most appropriate option for Lydia is a new-generation combined oral contraceptive pill containing drospirenone, which can alleviate her symptoms. Progesterone-only contraception is not recommended for PMS, and sodium valproate is not a recognized treatment for this condition. It is important to take the COC continuously for maximum benefit.

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.

Contraception for Women with Epilepsy

Women with epilepsy need to consider several factors when choosing a contraceptive method. Firstly, they need to consider how the contraceptive may affect the effectiveness of their anti-epileptic medication. Secondly, they need to consider how their anti-epileptic medication may affect the effectiveness of the contraceptive. Lastly, they need to consider the potential teratogenic effects of their anti-epileptic medication if they become pregnant.

To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends that women with epilepsy consistently use condoms in addition to other forms of contraception. For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends the use of the COCP and POP as UKMEC 3, the implant as UKMEC 2, and the Depo-Provera, IUD, and IUS as UKMEC 1.

For women taking lamotrigine, the FSRH recommends the use of the COCP as UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS as UKMEC 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol. By considering these recommendations, women with epilepsy can make informed decisions about their contraceptive options and ensure the safety and effectiveness of their chosen method.

Treatment Options for Symptomatic Cystocoele: Lifestyle Modifications, Medications, and Surgeries

Symptomatic cystocoele can be treated through various options, depending on the severity of the condition. The first line of treatment focuses on lifestyle modifications, such as smoking cessation and weight loss. Topical oestrogen may also be prescribed to post- or perimenopausal women suffering from vaginal dryness, urinary incontinence, recurrent urinary tract infections, or superficial dyspareunia. Inserting a ring pessary is the second line of treatment, which needs to be changed every six months and puts the patient at risk of ulceration. Per vaginal surgery is the third line of treatment, which is only possible if the cystocoele is small and puts the patient at risk of fibroids and adhesions. Hysterectomy is not recommended as it increases the risk of cystocoele due to the severance of the uterine ligaments and reduction in support following removal of the uterus.

On ultrasound imaging, the presence of a whirlpool sign and free fluid may indicate ovarian torsion. This sign occurs when a structure twists upon itself. It is important to note that appendicitis and ectopic pregnancy do not show this sign on imaging. Additionally, the pain associated with Mittelschmerz is typically less severe and would not be accompanied by the ultrasound finding.

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.

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.

The most appropriate method of HRT for the patient in this scenario is a transdermal oestrogen patch, as she has had a hysterectomy and oestrogen monotherapy is the regimen of choice. As the patient’s BMI is > 30 kg/m2, an oral oestrogen preparation is not recommended due to the increased risk of venous thromboembolism. HRT has benefits for the patient, including protection against osteoporosis, urogenital atrophy, and cardiovascular disorders. However, HRT also has risks, including an increased risk of venous thromboembolism and endometrial and breast cancer. Type 2 diabetes mellitus is not a contraindication to HRT, and there is no evidence that HRT affects glucose control. Combination HRT regimens are reserved for women with a uterus, and oral oestradiol once daily is not recommended for patients with a BMI > 30 kg/m2 due to the increased risk of venous thromboembolism. Women at high risk of developing venous thromboembolism or those with a strong family history or thrombophilia should be referred to haematology before starting HRT.

Injectable progesterone contraceptives should not be used in individuals with current breast cancer, as it is an absolute contraindication as per the UK medical eligibility criteria. Smoking more than 15 cigarettes a day is also a contraindication for the combined oral contraceptive pill, while migraine with aura is a contraindication for the same. Additionally, unexplained vaginal bleeding is a contraindication for starting the intrauterine device (IUD) or the intrauterine system (IUS).

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.

Caroline’s case of secondary amenorrhoea suggests a hypothalamic cause, as indicated by low levels of gonadotrophins (FSH and LH) and oestradiol. This is different from pituitary adenoma, which often presents with panhypopituitarism and normal prolactin levels, and premature ovarian failure, which is diagnosed in women under 40 with increased FSH levels and menopausal-like symptoms. PCOS is also unlikely as there is no hyperandrogenism or other symptoms present. Hypothalamic dysfunction can be caused by excessive exercise, stress, or dieting, which should be explored in the patient’s history.

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.

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

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 risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

Understanding Ectopic Pregnancy: The Pathophysiology

Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

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.

Common Causes of Lumps in the Vaginal Area in Women

The vaginal area in women can be affected by various lumps, which can cause discomfort and concern. Here are some of the most common causes of lumps in the vaginal area in women:

Bartholin Cyst: This type of cyst occurs when the ducts connecting the Bartholin glands, which are located near the introitus at the 4 and 8 o’clock positions, become obstructed. Bartholin cysts are usually soft, small, and asymptomatic, but they can cause discomfort and require removal in women over 40 to rule out vaginal carcinoma.

Lipoma: A lipoma is a benign adipose tissue that can be found on the labia majora. It is a larger and rarer lump than a Bartholin cyst.

Bartholin Abscess: This condition arises from an infected Bartholin cyst and causes significant labial swelling, erythema, tenderness, and pain on micturition and superficial dyspareunia. Treatment includes antibiotics and warm baths, but surgical management may be necessary.

Haematoma: A haematoma is a collection of blood cells outside the vessels, which presents as a firm, red-purple lump. It usually occurs after trauma or surgery.

Infected Epidermal Cyst: Epidermal cysts are benign tumors that can occur in the perineal area. When infected, they cause erythema, pain, and extravasation of keratin material.

Understanding the Different Types of Lumps in the Vaginal Area in Women

Based on the patient’s symptoms and an elevated level of CA-125, it is likely that she has ovarian cancer. Additionally, her family history of cancer in first-degree relatives and early onset cancer suggest the possibility of an inherited cancer-related gene. One such gene is BRCA1, which increases the risk of ovarian and breast cancer in those who have inherited a mutated copy. Other tumour suppressor genes, such as WT1 for Wilm’s tumour, Rb for retinoblastoma, and c-Myc for Burkitt lymphoma, confer a higher risk for other types of cancer.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

In the case of an inadequate smear test result, the patient will be advised to undergo a repeat test within 3 months. If the second test also yields an inadequate result, the patient will need to undergo colposcopy testing.

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.

Treatment Options for Stress Urinary Incontinence

Stress urinary incontinence is a common condition in women, especially those who have had vaginal deliveries and are getting older. It is caused by weak sphincter muscles, leading to leakage during activities such as coughing, sneezing, laughing, or exercising. The first-line treatment for this condition is pelvic floor muscle training, which involves a minimum of eight contractions three times per day for 12 weeks.

However, it is important to note that other treatment options, such as oxybutynin, pelvic ultrasound scans, urodynamic studies, and bladder training, are not recommended for stress urinary incontinence. Oxybutynin is used for overactive bladder or mixed urinary incontinence, while pelvic ultrasound scans are not indicated for urinary incontinence. Urodynamic studies are not recommended for women with simple stress incontinence on history and examination, and bladder training is used for urgency or mixed urinary incontinence, not stress incontinence. Therefore, pelvic floor muscle training remains the most effective treatment option for stress urinary incontinence.

After undergoing treatment for cervical intraepithelial neoplasia (CIN) during her colposcopy appointment, this woman needs to undergo follow-up cervical screening to ensure that the lesion has been effectively treated. Women who have received treatment for CIN II should be provided with cervical screening and an HPV test of cure after 6 months. If the test results are positive, the woman should go back for colposcopy.

