If a cervical smear test performed as part of the NHS cervical screening programme is inadequate, it should be first tested for high-risk HPV (hrHPV) and then repeated within 3 months. Colposcopy should only be performed if the second sample also returns as inadequate. Returning the patient to normal recall would result in a delay of 3 years for a repeat smear test, which is not recommended as it could lead to a missed diagnosis of cervical cancer. Repeating the test in 1 month is too soon, while repeating it in 6 months is not in line with current guidelines.

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.

The appropriate management for urgency urinary incontinence (UUI) is to refer the patient for bladder training. UUI is characterized by uncontrollable bladder leakage that occurs shortly after the patient experiences a sudden urge to urinate, and is often associated with an overactive bladder that causes symptoms such as increased urinary frequency and nocturia. Advising the patient to reduce fluid intake and use continence products is not the correct approach, as both too much and too little fluid can contribute to lower urinary tract symptoms. Instead, patients should be advised to make lifestyle changes such as reducing caffeine intake, losing weight, and quitting smoking. Referring the patient for pelvic floor muscle training is the appropriate management for stress incontinence, which causes urine leakage during exertion, sneezing, or coughing. However, this is not applicable in this case as the patient denies these symptoms. If conservative management is unsuccessful and the patient does not wish to explore surgical options, a trial treatment with duloxetine may be considered for stress incontinence.

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.

When an ovarian cyst ruptures, it can cause sudden and severe pain on one side of the pelvis, especially after sexual activity or strenuous exercise. During a physical exam, the lower abdomen may be tender, but there may not be any other noticeable abnormalities. An ultrasound can reveal the presence of fluid in the pelvic area. It’s important to note that ovarian or adnexal torsion can also cause similar symptoms, including sharp pain on one side, nausea, and vomiting. However, in this case, a palpable mass may be felt during a physical exam, and an ultrasound may show an enlarged ovary with reduced blood flow.

Gynaecological Causes of Abdominal Pain in Women

Abdominal pain is a common complaint among women, and it can be caused by various gynaecological disorders. To diagnose these disorders, a bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning should be performed in addition to routine diagnostic workup. If diagnostic doubt persists, a laparoscopy can be used to assess suspected tubulo-ovarian pathology.

There are several differential diagnoses of abdominal pain in females, including mittelschmerz, endometriosis, ovarian torsion, ectopic gestation, and pelvic inflammatory disease. Mittelschmerz is characterized by mid-cycle pain that usually settles over 24-48 hours. Endometriosis is a complex disease that may result in pelvic adhesion formation with episodes of intermittent small bowel obstruction. Ovarian torsion is usually sudden onset of deep-seated colicky abdominal pain associated with vomiting and distress. Ectopic gestation presents as an emergency with evidence of rupture or impending rupture. Pelvic inflammatory disease is characterized by bilateral lower abdominal pain associated with vaginal discharge and dysuria.

Each of these disorders requires specific investigations and treatments. For example, endometriosis is usually managed medically, but complex disease may require surgery and some patients may even require formal colonic and rectal resections if these areas are involved. Ovarian torsion is usually diagnosed and treated with laparoscopy. Ectopic gestation requires a salpingectomy if the patient is haemodynamically unstable. Pelvic inflammatory disease is usually managed medically with antibiotics.

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

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

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

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

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

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

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

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

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

Ectopic Pregnancy: Sites and Symptoms

Ectopic pregnancy is a condition where the fertilized egg implants outside the uterine cavity. The most common site for ectopic implantation is the Fallopian tube, particularly the ampullary region, accounting for 97% of cases. Symptoms include 4-8 weeks of amenorrhea, abdominal pain, vaginal bleeding, and signs of shock associated with rupture. Shoulder tip pain may also occur due to irritation of the phrenic nerve. Diagnosis is made through measurement of β-human chorionic gonadotrophin and ultrasound scan of the abdomen, with laparoscopic investigation as the definitive method. Treatment involves removal of the pregnancy and often the affected tube via laparoscopy or laparotomy.

Other sites for ectopic pregnancy include the peritoneum or abdominal cavity, which accounts for 1.4% of cases and may proceed to term. Cervical pregnancy is rare, accounting for less than 1% of cases. Ovarian pregnancy occurs in 1 in 7000 pregnancies and accounts for 0.5-3% of all ectopic pregnancies. The broad ligament is an uncommon site for ectopic pregnancies due to its poor vascularity.

Investigating Infertility: Recommended Tests and Procedures

When a patient presents with infertility, there are several tests and procedures that can be performed to identify the underlying cause. In the case of a patient with known co-morbidities such as previous ectopic pregnancy, pelvic inflammatory disease, or endometriosis, laparoscopy and dye is the most appropriate next step of investigation. This procedure involves Exploratory laparoscopy, allowing direct visualisation of the pelvis, and injection of dye into the uterus to assess tubal patency.

Luteinising hormone (LH) and follicle-stimulating hormone (FSH) testing is typically performed when a patient has irregular menses, but may not be necessary for those with regular cycles and normal mid-luteal progesterone levels indicating ovulation. Basal body temperature charts are not recommended by NICE guidelines, as a mid-luteal phase progesterone blood test is a more accurate measure of ovulation.

Cervical smears may be indicated if the patient is due for screening, but do not form part of infertility investigations. Hysterosalpingography is recommended by NICE guidelines for women without co-morbidities, but is not appropriate for those with a history of endometriosis. Understanding the appropriate tests and procedures for investigating infertility can help healthcare providers identify the underlying cause and develop an effective treatment plan.

The patient’s symptoms indicate that they may be suffering from migraine, specifically migraine with aura. This condition is classified as UKMEC 4, meaning that it poses a significant health risk when taking combined oral contraceptive pills. While visual disturbances are the most common aura symptoms, some patients may experience sensory or motor symptoms such as tingling, weakness, or difficulty speaking. While other factors in the patient’s medical history may also be relevant, migraine with aura is the primary concern when considering contraception options.

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

Possible Causes of Amenorrhea and Hirsutism in Women

Amenorrhea, the absence of menstrual periods, and hirsutism, excessive hair growth, are symptoms that can be caused by various conditions. Polycystic ovarian syndrome (PCOS) is a common cause of anovulatory infertility and is diagnosed by the presence of two out of three criteria: ultrasound appearance of enlarged ovaries with multiple cysts, infrequent ovulation or anovulation, and clinical or biochemical evidence of hyperandrogenism. Turner syndrome, characterized by short stature, webbed neck, and absence of periods, is a genetic disorder that would not cause primary amenorrhea. Hyperprolactinemia, a syndrome of high prolactin levels, can cause cessation of ovulation and lactation but not an increase in BMI or hair growth. Premature ovarian failure has symptoms similar to menopause, such as flushing and vaginal dryness. Virilizing ovarian tumor can also cause amenorrhea and hirsutism, but PCOS is more likely and should be ruled out first.