The likelihood of cervical ectropion is higher in individuals who take the COCP due to increased levels of oestrogen. Based on the patient’s medical history and examination results, cervical ectropion appears to be the most probable diagnosis. This condition is more prevalent during puberty, pregnancy, and while taking the pill. Endometrial cancer is improbable in a young person, and the presence of cervical ectropion on examination supports this straightforward diagnosis. Although chlamydia infection can cause cervicitis, the patient’s sexual history does not suggest this diagnosis, and the pill remains the most likely cause. It is recommended to undergo STI screenings annually.

Understanding Cervical Ectropion

Cervical ectropion is a condition that occurs when the columnar epithelium of the cervical canal extends onto the ectocervix, where the stratified squamous epithelium is located. This happens due to elevated levels of estrogen, which can occur during the ovulatory phase, pregnancy, or with the use of combined oral contraceptive pills. The term cervical erosion is no longer commonly used to describe this condition.

Cervical ectropion can cause symptoms such as vaginal discharge and post-coital bleeding. However, ablative treatments such as cold coagulation are only recommended for those experiencing troublesome symptoms. It is important to understand this condition and its symptoms in order to seek appropriate medical attention if necessary.

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.

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.

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

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

Patients experiencing secondary dysmenorrhoea should be referred to gynaecology for further investigation as it is often associated with underlying pathologies such as endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease. While the combined oral contraceptive pill may provide relief, it is important to determine the root cause first. Fluoxetine is not appropriate for managing secondary dysmenorrhoea, as it is used for premenstrual dysphoric disorder. Intra-uterine devices may actually cause secondary dysmenorrhoea and should not be used. Tranexamic acid is not indicated for the management of secondary dysmenorrhoea, but rather for menorrhagia.

Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

If a patient vomits within 3 hours of taking levonorgestrel, it is recommended to prescribe a second dose of emergency hormonal contraception to be taken as soon as possible, according to NICE guidelines. Therefore, reassuring Zoe that she is protected from pregnancy is incorrect as she needs to take another dose. Additionally, while it may be advisable for Zoe to start a regular form of contraception, this is not the most important advice to give initially. Instead, she should be offered choices of contraception, including long-acting reversible contraceptives. It is also incorrect to recommend other forms of emergency contraception, such as ulipristal acetate and the IUD, as Zoe has already taken levonorgestrel and the guidelines are clear that a second dose of this should be taken in this circumstance. However, if Zoe experiences persistent vomiting or diarrhea for more than 24 hours after taking emergency hormonal contraception, then the IUD may be offered.

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.

To manage unscheduled bleeding, which is a common side effect of Nexplanon, a 3-month course of the combined oral contraceptive pill may be prescribed. This will not only provide additional contraception but also make periods lighter and more regular. Prescribing a progesterone-only pill is not recommended as it can also cause irregular bleeding. A single dose of intramuscular methotrexate is not appropriate as the patient is not showing any symptoms of an ectopic pregnancy. Urgent referral for endometrial cancer is also not necessary as the patient’s age and symptoms suggest that the bleeding is most likely due to the contraceptive implant.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

progesterone Only Pill: What to Do When You Miss a Pill

The progesterone only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to note that the rules for the two types of pills should not be confused. The traditional POPs (Micronor, Noriday, Norgeston, Femulen) and Cerazette (desogestrel) have the following guidelines for missed pills:

– If the pill is less than 3 hours late, no action is required, and you can continue taking the pill as normal.
– If the pill is more than 3 hours late (i.e., more than 27 hours since the last pill was taken), action is needed.
– If the pill is less than 12 hours late, no action is required, and you can continue taking the pill as normal.
– If the pill is more than 12 hours late (i.e., more than 36 hours since the last pill was taken), action is needed.

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.

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.

Hormone Replacement Therapy: Risks and Benefits

Hormone Replacement Therapy (HRT) and Estrogen Replacement Therapy (ERT) are commonly used to alleviate symptoms of menopause, such as hot flashes and vaginal dryness. However, these treatments come with potential risks and benefits that should be carefully considered.

One of the main concerns with HRT is the increased risk of breast cancer, particularly with combined estrogen and progesterone therapy. The absolute risk is small, but it is important to discuss this with a healthcare provider. On the other hand, HRT and ERT have been shown to reduce the risk of osteoporosis and bone fractures.

