The patient is likely suffering from trichomoniasis caused by Trichomonas vaginalis, a sexually transmitted disease that results in a yellow/green discharge with a foul odor, vulval itching, and dysuria. During a speculum examination, the cervix may appear as a strawberry cervix due to multiple punctate haemorrhages. Bacterial vaginosis, which is not a sexually transmitted disease and can be caused by various factors, is less likely to be the diagnosis due to the recent unprotected sexual intercourse and the presence of an offensive discharge. Chlamydia and gonorrhoea, both sexually transmitted diseases, can also cause dysuria and vaginal discharge, but the punctate cervical haemorrhages and malodorous green discharge make them less likely diagnoses. Syphilis, which presents in three stages, is unlikely due to the acute onset of symptoms and the absence of genital lesions.

Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis

Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.

To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.

When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.

In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.

To detect Down’s syndrome, doctors recommend the combined test which involves measuring the thickness of the nuchal translucency during the 12-week scan, as well as conducting blood tests for B-HCG and PAPP-A. This test can only be done between 11 and 13+6 weeks of pregnancy. If the nuchal translucency is thickened, B-HCG levels are high, and PAPP-A levels are low, there is an increased likelihood of Down’s syndrome. The other options listed are incorrect. If a woman misses the window for the combined test, she may be offered the triple or quadruple test between 15-20 weeks, which includes AFP as a marker for Down’s syndrome. Low levels of AFP indicate a higher risk of Down’s syndrome.

NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.

If a foetal heartbeat is detected on ultrasound in the case of an ectopic pregnancy, surgical management is necessary, and the appropriate procedure is a salpingectomy. This is the recommended course of action for a patient with no significant medical history and both fallopian tubes. Expectant management is not suitable in this scenario, as the foetal heartbeat is visible on ultrasound. Medical management with methotrexate is also not an option due to the foetal heartbeat, and mifepristone is not used for ectopic pregnancies.

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 salpingotomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy 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.

Benefits and Risks of Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) is a treatment used to alleviate the symptoms of menopause, such as hot flushes, sweating, and palpitations. It has been proven effective in placebo-controlled randomized studies. HRT can also improve vaginal dryness, superficial dyspareunia, and urinary frequency and urgency. Long-term therapy is required to achieve these benefits, and symptoms may recur after stopping HRT.

HRT is commonly prescribed to prevent osteoporosis, particularly if started within the first five years after menopause onset. Women with decreased bone mineral density and those with a history of osteoporotic fractures also benefit from HRT. However, protection may be lost after stopping the hormones. HRT can reduce the incidence of hip fractures by about one case per 1000 women aged <70 years and by about 8 cases per 1000 women aged 70–79 years. The Women’s Health Initiative (WHI) study revealed an increased annual risk of heart attacks in women who took combined HRT compared to those who took estrogen only. HRT may also prevent and treat dementia and related disorders by enhancing cholinergic neurotransmission and preventing oxidative cell damage, neuronal atrophy, and glucocorticoid-induced neuronal damage. However, studies have failed to provide a consensus on this aspect due to issues of selection bias and extreme heterogeneity in study participants, treatments, cognitive function tests applied, and doses of HRT. In conclusion, HRT can provide relief for menopausal symptoms, improve vaginal health, prevent osteoporosis, and reduce the risk of heart attacks. However, it may increase the risk of dementia, particularly in women aged 65 years who take combination HRT and have relatively low cognitive function at the start of treatment. Therefore, the benefits and risks of HRT should be carefully considered before starting treatment.

Understanding Chorioamnionitis

Chorioamnionitis is a serious medical condition that can affect both the mother and the foetus during pregnancy. It is caused by a bacterial infection that affects the amniotic fluid, membranes, and placenta. This condition is considered a medical emergency and can be life-threatening if not treated promptly. It is more likely to occur when the membranes rupture prematurely, but it can also happen when the membranes are still intact.

Prompt delivery of the foetus is crucial in treating chorioamnionitis, and a cesarean section may be necessary. Intravenous antibiotics are also administered to help fight the infection. This condition affects up to 5% of all pregnancies, and it is important for pregnant women to be aware of the symptoms and seek medical attention immediately if they suspect they may have chorioamnionitis.

Medical treatment can be attempted for uterine fibroids that are smaller than 3 cm and do not distort the uterine cavity. This may include options such as an intrauterine system, tranexamic acid, or COCP. The NICE Clinical Knowledge Summaries suggest starting with an intrauterine system, which can also serve as a form of contraception.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

In the case of a pregnant woman who is not immune to rubella, it is recommended to offer the MMR vaccination after giving birth. Rubella can cause severe harm to the developing foetus, especially during the first 8-10 weeks of pregnancy. Although congenital rubella syndrome is now rare due to widespread MMR vaccination, there has been a resurgence of measles, mumps, and rubella outbreaks in developed countries due to the anti-vaccination movement. The woman should avoid contact with individuals who may have rubella and cannot receive the vaccine while pregnant. Referral to an obstetrician is not necessary at this time since the woman is asymptomatic and in good health. The MMR vaccine should not be administered at 20 weeks of pregnancy, and if the woman is not immune, it should be offered postnatally. If there is a suspicion of rubella based on the woman’s clinical presentation, the local Health Protection Team should be notified, but this is not necessary in this case since there is no suspicion.

Rubella and Pregnancy: Risks, Features, Diagnosis, and Management

Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.

If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.

Understanding Lyme Disease

Lyme disease is a bacterial infection caused by Borrelia burgdorferi and is transmitted through tick bites. The early symptoms of Lyme disease include erythema migrans, a characteristic bulls-eye rash that appears at the site of the tick bite. This rash is painless, slowly increases in size, and can be more than 5 cm in diameter. Other early symptoms include headache, lethargy, fever, and joint pain.

If erythema migrans is present, Lyme disease can be diagnosed clinically, and antibiotics should be started immediately. The first-line test for Lyme disease is an enzyme-linked immunosorbent assay (ELISA) to detect antibodies to Borrelia burgdorferi. If the ELISA is negative but Lyme disease is still suspected, it should be repeated 4-6 weeks later. If Lyme disease is suspected in patients who have had symptoms for 12 weeks or more, an immunoblot test should be done.

Tick bites can cause significant anxiety, but routine antibiotic treatment is not recommended by NICE. If the tick is still present, it should be removed using fine-tipped tweezers, and the area should be washed. In cases of suspected or confirmed Lyme disease, doxycycline is the preferred treatment for early disease, while ceftriaxone is used for disseminated disease. A Jarisch-Herxheimer reaction may occur after initiating therapy, which can cause fever, rash, and tachycardia.

In summary, Lyme disease is a bacterial infection transmitted through tick bites. Early symptoms include erythema migrans, headache, lethargy, fever, and joint pain. Diagnosis is made through clinical presentation and ELISA testing, and treatment involves antibiotics. Tick bites do not require routine antibiotic treatment, and ticks should be removed using fine-tipped tweezers.

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.

Cavernosal blood gas analysis is a crucial investigation for patients presenting with priapism. In this case, the patient has a partially erect, non-painful penis that has persisted for over 4 hours, indicating non-ischaemic priapism. This type of priapism is caused by large volume arterial inflow to the penis from trauma or congenital malformation. Confirming whether the priapism is ischaemic or non-ischaemic through cavernosal blood gas analysis is essential for appropriate management. Ischaemic priapism is a medical emergency that requires aspiration of blood from the cavernosa, while non-ischaemic priapism can be managed with observation initially. In paediatric patients, a doppler ultrasound may be a better alternative to cavernosal blood gases due to the potential trauma of the procedure.

A CT pelvis is not recommended in this case as it would expose the child to unnecessary radiation. Instead, a doppler ultrasound can be used to investigate the arterial/venous blood flow in the penis. A clotting screen may be useful if the patient has a history of bleeding problems or a family history of haemoglobinopathies. However, it should not delay cavernosal blood gas analysis as it is crucial to confirm the type of priapism. Testicular ultrasound is not a useful imaging modality for investigating priapism. If an imaging modality is required to assess penile blood flow, a doppler ultrasound is the preferred option.

Understanding Priapism: Causes, Symptoms, and Management

Priapism is a medical condition characterized by a persistent penile erection that lasts longer than four hours and is not associated with sexual stimulation. There are two types of priapism: ischaemic and non-ischaemic, each with a different pathophysiology. Ischaemic priapism is caused by impaired vasorelaxation, resulting in reduced vascular outflow and trapping of de-oxygenated blood within the corpus cavernosa. Non-ischaemic priapism, on the other hand, is due to high arterial inflow, often caused by fistula formation due to congenital or traumatic mechanisms.

Priapism can affect individuals of all ages, with a bimodal distribution of age at presentation, with peaks between 5-10 years and 20-50 years of age. The incidence of priapism has been estimated at up to 5.34 per 100,000 patient-years. There are various causes of priapism, including idiopathic, sickle cell disease or other haemoglobinopathies, erectile dysfunction medication, trauma, and drug use (both prescribed and recreational).

