The patient needs a fast-acting contraceptive method. The intrauterine device (IUD) is the quickest, but it’s not recommended due to the patient’s history of menorrhagia. The patient also prefers not to have intrauterine contraception, making the IUS and IUD less suitable. The next fastest option is the progesterone-only pill (POP), which becomes effective within 2 days if started mid-cycle. Therefore, the POP is the best choice for this patient. The combined oral contraceptive pill (COC) is not recommended due to the patient’s wheelchair use, and the IUS, contraceptive injection, and implant all take 7 days to become effective.

Counselling for Women Considering the progesterone-Only Pill

Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

Teratomas, also known as dermoid cysts, are non-cancerous tumors that originate from multiple germ cell layers. These tumors can produce a variety of tissues, including skin, hair, blood, fat, bone, nails, teeth, cartilage, and thyroid tissue, due to their germ cell origin.

Mature cystic teratomas have a white shiny mass or masses projecting from the wall towards the center of the cyst. This protuberance is called the Rokitansky protuberance and is where hair, bone, teeth, and other dermal appendages usually arise from.

While ovarian malignancy is rare in young females, suspicion can be assessed using the risk of malignancy index (RMI), which takes into account serum CA-125 levels, ultrasound findings, and menopausal status.

Understanding the Different Types of Ovarian Cysts

Ovarian cysts are a common occurrence in women, and they can be classified into different types. The most common type of ovarian cyst is the physiological cyst, which includes follicular cysts and corpus luteum cysts. Follicular cysts occur when the dominant follicle fails to rupture or when a non-dominant follicle fails to undergo atresia. These cysts usually regress after a few menstrual cycles. Corpus luteum cysts, on the other hand, occur when the corpus luteum fails to break down and disappear after the menstrual cycle. These cysts may fill with blood or fluid and are more likely to cause intraperitoneal bleeding than follicular cysts.

Another type of ovarian cyst is the benign germ cell tumour, which includes dermoid cysts. Dermoid cysts are also known as mature cystic teratomas and are usually lined with epithelial tissue. They may contain skin appendages, hair, and teeth. Dermoid cysts are the most common benign ovarian tumour in women under the age of 30, and they are usually asymptomatic. However, torsion is more likely to occur with dermoid cysts than with other ovarian tumours.

Lastly, there are benign epithelial tumours, which arise from the ovarian surface epithelium. The most common benign epithelial tumour is the serous cystadenoma, which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Serous cystadenomas are bilateral in around 20% of cases. The second most common benign epithelial tumour is the mucinous cystadenoma, which is typically large and may become massive. If it ruptures, it may cause pseudomyxoma peritonei.

In conclusion, understanding the different types of ovarian cysts is important for proper diagnosis and treatment. Complex ovarian cysts should be biopsied to exclude malignancy, while benign cysts may require monitoring or surgical removal depending on their size and symptoms.

If a woman has pelvic inflammatory disease, she cannot have a copper IUD inserted. Women who are at risk of this condition, such as those with multiple sexual partners or symptoms that suggest pelvic inflammatory disease, should be tested for infections like Chlamydia trachomatis and Neisseria gonorrhoeae and treated if necessary. To test for these infections, endocervical swabs are used. While the insertion of a copper IUD does carry a risk of developing pelvic inflammatory disease, this risk is low for women who are at low risk of sexually transmitted infections.

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.

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

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

Common Causes of Vaginal Discharge: Symptoms, Diagnosis, and Treatment

Vaginal discharge is a common symptom experienced by women, and it can be caused by various infections. Here are some of the most common causes of vaginal discharge, along with their symptoms, diagnosis, and treatment options.

Candidiasis: This infection is caused by Candida fungi, particularly Candida albicans. Symptoms include vaginal itch, thick discharge with a consistency similar to cottage cheese, vaginal discomfort, and pain during sexual intercourse. Diagnosis is usually clinical, and treatment includes good hygiene, emollients, loose-fitting underwear, and antifungal cream or pessary, or oral antifungal medication.

