First-line treatment for dysmenorrhoea involves NSAIDs, which work by inhibiting the synthesis of prostaglandins, a major contributor to menstrual pain.

Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

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

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

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

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingotomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Understanding Contraception: A Basic Overview

Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).

Barrier methods, such as condoms, physically block sperm from reaching the egg. While they can help protect against sexually transmitted infections (STIs), their success rate is relatively low, particularly when used by young people.

Daily methods include the combined oral contraceptive pill, which inhibits ovulation, and the progesterone-only pill, which thickens cervical mucus. However, the combined pill increases the risk of venous thromboembolism and breast and cervical cancer.

LARCs include implantable contraceptives and injectable contraceptives, which both inhibit ovulation and thicken cervical mucus. The implantable contraceptive lasts for three years, while the injectable contraceptive lasts for 12 weeks. The intrauterine system (IUS) and intrauterine device (IUD) are also LARCs, with the IUS preventing endometrial proliferation and thickening cervical mucus, and the IUD decreasing sperm motility and survival.

It is important to note that each method of contraception has its own set of benefits and risks, and it is essential to consult with a healthcare provider to determine the best option for individual needs and circumstances.

Weight gain is a known side effect of the Depo Provera contraceptive method. Additionally, it may take up to a year for fertility to return after discontinuing use, and there is an increased risk of osteoporosis and irregular bleeding. Other contraceptive methods such as the combined pill, progesterone only pill, and subdermal implant do not have a proven link to weight gain.

Injectable Contraceptives: Depo Provera

Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucus thickening and endometrial thinning.

However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

If the COC is initiated on the first day of the menstrual cycle, it becomes effective immediately. However, if it is started on any other day, additional contraception such as condoms should be used for the first 7 days. The injection, implant, IUS, and POP require 7 days to become effective, while the IUD is effective immediately upon insertion.

Counselling for Women Considering the Combined Oral Contraceptive Pill

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

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

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

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

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

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 patient is diagnosed with pre-eclampsia. According to the National Institute for Health and Care Excellence, initial treatment for severe hypertension in pregnancy (160/110mmHg or higher) should be labetalol. Delivery should not be considered before 34 weeks, unless the hypertension remains unresponsive to treatment or there are maternal or fetal indications as specified by the consultant plan. After completing a course of corticosteroids, delivery should be offered to women with pre-eclampsia at 34 weeks. In critical care situations, intravenous magnesium sulphate may be used for women who have previously experienced eclamptic fits due to severe hypertension or pre-eclampsia, but not solely to lower blood pressure. Frusemide should not be used to treat hypertension in pregnancy as it can reduce placental perfusion and cross the placental barrier.

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.

Pregnant women with obesity (BMI >30 kg/m2) are recommended to take a high dose of 5mg folic acid from before conception until the 12th week of pregnancy. This is because obesity puts them at a higher risk of neural tube defects. The suggestion of taking 400 micrograms would be for women who are not at a higher risk. Therefore, the other answers provided are incorrect.

Folic Acid: Importance, Deficiency, and Prevention

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

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

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

Women who have experienced heavy menstrual bleeding since their first period and have indications of a coagulation disorder in their personal or family medical history should undergo testing for such disorders, including von Willebrand’s disease. This recommendation is made by NICE CG44.

Understanding Menorrhagia: Causes and Definition

Menorrhagia is a condition characterized by heavy menstrual bleeding. While it was previously defined as total blood loss exceeding 80 ml per menstrual cycle, the assessment and management of the condition now focuses on the woman’s perception of excessive bleeding and its impact on her quality of life. Dysfunctional uterine bleeding, which occurs in the absence of underlying pathology, is the most common cause of menorrhagia, accounting for about half of all cases. Anovulatory cycles, uterine fibroids, hypothyroidism, pelvic inflammatory disease, and bleeding disorders such as von Willebrand disease are other potential causes of menorrhagia. It is important to note that the use of intrauterine devices, specifically copper coils, may also contribute to heavy menstrual bleeding. However, the intrauterine system (Mirena) is a treatment option for menorrhagia.

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

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

What is the effectiveness of secondary prevention measures for women with pre-eclampsia? A-level research has shown that low-dose aspirin, when started at 12-14 weeks’ gestation, is more effective than a placebo in reducing the occurrence of pre-eclampsia in high-risk women. This treatment also reduces perinatal mortality and the risk of babies being born small for gestational age. While low molecular weight heparin may reduce placental insufficiency in pre-eclampsia, there is currently a lack of long-term safety studies. Labetalol and methyldopa are commonly used antihypertensive drugs for acute management of pre-eclampsia, but they are not given prophylactically and do not reduce intrauterine growth retardation. Unfractionated heparin has also not been proven to prevent the development of uteroplacental insufficiency.

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.

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

Understanding Pelvic Inflammatory Disease

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

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

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

Breast cancer risk is increased by HRT, early menarche, late menopause, and COCP, while it is reduced by multiple pregnancy and breastfeeding.

