When it comes to patients with suspected endometriosis, laparoscopy is considered the most reliable investigation method.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

Pelvic inflammatory disease is primarily caused by Chlamydia trachomatis.

Understanding Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a condition that occurs when the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. The most common cause of PID is an ascending infection from the endocervix, often caused by Chlamydia trachomatis. Other causative organisms include 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 are often negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves a combination of antibiotics, such as oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

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. PID can also lead to infertility, with the risk as high as 10-20% after a single episode, chronic pelvic pain, and ectopic pregnancy. In mild cases of PID, intrauterine contraceptive devices may be left in, but recent guidelines suggest that removal of the IUD should be considered for better short-term clinical outcomes. Understanding PID and its potential complications is crucial for early diagnosis and effective management.

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.

postmenopausal Bleeding: Common Causes and Investigations

postmenopausal bleeding can be caused by various factors, including atrophic vaginitis, endometrial atrophy, cervical or endometrial polyps, and endometrial hyperplasia/cancer. Among these causes, endometrial cancer is the most likely. Therefore, investigation for patients with postmenopausal bleeding is typically done in a specialist clinic, with transvaginal ultrasound, hysteroscopy, and biopsy.

However, submucosal fibroids become quiescent following menopause and usually calcify, and there is no evidence of increased risk of endometrial cancer in women with fibroids. On the other hand, ovarian cancer rarely, if ever, presents with postmenopausal bleeding. Cervical ectropion is a condition of young women, and vaginal cancer is very rare and usually presents with vaginal discharge.

In summary, postmenopausal bleeding should be investigated thoroughly to rule out any underlying serious conditions, such as endometrial cancer.

If simple analgesia with paracetamol and NSAIDs is not effective in treating endometriosis symptoms, hormonal treatment with the combined oral contraceptive pill or a progesterone should be considered.

Although a referral to gynaecology may be necessary due to the recurrence of symptoms and potential pelvic/bowel involvement, primary care can offer further treatment options in the meantime. Hormonal treatment is recommended for this patient, and the combined oral contraceptive pill or any of the progesterone options can be used. As the patient plans to start a family soon, a hormonal option that can be quickly reversed is the most suitable.

Buscopan is not an appropriate treatment for endometriosis, as it only provides relief for menstrual cramps and is not a cure. It may be used to alleviate symptoms associated with irritable bowel syndrome.

Injectable depo-provera is not the best option for this patient, as it can delay the return of fertility, which conflicts with her desire to start a family within the next year.

Opioid analgesia is not recommended for endometriosis treatment, as it carries the risk of side effects and dependence. It is not a long-term solution for managing symptoms.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

Misconceptions about Menopause and Reproduction

Menopause is often associated with misconceptions about reproductive health. Here are some common misconceptions and the correct information:

Common Misconceptions about Menopause and Reproduction

1. Menopause is associated with a decrease in follicle-stimulating hormone (FSH).
Correction: Menopause is associated with an increase in FSH due to the loss of negative feedback from estrogen on the anterior pituitary.

2. Progesterone is necessary for ovulation to take place.
Correction: Both FSH and luteinizing hormone (LH) are needed for ovulation to take place. Progesterone is necessary for preparing the uterus for implantation.

3. Estrogen concentration peaks during menstruation.
Correction: Estrogen concentration peaks just before ovulation during the follicular phase of the menstrual cycle.

4. Ovarian tissue is the only source of estrogen production.
Correction: While ovarian tissue is the main source of estrogen production, the adrenal cortex and adipose tissue also contribute to estrogen production.

5. Fertilization of the human ovum normally takes place in the uterus.
Correction: Fertilization of the human ovum normally takes place in the outer third of the Fallopian tubes, not the uterus. The fertilized egg then implants in the uterus.

Endometriosis is characterized by pelvic pain, dysmenorrhoea, dyspareunia, and subfertility. The symptoms experienced by the patient in this case suggest the presence of intra-pelvic pathology, including a retroverted uterus and age-related factors. Chlamydia infection is often asymptomatic and does not typically cause dysmenorrhoea, although dyspareunia may occur. Lower abdominal pain may be caused by ovarian cysts, while ectopic pregnancy is associated with amenorrhoea and lower abdominal pain.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

The 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.

