Suspected Endometrial Cancer in postmenopausal Woman with Abnormal Bleeding

According to the 2015 NICE guidelines, women aged 55 and over with postmenopausal bleeding should be referred for suspected cancer pathway referral within two weeks. This includes women who experience unexplained vaginal bleeding more than 12 months after menstruation has stopped due to menopause.

In this case, the patient’s periods stopped 18 months ago, making her postmenopausal. Her recent bleeding episode, along with her nulliparity, obesity, menopause after 52, and family history of hereditary nonpolyposis colon cancer, all increase her risk for endometrial cancer. Although bleeding can occur when using HRT, the patient began bleeding six months after initiating HRT, and the bleeding persisted four weeks after stopping HRT, making it less likely that the medication is the cause.

Re-initiating HRT would be contraindicated until endometrial cancer is ruled out. While the patient has not experienced post-coital bleeding and has a normal-looking cervix with normal smear results, referral for colposcopy would not be the most appropriate next step. Inserting a Mirena coil may be useful in managing troublesome bleeding associated with HRT, but it would not be appropriate until the patient is investigated for endometrial cancer.

According to NICE, women who are at a high risk of developing VTE and are seeking HRT should be referred to haematology before starting any treatment, even if it is transdermal.

While there is no evidence to suggest that transdermal HRT preparations such as patches or gels increase the risk of VTE, it is recommended to seek specialist advice before starting treatment if there are any risk factors present.

For patients with a high risk of VTE, oral HRT, whether it is combined or oestrogen-only, would be risky. Although per vaginal oestrogen would be a safer option, it would only provide local relief and may not alleviate all of the patient’s symptoms.

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 progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

Management of Asymptomatic Fibroids in Women

The absence of menorrhagia is an important point to note in the management of asymptomatic fibroids in women. According to guidelines, annual follow-up to monitor size and growth is recommended for such cases. However, routine referral to a gynaecologist is not required unless there are symptoms that have not improved despite initial treatments, complications, fertility or obstetric problems associated with fibroids, or a suspicion of malignancy. Treatment options for menorrhagia associated with fibroids are available but have no role in the management of small asymptomatic fibroids. NSAIDs and/or tranexamic acid should be stopped if symptoms have not improved within three menstrual cycles. It is important to consider these factors when managing asymptomatic fibroids in women.

Suspected Cervical Cancer

This patient should be suspected to have cervical cancer until proven otherwise, due to inflammation of the cervix that has been shown to be non-infective and no documented smear history, which puts her at higher risk. Empirical treatment for Chlamydia or gonorrhoea would not usually be suggested in general practice unless the patient has symptoms and signs of PID. Referring to an STD clinic is incorrect, as urgent investigation for cancer is necessary. Referring routinely to gynaecology is an option, but it doesn’t fully take into account the urgency of ruling out cervical cancer. Arranging a smear test for a lady with suspected cervical cancer would be inappropriate, as smear tests do not diagnose cancer, they only assess the likelihood of cancer occurring in the future.

To alleviate vaginal symptoms, vaginal topical oestrogen can be used alongside HRT. Compared to systemic treatment, low-dose vaginal topical oestrogen is more effective in providing relief for vaginal symptoms. Patients should be reviewed after 3 months of treatment. It is recommended to consider stopping treatment at least once a year, but in some cases, long-term treatment may be necessary for persistent symptoms. If symptoms persist, increasing the dose or seeking specialist referral may be necessary. Testosterone supplementation is only recommended for sexual dysfunction and should be initiated after consulting a specialist. Sildenafil is not effective in treating menopausal symptoms.

Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

The use of Nexplanon® IMP is not limited by age and is licensed for contraception for a period of 3 years. It contains 68 mg etonogestrel and doesn’t pose an increased risk of VTE, stroke, or MI. Additionally, it has not been found to have a significant impact on bone mineral density (BMD). While the progesterone-only injectable contraceptive may initially decrease BMD, this effect is not exacerbated by menopause.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

For women over 40, combined hormonal contraception (COCP) can be beneficial in reducing menstrual bleeding and pain, as well as alleviating menopausal symptoms. However, it is important to consider certain factors when prescribing COCP to women over 40. The UKMEC criteria for women over 40 is 2, while for women from menarche until 40, it is 1. The Faculty of Sexual and Reproductive Health recommends the use of COCP until age 50, provided there are no other contraindications. However, women over 50 should be advised to switch to a safer alternative method of contraception, as the risks associated with COCP use outweigh the benefits. Women who smoke should stop using COCP at 35, as smoking increases the risk of mortality. While COCP is associated with a reduced risk of ovarian and endometrial cancer, there is a slightly increased risk of breast cancer among women using COCP, which diminishes after 10 years of cessation. Women using COCP for non-contraceptive benefits after the age of 50 should be considered on an individual basis using clinical judgement and informed choice.

Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

Strangulation of inguinal hernias is a rare occurrence.

Understanding Inguinal Hernias

Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main symptom is a lump in the groin area, which disappears when pressure is applied or when the patient lies down. Discomfort and aching are also common, especially during physical activity. However, severe pain is rare, and strangulation is even rarer.

The traditional classification of inguinal hernias into indirect and direct types is no longer relevant in clinical management. Instead, the current consensus is to treat medically fit patients, even if they are asymptomatic. A hernia truss may be an option for those who are not fit for surgery, but it has limited use in other patients. Mesh repair is the preferred method, as it has the lowest recurrence rate. Unilateral hernias are usually repaired through an open approach, while bilateral and recurrent hernias are repaired laparoscopically.

After surgery, patients are advised to return to non-manual work after 2-3 weeks for open repair and 1-2 weeks for laparoscopic repair. Complications may include early bruising and wound infection, as well as late chronic pain and recurrence. It is important to seek medical attention if any of these symptoms occur.

Suspected Inflammatory Breast Cancer

This patient’s medical history raises concerns for inflammatory breast cancer, a rare but easily missed subtype of breast cancer. Despite accounting for only 1-5% of cases, inflammatory breast cancer can be difficult to diagnose and is often initially misdiagnosed as mastitis. The patient’s unilateral nipple retraction, which she attributes to breastfeeding, is also a suspicious sign. Therefore, it is crucial to have a high level of suspicion and refer the patient to a breast clinic urgently.

In this scenario, advising the patient to stop breastfeeding, massage the nipple, or use a breast shield would not be appropriate. Referring routinely without considering the severity of the potential diagnosis would also not be appropriate. It is essential to prioritize the patient’s health and well-being by taking swift and appropriate action.

Prior to initiating tamoxifen treatment, women should be informed about the elevated risk of VTE, which is one of the most significant side effects of the medication. Additionally, tamoxifen has been linked to an increased risk of endometrial cancer.

Risk Factors for Venous Thromboembolism

Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While some common predisposing factors include malignancy, pregnancy, and the period following an operation, there are many other factors that can increase the risk of VTE. These include underlying conditions such as heart failure, thrombophilia, and nephrotic syndrome, as well as medication use such as the combined oral contraceptive pill and antipsychotics. It is important to note that around 40% of patients diagnosed with a PE have no major risk factors. Therefore, it is crucial to be aware of all potential risk factors and take appropriate measures to prevent VTE.

Treatment Options for Menorrhagia

Menorrhagia, or heavy menstrual bleeding, can be effectively treated with the Mirena intrauterine device. It is important to note that the Mirena also serves as a long-term contraceptive, making it a suitable option for many women. The copper coil, on the other hand, can actually increase vaginal bleeding and should be avoided in cases of menorrhagia. While the combined oral contraceptive pill is a viable option, it may not be the best choice for women with busy or unpredictable lifestyles. The progesterone-only pill is a third-line option, but there is no reason not to use the Mirena as a first-line treatment. Non-steroidal anti-inflammatory drugs like mefenamic acid may be helpful for dysmenorrhoea, but are not typically used for menorrhagia. For more information on treatment options for menorrhagia, visit http://cks.nice.org.uk/menorrhagia#!scenario.

Cervical Screening Guidelines in the UK

Cervical screening is an important aspect of women’s health in the UK. The age range for screening varies between 25-64 in England and Wales, and 20-60 in Scotland. The screening interval also varies depending on the country. It is important to note that a patient who is too young or has had a normal smear test within the recommended time frame is not overdue for screening.

According to the latest guidance, women who are taking maintenance immunosuppression medication post-transplantation should follow the national guidelines for non-immunosuppressed individuals. This also applies to other special circumstances, such as HIV-positive patients, who should follow the same age range for screening as the general population.

It is important to note that being homosexual and never having had a male partner doesn’t exempt a woman from screening. Women can still be exposed to HPV through a female partner who may have had previous male partners. Therefore, all women with a cervix should be considered as screening candidates and encouraged to attend.

Urgent Referral for Unexplained Vulval Lump or Non-Responsive Ulceration

Any woman who discovers a new, unexplained lump or experiences ulceration that doesn’t respond to treatment should be referred urgently. It is important to note that the term pressure sore should be used with caution, as it may not accurately describe the condition.