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.

Possible Causes of Amenorrhea and Hirsutism in Women

Amenorrhea, the absence of menstrual periods, and hirsutism, excessive hair growth, are symptoms that can be caused by various conditions. Polycystic ovarian syndrome (PCOS) is a common cause of anovulatory infertility and is diagnosed by the presence of two out of three criteria: ultrasound appearance of enlarged ovaries with multiple cysts, infrequent ovulation or anovulation, and clinical or biochemical evidence of hyperandrogenism. Turner syndrome, characterized by short stature, webbed neck, and absence of periods, is a genetic disorder that would not cause primary amenorrhea. Hyperprolactinemia, a syndrome of high prolactin levels, can cause cessation of ovulation and lactation but not an increase in BMI or hair growth. Premature ovarian failure has symptoms similar to menopause, such as flushing and vaginal dryness. Virilizing ovarian tumor can also cause amenorrhea and hirsutism, but PCOS is more likely and should be ruled out first.

Ovarian cancer typically spreads initially through local invasion, rather than through the lymphatic or hematological routes. This patient’s symptoms, including IBS-like symptoms, irregular vaginal bleeding, and a raised CA125, suggest ovarian cancer. The stages of ovarian cancer range from confined to the ovaries (Stage 1) to spread beyond the pelvis to the abdomen (Stage 3), with local spread within the pelvis (Stage 2) in between. While lymphatic and hematological routes can also be involved in the spread of ovarian cancer, they tend to occur later than local invasion within the pelvis. The para-aortic lymph nodes are a common site for lymphatic spread, while the liver is a common site for hematological spread.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

In the case of cervical cancer screening, if two consecutive samples are deemed inadequate, the patient will be referred for colposcopy testing. Prior to this, the patient will be asked to undergo a repeat test within a period of 3 months.

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.

It is common for HCG levels to remain positive for several weeks after a termination of pregnancy. HCG levels are typically measured every two days, and a positive result beyond four weeks may indicate a continuing pregnancy. However, in most cases, HCG levels will return to normal within four weeks.

In this scenario, the appropriate course of action is to repeat the urine pregnancy test in one week, as the patient is currently only three weeks post-termination. There is no need for further referrals or imaging at this time, as a positive test result is unlikely to indicate a continuing pregnancy, and the patient does not exhibit any urgent symptoms such as infection or hemorrhage.

Termination of Pregnancy in the UK

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

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

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

The addition of progesterone to hormone replacement therapy (HRT) has been linked to an increased risk of breast cancer, as well as venous thromboembolism and cardiovascular disease. HRT may be recommended for menopausal patients experiencing vasomotor symptoms such as hot flashes, night sweats, and palpitations. However, if a patient only presents with urogenital symptoms, topical oestrogens such as oestradiol creams or pessaries may be more appropriate. These act locally to alleviate vaginal dryness, reduce UTI recurrence, and ease dyspareunia. For patients with vasomotor symptoms, HRT preparations with systemic effects (such as oral medications, topical patches, and implants) may be considered. If the patient has not undergone a hysterectomy, their HRT regime must include both oestrogen and progesterone to prevent hypertrophy of the uterus and a 5-10x increased risk of endometrial carcinoma associated with unopposed oestrogen therapy.

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.

Prolapse refers to the descent of pelvic organs into the vagina, which can be categorized into different degrees. First-degree prolapse involves the descent of the uterus and cervix, but they do not reach the vaginal opening. Second-degree prolapse is when the cervix descends to the level of the introitus. Third-degree prolapse is the protrusion of the cervix and uterus outside of the vagina. Fourth-degree prolapse is the complete prolapse of the cervix, uterus, and vaginal wall, which can cause bleeding due to cervix ulceration. Vault prolapse is the prolapse of the top of the vagina down the vaginal canal, often occurring after a hysterectomy due to weakness of the upper vagina. The causes of urogenital prolapse are multifactorial and can include factors such as childbirth, menopause, chronic cough, obesity, constipation, and suprapubic surgery for urinary continence.

During the initial 6 months after the intrauterine system is inserted, experiencing irregular bleeding is a typical adverse effect. However, over time, the majority of women who use the IUS will experience reduced or absent menstrual periods, which is advantageous for those who experience heavy menstrual bleeding or prefer not to have periods.

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

Management Options for Endometriosis-Related Pain: A Guide for Healthcare Professionals

Endometriosis is a condition where endometrial tissue grows outside the uterus, causing pain and discomfort. Hormonal contraception is an effective treatment option for women who do not wish to conceive. The combined oral contraceptive pill suppresses ovarian function and limits the effect of estrogen on endometrial tissue. progesterone-containing contraceptives cause atrophy of the endometrial tissue. A trial of three months is recommended before reassessment.

Hysterectomy is indicated for adenomyosis or heavy menstrual bleeding that has not resolved with other treatments. A hysteroscopy is not necessary for a newly diagnosed young patient. A trial of ibuprofen or combination therapy is the first step in pain management, but NSAIDs are contraindicated for asthmatic patients who have already tried paracetamol.

Further laparoscopy for excision and/or ablation of endometriotic deposits is indicated if there is further disease. However, if all visible deposits were removed during diagnostic laparoscopy, a further laparoscopy is not necessary at present.

Ovarian cystectomy is recommended for women with endometriotic cysts who are concerned about fertility. Laparoscopic removal of the cyst wall can improve the chances of spontaneous pregnancy and reduce the risk of recurrence of endometriomas. These guidelines are based on NICE recommendations.

The copper IUD is suitable for fitting at any stage of the menstrual cycle. It can also be fitted right after a first or second-trimester abortion, as well as 4 weeks after giving birth. It is crucial to advise the patient to avoid sexual intercourse or use effective contraception until the IUD is in place to prevent pregnancy.

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

Chronic PID: A Possible Cause of Irregular Menses, Deep Dyspareunia, and Post-Coital Bleeding in Young Females

Chronic pelvic inflammatory disease (PID) is a possible diagnosis for young females experiencing irregular menses, deep dyspareunia, and post-coital bleeding. This condition is typically caused by a Chlamydia infection. PID is a result of the inflammation of the female reproductive organs, including the uterus, fallopian tubes, and ovaries. The inflammation can cause scarring and damage to the reproductive organs, leading to long-term complications such as infertility.

Irregular menses, deep dyspareunia, and post-coital bleeding are common symptoms of chronic PID. Irregular menses refer to menstrual cycles that are shorter or longer than the usual 28-day cycle. Deep dyspareunia is a condition where a woman experiences pain during sexual intercourse, particularly in the lower abdomen. Post-coital bleeding is the occurrence of vaginal bleeding after sexual intercourse.

Early diagnosis and treatment of chronic PID can prevent long-term complications. Treatment typically involves antibiotics to clear the infection and pain management to alleviate symptoms. In severe cases, surgery may be necessary to remove damaged tissue.

In conclusion, chronic PID is a possible cause of irregular menses, deep dyspareunia, and post-coital bleeding in young females.

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.

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.

The Importance of Urine Pregnancy Testing in Females with Abdominal Pain

Any female of childbearing age who presents to the Emergency Department with abdominal pain should have a urinary pregnancy test performed (β-HCG). This is because a negative pregnancy test is necessary to confirm that the patient is not pregnant. It is an easy and inexpensive test to perform.