Patients with priapism typically present acutely with a persistent erection lasting over four hours and pain localized to the penis. A history of haemoglobinopathy or medication use may also be present. Cavernosal blood gas analysis and Doppler or duplex ultrasonography can be used to differentiate between ischaemic and non-ischaemic priapism and assess blood flow within the penis. Treatment for ischaemic priapism is a medical emergency and includes aspiration of blood from the cavernosa, injection of a saline flush, and intracavernosal injection of a vasoconstrictive agent. Non-ischaemic priapism, on the other hand, is not a medical emergency and is usually observed as a first-line option.

The procedure being performed is called an episiotomy, which can be done using various techniques. In this case, the medio-lateral approach is being used, which involves making a cut at either the 7 o’clock or 5 o’clock positions. The main reasons for performing this procedure are twofold. Firstly, it helps to prevent the vagina from tearing during childbirth, particularly in cases where the baby’s head is too large for the mother’s pelvis. By making a controlled incision, the risk of the tear extending towards the anus and surrounding muscles is reduced, which could lead to long-term problems such as fecal incontinence. Secondly, the episiotomy creates more space for the baby to pass through, making delivery easier and safer for both the mother and child.

Understanding Episiotomy

Episiotomy is a surgical procedure that involves making an incision in the posterior wall of the vagina and perineum during the second stage of labor. This procedure is done to make it easier for the baby to pass through the birth canal. The incision is made in the area between the vagina and anus, and it can be either midline or mediolateral.

Episiotomy is usually performed when the baby is in distress, and there is a need to speed up the delivery process. It can also be done to prevent tearing of the perineum, which can be more difficult to repair than an episiotomy. However, the procedure is not without risks, and it can lead to complications such as pain, infection, and bleeding.

In recent years, there has been a decline in the use of episiotomy, as studies have shown that it does not necessarily reduce the risk of tearing or improve healing time. Many healthcare providers now only perform episiotomy when it is medically necessary. It is important for expectant mothers to discuss the use of episiotomy with their healthcare provider and understand the risks and benefits before making a decision.

Primary dysmenorrhoea is best treated with NSAIDs like mefenamic acid, which are the first line of treatment according to NICE guidelines. Paracetamol can be used if NSAIDs are not suitable, and a combination of both can be tried if NSAIDs alone are not effective. Hormonal options like the combined oral contraceptive pill can also be considered, but contraindications must be ruled out. The intrauterine device or copper coil is not recommended for this patient due to the risk of heavier bleeding. Instead, the intrauterine system or Mirena coil can be offered as an alternative option. While the IUS is the first-line treatment for menorrhagia, NSAIDs are the initial choice for primary dysmenorrhoea. It is important to consider the patient’s plans for conception when deciding on treatment options.

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.

Pros and Cons of the Progestogen Only Pill

The progestogen only pill, also known as the mini-pill, is a highly effective form of contraception with a failure rate of only 1 per 100 woman years. One of its advantages is that it does not interfere with sex and its contraceptive effects are reversible upon stopping. It can also be used while breastfeeding and in situations where the combined oral contraceptive pill is contraindicated, such as in smokers over 35 years of age and women with a history of venous thromboembolic disease.

However, the progestogen only pill also has its disadvantages. One of the most common adverse effects is irregular periods, with some users not having periods while others may experience irregular or light periods. It also does not protect against sexually transmitted infections and has an increased incidence of functional ovarian cysts. Common side-effects include breast tenderness, weight gain, acne, and headaches, although these symptoms generally subside after the first few months. Despite its drawbacks, the progestogen only pill remains a popular choice for women seeking a reliable and convenient form of contraception.

When women experience postmenopausal bleeding (PMB), it is important to rule out the possibility of endometrial cancer. The first step is to conduct a speculum examination to check for any visible abnormalities. For women over 40 years old, an endometrial biopsy and hysteroscopy should be performed to diagnose endometrial cancer. Risk factors for this type of cancer include advanced age, never having given birth, using unopposed estrogen therapy, starting menstruation at an early age and experiencing menopause later in life, being overweight, and having submucosal fibroids that typically calcify after menopause.

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. Progestogen 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.

Premature menopause is characterized by irregular menstrual cycles occurring before the age of 45, along with elevated FSH/LH levels and low oestradiol levels in blood tests. The pituitary gland releases more hormones in an attempt to stimulate the failing ovary to produce oestrogen, resulting in a negative feedback loop. Therefore, options 1, 3, 4, and 5 are incorrect. Option 5 depicts primary pituitary failure.

Premature Ovarian Insufficiency: Causes and Management

Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.

Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.

Benefits and Risks of Oral Contraceptives

Oral contraceptives, also known as birth control pills, are a popular form of contraception for women. They contain synthetic hormones that prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering the lining of the uterus. While oral contraceptives have many benefits, they also carry some risks.

Venous Thrombosis: The estrogen component of oral contraceptives can activate the blood-clotting mechanism, increasing the risk of venous thrombosis. However, low-dose oral contraceptives are associated with a lower risk of thromboembolism.

Benign Breast Disease: Oral contraceptives can prevent benign breast disease, but their association with breast cancer in young women is controversial. While some studies suggest a slightly increased risk of breast cancer, the risk is small and the resulting tumors spread less aggressively than usual.

Functional Ovarian Cysts: Oral contraceptives suppress ovarian stimulation, reducing the risk of developing functional ovarian cysts.

Carcinoma of the Ovary or Uterus: Oral contraceptives can prevent epithelial ovarian and endometrial carcinoma. They are associated with a 40% reduced risk of malignant and borderline ovarian epithelial cancer and a 50% reduction in the risk of endometrial adenocarcinoma.

Pelvic Inflammatory Disease: Oral contraceptives can prevent the development of pelvic inflammatory disease.

Overall, oral contraceptives are reliable and reversible, reduce menstrual symptoms, and lower the risk of certain cancers and pelvic inflammatory disease. However, they carry some risks, including an increased risk of venous thrombosis and a controversial association with breast cancer. Women should discuss the benefits and risks of oral contraceptives with their healthcare provider to determine if they are a suitable form of contraception.

Premature Ovarian Insufficiency: Causes and Management

Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.

Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.

Managing Menopause: Lifestyle Modifications, Hormone Replacement Therapy, and Non-Hormone Replacement Therapy

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms are common and can last for up to 7 years, with varying degrees of severity and duration. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage menopausal symptoms such as hot flushes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended. For women who cannot or do not want to take HRT, non-hormonal treatments such as fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturizers for vaginal dryness, and cognitive behavior therapy or antidepressants for psychological symptoms can be prescribed.

HRT is a treatment option for women with moderate to severe menopausal symptoms. However, it is contraindicated in women with current or past breast cancer, any estrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia. HRT brings certain risks, including venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer. Women should be advised of these risks and the fact that symptoms typically last for 2-5 years.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence of symptoms in the short term. However, in the long term, there is no difference in symptom control. Women who experience ineffective treatment, ongoing side effects, or unexplained bleeding should be referred to secondary care. Overall, managing menopause requires a personalized approach that takes into account a woman’s medical history, preferences, and individual symptoms.

The diagnosis that needs to be ruled out first is obstetric cholestasis, as it can heighten the chances of premature birth and fetal death. The condition is identified by abnormal liver function tests and itching without any skin rash. Unlike uric acid, it is the bile acids that are elevated in obstetric cholestasis.

Liver Complications During Pregnancy

During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.

Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.

Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.

The prognosis for endometrial cancer is generally favorable.

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. Progestogen 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.

If females over 50 experience bloating and abdominal cramps, it is important to consider the possibility of ovarian cancer. The recommended course of action is to conduct a serum CA125 test. If the results show elevated levels, an abdominal and pelvic ultrasound should be scheduled. This information is based on NICE CG122 guidelines.

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.

Expectant management of an ectopic pregnancy is only possible if the embryo is unruptured, less than 35mm in size, has no heartbeat, is asymptomatic, and has a B-hCG level of less than 1,000IU/L and is declining. However, this management option is very uncommon as most patients present with symptoms.

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 salpingotomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy 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.

Vaginal PGE2 is the preferred method of induction of labour, with other options such as emergency caesarean section, maternal oxytocin infusion, amniotomy, and cervical ripening balloon being considered only in certain situations. Women undergoing vaginal PGE2 should be aware of the risk of uterine hyperstimulation and may require additional analgesia. The cervix should be reassessed before considering oxytocin infusion. Amniotomy may be used in combination with oxytocin infusion in patients with a ripe cervix. Cervical ripening balloon should not be used as the primary method for induction of labour due to its potential pain, bleeding, and infection risks.

Induction of Labour: Reasons, Methods, and Complications

Induction of labour is a medical process that involves starting labour artificially. It is necessary in about 20% of pregnancies due to various reasons such as prolonged pregnancy, prelabour premature rupture of the membranes, diabetes, pre-eclampsia, and rhesus incompatibility. The Bishop score is used to assess whether induction of labour is required, which takes into account cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates that the cervix is ripe and there is a high chance of spontaneous labour or response to interventions made to induce labour.

There are several methods of induction of labour, including membrane sweep, vaginal prostaglandin E2, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. Membrane sweeping involves separating the chorionic membrane from the decidua by rotating the examining finger against the wall of the uterus. Vaginal prostaglandin E2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. Uterine hyperstimulation is the main complication of induction of labour, which refers to prolonged and frequent uterine contractions that can cause fetal hypoxemia and acidemia. In rare cases, uterine rupture may occur, which requires removing the vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and tocolysis with terbutaline.

