Myoma: Common Benign Tumor in Women

Myoma, also known as uterine fibroids, is a benign tumor commonly found in women. It is characterized by histological features and symptoms such as menorrhagia and pressure. Although it may occur in teenagers, it is most commonly seen in women in their fourth and fifth decades of life. Black women are more likely to develop myomas and become symptomatic earlier. Having fewer pregnancies and early menarche are reported to increase the risk.

Myomas are benign tumors and do not metastasize to other organs. However, they may cause obstetric complications such as red degeneration, malpresentation, and the requirement for a Caesarean section. Surgical complications or intervention-related infections may lead to mortality, but associated deaths are rare. The 5-year survival rate is not applicable in this case.

To manage unscheduled bleeding, which is a common side effect of Nexplanon, a 3-month course of the combined oral contraceptive pill may be prescribed. This will not only provide additional contraception but also make periods lighter and more regular. Prescribing a progesterone-only pill is not recommended as it can also cause irregular bleeding. A single dose of intramuscular methotrexate is not appropriate as the patient is not showing any symptoms of an ectopic pregnancy. Urgent referral for endometrial cancer is also not necessary as the patient’s age and symptoms suggest that the bleeding is most likely due to the contraceptive implant.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

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

Understanding Urinary Incontinence: Causes, Classification, and Management

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

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

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

MRI is the most effective imaging technique for diagnosing adenomyosis, which is the presence of endometrial tissue in the myometrium. While ultrasound can also aid in diagnosis, it is not as reliable as MRI. Laparoscopy is used to diagnose endometriosis, but it cannot detect adenomyosis as it occurs within the uterine wall. CT is not a suitable imaging technique for adenomyosis as it cannot differentiate between different types of tissue. Hysterosalpingography is used for imaging the uterine lining and fallopian tubes, typically during fertility treatment, but it cannot provide an image of the myometrium.

Understanding Adenomyosis

Adenomyosis is a medical condition that occurs when endometrial tissue grows within the muscular walls of the uterus. This condition is more common in women who have had multiple pregnancies and are nearing the end of their reproductive years. Symptoms of adenomyosis include painful menstrual cramps, heavy menstrual bleeding, and an enlarged and tender uterus.

To diagnose adenomyosis, doctors typically use magnetic resonance imaging (MRI) as it is the most effective method. Treatment options for adenomyosis include managing symptoms with pain relief medication, using tranexamic acid to control heavy bleeding, and administering gonadotropin-releasing hormone (GnRH) agonists to reduce estrogen levels. In severe cases, uterine artery embolization or hysterectomy may be necessary. Hysterectomy is considered the definitive treatment for adenomyosis.

In summary, adenomyosis is a condition that affects the uterus and can cause painful menstrual cramps, heavy bleeding, and an enlarged uterus. It is more common in women who have had multiple pregnancies and are nearing the end of their reproductive years. Diagnosis is typically done through MRI, and treatment options include managing symptoms, medication, and surgery.

Women with PCOS who undergo IVF are at a higher risk of experiencing ovarian hyperstimulation syndrome. However, treatment failure can occur as a complication of any IVF treatment, regardless of whether the woman has PCOS or not. Complications such as chronic pelvic pain, Caesarean section delivery, and haemorrhage are not typically associated with IVF treatment.

Understanding Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS) is a potential complication that can occur during infertility treatment. This condition is believed to be caused by the presence of multiple luteinized cysts in the ovaries, which can lead to high levels of hormones and vasoactive substances. As a result, the permeability of the membranes increases, leading to fluid loss from the intravascular compartment.

OHSS is more commonly seen following gonadotropin or hCG treatment, and it is rare with Clomiphene therapy. Approximately one-third of women undergoing in vitro fertilization (IVF) may experience a mild form of OHSS. The Royal College of Obstetricians and Gynaecologists (RCOG) has classified OHSS into four categories: mild, moderate, severe, and critical.

Symptoms of OHSS can range from abdominal pain and bloating to more severe symptoms such as thromboembolism and acute respiratory distress syndrome. It is important to monitor patients closely during infertility treatment to detect any signs of OHSS and manage the condition appropriately. By understanding OHSS and its potential risks, healthcare providers can work to minimize the occurrence of this complication and ensure the safety of their patients.

