Post coital literally means “after intercourse” which is when this fertility test is conducted. The patient has intercourse at home usually between cycle days 12 and 15 (or a day around the LH surge as measured by urinary ovulation predictor kits). Afterwards, the female comes to the office and a sample of the cervical mucus is taken for microscopic examination.

The post coital fertility test (PCT) allows for evaluation of sperm in the cervical mucus and to determine the consistency of the mucus. Sperm must swim through the cervical mucus from the vagina, through the cervix, and into the uterus. Normal sperm will be active and swim in approximate straight lines through the mucus. If the mucus is too thick, sperm impedance can be observed.

The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.

Factors shown to decrease risk of ovarian cancer are:
– Oral contraceptive use
– Higher Parity
– Breast feeding
– Hysterectomy
– Tubal Ligation
– Statins
– SLE

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

The treatment of Chlamydia includes avoidance of intercourse, use of condoms and antibiotic treatment. Erythromycin 500mg orally QID for 7 days or Amoxicillin 500mg TDS for 7 days or Ofloxacin 200mg orally BD for 7 days.

Premature menopause is most commonly idiopathic.

Pituitary tumours, the most common pathologic cause of galactorrhoea can result in hyperprolactinemia by producing prolactin or blocking the passage of dopamine from the hypothalamus to the pituitary gland. Approximately 30 percent of patients with chronic renal failure have elevated prolactin levels, possibly because of decreased renal clearance of prolactin. Primary hypothyroidism is a rare cause of galactorrhoea in children and adults. In patients with primary hypothyroidism, there is increased production of thyrotropin-releasing hormone, which may stimulate prolactin release. Nonpituitary malignancies, such as bronchogenic carcinoma, renal adenocarcinoma and Hodgkin’s and T-cell lymphomas, may also release prolactin.

In the foetus, the hypogastric artery ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

Nipple stimulation during breastfeeding triggers the production of oxytocin from the hypothalamus and its subsequent release from the posterior pituitary gland. The hormone causes the myoepithelial cells of the breast to contract causing milk to flow through the ducts.

Ergometrine and Prostaglandin E2 are used during labour to control uterine bleeding after delivery, or ripen the cervix, while Atosiban is an oxytocin antagonist.

Antidiuretic hormone is also released from the posterior pituitary, and acts on the kidneys to decrease fluid excretion.

There are between 250 and 400 lobules in each testis. The lobule is a structural unit of the testis with each lobule contained in one of the intervals between fibrous septa which extend between the mediastinum testis and the tunica albuginea. Each lobule contains 1 to 3 seminiferous tubules.

An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary. Although the discovery of an ovarian cyst causes considerable anxiety in women owing to fears of malignancy, the vast majority of these lesions are benign.

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

However, meta-analyses have since shown that there is no difference between OCP use and placebo in terms of treatment outcomes in ovarian cysts and that these masses should be monitored expectantly for several menstrual cycles.

If a cystic mass does not resolve after this timeframe, it is unlikely to be a functional cyst, and further workup may be indicated.

Other methods of management maybe revisited if cyst increases in size or becomes complex upon follow up.

This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.

For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.

If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.

A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.

Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.

During fertilization, a sperm must first fuse with the plasma membrane and then penetrate the female egg cell to fertilize it. Fusing to the egg cell usually causes little problem, whereas penetrating through the egg’s hard shell or extracellular matrix can be more difficult. Therefore, sperm cells go through a process known as the acrosome reaction, which is the reaction that occurs in the acrosome of the sperm as it approaches the egg. The acrosome is a cap-like structure over the anterior half of the sperm’s head. Upon penetration, if all is normally occurring, the process of egg-activation occurs, and the oocyte is said to have become activated. This is thought to be induced by a specific protein phospholipase c zeta. It undergoes its secondary meiotic division, and the two haploid nuclei (paternal and maternal) fuse to form a zygote. To prevent polyspermy and minimize the possibility of producing a triploid zygote, several changes to the egg’s cell membranes render them impenetrable shortly after the first sperm enters the egg.