When managing a miscarriage, medical treatment typically involves administering vaginal misoprostol alone. According to the NICE miscarriage Clinical Knowledge Summary, medical management is recommended if expectant management is not suitable or if a woman continues to experience symptoms after 14 days of expectant management. Misoprostol can be given orally or vaginally. If products of conception are not expelled after medical treatment or if symptoms persist after 14 days of expectant management, manual vacuum aspiration or surgical management may be considered. However, hospitalization and observation are not usually necessary unless the patient is experiencing hemodynamic instability. In most cases, women can take misoprostol and complete the miscarriage at home. Oral methotrexate is used for medical management of ectopic pregnancy.

Management Options for Miscarriage

Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.

Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.

Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.

It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.

Stages of Endometrial Carcinoma: TNM Classification Explained

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

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

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

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

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

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

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

Endometrial cancer is strongly linked to HNPCC/Lynch syndrome, while the use of combined oral contraceptives can help reduce the risk. Other factors that increase the risk of endometrial cancer include obesity, a higher number of ovulations (due to factors such as early menarche, late menopause, and fewer pregnancies), certain medications like tamoxifen, and medical conditions like diabetes and polycystic ovarian syndrome. Anorexia, the Mirena coil, and familial adenomatous polyposis are not considered risk factors for endometrial cancer.

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

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

If analgesia is ineffective in treating endometriosis, the first-line option to try is the combined oral contraceptive pill or a progesterone.

The patient’s chronic cyclical pelvic pain, dyspareunia, secondary dysmenorrhoea, and pain with bowel movements are consistent with endometriosis. The examination findings also support this diagnosis. Paracetamol with or without an NSAID (such as mefenamic acid or ibuprofen) is the initial treatment for endometriosis. If these medications do not work, hormonal therapy (such as the combined oral contraceptive pill or medroxyprogesterone acetate) is the second-line option.

Since the patient plans to start a family within the next year, the combined oral contraceptive pill is the more appropriate choice as it does not delay fertility. Medroxyprogesterone acetate, also known as Depo Provera, provides contraception for up to 12 weeks but can delay fertility for up to 12 months and is irreversible once given. Additionally, the patient’s BMI of 34 kg/m² is a known risk factor for weight gain, which is a potential side effect of the injectable contraceptive.

Offering mefenamic acid is not recommended as analgesia has already been tried without success. If analgesia is ineffective in treating endometriosis, the combined oral contraceptive pill or a progesterone should be considered.

Referring the patient for consideration of GnRH analogue is not appropriate at this stage. This option is only considered if hormonal therapy is ineffective. It is important to trial the combined oral contraceptive pill before considering a referral.

Understanding Endometriosis

Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

According to the GMC guidelines in good medical practice for individuals aged 0-18 years, it is important to disclose information regarding any abusive or seriously harmful sexual activity involving a child or young person. This includes situations where the young person is too immature to understand or consent, there are significant differences in age, maturity, or power between sexual partners, the young person’s sexual partner holds a position of trust, force or the threat of force, emotional or psychological pressure, bribery or payment is used to engage in sexual activity or keep it secret, drugs or alcohol are used to influence a young person to engage in sexual activity, or the person involved is known to the police or child protection agencies for having abusive relationships with children or young people.

Failing to disclose this information or simply prescribing contraception and waiting for a review can put both the patient and other students at the boyfriend’s school in harm’s way due to his position of trust. While informing the boyfriend or his school may breach confidentiality and not address the issue of his job and relationship, it is important to take appropriate action to protect the safety and well-being of the young person involved.

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.

Differential diagnosis of abdominal symptoms

Abdominal symptoms can have various causes, and a careful differential diagnosis is necessary to identify the underlying condition. In this case, the patient presents with bloating, early satiety, urinary symptoms, and an elevated CA-125 level. Here are some possible explanations for these symptoms, based on their typical features and diagnostic markers.

Ovarian cancer: This is a possible diagnosis, given the mass effect on the gastrointestinal and urinary organs, as well as the elevated CA-125 level. However, ovarian cancer often presents with vague symptoms initially, and other conditions can also increase CA-125 levels. Anorexia and weight loss are additional symptoms to consider.

Colorectal cancer: This is less likely, given the absence of typical symptoms such as change in bowel habits, rectal bleeding, or anemia. The classical marker for colorectal cancer is CEA, not CA-125.

