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.

Common Causes of Abnormal Uterine Bleeding in Young Women

Abnormal uterine bleeding is a common problem among young women, especially within the first years of menarche. There are several possible causes, including anovulatory dysfunctional uterine bleeding, cervical cancer, ovulatory dysfunctional uterine bleeding, submucosal leiomyoma, and prolactinoma.

Anovulatory dysfunctional uterine bleeding occurs when the hormonal axis that regulates the menstrual cycle is not fully matured. This can lead to irregular and unpredictable bleeding due to the lack of ovulation and the resulting hyperoestrogenic state that induces endometrial hyperplasia.

Cervical cancer is associated with human papillomavirus infection and other risk factors such as smoking, early intercourse, multiple sexual partners, oral contraceptive use, and immunosuppression. It can cause vaginal spotting, post-coital bleeding, dyspareunia, and vaginal discharge.

Ovulatory dysfunctional uterine bleeding is caused by excessive production of vasoconstrictive prostaglandins in the endometrium during a menstrual period. This can result in more severe and prolonged bleeding associated with painful uterine contractions.

Submucosal leiomyoma is a benign neoplastic mass that protrudes into the intrauterine cavity and can cause metrorrhagia or menorrhagia. It is rare in young women.

Prolactinoma can result in oligomenorrhoea/amenorrhoea or anovulation and metromenorrhagia by inhibiting the action of hypothalamic gonadotrophin-releasing hormone on the anterior pituitary gland. This leads to reduced follicle-stimulating hormone and luteinising hormone secretion, resulting in abnormal uterine bleeding.

In conclusion, abnormal uterine bleeding in young women can have various causes, and a proper diagnosis is essential for appropriate treatment. Anovulatory dysfunctional uterine bleeding is the most likely cause in this case due to the patient’s age.

For cervical cancer screening, if the first repeat smear test after 12 months shows a negative result for high risk HPV (hrHPV), the patient can return to routine recall. However, if the initial smear test shows a positive result for hrHPV but is cytologically normal, the patient will be called back for a repeat test after 12 months. If the second test also shows a negative result for hrHPV, the patient can return to normal recall. On the other hand, if the second test is still positive for hrHPV but cytologically normal, it will be repeated again after 12 months.

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.

Diagnostic Tests for Abdominal Pain in Women of Childbearing Age

Abdominal pain in women of childbearing age requires a thorough diagnostic workup to rule out gynaecological emergencies such as ectopic pregnancy. The following diagnostic tests should be considered:

1. Pregnancy test (beta-human chorionic gonadotrophin (β-hCG)): This test should be the first step in the diagnostic workup to rule out ectopic pregnancy. A positive result requires urgent referral to the gynaecological team.

2. Full blood count: This test may indicate an ongoing infective process or other pathology, but a pregnancy test should be done first to rule out ectopic pregnancy.

3. Ultrasound of the abdomen and pelvis: Imaging may be useful in determining the cause of the pain, but a pregnancy test should be done first before considering imaging studies.

4. Urine culture and sensitivity: This test may be useful if a urinary tract infection and possible pyelonephritis are considered, but an ectopic pregnancy has to be ruled out first.

5. Erect chest X-ray: This test can show free air under the diaphragm, indicating a ruptured viscus and a surgical emergency. However, a pregnancy test should be done first to rule out ectopic pregnancy.

In conclusion, a thorough diagnostic workup is necessary to determine the cause of abdominal pain in women of childbearing age, with a pregnancy test being the first step to rule out gynaecological emergencies.

The appropriate technique to treat cervical intraepithelial neoplasia (CIN2 or CIN3) is urgent large loop excision of the transformation zone (LLETZ). Cryotherapy may also be considered as an alternative. Offering the HPV vaccination is not a suitable option for individuals who have already been diagnosed with CIN2 or CIN3. A repeat cervical smear within 3 months may be offered if the high-risk human papillomavirus (hrHPV) test result is unavailable or cytology is inadequate. Routine referral to gynaecology is not necessary as the patient would already be under the care of the colposcopy service.

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.

This question involves two components. Firstly, the lady in question is seven weeks postpartum and has had unprotected intercourse after day 21, putting her at risk of pregnancy. Therefore, she must have a pregnancy test before receiving any form of contraception. Secondly, the safety of the combined oral contraceptive pill (COCP) at 7 weeks postpartum is being considered. While the COCP is contraindicated for breastfeeding women less than 6 weeks postpartum, this lady falls into the 6 weeks – 6 months postpartum category where the benefits of prescribing the COCP generally outweigh the risks. Therefore, it would be suitable to prescribe the COCP for her. It is important to note that even if a woman is exclusively breastfeeding, the lactational amenorrhea method (LAM) is only effective for up to 6 months postpartum. Additionally, while the progesterone only pill is a good form of contraception, it is not necessary to recommend it over the COCP in this case.

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

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