If there has been a delay in changing the patch for over 48 hours but no sexual activity has occurred within the past 10 days, emergency contraception is not necessary. However, the individual must use barrier contraception for the next 7 days and replace the patch immediately. If there is no sexual activity planned for the next 7 days, no further action is required, but it is important to advise the individual to use barrier contraception during this time. It is crucial to replace the patch as soon as possible to ensure effective contraceptive coverage.

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

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

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

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

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.

If a patient presents with primary amenorrhoea and raised FSH/LH levels, it is important to consider the possibility of gonadal dysgenesis, such as Turner’s syndrome. This condition is characterized by the presence of only one X chromosome or a deletion of the short arm of one X chromosome, which can result in widely spaced nipples and other physical characteristics. In Turner’s syndrome, the lack of estrogen and progesterone production by the ovaries leads to an increase in FSH/LH levels as a compensatory mechanism. Therefore, an increase in FSH/LH levels is consistent with this diagnosis. Cyclical pain due to an imperforate hymen typically presents with secondary sexual characteristics, while increased prolactin levels are associated with galactosemia, and increased androgen levels are associated with polycystic ovarian syndrome. In the case described, a diagnosis of Turner’s syndrome is likely, and serum estrogen levels would not be expected to be elevated due to gonadal dysgenesis.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls without secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

Management Options for Stress Incontinence: A Case-Based Discussion

Stress incontinence is a common condition that can significantly impact a patient’s quality of life. In this scenario, a female patient has attempted lifestyle changes and pelvic floor exercises for three months with little effect. What are the next steps in management?

Duloxetine is a second-line management option for stress incontinence when conservative measures fail. It works by inhibiting the reuptake of serotonin and noradrenaline, leading to continuous stimulation of the nerves in Onuf’s nucleus and preventing involuntary urine loss. However, caution should be exercised in patients with certain medical conditions.

Continuing pelvic floor exercises for another three months is unlikely to yield significant improvements, and referral is indicated at this stage.

Intramural urethral-bulking agents can be used when conservative management has failed, but they are not as effective as other surgical options and symptoms can recur.

The use of a ring pessary is not recommended as a first-line treatment option for stress incontinence.

A retropubic mid-urethral tape procedure is a successful surgical option, but it may not be appropriate for high-risk patients who wish to avoid surgery.

In conclusion, the management of stress incontinence requires a tailored approach based on the patient’s individual circumstances and preferences.

Common Causes of Abdominal Mass in Women

One of the common symptoms that women may experience is an abdominal mass that is painful on palpation. This can be caused by various conditions, including ovarian serous cystadenomas, polycystic ovarian syndrome, fibroids, cystocele, and rectocele.

Ovarian serous cystadenomas are benign tumors composed of cysts suspended within fibrotic stroma. They are usually asymptomatic but can cause pain and mass symptoms when they grow to a size greater than 10 cm. These tumors are prone to torsion and can present as an acute abdomen. Removal of the mass is curative, and histological examination is essential to ensure there are no malignant features.

Polycystic ovarian syndrome is associated with irregular periods, skin acne, and weight gain. Fibroids, on the other hand, are hormone-driven and can cause menorrhagia, dysmenorrhea, constipation, and urinary symptoms. Subserosal, pedunculated, or ovarian fibroids can also present as an abdominal mass.

Cystocele and rectocele are conditions that present with a lump or dragging sensation in the vagina. Cystocele is associated with urinary frequency, incontinence, and frequent urinary tract infections, while rectocele is associated with incomplete emptying following a bowel motion and pressure in the lower pelvis.

In conclusion, an abdominal mass in women can be caused by various conditions, and it is important to seek medical attention for proper diagnosis and treatment.

The use of COCP as a first-line contraceptive should be avoided for wheelchair users due to their increased risk of developing deep vein thrombosis (DVT). The presence of oestradiol in COCP increases the risk of DVT, and immobility associated with wheelchair use further exacerbates this risk. Therefore, the risks of using COCP outweigh the benefits for wheelchair users, and it is classified as UKMEC 3.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

Misconceptions about Menopause and Reproduction

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

Common Misconceptions about Menopause and Reproduction

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

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

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

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

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

When dealing with patients who have urinary incontinence, it is crucial to eliminate the possibility of a UTI and diabetes mellitus as underlying causes. The first step in investigating urinary incontinence would be to conduct a urine dipstick and culture test, which can be easily done in a GP’s office. Other initial investigations include keeping a bladder diary for at least three days and undergoing urodynamic studies. It is important to note that the reliability of urine dip tests is questionable in women over 65 years of age and those who have catheters. A three-day bladder diary is necessary for initial investigations, and a one-day diary would not suffice. CT scans are not typically used to investigate urinary incontinence but are useful in detecting renal pathology such as ureteric calculi. Cystoscopy is not appropriate for this patient and is usually reserved for cases where bladder cancer is suspected.

Understanding Urinary Incontinence: Causes, Classification, and Management

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

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

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

The appropriate answer is that the woman cannot use the pill anymore due to an unacceptably high clinical risk. She has developed systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies, which is classified as UK Medical Eligibility Criteria for Contraceptive Use UKMEC 4, meaning it is an absolute contraindication. The risks of arterial and venous thrombosis would be too high if she were to restart the combined pill, and alternative contraceptive options should be considered. It is important to note that both SLE with positive antiphospholipid antibodies and isolated presence of antiphospholipid antibodies are classified as UKMEC 4 conditions, but not the diagnosis of antiphospholipid syndrome. The advantages of using the pill generally outweigh the risks is an incorrect answer, as it is equivalent to UKMEC 2. The correct answer would be applicable if the woman did not test positive for any of the three antiphospholipid antibodies or if she did not test positive again after 12 weeks. The risks usually outweigh the advantages of using the combined pill is also incorrect, as it is equivalent to UKMEC 3. Lastly, there is no risk or contraindication to her restarting the combined pill is an incorrect answer, as it is equivalent to UKMEC 1.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

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

Understanding Endometriosis

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

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

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