If the ulcer appears to be caused by thrush, fluconazole may be considered. However, if the ulcer doesn’t arise from typical intertriginous areas and lacks satellite lesions or white discharge, a fungal infection is unlikely.

While primary syphilis can cause a solitary painless genital ulcer, it tends to resolve within four to eight weeks. Therefore, it is unlikely that this would be the first presentation of a lady with primary syphilis.

If the condition is suspected to be a pressure ulcer on the sacrum or another pressure point, a tissue viability nurse may be consulted. However, based on the given history, this seems unlikely. Referring to dermatology is not appropriate for a strongly suspected case of vulval carcinoma.

Women who have never had sex have a very low risk of cervical cancer and can opt out of screening, but remain eligible if they choose to do so. Screening is not recommended unless the woman develops symptoms, and the age range for screening is 25-64.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

According to NICE guidelines, women who are 30 years or older should be referred urgently to the local breast services if they have an unexplained breast lump with or without pain. As the woman in question is 28 years old, she should be referred to the local breast services, but it is not urgent.

In 2015, NICE released guidelines for referring individuals suspected of having breast cancer. If a person is 30 years or older and has an unexplained breast lump with or without pain, they should be referred using a suspected cancer pathway referral for an appointment within two weeks. Similarly, if a person is 50 years or older and experiences discharge, retraction, or other concerning changes in one nipple only, they should also be referred using this pathway. If a person has skin changes that suggest breast cancer or is 30 years or older with an unexplained lump in the axilla, a suspected cancer pathway referral should be considered for an appointment within two weeks. For individuals under 30 years old with an unexplained breast lump with or without pain, a non-urgent referral should be considered.

Special Situations for Combined Oral Contraceptive Pill

Concurrent Antibiotic Use:
In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

Switching Combined Oral Contraceptive Pills:
The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF.

Contraceptive Methods and Their Associated Risks of Unintended Pregnancy

When it comes to preventing unintended pregnancy, not all contraceptive methods are created equal. The risk of unintended pregnancy in the first year of typical use of the combined oral contraceptive pill (COCP) is 9%, but with perfect use, it drops to 0.3%. However, the risk of unintended pregnancy is even lower with other methods such as the progestogen implant (0.05%), the LNG-IUD (0.2%), and the copper IUD (0.8%) for typical use. The highest risk of unintended pregnancy is associated with the typical use of DMPA, which has a 6% failure rate. It’s important to consider these risks when choosing a contraceptive method that works best for you.

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 doesn’t 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 condition.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

To minimize the risk of breast cancer, it is recommended to avoid adding progestogen in hormone replacement therapy (HRT). Therefore, women who have had a hysterectomy are usually prescribed oestrogen-only treatment. According to the British National Formulary (BNF), the risk of stroke remains unchanged regardless of whether the HRT preparation includes progesterone.

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 progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

The Kyleena® is a newly licensed levonorgestrel (LNG) intrauterine system (IUS) that is designed for contraceptive use for up to 5 years. Unlike the Mirena® IUS, it is not approved for managing heavy menstrual bleeding or providing endometrial protection as part of hormonal replacement therapy. The Kyleena® IUS is smaller in size than the Mirena® coil and contains 19.5mg of LNG, which is less than the 52mg found in the Mirena®. The Jaydess IUS contains the least amount of LNG at 13.5mg, but it is only licensed for 3 years. The Kyleena® releases a lower amount of systemic LNG than the Mirena® IUS, which may result in lower rates of amenorrhea and a higher number of bleeding or spotting days.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

No additional contraception is needed if an LNG-IUS or Levonorgestrel-IUS is inserted on day 1-7 of the cycle. However, if it is inserted outside this timeframe, 7 days of additional contraception is required. Since the patient is currently on day 6 of her cycle, there is no need for extra precautions.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Patients with bacterial vaginosis who have a history of clue cells can be treated with topical clindamycin as an alternative to metronidazole, according to the BNF. This is particularly useful for patients who are allergic to metronidazole.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

The approach to managing secondary dysmenorrhoea varies depending on the root cause.

Understanding Dysmenorrhoea

Dysmenorrhoea is a medical condition that is characterized by excessive pain during the menstrual period. It is classified into two types: primary and secondary dysmenorrhoea. Primary dysmenorrhoea affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. It is caused by excessive endometrial prostaglandin production. The pain typically starts just before or within a few hours of the period starting and is felt as suprapubic cramping pains that may radiate to the back or down the thigh. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, while combined oral contraceptive pills are used second line.

