Androgens play a crucial role in the development of male reproductive organs, as they stimulate the formation of Wolffian ducts that eventually give rise to the vas deferens, epididymis, and seminal vesicles. In the absence of androgen activity, the Wolffian ducts break down, leading to the failure of male reproductive organ development. Additionally, Sertoli cells produce anti-Mullerian hormone, which prevents the formation of female internal genitalia. The lack of androgen effects also results in the absence of masculine characteristics in the external genitalia.

Understanding Androgen Insensitivity Syndrome

Androgen insensitivity syndrome is a genetic condition that affects individuals with an XY genotype, causing them to develop a female phenotype due to their body’s resistance to testosterone. This condition was previously known as testicular feminization syndrome. Common features of this condition include primary amenorrhea, little to no pubic and axillary hair, undescended testes leading to groin swellings, and breast development due to the conversion of testosterone to estrogen.

Diagnosis of androgen insensitivity syndrome can be done through a buccal smear or chromosomal analysis, which reveals a 46XY genotype. After puberty, testosterone levels in individuals with this condition are typically in the high-normal to slightly elevated range for postpubertal boys.

Management of androgen insensitivity syndrome involves counseling and raising the child as female. Bilateral orchidectomy is recommended to reduce the risk of testicular cancer due to undescended testes. Additionally, estrogen therapy may be used to promote the development of secondary sexual characteristics. Understanding androgen insensitivity syndrome is crucial for proper diagnosis and management of affected individuals.

Vitamin K levels in breast milk are insufficient, but lactoferrin levels are adequate and promote iron uptake and have antibacterial properties. Breastfeeding is also linked to lower rates of breast and ovarian cancer, ear infections, and type 1 diabetes mellitus.

Advantages and Disadvantages of Breastfeeding

Breastfeeding has numerous advantages for both the mother and the baby. For the mother, it promotes bonding with the baby and helps with the involution of the uterus. It also provides protection against breast and ovarian cancer and is a cheap alternative to formula feeding as there is no need to sterilize bottles. However, it should not be relied upon as a contraceptive method as it is unreliable.

Breast milk contains immunological components such as IgA, lysozyme, and lactoferrin that protect mucosal surfaces, have bacteriolytic properties, and ensure rapid absorption of iron so it is not available to bacteria. This reduces the incidence of ear, chest, and gastrointestinal infections, as well as eczema, asthma, and type 1 diabetes mellitus. Breastfeeding also reduces the incidence of sudden infant death syndrome.

One of the advantages of breastfeeding is that the baby is in control of how much milk it takes. However, there are also disadvantages such as the transmission of drugs and infections such as HIV. Prolonged breastfeeding may also lead to nutrient inadequacies such as vitamin D and vitamin K deficiencies, as well as breast milk jaundice.

In conclusion, while breastfeeding has numerous advantages, it is important to be aware of the potential disadvantages and to consult with a healthcare professional to ensure that both the mother and the baby are receiving adequate nutrition and care.

Understanding Absence of the Vas Deferens

Absence of the vas deferens is a condition that can occur either unilaterally or bilaterally. In 40% of cases, the cause is due to mutations in the CFTR gene, which is associated with cystic fibrosis. However, in some non-CF cases, the absence of the vas deferens is due to unilateral renal agenesis. Despite this condition, assisted conception may still be possible through sperm harvesting.

It is important to understand the underlying causes of absence of the vas deferens, as it can impact fertility and the ability to conceive. While the condition may be associated with cystic fibrosis, it can also occur independently. However, with advancements in assisted reproductive technologies, individuals with this condition may still have options for starting a family. By seeking medical advice and exploring available options, individuals can make informed decisions about their reproductive health.

When it comes to fibroids and difficulty conceiving, submucosal fibroids are the most likely culprit. These fibroids are located in the uterine cavity and can interfere with the implantation of an embryo. Intramural and subserosal fibroids are less likely to cause fertility issues, but they can cause symptoms such as increased urinary frequency and constipation due to their size and location. It’s important to note that fibroids are typically found within the uterus and not outside of it.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are believed to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility, but this is rare.