To ensure effectiveness, it is important to note that the progesterone-only pill (POP) requires 48 hours before it can be relied upon as a form of contraception. During this time, it is recommended to use additional precautions such as condoms. However, after the initial 48 hours, no further precautions are necessary as long as the POP is taken at the same time each day within a 3-hour window. It is important to note that the POP does not protect against sexually transmitted infections (STIs), so the use of condoms as a barrier method may be discussed for long-term protection. However, as the patient and her partner have recently tested negative for STIs, this may not be necessary at this time. In contrast, if the patient was prescribed the combined oral contraceptive pill (COCP), it is advised to use condoms for the first 7 days.

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.

When considering amenorrhoea, it is important to look at the underlying causes. There are two types: primary and secondary. Primary amenorrhoea occurs when a woman has never had a period, while secondary amenorrhoea occurs when a woman who has previously had periods now hasn’t for at least 6 months (or 12 months if she previously had irregular periods).

In cases of primary amenorrhoea, it is important to consider whether the woman has developed normal secondary sexual characteristics. If she has, then a mechanical obstruction may be the cause rather than a hormonal one. It is unusual for a 17-year-old girl with normal secondary sexual characteristics to have never had a period, so waiting a year before reassessment is not appropriate. Clinical judgement should be used, especially with younger women.

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.

If paracetamol and NSAIDs have not effectively controlled symptoms of endometriosis, GnRH analogues may be used as a next step in treatment. This is the appropriate course of action for a woman presenting with symptoms of deep dyspareunia and dysmenorrhoea, along with tender nodularity on examination in the posterior vaginal fornix. As endometriosis is exacerbated by rising oestrogen levels during the luteal phase of the menstrual cycle, inducing a menopause state with GnRH analogues can help alleviate symptoms. However, it is important to note that this treatment can cause menopause-like side effects and should only be initiated by specialists after careful consideration of the potential risks and benefits. The use of combined oral contraceptive pills is not recommended in this case due to the woman’s medical history of migraine with aura. Similarly, IM ceftriaxone and PO doxycycline are not appropriate treatments as they are used to manage pelvic inflammatory disease, which presents differently and is not influenced by hormones. Intra-uterine devices are also not recommended as a treatment for endometriosis as they lack a hormonal component and can worsen symptoms.

Understanding Endometriosis

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

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

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

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

Termination of Pregnancy in the UK

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

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

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

According to the BNF, the copper intra-uterine device is the most efficient option for emergency contraception and should be offered to all eligible women seeking such services. Unlike other medications, its effectiveness is not influenced by BMI. Additionally, it provides long-term contraception, which is an added advantage for the patient. If the copper intra-uterine device is not appropriate or acceptable to the patient, oral hormonal emergency contraception should be offered. However, the effectiveness of these contraceptives is reduced in patients with a high BMI. A double dose of levonorgestrel is recommended for patients with a BMI of over 26 kg/m² or body weight greater than 70kg. It is unclear which of the two oral hormonal contraceptives is more effective for patients with a raised BMI. The levonorgestrel intrauterine system and ethinylestradiol with levonorgestrel are not suitable for emergency contraception. In conclusion, the copper intrauterine device is the most effective method for this patient because it is not affected by BMI, unlike oral hormonal emergency contraceptives.

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.

If there is evidence of infection or an increased risk of haemorrhage, expectant management is not a suitable option for miscarriage. In such cases, NICE recommends either medical management (using oral or vaginal misoprostol) or surgical management (including manual vacuum aspiration). In this particular case, surgical management is the only option as the patient has evidence of infection, possibly due to septic miscarriage. Syntocinon is used for medical management of postpartum haemorrhage, while methotrexate is used for medical management of ectopic pregnancy. Oral mifepristone is used in combination with misoprostol for termination of pregnancy, but it is not recommended by NICE for the management of miscarriage.

Management Options for Miscarriage

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

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

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

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

Treatment Options for Stress Urinary Incontinence

Stress urinary incontinence is a common condition in women, especially those who have had vaginal deliveries and are getting older. It is caused by weak sphincter muscles, leading to leakage during activities such as coughing, sneezing, laughing, or exercising. The first-line treatment for this condition is pelvic floor muscle training, which involves a minimum of eight contractions three times per day for 12 weeks.