Trichomoniasis is considered a sexually transmitted infection found both in men and women, and is caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. About 20-30% of women with the infection however are asymptomatic. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis during pregnancy and breastfeeding is 400-500mg of metronidazole twice daily for 5 -7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated and screened for other STIs.

Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. It can be a sign of serious underlying pathology and is usually alarming for patients. About one-third of patients also have abnormal uterine bleeding that is not associated with coitus and about 15 percent have dyspareunia. The most serious cause of postcoital bleeding is cervical cancer. About 11 percent of women with cervical cancer present with postcoital bleeding. The patient should undergo cervical cancer screening according to local guidelines. Postcoital bleeding is not an indication for cervical cytology if previous screening tests are up-to-date and normal.

Cervical screening and liquid based cytology are superior to transvaginal ultrasound.

Coagulation profile can be done if cytology is normal to rule out bleeding diathesis.

Tranexamic acid can be considered once malignancy is ruled out and cause of bleeding has been established.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.

During pregnancy, anaemia increases more than fourfold from the first to third trimester. It is a well established fact that there is a physiological drop in haemoglobin (Hb) in the mid trimester. This physiological drop is attributed to increase of plasma volume and hence decrease of blood viscosity lead to better circulation in placenta.

Bicornuate uterus is associated with an increased chance of urinary tract anomalies. Urinary tract anomalies were present in about 23.6% of cases of bicornuate uterus patients.

As there has been no bleeding or expulsion of the products of conception this is a missed miscarriage

The femoral triangle is bounded superiorly by the inguinal ligament which forms the base of the triangle, medially by the lateral border of the adductor longus and laterally by the sartorius muscle.

The amniotic fluid volume increases up to week 35 of gestation and then decreases from then to term.

The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.

The ovarian arteries are considered the main blood supply for the ovaries. The ovarian arteries usually arise from the lateral aspect of the abdominal artery, though in some instances they may arise from the renal or iliac arteries.

The pudendal nerve has its origins form S2, S3 and S4 spinal segments. It provides sensation to the clitoris and labia along with the ilioinguinal nerve.

There are no interactions between the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone injections or levonorgestrel implants and the AEDs valproic acid (sodium valproate), vigabatrin, lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide, ethosuximide and the benzodiazepines. So she can use COCP along with Sodium valproate.

Afterpains may continue for 2-3 days (so none of the above). Breastfeeding may intensify pain due to stimulation of Oxytocin which causes uterine contractions

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges.

The most likely cause of her bleeding is an endometrial polyp formation due to the tamoxifen.

Tamoxifen is often prescribed to decrease risk of breast cancer recurrence in premenopausal women with oestrogen receptor-positive cancers.

As with any medication, it has known side effects, which include endometrial polyp formation, subendometrial oedema and, rarely, endometrial carcinoma.

A polyp or carcinoma can cause uterine bleeding, but a polyp is more likely to occur.

Routine endometrial thickness screening is not recommended in all women taking tamoxifen. However, in cases of abnormal bleeding, ultrasound assessment of endometrial thickness, hysteroscopy and curettage are indicated to assess the endometrium in more detail.

Tamoxifen is not associated with endometrial atrophy.

Endometrial metastasis from a breast cancer is rare, and tamoxifen would not usually induce follicular development in a woman who has had chemotherapy and resultant amenorrhoea.

The cardinal ligament (or Mackenrodt’s ligament, lateral or transverse cervical ligament) is a major ligament of the uterus. It is located at the base of the broad ligament of the uterus. It attaches the cervix to the lateral pelvic wall by its attachment to the Obturator fascia of the Obturator internus muscle, and is continuous externally with the fibrous tissue that surrounds the pelvic blood vessels. It thus provides support to the uterus.

Miscarriage rates:
20-24 – 9%
25-29 – 11%
30-34 – 15%
35-39 – 25%
40-44 – 51%
>45 – 75%