Diagnosis is usually done through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is necessary. For menorrhagia, treatment options include the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, oral progestogen, and injectable progestogen. Medical treatment to shrink or remove fibroids includes GnRH agonists and ulipristal acetate, while surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, and complications such as subfertility and iron-deficiency anaemia have been mentioned previously. Another complication is red degeneration, which is haemorrhage into the tumour and commonly occurs during pregnancy. Understanding uterine fibroids is important for women’s health, and seeking medical attention is necessary if symptoms arise.

In most women, the uterus is positioned in an anteverted and anteflexed manner. Anteversion refers to the uterus being tilted forward towards the bladder in the coronal plane, while retroversion describes a posterior tilt towards the rectum. Anteflexion refers to the position of the uterus body in relation to the cervix, with the fundus being anterior to the cervix in the sagittal plane.

Anatomy of the Uterus

The uterus is a female reproductive organ that is located within the pelvis and is covered by the peritoneum. It is supplied with blood by the uterine artery, which runs alongside the uterus and anastomoses with the ovarian artery. The uterus is supported by various ligaments, including the central perineal tendon, lateral cervical, round, and uterosacral ligaments. The ureter is located close to the uterus, and injuries to the ureter can occur when there is pathology in the area.

The uterus is typically anteverted and anteflexed in most women. Its topography can be visualized through imaging techniques such as ultrasound or MRI. Understanding the anatomy of the uterus is important for diagnosing and treating various gynecological conditions.

The Broad ligament is where the Fallopian tubes are located. If a tubal ectopic pregnancy is detected with a fetal heartbeat, the recommended treatment is a laparoscopic salpingectomy. This surgical procedure involves removing the affected Fallopian tube by accessing it within the Broad ligament. However, if there are other risk factors for infertility, a laparoscopic salpingotomy may be performed instead.

On the other hand, the Cardinal ligament contains the uterine vessels and is not involved in ectopic pregnancy. It may be operated on in cases of uterine fibroids through a laparoscopic myomectomy.

The Ovarian ligament attaches the ovaries to the uterus but does not contain any structures. Meanwhile, the Round ligament attaches the uterine fundus to the labia majora but also does not contain any structures.

Pelvic Ligaments and their Connections

Pelvic ligaments are structures that connect various organs within the female reproductive system to the pelvic wall. These ligaments play a crucial role in maintaining the position and stability of these organs. There are several types of pelvic ligaments, each with its own unique function and connection.

The broad ligament connects the uterus, fallopian tubes, and ovaries to the pelvic wall, specifically the ovaries. The round ligament connects the uterine fundus to the labia majora, but does not connect to any other structures. The cardinal ligament connects the cervix to the lateral pelvic wall and is responsible for supporting the uterine vessels. The suspensory ligament of the ovaries connects the ovaries to the lateral pelvic wall and supports the ovarian vessels. The ovarian ligament connects the ovaries to the uterus, but does not connect to any other structures. Finally, the uterosacral ligament connects the cervix and posterior vaginal dome to the sacrum, but does not connect to any other structures.

Overall, pelvic ligaments are essential for maintaining the proper position and function of the female reproductive organs. Understanding the connections between these ligaments and the structures they support is crucial for diagnosing and treating any issues that may arise.

The use of HRT is associated with a higher likelihood of thrombotic events, including stroke. This is due to platelet aggregation, which is distinct from the accumulation of cholesterol that primarily contributes to atheroma formation. HRT does not elevate the risk of thrombocytopaenia or vulval cancer, and the inclusion of progesterone in the HRT helps to reduce the risk of developing endometrial cancer.

Understanding Menopause and Contraception

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It typically occurs when a woman reaches the age of 51 in the UK. However, prior to menopause, women may experience a period known as the climacteric. During this time, ovarian function starts to decline, and women may experience symptoms such as hot flashes, mood swings, and vaginal dryness.

It is important for women to understand that they can still become pregnant during the climacteric period. Therefore, it is recommended to use effective contraception until a certain period of time has passed. Women over the age of 50 should use contraception for 12 months after their last period, while women under the age of 50 should use contraception for 24 months after their last period. By understanding menopause and the importance of contraception during the climacteric period, women can make informed decisions about their reproductive health.

During pregnancy, plasma urea and creatinine levels decrease due to increased renal perfusion, which allows for more efficient clearing of these substances from the circulation. Additionally, the increased plasma volume dilutes these substances. This is a result of physiological changes in pregnancy, such as increased uterine size, cervical ectropion, and increased vaginal discharge. Cardiovascular and haemodynamic changes also occur, including increased plasma volume and decreased levels of albumin, urea, and creatinine. Progesterone-related effects, such as muscle relaxation, can lead to decreased blood pressure, constipation, and bladder relaxation. It is important to note that the foetus does not have functioning kidneys, and the mother filters the blood for it.