Levonorgestrel is the correct choice, as the patient has expressed reluctance to try a different form of contraception. It is important to prioritize pregnancy prevention while also discussing the benefits of long-acting reversible contraception and allowing the patient time to consider it. While ulipristal and levonorgestrel are both oral options, ulipristal should be used cautiously in patients with severe asthma. As the patient is still within the 72-hour window for levonorgestrel use and has missed two doses of her oral contraceptive pill, levonorgestrel is the preferred option.

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.

Breast cancer is the second most common cancer in women and the leading cause of cancer death among women worldwide. Tamoxifen is a drug that can be used to treat breast cancer that requires estrogen to grow. It works by either blocking estrogen receptors or blocking the production of estrogen. For women with estrogen receptor-positive breast cancer, continuing tamoxifen for 10 years instead of stopping at 5 years can further reduce the risk of recurrence and mortality. However, tamoxifen does not affect the risk of breast cancer recurrence. The risk of endometrial cancer is slightly increased with tamoxifen treatment. Screening modalities include breast self-examination, clinical breast examination, mammography, ultrasonography, and magnetic resonance imaging. Early detection is crucial in preventing breast cancer, and screening intervals may need to be shortened to prevent more deaths. Physical examination and biopsy are also important diagnostic approaches. Treatment for breast cancer typically involves surgery, radiation therapy, and adjuvant hormone or chemotherapy when necessary.

Ectopic pregnancy presents with amenorrhoea, abdominal pain, vaginal bleeding, and shoulder tip pain indicating peritoneal bleeding.

Understanding Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

Investigation is necessary for any ovarian mass found in a woman who has undergone menopause.

Ovarian enlargement is typically diagnosed through ultrasound imaging, which can determine whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and symptoms. Younger women may be treated conservatively if the cyst is small and simple, with a repeat ultrasound scheduled in 8-12 weeks. Postmenopausal women, however, should always be referred to a gynecologist for assessment, as physiological cysts are unlikely in this population. It’s important to note that ovarian cancer can present with vague symptoms, leading to delayed diagnosis.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. 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.

During pregnancy, women with epilepsy should take 5mg of folic acid. Additionally, due to the potential harm of antiepileptic drugs to the fetus, they should receive specialized medical care.

Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

Starting September 2019, boys in school Year 8 who are 12-13 years old will also be provided with the HPV vaccine, which is currently administered in two doses. Girls receive the second dose within 6-24 months after the first, depending on local guidelines.

The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with the most significant being 6 & 11, which cause genital warts, and 16 & 18, which are linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for cervical cancer, such as smoking and contraceptive pill use, HPV is a significant contributor.

In 2008, the UK introduced a vaccination for HPV, initially using Cervarix, which protected against HPV 16 & 18 but not 6 & 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16 & 18. Initially given only to girls, boys were also offered the vaccine from September 2019. All 12- and 13-year-olds in school Year 8 are offered the HPV vaccine, which is typically given in school. Parents are informed that their daughter may receive the vaccine against their wishes. The vaccine is given in two doses, with the second dose administered between 6-24 months after the first, depending on local policy. Men who have sex with men under the age of 45 should also be offered the HPV vaccine to protect against anal, throat, and penile cancers. Injection site reactions are common with HPV vaccines.

Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme. Mammograms are provided every three years, and women over 70 years are encouraged to make their own appointments. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually.

For those with familial breast cancer, NICE guidelines recommend referral if there is a family history of breast cancer with any of the following: diagnosis before age 40, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, sarcoma in a relative under 45 years, glioma or childhood adrenal cortical carcinomas, complicated patterns of multiple cancers at a young age, or paternal history of breast cancer with two or more relatives on the father’s side. Women at increased risk due to family history may be offered screening at a younger age. Referral to a breast clinic is recommended for those with a first-degree relative diagnosed with breast cancer before age 40, a first-degree male relative with breast cancer, a first-degree relative with bilateral breast cancer before age 50, two first-degree relatives or one first-degree and one second-degree relative with breast cancer, or a first- or second-degree relative with breast and ovarian cancer.

If a woman experiences secondary amenorrhoea and has low levels of gonadotrophins, it suggests that the cause is related to the hypothalamus. High levels of gonadotrophins would indicate premature ovarian failure, while high levels of LH and androgens would suggest polycystic ovarian syndrome. Normal levels of prolactin and thyroxine have been observed in this woman.

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 with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

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.

The prevalence of aPL is significantly higher in women with recurrent miscarriage compared to those with a low risk obstetric history, with the former having a much higher incidence rate. In fact, the prevalence of aPL in the latter group is less than 2%.

Understanding Recurrent Miscarriage

Recurrent miscarriage is a condition that affects approximately 1% of women and is characterized by three or more consecutive spontaneous abortions. There are several potential causes of recurrent miscarriage, including antiphospholipid syndrome, endocrine disorders such as poorly controlled diabetes mellitus or thyroid disorders, polycystic ovarian syndrome, uterine abnormalities like a uterine septum, parental chromosomal abnormalities, and smoking.

It is important to note that while these factors may increase the risk of recurrent miscarriage, they do not necessarily guarantee that a woman will experience this condition. Additionally, there may be other underlying causes that have yet to be identified.

Differential Diagnosis: Abdominal Swelling and Tenderness in a Female Patient

Ovarian carcinoma is the most likely diagnosis for a female patient presenting with abdominal swelling and tenderness. This type of cancer is the leading cause of gynecological cancer deaths in developed countries, with a higher incidence in women over 55 years of age and those with a family history of breast or ovarian cancer. Imaging studies, such as ultrasonography, CT, and MRI, can aid in diagnosis, along with elevated levels of Ca-125. Surgery is often the initial treatment, followed by chemotherapy. However, the prognosis for advanced cases is poor.

Cervical carcinoma is unlikely in this patient, as it typically presents with abnormal vaginal bleeding, discomfort, and discharge, which are not reported.

Cirrhosis of the liver is a possibility, but the patient does not display common signs and symptoms, such as coagulopathy, hepatic encephalopathy, or variceal bleeding.

Wilson disease is a rare inherited disorder of copper metabolism that can cause hepatic dysfunction, but this patient does not display the characteristic hyperpigmentation, hepatomegaly, or diabetes mellitus.

Haemochromatosis is also unlikely, as the patient does not display the clinical features of the disease, such as hyperpigmentation, hepatomegaly, or diabetes mellitus, and there is no evidence of iron overload.

GnRH agonists can be effective in reducing the size of uterine fibroids, but their use is typically limited to short-term treatment. It is important to note that these agonists are primarily used to decrease the size of the uterus prior to surgery, as the risk of post-operative blood loss is directly related to the size of the uterus. Progesterone receptor inhibitors, on the other hand, do not have an impact on overall uterine size and are therefore not useful in preparing for surgery. However, they can be helpful in reducing the severity of fibroid-related bleeding. It is also important to avoid taking COCP 4-6 weeks prior to major surgery due to an increased risk of venous thromboembolism, and to avoid antiplatelet drugs such as Ibuprofen before surgery. While antifibrinolytics like tranexamic acid can be useful in reducing the severity of uterine bleeding, they are not helpful in preparing for surgery.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

The cessation of oestradiol and progesterone production in the ovaries, which can be caused naturally or by medical intervention, leads to menopause. This decrease in hormone production often results in elevated levels of FSH and LH.

Understanding Menopause and Contraception

Menopause is a natural biological process that marks the end of a woman’s reproductive years. On average, women in the UK experience menopause at the age of 51. However, prior to menopause, women may experience a period known as the climacteric. During this time, ovarian function starts to decline, and women may experience symptoms such as hot flashes, mood swings, and vaginal dryness.

It is important for women to understand that they can still become pregnant during the climacteric period. Therefore, it is recommended to use effective contraception until a certain period of time has passed. Women over the age of 50 should use contraception for 12 months after their last period, while women under the age of 50 should use contraception for 24 months after their last period. By understanding menopause and the importance of contraception during the climacteric period, women can make informed decisions about their reproductive health.

Adenomyosis is the condition where the tissue lining the uterus (endometrium) grows into the muscular wall of the uterus (myometrium).

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.

There are several methods for screening and diagnosing Down’s syndrome in pregnancy. The nuchal translucency scan, which measures fluid in the fetal neck, is best done between 11 and 14 weeks and can detect an increased risk of genetic syndromes. The triple screen, which measures levels of certain hormones in the mother’s blood, is done in the second trimester and can detect up to 69% of cases in singleton pregnancies, but may have a higher false positive or false negative in twin pregnancies. Amniocentesis and chorionic villous sampling are invasive diagnostic tests that can detect chromosomal disorders with high accuracy, but carry a small risk of pregnancy loss. The routine anomaly scan should not be used for Down’s syndrome screening. Cell-free fetal DNA screening is a newer method that can detect about 99% of Down’s syndrome pregnancies, but is currently only offered by private clinics at a high cost. A positive screening result suggests an increased risk for Down’s syndrome, and definitive testing with chorionic villous sampling or amniocentesis is indicated.