Breast Cancer Risk Factors: Understanding the Predisposing Factors

Breast cancer is a complex disease that can be influenced by various factors. Some of these factors are considered predisposing factors, which means they increase the likelihood of developing breast cancer. One of the most well-known predisposing factors is the presence of BRCA1 and BRCA2 genes, which can increase a person’s lifetime risk of breast and ovarian cancer by 40%. Other predisposing factors include having a first-degree relative with premenopausal breast cancer, nulliparity, having a first pregnancy after the age of 30, early menarche, late menopause, combined hormone replacement therapy, combined oral contraceptive use, past breast cancer, not breastfeeding, ionizing radiation, p53 gene mutations, obesity, and previous surgery for benign disease.

To reduce the risk of developing breast cancer, it is important to understand these predisposing factors and take steps to minimize their impact. For example, women with a family history of breast cancer may choose to undergo genetic testing to determine if they carry the BRCA1 or BRCA2 genes. Women who have not yet had children may consider having their first child before the age of 30, while those who have already had children may choose to breastfeed. Additionally, women who are considering hormone replacement therapy or oral contraceptives should discuss the potential risks and benefits with their healthcare provider. By understanding these predisposing factors and taking proactive steps to reduce their impact, women can help protect themselves against breast cancer.

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.

Pregnant women with symptomatic bacterial vaginosis (BV) should be offered treatment using oral metronidazole. If BV is incidentally detected in a pregnant woman without symptoms, it is advisable to discuss with her obstetrician whether treatment is necessary. High-dose regimens are not recommended during pregnancy. In case the woman prefers a topical treatment or is unable to tolerate oral metronidazole, intravaginal metronidazole gel or clindamycin cream can be used as alternative choices. However, oral clindamycin is not widely recommended in primary care due to the increased risk of pseudomembranous colitis. This information is sourced from NICE CKS – Bacterial Vaginosis.

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.

If a woman is over 35 years old and has been having regular intercourse for 6 months without conceiving, she should be investigated for infertility earlier. Regular sexual intercourse is defined as having intercourse every 2-3 days. However, if a woman is under 35 years old, investigation should wait until after 12 months of regular intercourse. It is important to consider early referral when the female has amenorrhea, previous pelvic surgery, abnormal genital examination, or is suffering from significant systemic illness. Similarly, early referral should be considered for males who have had previous surgery on genitalia, previous STI, varicocele, or abnormal genital examination.

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.

Breast masses are a common concern among women, and it is important to understand the possible causes to determine the appropriate course of action. Here are some of the most common causes of breast masses and their characteristics:

Fibroadenoma: This is the most common cause of breast mass in women under 35 years old. It appears as a singular, firm, rubbery, smooth, mobile, painless mass ranging in size from 1 cm to 5 cm. Ultrasonography reveals a well-defined, hypoechoic, homogeneous mass 1–20 cm in diameter.

Fat Necrosis: This is a benign inflammatory process that occurs when there is saponification of local fat. It can result from direct trauma or nodular panniculitis. The breast mass is usually firm, round, and painless, and there may be a single mass or multiple masses. It may be tender or painful in some people.

Breast Abscess: This usually presents with localised breast oedema, erythema, warmth, and pain. There may be associated symptoms of fever, nausea, vomiting, spontaneous drainage from the mass or nipple, and a history of previous breast infection.

Breast Cancer: Early breast cancer may be asymptomatic, and pain and discomfort are typically not present. It is often first detected as an abnormality on a mammogram before it is felt by the patient or healthcare professional. If a lump is discovered, there may be a change in breast size or shape, skin dimpling or skin changes, recent nipple inversion or skin change, or nipple abnormalities.

Lipoma: Lipomas are common benign tumors composed of mature adipocytes that typically present clinically as well-circumscribed, soft, mobile, nontender masses. The classic mammographic appearance of lipoma is a circumscribed fat-containing mass.

It is important to note that the physical examination findings may not always be enough to determine the cause of the breast mass, and further testing may be necessary. Consultation with a healthcare professional is recommended for proper diagnosis and treatment.

The risk factors for ovarian cancer are associated with a higher frequency of ovulations.

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.

The copper intrauterine device is the only suitable method for this patient as it can be used as emergency contraception if inserted within 5 days of unprotected sexual intercourse or within 5 days of the estimated ovulation date, whichever is later. As the patient has a regular 28-day cycle and is currently at day 17, she is within the 5-day window for fitting of the IUD. Levonorgestrel, a tablet used for emergency contraception, would not be suitable as it must be taken within 72 hours of unprotected sexual intercourse. The Mirena intrauterine system is a hormonal device used for regular contraception but cannot be used as emergency contraception. Norethisterone is a drug used for dysfunctional uterine bleeding and period delay but not 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.

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

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

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

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

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

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

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

The most likely diagnosis for this patient is androgen insensitivity syndrome (AIS). This is because she has not started menstruating by the age of 15, has little to no axillary or pubic hair, and elevated testosterone levels. These symptoms are all indicative of AIS, which is a genetic condition where individuals with male chromosomes (46XY) have a female appearance due to their body’s resistance to testosterone. The lower pelvic masses seen on examination are likely to be undescended testes.