However, it is important to note that other treatment options, such as oxybutynin, pelvic ultrasound scans, urodynamic studies, and bladder training, are not recommended for stress urinary incontinence. Oxybutynin is used for overactive bladder or mixed urinary incontinence, while pelvic ultrasound scans are not indicated for urinary incontinence. Urodynamic studies are not recommended for women with simple stress incontinence on history and examination, and bladder training is used for urgency or mixed urinary incontinence, not stress incontinence. Therefore, pelvic floor muscle training remains the most effective treatment option for stress urinary incontinence.

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.

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

Understanding Female Genital Mutilation

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

The patient is likely taking the progesterone-only contraceptive pill due to her history of migraine with aura and daily use of the contraceptive pill. According to the BNF, antibacterials that do not induce liver enzymes do not affect the effectiveness of oral progesterone-only preparations. As ciprofloxacin is a cytochrome P450 inhibitor and not an inducer, the patient’s contraception is not affected, and she does not require additional barrier contraception. However, if the patient were taking rifampicin, an alternative for meningococcal contact prophylaxis, she would need to use barrier contraception during and for four weeks after stopping treatment. Rifampicin is a potent enzyme inducer, which can decrease the plasma concentration and efficacy of contraceptive pills.

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.

Surgical management is recommended for ectopic pregnancies that are larger than 35mm or have a serum B-hCG level greater than 5,000 IU/L. In this case, the patient is experiencing typical symptoms of an ectopic pregnancy, including vaginal bleeding and referred shoulder tip pain. The ultrasound confirms the presence of a tubal ectopic, with a mass exceeding 35mm and tubal ring sign. Therefore, a laparoscopic salpingectomy is the appropriate surgical intervention.
Adrenalectomy is not relevant in this case, as the complex adnexal mass refers to the ectopic pregnancy located near the ovaries, uterus, and fallopian tubes, not the adrenal glands.
Expectant management is not suitable for this patient, as her serum b-hCG is significantly elevated, and the mass exceeds 35mm in size.
Medical management with methotrexate is an option for ectopic pregnancies that are smaller than 35mm or have a serum B-hCG level below 5,000 IU/L.
Ultrasound-guided potassium chloride injection is an alternative to methotrexate for medical management, but it is not currently standard practice in the UK.

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

Managing Polycystic Ovarian Syndrome

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

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

The combined oral contraceptive pill (COCP) has been found to have a slight increase in the risk of breast cancer, but this risk returns to normal after 10 years of stopping the pill. Additionally, the COCP may increase the risk of cervical cancer, but this could be due to a lack of barrier contraception use and increased exposure to HPV. While the COCP is associated with an increased risk of benign and malignant tumors, there is no evidence of an increased risk of lung cancer. On the other hand, the COCP has been shown to reduce the risk of ovarian cancer, endometrial cancer, and bowel cancer.

Pros and Cons of the Combined Oral Contraceptive Pill

The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than 1 per 100 woman years. It does not interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.

However, there are also some disadvantages to the combined oral contraceptive pill. One of the main issues is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side-effects such as headache, nausea, and breast tenderness may also be experienced.

It is important to weigh the pros and cons of the combined oral contraceptive pill before deciding if it is the right method of birth control for you. While some users report weight gain while taking the pill, a Cochrane review did not support a causal relationship. Overall, the combined oral contraceptive pill can be an effective and convenient method of birth control, but it is important to discuss any concerns or potential risks with a healthcare provider.

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.

The correct course of action for a patient who has a second repeat smear at 24 months that is hrHPV negative is to return to routine recall in 3 years. If the result had been positive, the patient would need to be recalled in 12 months for a repeat smear. Referring for colposcopy would only be necessary if the patient had tested positive for hrHPV. Repeating the smear in 3 months or 12 months would also be incorrect, as the patient has already had two smears and the third result will determine the next course of action. Repeating the smear in 5 years would only be appropriate for older women during routine screening.