Another potential risk of HRT and ERT is an increased risk of deep vein thrombosis. However, the risk may be lower with HRT compared to ERT. Additionally, both treatments have been shown to reduce all-cause mortality in women under 60.

Oestrogen replacement therapy (without progesterone) may reduce the risk of cardiovascular diseases, but it is important to note that the risk of breast cancer may not be significantly altered.

Overall, the decision to use HRT or ERT should be based on an individual’s symptoms, medical history, and potential risks and benefits. It is important to discuss these options with a healthcare provider and make an informed decision.

Weighing the Risks and Benefits of Hormone Replacement Therapy

If a patient presents with symptoms highly suggestive of vaginal candidiasis, a high vaginal swab is not necessary for diagnosis and treatment can be initiated with a single oral dose of fluconazole. Symptoms of vaginal candidiasis include vulval soreness, itching, and thick, white vaginal discharge. Prescribing oral metronidazole as a single dose or taking a high vaginal swab would be incorrect as they are used to treat Trichomonas vaginalis infections or bacterial vaginosis, respectively.

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 patient did not respond to methotrexate treatment for ectopic pregnancy, as indicated by the βhCG levels. Additionally, there is no history of increased infertility risk. According to NICE guidelines, salpingectomy is recommended for women with tubal ectopic unless they have other infertility risk factors, such as damage to the contralateral tube. Alternatively, salpingostomy may be offered. Women who undergo salpingostomy should be informed that up to 20% may require further treatment, which could include methotrexate and/or salpingectomy.

Understanding Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

Management of Menopausal Symptoms: Lifestyle Changes and Medication Options

Menopausal symptoms, such as hot flashes and mood disturbance, can significantly impact a woman’s quality of life. The first step in managing these symptoms should involve lifestyle changes, such as reducing caffeine and alcohol intake, regular exercise, and weight loss. If symptoms persist or worsen, medication options such as hormone replacement therapy (HRT) or selective serotonin reuptake inhibitors (SSRIs) can be considered.

Cognitive behavioral therapy (CBT) is also an option for women experiencing mood disturbance, anxiety, or depression. However, it is important to note that SSRIs should only be used for severe symptoms that have not improved with lifestyle changes. When starting SSRIs, patients should be reviewed after two weeks and then again after three months if symptoms have improved.

While over-the-counter herbal products like St John’s wort, isoflavones, and black cohosh have been associated with symptom improvement, their safety and efficacy are unknown. It is not recommended for doctors to suggest these products, and patients should be warned of potential risks and interactions with other medications.

Overall, the management of menopausal symptoms should involve a combination of lifestyle changes and medication options, with regular review of symptoms to ensure the best possible outcome for the patient.

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

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

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

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

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

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

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

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.

During pregnancy, fibroid degeneration can occur and may cause symptoms such as low-grade fever, pain, and vomiting.

If the ultrasound scan does not show any signs of inflammation in the appendix, it is unlikely that the patient has appendicitis.

Since the patient has fibroids in her uterus, she is at risk of experiencing fibroid degeneration, which is a common complication during pregnancy. Symptoms of fibroid degeneration may include fever, pain, and vomiting.

The absence of vaginal bleeding makes it unlikely that the patient is experiencing a threatened miscarriage.

While ovarian torsion can cause pain and vomiting, it typically occurs in patients with risk factors such as ovarian cysts or ovarian enlargement.

Understanding Fibroid Degeneration

Uterine fibroids are non-cancerous growths that can develop in the uterus. They are sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.

Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days.

To diagnose PCOS, at least two out of three features must be present: oligomenorrhoea, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. In this case, the patient has oligomenorrhoea and clinical signs of hyperandrogenism, making a clinical diagnosis of PCOS likely. However, NICE guidelines recommend ruling out other potential causes of menstrual disturbance before confirming the diagnosis. BMI measurement is not necessary for diagnosis, although obesity is a common feature of PCOS. Testing for free or total testosterone levels is also not essential if clinical signs of hyperandrogenism are present.

Polycystic ovary 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 believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.

To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.

