Intersex and Genetic Disorders: Understanding the Different Types

Intersex conditions and genetic disorders can affect an individual’s physical and biological characteristics. Understanding the different types can help in diagnosis and treatment.

Male Pseudointersex
Male pseudointersex is a condition where an individual has a 46XY karyotype and testes but presents phenotypically as a woman. This is caused by androgen insensitivity, deficit in testosterone production, or deficit in dihydrotestosterone production. Androgen insensitivity syndrome is the most common mechanism, which obstructs the development of male genitalia and secondary sexual characteristics, resulting in a female phenotype.

True Intersex
True intersex is when an individual carries both male and female gonads.

Female Intersex
Female intersex is a term used to describe an individual who is phenotypically male but has a 46XX genotype and ovaries. This is usually due to hyperandrogenism or a deficit in estrogen synthesis, leading to excessive androgen synthesis.

Fragile X Syndrome
Fragile X syndrome is an X-linked dominant disorder that affects more men than women. It is associated with a long and narrow face, large ears, large testicles, significant intellectual disability, and developmental delay. The karyotype correlates with the phenotype and gonads.

Turner Syndrome
Turner syndrome is associated with the genotype 45XO. Patients are genotypically and phenotypically female, missing part of, or a whole, X chromosome. They have primary or secondary amenorrhea due to premature ovarian failure and failure to develop secondary sexual characteristics.

The most effective method of emergency contraception is a copper IUD, and it should be the first option offered to all women who have had unprotected sexual intercourse. This IUD can be used up to 5 days after the UPSI or the earliest estimated date of ovulation. The combined oral contraceptive pill, intrauterine system, and levonorgestrel are not as effective as the copper IUD and should not be the first option offered. Levonorgestrel can only be used within 72 hours of UPSI, and even then, the copper IUD is still more effective.

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.

For cervical cancer screening, if the first repeat smear test after 12 months shows a negative result for high risk HPV (hrHPV), the patient can return to routine recall. However, if the initial smear test shows a positive result for hrHPV but is cytologically normal, the patient will be called back for a repeat test after 12 months. If the second test also shows a negative result for hrHPV, the patient can return to normal recall. On the other hand, if the second test is still positive for hrHPV but cytologically normal, it will be repeated again after 12 months.

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

The Pearl Index is frequently utilized to measure the effectiveness of a contraception method. It indicates the number of pregnancies that would occur if one hundred women used the contraceptive method for one year. Therefore, if the Pearl Index is 0.2 and the medication is used perfectly, we can expect to see 0.2 pregnancies for every hundred women using the pill for one year – or 2 for every thousand.

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 mucous. 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 mucous. 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 mucous, 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.

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.

Urodynamic studies are necessary when there is a lack of clarity in diagnosis or when surgery is being considered.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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.

Methods for Checking Ovulation

There are several methods for checking ovulation, but not all of them are definitive. The easiest way to check for ovulation is through a day-21 progesterone level test, which measures the progesterone released by the corpus luteum after ovulation. However, an increase in basal body temperature is not a definitive indicator of ovulation.

Luteinising hormone (LH) and follicle stimulating hormone (FSH) are released from the pituitary gland and cause the development of the follicle ready for ovulation. However, if the day-21 progesterone level is normal, then FSH and LH will also be normal. An endometrial biopsy may confirm the absence of any uterine abnormality, but it does not ensure ovulation has taken place.

The cervical fern test is an assessment of cervical mucous, which is dependent on hormone levels. However, there is diagnostic uncertainty with this method, and measuring hormone levels directly is a more reliable indicator of ovulation. Overall, a combination of these methods may be used to confirm ovulation.

Understanding Uterine Fibroids

Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

In the case of cervical cancer screening, if two consecutive samples are deemed inadequate, the patient will be referred for colposcopy testing. Prior to this, the patient will be asked to undergo a repeat test within a period of 3 months.

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.

Levonorgestrel can still be taken within 72 hours of unprotected sexual intercourse (UPSI) in this case. Ulipristal acetate can also be taken up to 120 hours later, but the efficacy of oral options may have decreased after 61 hours. The copper coil is not a suitable option as the patient has declined any form of birth control. Therefore, the correct answer is that levonorgestrel can still be taken within 72 hours of UPSI.

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.

Diagnosing Gynaecological Malignancies: Understanding the Differences

When a postmenopausal woman presents with vaginal bleeding, pelvic mass, and pelvic lymphadenopathy, it is important to consider the different types of Gynaecological malignancies that could be causing these symptoms. The most likely diagnosis in this case is cervical squamous cell carcinoma, which typically metastasises to the pelvic lymph nodes along the iliac arteries.

