If a cervical smear is inadequate, it is recommended to repeat the test within 3 months. This is the correct course of action for the patient in question, as her routine smear was deemed inadequate. Referral for colposcopy is not necessary at this stage, as it is only indicated if there are two consecutive inadequate smears that are 3 months apart. Waiting for 3 years to repeat the smear would not be appropriate, as this is the interval for routine recall for a patient of her age. Similarly, waiting for 6 or 12 months to repeat the smear would not be appropriate, as these timeframes are only indicated for specific circumstances such as testing for cure following treatment or if the most recent smear was hrHPV positive without cytological abnormalities.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

Treatment options for menorrhagia caused by fibroids in a patient hoping to conceive

Menorrhagia, or heavy menstrual bleeding, can be caused by fibroids in the uterus. In a patient hoping to conceive, treatment options must be carefully considered. One option is myomectomy, which involves removing the fibroids while preserving the uterus. However, this procedure can lead to heavy bleeding during surgery and may result in a hysterectomy. Endometrial ablation, which destroys the lining of the uterus, is not suitable for a patient hoping to have another child. Tranexamic acid may help reduce bleeding, but it may not be a definitive treatment if the fibroids are large or in a problematic location. Laparoscopic hysterectomy, which removes the uterus, is a definitive treatment for menorrhagia but is not suitable for a patient hoping to conceive. The Mirena® intrauterine system is an effective treatment for menorrhagia but is not suitable for a patient hoping to conceive. Ultimately, the best treatment option for this patient will depend on the size and location of the fibroids and the patient’s desire to conceive.

The COCP should not be prescribed in the first 21 days post-partum due to the increased risk of venous thromboembolism. Breastfeeding patients should use caution when taking the COCP. Physiological parameters return to normal by 3 months post-partum, but it would be inappropriate to make the patient wait that long to resume the COCP. Pregnancy is a hypercoagulable state, increasing the risk of venous thromboembolism.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

Surgical Options for Ovarian Cancer with Omental Involvement

When it comes to ovarian cancer with confirmed malignancy, the first-line surgery should be a total abdominal hysterectomy with bilateral salpingo-oophorectomy. This surgery should also include the removal of any omental involvement. Adjuvant chemotherapy may also be necessary. It’s important to note that ovarian cysts in postmenopausal women should always be assumed to be malignant. If there is omental metastasis, it confirms the diagnosis of ovarian cancer and surgery should include the removal of the ovaries, tubes, uterus, and omentum.

If a patient wants to preserve the possibility of future fertility, excision of the omental metastasis and unilateral oophorectomy could be considered. However, for older patients, this is an unnecessary risk. Total abdominal hysterectomy with bilateral salpingo-oophorectomy would have been the correct approach without omental involvement. Total abdominal hysterectomy with unilateral oophorectomy could be used in younger patients to maintain hormonal balance and avoid the need for HRT. However, there is a risk for recurrence, and for this patient, the omental lesion should still be removed. It’s safer to remove the uterus as well to reduce the risk of ovarian malignancy recurrence and potential uterine malignancy.

Levonorgestrel emergency contraception (Levonelle) does not affect the effectiveness of hormonal contraception, so it can be started immediately after use. However, ulipristal acetate emergency contraception (EllaOne) should not be used concurrently with hormonal contraception, and patients should wait 5 days after taking it before starting a COCP regimen. The COCP must be taken within a 24-hour window each day to ensure effectiveness, while levonorgestrel emergency contraception must be taken within 72 hours of unprotected sexual intercourse. The interval to wait before starting or restarting hormonal contraception after using ulipristal acetate emergency contraception is 5 days. Day 1 of the menstrual cycle is the preferred day to start a COCP regimen for immediate protection against pregnancy, but it is not the earliest option in this scenario.

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.

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

Contraception for Women with Epilepsy

Women with epilepsy need to consider several factors when choosing a contraceptive method. Firstly, they need to consider how the contraceptive may affect the effectiveness of their anti-epileptic medication. Secondly, they need to consider how their anti-epileptic medication may affect the effectiveness of the contraceptive. Lastly, they need to consider the potential teratogenic effects of their anti-epileptic medication if they become pregnant.

To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends that women with epilepsy consistently use condoms in addition to other forms of contraception. For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends the use of the COCP and POP as UKMEC 3, the implant as UKMEC 2, and the Depo-Provera, IUD, and IUS as UKMEC 1.