Types of Progestogen Only Pills

Progestogen only pills (POPs) are a type of birth control pill that contain only progestogen hormone. There are two generations of POPs, with the second generation including norethisterone, levonorgestrel, and ethynodiol diacetate. The third generation of POPs includes desogestrel, which is also known as Cerazette. This new type of POP is highly effective in inhibiting ovulation in most women. One of the advantages of Cerazette is that users can take the pill up to 12 hours late, which is longer than the 3-hour window for other POPs. Overall, there are different types of POPs available, and women can choose the one that best suits their needs and preferences.

Women who have had a previous baby affected by early- or late-onset GBS disease should be offered maternal intravenous antibiotic prophylaxis. The recommended option is to prescribe intrapartum intravenous benzylpenicillin or ampicillin to the mother. This is according to the Royal College of Obstetricians and Gynaecologists guidelines published in 2017. Administering intravenous benzylpenicillin to the child at birth is not appropriate unless they show signs of neonatal sepsis. Prescribing intrapartum intravenous ceftazidime is also not recommended. Monitoring the newborn for signs of sepsis for the next 72 hours is not sufficient in this case. The best approach is to administer antibiotics to the mother to prevent the development of neonatal sepsis.

Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection. The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.

The recommended treatment for the patient’s likely diagnosis of trichomoniasis is oral metronidazole, either as a 7-day course of 200mg or a one-time dose of 2g. Intramuscular ceftriaxone, benzathine benzylpenicillin, and oral doxycycline are not indicated for the treatment of trichomoniasis. Oral azithromycin is also not effective for this condition.

Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis

Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.

To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.

When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.

In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.

Syphilis, Lymphogranuloma venereum (LGV), and donovanosis (granuloma inguinal) can all lead to the development of genital ulcers that are not accompanied by pain. However, in the case of the patient who has recently changed sexual partners and is not experiencing any other symptoms, herpes simplex is the more probable cause of the painful genital ulcers. Behcets may also cause painful genital ulcers.

STI Ulcers: Causes and Symptoms

Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most common causes of genital ulcers is the herpes simplex virus (HSV) type 2, which is responsible for genital herpes. The primary attack of genital herpes is usually severe and accompanied by fever, while subsequent attacks are less severe and localized to one site. The ulcers caused by genital herpes are multiple and painful.

Syphilis is another STI that can cause genital ulcers. It is caused by the spirochaete Treponema pallidum and is characterized by primary, secondary, and tertiary stages. The primary stage of syphilis is marked by the appearance of a painless ulcer, known as a chancre. The incubation period for syphilis is between 9-90 days.

Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers that are associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis and typically occurs in three stages. The first stage is marked by a small, painless pustule that later forms an ulcer. The second stage is characterized by painful inguinal lymphadenopathy, while the third stage is proctocolitis. LGV is treated using doxycycline.

Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale, which is caused by Klebsiella granulomatis (previously called Calymmatobacterium granulomatis).

Premature Ovarian Insufficiency: Causes and Management

Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.

Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.

For the treatment of menorrhagia, the first-line option would be the intrauterine system. Specifically, the Mirena, which contains levonorgestrel, is highly effective in treating menorrhagia and also serves as a long-acting reversible contraceptive. While the combined oral contraceptive pill, tranexamic acid, and mefenamic acid may provide relief from symptoms, they are not the preferred initial treatment. On the other hand, the intrauterine device would not be suitable for addressing this patient’s menorrhagia.

Managing Heavy Menstrual Bleeding

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

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

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

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If a patient’s cervical cancer screening shows a positive result for high-risk HPV (hrHPV) and cytological abnormalities, they should be referred for a colposcopy. This is because HPV increases the risk of developing cervical intraepithelial neoplasia and abnormal cytology indicates the need for further investigation. If the sample is inadequate, a repeat test should be offered in 3 months. However, there is no situation in which a patient is asked to return for a repeat test in 6 months. If the patient is hrHPV negative, they would be returned to normal recall as the NHS now follows an HPV first system. If the patient is hrHPV positive but has normal cytology, they would be invited for a repeat test in 12 months to assess for resolution of HPV or for further increased surveillance before considering a colposcopy. It would be inappropriate to reassure the patient and return them to normal recall if they are hrHPV positive and have dyskaryosis.

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.

Levonorgestrel should be taken within 72 hours of unprotected sexual intercourse (UPSI). Administration of a single dose of levonorgestrel after this time is not licensed but may be considered.

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.

Screening for Down’s syndrome, which involves the nuchal scan, is conducted during antenatal care at 11-13+6 weeks. The combined test, which also includes the nuchal scan, is performed during this time frame. However, if the patient prefers to undergo the screening at a later stage of pregnancy, they can opt for the triple or quadruple test between 15 and 20 weeks.

NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.

Urinary tract infections in pregnancy should be treated to prevent pyelonephritis. Trimethoprim should be avoided in the first trimester due to teratogenicity risk. Erythromycin is not typically used for UTIs and nitrofurantoin should be avoided close to full term. Sulfonamides and quinolones should also be avoided in pregnancy.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

If a woman with large fibroids is experiencing fertility issues, the most effective treatment option that also preserves her ability to conceive in the future is myomectomy. However, depending on the specifics of the procedure, the woman may need to consider delivery options, such as a caesarean section, due to the risk of uterine rupture.

While GnRH agonists can shrink fibroids and make them easier to remove surgically, they also temporarily turn off the ovaries, inhibiting ovulation and making pregnancy impossible during treatment. Additionally, fibroids tend to regrow after treatment is stopped. However, when combined with myomectomy, GnRH agonists can be a suitable treatment option.

Endometrial ablation, on the other hand, destroys the endometrial lining, making it impossible for an embryo to implant. Uterine artery embolisation is also not recommended for women trying to conceive, as it significantly reduces blood supply to the uterus, making it impossible for a fetus to implant and grow.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

The most common adverse effect associated with the progesterone-only pill, also known as the ‘mini pill’, is irregular vaginal bleeding. Patients should be advised to take the pill at the same time every day without a pill-free break. While oily skin may occur due to increased sebum production, this is not as common as irregular vaginal bleeding. Patients with a history of acne vulgaris who take the progesterone-only pill may experience increased sebum production. The combined oral contraceptive pill (COCP) is commonly used to manage acne vulgaris and hirsutism in polycystic ovarian syndrome. Headaches may occur during the first few months of using hormonal contraception, but this is less likely to occur with the POP as the most common time to experience headaches is during the ‘pill-free interval’. Patients with a history of migraine with aura should be advised of the risks associated with the COCP and migraine with aura and informed that the POP is likely to be a safer alternative. While mood changes have been studied with birth control, there is no definite outcome of recent studies, and epidemiological data gathered by NICE does not support this as the most common adverse effect.

Counselling for Women Considering the Progestogen-Only Pill

Women who are considering taking the progestogen-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.

If a woman who is pregnant lacks immunity to rubella, she should receive the MMR vaccine after giving birth.

In the absence of any indication that this pregnant woman has been exposed to rubella, she should avoid contact with individuals who may have the disease and receive the MMR vaccine after giving birth, as it cannot be administered during pregnancy. There is no recommended treatment for preventing rubella after exposure based on the clinical history. To prevent complications in future pregnancies, it is important to offer her the MMR vaccine.

Rubella and Pregnancy: Risks, Features, Diagnosis, and Management

Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.

If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.

Placenta praevia is a condition where the placenta is located in the lower part of the uterus, either partially or completely. If the placenta covers the internal cervical os, it is classified as major praevia, while it is considered minor or partial if it does not. Bleeding can occur spontaneously, due to trauma, or during labor as the cervix opens.

The Royal College of Obstetricians and Gynaecologists recommends considering placenta praevia in all cases of vaginal bleeding after 20 weeks of pregnancy. Symptoms that increase suspicion of this condition include painless bleeding, a high presenting part, and abnormal fetal lie. A definitive diagnosis usually requires an ultrasound to determine the position of the placenta.
(RCOG Green-top Guideline No. 27)

In this case, the absence of pain makes placental abruption unlikely, and the normal appearance of the cervix rules out cervical trauma, cervical neoplasm, and inevitable miscarriage as the cause.

Understanding Placenta Praevia

Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.

There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.

Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.

In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.

Oligohydramnios is indicated by an amniotic fluid volume of 440ml, while polyhydramnios is associated with tracheo-oesophageal fistula.

Oligohydramnios is a condition characterized by a decrease in the amount of amniotic fluid present in the womb. The definition of oligohydramnios varies, but it is generally considered to be present when there is less than 500ml of amniotic fluid at 32-36 weeks of gestation or an amniotic fluid index (AFI) that falls below the 5th percentile.

There are several potential causes of oligohydramnios, including premature rupture of membranes, Potter sequence, bilateral renal agenesis with pulmonary hypoplasia, intrauterine growth restriction, post-term gestation, and pre-eclampsia. These conditions can all contribute to a reduction in the amount of amniotic fluid present in the womb, which can have significant implications for fetal development and health. It is important for healthcare providers to monitor amniotic fluid levels and identify any potential causes of oligohydramnios in order to provide appropriate care and support for both the mother and the developing fetus.