Irritable bowel syndrome: This is also less likely, given the age of the patient and the presence of urinary symptoms. Irritable bowel syndrome is a diagnosis of exclusion, and other likely conditions should be ruled out first.

Genitourinary prolapse: This is a possible diagnosis, given the urinary symptoms and the sensation of bulging or fullness. Vaginal spotting, pain, or irritation are additional symptoms to consider. However, abdominal bloating and early satiety are not typical, and CA-125 levels should not be affected.

Diverticulosis: This is unlikely, given the absence of typical symptoms such as altered bowel habits or left iliac fossa pain. Diverticulitis can cause rectal bleeding, but fever and acute onset of pain are more characteristic.

In summary, the differential diagnosis of abdominal symptoms should take into account the patient’s age, gender, medical history, and specific features of the symptoms. Additional tests and imaging may be necessary to confirm or exclude certain conditions.

If a patient was assigned male at birth and is undergoing treatment with oestradiol, GNRH analogs, finasteride or cyproterone, there may be a decrease or cessation of sperm production. However, this cannot be considered a reliable method of contraception. In the case of a trans female patient, who was assigned male at birth, hormonal treatments cannot be relied upon for contraception. There is a possibility of her female partner becoming pregnant, and therefore, barrier methods are recommended. Hormonal contraceptives are not suitable for this patient, and the copper IUD is not an option as she does not have a uterus.

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.

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

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

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

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

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

If pelvic floor muscle exercises are ineffective and surgical intervention is not desired, duloxetine may be used to manage stress incontinence, as per NICE guidance from 2019. It should be noted that bladder retraining is not recommended for this type of incontinence, and oxybutynin is only indicated for urge incontinence if bladder retraining has failed. Referral for urodynamics testing is also not recommended, with urogynaecology being the preferred option for secondary care. Additionally, NICE does not recommend continuing pelvic floor exercises for an additional 3 months.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

The recommended first-line treatment for non-pregnant women with symptoms of vaginal thrush, such as a curd-like discharge and itching, is a single dose of oral fluconazole. This medication can often be obtained directly from a pharmacist without needing to see a GP. Using low dose topical corticosteroids until symptoms improve is not an appropriate treatment for managing the fungal infection. Similarly, taking oral cetirizine daily for two weeks is not the recommended course of action, although it may be used for treatment-resistant thrush. Oral fluconazole should be tried first before considering cetirizine. Lastly, a three-day course of oral fluconazole is not the appropriate duration of treatment for this patient population.

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.

Different Types of Ovarian Tumours and their Histological Features

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

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

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

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

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

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

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

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.

If there has been a delay in changing the patch for over 48 hours but no sexual activity has occurred within the past 10 days, emergency contraception is not necessary. However, the individual must use barrier contraception for the next 7 days and replace the patch immediately. If there is no sexual activity planned for the next 7 days, no further action is required, but it is important to advise the individual to use barrier contraception during this time. It is crucial to replace the patch as soon as possible to ensure effective contraceptive coverage.

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

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

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

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

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

Managing Polycystic Ovarian Syndrome

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

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

The UK Government implemented legal modifications in October 2015 regarding the response of doctors in England and Wales to instances of female genital mutilation (FGM). As per the guidelines of the General Medical Council (GMC), doctors are required to report all cases of FGM in individuals under the age of 18 to the police. This can be done by contacting 101 or using the established local channels. Reporting is compulsory to align with our responsibilities towards child protection and safeguarding.

Understanding Female Genital Mutilation

Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

Management of Unprovoked Vulvodynia: Medications, Referrals, and Other Modalities

Unprovoked vulvodynia is a chronic pain syndrome characterized by chronic vulvovaginal pain lasting at least three months, without identifiable cause. The pain can be localized or generalized, has no triggers, and cannot be provoked by light touch on examination. In addition, there is associated dyspareunia. The intensity of the pain and the impact on the patient varies greatly between cases. The mainstay of first-line treatment is pain-modifying medication such as amitriptyline, an oral tricyclic antidepressant medication, which is also used in the management of depression, migraines, and chronic pain. However, if an adequate trial of amitriptyline fails to improve symptoms or if the side-effects are not tolerated by the patient, then gabapentin or pregabalin can be offered as second line. Other modalities that should be considered in the management of unprovoked vulvodynia include cognitive behavioural therapy, acupuncture, and pelvic floor exercise training. Severe unprovoked vulvodynia that persists despite the above measurements should be dealt with in secondary care by the pain team. Referral to the Gynaecology team is unnecessary unless there are concerning factors in the history or examination to point towards causes like carcinoma, sexually transmitted infections, or chronic inflammatory skin conditions.