Congenital adrenal hyperplasia (CAH) is an unlikely diagnosis as it typically causes excess male-pattern hair growth, including axillary and pubic hair, which is not seen in this patient. Additionally, CAH would not explain the presence of the lower pelvic masses.

Functional hypothalamic amenorrhoea is also unlikely as this condition is typically associated with low body weight, which is not the case for this patient. Furthermore, her FSH and LH levels are within the normal range, indicating that there is no hypothalamic dysfunction.

Polycystic ovarian syndrome (PCOS) is an unlikely diagnosis as it typically causes irregular periods rather than a complete absence of menstruation. Additionally, patients with PCOS often have excessive hair growth, which is not seen in this patient. PCOS would also not explain the presence of the lower pelvic masses.

Understanding Androgen Insensitivity Syndrome

Androgen insensitivity syndrome is a genetic condition that affects individuals with an XY genotype, causing them to develop a female phenotype due to their body’s resistance to testosterone. This condition was previously known as testicular feminization syndrome. The main features of this condition include primary amenorrhea, little or no pubic and axillary hair, undescended testes leading to groin swellings, and breast development due to the conversion of testosterone to estrogen.

Diagnosis of androgen insensitivity syndrome can be made through a buccal smear or chromosomal analysis, which reveals a 46XY genotype. After puberty, testosterone levels in affected individuals are typically in the high-normal to slightly elevated range for postpubertal boys.

Management of androgen insensitivity syndrome involves counseling and raising the child as female. Bilateral orchidectomy is recommended to reduce the risk of testicular cancer due to undescended testes. Additionally, estrogen therapy may be used to promote the development of secondary sexual characteristics.

In summary, androgen insensitivity syndrome is a genetic condition that affects the development of individuals with an XY genotype, causing them to develop a female phenotype. Early diagnosis and management can help affected individuals lead healthy and fulfilling lives.

The most suitable emergency contraception option in this case is the copper intrauterine device, which can be inserted up to 5 days after the estimated ovulation date or the first instance of unprotected sexual intercourse in a cycle, whichever is later. As ovulation is likely to have already occurred (estimated as day 14, now on day 17), the copper IUD is the most effective option. It is considered the most reliable form of emergency contraception and should be offered to all patients unless there are contraindications. If the patient declines or the IUD is contraindicated, one of the hormonal pill options may be offered, although they may be less effective in this case. The Mirena intrauterine system is not suitable for emergency contraception as it has a delayed action. It is important to offer emergency contraception to all women who request it, even if it falls outside the recommended window of use, and to inform them that it may not be completely effective in preventing pregnancy.

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

Women who have recently given birth, whether they are breastfeeding or not, can begin taking the progesterone-only pill at any time postpartum.

It is safe to use progesterone-only pills while breastfeeding, and there is no need to wait for a specific amount of time before starting them. If the pills are started after 21 days, it is recommended to use additional protection for the first 2 days. However, if the woman starts taking the pills immediately, there is no need for extra protection.

Delaying the start of progesterone-only pills can increase the risk of unwanted pregnancy. Therefore, it is important to begin taking them as soon as possible, regardless of whether the woman is breastfeeding or not.

In summary, there is no contraindication to starting progesterone-only pills during the first 21 days postpartum, and breastfeeding does not affect the decision to start them. Women can continue breastfeeding while taking these pills.

After giving birth, women need to use contraception after 21 days. The progestogen-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 progestogen 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.

Endometriosis is characterized by pelvic pain, dysmenorrhoea, dyspareunia, and subfertility. The main indicators of this condition are cyclic abdominal pain and deep dyspareunia, which may be accompanied by fertility issues. Unlike endometriosis, pelvic inflammatory disease does not typically cause pain during menstruation. A bicornuate uterus, which is a congenital anomaly resulting in a heart-shaped uterus, is associated with a higher risk of recurrent miscarriages. Cervical carcinomas are usually accompanied by abnormal bleeding, such as post-coital and inter-menstrual bleeding, but they are unlikely to have been present for as long as three years.

Understanding Endometriosis

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

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

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

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

Special Situations for Combined Oral Contraceptive Pill

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

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

Management of Fibrocystic Breast Disease: Referral to Breast Surgery Team

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

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

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

The gestational diabetes guidelines of NICE have been updated, stating that insulin treatment must commence if the fasting glucose level is equal to or greater than 7 mmol/l. Additionally, it is recommended to consider administering aspirin due to the heightened risk of pre-eclampsia.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

A young woman who has never had a menstrual period before and has underdeveloped secondary sexual characteristics presents with raised FSH and LH levels. The most likely cause of her primary amenorrhoea is gonadal dysgenesis, which can be seen in syndromes such as Turner’s syndrome. In this condition, the gonads are atypically developed and may be functionless, resulting in the absence of androgen production in response to FSH and LH. This leads to underdeveloped secondary sexual characteristics and primary amenorrhoea. Asherman syndrome, imperforate hymen, Kallmann syndrome, and pregnancy are incorrect answers.

Understanding Amenorrhoea: Causes, Investigations, and Management

Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

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

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