During pregnancy, a woman’s body undergoes various physiological changes. The cardiovascular system experiences an increase in stroke volume, heart rate, and cardiac output, while systolic blood pressure remains unchanged and diastolic blood pressure decreases in the first and second trimesters before returning to normal levels by term. The enlarged uterus may cause issues with venous return, leading to ankle swelling, supine hypotension, and varicose veins.

The respiratory system sees an increase in pulmonary ventilation and tidal volume, with oxygen requirements only increasing by 20%. This can lead to a sense of dyspnea due to over-breathing and a fall in pCO2. The basal metabolic rate also increases, potentially due to increased thyroxine and adrenocortical hormones.

Maternal blood volume increases by 30%, with red blood cells increasing by 20% and plasma increasing by 50%, leading to a decrease in hemoglobin levels. Coagulant activity increases slightly, while fibrinolytic activity decreases. Platelet count falls, and white blood cell count and erythrocyte sedimentation rate rise.

The urinary system experiences an increase in blood flow and glomerular filtration rate, with elevated sex steroid levels leading to increased salt and water reabsorption and urinary protein losses. Trace glycosuria may also occur.

Calcium requirements increase during pregnancy, with gut absorption increasing substantially due to increased 1,25 dihydroxy vitamin D. Serum levels of calcium and phosphate may fall, but ionized calcium levels remain stable. The liver experiences an increase in alkaline phosphatase and a decrease in albumin levels.

The uterus undergoes significant changes, increasing in weight from 100g to 1100g and transitioning from hyperplasia to hypertrophy. Cervical ectropion and discharge may increase, and Braxton-Hicks contractions may occur in late pregnancy. Retroversion may lead to retention in the first trimester but usually self-corrects.

If a woman experiences postmenopausal bleeding, it is important for medical professionals to consider the possibility of endometrial cancer. According to NICE guidelines from 2015, women aged 55 or older with postmenopausal bleeding should be urgently referred for further evaluation.

One common method of evaluation is a transvaginal ultrasound, which can measure the thickness of the endometrial lining. A 3-mm cut-off is often used and has been found to be highly effective in detecting endometrial cancer. This method can also identify women who are unlikely to have endometrial cancer, which can help avoid more invasive procedures such as endometrial biopsy. However, some medical centers may use a cut-off of 4 mm or even 5 mm for endometrial biopsy.

In the case of a woman with an endometrial thickness of 6mm, the next step would be to perform an endometrial biopsy.

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

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

The most probable cause of the woman’s pain during defecation is bleeding in either the bowel or the pouch of Douglas. Since the only given option is the latter, it is the correct answer. Bleeding into the ovaries can result in ‘chocolate cysts’ that can be observed during laparoscopy. None of the other options mentioned provide anatomical landmarks that could lead to bleeding in the spaces and pain during defecation.

Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

Cystic Fibrosis Inheritance

Cystic fibrosis is a genetic disorder that is inherited in an autosomal recessive pattern. This means that both copies of the gene in each cell have mutations. Individuals with only one copy of the mutated gene are carriers and typically do not show signs or symptoms of the condition.

In the case of a female carrier for the CF gene, there is a 1 in 2 chance of producing a gamete carrying the CF gene. If her new partner is also a carrier, he has a 1 in 25 chance of having the CF gene and a 1 in 50 chance of producing a gamete with the CF gene. Therefore, the chance of producing a child with cystic fibrosis is 1 in 100.

It is important to understand the inheritance pattern of cystic fibrosis to make informed decisions about family planning and genetic testing. This knowledge can help individuals and families better understand the risks and potential outcomes of having children with this condition.

The main cause of menopausal symptoms is low levels of oestrogen, which is why hormone replacement therapy (HRT) aims to alleviate these symptoms by supplementing oestrogen. However, oestrogen can lead to thickening of the endometrium, which increases the risk of neoplasia. To counteract this risk, progesterone is also included in HRT to prevent endometrial thickening and any associated malignancy.

Therefore, any statement suggesting that progesterone is used for symptomatic relief, that oestrogen is protective, or that progesterone and oestrogen work together in a synergistic manner is incorrect.