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 the Referred Pain of Ovarian Inflammation

The ovaries receive both sympathetic and parasympathetic innervation, with the nerve supply running along the suspensory ligament of the ovary. Ovarian pain is typically referred to the periumbilical region due to its sympathetic nerve supply originating at T10. Inflammation of an ovary can also cause referred pain to the inner thigh through stimulation of the adjacent obturator nerve. While pain may radiate to the suprapubic area, the most common site of ovarian pain is the periumbilical region. Pain in the hypochondria is more commonly associated with liver, gallbladder, or cardiac conditions. Understanding the referred pain of ovarian inflammation can aid in diagnosis and treatment.

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 patient has primary amenorrhoea due to a macroprolactinoma, which is a benign prolactin-secreting tumor of the anterior pituitary gland. Treatment in the first instance is with a dopamine receptor agonist such as bromocriptine or cabergoline. Surgery is the most appropriate management if conservative management fails or the patient presents with visual field defects. Radiotherapy is rarely used. Exclusion of pregnancy is the first step in every case of amenorrhoea. Metoclopramide is a dopamine receptor antagonist and a cause of hyperprolactinaemia, so it should not be used to treat this patient. Thyroxine is not appropriate as hyperprolactinaemia is secondary to a pituitary adenoma. Indications for surgery are failure to respond to medical therapy or presentation with acute visual field defects.

The addition of progesterone to hormone replacement therapy (HRT) has been found to raise the risk of breast cancer. It is worth noting that taking low doses of progesterone alone, without oestrogen, does not seem to have the same effect on breast cancer risk. If used for less than 10 years, oestrogen-only HRT does not appear to increase the likelihood of developing breast cancer. However, it does increase the risk of endometrial cancer and should be avoided unless the patient has had a hysterectomy.

Adverse Effects of Hormone Replacement Therapy

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

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

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

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

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

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.

When a complex ovarian cyst is discovered, there should be a high level of suspicion for ovarian cancer and a biopsy should be performed. The IOTA criteria can be used to determine if a cyst is likely benign or malignant. If any of the ‘M rules’ are present, such as an irregular solid tumor, ascites, at least 4 papillary structures, an irregular multilocular solid tumor with a diameter of at least 100mm, or very strong blood flow, the patient should be referred to a gynecology oncology department for further evaluation. In this case, the patient has a multiloculated cyst with strong blood flow, so a referral to the gynecology oncology service for biopsy is necessary. It is important not to reassure the patient that the cyst is benign just because it is asymptomatic, as many ovarian cancers are asymptomatic until a late stage. It is also not appropriate to immediately perform surgery, as the cyst may be benign and not require urgent intervention. Yearly ultrasounds may be appropriate for simple ovarian cysts of a certain size, but in this case, further investigation is necessary due to the concerning features of the cyst. While cysts under 5 cm in diameter are often physiological and do not require follow-up, the presence of a multiloculated cyst with strong blood flow warrants further investigation.

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.

Contraception and Treatment for Menorrhagia

When a woman is experiencing problematical menorrhagia and needs contraception, it is recommended to use progesterone-based long-acting reversible contraception over progesterone-only or combined-oral contraceptive pills due to its higher efficacy in preventing pregnancy. While tranexamic acid may help reduce menorrhagia, it is not a contraceptive. Mefenamic acid is more effective in providing analgesia than in treating menorrhagia and is also not a contraceptive.

The most appropriate therapy for this situation would be Mirena, which is expected to provide good contraception while also potentially leading to amenorrhoea in the majority of cases. It is important to consider both contraception and treatment for menorrhagia in order to provide comprehensive care for women experiencing these issues. These recommendations are based on the FSRH guidelines on contraception from July 2019.

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.

Treatment Options for Cystourethrocele: Conservative and Surgical Approaches

Cystourethrocele, the descent of the anterior part of the vagina attached to the urethra and the base of the bladder, can cause disruption of the continence mechanism and stress incontinence. Conservative measures such as pelvic floor exercises, pessaries, and oestrogen therapy may be used prior to surgery or as a therapeutic test to improve symptoms. However, the surgical treatment of choice is an anterior repair, also known as anterior colporrhaphy, which involves making a midline incision through the vaginal skin, reflecting the underlying bladder off the vaginal mucosa, and placing lateral supporting sutures into the fascia to elevate the bladder and bladder neck. Posterior colpoperineorrhaphy is a procedure to surgically correct lacerations or tears in the vagina and perineum. Sacrocolpopexy and sacrospinous fixation are not relevant for this patient. Approximately 50% of patients may experience post-operative urinary retention following anterior colporrhaphy.