Trichomoniasis: This infection is caused by the parasite Trichomonas vaginalis. Symptoms include dysuria, itch, and yellow-green discharge that can have a strong odor. Up to 50% of infected individuals are asymptomatic.

Bacterial vaginosis: This infection is caused by an overgrowth of anaerobes in the vagina, most commonly Gardnerella vaginalis. Symptoms include a thin, white discharge, vaginal pH >4.5, and clue cells seen on microscopy. Treatment of choice is oral metronidazole.

Streptococcal infection: Streptococcal vulvovaginitis presents with inflammation, itch, and a strong-smelling vaginal discharge. It is most commonly seen in pre-pubertal girls.

Chlamydia: Although Chlamydia infection can present with urethral purulent discharge and dyspareunia, most infected individuals are asymptomatic. Chlamydia-associated discharge is typically more purulent and yellow-clear in appearance, rather than cheese-like.

In conclusion, proper diagnosis and treatment of vaginal discharge depend on identifying the underlying cause. It is important to seek medical attention if you experience any symptoms of vaginal discharge.

Clomiphene is the correct answer for the first-line treatment of infertility in PCOS. This patient is experiencing infertility, which is a common consequence of polycystic ovarian syndrome. Clomiphene is typically used as the initial treatment for fertility issues in PCOS patients, as it has a lower risk of inducing ovarian hyperstimulation syndrome compared to other treatments like gonadotropins. Goserelin, on the other hand, is incorrect as it is a gonadotropin-releasing hormone agonist used for hormone-sensitive prostate cancer and may not be suitable for PCOS patients. In vitro fertilisation (IVF) is also incorrect as it is typically not offered until after two years of trying to conceive, and medical optimisation with agents like Clomiphene is preferred before referral for IVF. Metformin may have a role in promoting fertility in obese PCOS patients, but for this patient with a normal BMI, Clomiphene is a better option than metformin as monotherapy.

Managing Polycystic Ovarian Syndrome

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

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

The patient’s symptoms of dysmenorrhoea, dyspareunia, and subfertility are classic signs of endometriosis, a common condition where endometrial tissue grows outside of the uterus. The presence of uterosacral nodularity and tenderness further supports this diagnosis. Some patients with endometriosis may also experience urinary symptoms due to bladder involvement or adhesions. Uterine leiomyoma, or fibroid, is a common pelvic tumor that causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. However, it does not typically present with uterosacral nodularity and tenderness on rectal examination. Interstitial cystitis causes urinary frequency and urgency, with pain relieved upon voiding. Pelvic inflammatory disease presents with fever, nausea, acute pain, malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.

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.

Breastfeeding mothers should steer clear of aspirin

Breastfeeding mothers are advised against taking aspirin, especially in high doses for pain relief. This is because aspirin has been linked to Reye’s syndrome, a condition that can result in liver and brain harm.

Breastfeeding has some contraindications that are important to know, especially when it comes to drugs. Antibiotics like penicillins, cephalosporins, and trimethoprim are safe for breastfeeding mothers, as are endocrine drugs like glucocorticoids (in low doses) and levothyroxine. Epilepsy drugs like sodium valproate and carbamazepine, asthma drugs like salbutamol and theophyllines, and hypertension drugs like beta-blockers and hydralazine are also safe. Anticoagulants like warfarin and heparin, as well as digoxin, are also safe. However, some drugs should be avoided, such as antibiotics like ciprofloxacin, tetracycline, chloramphenicol, and sulphonamides, psychiatric drugs like lithium and benzodiazepines, aspirin, carbimazole, methotrexate, sulfonylureas, cytotoxic drugs, and amiodarone. Other contraindications include galactosaemia and viral infections, although the latter is controversial in the developing world due to the increased risk of infant mortality and morbidity associated with bottle feeding.

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.

If a cervical smear test performed as part of the NHS cervical screening programme is inadequate, it should be first tested for high-risk HPV (hrHPV) and then repeated within 3 months. Colposcopy should only be performed if the second sample also returns as inadequate. Returning the patient to normal recall would result in a delay of 3 years for a repeat smear test, which is not recommended as it could lead to a missed diagnosis of cervical cancer. Repeating the test in 1 month is too soon, while repeating it in 6 months is not in line with current guidelines.