Symptoms of Menopause

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is characterized by a decrease in the levels of female hormones, particularly oestrogen, which can lead to a range of symptoms. One of the most common symptoms is a change in periods, including changes in the length of menstrual cycles and dysfunctional uterine bleeding.

Around 80% of women experience vasomotor symptoms, which can occur daily and last for up to five years. These symptoms include hot flushes and night sweats. Urogenital changes are also common, affecting around 35% of women. These changes can include vaginal dryness and atrophy, as well as urinary frequency.

In addition to physical symptoms, menopause can also have psychological effects. Approximately 10% of women experience anxiety and depression during this time, as well as short-term memory impairment. It is important to note that menopause can also have longer-term complications, such as an increased risk of osteoporosis and ischaemic heart disease.

Causes of Right Iliac Fossa Pain in Women

Right iliac fossa pain in women can be caused by various conditions such as mittelschmerz, appendicitis, and ectopic pregnancy. However, in the case of a young woman who is seven weeks past her last period, ectopic pregnancy is highly suspected. This condition occurs when a fertilized egg implants outside the uterus, usually in the fallopian tube.

To confirm or rule out ectopic pregnancy, the most appropriate initial test would be a pregnancy test. This test detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta after implantation. If the test is positive, further evaluation such as ultrasound and blood tests may be necessary to determine the location of the pregnancy and the appropriate management. It is important to seek medical attention promptly if experiencing RIF pain, as delay in diagnosis and treatment of ectopic pregnancy can lead to serious complications.

The initial step recommended for managing shoulder dystocia is the use of McRobert’s manoeuvre. This involves the mother’s hips being flexed towards her abdomen and abducting them outwards, typically with the assistance of two individuals. By doing so, the pelvis is tilted upwards, causing the pubic symphysis to move in the same direction. This results in an increase in the functional dimensions of the pelvic outlet, providing more space for the anterior shoulder to be delivered. McRobert’s manoeuvre is successful in the majority of cases of shoulder dystocia and should be performed before any invasive or potentially harmful procedures.

Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the baby.

There are several risk factors that increase the likelihood of shoulder dystocia, including fetal macrosomia (large baby), high maternal body mass index, diabetes mellitus, and prolonged labor.

If shoulder dystocia is identified, it is important to call for senior medical assistance immediately. The McRoberts’ maneuver is often used to help deliver the baby. This involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant harm to the mother. Oxytocin administration is not effective in treating shoulder dystocia.

Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury or neonatal death for the baby. It is important to manage shoulder dystocia promptly and effectively to minimize these risks.

The internal mammary artery is the primary source of arterial supply to the breast, with the external mammary and lateral thoracic arteries playing a smaller role. This information is relevant for surgeons performing reduction mammoplasty surgeries.

The breast is situated on a layer of pectoral fascia and is surrounded by the pectoralis major, serratus anterior, and external oblique muscles. The nerve supply to the breast comes from branches of intercostal nerves from T4-T6, while the arterial supply comes from the internal mammary (thoracic) artery, external mammary artery (laterally), anterior intercostal arteries, and thoraco-acromial artery. The breast’s venous drainage is through a superficial venous plexus to subclavian, axillary, and intercostal veins. Lymphatic drainage occurs through the axillary nodes, internal mammary chain, and other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease).

The preparation for lactation involves the hormones oestrogen, progesterone, and human placental lactogen. Oestrogen promotes duct development in high concentrations, while high levels of progesterone stimulate the formation of lobules. Human placental lactogen prepares the mammary glands for lactation. The two hormones involved in stimulating lactation are prolactin and oxytocin. Prolactin causes milk secretion, while oxytocin causes contraction of the myoepithelial cells surrounding the mammary alveoli to result in milk ejection from the breast. Suckling of the baby stimulates the mechanoreceptors in the nipple, resulting in the release of both prolactin and oxytocin from the pituitary gland (anterior and posterior parts respectively).

During the early stages of pregnancy, the syncytiotrophoblast secretes hCG to prompt the corpus luteum to produce progesterone. This process typically begins around 6-7 days after fertilization and is complete by day 9-10. To ensure accurate results, it is recommended that women wait until at least the first day of their missed period to take a pregnancy test, as testing too early can result in a false-negative.