Ovulation induction can lead to ovarian hyperstimulation syndrome (OHSS) as a potential side effect. The symptoms of OHSS often involve gastrointestinal discomfort such as bloating, abdominal pain, nausea, vomiting, and diarrhea. Additionally, patients may experience shortness of breath, fever, peripheral edema, and oliguria. OHSS can range in severity from mild to life-threatening, with complications such as dehydration, thromboembolism, acute kidney injury (AKI), and pulmonary edema. Severe OHSS typically has a delayed onset compared to milder cases. In the given scenario, the patient received a GnRH agonist injection within the past week, indicating that her symptoms may be less severe.

Ovulation induction is often required for couples who have difficulty conceiving naturally due to ovulation disorders. Normal ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. There are three main categories of anovulation: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation to lead to a singleton pregnancy. Forms of ovulation induction include exercise and weight loss, letrozole, clomiphene citrate, and gonadotropin therapy. Ovarian hyperstimulation syndrome is a potential side effect of ovulation induction and can be life-threatening if not managed promptly.

Intersex and Genetic Disorders: Understanding the Different Types

Intersex conditions and genetic disorders can affect an individual’s physical and biological characteristics. Understanding the different types can help in diagnosis and treatment.

Male Pseudointersex
Male pseudointersex is a condition where an individual has a 46XY karyotype and testes but presents phenotypically as a woman. This is caused by androgen insensitivity, deficit in testosterone production, or deficit in dihydrotestosterone production. Androgen insensitivity syndrome is the most common mechanism, which obstructs the development of male genitalia and secondary sexual characteristics, resulting in a female phenotype.

True Intersex
True intersex is when an individual carries both male and female gonads.

Female Intersex
Female intersex is a term used to describe an individual who is phenotypically male but has a 46XX genotype and ovaries. This is usually due to hyperandrogenism or a deficit in estrogen synthesis, leading to excessive androgen synthesis.

Fragile X Syndrome
Fragile X syndrome is an X-linked dominant disorder that affects more men than women. It is associated with a long and narrow face, large ears, large testicles, significant intellectual disability, and developmental delay. The karyotype correlates with the phenotype and gonads.

Turner Syndrome
Turner syndrome is associated with the genotype 45XO. Patients are genotypically and phenotypically female, missing part of, or a whole, X chromosome. They have primary or secondary amenorrhea due to premature ovarian failure and failure to develop secondary sexual characteristics.

This woman is displaying symptoms that are commonly associated with endometrial cancer, such as abdominal pain and bloating. She also has several risk factors for this type of cancer, including a history of PCOS, being nulliparous, and experiencing menopause after the age of 52. Other risk factors include obesity, endometrial hyperplasia, diabetes, tamoxifen, and unopposed estrogen. Interestingly, the risk associated with unopposed estrogen can be eliminated if progesterone is given concurrently.

While this woman has risk factors for breast cancer, her current symptoms are not indicative of this type of cancer. She does not have any risk factors for cervical cancer. It is important to note that abdominal pain and bloating are not normal symptoms of menopause. Normal menopausal symptoms include hot flashes, mood changes, musculoskeletal symptoms, vaginal dryness/itching, sexual dysfunction, and sleep disturbance.

Vaginal cancer typically presents with symptoms such as a vaginal mass, vaginal itching, discharge and pain, and vulval bleeding. Risk factors for this type of cancer include advancing age, infection with human papillomavirus, previous or current cervical cancer, smoking, and alcohol consumption.

The appropriate option for emergency contraception in this case is ulipristal, which can be prescribed up to 120 hours after unprotected sexual intercourse. Levonorgestrel, which must be taken within 72 hours, is not a suitable option. Insertion of an intrauterine device or system is also inappropriate as the patient declined invasive contraception. Mifepristone is not licensed for emergency contraception.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.

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.

