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 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.

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.

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

The woman’s symptoms are most likely caused by the intrauterine device (IUD), which is known to increase the intensity and discomfort of periods. Ectopic pregnancy and miscarriage are unlikely as the pregnancy test was negative. A urinary tract infection is also unlikely as the urine dip was normal. Although appendicitis should be considered, it does not explain the vaginal bleeding, and the woman’s normal appetite, lack of fever, and mild examination results do not support this diagnosis.

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

The combined oral contraceptive pill is associated with a higher likelihood of developing breast and cervical cancer, but it can also provide protection against ovarian and endometrial cancer.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

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

When a pregnant woman is exposed to chickenpox, the first step is to check for antibodies. Chickenpox is caused by a virus called varicella-zoster and can cause a range of symptoms including myalgia and headache, followed by a rash of small macules, clear vesicles, and pustules. The disease can be more severe in adults and can lead to complications such as pneumonia and secondary bacterial infections. In pregnant women, there is a risk of complications for the fetus, particularly after 36 weeks gestation. If a child is born within 7 days of the mother developing the rash, they are at increased risk of severe chickenpox and may require treatment. Significant exposure to chickenpox is defined as being in the same room for 15 minutes or more with someone who has the disease. If a pregnant woman is unsure of their chickenpox exposure, they should be tested for varicella-zoster IgG levels. If positive, they are immune, but if negative, further advice should be sought from obstetrics and gynecology. It is important to act promptly and seek medical advice if a pregnant woman displays any symptoms of chickenpox.

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.

Despite the absence of symptoms, the patient’s blood pressure remains elevated at a level exceeding 160/100 mmHg, and there is also significant proteinuria, despite receiving labetalol treatment. As a result, emergency admission is necessary to monitor and manage the hypertension in a controlled setting. If there is no improvement, delivery may be considered as an option.

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.

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.

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.

According to FSRH guidelines, it is acceptable to begin hormonal contraception immediately after taking levonorgestrel (Levonelle) for emergency contraception. It is important to wait 5 days after taking ulipristal acetate (Ella-OneTM) before starting ongoing hormonal contraception. Waiting until the start of the next menstrual period is not necessary for quick-starting hormonal contraception, which can be done if the patient prefers it or if there is ongoing risk of pregnancy. While a negative pregnancy test at 21 days post-UPSI can reasonably exclude pregnancy, it is still recommended to take a pregnancy test 21 days after the episode of UPSI in case emergency contraception has failed.

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.

Hyperreflexia and clonus are commonly observed in patients with severe pre-eclampsia, while a decrease in platelet count may indicate the onset of HELLP syndrome.

Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

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.

Bacterial vaginosis (BV) is a common vaginal infection that affects many women, with up to 50% of cases being asymptomatic. The main symptom of BV is a fishy-smelling discharge from the vagina.

In pregnant women, BV can lead to late miscarriage and preterm delivery if left untreated. Therefore, all pregnant women who experience symptoms should receive treatment. This typically involves taking oral metronidazole twice a day for 5-7 days, as a single 2-gram dose is not recommended during pregnancy.

However, for asymptomatic pregnant women with BV, treatment is considered on a case-by-case basis. This is because research suggests that identifying and treating asymptomatic cases does not necessarily reduce the risk of preterm birth. This information is based on guidelines from NICE CKS.

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.

The symptoms of HELLP syndrome, a severe form of pre-eclampsia, include haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A patient with this condition may experience malaise, nausea, vomiting, and headache, as well as hypertension with proteinuria and epigastric and/or upper abdominal pain. The patient in this case meets the requirements for a diagnosis of HELLP syndrome.

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.

Oligohydramnios is a condition that occurs during pregnancy when there is a shortage of amniotic fluid. This can result in a smaller symphysiofundal height.

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.

For women with risk factors for infertility, such as contralateral tube damage, salpingotomy should be considered as the preferred surgical management for ectopic pregnancy. In the case of this patient, who presented with acute-onset abdominal pain and vaginal bleeding 6-8 weeks after her last period, a positive pregnancy test, and ultrasound findings confirming ectopic pregnancy, surgical intervention is necessary. Given the size of the ectopic pregnancy and beta-hCG levels, either laparoscopic salpingectomy or salpingotomy is appropriate. However, since the patient has a history of PID and scarring of the contralateral tube, salpingotomy is the preferred option as it preserves the affected tube and her fertility. Expectant management, laparoscopic salpingectomy, and medical management with methotrexate are not appropriate for this patient’s case.

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.

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.

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.

[Insert flowchart here]

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).

Differential Diagnosis of a Woman with Acne and Infertility

Polycystic ovarian syndrome (PCOS), endogenous Cushing’s syndrome, Addison’s disease, congenital adrenal hyperplasia (CAH), and primary hypoparathyroidism are all potential differential diagnoses for a woman presenting with acne and infertility. PCOS is the most likely diagnosis, as it presents with menstrual dysfunction, anovulation, and signs of hyperandrogenism, including excess terminal body hair in a male distribution pattern, acne, and male-pattern hair loss. Endogenous Cushing’s syndrome and primary hypoparathyroidism are less likely, as they do not present with acne and infertility. Addison’s disease is characterized by hyperpigmentation, weakness, fatigue, poor appetite, and weight loss, while CAH may present with oligomenorrhoea, hirsutism, and/or infertility.

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.

It was once believed that taking antibiotics while on any form of contraceptive pill could reduce the pill’s effectiveness. However, it is now known that broad-spectrum antibiotics do not interact with the progesterone-only pill, and therefore no extra precautions are necessary. The only exception is enzyme-inducing antibiotics like rifampicin, which may affect the pill’s efficacy. Additionally, if an antibiotic causes vomiting or diarrhea, it may also affect the pill’s effectiveness, but this is true for any form of vomiting or diarrhea. Therefore, the correct advice is to reassure patients that no additional precautions are needed. Advising the use of barrier contraceptives or ceasing the pill is incorrect, as there is no evidence to support these actions.

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.

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.

During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.

If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during 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.

Couples are advised to engage in regular sexual intercourse every 2-3 days for a period of 12 months before seeking referral to a specialist. After this time, fertility testing should be conducted, including semen analysis for the male and mid-luteal progesterone level for the female to confirm ovulation. The use of basal body temperature kits is not recommended as they can increase anxiety and have not been proven effective. However, early referral should be considered for females over 35 years of age, those with a history of amenorrhea or pelvic surgery, and those with abnormal genital examinations. Males with a history of genital surgery, STIs, varicocele, or significant systemic illness should also be referred early.

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.

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.

If a pregnant woman is not immune to the varicella zoster virus and has been in close contact with someone who has the virus, it is recommended that she receive varicella-zoster immunoglobulin (VZIG) as soon as possible. VZIG can be effective up to 10 days after contact, or 10 days after the appearance of the rash in the person with the virus if there are continuous exposures.
For pregnant women who are not immune and have been exposed to chickenpox, they should be considered potentially infectious from 8-28 days after exposure if they receive VZIG, and from 8-21 days after exposure if they do not receive VZIG.
Source: RCOG

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.

Cervical cancer screening now includes testing all samples for hrHPV. If the result is positive, cytology is performed. If the cytology is normal, the test is repeated after 12 months.

Upon repeat testing, if the result is now negative for hrHPV, the patient can resume normal recall. However, if the result is still positive for hrHPV and the cytology is normal, another repeat test should be done after 12 months. This applies to the patient in the given scenario.

If the second repeat test at 24 months is negative for hrHPV, the patient can return to normal recall. However, if the result is positive for hrHPV, they should be referred for colposcopy.

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