The role of hCG in pregnancy is crucial, as it stimulates the corpus luteum to produce progesterone, which is essential for maintaining a healthy pregnancy. In the first four weeks of pregnancy, hCG levels should double every 48-72 hours until they eventually plateau. Monitoring hCG levels through sequential blood tests can help identify potential issues such as miscarriage or ectopic pregnancy, as hCG levels may fall or plateau prematurely. It is important to note that hCG is not secreted by the blastocyst, corpus luteum, ovary, or zygote.

Endocrine Changes During Pregnancy

During pregnancy, there are several physiological changes that occur in the body, including endocrine changes. Progesterone, which is produced by the fallopian tubes during the first two weeks of pregnancy, stimulates the secretion of nutrients required by the zygote/blastocyst. At six weeks, the placenta takes over the production of progesterone, which inhibits uterine contractions by decreasing sensitivity to oxytocin and inhibiting the production of prostaglandins. Progesterone also stimulates the development of lobules and alveoli.

Oestrogen, specifically oestriol, is another major hormone produced during pregnancy. It stimulates the growth of the myometrium and the ductal system of the breasts. Prolactin, which increases during pregnancy, initiates and maintains milk secretion of the mammary gland. It is essential for the expression of the mammotropic effects of oestrogen and progesterone. However, oestrogen and progesterone directly antagonize the stimulating effects of prolactin on milk synthesis.

Human chorionic gonadotropin (hCG) is secreted by the syncitiotrophoblast and can be detected within nine days of pregnancy. It mimics LH, rescuing the corpus luteum from degenerating and ensuring early oestrogen and progesterone secretion. It also stimulates the production of relaxin and may inhibit contractions induced by oxytocin. Other hormones produced during pregnancy include relaxin, which suppresses myometrial contractions and relaxes the pelvic ligaments and pubic symphysis, and human placental lactogen (hPL), which has lactogenic actions and enhances protein metabolism while antagonizing insulin.

The woman has HELLP syndrome, a severe form of pre-eclampsia. Management includes magnesium sulfate, dexamethasone, blood pressure control, and blood product replacement. Delivery of the fetus is the only cure.

Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, age over 40, high BMI, family history of pre-eclampsia, and multiple pregnancy. To reduce the risk of hypertensive disorders in pregnancy, women with high or moderate risk factors should take aspirin daily. Management involves emergency assessment, admission for severe cases, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

Anatomy of the Ovarian Follicle

The ovarian follicle is a complex structure that plays a crucial role in female reproductive function. It consists of several components, including granulosa cells, the zona pellucida, the theca, the antrum, and the cumulus oophorus.

Granulosa cells are responsible for producing oestradiol, which is essential for follicular development. Once the follicle becomes the corpus luteum, granulosa lutein cells produce progesterone, which is necessary for embryo implantation. The zona pellucida is a membrane that surrounds the oocyte and contains the protein ZP3, which is responsible for sperm binding.

The theca produces androstenedione, which is converted into oestradiol by granulosa cells. The antrum is a fluid-filled portion of the follicle that marks the transition of a primary oocyte into a secondary oocyte. Finally, the cumulus oophorus is a cluster of cells surrounding the oocyte that must be penetrated by spermatozoa for fertilisation to occur.

Understanding the anatomy of the ovarian follicle is essential for understanding female reproductive function and fertility. Each component plays a unique role in the development and maturation of the oocyte, as well as in the processes of fertilisation and implantation.

The patient is exhibiting signs of HELLP syndrome, which is a complication during pregnancy that involves haemolysis, elevated liver enzymes, and low platelets. This condition often occurs alongside pregnancy-induced hypertension or pre-eclampsia. Although the patient is also displaying symptoms of pre-eclampsia such as headache, shoulder tip pain, and nausea, the presence of jaundice indicates that it is HELLP syndrome rather than pre-eclampsia. Pre-eclampsia is a pregnancy disorder that typically involves high blood pressure and damage to another organ system, usually the kidneys in the form of proteinuria. It usually develops after 20 weeks of pregnancy in women who previously had normal blood pressure.

Jaundice During Pregnancy

During pregnancy, jaundice can occur due to various reasons. One of the most common liver diseases during pregnancy is intrahepatic cholestasis of pregnancy, which affects around 1% of pregnancies and is usually seen in the third trimester. Symptoms include itching, especially in the palms and soles, and raised bilirubin levels. Ursodeoxycholic acid is used for symptomatic relief, and women are typically induced at 37 weeks. However, this condition can increase the risk of stillbirth.