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.

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

Understanding Endometriosis

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

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

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

Disorders of Sexual Development: An Overview

Disorders of sexual development (DSD) are a group of conditions that affect the development of the reproductive system. Here are some of the most common DSDs:

Androgen Insensitivity Syndrome (AIS)
AIS is a condition where cells cannot respond to androgens, resulting in disrupted sexual development. Patients with complete AIS have a female phenotype with male internal genitalia, while those with partial or mild AIS may have a mix of male and female characteristics. Treatment involves careful gender assignment and hormone replacement therapy.

Turner Syndrome
Turner syndrome is a condition where patients are missing all or part of an X chromosome, resulting in premature ovarian failure and delayed puberty. Patients are phenotypically female with normal external genitalia.

Klinefelter’s Syndrome
Klinefelter’s syndrome is a chromosomal aneuploidy where patients have an extra copy of an X chromosome, resulting in hypogonadism and infertility. Patients are phenotypically male with normal external genitalia.

Congenital Adrenal Hyperplasia
Congenital adrenal hyperplasia is a group of conditions associated with abnormal enzymes involved in the production of hormones from the adrenals. Patients may have ambiguous genitalia at birth and later present with symptoms of polycystic ovary syndrome or hyperpigmentation.

5-α Reductase Deficiency
5-α reductase deficiency is a condition where patients have a mutation in the SDR5A2 gene, resulting in disrupted formation of external genitalia before birth. Patients may have ambiguous genitalia at birth and later show virilisation during puberty. Patients are infertile.

Treatment for DSDs involves hormone replacement therapy and supportive care. It is important to provide psychosocial support for patients and their families.

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.

The patient should not restart the COCP within the first 21 days after giving birth due to the increased risk of venous thromboembolism. However, since the patient is not breastfeeding and has no additional risk factors for thromboembolic disease, she can safely restart the pill at 3 weeks postpartum. Restarting at any other time before the 21-day mark is not recommended.

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.

The method of contraception that is commonly linked to weight gain is injectable contraception, which includes Depo-Provera. The combined oral contraceptive pill has been associated with an increased risk of venous thromboembolic disease, breast cancer, and cervical cancer, but there is no evidence to suggest that it causes weight gain. Implantable contraceptives like Implanon are typically associated with irregular or heavy bleeding, but not weight gain. Intrauterine devices, such as the copper coil, are known to cause heavier and more painful periods, but they are not associated with weight gain.

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.

Postmenopausal women are at risk of developing endometrial cancer, making it crucial to rule out this possibility in cases of postmenopausal bleeding. Hormone replacement therapy, nulliparity, late menopause, early menses, obesity, diabetes, polycystic ovarian syndrome, and family history are all risk factors for this type of cancer. The first step in investigating endometrial cancer is to conduct a trans-vaginal ultrasound scan to measure the thickness of the endometrial lining. Different hospitals have varying cut-offs for endometrial thickness and further investigation. If the endometrial lining is thickened, a hysteroscopy will be performed, and an endometrial biopsy will be taken. Treatment for endometrial cancer typically involves laparoscopic hysterectomy with bilateral salpingo-oophorectomy, with or without radiotherapy.

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.

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

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

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women of reproductive age, characterized by cyclic behavioral, emotional, and physical changes during the late luteal phase of the menstrual cycle. The most severe form of PMS is known as premenstrual dysphoric syndrome. The hallmark psychological changes are depression, irritability, and emotional lability, while physical manifestations include fluid retention, weight gain, and breast tenderness. Symptoms improve shortly after the onset of menses, and the syndrome is unrelated to the menstrual phase. The exact cause of PMS is unknown, but a multifactorial causation has been suggested, including decreased progesterone synthesis and increased prolactin, estrogen, aldosterone, and prostaglandin synthesis during the luteal phase. Hypoglycemia and serotonin deficiency also play a role. Severe PMS is treated with selective serotonin reuptake inhibitors. It is important to understand PMS and its symptoms to seek appropriate treatment and improve quality of life.