While endometrial carcinoma (adenocarcinoma) is the most common Gynaecological malignancy, it would also be a possibility in this patient. Ovarian cancer, the second most common Gynaecological cancer, typically metastasises to the para-aortic lymph nodes and is not associated with vaginal bleeding.

Vulval cancers tend to metastasise to the superficial inguinal node and are unlikely to present with a pelvic mass or vaginal bleeding. Cervical adenocarcinomas are rare and derived from the endocervix, while uterine leiomyosarcoma often extends beyond the uterine serosa and occasionally metastasises to distant organs through blood vessels. However, neither of these malignancies typically present with vaginal bleeding and pelvic lymphadenopathy.

In summary, understanding the differences between the various types of Gynaecological malignancies is crucial in accurately diagnosing and treating patients with these conditions.

Fitz-Hugh-Curtis syndrome is characterized by hepatic adhesions, which are not present in any of the other options. Therefore, the diagnosis is based on the presence of lesions rather than just the symptoms described. This syndrome is a complication of PID that causes inflammation of the liver capsule, known as Glisson’s Capsule.

Gynaecological Causes of Abdominal Pain in Women

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

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

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

Types of Vulval Cancers and Their Characteristics

Vulval cancers are rare gynaecological malignancies that primarily affect elderly women. The most common type of vulval cancer is squamous cell carcinoma, which typically presents as a growth on the inner surface of the labia minora. Symptoms include vulval discomfort, itching, discharge, and bleeding. Biopsy and histological investigation are necessary to diagnose vulval lumps, and treatment involves vulvectomy and dissection of inguinal glands. Malignant melanoma, basal cell carcinomas, Bartholin’s gland cancer, and sarcoma are other types of vulval cancers, each with their own unique characteristics and rarity. Early detection and treatment are crucial for a positive prognosis.

When dealing with patients who have urinary incontinence, it is crucial to eliminate the possibility of a UTI and diabetes mellitus as underlying causes. The first step in investigating urinary incontinence would be to conduct a urine dipstick and culture test, which can be easily done in a GP’s office. Other initial investigations include keeping a bladder diary for at least three days and undergoing urodynamic studies. It is important to note that the reliability of urine dip tests is questionable in women over 65 years of age and those who have catheters. A three-day bladder diary is necessary for initial investigations, and a one-day diary would not suffice. CT scans are not typically used to investigate urinary incontinence but are useful in detecting renal pathology such as ureteric calculi. Cystoscopy is not appropriate for this patient and is usually reserved for cases where bladder cancer is suspected.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

The diagnosis of vaginal candidiasis does not require a high vaginal swab if the symptoms are highly suggestive. In fact, the diagnosis can be made clinically based on the patient’s symptoms. For example, if a patient presents with thickened, white discharge that resembles cottage cheese and vaginal itching, along with a normal vaginal pH, it is very likely that they have vaginal candidiasis. It is important to note that glycated haemoglobin (HbA1c) is not necessary for diagnosis unless the patient has recurrent episodes of vaginal candidiasis, which may indicate diabetes mellitus. Additionally, a midstream urine sample is not useful in diagnosing vaginal candidiasis and should only be used if a sexually-transmitted infection is suspected.

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.

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

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

The appropriate medical management for a miscarriage involves administering vaginal misoprostol alone. This is a prostaglandin analogue that stimulates uterine contractions, expediting the passing of the products of conception. Oral methotrexate and oral mifepristone alone are not suitable for managing a miscarriage, as they are used for ectopic pregnancies and terminations of pregnancy, respectively. The combination of oral misoprostol and oral mifepristone, as well as vaginal misoprostol and oral mifepristone, are also not recommended due to limited evidence of their efficacy. The current recommended approach is to use vaginal misoprostol alone, as it limits side effects and has a strong evidence base.

Management Options for Miscarriage

Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.

Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.

Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.

It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.

If pelvic floor muscle exercises and surgical intervention are not effective, duloxetine can be used to treat stress incontinence in patients. However, it is important to rule out other potential causes such as infection before starting treatment. Non-pharmacological management should be attempted first, including pelvic floor exercises and reducing caffeine intake. Duloxetine is a medication that works as a serotonin/norepinephrine reuptake inhibitor and may cause side effects such as nausea, dizziness, and insomnia. For urge incontinence, antimuscarinic agents like oxybutynin, tolterodine, and solifenacin are typically used as first-line treatment. If these are not effective, a β3 agonist called mirabegron can be used as a second-line therapy.

