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.

postmenopausal Bleeding: Common Causes and Investigations

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

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

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

The risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

Understanding Ectopic Pregnancy: The Pathophysiology

Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

Levonorgestrel can still be taken within 72 hours of unprotected sexual intercourse (UPSI) in this case. Ulipristal acetate can also be taken up to 120 hours later, but the efficacy of oral options may have decreased after 61 hours. The copper coil is not a suitable option as the patient has declined any form of birth control. Therefore, the correct answer is that levonorgestrel can still be taken within 72 hours of UPSI.

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.

On ultrasound imaging, the presence of a whirlpool sign and free fluid may indicate ovarian torsion. This sign occurs when a structure twists upon itself. It is important to note that appendicitis and ectopic pregnancy do not show this sign on imaging. Additionally, the pain associated with Mittelschmerz is typically less severe and would not be accompanied by the ultrasound finding.

Understanding Ovarian Torsion

Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.

If pelvic floor muscle exercises and surgical intervention are not effective, duloxetine can be used to treat stress incontinence in patients. However, it is important to rule out other potential causes such as infection before starting treatment. Non-pharmacological management should be attempted first, including pelvic floor exercises and reducing caffeine intake. Duloxetine is a medication that works as a serotonin/norepinephrine reuptake inhibitor and may cause side effects such as nausea, dizziness, and insomnia. For urge incontinence, antimuscarinic agents like oxybutynin, tolterodine, and solifenacin are typically used as first-line treatment. If these are not effective, a β3 agonist called mirabegron can be used as a second-line therapy.

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.

Diagnosis of Fibroids: Ultrasound vs CT Scan vs MRI

Fibroids, or leiomyomatas, are common tumours of smooth muscle origin found in the uterus and cervix. They can cause symptoms such as heavy periods, dysmenorrhoea, and lower abdominal pain. Risk factors include Afro-Caribbean origin, obesity, nulliparity, and family history. Clinical examination may reveal a palpable abdominal mass or a uterus palpable on bimanual examination, but ultrasound is the preferred diagnostic tool. CT scans are reserved for complex cases, while MRI is used for localisation and characterisation of fibroids. A full blood count is also important to diagnose and treat anaemia associated with heavy periods.

Treatment Options for Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) is a common condition caused by the ascending infection of Chlamydia or gonorrhoeae from the vagina. The symptoms include bilateral lower abdominal pain, deep dyspareunia, and abnormal bleeding or discharge. The recent British Association for Sexual Health and HIV (BASHH) guideline recommends empirical antibiotic treatment for sexually active women under 25 who have these symptoms. The treatment includes stat im ceftriaxone and a 2-week course of doxycycline and metronidazole. Intravenous therapy is indicated in severe cases.

Pelvic ultrasound scan is not necessary for the diagnosis of PID. Blood tests to check inflammatory markers and serum β-HCG are not required if the clinic history and examination suggest PID. Analgesia and observation are not sufficient for the treatment of PID. Oral antibiotics alone are not recommended for the treatment of PID.

In conclusion, PID requires prompt and appropriate treatment with broad-spectrum antibiotics. The recommended treatment options should be followed based on the severity of the disease.

Types of Vulval Cancer: Symptoms, Diagnosis, and Treatment

Vulval cancer is a rare type of cancer that affects the external female genitalia. There are different types of vulval cancer, each with its own set of symptoms, risk factors, and treatment options. Here are some of the most common types of vulval cancer:

Squamous cell carcinoma: This is the most common type of vulval cancer, accounting for about 85% of cases. It usually affects women over 60 who smoke or have a weakened immune system. Symptoms include vulval irritation or itching, and as the disease progresses, pain and discharge. Squamous cell carcinoma can be cured if caught early, and treatment usually involves surgical excision.

Basal cell carcinoma: This type of vulval cancer is rare and usually occurs in sun-exposed areas of the skin. It is often treated with surgery.

Sarcoma: Sarcoma is a rare type of vulval cancer that can occur at any age, including childhood. Treatment usually involves surgery and radiation therapy.

Bartholin’s gland carcinoma: This is a rare cause of vulval cancer that affects the Bartholin glands, which are two small mucous-producing glands on either side of the vaginal opening. Risk factors include HPV infection and Paget’s disease of the vulva. It is often diagnosed late, as it is often confused with Bartholin gland cyst, which is a benign condition.

