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.

Understanding Cervical Ectropion

Cervical ectropion is a condition that occurs when the columnar epithelium of the cervical canal extends onto the ectocervix, where the stratified squamous epithelium is located. This happens due to elevated levels of estrogen, which can occur during the ovulatory phase, pregnancy, or with the use of combined oral contraceptive pills. The term cervical erosion is no longer commonly used to describe this condition.

Cervical ectropion can cause symptoms such as vaginal discharge and post-coital bleeding. However, ablative treatments such as cold coagulation are only recommended for those experiencing troublesome symptoms. It is important to understand this condition and its symptoms in order to seek appropriate medical attention if necessary.

The use of the levonorgestrel IUS as a contraceptive or treatment for menorrhagia is not recommended in women with a distorted fibroid uterus due to the complexity and difficulty of the procedure. Other contraindications include current pregnancy, pelvic inflammatory disease, trophoblastic disease, breast/endometrial/ovarian/cervical cancer, postpartum endometritis, septic abortion/miscarriage in the last three months, and cervical intra-epithelial neoplasia. Migraine with aura is an absolute contraindication to the use of the combined oral contraceptive pill, but the levonorgestrel IUS can be safely used. It is safe to use the levonorgestrel IUS during breastfeeding, and it can be used by women of all ages, regardless of parity. A history of venous thromboembolism is a contraindication to the use of the combined oral contraceptive pill, but the levonorgestrel IUS is safe to use according to NICE guidance.

Common Causes of Vaginal Discharge: Symptoms and Treatment

Bacterial vaginosis, Trichomonas vaginalis, Candidiasis, gonorrhoeae, and Pelvic inflammatory disease are some of the most common causes of vaginal discharge in women.

Bacterial vaginosis is caused by an overgrowth of anaerobic bacteria and loss of lactobacilli in the vagina. It presents with a grey-white, thin discharge with a fishy odour and an increased vaginal pH. Metronidazole is the treatment of choice.

Trichomonas vaginalis is a sexually transmitted infection that presents with a yellow-green discharge and an erythematosus cervix with a punctate exudate.

Candidiasis is a fungal infection associated with pruritus, burning, erythema, and oedema of the vestibule. The vaginal discharge is thick, curd-like, and white.

gonorrhoeae can be asymptomatic or present with abdominal pain, mucopurulent discharge, cervicitis, dyspareunia, or abnormal bleeding.

Pelvic inflammatory disease is the result of an ascending infection and presents with dyspareunia, lower abdominal pain, menstrual irregularities, irregular bleeding, and a blood stained, purulent vaginal discharge. Cervicitis and cervical excitation are also present.

Proper diagnosis and treatment are essential to prevent complications and improve the quality of life of affected women.

Myoma: Common Benign Tumor in Women

Myoma, also known as uterine fibroids, is a benign tumor commonly found in women. It is characterized by histological features and symptoms such as menorrhagia and pressure. Although it may occur in teenagers, it is most commonly seen in women in their fourth and fifth decades of life. Black women are more likely to develop myomas and become symptomatic earlier. Having fewer pregnancies and early menarche are reported to increase the risk.

Myomas are benign tumors and do not metastasize to other organs. However, they may cause obstetric complications such as red degeneration, malpresentation, and the requirement for a Caesarean section. Surgical complications or intervention-related infections may lead to mortality, but associated deaths are rare. The 5-year survival rate is not applicable in this case.

Understanding Hormonal Patterns in Hypogonadism: A Guide to Diagnosis

Hypogonadism is a condition that affects the production of hormones necessary for sexual development. One form of hypogonadism is Kallmann syndrome, which is characterized by delayed or absent puberty and an inability to smell. This condition is caused by a defect in the release or action of gonadotropin-releasing hormone (GnRH), leading to gonadal failure. As a result, we expect to see reduced levels of GnRH, luteinising hormone (LH), follicle-stimulating hormone (FSH), and oestrogen in affected individuals.

Secondary hypogonadism, on the other hand, is caused by a problem in the pituitary gland. This can result in increased levels of GnRH, but decreased levels of LH, FSH, and oestrogen.

Primary hypogonadism, such as in Klinefelter’s and Turner syndrome, is characterized by problems with the gonads. In these cases, we expect to see increased levels of GnRH, LH, and FSH, but decreased levels of oestrogen.

Ectopic or unregulated oestrogen production can also cause hormonal imbalances, leading to decreased levels of GnRH, LH, and FSH, but increased levels of oestrogen.

It is important to understand these hormonal patterns in order to diagnose and treat hypogonadism effectively. By identifying the underlying cause of the condition, healthcare professionals can provide appropriate interventions to improve sexual development and overall health.

Starting hormonal contraception immediately after using levonorgestrel emergency contraceptive pill is safe. However, if ulipristal was used, hormonal contraception should be started or restarted after 5 days, and barrier methods should be used during this time. Waiting for 7 or 30 days before starting hormonal contraception is unnecessary as levonorgestrel does not affect its efficacy. A pregnancy test is only recommended if the patient’s next period is more than 5-7 days late or lighter than usual, not routinely after taking levonorgestrel.

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.

Possible Diagnoses for Hirsutism and Menstrual Irregularity in Reproductive-Age Women

Hirsutism and menstrual irregularity in reproductive-age women can be caused by various conditions. Polycystic ovarian syndrome (PCOS) and late-onset (non-classic) congenital adrenal hyperplasia are two possible diagnoses to consider. In this case, the normal 17-hydroxyprogesterone concentration rules out congenital adrenal hyperplasia, while the presence of bilaterally enlarged ovaries with multiple cysts and impaired glucose tolerance suggests PCOS.

An androgen-secreting adrenal tumour can also cause hirsutism, but it typically results in rapid onset and severe symptoms. Ovarian stromal hyperthecosis, which shares some resemblance with PCOS, may occur in premenopausal and postmenopausal women, but PCOS is more likely in this case due to the ultrasound scan findings.

Late-onset congenital adrenal hyperplasia can present with gradual onset of hirsutism without virilisation, but an elevated serum 17-hydroxyprogesterone concentration is a distinguishing feature. Luteoma of pregnancy, a benign solid ovarian tumour associated with excess androgen production, is unlikely in this case as the patient has not been pregnant.

In summary, PCOS is the most likely diagnosis for this patient’s hirsutism and menstrual irregularity, based on the ultrasound appearance and hormone results.

The patient should not restart the COCP within the first 21 days after giving birth due to the increased risk of venous thromboembolism. However, since the patient is not breastfeeding and has no additional risk factors for thromboembolic disease, she can safely restart the pill at 3 weeks postpartum. Restarting at any other time before the 21-day mark is not recommended.

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

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

If the patient has missed two pills between days 8-14 of her cycle but has taken the previous 7 days of COCP correctly, emergency contraception is not necessary according to the Faculty of Sexual and Reproductive Health. Since the patient is not in need of emergency contraception, offering her a hormonal-based emergency contraceptive would be inappropriate. However, if emergency contraception is required, options include EllaOne (ulipristal acetate) up to 120 hours after unprotected intercourse or Levonelle (levonorgestrel) up to 96 hours after unprotected intercourse. Inserting a copper IUD to prevent pregnancy would also be inappropriate in this case. If the patient is having difficulty remembering to take her pill correctly and is interested in long-acting contraception, counseling her on options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection would be appropriate. It should be noted that contraceptive injections are not used as a form of emergency contraception and advising a patient to take emergency contraception within 12 hours would be incorrect.

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.