Currently, there is no dependable screening test for detecting ovarian cancer in its early stages. However, women, especially those over 50 years old, who experience persistent symptoms such as abdominal bloating, early satiety, loss of appetite, pelvic or abdominal pain, and increased urinary urgency or frequency should be suspected of having ovarian cancer and should undergo further tests.

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 two combined oral contraceptive pills (COCPs) are missed in week three, the woman should finish the remaining pills in the current pack and immediately start a new pack without taking the pill-free interval. It is important to note that contraceptive protection may be reduced during this time. Seeking emergency contraception is not necessary if there has been no unprotected sexual intercourse during the period of missed pills. Simply taking an active pill and continuing with the upcoming pill-free interval is not sufficient as the woman has likely lost contraceptive protection during the missed pill days. Taking an active pill as soon as possible without exercising caution is also not recommended as the woman may have reduced contraceptive protection.

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.

According to NICE guidelines, clinicians should diagnose pelvic inflammatory disease based on clinical symptoms and start antibiotic treatment promptly. While investigations such as endocervical and high vaginal swabs for microscopy and culture should be performed, they should not delay treatment. Negative swab results do not exclude the possibility of the disease. Blood cultures are not necessary unless the patient shows signs of systemic illness. Transvaginal ultrasound is not the first choice but may be necessary if an abscess is suspected.
(NICE CKS – Pelvic Inflammatory Disease)

Understanding Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a condition that occurs when the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. The most common cause of PID is an ascending infection from the endocervix, often caused by Chlamydia trachomatis. Other causative organisms include Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and Gonorrhoea. However, these tests are often negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves a combination of antibiotics, such as oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis. PID can also lead to infertility, with the risk as high as 10-20% after a single episode, chronic pelvic pain, and ectopic pregnancy. In mild cases of PID, intrauterine contraceptive devices may be left in, but recent guidelines suggest that removal of the IUD should be considered for better short-term clinical outcomes. Understanding PID and its potential complications is crucial for early diagnosis and effective management.

Post-menopausal women often experience atrophic vaginitis, which is characterized by symptoms such as vaginal dryness, dyspareunia, and occasional spotting. During examination, the vagina may appear dry and pale. Treatment options include the use of vaginal lubricants and moisturizers. If these prove ineffective, topical oestrogen cream may be prescribed.

Atrophic vaginitis is a condition that commonly affects women who have gone through menopause. Its symptoms include vaginal dryness, pain during sexual intercourse, and occasional spotting. Upon examination, the vagina may appear dry and pale. The recommended treatment for this condition is the use of vaginal lubricants and moisturizers. If these do not provide relief, a topical estrogen cream may be prescribed.

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.

Contraception is still necessary after menopause. Women who are over 50 years old should use contraception for at least 12 months after their last period, while those under 50 years old should use it for at least 24 months after their last period.

Understanding Menopause and Contraception

Menopause is a natural biological process that marks the end of a woman’s reproductive years. On average, women in the UK experience menopause at the age of 51. However, prior to menopause, women may experience a period known as the climacteric. During this time, ovarian function starts to decline, and women may experience symptoms such as hot flashes, mood swings, and vaginal dryness.

It is important for women to understand that they can still become pregnant during the climacteric period. Therefore, it is recommended to use effective contraception until a certain period of time has passed. Women over the age of 50 should use contraception for 12 months after their last period, while women under the age of 50 should use contraception for 24 months after their last period. By understanding menopause and the importance of contraception during the climacteric period, women can make informed decisions about their reproductive health.

The appropriate medical treatments for postpartum haemorrhage caused by uterine atony are oxytocin, ergometrine, carboprost, and misoprostol. In this scenario, the patient has experienced a blood loss of over 500 ml after delivery, indicating PPH as the likely cause, with uterine atony being the most probable reason. The first steps in managing PPH involve an ABCDE approach, including IV access, warm crystalloid administration, uterine fundus palpation, and catheterisation to prevent bladder distention. If these measures fail, medical therapy is initiated, starting with IV oxytocin. IM carboprost is not the correct choice as it requires senior approval and can worsen bronchoconstriction in patients with asthma. IV carboprost is also not recommended as it can cause bronchospasm, hypertension, and fever, and requires senior approval. IV tocolytics are not appropriate as they suppress uterine contractions, which would exacerbate the problem in this case. Therefore, agents that stimulate uterine contraction are given to manage PPH caused by uterine atony.

Understanding Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

If the COC is not started on the first day of the next period, it is important to follow the standard guidelines and use condoms for 7 days.

Special Situations for Combined Oral Contraceptive Pill

Concurrent antibiotic use has been a concern for many years in the UK, as doctors have advised that it may interfere with the effectiveness of the combined oral contraceptive pill. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines to abandon the extra precautions previously advised during antibiotic treatment and for 7 days afterwards. The latest edition of the British National Formulary (BNF) has also been updated to reflect this guidance, although precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

When it comes to switching combined oral contraceptive pills, the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The FSRH’s Combined Oral Contraception guidelines state that the pill-free interval does not need to be omitted, while the BNF advises missing the pill-free interval if the progesterone changes. Given this uncertainty, it is best to follow the BNF’s advice.

Contraceptives – Time to become effective (if not used on the first day of period):
Immediate: IUD
2 days: Progestin-only pill (POP)
7 days: Combined oral contraceptive (COC), injection, implant, intrauterine system (IUS)

Counselling for Women Considering the Combined Oral Contraceptive Pill

Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on the potential harms and benefits of the pill. The COC is highly effective if taken correctly, with a success rate of over 99%. However, there is a small risk of blood clots, heart attacks, and strokes, as well as an increased risk of breast and cervical cancer.

In addition to discussing the potential risks and benefits, women should also receive advice on how to take the pill. If the COC is started within the first 5 days of the menstrual cycle, there is no need for additional contraception. However, if it is started at any other point in the cycle, alternative contraception should be used for the first 7 days. Women should take the pill at the same time every day and should be aware that intercourse during the pill-free period is only safe if the next pack is started on time.

There have been recent changes to the guidelines for taking the COC. While it was previously recommended to take the pill for 21 days and then stop for 7 days to mimic menstruation, it is now recommended to discuss tailored regimes with women. This is because there is no medical benefit to having a withdrawal bleed, and options include never having a pill-free interval or taking three 21-day packs back-to-back before having a 4 or 7 day break.

Women should also be informed of situations where the efficacy of the pill may be reduced, such as vomiting within 2 hours of taking the pill, medication that induces diarrhoea or vomiting, or taking liver enzyme-inducing drugs. It is also important to discuss sexually transmitted infections and precautions that should be taken with enzyme-inducing antibiotics such as rifampicin.

Overall, counselling for women considering the COC should cover a range of topics to ensure that they are fully informed and able to make an informed decision about their contraceptive options.

In the UK, it is recommended that all women who are HIV-positive should not breastfeed their babies. This advice remains the same even if the mother’s viral load is undetectable. The decision should not be left to the HIV consultant as the national guidelines are clear on this matter. Although breastfeeding may reduce the risk of transmission if the maternal viral load is less than 50 copies/ml, there is still a risk involved. Therefore, the advice remains not to breastfeed. Continuing with antiretroviral therapy is expected regardless of the decision not to breastfeed as it significantly reduces the risk of vertical transmission during pregnancy. Babies born to HIV-positive mothers are given antiretroviral therapy, either zidovudine alone if the maternal viral load is less than 50 copies/ml or triple-therapy if it is higher. However, this does not change the advice to avoid breastfeeding.

HIV and Pregnancy: Guidelines for Minimizing Vertical Transmission

With the increasing prevalence of HIV infection among heterosexual individuals, there has been a rise in the number of HIV-positive women giving birth in the UK. In fact, in London alone, the incidence may be as high as 0.4% of pregnant women. The primary goal of treating HIV-positive women during pregnancy is to minimize harm to both the mother and fetus, and to reduce the chance of vertical transmission.

To achieve this goal, various factors must be considered. Firstly, all pregnant women should be offered HIV screening, according to NICE guidelines. Additionally, antiretroviral therapy should be offered to all pregnant women, regardless of whether they were taking it previously. This therapy has been shown to significantly reduce vertical transmission rates, which can range from 25-30% to just 2%.

The mode of delivery is also an important consideration. Vaginal delivery is recommended if the viral load is less than 50 copies/ml at 36 weeks. If the viral load is higher, a caesarean section is recommended, and a zidovudine infusion should be started four hours before the procedure. Neonatal antiretroviral therapy is also typically administered to the newborn, with zidovudine being the preferred medication if the maternal viral load is less than 50 copies/ml. If the viral load is higher, triple ART should be used, and therapy should be continued for 4-6 weeks.

Finally, infant feeding is an important consideration. In the UK, all women should be advised not to breastfeed, as this can increase the risk of vertical transmission. By following these guidelines, healthcare providers can help to minimize the risk of vertical transmission and ensure the best possible outcomes for both mother and child.

If the 1st repeat smear at 12 months is still positive for high-risk strains of human papillomavirus (hrHPV), the correct course of action is to repeat the smear 12 months later (i.e. at 24 months). Colposcopy is not indicated in this case, as it would only be necessary if this was her 3rd successive annual cervical smear that is still positive for hrHPV but with no cytological abnormalities. Repeating the cervical smear after 3 months is also not necessary, as this is only indicated if the first smear is inadequate. Similarly, repeating the cervical smear in 3 years is not appropriate, as hrHPV has been detected. Repeating the cervical smear after 6 months is also not necessary, as this is usually done as a test of cure following 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.

