Understanding Cervical Screening: Guidelines and Options

Cervical screening, also known as a smear test, is a vital tool in detecting precancerous cell changes in the cervix and preventing cervical cancer. Here are some important guidelines and options to keep in mind:

Age and Frequency: In the UK, women aged 25-64 are invited for screening, with those aged 25-49 screened every three years and those aged 50-64 screened every five years. In Scotland, screening is recommended every five years for women aged 25-65.

Hysterectomy: Women who have had a total hysterectomy (removal of the uterus and cervix) do not require cervical screening. However, those who have had a partial hysterectomy (removal of the uterus but not the cervix) should continue to be screened according to age guidelines.

Age Limit: Women over the age of 65 may still be eligible for screening if they have had recent abnormal results or have not been screened since the age of 50.

Opting Out: While cervical screening is not obligatory, it is highly recommended. Patients can opt out by speaking to their doctor and signing an ‘opting out’ form, but this decision can be reversed at any time. It is important to understand the benefits and risks associated with screening before making a decision.

There are many options available for contraception, each with their own advantages and disadvantages. It is important to discuss these options to find the best fit for the patient. In this case, the progesterone only contraceptive pill is the most appropriate option due to the patient’s history of migraine with aura and heavy menstrual cycle. The combined oral contraceptive pill is not recommended for this patient. The intrauterine system is a popular option for menorrhagia, but the patient does not want an invasive device. The contraceptive implant is also invasive and not preferred by the patient. Condoms are a good barrier method, but the POCP will also help with the patient’s heavy and irregular periods.

The patient’s symptoms of dysmenorrhoea, dyspareunia, and subfertility are classic signs of endometriosis, a common condition where endometrial tissue grows outside of the uterus. The presence of uterosacral nodularity and tenderness further supports this diagnosis. Some patients with endometriosis may also experience urinary symptoms due to bladder involvement or adhesions. Uterine leiomyoma, or fibroid, is a common pelvic tumor that causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. However, it does not typically present with uterosacral nodularity and tenderness on rectal examination. Interstitial cystitis causes urinary frequency and urgency, with pain relieved upon voiding. Pelvic inflammatory disease presents with fever, nausea, acute pain, malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.

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.

Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.

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.

Treatment Options for Cervical Carcinoma: A Comparison

Cervical carcinoma is a type of cancer that primarily affects the squamous cells of the cervix. Its main symptoms include abnormal bleeding or watery discharge, especially after sexual intercourse. The risk of developing cervical cancer increases with sexual activity.

The disease is staged based on the extent of its spread, with stages 0 to 4 indicating increasing severity. For stage 1b cervical cancer, the recommended treatment is a Wertheim’s radical abdominal hysterectomy. This procedure involves removing the uterus, tubes, ovaries, broad ligaments, parametrium, upper half or two-thirds of the vagina, and regional lymph glands. However, in older patients, the surgeon may try to preserve the ovaries to avoid premature menopause.

Other treatment options include simple hysterectomy, which is not suitable for cervical cancer that has spread beyond the cervix, and radical trachelectomy, which is appropriate for stage 1 cancers in women who wish to preserve their fertility. Close cytological follow-up is not recommended for confirmed cases of cervical cancer, while platinum-based chemotherapy is typically used only when surgery is not possible.

In summary, the choice of treatment for cervical carcinoma depends on the stage of the disease, the patient’s age and fertility preferences, and the feasibility of surgical intervention.

Management of Women after Treatment for Cervical Intra-epithelial Neoplasia

After treatment for cervical intra-epithelial neoplasia (CIN) at colposcopy, women undergo a repeat smear six months later to check for any residual disease. The management plan following this test of cure depends on the results.

HPV Test of Cure in Six Months, If Negative Recall in Three Years

If the test is negative for dyskaryosis and high-risk HPV (HR HPV), the woman is recalled in three years, regardless of her age. If the test remains negative at the three-year mark, she can return to routine screening based on her age group.