Treatment Options for Menorrhagia

Menorrhagia, or heavy menstrual bleeding, can be a distressing condition for women. Current guidelines recommend the use of Mirena (IUS) as the first line of treatment, even for women who do not require contraception. Patient preference is important in the decision-making process, but IUS is still the preferred option.

If IUS is not suitable or preferred, there are several other treatment options available. Tranexamic acid, a medication that prevents the breakdown of blood clots, is a second-line option. Non-steroidal anti-inflammatory drugs (NSAIDs) and combined oral contraceptive pills can also be used to prevent the proliferation of the endometrium.

If these options are not effective, oral or injected progestogens can be used to prevent endometrial proliferation. Gonadotrophin-releasing hormone (GnRH) agonists, such as Goserelin, are also available as a last resort.

It is important for women to discuss their options with their healthcare provider and choose the treatment that is best for them. With the variety of options available, there is likely a treatment that can effectively manage menorrhagia and improve quality of life.

Types of Ectopic Pregnancy in the Fallopian Tube

Ectopic pregnancy, a condition where the fertilized egg implants outside the uterus, can occur in different parts of the Fallopian tube. Here are the different types of ectopic pregnancy in the Fallopian tube and their characteristics:

1. Isthmus – Ectopic pregnancy in the isthmus is rare but can occur. The tube is rigid, making rupture occur earlier than in other parts of the tube.

2. Interstitial part – This is the proximal segment of the tube embedded within the uterine wall. Ectopic pregnancy in this part is very rare and is more likely to occur in women who have had ipsilateral salpingectomy.

3. Ampulla – Ectopic pregnancy occurs most frequently in the ampullary part of the tube, which is relatively wide. Rupture usually occurs about 2 months after the last menstrual period, but it happens later than in the isthmus due to the elasticity of the tube.

4. Fimbrial end – Ectopic pregnancy near the fimbrial end can result in an ovarian pregnancy, which is rare and not associated with pelvic inflammatory disease or an intrauterine device.

5. Cornua – Pregnancy may implant itself in the cornua, which is the opening of the Fallopian tube. Combined with interstitial pregnancies, this represents a small percentage of all ectopic pregnancies.

Knowing the different types of ectopic pregnancy in the Fallopian tube can help in early detection and management of this potentially life-threatening condition.

If a cervical cancer screening sample is positive for high-risk strains of human papillomavirus (hrHPV) but shows no cytological abnormalities, the recommended course of action is to repeat the smear after 12 months. This is in accordance with current guidance. Colposcopy is not necessary in this case. Repeating the smear after 3 months or waiting 3 years for routine recall are also not appropriate. A repeat smear after 6 months would only be necessary after treatment for cervical intraepithelial neoplasia.

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.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

If the patient has missed two pills between days 8-14 of her cycle but has taken the previous 7 days of COCP correctly, emergency contraception is not necessary according to the Faculty of Sexual and Reproductive Health. Since the patient is not in need of emergency contraception, offering her a hormonal-based emergency contraceptive would be inappropriate. However, if emergency contraception is required, options include EllaOne (ulipristal acetate) up to 120 hours after unprotected intercourse or Levonelle (levonorgestrel) up to 96 hours after unprotected intercourse. Inserting a copper IUD to prevent pregnancy would also be inappropriate in this case. If the patient is having difficulty remembering to take her pill correctly and is interested in long-acting contraception, counseling her on options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection would be appropriate. It should be noted that contraceptive injections are not used as a form of emergency contraception and advising a patient to take emergency contraception within 12 hours would be incorrect.

Missed Pills in Combined Oral Contraceptive Pill

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

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

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

Contraceptive Options for Patients with Uterine Fibroids and Carbamazepine Use

Patients with uterine fibroids and concurrent use of carbamazepine may have limited contraceptive options due to drug interactions and uterine cavity distortion. The progesterone-only injectable is a suitable option as it does not interact with enzyme inducers and is not affected by uterine cavity distortion. The copper intrauterine device and levonorgestrel-releasing intrauterine system are not recommended in this case. The progesterone-only implant and combined oral contraceptive pill have severe interactions with carbamazepine, reducing their efficacy. It is important to consider individual patient factors and discuss all available contraceptive options with them.