Levonorgestrel (Levonelle) can be followed immediately by hormonal contraception for emergency contraception.

Patients can resume their regular pill regimen right after taking levonorgestrel for emergency contraception. Levonorgestrel is an approved method of emergency contraception that can be used within 72 hours of unprotected sexual intercourse. It is the preferred oral emergency contraceptive for patients with asthma, as ulipristal is not recommended for those with severe asthma. Unlike ulipristal, which requires a waiting period of 5 days, patients can start hormonal contraception immediately after taking levonorgestrel. However, patients should use condoms for 7 days after restarting their combined oral contraceptive pill (COCP). It is important to note that the other options provided are incorrect. The progesterone-only pill requires condom use for 48 hours, unless initiated within the first 5 days of the menstrual cycle. Ulipristal acetate requires a waiting period of 5 days before restarting hormonal contraception. The COCP requires condom use for 7 days after restarting.

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.

Contraceptives – Time to become effective (if not used on the first day of period):
Immediate: IUD
2 days: Progestin-only pill (POP)
7 days: Combined oral contraceptive (COC), injection, implant, intrauterine system (IUS)

Counselling for Women Considering the Progestogen-Only Pill

Women who are considering taking the progestogen-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.

For patients with active hormone-responsive breast cancer, hormonal methods like HRT and tibolone are not recommended. Instead, non-hormonal methods like selective serotonin reuptake inhibitors and venlafaxine may be used to alleviate vasomotor symptoms of menopause. Topical estrogen can also be used to alleviate symptoms of vaginal atrophy, but it does not help with vasomotor symptoms. COCP is not a suitable treatment for menopausal symptoms.

Managing Menopause: Lifestyle Modifications, Hormone Replacement Therapy, and Non-Hormone Replacement Therapy

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms are common and can last for up to 7 years, with varying degrees of severity and duration. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage menopausal symptoms such as hot flushes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended. For women who cannot or do not want to take HRT, non-hormonal treatments such as fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturizers for vaginal dryness, and cognitive behavior therapy or antidepressants for psychological symptoms can be prescribed.

HRT is a treatment option for women with moderate to severe menopausal symptoms. However, it is contraindicated in women with current or past breast cancer, any estrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia. HRT brings certain risks, including venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer. Women should be advised of these risks and the fact that symptoms typically last for 2-5 years.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence of symptoms in the short term. However, in the long term, there is no difference in symptom control. Women who experience ineffective treatment, ongoing side effects, or unexplained bleeding should be referred to secondary care. Overall, managing menopause requires a personalized approach that takes into account a woman’s medical history, preferences, and individual symptoms.

Understanding Herpes Simplex Virus

Herpes simplex virus (HSV) is a common viral infection that affects humans. There are two strains of the virus, HSV-1 and HSV-2, which were previously thought to cause oral and genital herpes, respectively. However, there is now considerable overlap between the two strains. The primary infection may present with severe gingivostomatitis, while cold sores and painful genital ulceration are common features.

Management of HSV includes oral aciclovir for gingivostomatitis and genital herpes, and topical aciclovir for cold sores, although the evidence base for the latter is modest. Patients with frequent exacerbations may benefit from longer-term aciclovir. In pregnant women, a primary attack of herpes during pregnancy at greater than 28 weeks gestation may require elective caesarean section at term. Women with recurrent herpes who are pregnant should be treated with suppressive therapy and advised that the risk of transmission to their baby is low.

The cytopathic effect of HSV can be seen in Pap smears, which show multinucleated giant cells representing infection by the virus. The 3 M’s – multinucleation, margination of the chromatin, and molding of the nuclei – are characteristic features of HSV infection. Understanding the features and management of HSV is important for effective treatment and prevention of transmission.

Understanding Urinary Incontinence: Types and Treatment Options

Urinary incontinence is a common problem that affects people of all ages, but is more prevalent in elderly individuals and females. It is important to classify the type of urinary incontinence to determine the underlying cause and appropriate treatment.

Functional incontinence occurs due to reasons other than lower urinary tract dysfunction, such as delirium, psychiatric disorders, urinary infection, or impaired mobility. Treatment is directed at the underlying cause.

Mixed incontinence is a combination of stress incontinence and urge incontinence, characterized by mild-to-moderate urine loss with physical activities and acute urine loss without warning, respectively. Urinary frequency, urgency, and nocturia are also present.

Overflow incontinence occurs when the bladder is overdistended and urine overflows despite the absence of detrusor contraction. Symptoms may mimic those of mixed incontinence and may suggest a cause of bladder outlet obstruction or neurological dysfunction.

Stress incontinence is triggered by increased intra-abdominal pressure and is characterized by involuntary urine loss during coughing, laughing, and sneezing. Irritative voiding symptoms are typically absent.

Urge incontinence is associated with an overactive bladder and is characterized by uncontrolled urine loss associated with a strong desire to void, which occurs suddenly and without warning. Patients are unable to hold back urine and experience urinary frequency, urgency, and nocturia.

Treatment options include pelvic floor muscle training, anticholinergic medications such as oxybutynin and solifenacin, bladder retraining, and topical estrogen for postmenopausal women with vaginal atrophy. Treatment is directed at the underlying cause of urinary incontinence.

Breast Masses: Differential Diagnosis and Clinical Features

Breast masses are a common concern for women, and it is important to differentiate between benign and malignant causes. Here, we discuss the clinical features and differential diagnosis of various breast masses.

Diffuse cystic mastopathy is a benign condition that affects a significant proportion of women. It is characterized by the formation of cysts in the breast lobules due to hormonal changes in the menstrual cycle. The lumps are smooth, mobile, and tend to peak in size before each period. Diagnosis is primarily based on clinical examination, but a biopsy may be needed to confirm the diagnosis.

Fat necrosis is another benign condition that can occur due to direct trauma or surgery. It is characterized by the formation of firm, round, and painless masses in the breast. The skin around the lump may be red or bruised, and a biopsy may be needed to differentiate it from breast cancer.

Breast abscesses are characterized by local inflammation, pain, and fever. They may be associated with previous breast infections and may require drainage. However, there is no evidence of an infectious process in this patient.

Breast cancer is a concern in any patient with a breast mass, but early breast cancer is often asymptomatic. Physical findings that may indicate the possible presence of breast cancer include changes in breast size or shape, skin dimpling or changes, nipple abnormalities, and axillary lumps. However, none of these symptoms are present in this patient.

Fibroadenoma is the most common cause of breast mass in women under 35 years of age. It is characterized by a singular, firm, rubbery, smooth, and mobile mass. However, this patient reports multiple lumps, making a diagnosis of fibroadenoma less likely.

In conclusion, the cyclic nature of this patient’s breast masses makes diffuse cystic mastopathy the most likely diagnosis. However, a biopsy may be needed to confirm the diagnosis and rule out other causes.

To lower the risk of a pulmonary embolism, it is advised to discontinue the use of contraceptive pills four weeks prior to undergoing an operation, as per NICE guidelines. This is because oral contraceptives are recognized as a risk factor for thrombosis.

Venous Thromboembolism: Common Risk Factors

Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While there are many factors that can increase the risk of VTE, some are more common than others. These include malignancy, pregnancy, and the period following an operation. Other general risk factors include advancing age, obesity, family history of VTE, immobility, hospitalization, anaesthesia, and the use of central venous catheters. Underlying conditions such as heart failure, thrombophilia, and antiphospholipid syndrome can also increase the risk of VTE. Additionally, certain medications like the combined oral contraceptive pill, hormone replacement therapy, raloxifene, tamoxifen, and antipsychotics have been shown to be risk factors.

It is important to note that while these factors can increase the risk of VTE, around 40% of patients diagnosed with a PE have no major risk factors.

The primary cause of breast abscess in lactational women is Staphylococcus aureus, while Candida species is not a frequent culprit. On the other hand, Group B streptococcus and Klebsiella pneumoniae are responsible for breast abscess in non-lactating women.

Breast Abscess: Causes and Management

Breast abscess is a condition that commonly affects lactating women, with Staphylococcus aureus being the most common cause. The condition is characterized by the presence of a tender, fluctuant mass in the breast. To manage the condition, healthcare providers may opt for either incision and drainage or needle aspiration, typically using ultrasound. Antibiotics are also prescribed to help manage the infection.

Breast abscess is a condition that can cause discomfort and pain in lactating women. It is caused by Staphylococcus aureus, a common bacterium that can infect the breast tissue. The condition is characterized by the presence of a tender, fluctuant mass in the breast. To manage the condition, healthcare providers may opt for either incision and drainage or needle aspiration, typically using ultrasound. Antibiotics are also prescribed to help manage the infection. Proper management of breast abscess is crucial to prevent complications and ensure a speedy recovery.