Shoulder tip pain may indicate diaphragmatic irritation secondary to free intraperitoneal fluid, which can be caused by a ruptured ectopic pregnancy. However, a full blood count (FBC) and urea and electrolytes (U & Es) will not diagnose a potential ruptured ectopic pregnancy and, as such, will not guide subsequent management.

An erect chest X-ray may be requested if perforation is suspected, but a urine pregnancy test would be much more useful in this scenario. An abdominal X-ray is not indicated.

In summary, a urine pregnancy test is crucial in females of childbearing age with abdominal pain to rule out pregnancy and potentially diagnose a ruptured ectopic pregnancy.

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.

When a teenage girl experiences regular painful cycles but has not yet started menstruating, an imperforate hymen is a likely cause. This condition blocks the flow of menstrual blood, leading to primary amenorrhoea while allowing for normal development of secondary sexual characteristics like pubic hair and breast growth. The accumulation of menstrual blood in the vagina can cause discomfort and bloating due to pressure. Other potential causes of amenorrhoea include chemotherapy during childhood, Turner’s syndrome, and polycystic ovary syndrome, which can all interfere with the production of estrogen and the development of secondary sexual characteristics.

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.

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

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

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

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

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

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

If a woman has a suspected or personal history of breast cancer or a confirmed BRCA mutation, the safest form of contraception for her is the copper coil. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides guidelines for the choice of contraception, grading non-barrier contraceptives on a scale of 1-4 based on a woman’s personal circumstances. Contraceptive methods that fall under category 1 or 2 are generally considered safe for use in primary care. In this case, all forms of contraception except the combined pill (category 3) can be offered, with the copper coil being the safest option as it falls under category 1.

Understanding Contraception: A Basic Overview

Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).

Barrier methods, such as condoms, physically block sperm from reaching the egg. While they can help protect against sexually transmitted infections (STIs), their success rate is relatively low, particularly when used by young people.

Daily methods include the combined oral contraceptive pill, which inhibits ovulation, and the progesterone-only pill, which thickens cervical mucous. However, the combined pill increases the risk of venous thromboembolism and breast and cervical cancer.

LARCs include implantable contraceptives and injectable contraceptives, which both inhibit ovulation and thicken cervical mucous. The implantable contraceptive lasts for three years, while the injectable contraceptive lasts for 12 weeks. The intrauterine system (IUS) and intrauterine device (IUD) are also LARCs, with the IUS preventing endometrial proliferation and thickening cervical mucous, and the IUD decreasing sperm motility and survival.

It is important to note that each method of contraception has its own set of benefits and risks, and it is essential to consult with a healthcare provider to determine the best option for individual needs and circumstances.

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.

The current guidelines for cervical cancer screening recommend using hrHPV as the first screening test. If the result is negative, the patient can return to routine recall. However, if the result is positive, the sample is examined for cytology. If the cytology is normal, the patient is asked to return for screening in 12 months instead of the usual 3 years. If the hrHPV result is negative at the 12-month follow-up, the patient can return to routine recall. But if the result is positive again, as in this scenario, and the cytology is normal, the patient should attend another screening in 12 months. If the cytology is abnormal at any point, the patient should be referred for colposcopy. If the patient attends a third screening in another 12 months and the hrHPV result is still positive, she should be referred for colposcopy regardless of the cytology result.

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

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

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

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

If a woman misses 2 pills in week 3 of taking the COCP, she should finish the remaining pills in the current pack and start a new pack immediately without taking the pill-free interval. Missing 2 pills means that it has been 72 hours since the last pill was taken, and the standard rule is to take 2 pills on the same day and continue taking one pill each day until the end of the pack. It is important not to take more than 2 pills in one day, and emergency contraception is only necessary if more than 7 consecutive pills are missed. In this case, the woman has not taken the required 7 consecutive pills to be protected during the pill-free interval, so she should start the new pack immediately. However, the chances of pregnancy are low if she has taken 7 pills consecutively the prior week.

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.

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.

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.

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.

Stages of Endometrial Carcinoma: TNM Classification Explained

Endometrial carcinoma is a type of cancer that affects the lining of the uterus. The TNM classification system is used to describe the extent of the cancer and guide treatment decisions. Here are some common stages of endometrial carcinoma:

T3a N0 M0: This stage describes endometrial carcinoma that involves the uterine serosa or adnexae, but has not spread to lymph nodes or other organs.

T3b N0 M0: This stage describes endometrial carcinoma that involves the vagina or parametrial tissues, but has not spread to lymph nodes or other organs.

T1a N0 M0: This stage describes endometrial carcinoma that is confined to the endometrium or has invaded less than half of the myometrium, without lymph node or distal metastases.

T1b N0 M0: This stage describes endometrial carcinoma that is confined to the uterus but has invaded more than half of the myometrium, without lymph node or distal metastases.

T2 N0 M0: This stage describes endometrial carcinoma that involves the cervix but has not spread beyond the uterus, without lymph node or distal metastases.

Understanding the stage of endometrial carcinoma is important for determining the best treatment options and predicting outcomes.

The use of COCP as a first-line contraceptive should be avoided for wheelchair users due to their increased risk of developing deep vein thrombosis (DVT). The presence of oestradiol in COCP increases the risk of DVT, and immobility associated with wheelchair use further exacerbates this risk. Therefore, the risks of using COCP outweigh the benefits for wheelchair users, and it is classified as UKMEC 3.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

When experiencing atrophic vaginitis, the dryness of the vaginal mucosa can cause pain, itching, and dyspareunia. The first-line treatment for this condition is topical oestrogen cream, which helps to restore the vaginal mucosa. However, lubricants and moisturisers can also provide short-term relief while waiting for the topical oestrogen cream to take effect. Oestrogen secreting pessaries are an alternative to topical oestrogen cream, but using them together would result in an excessive dose of oestrogen. Sitz baths are useful for irritation and itching of the perineum, but they do not address internal vaginal symptoms. Warm or cold compresses may provide temporary relief, but they are not a long-term solution.

Atrophic vaginitis is a condition that commonly affects women who have gone through menopause. Its symptoms include vaginal dryness, pain during sexual intercourse, and occasional spotting. Upon examination, the vagina may appear dry and pale. The recommended treatment for this condition is the use of vaginal lubricants and moisturizers. If these do not provide relief, a topical estrogen cream may be prescribed.

The most common reason for delayed puberty in women is constitutional delay, which is a normal variation where puberty starts later than usual. This may be due to a family history of late menarche. However, it is important to refer the patient to a specialist for further investigation. Hypogonadotrophic hypogonadism is another cause, which is a result of a deficiency in gonadotrophin-releasing hormone secretion. This can be managed by restoring weight in cases such as athletes, dancers, or anorexia sufferers. Primary gonadal failure is rare and may occur in isolation or as part of chromosomal anomalies. Hormone replacement therapy is the treatment for this condition. Hyperprolactinaemia is a rare cause of primary amenorrhoea, which is caused by high levels of prolactin from a tumour. However, it is unlikely to affect normal development. Hypothyroidism can also cause amenorrhoea, but it is usually accompanied by other symptoms such as cold intolerance, mood changes, and weight gain.

Diagnosis and Testing for Trichomoniasis: A Common STD

Trichomoniasis is a sexually transmitted disease caused by the protozoan parasite T. vaginalis. While both men and women can be affected, women are more likely to experience symptoms. Diagnosis of trichomoniasis is typically made through wet mount microscopy and direct visualisation, with DNA amplification techniques offering higher sensitivity. Urine testing is not considered the gold standard, and cervical swabs are not sensitive enough. Treatment involves a single dose of metronidazole, and sexual partners should be treated simultaneously. Trichomoniasis may increase susceptibility to HIV infection and transmission. Symptoms in women include a yellow-green vaginal discharge with a strong odour, dysuria, pain on intercourse, and vaginal itching. Men may experience penile irritation, mild discharge, dysuria, or pain after ejaculation.

