Tumour Markers for Different Types of Cancer

Tumour markers are substances that are produced by cancer cells or by the body in response to cancer. They can be detected in blood, urine, or tissue samples and can help in the diagnosis, monitoring, and treatment of cancer. Here are some tumour markers for different types of cancer:

– Ovarian cancer: CA125 is highly suggestive of ovarian cancer.
– Colorectal cancer: CEA is a tumour marker for bowel cancer.
– Breast cancer: CA 15–3 is a tumour marker for breast cancer.
– Pancreatic cancer: CA19–9 is a tumour marker for pancreatic cancer.
– Rectal cancer: Unfortunately, there is no specific marker for rectal cancer.

It is important to note that tumour markers are not always reliable and can be elevated in non-cancerous conditions as well. Therefore, they should be used in conjunction with other diagnostic tests and clinical evaluations.

Due to a weakened immune response and reduced clearance of the human papillomavirus, women who are HIV positive face an elevated risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer. If HIV positive women have low-grade lesions (CIN1), these lesions may not clear and could progress to high-grade CIN or cervical cancer. Even with effective antiretroviral treatment, these women still have a high risk of abnormal cytology and an increased risk of false-negative results. Therefore, it is recommended that women with HIV receive cervical cytology at the time of diagnosis and annually thereafter for screening purposes.

Understanding Cervical Cancer: Risk Factors and Mechanism of HPV

Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.

The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.

The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.

The topic of primary amenorrhoea is being discussed, where the patient is experiencing cyclical pain but has not had any evidence of menstruation. This eliminates certain possibilities such as mullerian agenesis and constitutional delay, which are typically painless. Turner syndrome is also unlikely as it is often accompanied by distinct physical features and health issues. Pregnancy cannot be ruled out entirely, but it is improbable given the patient’s lack of menarche and cyclical pain. Therefore, imperforate hymen is the most probable diagnosis.

Amenorrhoea refers to the absence of menstruation, which can be primary (when menarche has never occurred) or secondary (when the patient has not had periods for more than six months despite having had them in the past). Primary amenorrhoea is diagnosed if the patient has not had a period by the age of 14 without any secondary sexual characteristics, or over the age of 16 if such characteristics are present. The causes of primary amenorrhoea can include constitutional delay (when the patient is a late bloomer but has secondary sexual characteristics) or anatomical issues such as mullerian agenesis (where the patient has varying degrees of absence of female sexual organs despite developing secondary sexual characteristics).

Common Causes of Delayed Puberty

Delayed puberty is a condition where the onset of puberty is later than the normal age range. This can be caused by various factors such as genetic disorders, hormonal imbalances, and chronic illnesses. Delayed puberty with short stature is often associated with Turner’s syndrome, Prader-Willi syndrome, and Noonan’s syndrome. These conditions affect the growth and development of the body, resulting in a shorter stature.

On the other hand, delayed puberty with normal stature can be caused by polycystic ovarian syndrome, androgen insensitivity, Kallmann syndrome, and Klinefelter’s syndrome. These conditions affect the production and regulation of hormones, which can lead to delayed puberty.

It is important to note that delayed puberty does not necessarily mean there is a serious underlying condition. However, it is recommended to consult a healthcare professional if there are concerns about delayed puberty. Treatment options may include hormone therapy or addressing any underlying medical conditions.

In summary, delayed puberty can be caused by various factors and can be associated with different genetic disorders. It is important to seek medical advice if there are concerns about delayed puberty.

Treatment and Management of Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a serious condition resulting from an ascending sexually transmitted infection, commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Patients with PID may present with symptoms such as chronic lower abdominal pain, dyspareunia, irregular bleeding, dysmenorrhoea, and purulent vaginal discharge. It is important to identify and treat PID promptly, as it can lead to complications such as infertility, ectopic pregnancy, and pelvic adhesion formation.

The management of PID depends on the severity of the presentation. Patients who are haemodynamically stable can be treated in the primary care setting with a single dose of ceftriaxone IM, followed by metronidazole and doxycycline for 14 days. However, patients with pyrexia, nausea and vomiting, or suspicion of a tubo-ovarian abscess or pelvic peritonitis should be admitted to hospital for IV antibiotics.

It is important to note that NICE recommends treating patients who are likely to have PID without waiting for swab results. In patients considered high-risk for gonococcal infection, who have no indication for admission to hospital for parenteral antimicrobial treatment, a single dose of ceftriaxone 1 g IM, followed by 14 days of metronidazole and doxycycline is recommended. Ofloxacin, moxifloxacin, or azithromycin should be avoided in women at high risk of a gonococcal infection due to increased resistance against quinolones.