The copper intrauterine device is a viable option for emergency contraception if inserted within 5 days after the first unprotected sexual intercourse in a cycle or within 5 days of the earliest estimated ovulation date, whichever is later. It can be inserted up to 120 hours after unprotected sex, but if the patient presents after this time period, it can still be inserted up to 5 days after the earliest predicted ovulation date, which is typically 14 days before the start of the next cycle for patients with a regular 28-day cycle. It should be noted that the intrauterine system cannot be used for emergency contraception, and options 1, 3, and 4 are incorrect as they fall outside of the recommended time frame.

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.

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 addition of progesterone to hormone replacement therapy (HRT) has been linked to an increased risk of breast cancer, as well as venous thromboembolism and cardiovascular disease. HRT may be recommended for menopausal patients experiencing vasomotor symptoms such as hot flashes, night sweats, and palpitations. However, if a patient only presents with urogenital symptoms, topical oestrogens such as oestradiol creams or pessaries may be more appropriate. These act locally to alleviate vaginal dryness, reduce UTI recurrence, and ease dyspareunia. For patients with vasomotor symptoms, HRT preparations with systemic effects (such as oral medications, topical patches, and implants) may be considered. If the patient has not undergone a hysterectomy, their HRT regime must include both oestrogen and progesterone to prevent hypertrophy of the uterus and a 5-10x increased risk of endometrial carcinoma associated with unopposed oestrogen therapy.

Adverse Effects of Hormone Replacement Therapy

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

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

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

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

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

Postcoital Bleeding

Postcoital bleeding is a condition that occurs when there is trauma to superficial lesions within the vaginal tract. This can be caused by a variety of factors, including cervical trauma, cervical polyps, endometrial and cervical carcinoma, cervicitis, and vaginitis. In some cases, invasive cervical carcinoma may be found in those who are referred to the hospital, accounting for 3.8% of cases.

Vaginitis is also a possibility, but it is more common in elderly patients with low estrogen levels. On the other hand, salpingo-oophoritis, which is usually caused by pelvic inflammatory disease from sexually transmitted infections, typically presents with deep dyspareunia and purulent vaginal discharge. However, post-coital bleeding is highly unlikely to be caused by salpingo-oophoritis.

Treatment Options for Symptomatic Cystocoele: Lifestyle Modifications, Medications, and Surgeries

Symptomatic cystocoele can be treated through various options, depending on the severity of the condition. The first line of treatment focuses on lifestyle modifications, such as smoking cessation and weight loss. Topical oestrogen may also be prescribed to post- or perimenopausal women suffering from vaginal dryness, urinary incontinence, recurrent urinary tract infections, or superficial dyspareunia. Inserting a ring pessary is the second line of treatment, which needs to be changed every six months and puts the patient at risk of ulceration. Per vaginal surgery is the third line of treatment, which is only possible if the cystocoele is small and puts the patient at risk of fibroids and adhesions. Hysterectomy is not recommended as it increases the risk of cystocoele due to the severance of the uterine ligaments and reduction in support following removal of the uterus.

According to NICE guidelines for cervical cancer screening, if the first repeat smear at 12 months is still positive for high-risk human papillomavirus (hrHPV), the next step is to repeat the smear 12 months later (i.e. at 24 months). If the patient remains hrHPV positive but cytology negative at 12 months, they should have another HPV test in a further 12 months. If the patient becomes hrHPV negative at 24 months, they can return to routine recall. However, if they remain hrHPV positive, cytology negative or inadequate at 24 months, they should be referred to colposcopy.

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.

Long-Term Complications of Vaginal Hysterectomy

Vaginal hysterectomy with antero-posterior repair is a common surgical procedure for women. However, it may lead to long-term complications such as enterocoele and vaginal vault prolapse. These conditions occur when the pelvic organs shift and push against the vaginal wall, causing discomfort and pain. While urinary retention may occur immediately after the surgery, it is not typically a chronic complication.

It is important for women who undergo vaginal hysterectomy to be aware of these potential complications and to discuss them with their healthcare provider. Regular check-ups and pelvic exams can help detect any issues early on and prevent further complications. Additionally, women can take steps to reduce their risk of developing these conditions by maintaining a healthy weight, avoiding heavy lifting, and practicing pelvic floor exercises. By being proactive and informed, women can minimize the impact of long-term complications and enjoy a better quality of life after surgery.