For patients experiencing recurrent vaginal candidiasis, it is recommended to consider an induction-maintenance regime of oral fluconazole. Over the counter antifungal treatments, such as clotrimazole cream, are typically effective for one-off episodes of thrush. However, in cases of recurrent symptoms, a more comprehensive treatment plan may be necessary. It is important to ensure that the patient is not taking SSRI medications or has hypersensitivity to ‘azole’ antifungal medications before prescribing fluconazole. It should be noted that IM ceftriaxone and oral ciprofloxacin are used to manage Neisseria gonorrhoea, not thrush, and oral metronidazole is used to manage bacterial vaginosis, not thrush.

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.

Ulipristal, also known as EllaOne, is a form of emergency hormonal contraception that can be taken within 120 hours after engaging in unprotected sexual intercourse.

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.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

Management of Fibrocystic Breast Disease: Referral to Breast Surgery Team

Fibrocystic breast disease, also known as fibro-adenosis or fibrosclerosis, is a common benign condition that often presents with breast lumps or nodularity. According to National Institute for Health and Care Excellence (NICE) guidelines, patients under 30 years of age with a new breast lump without other suspicious features should be routinely referred to the Breast Clinic.

For patients presenting with a persistent lump, watch and wait may not be appropriate, and referral for assessment is indicated. Urgent 2-week wait referral is recommended for patients over 30 years of age with a new unexplained breast or axillary lump, or skin or nipple changes suggestive of breast cancer.

Mammography is not indicated for patients under 35 years of age with a suspected fibro-adenoma. Instead, triple assessment with ultrasonography is recommended. Antibiotics are not indicated unless there is evidence of infection or abscess.

The Mirena intrauterine system is approved for use as the progesterone component of hormone replacement therapy for a duration of 4 years. In a woman with a uterus, hormone replacement therapy aims to replace oestrogen to alleviate menopausal symptoms, but an additional source of progesterone is required to counteract the effects of unopposed oestrogen on the uterus, which increases the risk of endometrial hyperplasia and malignancy. As this patient already has the Mirena coil in place, which releases progesterone locally to act on the uterus, the only necessary treatment is oestrogen. Estradiol is the only option that provides only oestrogen therapy and can be administered topically or transdermally. Combined HRT, which includes both oestrogen and progesterone, would be inappropriate as the patient is already receiving progesterone from the Mirena coil. Levonorgestrel and medroxyprogesterone are both progesterones and would not provide oestrogen supplementation to the patient, which is necessary to alleviate her menopausal symptoms.

Managing Menopause: Lifestyle Modifications, Hormone Replacement Therapy, and Non-Hormone Replacement Therapy

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms are common and can last for up to 7 years, with varying degrees of severity and duration. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage menopausal symptoms such as hot flushes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended. For women who cannot or do not want to take HRT, non-hormonal treatments such as fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturizers for vaginal dryness, and cognitive behavior therapy or antidepressants for psychological symptoms can be prescribed.

HRT is a treatment option for women with moderate to severe menopausal symptoms. However, it is contraindicated in women with current or past breast cancer, any estrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia. HRT brings certain risks, including venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer. Women should be advised of these risks and the fact that symptoms typically last for 2-5 years.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence of symptoms in the short term. However, in the long term, there is no difference in symptom control. Women who experience ineffective treatment, ongoing side effects, or unexplained bleeding should be referred to secondary care. Overall, managing menopause requires a personalized approach that takes into account a woman’s medical history, preferences, and individual symptoms.

In the context of managing a pregnant patient with well-controlled type 1 diabetes, it is crucial to implement preventive measures that can enhance maternal and fetal health. At 12 weeks of gestation, the initiation of low-dose aspirin is recommended for women with diabetes. This intervention is aimed at reducing the risk of preeclampsia, a condition characterized by high blood pressure and potential organ dysfunction that can arise during pregnancy, particularly in women with pre-existing conditions such as diabetes. While vitamin B12 supplementation is important for certain populations, it is not routinely initiated at this stage unless there is a specific deficiency. Ascorbic acid, or vitamin C, does not have established guidelines for routine supplementation during pregnancy. Multivitamins are generally beneficial, but they are not specifically indicated to be started at 12 weeks for this patient group. Ferrous fumarate, an iron supplement, is typically reserved for cases of iron deficiency anemia, which may not be applicable in this scenario given the patient’s current health status.

Key Takeaways:

– Low-dose aspirin is recommended at 12 weeks gestation for women with diabetes to lower the risk of preeclampsia.

– Vitamin B12, ascorbic acid, multivitamins, and ferrous fumarate are not specifically indicated for initiation at this gestational age in this patient population.

– Monitoring and preventive strategies are essential in managing pregnancies complicated by pre-existing diabetes.

It is essential to treat the candidal infection by administering miconazole cream to both the mother and child. The cream should be applied to the nipple after feeding and the infant’s oral mucosa. Breastfeeding should continue during the treatment period. Additionally, the mother should be educated on maintaining good hand hygiene after changing the baby’s nappy and sterilizing any objects that the baby puts in their mouth, such as dummies and teats. This information is provided by NICE CKS.

Breastfeeding Problems and Their Management

Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.

Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.

Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.

If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.

The human papillomavirus (HPV) is a common sexually transmitted infection that can lead to cervical cancer. There are over 100 types of HPV, with types 16 and 18 being high-risk types that are responsible for the majority of cervical cancers. Types 6 and 11 are low-risk types that typically cause benign genital warts. Although not part of the screening process, the Gardasil vaccine can protect against both HPV types 6 and 11.

Contrary to popular belief, not all samples undergo both HPV testing and cytology. Only samples that test positive for high-risk HPV undergo cytology testing. Samples that test negative for high-risk HPV do not require further testing.

In the past, samples were first examined under a microscope (cytology) before HPV testing. However, research has shown that testing for high-risk HPV first is more effective. If a woman tests positive for HPV, she will receive a single letter informing her of her HPV status and whether any abnormal cells were detected.

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.

Penile cancer can manifest as an ulcer. The most prevalent form of penile cancer is squamous cell carcinoma, not adenocarcinoma. While stress ulcers cause abdominal pain and bleeding, they are not responsible for this presentation. Herpes outbreaks can be triggered by significant stress, but they typically cause painful lesions that heal within a week. Syphilis, caused by Treponema pallidum, can result in a painless ulcer called a chancre, but it does not cause weight loss, and the lesion usually resolves within six to eight weeks, even without treatment.

Understanding Penile Cancer: Causes, Symptoms, and Treatment

Penile cancer is a rare type of cancer that is typically characterized by squamous cell carcinoma. It is a condition that affects the penis and can cause a variety of symptoms, including penile lump and ulceration. There are several risk factors associated with penile cancer, including human immunodeficiency virus infection, human papillomavirus virus infection, genital warts, poor hygiene, phimosis, paraphimosis, balanitis, and age over 50.

When it comes to treating penile cancer, there are several options available, including radiotherapy, chemotherapy, and surgery. The prognosis for penile cancer can vary depending on the stage of the cancer and the treatment options chosen. However, the overall survival rate for penile cancer is approximately 50% at 5 years.

Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

Ovulation is caused by the LH surge.

Phases of the Menstrual Cycle

The menstrual cycle is a complex process that can be divided into four phases: menstruation, follicular phase, ovulation, and luteal phase. During the follicular phase, a number of follicles develop in the ovaries, with one follicle becoming dominant around the mid-follicular phase. At the same time, the endometrium begins to proliferate. This phase is characterized by a rise in follicle-stimulating hormone (FSH), which results in the development of follicles that secrete oestradiol.

During ovulation, the mature egg is released from the dominant follicle and triggers the acute release of luteinizing hormone (LH). This phase occurs on day 14 of the menstrual cycle. Following ovulation, the luteal phase begins, during which the corpus luteum secretes progesterone. This hormone causes the endometrium to change into a secretory lining. If fertilization does not occur, the corpus luteum will degenerate, and progesterone levels will fall.

The cervical mucus also changes throughout the menstrual cycle. Following menstruation, the mucus is thick and forms a plug across the external os. Just prior to ovulation, the mucus becomes clear, acellular, and low viscosity. It also becomes ‘stretchy’ – a quality termed spinnbarkeit. Under the influence of progesterone, it becomes thick, scant, and tacky.

Basal body temperature is another indicator of the menstrual cycle. It falls prior to ovulation due to the influence of oestradiol and rises following ovulation in response to higher progesterone levels. Understanding the different phases of the menstrual cycle can help individuals track their fertility and plan for pregnancy.

The Benefits and Risks of Oral Contraceptives in Relation to Cancer

Oral contraceptives have been a topic of controversy when it comes to their association with cancer in women. However, various studies have shown that they can have both positive and negative effects on different types of cancer.

Breast Cancer:
The Collaborative Group on Hormonal Factors in Breast Cancer conducted a comprehensive analysis and found that current oral contraceptive users and those who had used them within the past 1-4 years had a slightly increased risk of breast cancer. However, the risk is small and resulting tumors spread less aggressively than usual.

Dysmenorrhoea:
For women with primary dysmenorrhoea who do not wish to conceive, a 3-6 month trial of hormonal contraception is reasonable. Monophasic combined oral contraceptives containing 30-35 μg of ethinylestradiol and norethisterone, norgestimate or levonorgestrel are usually the first choice.

Ovarian Cancer:
Oral contraceptives have been noted to prevent epithelial ovarian carcinoma, with studies showing an approximately 40% reduced risk of malignant and borderline ovarian epithelial cancer. This protection lasts for at least 15 years after discontinuation of use and increases with duration of use.