In conclusion, early identification and prompt treatment of PID is crucial to prevent complications. Treatment should be tailored to the severity of the presentation and the patient’s risk factors.

To diagnose PCOS, at least two out of three features must be present: oligomenorrhoea, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. In this case, the patient has oligomenorrhoea and clinical signs of hyperandrogenism, making a clinical diagnosis of PCOS likely. However, NICE guidelines recommend ruling out other potential causes of menstrual disturbance before confirming the diagnosis. BMI measurement is not necessary for diagnosis, although obesity is a common feature of PCOS. Testing for free or total testosterone levels is also not essential if clinical signs of hyperandrogenism are present.

Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.

To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.

Patients who have taken ulipristal acetate should wait for 5 days before resuming regular hormonal contraception. This is because hormonal contraception may be less effective when taken with ulipristal acetate, which could compromise its ability to prevent ovulation. However, there is an exception to this rule. If a patient is already taking the combined oral contraceptive pill (COCP) and has missed pills later than the first week of taking them, they can resume the COCP immediately after taking ulipristal acetate. Otherwise, patients should wait for 5 days before restarting hormonal contraception and use barrier methods during this period. It is not necessary to take a pregnancy test after taking ulipristal acetate unless the patient’s next period is more than 7 days late or lighter than usual. It is not contraindicated to use hormonal contraception with ulipristal acetate, but it is recommended to wait for 5 days before resuming it.

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 only accurate statement among the given options is that the intrauterine copper device is a safe contraceptive option for transgender males. This is because it is non-hormonal and does not interfere with testosterone therapy, although it may worsen menstrual bleeding. Condoms are also a viable option, but not the only safe one. Testosterone therapy does not prevent pregnancy and can even cause birth defects if the patient becomes pregnant. The combined oral contraceptive pill and vaginal ring are not recommended as they contain estrogen, which can counteract the effects of testosterone therapy. However, progesterone-only methods such as injections, the intrauterine system, and the progesterone-only pill are suitable options.

Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies.

For individuals engaging in vaginal sex where there may be a risk of pregnancy and/or sexually transmitted infections, condoms and dental dams are recommended. Cervical screening and human papillomavirus vaccinations should also be offered to sexually active individuals with a uterus. Those engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations. Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.

For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy. Testosterone therapy does not provide protection against pregnancy, and oestrogen-containing regimes are not recommended in patients undergoing testosterone therapy. Progesterone-only contraceptives are considered safe, and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding.

In patients assigned male at birth, there may be a reduction or cessation of sperm production with certain therapies, but the variability of effects means they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients engaging in vaginal sex wishing to avoid the risk of pregnancy. Emergency contraception may be required in patients assigned female at birth following unprotected vaginal intercourse, and either of the available oral emergency contraceptive options may be considered. The non-hormonal intrauterine device may also be an option, but it may have unacceptable side effects in some patients.

Overall, the guidance stresses the importance of individualized care and communication in contraceptive and sexual health decisions for transgender and non-binary individuals.

The copper intrauterine device is a viable option for emergency contraception if inserted within 5 days after the first unprotected sexual intercourse in a cycle or within 5 days of the earliest estimated ovulation date, whichever is later. It can be inserted up to 120 hours after unprotected sex, but if the patient presents after this time period, it can still be inserted up to 5 days after the earliest predicted ovulation date, which is typically 14 days before the start of the next cycle for patients with a regular 28-day cycle. It should be noted that the intrauterine system cannot be used for emergency contraception, and options 1, 3, and 4 are incorrect as they fall outside of the recommended time frame.

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.

Teratomas, also known as dermoid cysts, are non-cancerous tumors that originate from multiple germ cell layers. These tumors can produce a variety of tissues, including skin, hair, blood, fat, bone, nails, teeth, cartilage, and thyroid tissue, due to their germ cell origin.

Mature cystic teratomas have a white shiny mass or masses projecting from the wall towards the center of the cyst. This protuberance is called the Rokitansky protuberance and is where hair, bone, teeth, and other dermal appendages usually arise from.

While ovarian malignancy is rare in young females, suspicion can be assessed using the risk of malignancy index (RMI), which takes into account serum CA-125 levels, ultrasound findings, and menopausal status.