Types of Urinary Incontinence and Their Causes

Urinary incontinence is a common condition that affects many people, particularly women. There are different types of urinary incontinence, each with its own causes and management options.

Stress incontinence is the most common form of urinary incontinence in women. It occurs when there is either loss of muscle tension of the pelvic floor muscles or damage to the urethral sphincter, leading to leakage of urine with stress. Risk factors include vaginal delivery, obesity, previous pelvic surgery, increasing age, family history, and use of certain medications.

Functional incontinence occurs when one cannot make it to the toilet in time due to physical or environmental problems. This is not applicable to the patient in the scenario.

Overflow incontinence occurs in the presence of a physical obstruction to bladder outflow, which may be caused by a pelvic tumour, faecal impaction, or prostatic hyperplasia. The patient in the scenario has no known obstructive pathology.

True incontinence is a rare form of urinary incontinence and is associated with the formation of a fistula between the bladder or the ureter and the vagina, resulting in leakage of urine through the vagina. It is associated with cases of trauma following surgery or the presence of a pelvic cancer that has invaded through the wall resulting in damage to adjacent organs.

Urge incontinence is the second most common form of urinary incontinence in women. It is defined as urinary leakage that is preceded by a strong desire to pass urine, a symptom referred to as urgency. It can be the result of detrusor instability or an overactive bladder. Management options include lifestyle modifications, bladder training, medications, and referral to secondary care for more advanced options.

The patient’s symptoms of dysmenorrhoea, dyspareunia, and subfertility are classic signs of endometriosis, a common condition where endometrial tissue grows outside of the uterus. The presence of uterosacral nodularity and tenderness further supports this diagnosis. Some patients with endometriosis may also experience urinary symptoms due to bladder involvement or adhesions. Uterine leiomyoma, or fibroid, is a common pelvic tumor that causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. However, it does not typically present with uterosacral nodularity and tenderness on rectal examination. Interstitial cystitis causes urinary frequency and urgency, with pain relieved upon voiding. Pelvic inflammatory disease presents with fever, nausea, acute pain, malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.

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.

The luteal phase of the menstrual cycle remains constant at 14 days, while the follicular phase can vary. The serum progesterone level reaches its peak 7 days after ovulation. For a 35-day cycle, the follicular phase would be 21 days (with ovulation occurring on day 21) and the luteal phase would be 14 days, resulting in the progesterone level peaking on day 28 (35-7). However, relying on day 21 progesterone levels would only be useful for women with a regular menstrual cycle of 28 days. While basal body temperature charting can be used to track ovulation, it is not the recommended method by NICE. An increase in basal temperature after ovulation can indicate successful ovulation.

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

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

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

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.

Injectable progesterone contraceptives are not recommended for individuals with current breast cancer.

This is considered an absolute contraindication (UKMEC 4) for prescribing injectable progesterone contraceptives. It is also an absolute contraindication for most other forms of contraception, except for the non-hormonal copper intrauterine device.

Current deep vein thrombosis is a UKMEC 2 contraindication for injectable progesterone, while it is a UKMEC 4 contraindication for the combined oral contraceptive pill. Multiple cardiovascular risk factors are a UKMEC 3 contraindication, which is not absolute, but the risks are generally considered to outweigh the benefits.

Smoking 30 cigarettes per day is only a UKMEC 1 contraindication for injectable progesterone contraception. However, considering the individual’s age, it would be a UKMEC 4 contraindication for the combined oral contraceptive pill.

High BMI is a UKMEC 1 contraindication for most forms of contraception, including injectable progesterone. However, it would be a UKMEC 4 contraindication for the combined pill.

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.

The only accurate statement among the given options is that the intrauterine copper device is a safe contraceptive option for transgender males. This is because it is non-hormonal and does not interfere with testosterone therapy, although it may worsen menstrual bleeding. Condoms are also a viable option, but not the only safe one. Testosterone therapy does not prevent pregnancy and can even cause birth defects if the patient becomes pregnant. The combined oral contraceptive pill and vaginal ring are not recommended as they contain estrogen, which can counteract the effects of testosterone therapy. However, progesterone-only methods such as injections, the intrauterine system, and the progesterone-only pill are suitable options.

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 Vulvodynia: Types, Causes, and Associated Conditions

Vulvodynia is a chronic pain condition that affects the vulvovaginal region and lasts for at least three months without any identifiable cause. There are two types of vulvodynia: provoked and unprovoked. Provoked vulvodynia is triggered by sexual intercourse or tampon insertion, while unprovoked vulvodynia is a spontaneous chronic pain that is present most of the time.

Vulvodynia can be localised or generalised and can be primary or secondary. It can affect women of any age and is associated with various factors such as neurological conditions, chronic pain syndromes, genetic predisposition, pelvic muscle overactivity, anxiety, and depression. The exact mechanism of vulvodynia is not yet understood, but it is believed to be multifactorial and complex.

Other conditions that can cause pain in the vulvovaginal region include sexually transmitted infections, lichen sclerosus, and lichen planus. Sexually transmitted infections usually present with dyspareunia, abnormal bleeding, and a vaginal discharge. Lichen sclerosus presents with itching and burning, while lichen planus presents with purple-red lesions and overlying lacy markings.

Vulvodynia is a dysfunctional pain syndrome that can significantly impact a woman’s quality of life. It is essential to seek medical attention if you experience any pain or discomfort in the vulvovaginal region to determine the underlying cause and receive appropriate treatment.

After a termination of pregnancy, a urine pregnancy test can still show positive results for up to 4 weeks. If the test remains positive beyond this time frame, it may indicate an incomplete abortion or persistent trophoblast. In this case, the correct answer to when the pregnancy test should be negative is 2 weeks from now, as the termination occurred 2 weeks ago. A negative result one week ago is not relevant, and 4 weeks from today or 8 weeks from today are both incorrect as they fall outside of the 4-week window.

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.

To ensure effectiveness, it is important to note that the progesterone-only pill (POP) requires 48 hours before it can be relied upon as a form of contraception. During this time, it is recommended to use additional precautions such as condoms. However, after the initial 48 hours, no further precautions are necessary as long as the POP is taken at the same time each day within a 3-hour window. It is important to note that the POP does not protect against sexually transmitted infections (STIs), so the use of condoms as a barrier method may be discussed for long-term protection. However, as the patient and her partner have recently tested negative for STIs, this may not be necessary at this time. In contrast, if the patient was prescribed the combined oral contraceptive pill (COCP), it is advised to use condoms for the first 7 days.

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 woman’s ovulation usually occurs on day 14 of her 28-day menstrual cycle. After ovulation, hormonal changes occur.

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

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

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

Common Causes of Abnormal Uterine Bleeding in Young Women

Abnormal uterine bleeding is a common problem among young women, especially within the first years of menarche. There are several possible causes, including anovulatory dysfunctional uterine bleeding, cervical cancer, ovulatory dysfunctional uterine bleeding, submucosal leiomyoma, and prolactinoma.