Acute fatty liver of pregnancy is a rare complication that can occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea, vomiting, headache, jaundice, and hypoglycemia. ALT levels are typically elevated. Supportive care is the initial management, and delivery is the definitive management once the patient is stabilized.

Gilbert’s and Dubin-Johnson syndrome may also be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for Haemolysis, Elevated Liver enzymes, Low Platelets, can also cause jaundice during pregnancy. It is important to monitor liver function tests and seek medical attention if any symptoms of jaundice occur during pregnancy.

The production of testosterone in response to LH is carried out by Leydig cells, not Sertoli cells in the testes.

Leydig cells are responsible for the secretion of testosterone when LH is released from the anterior pituitary gland. On the other hand, Sertoli cells are referred to as nurse cells because they provide nourishment to developing sperm during spermatogenesis. These cells have an elongated shape, secrete androgen-binding protein and tubular fluid, support the development of sperm during spermatogenesis, and form the blood-testes barrier.

Endocrine Changes During Pregnancy

During pregnancy, there are several physiological changes that occur in the body, including endocrine changes. Progesterone, which is produced by the fallopian tubes during the first two weeks of pregnancy, stimulates the secretion of nutrients required by the zygote/blastocyst. At six weeks, the placenta takes over the production of progesterone, which inhibits uterine contractions by decreasing sensitivity to oxytocin and inhibiting the production of prostaglandins. Progesterone also stimulates the development of lobules and alveoli.

Oestrogen, specifically oestriol, is another major hormone produced during pregnancy. It stimulates the growth of the myometrium and the ductal system of the breasts. Prolactin, which increases during pregnancy, initiates and maintains milk secretion of the mammary gland. It is essential for the expression of the mammotropic effects of oestrogen and progesterone. However, oestrogen and progesterone directly antagonize the stimulating effects of prolactin on milk synthesis.

Human chorionic gonadotropin (hCG) is secreted by the syncitiotrophoblast and can be detected within nine days of pregnancy. It mimics LH, rescuing the corpus luteum from degenerating and ensuring early oestrogen and progesterone secretion. It also stimulates the production of relaxin and may inhibit contractions induced by oxytocin. Other hormones produced during pregnancy include relaxin, which suppresses myometrial contractions and relaxes the pelvic ligaments and pubic symphysis, and human placental lactogen (hPL), which has lactogenic actions and enhances protein metabolism while antagonizing insulin.

The patient is experiencing secondary amenorrhoea, which is indicative of hypothalamic amenorrhoea due to low-level gonadotrophins. This could be caused by the patient’s intensive training for marathons, as well as other risk factors such as stress and anorexia nervosa. Hyperthyroidism is unlikely as the patient does not exhibit any symptoms or abnormal thyroid function test results. Polycystic ovarian syndrome (PCOS) can be ruled out as the patient does not have hirsutism, a high BMI, or elevated LH and FSH levels. Pregnancy is also not a possibility as the patient’s test was negative and she does not exhibit any signs of pregnancy.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

The causes of amenorrhoea vary depending on the type. Primary amenorrhoea may be caused by gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, and thyrotoxicosis. Meanwhile, secondary amenorrhoea may be caused by stress, excessive exercise, PCOS, Sheehan’s syndrome, Asherman’s syndrome, and other underlying medical conditions.

To diagnose amenorrhoea, initial investigations may include pregnancy tests, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels. Management of amenorrhoea involves treating the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause and treat the underlying cause accordingly. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis and other complications.

In conclusion, amenorrhoea is a condition that requires proper diagnosis and management. Understanding the causes and appropriate investigations can help in providing the necessary treatment and care for women experiencing this condition.

The abdominal aorta gives rise to the testicular artery.

Anatomy of the Scrotum and Testes

The scrotum is composed of skin and dartos fascia, with an arterial supply from the anterior and posterior scrotal arteries. It is also the site of lymphatic drainage to the inguinal lymph nodes. The testes are surrounded by the tunica vaginalis, a closed peritoneal sac, with the parietal layer adjacent to the internal spermatic fascia. The testicular arteries arise from the aorta, just below the renal arteries, and the pampiniform plexus drains into the testicular veins. The left testicular vein drains into the left renal vein, while the right testicular vein drains into the inferior vena cava. Lymphatic drainage occurs to the para-aortic nodes.