Understanding Urinary Incontinence: Causes, Classification, and Management

Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

Distinguishing between common vaginal infections: Trichomoniasis, Bacterial Vaginosis, gonorrhoeae, Chlamydia, and Mycoplasma Genitalium

When a woman presents with an elevated vaginal pH, a fish-smelling, yellow vaginal discharge, and ovoid trichomonads, the diagnosis of trichomoniasis (Trichomonas vaginalis) is strongly supported. A wet saline mount or anaerobic culture can confirm the diagnosis, with culture being particularly useful in men. Treatment involves oral metronidazole for seven days or a single 2g dose, and sexual partners should also be treated to prevent re-infection.

Bacterial vaginosis is a differential diagnosis to consider, as it also presents with a fish-smelling discharge and a pH > 4.5. However, the presence of ovoid mobile parasites on wet saline mount suggests trichomoniasis as the more likely diagnosis. Bacterial vaginosis would show clue cells on wet saline mount.

gonorrhoeae and Chlamydia are sexually transmitted infections that are more likely to be seen in patients with a history of unprotected sex. However, fish-smelling discharge is not characteristic of either infection. A specimen culture of gonorrhoeae would show Gram-negative diplococci, while chlamydia would not show ovoid mobile parasites on wet saline mount.

Mycoplasma genitalium is another potential sexually transmitted infection that can cause urethritis, discharge, cervicitis, or endometritis in women. However, the wet saline mount results suggest that this is not the diagnosis, and fish-smelling discharge is not characteristic of this infection.

In summary, a combination of clinical presentation, wet saline mount, and culture can help distinguish between common vaginal infections such as trichomoniasis, bacterial vaginosis, gonorrhoeae, chlamydia, and mycoplasma genitalium.

According to the GMC guidelines in good medical practice for individuals aged 0-18 years, it is important to disclose information regarding any abusive or seriously harmful sexual activity involving a child or young person. This includes situations where the young person is too immature to understand or consent, there are significant differences in age, maturity, or power between sexual partners, the young person’s sexual partner holds a position of trust, force or the threat of force, emotional or psychological pressure, bribery or payment is used to engage in sexual activity or keep it secret, drugs or alcohol are used to influence a young person to engage in sexual activity, or the person involved is known to the police or child protection agencies for having abusive relationships with children or young people.

Failing to disclose this information or simply prescribing contraception and waiting for a review can put both the patient and other students at the boyfriend’s school in harm’s way due to his position of trust. While informing the boyfriend or his school may breach confidentiality and not address the issue of his job and relationship, it is important to take appropriate action to protect the safety and well-being of the young person involved.

When it comes to providing contraception to young people, there are legal and ethical considerations to take into account. In the UK, the age of consent for sexual activity is 16 years, but practitioners may still offer advice and contraception to young people they deem competent. The Fraser Guidelines are often used to assess a young person’s competence. Children under the age of 13 are considered unable to consent to sexual intercourse, and consultations regarding this age group should trigger child protection measures automatically.

It’s important to advise young people to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. Long-acting reversible contraceptive methods (LARCs) are often the best choice for young people, as they may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.

No additional contraception is needed when switching from an IUD to COCP if it is removed on days 1-5 of the menstrual cycle. The COCP is effective immediately if started on these days, but if started from day 6 onwards, barrier contraception is required for 7 days. There is no need to delay starting the COCP after IUD removal. If the patient had recently taken ulipristal as an emergency contraceptive, she would need to wait for 5 days before starting hormonal contraception.

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.

Management Options for Endometriosis-Related Pain: A Guide for Healthcare Professionals

Endometriosis is a condition where endometrial tissue grows outside the uterus, causing pain and discomfort. Hormonal contraception is an effective treatment option for women who do not wish to conceive. The combined oral contraceptive pill suppresses ovarian function and limits the effect of estrogen on endometrial tissue. progesterone-containing contraceptives cause atrophy of the endometrial tissue. A trial of three months is recommended before reassessment.

Hysterectomy is indicated for adenomyosis or heavy menstrual bleeding that has not resolved with other treatments. A hysteroscopy is not necessary for a newly diagnosed young patient. A trial of ibuprofen or combination therapy is the first step in pain management, but NSAIDs are contraindicated for asthmatic patients who have already tried paracetamol.

Further laparoscopy for excision and/or ablation of endometriotic deposits is indicated if there is further disease. However, if all visible deposits were removed during diagnostic laparoscopy, a further laparoscopy is not necessary at present.

Ovarian cystectomy is recommended for women with endometriotic cysts who are concerned about fertility. Laparoscopic removal of the cyst wall can improve the chances of spontaneous pregnancy and reduce the risk of recurrence of endometriomas. These guidelines are based on NICE recommendations.