Anovulatory dysfunctional uterine bleeding occurs when the hormonal axis that regulates the menstrual cycle is not fully matured. This can lead to irregular and unpredictable bleeding due to the lack of ovulation and the resulting hyperoestrogenic state that induces endometrial hyperplasia.

Cervical cancer is associated with human papillomavirus infection and other risk factors such as smoking, early intercourse, multiple sexual partners, oral contraceptive use, and immunosuppression. It can cause vaginal spotting, post-coital bleeding, dyspareunia, and vaginal discharge.

Ovulatory dysfunctional uterine bleeding is caused by excessive production of vasoconstrictive prostaglandins in the endometrium during a menstrual period. This can result in more severe and prolonged bleeding associated with painful uterine contractions.

Submucosal leiomyoma is a benign neoplastic mass that protrudes into the intrauterine cavity and can cause metrorrhagia or menorrhagia. It is rare in young women.

Prolactinoma can result in oligomenorrhoea/amenorrhoea or anovulation and metromenorrhagia by inhibiting the action of hypothalamic gonadotrophin-releasing hormone on the anterior pituitary gland. This leads to reduced follicle-stimulating hormone and luteinising hormone secretion, resulting in abnormal uterine bleeding.

In conclusion, abnormal uterine bleeding in young women can have various causes, and a proper diagnosis is essential for appropriate treatment. Anovulatory dysfunctional uterine bleeding is the most likely cause in this case due to the patient’s age.

Common Causes of Abnormal Uterine Bleeding in Women

Abnormal uterine bleeding is a common gynecological problem that can have various underlying causes. Here are some of the most common causes of abnormal uterine bleeding in women:

Endometriosis: This condition occurs when the endometrial tissue grows outside the uterus, usually in the ovaries or pelvic cavity. Symptoms include painful periods, painful intercourse, painful bowel movements, and adnexal tenderness. Endometriosis can also lead to infertility.

Ovulatory dysfunctional uterine bleeding: This condition is caused by excessive production of vasoconstrictive prostaglandins in the endometrium during a menstrual period. Symptoms include heavy and painful periods. Non-steroidal anti-inflammatory drugs are the treatment of choice.

Cervical cancer: This type of cancer is associated with human papillomavirus infection, smoking, early intercourse, multiple sexual partners, use of oral contraceptives, and immunosuppression. Symptoms include vaginal spotting, post-coital bleeding, dyspareunia, and vaginal discharge. Cervical cancer is rare before the age of 25 and is unlikely to cause dysmenorrhea, dyspareunia, dyschezia, or adnexal tenderness.

Submucosal leiomyoma: This is a benign neoplastic mass of myometrial origin that protrudes into the intrauterine cavity. Symptoms include heavy and painful periods, but acute pain is rare.

Endometrial polyps: These are masses of endometrial tissue attached to the inner surface of the uterus. They are more common around menopausal age and can cause heavy or irregular bleeding. They are usually not associated with pain or menstrual cramps and are not pre-malignant.

Understanding the Common Causes of Abnormal Uterine Bleeding in Women

The most appropriate investigation for a suspected ectopic pregnancy is a transvaginal ultrasound. In this case, the patient’s symptoms and examination findings suggest an ectopic pregnancy, making transvaginal ultrasound the investigation of choice. Transabdominal ultrasound is less sensitive and therefore not ideal. NAAT, which is used to detect chlamydia, is not relevant in this case as the patient’s history suggests a higher likelihood of ectopic pregnancy rather than infection. Laparoscopy, which is used to diagnose endometriosis, is not indicated based on the clinical presentation.

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.

Distinguishing between common vaginal infections: Trichomoniasis, Bacterial Vaginosis, gonorrhoeae, Chlamydia, and Mycoplasma Genitalium

When a woman presents with an elevated vaginal pH, a fish-smelling, yellow vaginal discharge, and ovoid trichomonads, the diagnosis of trichomoniasis (Trichomonas vaginalis) is strongly supported. A wet saline mount or anaerobic culture can confirm the diagnosis, with culture being particularly useful in men. Treatment involves oral metronidazole for seven days or a single 2g dose, and sexual partners should also be treated to prevent re-infection.

Bacterial vaginosis is a differential diagnosis to consider, as it also presents with a fish-smelling discharge and a pH > 4.5. However, the presence of ovoid mobile parasites on wet saline mount suggests trichomoniasis as the more likely diagnosis. Bacterial vaginosis would show clue cells on wet saline mount.

gonorrhoeae and Chlamydia are sexually transmitted infections that are more likely to be seen in patients with a history of unprotected sex. However, fish-smelling discharge is not characteristic of either infection. A specimen culture of gonorrhoeae would show Gram-negative diplococci, while chlamydia would not show ovoid mobile parasites on wet saline mount.

Mycoplasma genitalium is another potential sexually transmitted infection that can cause urethritis, discharge, cervicitis, or endometritis in women. However, the wet saline mount results suggest that this is not the diagnosis, and fish-smelling discharge is not characteristic of this infection.

In summary, a combination of clinical presentation, wet saline mount, and culture can help distinguish between common vaginal infections such as trichomoniasis, bacterial vaginosis, gonorrhoeae, chlamydia, and mycoplasma genitalium.

Patients with stress incontinence who do not respond to pelvic floor muscle exercises and decline surgical intervention may be prescribed duloxetine, a serotonin-norepinephrine re-uptake inhibitor. This drug increases sphincter tone during the filling phase of urinary bladder function. However, before starting drug therapy, patients should try pelvic floor exercises and consider surgical intervention. Oxybutynin, an anticholinergic drug, is used to treat urge incontinence or symptoms of detrusor overactivity, but it is not recommended for frail, older women at risk of health deterioration. Desmopressin is the preferred drug treatment for children with nocturnal enuresis and may also be used for women with nocturia. Mirabegron is prescribed for patients with urge incontinence who cannot tolerate antimuscarinic/anticholinergic drugs. It is a beta-3 adrenergic agonist that relaxes the bladder.

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.

Treatment and Management of Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a serious condition resulting from an ascending sexually transmitted infection, commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Patients with PID may present with symptoms such as chronic lower abdominal pain, dyspareunia, irregular bleeding, dysmenorrhoea, and purulent vaginal discharge. It is important to identify and treat PID promptly, as it can lead to complications such as infertility, ectopic pregnancy, and pelvic adhesion formation.

The management of PID depends on the severity of the presentation. Patients who are haemodynamically stable can be treated in the primary care setting with a single dose of ceftriaxone IM, followed by metronidazole and doxycycline for 14 days. However, patients with pyrexia, nausea and vomiting, or suspicion of a tubo-ovarian abscess or pelvic peritonitis should be admitted to hospital for IV antibiotics.

It is important to note that NICE recommends treating patients who are likely to have PID without waiting for swab results. In patients considered high-risk for gonococcal infection, who have no indication for admission to hospital for parenteral antimicrobial treatment, a single dose of ceftriaxone 1 g IM, followed by 14 days of metronidazole and doxycycline is recommended. Ofloxacin, moxifloxacin, or azithromycin should be avoided in women at high risk of a gonococcal infection due to increased resistance against quinolones.

In conclusion, early identification and prompt treatment of PID is crucial to prevent complications. Treatment should be tailored to the severity of the presentation and the patient’s risk factors.