Even if a child is Gillick competent, they are still unable to consent to sexual intercourse if they are under the age of 13. Therefore, any interaction with this age group should prompt child protection measures to be taken. Simply prescribing medication or ignoring the situation would not be in compliance with this protocol.

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

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

Treatment Options for Sexually Transmitted Infections

Sexually transmitted infections (STIs) can cause a range of symptoms in women, including post-coital bleeding, vaginal discharge, cervicitis, and more. Here are some common treatment options for STIs:

– Metronidazole: This medication is used to treat Trichomonas vaginalis infections. Patients typically take 400-500 mg twice daily for 5-7 days. It’s important to treat the partner simultaneously and abstain from sex for at least one week.
– Referral for colposcopy: If symptoms persist after treatment, patients may be referred for colposcopy to rule out cervical carcinoma.
– Azithromycin or doxycycline: These medications are used to treat uncomplicated genital Chlamydia infections. Most women with a chlamydial infection remain asymptomatic.
– Ceftriaxone and azithromycin: This combination is the treatment of choice for gonorrhoea infections. Symptoms may include increased vaginal discharge, lower abdominal pain, dyspareunia, and dysuria.
– No treatment is required: This is not an option for symptomatic patients with T vaginalis, as it is a sexually transmitted infection that requires treatment.

It’s important to seek medical attention if you suspect you have an STI, as early treatment can prevent complications and transmission to others.

The combined oral contraceptive has only one absolute contraindication in a patient’s history, which is factor V Leiden (a UKMEC 4 level indicating an unacceptable health risk). Other elements of the patient’s history fall into UKMEC 3, where the disadvantages generally outweigh the benefits. However, it is important to note that some concurrent UKMEC 3 contraindications may become absolute contraindications when combined. Therefore, it is crucial to carefully study guidelines before prescribing.

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.

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.

Based on the patient’s symptoms and an elevated level of CA-125, it is likely that she has ovarian cancer. Additionally, her family history of cancer in first-degree relatives and early onset cancer suggest the possibility of an inherited cancer-related gene. One such gene is BRCA1, which increases the risk of ovarian and breast cancer in those who have inherited a mutated copy. Other tumour suppressor genes, such as WT1 for Wilm’s tumour, Rb for retinoblastoma, and c-Myc for Burkitt lymphoma, confer a higher risk for other types of cancer.

Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

Understanding Hormone Replacement Therapy (HRT) for perimenopausal Symptoms

perimenopausal symptoms can significantly affect a woman’s daily routine, work, and mood. Hormone Replacement Therapy (HRT) is one of the treatment options available for managing these symptoms. However, before commencing HRT, patients need to be consulted and informed of the risks and benefits associated with this treatment.

HRT can be either oestrogen replacement only or combined. Combined HRT is given to women who have a uterus, as oestrogen alone can increase the risk of developing endometrial cancer. Combined HRT can be either cyclical or continuous, depending on the patient’s menopausal status.

For women with irregular menses, a cyclical regime is indicated. This involves taking an oestrogen tablet once daily for a 3-month period, with norethisterone added on the last 14 days. Patients on this regime have a period every three months. Once a woman has completed a year on cyclical therapy or has established menopause, then she can change to combined continuous HRT.

It is important to note that oestrogen-only HRT is only given to women who have had a hysterectomy. Oestrogen therapy alone increases the risk of developing endometrial hyperplasia and endometrial carcinoma. Therefore, in women who have a uterus, combined HRT, with the addition of a progesterone, is preferred to reduce this risk.

In summary, HRT is a treatment option for perimenopausal symptoms. The type of HRT prescribed depends on the patient’s menopausal status and whether they have a uterus. Patients need to be informed of the risks and benefits associated with HRT before commencing treatment.