On the other hand, secondary dysmenorrhoea typically develops many years after the menarche and is the result of 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 normal copper coils may worsen the condition.

If a patient with primary amenorrhea has elevated FSH/LH levels, it may indicate gonadal dysgenesis, such as Turner’s syndrome.

Understanding Amenorrhoea: Causes, Investigations, and Management

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

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

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

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

Breast cancers can be detected by the presence of the tumour marker CA 15-3.

Understanding Tumour Markers

Tumour markers are substances that can be found in the blood, urine, or tissues of people with cancer. They are used to help diagnose and monitor cancer, as well as to determine the effectiveness of treatment. Tumour markers can be divided into different categories, including monoclonal antibodies against carbohydrate or glycoprotein tumour antigens, tumour antigens, enzymes, and hormones. However, it is important to note that tumour markers usually have a low specificity, meaning that they can also be present in people without cancer.

Monoclonal antibodies are a type of tumour marker that target specific carbohydrate or glycoprotein tumour antigens. Some examples of monoclonal antibodies and their associated cancers include CA 125 for ovarian cancer, CA 19-9 for pancreatic cancer, and CA 15-3 for breast cancer.

Tumour antigens are another type of tumour marker that are produced by cancer cells. Examples of tumour antigens and their associated cancers include prostate specific antigen (PSA) for prostatic carcinoma, alpha-feto protein (AFP) for hepatocellular carcinoma and teratoma, carcinoembryonic antigen (CEA) for colorectal cancer, S-100 for melanoma and schwannomas, and bombesin for small cell lung carcinoma, gastric cancer, and neuroblastoma.

Understanding tumour markers and their associations with different types of cancer can aid in the diagnosis and management of cancer. However, it is important to interpret tumour marker results in conjunction with other diagnostic tests and clinical findings.

There is not enough evidence to recommend any specific treatment for recurrent BV in primary care. However, in women with an intrauterine contraceptive device and persistent BV, it may be advisable to remove the device and suggest an alternative form of contraception.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

HPV Testing in Cervical Screening

The use of HPV testing in cervical screening has been studied to determine if it can improve the accuracy of identifying women who need further investigation and treatment. Currently, only a small percentage of women referred for colposcopy actually require treatment as low-grade abnormalities often resolve on their own. By incorporating HPV testing, women with borderline or mild dyskaryosis who test negative for high-risk HPV can simply return to routine screening recall, while those who test positive are referred for colposcopy.

HPV testing is also used as a test of cure for women who have been treated for cervical intraepithelial neoplasia. Those with normal, borderline, or mild dyskaryosis smear results who are HPV negative can return to three-yearly recall. This approach ensures that women receive appropriate follow-up care while minimizing unnecessary referrals and treatments. Overall, the use of HPV testing in cervical screening has the potential to improve the accuracy and efficiency of the screening process.

Ovulation induction can lead to ovarian hyperstimulation syndrome (OHSS) as a potential side effect. The symptoms of OHSS often involve gastrointestinal discomfort such as bloating, abdominal pain, nausea, vomiting, and diarrhea. Additionally, patients may experience shortness of breath, fever, peripheral edema, and oliguria.

OHSS can range in severity from mild to life-threatening, and can result in complications such as dehydration, thromboembolism, acute kidney injury (AKI), and pulmonary edema. Severe OHSS typically has a delayed onset compared to milder cases. In the given scenario, the patient received a GnRH agonist injection within the past week, indicating that her symptoms may be less severe.

Understanding Ovulation Induction and Its Categories

Ovulation induction is a common treatment for couples who have difficulty conceiving naturally due to ovulation disorders. The process of ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. Anovulation can occur due to alterations in this balance, which can be classified into three categories: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation, leading to a singleton pregnancy.

There are various forms of ovulation induction, starting with the least invasive and simplest management option first. Exercise and weight loss are typically the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss. Letrozole is now considered the first-line medical therapy for patients with PCOS due to its reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate. Clomiphene citrate is a selective estrogen receptor modulator that acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. Gonadotropin therapy tends to be the treatment used mostly for women with hypogonadotropic hypogonadism.

One potential side effect of ovulation induction is ovarian hyperstimulation syndrome (OHSS), which can be life-threatening if not identified and managed promptly. OHSS occurs when ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space. The severity of OHSS varies, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction. Management includes fluid and electrolyte replacement, anticoagulation therapy, abdominal ascitic paracentesis, and pregnancy termination to prevent further hormonal imbalances.