For women taking lamotrigine, the FSRH recommends the use of the COCP as UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS as UKMEC 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol. By considering these recommendations, women with epilepsy can make informed decisions about their contraceptive options and ensure the safety and effectiveness of their chosen method.

If a woman of reproductive age has been having unprotected vaginal sexual intercourse for a year without conceiving and there is no known cause of infertility, NICE guidance recommends that she and her partner undergo further clinical assessment and investigation. The most appropriate initial investigation for this patient is a day 21 progesterone test, which is non-invasive and can determine if the patient is ovulating. Serum prolactin and thyroid function tests are not recommended unless there is a specific reason for testing, such as a pituitary tumor or overt thyroid disease. Transvaginal or abdominal ultrasounds are unlikely to reveal the cause of subfertility and are therefore not necessary. As part of the initial assessment, the male partner should also undergo a semen analysis.

Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.

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.

The Pearl Index is frequently utilized to measure the effectiveness of a contraception method. It indicates the number of pregnancies that would occur if one hundred women used the contraceptive method for one year. Therefore, if the Pearl Index is 0.2 and the medication is used perfectly, we can expect to see 0.2 pregnancies for every hundred women using the pill for one year – or 2 for every thousand.

Understanding Contraception: A Basic Overview

Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).

Barrier methods, such as condoms, physically block sperm from reaching the egg. While they can help protect against sexually transmitted infections (STIs), their success rate is relatively low, particularly when used by young people.

Daily methods include the combined oral contraceptive pill, which inhibits ovulation, and the progesterone-only pill, which thickens cervical mucous. However, the combined pill increases the risk of venous thromboembolism and breast and cervical cancer.

LARCs include implantable contraceptives and injectable contraceptives, which both inhibit ovulation and thicken cervical mucous. The implantable contraceptive lasts for three years, while the injectable contraceptive lasts for 12 weeks. The intrauterine system (IUS) and intrauterine device (IUD) are also LARCs, with the IUS preventing endometrial proliferation and thickening cervical mucous, and the IUD decreasing sperm motility and survival.

It is important to note that each method of contraception has its own set of benefits and risks, and it is essential to consult with a healthcare provider to determine the best option for individual needs and circumstances.

This condition is rare, but it is more common in pregnancies that have exceeded 20 weeks of gestation.

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.

Causes and Precipitants of Urge Incontinence: A Brief Overview

Urge incontinence, characterized by involuntary leakage of urine associated with or following urgency, is a common condition in women. It is caused by overactivity of the detrusor muscle in the bladder wall, leading to irregular contractions during the filling phase and subsequent leakage of urine. While there are many causes and precipitants of urge incontinence, it is often difficult to identify a single factor in the presence of multiple contributing factors.

Some of the common causes of urge incontinence include poorly controlled diabetes, excess caffeine and alcohol intake, neurological dysfunction, urinary infection or faecal impaction, and adverse medication effects. In the case of a patient presenting with a short history of symptoms, urinary tract infection is the most likely cause, and prompt treatment is necessary to prevent complications.

It is important to rule out developing cauda equina, a medical emergency that can lead to paralysis, in patients presenting with short-term urinary incontinence. Normal anal tone and perineal sensation can help exclude this condition.

Excess alcohol and caffeine intake can precipitate symptoms of urge incontinence by inducing diuresis, causing frequency and polyuria. Chronic constipation, particularly in patients with diverticular disease, can also compress the bladder and lead to urge incontinence symptoms. Systemic illnesses such as diabetes mellitus can cause glycosuria and polyuria, leading to bladder irritation and detrusor instability. Finally, oestrogen deficiency associated with postmenopausal status can cause vaginitis and urethritis, both of which can precipitate urge incontinence symptoms.

In conclusion, urge incontinence is a complex condition with multiple contributing factors. Identifying and addressing these factors can help manage symptoms and improve quality of life for affected patients.

Polycystic ovary syndrome (PCOS) is a prevalent disorder that is often complicated by chronic anovulation and hyperandrogenism. This condition can lead to long-term complications such as subfertility, diabetes mellitus, stroke and transient ischemic attack, coronary artery disease, obstructive sleep apnea, and endometrial cancer. These complications are more likely to occur in patients who are obese. Women with oligo/amenorrhea and pre-menopausal levels of estrogen are at an increased risk of endometrial hyperplasia and carcinoma. This risk is highest in those with menstrual cycle lengths of over three months. However, it can be reduced by inducing a withdrawal bleed every one to three months using a combined contraceptive pill or cyclical medroxyprogesterone or by inserting a mirena coil. Overweight patients can regulate their menstrual cycles and reduce the risk of endometrial hyperplasia by optimizing their BMI. Unlike in other conditions, there is no increased risk of osteoporosis in PCOS because there is no estrogen deficiency. The RCOG Greentop guidelines provide more information on the long-term consequences of polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

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

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

Understanding Cervical 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.