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

Termination of Pregnancy in the UK

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

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

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

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

Missed Pills in Combined Oral Contraceptive Pill

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

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

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

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.

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

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.

Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.

Treatment Options for Primary Dysmenorrhoea: A Guide for Healthcare Professionals

Primary dysmenorrhoea is a common condition that affects many women of reproductive age. When treating this condition, healthcare professionals have several options to consider. Here, we will discuss the most common treatments and their appropriateness for different patients.

Paracetamol is a suitable first-line treatment for patients with primary dysmenorrhoea who cannot take NSAIDs. If the patient does not wish to conceive, a hormonal contraceptive may also be considered as a first-line treatment.

Gabapentin is not recommended for the treatment of dysmenorrhoea, as it is primarily used for epilepsy and neuropathic pain.

Mefenamic acid and naproxen are both NSAIDs and are recommended as first-line treatments for primary dysmenorrhoea. However, they are contraindicated in patients with a history of asthma triggered by NSAID use.

Oral morphine is not typically used as a first-line treatment for dysmenorrhoea. If NSAIDs and paracetamol are not effective, transelectrical nerve stimulation (TENS) may be trialled. If none of these treatments are effective within 3-6 months, the patient should be referred to a gynaecologist for further assessment.

In summary, healthcare professionals should consider the patient’s medical history and preferences when selecting a treatment for primary dysmenorrhoea. Paracetamol and hormonal contraceptives are suitable first-line treatments, while NSAIDs and TENS may also be effective in some patients. Referral to a specialist may be necessary if initial treatments are not effective.

No additional contraception is needed when switching from an IUD to COCP if it is removed on days 1-5 of the menstrual cycle. The COCP is effective immediately if started on these days, but if started from day 6 onwards, barrier contraception is required for 7 days. There is no need to delay starting the COCP after IUD removal. If the patient had recently taken ulipristal as an emergency contraceptive, she would need to wait for 5 days before starting hormonal contraception.

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

Depo-provera is linked to an increase in weight.

If this woman is concerned about weight gain, it is best to avoid depo-provera, which is the primary injectable contraceptive in the UK. Depo-provera can cause various adverse effects, including weight gain, irregular bleeding, delayed return to fertility, and an increased risk of osteoporosis.

While some users of the combined oral contraceptive pill have reported weight gain, a Cochrane review does not support a causal relationship. There are no reasons for this woman to avoid the combined oral contraceptive pill.

The progesterone-only pill has not been associated with weight gain and is safe for use in this woman.

The intra-uterine system (IUS) does not cause weight gain in users and is a viable option for this woman.

The subdermal contraceptive implant can cause irregular or heavy bleeding, as well as progesterone-related side effects such as headaches, nausea, and breast pain. However, it is not typically associated with weight gain and is not contraindicated for use in this situation.

Injectable Contraceptives: Depo Provera

Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150 mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucous thickening and endometrial thinning.

However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

Diagnosis of Hydatidiform Mole in Early Pregnancy: Clinical Features and Treatment Options

Hydatidiform mole is a type of gestational trophoblastic disease that occurs due to abnormal fertilization of an ovum, resulting in a non-viable pregnancy. The condition presents with clinical features such as vaginal bleeding, excessive vomiting, a large-for-dates uterus, and a very high hCG level. Pelvic ultrasound may reveal a ‘snowstorm’ appearance from the intrauterine mass and cystic components.

The diagnosis of hydatidiform mole is crucial as it determines the treatment options. If the patient wishes to retain her fertility, dilation and evacuation are offered. However, if fertility is not desired, a hysterectomy is recommended. The former has fewer post-operative complications but carries a higher risk of post-operative gestational trophoblastic neoplasia. Antiemetics are prescribed to manage nausea and vomiting.