The spermatic cord is formed by the vas deferens and is covered by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia. The cord contains the vas deferens, testicular artery, artery of vas deferens, cremasteric artery, pampiniform plexus, sympathetic nerve fibers, genital branch of the genitofemoral nerve, and lymphatic vessels. The vas deferens transmits sperm and accessory gland secretions, while the testicular artery supplies the testis and epididymis. The cremasteric artery arises from the inferior epigastric artery, and the pampiniform plexus is a venous plexus that drains into the right or left testicular vein. The sympathetic nerve fibers lie on the arteries, while the parasympathetic fibers lie on the vas. The genital branch of the genitofemoral nerve supplies the cremaster. Lymphatic vessels drain to lumbar and para-aortic nodes.

Upper right quadrant pain can be caused by various conditions, but in this case, the woman is suffering from pelvic inflammatory disease, which is often associated with Fitz-Hugh-Curtis syndrome (adhesions of liver to peritoneum).

It is important to note that cholecystitis, pulmonary embolisms, pleurisy, and viral hepatitis do not typically present with symptoms such as dyspareunia, dysuria, or vaginal discharge.

Pelvic inflammatory disease (PID) is a condition where the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. It is typically caused by an infection that spreads from the endocervix. The most common causative organism is Chlamydia trachomatis, followed by Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and gonorrhoeae. However, these tests may often be negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole. In mild cases of PID, intrauterine contraceptive devices may be left in, but the evidence is limited, and removal of the IUD may be associated with better short-term clinical outcomes according to recent guidelines.

Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis, infertility (with a risk as high as 10-20% after a single episode), chronic pelvic pain, and ectopic pregnancy.

During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually at 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a woman requires oral iron therapy. For the first trimester, the cut-off is less than 110 g/L, for the second and third trimesters, it is less than 105 g/L, and for the postpartum period, it is less than 100 g/L. If a woman falls below these levels, she should receive oral ferrous sulfate or ferrous fumarate. Treatment should continue for three months after iron deficiency is corrected to allow for the replenishment of iron stores.

Pelvic inflammatory disease is most commonly caused by chlamydia and gonorrhoeae, with gonorrhoeae being the likely cause in this patient since they do not have chlamydia. While HIV does not directly cause pelvic inflammatory disease, it can increase the risk of contracting sexually transmitted infections. Syphilis follows its own distinct clinical course and does not cause pelvic inflammatory disease, while herpes typically presents with painful genital blisters but does not cause pelvic inflammatory disease.

Pelvic inflammatory disease (PID) is a condition where the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. It is typically caused by an infection that spreads from the endocervix. The most common causative organism is Chlamydia trachomatis, followed by Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and gonorrhoeae. However, these tests may often be negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole. In mild cases of PID, intrauterine contraceptive devices may be left in, but the evidence is limited, and removal of the IUD may be associated with better short-term clinical outcomes according to recent guidelines.

Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis, infertility (with a risk as high as 10-20% after a single episode), chronic pelvic pain, and ectopic pregnancy.

Breast Milk lactoferrin facilitates the quick absorption of iron in the gut, while simultaneously limiting the amount of iron accessible to gut bacteria due to its antibacterial properties. Additionally, lactoferrin has been found to promote bone health by increasing bone formation and reducing bone resorption.

Advantages and Disadvantages of Breastfeeding

Breastfeeding has numerous advantages for both the mother and the baby. For the mother, it promotes bonding with the baby and helps with the involution of the uterus. It also provides protection against breast and ovarian cancer and is a cheap alternative to formula feeding as there is no need to sterilize bottles. However, it should not be relied upon as a contraceptive method as it is unreliable.

Breast milk contains immunological components such as IgA, lysozyme, and lactoferrin that protect mucosal surfaces, have bacteriolytic properties, and ensure rapid absorption of iron so it is not available to bacteria. This reduces the incidence of ear, chest, and gastrointestinal infections, as well as eczema, asthma, and type 1 diabetes mellitus. Breastfeeding also reduces the incidence of sudden infant death syndrome.

One of the advantages of breastfeeding is that the baby is in control of how much milk it takes. However, there are also disadvantages such as the transmission of drugs and infections such as HIV. Prolonged breastfeeding may also lead to nutrient inadequacies such as vitamin D and vitamin K deficiencies, as well as breast milk jaundice.