If the sample is negative for high-risk strains of human papillomavirus (hrHPV), the patient should return to routine recall for their next cervical smear in 3 years, according to current guidance. Cytological examination is not necessary in this case as it is only performed if the hrHPV test is positive. Repeating the cervical smear in 3 months or 5 years is not appropriate as these are not the recommended timeframes for recall. Repeating the cervical smear after 12 months is only indicated if the previous smear was hrHPV positive but without cytological abnormalities.

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.

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.

For overweight or obese women with polycystic ovarian syndrome (PCOS) who are having difficulty getting pregnant, the initial approach is weight loss. If weight loss is not successful, either due to the woman’s inability to lose weight or failure to conceive despite weight loss, metformin can be used as an additional treatment.

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.

The combined oral contraceptive pill (COCP) is a highly effective birth control method that contains both oestrogen and progesterone. Studies have shown that the use of COCP can increase or decrease the risk of certain cancers. It has been found that the use of COCP can decrease the risk of endometrial cancer by suppressing the growth of endometrial cells. However, prolonged use of COCP has been associated with an increased risk of breast cancer, as synthetic hormones in the pill may stimulate the growth of breast cancer cells. Similarly, the use of COCP has been linked to an increased risk of cervical cancer, as it may make cervical cells more susceptible to human papillomavirus infections. It is important to note that COCP does not provide protection against sexually transmitted infections. Additionally, the use of oestrogen-containing contraception has been associated with an increased risk of strokes and ischaemic heart disease, particularly in patients with additional risk factors such as smoking and diabetes. The exact mechanism for this increased risk is not yet clear, but it may be due to increased blood pressure and/or hypercoagulation.

Pros and Cons of the Combined Oral Contraceptive Pill

The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than 1 per 100 woman years. It does not interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.

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

It is important to weigh the pros and cons of the combined oral contraceptive pill before deciding if it is the right method of birth control for you. While some users report weight gain while taking the pill, a Cochrane review did not support a causal relationship. Overall, the combined oral contraceptive pill can be an effective and convenient method of birth control, but it is important to discuss any concerns or potential risks with a healthcare provider.

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.

Diagnostic Modalities for Endometriosis: Exploratory Laparoscopy, Transabdominal Ultrasound, Hysterosalpingography, MRI Abdomen Pelvis, and CA-125

Endometriosis is a condition where endometrial tissue grows outside the endometrial cavity, causing cyclical proliferation and bleeding. It can lead to scarring, adhesions, and cysts with haemorrhagic contents. The classic symptoms are dyspareunia, infertility, cyclical pelvic pain, and dysmenorrhoea. Diagnosis is often made through Exploratory laparoscopy, where small, dark purple-black spots on the peritoneum can be identified and sampled for histological analysis. Transabdominal ultrasound is not very sensitive at detecting small deposits, but can detect endometriotic cysts. Hysterosalpingography is recommended for investigating infertility and recurrent miscarriage, but is not a definitive diagnosis for endometriosis. MRI of the pelvis is sensitive for endometriomas and adnexal masses, but not small deposits. CA-125 testing is not recommended for diagnosis.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

Diagnostic Tests for Abdominal Pain in Women of Childbearing Age

Abdominal pain in women of childbearing age requires a thorough diagnostic workup to rule out gynaecological emergencies such as ectopic pregnancy. The following diagnostic tests should be considered:

1. Pregnancy test (beta-human chorionic gonadotrophin (β-hCG)): This test should be the first step in the diagnostic workup to rule out ectopic pregnancy. A positive result requires urgent referral to the gynaecological team.

2. Full blood count: This test may indicate an ongoing infective process or other pathology, but a pregnancy test should be done first to rule out ectopic pregnancy.

3. Ultrasound of the abdomen and pelvis: Imaging may be useful in determining the cause of the pain, but a pregnancy test should be done first before considering imaging studies.

4. Urine culture and sensitivity: This test may be useful if a urinary tract infection and possible pyelonephritis are considered, but an ectopic pregnancy has to be ruled out first.

5. Erect chest X-ray: This test can show free air under the diaphragm, indicating a ruptured viscus and a surgical emergency. However, a pregnancy test should be done first to rule out ectopic pregnancy.

In conclusion, a thorough diagnostic workup is necessary to determine the cause of abdominal pain in women of childbearing age, with a pregnancy test being the first step to rule out gynaecological emergencies.

Diagnosing Gynaecological Malignancies: Understanding the Differences

When a postmenopausal woman presents with vaginal bleeding, pelvic mass, and pelvic lymphadenopathy, it is important to consider the different types of Gynaecological malignancies that could be causing these symptoms. The most likely diagnosis in this case is cervical squamous cell carcinoma, which typically metastasises to the pelvic lymph nodes along the iliac arteries.

While endometrial carcinoma (adenocarcinoma) is the most common Gynaecological malignancy, it would also be a possibility in this patient. Ovarian cancer, the second most common Gynaecological cancer, typically metastasises to the para-aortic lymph nodes and is not associated with vaginal bleeding.

Vulval cancers tend to metastasise to the superficial inguinal node and are unlikely to present with a pelvic mass or vaginal bleeding. Cervical adenocarcinomas are rare and derived from the endocervix, while uterine leiomyosarcoma often extends beyond the uterine serosa and occasionally metastasises to distant organs through blood vessels. However, neither of these malignancies typically present with vaginal bleeding and pelvic lymphadenopathy.

In summary, understanding the differences between the various types of Gynaecological malignancies is crucial in accurately diagnosing and treating patients with these conditions.

Endometrial cancer is the cause of PMB in a minority of patients, with vaginal atrophy being the most common cause. Approximately 90% of patients with PMB do not have endometrial cancer.

Understanding Postmenopausal Bleeding

Postmenopausal bleeding refers to vaginal bleeding that occurs after a woman has gone 12 months without a menstrual period. While most cases do not involve cancer, it is important to rule out this possibility in all women. The most common cause of postmenopausal bleeding is vaginal atrophy, which occurs due to a reduction in estrogen following menopause. Other causes include hormone replacement therapy, endometrial hyperplasia, endometrial cancer, cervical cancer, ovarian cancer, and vaginal cancer.

To investigate postmenopausal bleeding, women over the age of 55 should undergo an ultrasound within two weeks to check for endometrial cancer. If referred on a cancer pathway, a transvaginal ultrasound is the preferred method of investigation. Treatment options depend on the underlying cause of the bleeding. For vaginal atrophy, topical estrogen and lifestyle changes can help alleviate symptoms, while HRT may also be used. If the bleeding is due to a specific type of HRT, switching to a different preparation may be helpful. In cases of endometrial hyperplasia, dilation and curettage may be necessary to remove excess tissue.

Overall, it is important for women experiencing postmenopausal bleeding to seek medical attention and undergo appropriate testing to rule out any serious underlying conditions.

Types of Vulval Cancer: Symptoms, Diagnosis, and Treatment

Vulval cancer is a rare type of cancer that affects the external female genitalia. There are different types of vulval cancer, each with its own set of symptoms, risk factors, and treatment options. Here are some of the most common types of vulval cancer:

Squamous cell carcinoma: This is the most common type of vulval cancer, accounting for about 85% of cases. It usually affects women over 60 who smoke or have a weakened immune system. Symptoms include vulval irritation or itching, and as the disease progresses, pain and discharge. Squamous cell carcinoma can be cured if caught early, and treatment usually involves surgical excision.

Basal cell carcinoma: This type of vulval cancer is rare and usually occurs in sun-exposed areas of the skin. It is often treated with surgery.