Twin pregnancy and complete miscarriage are differential diagnoses, but the absence of fetal parts and the grossly elevated hCG level point towards hydatidiform mole. Pre-eclampsia cannot be diagnosed before the second trimester, and endometrial carcinoma is unlikely to cause a uterine mass or elevated hCG levels.

In conclusion, early diagnosis of hydatidiform mole is crucial for appropriate management and prevention of complications.

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

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

Treatment Options for Menopausal Symptoms in Breast Cancer Patients

Breast cancer patients experiencing mood disturbance, anxiety, and depression related to menopausal symptoms can benefit from cognitive behavioural therapy (CBT) and lifestyle modifications. A 2-week trial of fluoxetine may be an option, but it is contraindicated in patients receiving tamoxifen therapy. Combined cyclic hormonal replacement therapy (HRT) is not routinely offered due to the increased risk of breast cancer recurrence, but can be prescribed in exceptional circumstances. Over-the-counter herbal products like black cohosh are not recommended due to safety concerns and potential interactions with medications. Lifestyle changes such as reducing caffeine and alcohol consumption, using a handheld fan, and regular exercise can also help alleviate symptoms.

Understanding Mittelschmerz: Mid-Cycle Pain in Women

Mittelschmerz, which translates to middle pain in German, is a common experience for approximately 20% of women during mid-cycle. This pain or discomfort occurs when the membrane covering the ovary stretches to release the egg, resulting in pressure and pain. While the amount of pain varies from person to person, some may experience intense pain that can last for days. In severe cases, the pain may be mistaken for appendicitis.

However, other conditions such as acute appendicitis, ruptured ectopic pregnancy, incarcerated hernia, and pelvic inflammatory disease should also be considered and ruled out through physical examination and investigations. It is important to note that a ruptured ectopic pregnancy is a medical emergency and can present with profuse internal bleeding and hypovolaemic shock.

In this case, the patient’s physical examination and investigations suggest recent ovulation and fluid in the pouch of Douglas, making Mittelschmerz the most likely diagnosis. It is important for women to understand and recognize this common experience to differentiate it from other potential conditions.

Homologous Cells in Male and Female Reproductive Systems

The male and female reproductive systems have homologous cells that perform similar functions. Leydig cells, also known as pure Leydig cell tumors, are found in both males and females. In females, these cells are located in the ovarian hilus and secrete androgens, causing masculinization when a tumor arises. Sertoli cells, on the other hand, have a female homologue called granulosa cells, both of which are sensitive to follicle-stimulating hormone. Epithelial cells in the epididymis have a vestigial structure in females called the epoophoron, which is lined by cells similar to those found in the epididymis. Spermatocytes have female homologues in oocytes and polar bodies, while spermatogonia have female homologues in oogonia. Understanding these homologous cells can aid in the diagnosis and treatment of reproductive system disorders.

Appropriate Treatment Options for Vaginal Infections

Bacterial vaginosis is a common vaginal infection that results in a decrease in lactobacilli and an increase in anaerobic bacteria. The typical symptoms include a white, milky, non-viscous discharge with a fishy odor and a pH greater than 4.5. The recommended treatment for bacterial vaginosis is metronidazole 400 mg twice a day for a week.

Azithromycin is the treatment of choice for Chlamydia, but it is not appropriate for bacterial vaginosis. acyclovir is used to treat herpes infections, which is not the cause of this patient’s symptoms. Fluconazole is a treatment option for vaginal candidiasis, but it is unlikely to be the cause of this patient’s symptoms. Pivmecillinam is used to treat urinary tract infections, which is not the cause of this patient’s symptoms.

In conclusion, the appropriate treatment for bacterial vaginosis is metronidazole, and other treatments should be considered based on the specific diagnosis.

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.

It is a common scenario for surgical patients to face an increased risk of venous thromboembolism when they are on the pill and undergoing surgery, particularly abdominal or lower limb surgery. Therefore, it is necessary to discontinue the pill.

However, stopping the pill too early would increase the risk of pregnancy, and restarting it too soon after surgery would still pose a risk due to the surgery’s effects on coagulation. Ceasing the pill on the day of surgery would not eliminate the risk of clotting either.

The best course of action is to stop the pill four weeks before surgery to allow for a return to normal coagulation levels. Then, restarting it two weeks after surgery would allow the procoagulant effects of surgery to subside.

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