Malignant melanoma: This is a rare type of vulval cancer that accounts for about 5% of cases. Symptoms include itching, bleeding, and an irregular border. Treatment usually involves surgery and chemotherapy.

If you experience any symptoms of vulval cancer, such as itching, pain, or bleeding, it is important to see a doctor as soon as possible. Early diagnosis and treatment can improve your chances of a full recovery.

When a teenage girl experiences regular painful cycles but has not yet started menstruating, an imperforate hymen is a likely cause. This condition blocks the flow of menstrual blood, leading to primary amenorrhoea while allowing for normal development of secondary sexual characteristics like pubic hair and breast growth. The accumulation of menstrual blood in the vagina can cause discomfort and bloating due to pressure. Other potential causes of amenorrhoea include chemotherapy during childhood, Turner’s syndrome, and polycystic ovary syndrome, which can all interfere with the production of estrogen and the development of secondary sexual characteristics.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods in women. 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 without 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.

There are various causes of amenorrhoea, including 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, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

Possible Causes of Abdominal Pain and Signs of Shock in Women: Differential Diagnosis

When a woman presents with abdominal pain and signs of shock, it is important to consider several possible causes. One of the most urgent and life-threatening conditions is ectopic pregnancy, which should be suspected until proven otherwise. A positive pregnancy test and pain localized to one side, especially with evidence of shock, are key indicators. The patient should be given intravenous access, blood tests, serum β-HCG, group and save, and a transvaginal ultrasound scan if stable. If necessary, she may need to undergo a laparoscopy urgently.

Other conditions that may cause abdominal pain in women include urinary tract infection, acute appendicitis, pelvic inflammatory disease, and miscarriage. However, these conditions are less likely to present with signs of shock. Urinary tract infection would show leukocytes, nitrites, and protein on dipstick. Acute appendicitis would cause pain in the right iliac fossa, but cervical excitation and signs of shock would be rare unless the patient is severely septic. Pelvic inflammatory disease would give rise to pain in the right iliac fossa and cervical excitation, but signs of shock would not be present on examination. Miscarriage rarely presents with signs of shock, unless it is a septic miscarriage, and the cervical os would be open with a history of passing some products of conception recently.

In summary, when a woman presents with abdominal pain and signs of shock, ectopic pregnancy should be considered as the most likely cause until proven otherwise. Other conditions may also cause abdominal pain, but they are less likely to present with signs of shock. A thorough differential diagnosis and appropriate diagnostic tests are necessary to determine the underlying cause and provide timely and effective treatment.

During laparoscopy, carbon dioxide gas is used to inflate the abdomen for better visibility and access to abdominal organs. However, after surgery, the remaining gas can cause referred pain in the C3-5 nerve distribution by pressing on the diaphragm. While pulmonary embolus is a potential side effect of any surgery, it is unlikely in a young patient who is not immobilized for long periods. Incontinence is also unlikely in a young, nulliparous woman, even with the risk of urinary tract infection from the catheter used during surgery. Flatulence is not a common side effect as the gas is not passed into the colon. Finally, sciatic nerve damage is not a concern during abdominal surgery as it is a common side effect of hip arthroplasty, which involves a posterior approach to the hip.

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

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

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

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

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

Understanding Endometriosis

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

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

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

Injectable progesterone contraceptives are not recommended for individuals with current breast cancer.

This is considered an absolute contraindication (UKMEC 4) for prescribing injectable progesterone contraceptives. It is also an absolute contraindication for most other forms of contraception, except for the non-hormonal copper intrauterine device.

Current deep vein thrombosis is a UKMEC 2 contraindication for injectable progesterone, while it is a UKMEC 4 contraindication for the combined oral contraceptive pill. Multiple cardiovascular risk factors are a UKMEC 3 contraindication, which is not absolute, but the risks are generally considered to outweigh the benefits.

Smoking 30 cigarettes per day is only a UKMEC 1 contraindication for injectable progesterone contraception. However, considering the individual’s age, it would be a UKMEC 4 contraindication for the combined oral contraceptive pill.

High BMI is a UKMEC 1 contraindication for most forms of contraception, including injectable progesterone. However, it would be a UKMEC 4 contraindication for the combined pill.