Sarcoma: Sarcoma is a rare type of vulval cancer that can occur at any age, including childhood. Treatment usually involves surgery and radiation therapy.

Bartholin’s gland carcinoma: This is a rare cause of vulval cancer that affects the Bartholin glands, which are two small mucous-producing glands on either side of the vaginal opening. Risk factors include HPV infection and Paget’s disease of the vulva. It is often diagnosed late, as it is often confused with Bartholin gland cyst, which is a benign condition.

Malignant melanoma: This is a rare type of vulval cancer that accounts for about 5% of cases. Symptoms include itching, bleeding, and an irregular border. Treatment usually involves surgery and chemotherapy.

If you experience any symptoms of vulval cancer, such as itching, pain, or bleeding, it is important to see a doctor as soon as possible. Early diagnosis and treatment can improve your chances of a full recovery.

If a patient’s 2nd repeat smear at 24 months is now negative for high-risk human papillomavirus (hrHPV), the correct course of action is to return to routine recall in 3 years. This assumes that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but normal cytology, and a repeat test at 12 months that was also hrHPV positive but cytologically normal. If the patient had still been hrHPV positive, they would have been referred for colposcopy. However, since they are now negative, they can go back to routine recall. The latest cervical screening programme does not require cytology to be performed if hrHPV is negative, so it would be inappropriate and impractical for the GP to request cytology on the sample. There is no need to repeat the smear in 4 weeks or 12 months, as transient hrHPV infection is common and self-resolves, and does not necessarily indicate a high risk of cervical cancer.

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.

Nerve Damage in Obstetric and Surgical Procedures

During obstetric and surgical procedures, nerve damage can occur in various parts of the body. One such instance is a total vault prolapse, which can occur following a hysterectomy. Two surgical options for management include sacrocolpopexy and sacrospinous fixation. While sacrocolpopexy involves suturing the vaginal vault to the sacrum, sacrospinous fixation requires suturing the top of the vaginal vault to the sacrospinous ligament. However, complications such as damage to the sciatic nerve and pudendal vessels can occur with the latter procedure.

Damage to the common peroneal nerve is most common during total knee arthroplasties when the patient is placed in the lithotomy and lateral positions for extended periods of time. On the other hand, the femoral nerve can be injured during abdomino-pelvic surgery, aortic cross-clamp, invasive procedures to access the femoral vessels, and hip arthroplasty. Inguinal hernia repair is the most common cause of damage to the inguinal nerve.

Lastly, isolated damage to the posterior cutaneous nerve of the thigh is not associated with obstetric surgery. However, damage to the main femoral nerve is commonly seen in abdominal hysterectomies due to compression by retractor blades. It is important for healthcare professionals to be aware of these potential complications and take necessary precautions to prevent nerve damage during procedures.

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.

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

Treatment Options for Vulval Cancer: Simple Vulvectomy and Bilateral Inguinal Lymphadenectomy

Vulval cancer is a rare form of cancer that accounts for less than 1% of cancer diagnoses. The labia majora are the most common site, followed by labia minora. Squamous cell carcinoma is the most common type of vulval cancer, with carcinoma-in-situ being a precursor lesion that does not invade through the basement membrane. Risk factors for developing vulval cancer include increasing age, exposure to HPV, vulval lichen sclerosus et atrophicus, smoking, and immunosuppression.

Patients may present with symptoms such as itching, pain, easy-contact bleeding of the vulva, changes in vulval skin, or frank ulcers/masses. The first lymph node station for metastases is the inguinal group. Surgery is the primary treatment for vulval cancer, with a simple vulvectomy and bilateral inguinal lymphadenectomy being the usual surgery performed, even in the absence of clinically palpable groin lymph nodes.

Radiotherapy is commonly used before and/or after surgery depending on the stage of the disease, but it is not curative and would not be offered in isolation to an otherwise healthy patient. Chemotherapy is not usually used as a primary treatment but is offered in disseminated malignancy. Wide local excision is only used for lesions less than 2 cm in diameter with a depth of less than 1 mm. Lesions larger than this require vulvectomy and lymph node clearance due to the risk of metastasis.

In conclusion, a simple vulvectomy and bilateral inguinal lymphadenectomy are the mainstay of treatment for vulval cancer, with radiotherapy and chemotherapy being used in certain cases. Early detection and treatment are crucial for improving outcomes in patients with vulval cancer.

For women with atypical endometrial hyperplasia who are postmenopausal, it is recommended to undergo a total hysterectomy with bilateral salpingo-oophorectomy to prevent malignant progression. A total hysterectomy alone is not sufficient for postmenopausal women. It is also not recommended to undergo a bilateral salpingo-oophorectomy without removing the endometrium. A watch and wait approach is not advisable due to the potential for malignancy, and radiotherapy is not recommended as the condition is not yet malignant.

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.

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.

Expectant management of an ectopic pregnancy is only suitable for an embryo that is unruptured, <35mm in size, has no heartbeat, is asymptomatic, and has a β-hCG level of <1,000 IU/L and declining. In this case, the woman has a small ectopic pregnancy without cardiac activity and a declining β-hCG level. Therefore, expectant management is appropriate, and the woman should be given safety netting advice and asked to return for a follow-up blood test in 48 hours. Admitting her for 12-hourly β-hCG monitoring is unnecessary, and performing a salpingectomy or salpingostomy is not indicated. Prescribing medical management is also inappropriate in this case. 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.

Possible Diagnoses for Hirsutism and Menstrual Irregularity in Reproductive-Age Women

Hirsutism and menstrual irregularity in reproductive-age women can be caused by various conditions. Polycystic ovarian syndrome (PCOS) and late-onset (non-classic) congenital adrenal hyperplasia are two possible diagnoses to consider. In this case, the normal 17-hydroxyprogesterone concentration rules out congenital adrenal hyperplasia, while the presence of bilaterally enlarged ovaries with multiple cysts and impaired glucose tolerance suggests PCOS.

An androgen-secreting adrenal tumour can also cause hirsutism, but it typically results in rapid onset and severe symptoms. Ovarian stromal hyperthecosis, which shares some resemblance with PCOS, may occur in premenopausal and postmenopausal women, but PCOS is more likely in this case due to the ultrasound scan findings.

Late-onset congenital adrenal hyperplasia can present with gradual onset of hirsutism without virilisation, but an elevated serum 17-hydroxyprogesterone concentration is a distinguishing feature. Luteoma of pregnancy, a benign solid ovarian tumour associated with excess androgen production, is unlikely in this case as the patient has not been pregnant.

In summary, PCOS is the most likely diagnosis for this patient’s hirsutism and menstrual irregularity, based on the ultrasound appearance and hormone results.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

Understanding Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects women of reproductive age. It is characterized by menstrual irregularities, signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries. The Rotterdam criteria provide diagnostic criteria for PCOS, which include oligomenorrhoea or amenorrhoea, clinical or biochemical signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries.

Follicle counts and ovarian volume are important ultrasonographic features used to diagnose PCOS. At least 12 follicles in one ovary, measuring 2-9 mm in diameter, and an ovarian volume of >10 ml are diagnostic of PCOS. However, the absence of these features does not exclude the diagnosis if two of the three criteria are met.

Total testosterone levels are usually raised in PCOS, while FSH is usually within the normal range or low, and LH is raised. The ratio of LH:FSH is usually >3:1 in PCOS.

A single complex cyst in one ovary is an abnormal finding and requires referral to a gynaecology team for further assessment.