HPV Test of Cure in Six Months, If Negative Recall in Five Years

Even if the patient is 54 years old, women who have a negative HPV test of cure at six months are recalled for a smear three years later. If this is negative, she will then be returned to routine recall every five years.

HPV Test of Cure in Three Months, If Negative Recall in Five Years

The screening test should not be repeated at three months, as this is not enough time for the cervical tissue to heal. Reactive/healing changes in the cytological sample may give a false impression of dyskaryosis. Instead, a HPV test of cure is performed at six months, and if negative, the woman is recalled for routine screening every five years.

Refer Back to Routine Screening, Repeat in Three/Five Years

If the HPV test of cure is positive for HPV or there is evidence of moderate/severe dyskaryosis, the woman is referred back to colposcopy for further investigation. If the test is negative, she is referred back to routine screening and recalled in three or five years, depending on the scenario.

According to the BNF, the copper intra-uterine device is the most efficient option for emergency contraception and should be offered to all eligible women seeking such services. Unlike other medications, its effectiveness is not influenced by BMI. Additionally, it provides long-term contraception, which is an added advantage for the patient. If the copper intra-uterine device is not appropriate or acceptable to the patient, oral hormonal emergency contraception should be offered. However, the effectiveness of these contraceptives is reduced in patients with a high BMI. A double dose of levonorgestrel is recommended for patients with a BMI of over 26 kg/m² or body weight greater than 70kg. It is unclear which of the two oral hormonal contraceptives is more effective for patients with a raised BMI. The levonorgestrel intrauterine system and ethinylestradiol with levonorgestrel are not suitable for emergency contraception. In conclusion, the copper intrauterine device is the most effective method for this patient because it is not affected by BMI, unlike oral hormonal emergency contraceptives.

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.

Hormone Replacement Therapy: Risks and Benefits

Hormone Replacement Therapy (HRT) and Estrogen Replacement Therapy (ERT) are commonly used to alleviate symptoms of menopause, such as hot flashes and vaginal dryness. However, these treatments come with potential risks and benefits that should be carefully considered.

One of the main concerns with HRT is the increased risk of breast cancer, particularly with combined estrogen and progesterone therapy. The absolute risk is small, but it is important to discuss this with a healthcare provider. On the other hand, HRT and ERT have been shown to reduce the risk of osteoporosis and bone fractures.

Another potential risk of HRT and ERT is an increased risk of deep vein thrombosis. However, the risk may be lower with HRT compared to ERT. Additionally, both treatments have been shown to reduce all-cause mortality in women under 60.

Oestrogen replacement therapy (without progesterone) may reduce the risk of cardiovascular diseases, but it is important to note that the risk of breast cancer may not be significantly altered.

Overall, the decision to use HRT or ERT should be based on an individual’s symptoms, medical history, and potential risks and benefits. It is important to discuss these options with a healthcare provider and make an informed decision.

Weighing the Risks and Benefits of Hormone Replacement Therapy

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.

Treatment options for menorrhagia caused by fibroids in a patient hoping to conceive

Menorrhagia, or heavy menstrual bleeding, can be caused by fibroids in the uterus. In a patient hoping to conceive, treatment options must be carefully considered. One option is myomectomy, which involves removing the fibroids while preserving the uterus. However, this procedure can lead to heavy bleeding during surgery and may result in a hysterectomy. Endometrial ablation, which destroys the lining of the uterus, is not suitable for a patient hoping to have another child. Tranexamic acid may help reduce bleeding, but it may not be a definitive treatment if the fibroids are large or in a problematic location. Laparoscopic hysterectomy, which removes the uterus, is a definitive treatment for menorrhagia but is not suitable for a patient hoping to conceive. The Mirena® intrauterine system is an effective treatment for menorrhagia but is not suitable for a patient hoping to conceive. Ultimately, the best treatment option for this patient will depend on the size and location of the fibroids and the patient’s desire to conceive.