Injectable Contraceptives: Depo Provera

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

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

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

The Importance of Urine Pregnancy Testing in Females with Abdominal Pain

Any female of childbearing age who presents to the Emergency Department with abdominal pain should have a urinary pregnancy test performed (β-HCG). This is because a negative pregnancy test is necessary to confirm that the patient is not pregnant. It is an easy and inexpensive test to perform.

Shoulder tip pain may indicate diaphragmatic irritation secondary to free intraperitoneal fluid, which can be caused by a ruptured ectopic pregnancy. However, a full blood count (FBC) and urea and electrolytes (U & Es) will not diagnose a potential ruptured ectopic pregnancy and, as such, will not guide subsequent management.

An erect chest X-ray may be requested if perforation is suspected, but a urine pregnancy test would be much more useful in this scenario. An abdominal X-ray is not indicated.

In summary, a urine pregnancy test is crucial in females of childbearing age with abdominal pain to rule out pregnancy and potentially diagnose a ruptured ectopic pregnancy.

How the Copper IUD Affects Different Parts of Sperm

The copper IUD is a popular form of birth control that works by preventing fertilization. It does this by affecting different parts of the sperm. The Golgi apparatus, which contributes to the acrosome of the sperm, is inhibited by the IUD, preventing capacitation. The mitochondria, which form the middle piece of the sperm, are not affected. The nucleus is also unaffected. Sperm do not have cell walls, so this is not a factor. Finally, the centrioles contribute to the flagellum of the sperm, but the copper IUD does not target this part of the sperm. Understanding how the copper IUD affects different parts of the sperm can help individuals make informed decisions about their birth control options.

During pregnancy, uterine fibroids may experience growth. These fibroids are common and often do not show any symptoms. However, in non-pregnant women, they can cause menorrhagia. In early pregnancy, they grow due to oestrogen and can cause pelvic pain and pressure. If they grow too quickly and surpass their blood supply, they may undergo ‘red degeneration’. This patient’s symptoms, including pelvic pain and a history of menorrhagia, suggest that the growth of pre-existing fibroids due to oestrogen may be the cause. However, further investigation with ultrasound is necessary to confirm this diagnosis. Ectopic pregnancies are rare in the second trimester and are typically detected during routine ultrasound scans. This patient is unlikely to have an ectopic pregnancy as her first ultrasound scan would have confirmed an intrauterine pregnancy. Pelvic inflammatory disease is not the most likely cause of this patient’s symptoms as it is associated with additional symptoms such as vaginal discharge and dysuria, and the patient would likely be febrile. The growth of pre-existing fibroids due to decreased progesterone is incorrect as progesterone, like oestrogen, is increased during pregnancy. This patient does not exhibit symptoms of dysuria, renal angle tenderness, or pyrexia.

Understanding Fibroid Degeneration

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

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

Understanding Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects women of reproductive age. It is characterized by menstrual irregularities, signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries. The Rotterdam criteria provide diagnostic criteria for PCOS, which include oligomenorrhoea or amenorrhoea, clinical or biochemical signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries.

Follicle counts and ovarian volume are important ultrasonographic features used to diagnose PCOS. At least 12 follicles in one ovary, measuring 2-9 mm in diameter, and an ovarian volume of >10 ml are diagnostic of PCOS. However, the absence of these features does not exclude the diagnosis if two of the three criteria are met.

Total testosterone levels are usually raised in PCOS, while FSH is usually within the normal range or low, and LH is raised. The ratio of LH:FSH is usually >3:1 in PCOS.

A single complex cyst in one ovary is an abnormal finding and requires referral to a gynaecology team for further assessment.

Understanding the Diagnostic Criteria and Ultrasonographic Features of PCOS

When it comes to patients with suspected endometriosis, laparoscopy is considered the most reliable investigation method. This is because it enables direct visualization and biopsy of the endometrial deposits. While a CT scan may also be used to detect such deposits, it is less specific compared to MRI scans. Ultrasound can be useful in detecting endometriomas, but it is important to note that a normal scan does not necessarily rule out the possibility of endometriosis.