Understanding the Diagnostic Criteria and Ultrasonographic Features of PCOS

First-Line Treatment for Couples Trying to Conceive

When a couple is trying to conceive, lifestyle measures should be the first-line treatment. This includes weight loss and quitting smoking, as both can negatively impact fertility. It’s also important to check for folic acid intake, alcohol and drug use, previous infections, and mental health issues. If the couple is having regular sexual intercourse without contraception, 84% will become pregnant within a year and 92% within two years. Therefore, further investigations and referrals to infertility services are not recommended until after a year of trying. Blood tests are not necessary if the woman is having regular periods. Sperm analysis can be performed after a year of trying, and a female pelvic ultrasound is not necessary at this point. The focus should be on lifestyle changes to improve the chances of conception.

Contraceptive Options for Patients with Uterine Fibroids and Carbamazepine Use

Patients with uterine fibroids and concurrent use of carbamazepine may have limited contraceptive options due to drug interactions and uterine cavity distortion. The progesterone-only injectable is a suitable option as it does not interact with enzyme inducers and is not affected by uterine cavity distortion. The copper intrauterine device and levonorgestrel-releasing intrauterine system are not recommended in this case. The progesterone-only implant and combined oral contraceptive pill have severe interactions with carbamazepine, reducing their efficacy. It is important to consider individual patient factors and discuss all available contraceptive options with them.

Ovarian hyperstimulation syndrome can occur as a possible adverse effect of ovulation induction. The symptoms of this syndrome, such as ascites, vomiting, diarrhea, and high hematocrit, are typical. There are various medications used for ovulation induction, and the risk of ovarian hyperstimulation syndrome is higher with gonadotropin therapy than with clomiphene citrate, raloxifene, letrozole, or anastrozole. Therefore, it is probable that the patient received gonadotropin therapy.

Ovulation induction is often required for couples who have difficulty conceiving naturally due to ovulation disorders. Normal ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. There are three main categories of anovulation: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation to lead to a singleton pregnancy. Forms of ovulation induction include exercise and weight loss, letrozole, clomiphene citrate, and gonadotropin therapy. Ovarian hyperstimulation syndrome is a potential side effect of ovulation induction and can be life-threatening if not managed promptly.

Understanding Ectopic Pregnancy: Incidence and Risk Factors

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. This condition is a serious medical emergency that requires immediate attention. According to epidemiological studies, ectopic pregnancy occurs in approximately 0.5% of all pregnancies.

Several risk factors can increase the likelihood of ectopic pregnancy. These include damage to the fallopian tubes due to pelvic inflammatory disease or surgery, a history of previous ectopic pregnancy, endometriosis, the use of intrauterine contraceptive devices (IUCDs), and the progesterone-only pill. In vitro fertilization (IVF) also increases the risk of ectopic pregnancy, with approximately 3% of IVF pregnancies resulting in ectopic implantation.

It is important to note that any factor that slows down the passage of the fertilized egg to the uterus can increase the risk of ectopic pregnancy. Early detection and prompt treatment are crucial in managing this condition and preventing serious complications.

Ovulation induction can lead to ovarian hyperstimulation syndrome (OHSS) as a potential side effect. The symptoms of OHSS often involve gastrointestinal discomfort such as bloating, abdominal pain, nausea, vomiting, and diarrhea. Additionally, patients may experience shortness of breath, fever, peripheral edema, and oliguria. OHSS can range in severity from mild to life-threatening, with complications such as dehydration, thromboembolism, acute kidney injury (AKI), and pulmonary edema. Severe OHSS typically has a delayed onset compared to milder cases. In the given scenario, the patient received a GnRH agonist injection within the past week, indicating that her symptoms may be less severe.

Ovulation induction is often required for couples who have difficulty conceiving naturally due to ovulation disorders. Normal ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. There are three main categories of anovulation: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation to lead to a singleton pregnancy. Forms of ovulation induction include exercise and weight loss, letrozole, clomiphene citrate, and gonadotropin therapy. Ovarian hyperstimulation syndrome is a potential side effect of ovulation induction and can be life-threatening if not managed promptly.

Understanding Hormonal Patterns in Hypogonadism: A Guide to Diagnosis

Hypogonadism is a condition that affects the production of hormones necessary for sexual development. One form of hypogonadism is Kallmann syndrome, which is characterized by delayed or absent puberty and an inability to smell. This condition is caused by a defect in the release or action of gonadotropin-releasing hormone (GnRH), leading to gonadal failure. As a result, we expect to see reduced levels of GnRH, luteinising hormone (LH), follicle-stimulating hormone (FSH), and oestrogen in affected individuals.

Secondary hypogonadism, on the other hand, is caused by a problem in the pituitary gland. This can result in increased levels of GnRH, but decreased levels of LH, FSH, and oestrogen.

Primary hypogonadism, such as in Klinefelter’s and Turner syndrome, is characterized by problems with the gonads. In these cases, we expect to see increased levels of GnRH, LH, and FSH, but decreased levels of oestrogen.

Ectopic or unregulated oestrogen production can also cause hormonal imbalances, leading to decreased levels of GnRH, LH, and FSH, but increased levels of oestrogen.

It is important to understand these hormonal patterns in order to diagnose and treat hypogonadism effectively. By identifying the underlying cause of the condition, healthcare professionals can provide appropriate interventions to improve sexual development and overall health.

Thrush, also known as candidal infection, is a prevalent condition that is often triggered or worsened by recent use of antibiotics. Therefore, it is the most probable reason for the symptoms in this case. It should be noted that urinary tract infections do not typically cause vaginal discharge.

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.

The appropriate time to test progesterone levels is on Day 28, which is 7 days before the end of a woman’s regular menstrual cycle. However, for individuals with a different cycle length, the timing may vary. It is recommended to take into account the individual’s menstrual cycle history to determine the appropriate time for testing. According to NICE guidelines, women with regular menstrual cycles should be informed that they are likely ovulating, but a mid-luteal serum progesterone level should be checked to confirm.

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

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

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

The 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.

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women of reproductive age, characterized by cyclic behavioral, emotional, and physical changes during the late luteal phase of the menstrual cycle. The most severe form of PMS is known as premenstrual dysphoric syndrome. The hallmark psychological changes are depression, irritability, and emotional lability, while physical manifestations include fluid retention, weight gain, and breast tenderness. Symptoms improve shortly after the onset of menses, and the syndrome is unrelated to the menstrual phase. The exact cause of PMS is unknown, but a multifactorial causation has been suggested, including decreased progesterone synthesis and increased prolactin, estrogen, aldosterone, and prostaglandin synthesis during the luteal phase. Hypoglycemia and serotonin deficiency also play a role. Severe PMS is treated with selective serotonin reuptake inhibitors. It is important to understand PMS and its symptoms to seek appropriate treatment and improve quality of life.

If a woman of reproductive age has been having unprotected vaginal sexual intercourse for a year without conceiving and there is no known cause of infertility, NICE guidance recommends that she and her partner undergo further clinical assessment and investigation. The most appropriate initial investigation for this patient is a day 21 progesterone test, which is non-invasive and can determine if the patient is ovulating. Serum prolactin and thyroid function tests are not recommended unless there is a specific reason for testing, such as a pituitary tumor or overt thyroid disease. Transvaginal or abdominal ultrasounds are unlikely to reveal the cause of subfertility and are therefore not necessary. As part of the initial assessment, the male partner should also undergo a semen analysis.

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

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

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