Understanding the Different Types of Ovarian Cysts

Ovarian cysts are a common occurrence in women, and they can be classified into different types. The most common type of ovarian cyst is the physiological cyst, which includes follicular cysts and corpus luteum cysts. Follicular cysts occur when the dominant follicle fails to rupture or when a non-dominant follicle fails to undergo atresia. These cysts usually regress after a few menstrual cycles. Corpus luteum cysts, on the other hand, occur when the corpus luteum fails to break down and disappear after the menstrual cycle. These cysts may fill with blood or fluid and are more likely to cause intraperitoneal bleeding than follicular cysts.

Another type of ovarian cyst is the benign germ cell tumour, which includes dermoid cysts. Dermoid cysts are also known as mature cystic teratomas and are usually lined with epithelial tissue. They may contain skin appendages, hair, and teeth. Dermoid cysts are the most common benign ovarian tumour in women under the age of 30, and they are usually asymptomatic. However, torsion is more likely to occur with dermoid cysts than with other ovarian tumours.

Lastly, there are benign epithelial tumours, which arise from the ovarian surface epithelium. The most common benign epithelial tumour is the serous cystadenoma, which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Serous cystadenomas are bilateral in around 20% of cases. The second most common benign epithelial tumour is the mucinous cystadenoma, which is typically large and may become massive. If it ruptures, it may cause pseudomyxoma peritonei.

In conclusion, understanding the different types of ovarian cysts is important for proper diagnosis and treatment. Complex ovarian cysts should be biopsied to exclude malignancy, while benign cysts may require monitoring or surgical removal depending on their size and symptoms.

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.

Tranexamic acid is the recommended first-line non-hormonal treatment for menorrhagia, particularly for this patient who is trying to conceive. The contraceptive pill and IUS are not suitable options, and endometrial ablation is not recommended for those who wish to have children in the future. As the patient’s periods are painless, mefenamic acid is not necessary. Tranexamic acid is an anti-fibrinolytic that prevents heavy menstrual bleeding by inhibiting plasminogen activators. This treatment aligns with the guidelines set by NICE for managing heavy menstrual bleeding.

Managing Heavy Menstrual Bleeding

Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

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The recommended first-line treatment for non-pregnant women with symptoms of vaginal thrush, such as a curd-like discharge and itching, is a single dose of oral fluconazole. This medication can often be obtained directly from a pharmacist without needing to see a GP. Using low dose topical corticosteroids until symptoms improve is not an appropriate treatment for managing the fungal infection. Similarly, taking oral cetirizine daily for two weeks is not the recommended course of action, although it may be used for treatment-resistant thrush. Oral fluconazole should be tried first before considering cetirizine. Lastly, a three-day course of oral fluconazole is not the appropriate duration of treatment for this patient population.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

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.

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.

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.

If analgesia is ineffective in treating endometriosis, the first-line option to try is the combined oral contraceptive pill or a progesterone.

The patient’s chronic cyclical pelvic pain, dyspareunia, secondary dysmenorrhoea, and pain with bowel movements are consistent with endometriosis. The examination findings also support this diagnosis. Paracetamol with or without an NSAID (such as mefenamic acid or ibuprofen) is the initial treatment for endometriosis. If these medications do not work, hormonal therapy (such as the combined oral contraceptive pill or medroxyprogesterone acetate) is the second-line option.

Since the patient plans to start a family within the next year, the combined oral contraceptive pill is the more appropriate choice as it does not delay fertility. Medroxyprogesterone acetate, also known as Depo Provera, provides contraception for up to 12 weeks but can delay fertility for up to 12 months and is irreversible once given. Additionally, the patient’s BMI of 34 kg/m² is a known risk factor for weight gain, which is a potential side effect of the injectable contraceptive.

Offering mefenamic acid is not recommended as analgesia has already been tried without success. If analgesia is ineffective in treating endometriosis, the combined oral contraceptive pill or a progesterone should be considered.

Referring the patient for consideration of GnRH analogue is not appropriate at this stage. This option is only considered if hormonal therapy is ineffective. It is important to trial the combined oral contraceptive pill before considering a referral.

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.