Understanding the Different Types of Urinary Incontinence in Women

Urinary incontinence is a common condition that affects many women. There are different types of urinary incontinence, each with its own causes and treatment options. The most common type of incontinence in women is genuine stress incontinence, which is caused by sphincter incompetence and leads to leakage of small amounts of urine on stress, such as sneezing, standing, laughing, and coughing.

To diagnose incontinence, common investigations include a midstream urine specimen, frequency volume chart, filling urodynamic assessment, and voiding urodynamic assessment. Treatment options vary depending on the patient’s wishes, desire for future children, and severity of symptoms. Conservative treatment involves pelvic floor exercises, vaginal cones, and drugs such as estrogen. Surgery is the most effective way of restoring continence, with a cure rate of 80-90%. Procedures include burch colposuspension, anterior repair and bladder buttress, tension-free vaginal tape, and suburethral sling.

Other types of urinary incontinence in women include fistula, which is a rare cause of incontinence caused by pelvic surgery, overactive bladder, which is the second most common type of incontinence, retention with overflow, which is a rare cause of incontinence more common in men, and congenital abnormalities, which is a rare cause of incontinence that is often apparent since early life.

It is important for women to understand the different types of urinary incontinence and seek medical advice if they experience any symptoms. With proper diagnosis and treatment, urinary incontinence can be effectively managed, improving quality of life and overall health.

Types of Vulval Cancers and Their Characteristics

Vulval cancers are rare gynaecological malignancies that primarily affect elderly women. The most common type of vulval cancer is squamous cell carcinoma, which typically presents as a growth on the inner surface of the labia minora. Symptoms include vulval discomfort, itching, discharge, and bleeding. Biopsy and histological investigation are necessary to diagnose vulval lumps, and treatment involves vulvectomy and dissection of inguinal glands. Malignant melanoma, basal cell carcinomas, Bartholin’s gland cancer, and sarcoma are other types of vulval cancers, each with their own unique characteristics and rarity. Early detection and treatment are crucial for a positive prognosis.

Understanding Polycystic Ovarian Syndrome (PCOS) and Related Conditions

Polycystic ovarian syndrome (PCOS) is a hormonal disorder that affects women of reproductive age. It is characterized by enlarged ovaries with many atretic follicles but no mature antral follicles. This leads to increased production of luteinizing hormone (LH), which stimulates the cells of the theca interna to secrete testosterone. Peripheral aromatase then converts testosterone to estrogen, which suppresses follicle-stimulating hormone (FSH) secretion and upregulates LH secretion from the adenohypophysis. This results in decreased aromatase production in granulosa cells, low levels of estradiol, and failure of follicles to develop normally.

To remember the signs and symptoms of PCOS, use the mnemonic PCOS PAL. PCOS is associated with male pattern balding (alopecia), hirsutism, obesity, hypertension, acanthosis nigricans (thickening and hyperpigmentation of the skin), and menstrual irregularities (oligo- or amenorrhea). It can also cause hypogonadotropic hypogonadism, which is characterized by impaired secretion of gonadotropins from the pituitary, including FSH and LH. This condition can be caused by various factors, such as Kallmann syndrome and GnRH insensitivity. Gonadal dysgenesis, monosomy X variant, is another condition that affects sexually juvenile women with an abnormal karyotype (45, X). It results in complete failure of development of the ovary and therefore no secondary sexual characteristics. Chronic adrenal insufficiency (or Addison’s disease) is another condition that can cause anorexia, weight loss, and hyperpigmentation of the skin in sun-exposed areas.

It is important to note that early pregnancy is not a possibility in women with PCOS who are not ovulating. Additionally, if a woman with PCOS were pregnant, she would have elevated beta human chorionic gonadotropin. Understanding these conditions and their associated symptoms can help healthcare providers diagnose and manage PCOS effectively.