Understanding Cervical Screening: Guidelines and Options

Cervical screening, also known as a smear test, is a vital tool in detecting precancerous cell changes in the cervix and preventing cervical cancer. Here are some important guidelines and options to keep in mind:

Age and Frequency: In the UK, women aged 25-64 are invited for screening, with those aged 25-49 screened every three years and those aged 50-64 screened every five years. In Scotland, screening is recommended every five years for women aged 25-65.

Hysterectomy: Women who have had a total hysterectomy (removal of the uterus and cervix) do not require cervical screening. However, those who have had a partial hysterectomy (removal of the uterus but not the cervix) should continue to be screened according to age guidelines.

Age Limit: Women over the age of 65 may still be eligible for screening if they have had recent abnormal results or have not been screened since the age of 50.

Opting Out: While cervical screening is not obligatory, it is highly recommended. Patients can opt out by speaking to their doctor and signing an ‘opting out’ form, but this decision can be reversed at any time. It is important to understand the benefits and risks associated with screening before making a decision.

According to NICE guidelines for cervical screening, if the smear test is inadequate or the high-risk human papillomavirus (hrHPV) test result is unavailable, the sample should be repeated within 3 months. Therefore, repeating the sample in 3 months is the correct course of action. Repeating HPV testing in 1 week would not change the management plan as Sarah has already tested positive for hrHPV and requires an adequate cervical cytology result. Colposcopy is only necessary if there are two consecutive inadequate results. Waiting 12 months to repeat the sample would be inappropriate as it would be too long between tests. Similarly, returning Sarah to routine recall is not appropriate as she requires an adequate 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.

Management Options for Fibroids in Women

Fibroids are a common gynecological condition that can cause symptoms such as dysmenorrhoea and menorrhagia. There are several management options available for women with fibroids, depending on their individual circumstances.

Progesterone-releasing intrauterine system: This is recommended as a first-line treatment for women with fibroid-associated menorrhagia, where the fibroids are < 3 cm and do not distort the uterine cavity. It also provides a long-term form of contraception for up to two years. Combined oral contraceptive pill: This can be used as a management option for fibroids and is a suitable option for women who do not wish to conceive at present. However, the intrauterine system is more effective and provides longer-term contraception. Expectant management: This can be considered for women who have asymptomatic fibroids. However, it is not appropriate for women who are experiencing symptoms such as dysmenorrhoea and menorrhagia. Hysterectomy: This is a surgical option for women with symptomatic fibroids who do not wish to preserve their fertility. It is not appropriate for women who wish to become pregnant in the future. Non-steroidal anti-inflammatory drugs (NSAIDs): These can be a useful management option for fibroid-related dysmenorrhoea and menorrhagia. However, hormonal contraceptives may be more appropriate for women who do not wish to conceive. Management Options for Women with Fibroids

The menopause is diagnosed retrospectively and occurs 12 months after the last menstrual period. Women who experience menopause before the age of 50 need contraception for at least 2 years after their last menstrual period, while those over 50 require only 1 year of contraception. Therefore, it would be incorrect to assume that this woman does not need contraception because she is protected. Prescribing the COCP for only 12 months would also be inappropriate, especially since she is a smoker over the age of 35. Hormone replacement therapy should not be used as a sole form of contraception, and barrier methods are less effective than other types of contraception. The most appropriate option is the IUS, which can be used for 7 years (off-licence) or 2 years after her last menstrual period and will take her through menopause. This information is based on the FSRH’s guidelines on contraception for women aged over 40 (July 2010).

Understanding Menopause and Contraception

Menopause is a natural biological process that marks the end of a woman’s reproductive years. On average, women in the UK experience menopause at the age of 51. 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.

If a patient’s cervical cancer screening sample is positive for high-risk HPV and shows cytological abnormalities, the next step according to guidelines is to refer the patient for a colposcopy. During this procedure, the cervix is closely examined to identify any disease. If significant abnormalities are found, loop excision of the transformation zone may be necessary. It is not appropriate to return the patient to normal recall without further investigation. Repeating the sample in 3 months is not necessary for a patient with high-risk HPV and requires specialist assessment. However, repeating the sample in 3 months may be considered if the initial sample was inadequate. Similarly, repeating the sample in 12 months is not the next step and may only be recommended after colposcopy. At this stage, the patient needs further assessment. Repeating the sample in 12 months may be considered if the patient has high-risk HPV with normal cytological findings.