During pregnancy, uterine fibroids may experience growth. These fibroids are common and often do not show any symptoms. However, in non-pregnant women, they can cause menorrhagia. In early pregnancy, they grow due to oestrogen and can cause pelvic pain and pressure. If they grow too quickly and surpass their blood supply, they may undergo ‘red degeneration’. This patient’s symptoms, including pelvic pain and a history of menorrhagia, suggest that the growth of pre-existing fibroids due to oestrogen may be the cause. However, further investigation with ultrasound is necessary to confirm this diagnosis. Ectopic pregnancies are rare in the second trimester and are typically detected during routine ultrasound scans. This patient is unlikely to have an ectopic pregnancy as her first ultrasound scan would have confirmed an intrauterine pregnancy. Pelvic inflammatory disease is not the most likely cause of this patient’s symptoms as it is associated with additional symptoms such as vaginal discharge and dysuria, and the patient would likely be febrile. The growth of pre-existing fibroids due to decreased progesterone is incorrect as progesterone, like oestrogen, is increased during pregnancy. This patient does not exhibit symptoms of dysuria, renal angle tenderness, or pyrexia.

Understanding Fibroid Degeneration

Uterine fibroids are non-cancerous growths that can develop in the uterus. They are sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.

Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days.

Differentiating Gynecologic Cancers: Understanding the Symptoms and Metastasis Patterns

When a postmenopausal woman presents with vaginal bleeding, pelvic mass, and pelvic lymphadenopathy, it is important to consider the different types of gynecologic cancers that may be causing these symptoms.

Cervical squamous cell carcinoma is the most likely diagnosis in this case, as it typically metastasizes to the pelvic lymph nodes along the iliac arteries. On the other hand, endometrial carcinoma first metastasizes to the para-aortic lymph nodes, while ovarian malignancies typically spread to the para-aortic lymph nodes and are not associated with vaginal bleeding.

Uterine leiomyosarcoma, which is the most common type of sarcoma in the female pelvis, often extends beyond the uterine serosa and may metastasize to distant organs through blood vessels. However, vaginal bleeding and pelvic lymphadenopathy are not typical features of this cancer.

Cervical adenocarcinomas, which are rare and account for about 25% of cervical cancers, are associated with human papillomavirus and prolonged exposure to exogenous estrogens, but not with smoking. Their presentation and management are similar to those of squamous cancer.

Understanding the symptoms and metastasis patterns of different gynecologic cancers is crucial in making an accurate diagnosis and providing appropriate treatment.

If a patient vomits within 3 hours of taking levonorgestrel, it is recommended to prescribe a second dose of emergency hormonal contraception to be taken as soon as possible, according to NICE guidelines. Therefore, reassuring Zoe that she is protected from pregnancy is incorrect as she needs to take another dose. Additionally, while it may be advisable for Zoe to start a regular form of contraception, this is not the most important advice to give initially. Instead, she should be offered choices of contraception, including long-acting reversible contraceptives. It is also incorrect to recommend other forms of emergency contraception, such as ulipristal acetate and the IUD, as Zoe has already taken levonorgestrel and the guidelines are clear that a second dose of this should be taken in this circumstance. However, if Zoe experiences persistent vomiting or diarrhea for more than 24 hours after taking emergency hormonal contraception, then the IUD may be offered.

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.

If a woman has pelvic inflammatory disease, she cannot have a copper IUD inserted. Women who are at risk of this condition, such as those with multiple sexual partners or symptoms that suggest pelvic inflammatory disease, should be tested for infections like Chlamydia trachomatis and Neisseria gonorrhoeae and treated if necessary. To test for these infections, endocervical swabs are used. While the insertion of a copper IUD does carry a risk of developing pelvic inflammatory disease, this risk is low for women who are at low risk of sexually transmitted infections.

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 mucous. 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.

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.

If a patient’s 2nd repeat smear at 24 months is now negative for high-risk human papillomavirus (hrHPV), the correct course of action is to return to routine recall in 3 years. This assumes that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but normal cytology, and a repeat test at 12 months that was also hrHPV positive but cytologically normal. If the patient had still been hrHPV positive, they would have been referred for colposcopy. However, since they are now negative, they can go back to routine recall. The latest cervical screening programme does not require cytology to be performed if hrHPV is negative, so it would be inappropriate and impractical for the GP to request cytology on the sample. There is no need to repeat the smear in 4 weeks or 12 months, as transient hrHPV infection is common and self-resolves, and does not necessarily indicate a high risk of cervical cancer.

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.

Fertility Testing Methods

When it comes to fertility testing, there are several methods available to determine a female’s ovulatory status. One of the easiest tests is the day 21 progesterone level. If the results are greater than 30 nmol/l in two cycles, then the patient is said to be ovulating.