Understanding Endometriosis

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

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

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

The appropriate time to test progesterone levels is on Day 28, which is 7 days before the end of a woman’s regular menstrual cycle. However, for individuals with a different cycle length, the timing may vary. It is recommended to take into account the individual’s menstrual cycle history to determine the appropriate time for testing. According to NICE guidelines, women with regular menstrual cycles should be informed that they are likely ovulating, but a mid-luteal serum progesterone level should be checked to confirm.

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.

Based on the given history, it appears that there is a blockage preventing the normal flow of menstrual blood. This is indicated by the presence of secondary sexual characteristics and recurring abdominal pain. It can be ruled out that the cause of this condition is a bicornuate uterus, dermoid cysts, endometriosis, or pelvic inflammatory disease, as these are not associated with primary amenorrhoea.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods in women. 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 without 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.

There are various causes of amenorrhoea, including 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, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

When an ovarian cyst ruptures, it can cause sudden and severe pain on one side of the pelvis, especially after sexual activity or strenuous exercise. During a physical exam, the lower abdomen may be tender, but there may not be any other noticeable abnormalities. An ultrasound can reveal the presence of fluid in the pelvic area. It’s important to note that ovarian or adnexal torsion can also cause similar symptoms, including sharp pain on one side, nausea, and vomiting. However, in this case, a palpable mass may be felt during a physical exam, and an ultrasound may show an enlarged ovary with reduced blood flow.

Gynaecological Causes of Abdominal Pain in Women

Abdominal pain is a common complaint among women, and it can be caused by various gynaecological disorders. To diagnose these disorders, a bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning should be performed in addition to routine diagnostic workup. If diagnostic doubt persists, a laparoscopy can be used to assess suspected tubulo-ovarian pathology.

There are several differential diagnoses of abdominal pain in females, including mittelschmerz, endometriosis, ovarian torsion, ectopic gestation, and pelvic inflammatory disease. Mittelschmerz is characterized by mid-cycle pain that usually settles over 24-48 hours. Endometriosis is a complex disease that may result in pelvic adhesion formation with episodes of intermittent small bowel obstruction. Ovarian torsion is usually sudden onset of deep-seated colicky abdominal pain associated with vomiting and distress. Ectopic gestation presents as an emergency with evidence of rupture or impending rupture. Pelvic inflammatory disease is characterized by bilateral lower abdominal pain associated with vaginal discharge and dysuria.

Each of these disorders requires specific investigations and treatments. For example, endometriosis is usually managed medically, but complex disease may require surgery and some patients may even require formal colonic and rectal resections if these areas are involved. Ovarian torsion is usually diagnosed and treated with laparoscopy. Ectopic gestation requires a salpingectomy if the patient is haemodynamically unstable. Pelvic inflammatory disease is usually managed medically with antibiotics.

The patient’s symptoms indicate that they may be suffering from migraine, specifically migraine with aura. This condition is classified as UKMEC 4, meaning that it poses a significant health risk when taking combined oral contraceptive pills. While visual disturbances are the most common aura symptoms, some patients may experience sensory or motor symptoms such as tingling, weakness, or difficulty speaking. While other factors in the patient’s medical history may also be relevant, migraine with aura is the primary concern when considering contraception options.

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

Sacrocolpopexy is the recommended treatment for vaginal vault prolapse. This surgical procedure involves suspending the vaginal apex to the sacral promontory, typically using the uterosacral ligaments for support. Other surgical options include anterior colporrhaphy for repairing a cystocele, vaginoplasty for reconstructing the vagina, vaginal hysterectomy for removing the uterus via the vagina, and bilateral oophorectomy for removing the ovaries. However, these options would not be appropriate for treating vaginal vault prolapse as the ovaries are not involved in the underlying pathology.

Understanding Urogenital Prolapse

Urogenital prolapse is a condition where one of the pelvic organs descends, causing protrusion on the vaginal walls. This condition is prevalent among postmenopausal women, affecting around 40% of them. There are different types of urogenital prolapse, including cystocele, cystourethrocele, rectocele, uterine prolapse, urethrocele, and enterocele.

Several factors increase the risk of developing urogenital prolapse, such as increasing age, vaginal deliveries, obesity, and spina bifida. The condition presents with symptoms such as pressure, heaviness, and a sensation of bearing down. Urinary symptoms such as incontinence, frequency, and urgency may also occur.