Endometrial Cancer:
Use of oral contraceptives is associated with a 50% reduction of risk of endometrial adenocarcinoma. Protection appears to persist for at least 15 years following discontinuation of use.

Colorectal Cancer:
Women who take combined oral contraceptives are 19% less likely to develop colorectal cancer.

In conclusion, while there are some risks associated with oral contraceptives, they also have benefits in reducing the risk of certain types of cancer. It is important for women to discuss their individual risks and benefits with their healthcare provider when considering the use of oral contraceptives.

Having endometriosis increases the risk of experiencing an ectopic pregnancy. This patient’s symptoms and positive pregnancy test suggest a likely diagnosis of an ectopic pregnancy. Other risk factors for ectopic pregnancy include previous ectopic pregnancy, fallopian tube damage, and IVF. However, multiparity, previous pre-eclampsia, twin pregnancy, and type 2 diabetes mellitus are not associated with an increased risk of ectopic pregnancy.

Understanding Ectopic Pregnancy: Incidence and Risk Factors

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. This condition is a serious medical emergency that requires immediate attention. According to epidemiological studies, ectopic pregnancy occurs in approximately 0.5% of all pregnancies.

Several risk factors can increase the likelihood of ectopic pregnancy. These include damage to the fallopian tubes due to pelvic inflammatory disease or surgery, a history of previous ectopic pregnancy, endometriosis, the use of intrauterine contraceptive devices (IUCDs), and the progesterone-only pill. In vitro fertilization (IVF) also increases the risk of ectopic pregnancy, with approximately 3% of IVF pregnancies resulting in ectopic implantation.

It is important to note that any factor that slows down the passage of the fertilized egg to the uterus can increase the risk of ectopic pregnancy. Early detection and prompt treatment are crucial in managing this condition and preventing serious complications.

Women with premature ovarian insufficiency should be offered hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of 51 years to manage symptoms of low estrogen, prevent osteoporosis, and protect against possible cardiovascular complications. As this patient has a uterus, combined replacement therapy is necessary to avoid the risk of endometrial cancer from unopposed estrogen. Therefore, the most appropriate answer is combined hormone replacement therapy until the age of 51. It is important to note that hormone replacement therapy should be offered to all women with premature ovarian failure to protect bone mineral density and manage symptoms of low estrogen. The progestogen-only pill alone is not sufficient as estrogen is needed to treat symptoms and promote bone mineral density, while progesterone is added to oppose estrogen and reduce the risk of endometrial cancer.

Premature Ovarian Insufficiency: Causes and Management

Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.

Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.

When a couple is trying to conceive, it is normal for it to take up to one year for them to be successful. Therefore, medical examinations are typically conducted after one year of consistent attempts to conceive. However, it may be wise to address any physical barriers that could be hindering the couple’s ability to conceive, which is why their sexual history is taken into consideration.

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

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

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

The recommended first-line treatment for menorrhagia is the intra-uterine system (IUS), which has a high success rate in stopping bleeding and only requires one insertion procedure. Additionally, it provides reliable contraception. Conversely, the copper coil may exacerbate menorrhagia symptoms. While medication such as the progesterone-only pill or combined oral contraceptive pill can be used, they are not the first choice. It would be an extreme measure to refer a woman of child-bearing age for a hysterectomy, especially when there are less invasive and reversible options available to treat menorrhagia, even if the patient expresses no desire for children.

Managing Heavy Menstrual Bleeding

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

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

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

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Pregnant women who have mild or moderate gestational hypertension, are beyond 37 weeks of pregnancy, and exhibit pre-eclampsia symptoms, should be advised to deliver their baby within 24 to 48 hours as per the existing recommendations.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

The patient has suffered a third degree perineal tear that has extended beyond the perineal mucosa and muscle, involving the EAS but not the rectal mucosa. Therefore, it is classified as a third degree tear. The appropriate course of action is to repair the tear in theatre by a clinician who is suitably trained. Repairing the tear on the ward by a midwife is not an option as it is a third degree tear. Similarly, repairing it in theatre by a clinician trained for fourth degree tears is not necessary. It is important to note that first degree tears do not require repair, but in this case, as it is a third degree tear, not repairing it would not be appropriate as it may not heal properly.

Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.

There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.

Induction of Labour: Reasons, Methods, and Complications

Induction of labour is a medical process that involves starting labour artificially. It is necessary in about 20% of pregnancies due to various reasons such as prolonged pregnancy, prelabour premature rupture of the membranes, diabetes, pre-eclampsia, and rhesus incompatibility. The Bishop score is used to assess whether induction of labour is required, which takes into account cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates that the cervix is ripe and there is a high chance of spontaneous labour or response to interventions made to induce labour.

There are several methods of induction of labour, including membrane sweep, vaginal prostaglandin E2, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. Membrane sweeping involves separating the chorionic membrane from the decidua by rotating the examining finger against the wall of the uterus. Vaginal prostaglandin E2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. Uterine hyperstimulation is the main complication of induction of labour, which refers to prolonged and frequent uterine contractions that can cause fetal hypoxemia and acidemia. In rare cases, uterine rupture may occur, which requires removing the vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and tocolysis with terbutaline.

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.

If a woman on COCP misses one pill, she should take the missed pill immediately and then take the next pill at the usual time. There is no need for any further action or emergency contraception such as a copper IUD. She can continue with the 7-day pill-free break as normal. Discarding the missed pill is not recommended as it could increase the risk of an unwanted pregnancy. Starting the next pack without the 7-day break is also not necessary in this case. However, if she misses two pills and there are fewer than seven pills left in the pack, she would need to start the next pack without a break.

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.

Pregnant women who contract chickenpox after 20 weeks of gestation should seek medical attention immediately. This is because chickenpox can lead to serious complications such as pneumonia, hepatitis, and encephalitis. Treatment with oral aciclovir is recommended if the woman presents within 24 hours of developing the rash. Aciclovir can help reduce the duration of fever and other symptoms. Symptomatic treatment can also be used alongside aciclovir. If the chickenpox is severe, the woman should be referred to the hospital for intravenous aciclovir. Additionally, a referral to fetal medicine may be necessary due to the small risk of fetal varicella syndrome in the first 28 weeks of pregnancy. It is important to advise anyone with chickenpox to avoid contact with pregnant women and neonates until all lesions have crusted over, which usually takes about 5 days after the onset of the rash. VZIG has no therapeutic benefit once the rash has started. These guidelines are based on the RCOG Greentop guidelines for chickenpox in pregnancy.

Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

To prevent neural tube defects in the foetus, it is crucial to consume folic acid. It is advised that women who are planning to conceive should take a supplement of 400 micrograms of folic acid daily. This dose should be continued until the 12th week of pregnancy. If there is a family history or a previous pregnancy affected by neural tube defects, the recommended dose should be increased.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

The recommended treatment for bacterial vaginosis in this patient is metronidazole, but high doses of this medication are not safe for breastfeeding. Fluconazole is used to treat thrush, while azithromycin is used for Chlamydia. Clarithromycin is prescribed for pneumonia, strep throat, and H. pylori infections.

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

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

Infertility may be linked to varicoceles.

Understanding Varicocele: Symptoms, Diagnosis, and Management

Varicocele is a medical condition characterized by the abnormal enlargement of the veins in the testicles. Although it is often asymptomatic, it can lead to infertility, making it an important condition to address. Varicoceles are more commonly found on the left side of the testicles, with over 80% of cases occurring on this side. The condition is often described as a bag of worms due to the appearance of the affected veins.

Diagnosis of varicocele is typically done through ultrasound with Doppler studies. This allows doctors to visualize the affected veins and determine the extent of the condition. While conservative management is often recommended, surgery may be necessary if the patient experiences pain or discomfort. However, there is ongoing debate regarding the effectiveness of surgery in treating infertility associated with varicocele.

Overall, understanding varicocele is important for men who may be experiencing infertility or other symptoms related to the condition. With proper diagnosis and management, it is possible to address the issue and improve overall reproductive health.

Maternal obesity with a BMI of 30 kg/m2 or more increases the risk of neural tube defects in babies. There is no strong evidence linking obesity to hyper- or hypothyroidism in neonates, an increased risk of Down syndrome, or cystic fibrosis.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

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.

Understanding Cervical Cancer and Abnormal Smear Test Results

Cervical cancer is a common malignancy in women worldwide and can be detected through routine cervical screening. An abnormal Papanicolaou (‘smear’) test result is the most common finding in patients with cervical cancer. Physical symptoms may include abnormal vaginal bleeding, vaginal discomfort, malodorous discharge, and dysuria. Referral for colposcopy and biopsy should be made within two weeks for patients with symptoms of cervical cancer. Women with a cervical cytology result of moderate, high-grade dyskaryosis, suspected invasive cancer or glandular neoplasia should also be referred for colposcopy within two weeks. Cervical cauterisation with silver nitrate is not associated with the development of cervical cancer and is used to treat cervical ectropion. Endocervical swab for Chlamydia spp. may be necessary for women presenting with mucopurulent cervicitis. Understanding these guidelines and symptoms can help with early detection and treatment of cervical cancer.