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.

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.

Women who would otherwise experience symptoms of polycystic ovarian syndrome may not realize they have the condition if they are using the combined oral contraceptive pill.

Polycystic ovary 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 believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.

To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.

The whirlpool sign is indicative of an ovarian torsion or a volvulus caused by the twisting of the bowel. An enlarged ovary located in the midline and free pelvic fluid may also be observed on the ultrasound scan. Additionally, a doppler scan may reveal little or no ovarian venous flow with absent or reversed diastolic flow. On the other hand, Rovsing’s sign is characterized by increased tenderness in the right iliac fossa upon palpation of the left iliac fossa. This sign is often associated with cases of appendicitis.

Causes of Pelvic Pain in Women

Pelvic pain is a common complaint among women, with primary dysmenorrhoea being the most frequent cause. Mittelschmerz, or pain during ovulation, may also occur. However, there are other conditions that can cause pelvic pain, which can be acute or chronic in nature.

Acute pelvic pain can be caused by conditions such as ectopic pregnancy, urinary tract infection, appendicitis, pelvic inflammatory disease, and ovarian torsion. Ectopic pregnancy is characterized by lower abdominal pain and vaginal bleeding in women with a history of 6-8 weeks of amenorrhoea. Urinary tract infection may cause dysuria and frequency, while appendicitis may present with pain in the central abdomen before localizing to the right iliac fossa. Pelvic inflammatory disease may cause pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria, and menstrual irregularities. Ovarian torsion, on the other hand, may cause sudden onset unilateral lower abdominal pain, nausea, vomiting, and a tender adnexal mass on examination.

Chronic pelvic pain, on the other hand, may be caused by conditions such as endometriosis, irritable bowel syndrome, ovarian cysts, and urogenital prolapse. Endometriosis is characterized by chronic pelvic pain, dysmenorrhoea, deep dyspareunia, and subfertility. Irritable bowel syndrome is a common condition that presents with abdominal pain, bloating, and change in bowel habit. Ovarian cysts may cause a dull ache that is intermittent or only occurs during intercourse, while urogenital prolapse may cause a sensation of pressure, heaviness, and urinary symptoms such as incontinence, frequency, and urgency.

In summary, pelvic pain in women can be caused by various conditions, both acute and chronic. It is important to seek medical attention if the pain is severe or persistent, or if there are other concerning symptoms present.

When choosing a contraceptive method, individual preferences and any cautions or contraindications must be taken into account. In this case, the priority is to find a method that won’t be affected by carbamazepine’s enzyme-inducing effect, such as the intrauterine system. While the combined oral contraceptive pill (COCP) could help with heavy bleeding, its failure rate would be high due to enzyme induction. Nexplanon may cause heavy bleeding and its low progesterone dose would also be affected by enzyme induction. Depo-Provera is an option, but prolonged use in young individuals could lead to reduced bone density. The Mirena intrauterine system would be effective in reducing heavy bleeding and providing reliable contraception alongside the anti-epileptic medication.

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.

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.

According to the GMC’s good medical practice advice, healthcare professionals can provide contraceptive, abortion, and STI advice and treatment to individuals aged 0-18 years without parental knowledge or consent if certain criteria are met. These include ensuring that the individual fully understands the advice and its implications, not persuading them to tell their parents or allowing you to do so, and determining that their physical or mental health is likely to suffer without such advice or treatment. Confidentiality should be maintained even if advice or treatment is not provided. In this scenario, the correct course of action is to prescribe the pill as the young girl fulfills the Fraser guidelines. Breaking confidentiality, as suggested in answer 4, is not recommended by the GMC guidelines. Therefore, the correct answer is 1.

When it comes to providing contraception to young people, there are legal and ethical considerations to take into account. In the UK, the age of consent for sexual activity is 16 years, but practitioners may still offer advice and contraception to young people they deem competent. The Fraser Guidelines are often used to assess a young person’s competence. Children under the age of 13 are considered unable to consent to sexual intercourse, and consultations regarding this age group should trigger child protection measures automatically.

It’s important to advise young people to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. Long-acting reversible contraceptive methods (LARCs) are often the best choice for young people, as they may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.