Treatment Options for Cervical Carcinoma: A Comparison

Cervical carcinoma is a type of cancer that primarily affects the squamous cells of the cervix. Its main symptoms include abnormal bleeding or watery discharge, especially after sexual intercourse. The risk of developing cervical cancer increases with sexual activity.

The disease is staged based on the extent of its spread, with stages 0 to 4 indicating increasing severity. For stage 1b cervical cancer, the recommended treatment is a Wertheim’s radical abdominal hysterectomy. This procedure involves removing the uterus, tubes, ovaries, broad ligaments, parametrium, upper half or two-thirds of the vagina, and regional lymph glands. However, in older patients, the surgeon may try to preserve the ovaries to avoid premature menopause.

Other treatment options include simple hysterectomy, which is not suitable for cervical cancer that has spread beyond the cervix, and radical trachelectomy, which is appropriate for stage 1 cancers in women who wish to preserve their fertility. Close cytological follow-up is not recommended for confirmed cases of cervical cancer, while platinum-based chemotherapy is typically used only when surgery is not possible.

In summary, the choice of treatment for cervical carcinoma depends on the stage of the disease, the patient’s age and fertility preferences, and the feasibility of surgical intervention.

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

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

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

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

Misconceptions about Menopause and Reproduction

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

Common Misconceptions about Menopause and Reproduction

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

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

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

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

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

Premenstrual syndrome can be treated with a combination of oral contraceptives and SSRIs, along with cognitive behavioral therapy. While the copper intrauterine device is effective for long-term contraception, it does not address the hormonal changes that cause PMS symptoms. The most appropriate option for Lydia is a new-generation combined oral contraceptive pill containing drospirenone, which can alleviate her symptoms. Progesterone-only contraception is not recommended for PMS, and sodium valproate is not a recognized treatment for this condition. It is important to take the COC continuously for maximum benefit.

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

Patients experiencing secondary dysmenorrhoea should be referred to gynaecology for further investigation as it is often associated with underlying pathologies such as endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease. While the combined oral contraceptive pill may provide relief, it is important to determine the root cause first. Fluoxetine is not appropriate for managing secondary dysmenorrhoea, as it is used for premenstrual dysphoric disorder. Intra-uterine devices may actually cause secondary dysmenorrhoea and should not be used. Tranexamic acid is not indicated for the management of secondary dysmenorrhoea, but rather for menorrhagia.

Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

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.

Trichomonas vaginalis is a protozoan that causes trichomoniasis, characterized by a green-yellow discharge with a foul odor. Men usually do not show symptoms, while women may experience dysuria, frequent urination, and itching. Treatment involves taking oral metronidazole for seven days. Although complications are rare, pregnant women with trichomoniasis may experience premature labor. The disease is sexually transmitted, so a thorough sexual history should be taken.

Neisseria gonorrhoeae is a diplococcus that causes gonorrhea, which may be asymptomatic in women but can cause vaginal discharge and painful urination. Treatment involves a single intramuscular injection of ceftriaxone 500 mg.

Chlamydia trachomatis is an intracellular organism that causes chlamydia, which is often asymptomatic in women but may cause cervicitis, urethritis, or salpingitis. Treatment involves a single oral dose of azithromycin 1 g.

Candida albicans causes thrush, which is characterized by white curd-like discharge, red and sore vulva, and hyphae visible on microscopy. Treatment involves using clotrimazole in pessary or topical form, with fluconazole used for resistant cases.

Treponema pallidum causes syphilis, which may present as a painless ulcer in the genital area called a chancre. Treatment involves using benzathine penicillin. While secondary and further stages of syphilis are becoming rare, it is important to seek treatment promptly.

If a cervical smear test is hrHPV positive but cytologically normal, the recommended course of action is to repeat the test in 12 months. This is in contrast to negative hrHPV results, which are returned to normal recall. Abnormal cytology results require colposcopy, but normal cytology results do not. It is important to note that returning to normal recall is not appropriate in this case, as the patient’s higher risk status warrants a repeat test sooner than the standard 3-year interval. Repeating the test within 3 or 6 months is also not recommended.

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.

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.