Treatment Options for Primary Dysmenorrhoea: A Guide for Healthcare Professionals

Primary dysmenorrhoea is a common condition that affects many women of reproductive age. When treating this condition, healthcare professionals have several options to consider. Here, we will discuss the most common treatments and their appropriateness for different patients.

Paracetamol is a suitable first-line treatment for patients with primary dysmenorrhoea who cannot take NSAIDs. If the patient does not wish to conceive, a hormonal contraceptive may also be considered as a first-line treatment.

Gabapentin is not recommended for the treatment of dysmenorrhoea, as it is primarily used for epilepsy and neuropathic pain.

Mefenamic acid and naproxen are both NSAIDs and are recommended as first-line treatments for primary dysmenorrhoea. However, they are contraindicated in patients with a history of asthma triggered by NSAID use.

Oral morphine is not typically used as a first-line treatment for dysmenorrhoea. If NSAIDs and paracetamol are not effective, transelectrical nerve stimulation (TENS) may be trialled. If none of these treatments are effective within 3-6 months, the patient should be referred to a gynaecologist for further assessment.

In summary, healthcare professionals should consider the patient’s medical history and preferences when selecting a treatment for primary dysmenorrhoea. Paracetamol and hormonal contraceptives are suitable first-line treatments, while NSAIDs and TENS may also be effective in some patients. Referral to a specialist may be necessary if initial treatments are not effective.

Surgical management is recommended for all ectopic pregnancies with a foetal sac larger than 35mm or a serum B-hCG level exceeding 5,000 IU/L, as per NICE guidelines. Foetal sacs larger than 35mm are at a higher risk of spontaneous rupture, making expectant or medical management unsuitable. The size of the foetal sac is measured using transvaginal ultrasound. Detection of a foetal heartbeat on transvaginal ultrasound requires urgent surgical management. A history of pelvic inflammatory disease is not an indication for surgical management, although it is a risk factor for ectopic pregnancy. Serum HCG levels between 1,500IU/L and 5,000 IU/L may be managed medically if the patient can return for follow-up and has no significant abdominal pain or haemodynamic instability. A septate uterus is not an indication for surgical management of ectopic pregnancy, but it may increase the risk of miscarriage.

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 salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy 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.

Injectable progesterone contraceptives are not recommended for individuals with current breast cancer.

This is considered an absolute contraindication (UKMEC 4) for prescribing injectable progesterone contraceptives. It is also an absolute contraindication for most other forms of contraception, except for the non-hormonal copper intrauterine device.

Current deep vein thrombosis is a UKMEC 2 contraindication for injectable progesterone, while it is a UKMEC 4 contraindication for the combined oral contraceptive pill. Multiple cardiovascular risk factors are a UKMEC 3 contraindication, which is not absolute, but the risks are generally considered to outweigh the benefits.

Smoking 30 cigarettes per day is only a UKMEC 1 contraindication for injectable progesterone contraception. However, considering the individual’s age, it would be a UKMEC 4 contraindication for the combined oral contraceptive pill.

High BMI is a UKMEC 1 contraindication for most forms of contraception, including injectable progesterone. However, it would be a UKMEC 4 contraindication for the combined pill.

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 150 mg 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 mucous 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.

Misconceptions about Menopause and Reproduction

Menopause is often associated with misconceptions about reproductive health. Here are some common misconceptions and the correct information:

Common Misconceptions about Menopause and Reproduction

1. Menopause is associated with a decrease in follicle-stimulating hormone (FSH).
Correction: Menopause is associated with an increase in FSH due to the loss of negative feedback from estrogen on the anterior pituitary.

2. Progesterone is necessary for ovulation to take place.
Correction: Both FSH and luteinizing hormone (LH) are needed for ovulation to take place. Progesterone is necessary for preparing the uterus for implantation.

3. Estrogen concentration peaks during menstruation.
Correction: Estrogen concentration peaks just before ovulation during the follicular phase of the menstrual cycle.

4. Ovarian tissue is the only source of estrogen production.
Correction: While ovarian tissue is the main source of estrogen production, the adrenal cortex and adipose tissue also contribute to estrogen production.

5. Fertilization of the human ovum normally takes place in the uterus.
Correction: Fertilization of the human ovum normally takes place in the outer third of the Fallopian tubes, not the uterus. The fertilized egg then implants in the uterus.

Thrush, also known as candidal infection, is a prevalent condition that is often triggered or worsened by recent use of antibiotics. Therefore, it is the most probable reason for the symptoms in this case. It should be noted that urinary tract infections do not typically cause vaginal discharge.

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.

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.

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.