Investigation is necessary for any postmenopausal bleeding. The first step is to conduct a transvaginal ultrasound scan to examine the thickness of the endometrium. To diagnose endometrial cancer, a Pipelle biopsy is used to sample the endometrium, which is effective in most cases. Hysteroscopy with directed sampling (dilation and curettage) can be used to detect lesions or when Pipelle has been inconclusive. CT scan is not required as a pre-operative imaging test nor is it used to diagnose endometrial cancer.
Reference: Colombo N, Preti E, Landoni F, Carinelli S, Colombo A, et al. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013; 24 (6): vi33-vi38.

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.

The most appropriate method of HRT for the patient in this scenario is a transdermal oestrogen patch, as she has had a hysterectomy and oestrogen monotherapy is the regimen of choice. As the patient’s BMI is > 30 kg/m2, an oral oestrogen preparation is not recommended due to the increased risk of venous thromboembolism. HRT has benefits for the patient, including protection against osteoporosis, urogenital atrophy, and cardiovascular disorders. However, HRT also has risks, including an increased risk of venous thromboembolism and endometrial and breast cancer. Type 2 diabetes mellitus is not a contraindication to HRT, and there is no evidence that HRT affects glucose control. Combination HRT regimens are reserved for women with a uterus, and oral oestradiol once daily is not recommended for patients with a BMI > 30 kg/m2 due to the increased risk of venous thromboembolism. Women at high risk of developing venous thromboembolism or those with a strong family history or thrombophilia should be referred to haematology before starting HRT.

The menopause is a natural process that occurs when a woman’s menstrual periods stop due to decreased production of oestradiol and progesterone. While menopause can cause symptoms such as hot flashes, mood changes, and reduced libido, treatment with hormone replacement therapy (HRT) is not necessary and should be based on individual circumstances and patient choice. However, if HRT is used, it is important to note that oestrogen-only therapy can increase the risk of endometrial cancer and should only be given to women without a uterus. This is because oestrogen promotes endometrial growth, which can lead to oncogenesis. Adding progesterone to HRT can prevent this risk. Testosterone may also be used to address libido issues, but it should be prescribed under specialist guidance and can cause virilising side-effects. Selective serotonin reuptake inhibitors (SSRIs) such as venlafaxine can be an alternative to HRT and are effective at managing symptoms without increasing the risk of endometrial cancer. However, SSRIs can cause side-effects such as gastrointestinal disturbances, reduced libido, and potentially life-threatening serotonin syndrome.

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.

Women can begin using hormonal contraception right away after taking levonorgestrel (Levonelle) for emergency contraception. However, if ulipristal acetate was used instead, it is recommended to wait for 5 days or use barrier methods before resuming hormonal contraception.

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.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

Investigating Postcoital Bleeding: The Role of Speculum Examination and Other Tests

Postcoital bleeding can be caused by various abnormalities of the cervix, including cervical ectropion, polyps, infection, or cervical cancer. In women presenting with postcoital bleeding, cervical cancer should be suspected if there are other symptoms such as vaginal discharge, pelvic pain, or dyspareunia. Risk factors for cervical cancer include smoking, oral contraceptive use, HPV infection, HIV infection, immunosuppression, and family history.

The primary screening tool for cervical cancer is a cervical smear, which should be done every three years for women aged 25-49. If a patient presents with postcoital bleeding, the first step is to perform a speculum examination to visualize the cervix, which can detect over 80% of cervical cancers. If the cervix appears normal, a smear may be taken if it is due, and swabs can be taken for STI testing and pregnancy testing. If symptoms persist, referral to colposcopy may be necessary.

Other tests such as blood tests, urine dipstick, and high vaginal swab may be useful in certain cases, but they are not the primary investigation for postcoital bleeding. Blood tests may be indicated later, while urine dipstick and high vaginal swab are secondary investigations following visualisation of the cervix.

In summary, speculum examination is the key initial investigation for postcoital bleeding, and cervical smear is the primary screening tool for cervical cancer. Other tests may be useful in specific situations, but they should not replace the essential role of speculum examination and cervical smear in the evaluation of postcoital bleeding.