Another method is the cervical fern test, which involves observing the formation of ferns in the cervical mucous under the influence of estrogen. However, measuring progesterone levels is a more accurate test as estrogen levels can vary.

Basal body temperature estimation is also commonly used, as the basal body temperature typically increases after ovulation. However, measuring progesterone levels is still considered the most accurate way to determine ovulation.

It’s important to note that day 2 luteinising hormone (LH) and follicle-stimulating hormone (FSH) are not reliable markers of ovulation. Additionally, endometrial biopsy is not a test used in fertility testing.

In conclusion, there are several methods available for fertility testing, but measuring progesterone levels is the most accurate way to determine ovulatory status.

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 Vaginal Infections and Their Symptoms

Vaginal infections can be caused by various organisms and can present with different symptoms. Here are some common vaginal infections and their symptoms:

1. Candida albicans: This fungal infection can cause candidiasis, which presents with a thick, cottage-cheese yellowish discharge and pain upon urination. Treatment involves antifungal medication.

2. Normal discharge: A normal vaginal discharge is clear and mucoid, without smell or other concerning symptoms.

3. gonorrhoeae: This sexually transmitted infection caused by Neisseria gonorrhoeae can cause a thick green-yellow discharge, painful urination, and bleeding between periods.

4. Chlamydia: This common sexually transmitted infection is often asymptomatic but can eventually cause pain upon urination, vaginal/penile discharge, and bleeding between periods.

5. Bacterial vaginosis: This infection is caused by an overgrowth of bacteria in the vagina and presents with a grey, watery discharge with a fishy odor. Treatment involves antibiotics and topical gels or creams.

It is important to seek medical attention if you experience any concerning symptoms or suspect a vaginal infection.

Treatment Options for Infertility in Women with PCOS

Polycystic ovary syndrome (PCOS) is a common cause of infertility in women. Clomiphene citrate is the first-line medication used to induce ovulation in women with PCOS who wish to conceive. It works by binding to hypothalamic estrogen receptors, inhibiting the negative feedback on follicle-stimulating hormone (FSH) and triggering ovulation. However, it is important to counsel women about the increased risk of multiple pregnancy when treated with Clomiphene. Metformin, once considered a viable option for PCOS-related infertility, is now considered inferior to Clomiphene. However, it can be used in combination with Clomiphene to increase the success of ovulation induction. Gonadotrophins are recommended as second-line treatment for women who do not respond to Clomiphene. Laparoscopic ovarian drilling is a surgical option reserved for cases where Clomiphene has failed. It involves destroying ovarian stroma to reduce androgen-secreting tissue and induce ovulation. The choice of treatment depends on individual patient factors and should be discussed with a healthcare provider.

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.

During pregnancy, fibroid degeneration can occur and may cause symptoms such as low-grade fever, pain, and vomiting.

If the ultrasound scan does not show any signs of inflammation in the appendix, it is unlikely that the patient has appendicitis.

Since the patient has fibroids in her uterus, she is at risk of experiencing fibroid degeneration, which is a common complication during pregnancy. Symptoms of fibroid degeneration may include fever, pain, and vomiting.

The absence of vaginal bleeding makes it unlikely that the patient is experiencing a threatened miscarriage.

While ovarian torsion can cause pain and vomiting, it typically occurs in patients with risk factors such as ovarian cysts or ovarian enlargement.

Understanding Fibroid Degeneration

Uterine fibroids are non-cancerous growths that can develop in the uterus. They are sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.

Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days.

The combined oral contraceptive pill (COCP) has been found to have a slight increase in the risk of breast cancer, but this risk returns to normal after 10 years of stopping the pill. Additionally, the COCP may increase the risk of cervical cancer, but this could be due to a lack of barrier contraception use and increased exposure to HPV. While the COCP is associated with an increased risk of benign and malignant tumors, there is no evidence of an increased risk of lung cancer. On the other hand, the COCP has been shown to reduce the risk of ovarian cancer, endometrial cancer, and bowel cancer.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

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

If a cervical smear test performed as part of the NHS cervical screening programme returns as hr HPV positive, cytology is performed. If the cytology shows normal cells, the test is repeated in 12 months. If the second repeat test is still hr HPV positive and cytology normal, the test should be repeated in a further 12 months. However, if the third test at 24 months is still hr HPV positive, colposcopy should be performed instead of returning the patient to routine recall. Repeating the test in 3, 6 or 12 months is not appropriate in this case.

The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hr HPV 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.