Treatment for urogenital prolapse depends on the severity of the condition. If the prolapse is mild and asymptomatic, no treatment may be necessary. Conservative treatment options include weight loss and pelvic floor muscle exercises. A ring pessary may also be used. In severe cases, surgery may be required. The surgical options for cystocele/cystourethrocele include anterior colporrhaphy and colposuspension. Uterine prolapse may require hysterectomy or sacrohysteropexy, while posterior colporrhaphy is used for rectocele.

In conclusion, urogenital prolapse is a common condition among postmenopausal women. It is important to understand the different types, risk factors, and treatment options available to manage the condition effectively.

When dealing with patients who have urinary incontinence, it is crucial to eliminate the possibility of a UTI and diabetes mellitus as underlying causes. The first step in investigating urinary incontinence would be to conduct a urine dipstick and culture test, which can be easily done in a GP’s office. Other initial investigations include keeping a bladder diary for at least three days and undergoing urodynamic studies. It is important to note that the reliability of urine dip tests is questionable in women over 65 years of age and those who have catheters. A three-day bladder diary is necessary for initial investigations, and a one-day diary would not suffice. CT scans are not typically used to investigate urinary incontinence but are useful in detecting renal pathology such as ureteric calculi. Cystoscopy is not appropriate for this patient and is usually reserved for cases where bladder cancer is suspected.

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 the 2nd repeat smear at 24 months shows a negative result for high-risk human papillomavirus (hrHPV), the patient can return to routine recall for cervical cancer screening. Since the patient is over 50 years old, a smear test should be taken every 5 years as part of routine recall. It is not necessary to perform a cytology swab or refer the patient to colposcopy as a negative HPV result does not indicate the presence of cervical cancer. Additionally, repeating the HPV test in 3 years is not necessary for this patient as it is only the routine recall protocol for patients aged 25-49.

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.

Surgical intervention is necessary for the management of ectopic pregnancy.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

For patients with menorrhagia who have completed their family and do not have any underlying pathology, pharmaceutical therapy is recommended. The first-line management for these patients, according to NICE CKS, is the Mirena coil, provided that long-term contraception with an intrauterine device is acceptable.

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.

[Insert flowchart here]

During the initial 6 months after the intrauterine system is inserted, experiencing irregular bleeding is a typical adverse effect. However, over time, the majority of women who use the IUS will experience reduced or absent menstrual periods, which is advantageous for those who experience heavy menstrual bleeding or prefer not to have periods.

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

Management of Ectopic Pregnancy: Laparoscopic Salpingostomy

Ectopic pregnancy, defined as pregnancy occurring outside the uterine cavity, is a serious condition that requires prompt diagnosis and management. Laparoscopic salpingostomy is a preferred method of treatment for ectopic pregnancies, but it may not be suitable for all cases.

Diagnosis of ectopic pregnancy can be challenging as it presents with non-specific symptoms such as lower abdominal/pelvic pain, vaginal discharge, and urinary symptoms. A urinary pregnancy test and an ultrasound scan are necessary to confirm the diagnosis. In emergency cases where the patient is haemodynamically unstable, laparotomy may be necessary.

Laparoscopic salpingectomy, the removal of the tube containing the ectopic pregnancy, is the gold standard for treating ectopic pregnancies. However, if the patient has only one Fallopian tube, laparoscopic salpingostomy, where the tube is incised, the ectopic removed, and the tube repaired, is preferred to preserve the patient’s chances of conceiving naturally in the future.

A single intramuscular dose of methotrexate may be used as medical management of an ectopic pregnancy, but only if certain conditions are met. These include the absence of significant pain, an unruptured ectopic pregnancy, and a serum βhCG level of <1500 iu/l. In cases where right iliac fossa pain is present in a woman of reproductive age, associated with vaginal discharge, cervical excitation, and the last menstrual period of >4 weeks before, ectopic pregnancy should be treated as the primary diagnosis until proven otherwise. Referral to the surgical team may be necessary to rule out appendicitis.

In conclusion, laparoscopic salpingostomy is a suitable method of treatment for ectopic pregnancies in patients with only one Fallopian tube. Early diagnosis and prompt management are crucial in ensuring the best possible outcome for the patient.