Patients with stress incontinence who do not respond to pelvic floor muscle exercises and decline surgical intervention may be prescribed duloxetine, a serotonin-norepinephrine re-uptake inhibitor. This drug increases sphincter tone during the filling phase of urinary bladder function. However, before starting drug therapy, patients should try pelvic floor exercises and consider surgical intervention. Oxybutynin, an anticholinergic drug, is used to treat urge incontinence or symptoms of detrusor overactivity, but it is not recommended for frail, older women at risk of health deterioration. Desmopressin is the preferred drug treatment for children with nocturnal enuresis and may also be used for women with nocturia. Mirabegron is prescribed for patients with urge incontinence who cannot tolerate antimuscarinic/anticholinergic drugs. It is a beta-3 adrenergic agonist that relaxes the bladder.

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.

If a woman with stage IA cervical cancer desires to preserve her fertility, a cone biopsy with negative margins may be considered as an option. However, for women who do not wish to have children, a hysterectomy with lymph node clearance is recommended. Cisplatin chemotherapy and radiotherapy are not appropriate for this stage of cervical cancer, while laser ablation is only used for cervical intraepithelial dysplasias. Radical trachelectomy is not recommended as it may negatively impact fertility.

Management of Cervical Cancer Based on FIGO Staging

Cervical cancer management is determined by the FIGO staging and the patient’s desire to maintain fertility. The FIGO staging system categorizes cervical cancer into four stages based on the extent of the tumor’s spread. Stage IA and IB tumors are confined to the cervix, with IA tumors only visible under a microscope and less than 7 mm wide. Stage II tumors have spread beyond the cervix but not to the pelvic wall, while stage III tumors have spread to the pelvic wall. Stage IV tumors have spread beyond the pelvis or involve the bladder or rectum.

The management of stage IA tumors involves a hysterectomy with or without lymph node clearance. For patients who want to maintain fertility, a cone biopsy with negative margins can be performed, but close follow-up is necessary. Stage IB tumors are managed with radiotherapy and concurrent chemotherapy for B1 tumors and radical hysterectomy with pelvic lymph node dissection for B2 tumors.

Stage II and III tumors are managed with radiation and concurrent chemotherapy, with consideration for nephrostomy if hydronephrosis is present. Stage IV tumors are treated with radiation and/or chemotherapy, with palliative chemotherapy being the best option for stage IVB. Recurrent disease is managed with either surgical treatment followed by chemoradiation or radiotherapy followed by surgical therapy.

The prognosis of cervical cancer depends on the FIGO staging, with higher survival rates for earlier stages. Complications of treatments include standard surgical risks, increased risk of preterm birth with cone biopsies and radical trachelectomy, and ureteral fistula with radical hysterectomy. Complications of radiotherapy include short-term symptoms such as diarrhea and vaginal bleeding and long-term effects such as ovarian failure and fibrosis of various organs.

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.

According to NICE CG44, when heavy menstrual bleeding is not caused by any structural or histological abnormality, the first recommended treatment is the intrauterine system, also known as Mirena.

Managing Heavy Menstrual Bleeding

Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

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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.

If a patient’s 2nd repeat smear at 24 months is now negative for high-risk human papillomavirus (hrHPV), the correct course of action is to return to routine recall in 3 years. This assumes that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but normal cytology, and a repeat test at 12 months that was also hrHPV positive but cytologically normal. If the patient had still been hrHPV positive, they would have been referred for colposcopy. However, since they are now negative, they can go back to routine recall. The latest cervical screening programme does not require cytology to be performed if hrHPV is negative, so it would be inappropriate and impractical for the GP to request cytology on the sample. There is no need to repeat the smear in 4 weeks or 12 months, as transient hrHPV infection is common and self-resolves, and does not necessarily indicate a high risk of cervical cancer.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

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.

Diagnostic Modalities for Endometriosis: Exploratory Laparoscopy, Transabdominal Ultrasound, Hysterosalpingography, MRI Abdomen Pelvis, and CA-125

Endometriosis is a condition where endometrial tissue grows outside the endometrial cavity, causing cyclical proliferation and bleeding. It can lead to scarring, adhesions, and cysts with haemorrhagic contents. The classic symptoms are dyspareunia, infertility, cyclical pelvic pain, and dysmenorrhoea. Diagnosis is often made through Exploratory laparoscopy, where small, dark purple-black spots on the peritoneum can be identified and sampled for histological analysis. Transabdominal ultrasound is not very sensitive at detecting small deposits, but can detect endometriotic cysts. Hysterosalpingography is recommended for investigating infertility and recurrent miscarriage, but is not a definitive diagnosis for endometriosis. MRI of the pelvis is sensitive for endometriomas and adnexal masses, but not small deposits. CA-125 testing is not recommended for diagnosis.