In conclusion, while breastfeeding has numerous advantages, it is important to be aware of the potential disadvantages and to consult with a healthcare professional to ensure that both the mother and the baby are receiving adequate nutrition and care.

The lining of the ectocervix consists of non-keratinized stratified squamous epithelium.

Anatomy of the Uterus

The uterus is a female reproductive organ that is located within the pelvis and is covered by the peritoneum. It is supplied with blood by the uterine artery, which runs alongside the uterus and anastomoses with the ovarian artery. The uterus is supported by various ligaments, including the central perineal tendon, lateral cervical, round, and uterosacral ligaments. The ureter is located close to the uterus, and injuries to the ureter can occur when there is pathology in the area.

The uterus is typically anteverted and anteflexed in most women. Its topography can be visualized through imaging techniques such as ultrasound or MRI. Understanding the anatomy of the uterus is important for diagnosing and treating various gynecological conditions.

PPH is the loss of >500ml blood within 24 hours of delivery. Uterine atony is the most common cause, followed by retained placenta.

Postpartum Haemorrhage: Causes, Risk Factors, and Management

Postpartum haemorrhage (PPH) is a condition characterized by excessive blood loss of more than 500 ml after a vaginal delivery. It can be primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia. Management of PPH is a life-threatening emergency that requires immediate involvement of senior staff. The ABC approach is used, and bloods are taken, including group and save. Medical management includes IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options are considered if medical management fails to control the bleeding. Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis.

Understanding Postpartum Haemorrhage

Postpartum haemorrhage is a serious condition that can occur after vaginal delivery. It is important to understand the causes, risk factors, and management of this condition to ensure prompt and effective treatment. Primary PPH is caused by the 4 Ts, with uterine atony being the most common cause. Risk factors for primary PPH include previous PPH, prolonged labour, and emergency Caesarean section. Management of PPH is a life-threatening emergency that requires immediate involvement of senior staff. Medical management includes IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options are considered if medical management fails to control the bleeding. Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to be aware of the signs and symptoms of PPH and seek medical attention immediately if they occur.

Primary amenorrhoea occurs when a girl has not started menstruating by the age of 15, despite having normal secondary sexual characteristics like breast development. In girls with no secondary sexual characteristics, primary amenorrhoea is defined as the absence of menstruation by the age of 13. Possible causes of primary amenorrhoea include hypothyroidism and imperforate hymen, but not endometriosis, which typically causes heavy and/or painful periods. While delayed menarche can occur spontaneously before the age of 18, this girl’s symptoms are not within the normal range of variation. Malnutrition or extreme exercise are more likely to cause primary amenorrhoea than obesity-induced amenorrhoea, which typically results in secondary amenorrhoea where periods stop for 6 months or more after menarche has occurred.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

The causes of amenorrhoea vary depending on the type. Primary amenorrhoea may be caused by gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, and thyrotoxicosis. Meanwhile, secondary amenorrhoea may be caused by stress, excessive exercise, PCOS, Sheehan’s syndrome, Asherman’s syndrome, and other underlying medical conditions.

To diagnose amenorrhoea, initial investigations may include pregnancy tests, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels. Management of amenorrhoea involves treating the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause and treat the underlying cause accordingly. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis and other complications.

In conclusion, amenorrhoea is a condition that requires proper diagnosis and management. Understanding the causes and appropriate investigations can help in providing the necessary treatment and care for women experiencing this condition.

When a cervical smear sample tests positive for high-risk HPV (hrHPV), it undergoes cytological examination to check for abnormal cellular changes that may indicate early cervical cancer. In the UK, cervical screening is offered to women between the ages of 25 and 65, with those aged 25-50 offered a smear every 3 years and those aged 50-65 offered a smear every 5 years. The aim of the screening programme is to detect cervical changes early on. HPV, a sexually transmitted virus, is present in almost all sexually active individuals, and HPV 16 or 18 is present in almost all cases of cervical cancer. If hrHPV is not detected, no further testing is required, and the patient can return to routine screening. Repeating the smear is not necessary following the presence of hrHPV, but a repeat smear may be required if the laboratory report an inadequate sample. Prior to colposcopy investigation, the sample must be positive for hrHPV and dyskaryosis.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.