If a woman misses two COCP doses between days 8-14 of her menstrual cycle, emergency contraception is not necessary as long as the previous seven doses were taken correctly. In this case, the woman missed doses on days 8 and 9 but resumed taking the medication on day 10, so emergency contraception is not needed. However, until seven consecutive days of the COCP are taken, using barrier contraception or abstaining from sex is recommended to prevent pregnancy. The intrauterine system is not a form of emergency contraception, and introducing it in this situation is unnecessary. Levonorgestrel is an emergency contraception option that must be taken within 72 hours of unprotected sex, but it is not needed in this case. If the patient had missed more than two COCP doses, levonorgestrel and barrier contraception for seven days would be appropriate. Ulipristal acetate is another emergency contraception option that must be taken within five days of unprotected sex, but it is also not necessary in this situation. If it were indicated, barrier contraception would need to be used for the next seven days until the COCP takes effect.

Missed Pills in Combined Oral Contraceptive Pill

When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

Treatment Options for Stress Urinary Incontinence

Stress urinary incontinence is a common condition in women, especially those who have had vaginal deliveries and are getting older. It is caused by weak sphincter muscles, leading to leakage during activities such as coughing, sneezing, laughing, or exercising. The first-line treatment for this condition is pelvic floor muscle training, which involves a minimum of eight contractions three times per day for 12 weeks.

However, it is important to note that other treatment options, such as oxybutynin, pelvic ultrasound scans, urodynamic studies, and bladder training, are not recommended for stress urinary incontinence. Oxybutynin is used for overactive bladder or mixed urinary incontinence, while pelvic ultrasound scans are not indicated for urinary incontinence. Urodynamic studies are not recommended for women with simple stress incontinence on history and examination, and bladder training is used for urgency or mixed urinary incontinence, not stress incontinence. Therefore, pelvic floor muscle training remains the most effective treatment option for stress urinary incontinence.

The patient is likely suffering from endometriosis, which is the presence of endometrial tissue outside of the uterus. This condition can cause subfertility, chronic pelvic pain, dysmenorrhoea, and dyspareunia. It may also lead to an increase in serum CA-125 levels and the development of ovarian deposits known as chocolate cysts. Acute appendicitis and ovarian neoplasms are unlikely causes of the patient’s symptoms, while mittelschmerz only causes mid-cycle pain and does not explain the elevated CA-125 levels. Granulosa cell tumors of the ovary typically secrete inhibin and estrogen, making endometriosis a more likely diagnosis. Symptoms of ovarian cancer are often vague and include abdominal discomfort, bloating, back and pelvic pain, irregular menstruation, loss of appetite, fatigue, and weight loss. Risk factors for ovarian cancer include not having children, early first menstruation and last menopause, hormone replacement therapy, endometriosis, and the BRCA genes. In this age group, germ cell tumors are the most likely ovarian carcinoma.

If a woman of reproductive age has been having unprotected vaginal sexual intercourse for a year without conceiving and there is no known cause of infertility, NICE guidance recommends that she and her partner undergo further clinical assessment and investigation. The most appropriate initial investigation for this patient is a day 21 progesterone test, which is non-invasive and can determine if the patient is ovulating. Serum prolactin and thyroid function tests are not recommended unless there is a specific reason for testing, such as a pituitary tumor or overt thyroid disease. Transvaginal or abdominal ultrasounds are unlikely to reveal the cause of subfertility and are therefore not necessary. As part of the initial assessment, the male partner should also undergo a semen analysis.

Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.

For postmenopausal women with atypical endometrial hyperplasia, it is recommended to undergo a total hysterectomy with bilateral salpingo-oophorectomy to reduce the risk of malignant progression. If bilateral salpingo-oophorectomy is not performed, there is an increased risk of ovarian malignancy. Endometrial ablation is not advised due to the risk of intrauterine adhesion formation and irreversible damage to the endometrium. In premenopausal patients with atypia or those who do not respond to medical management or have persistent bleeding, hysterectomy alone may be considered. However, the royal college of obstetrics and gynaecology green-top guidelines suggest that bilateral salpingectomy should still be considered in these patients due to the risk of further ovarian malignancy. For hyperplasia without atypia, the first-line treatment is a levonorgestrel-releasing intrauterine system such as the Mirena coil.

Endometrial hyperplasia is a condition where the endometrium, the lining of the uterus, grows excessively beyond what is considered normal during the menstrual cycle. This abnormal proliferation can lead to endometrial cancer in some cases. There are four types of endometrial hyperplasia: simple, complex, simple atypical, and complex atypical. Symptoms of this condition include abnormal vaginal bleeding, such as intermenstrual bleeding.

The management of endometrial hyperplasia depends on the type and severity of the condition. For simple endometrial hyperplasia without atypia, high dose progestogens may be prescribed, and repeat sampling is recommended after 3-4 months. The levonorgestrel intra-uterine system may also be used. However, if atypia is present, hysterectomy is usually advised.

The appropriate answer is that the woman cannot use the pill anymore due to an unacceptably high clinical risk. She has developed systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies, which is classified as UK Medical Eligibility Criteria for Contraceptive Use UKMEC 4, meaning it is an absolute contraindication. The risks of arterial and venous thrombosis would be too high if she were to restart the combined pill, and alternative contraceptive options should be considered. It is important to note that both SLE with positive antiphospholipid antibodies and isolated presence of antiphospholipid antibodies are classified as UKMEC 4 conditions, but not the diagnosis of antiphospholipid syndrome. The advantages of using the pill generally outweigh the risks is an incorrect answer, as it is equivalent to UKMEC 2. The correct answer would be applicable if the woman did not test positive for any of the three antiphospholipid antibodies or if she did not test positive again after 12 weeks. The risks usually outweigh the advantages of using the combined pill is also incorrect, as it is equivalent to UKMEC 3. Lastly, there is no risk or contraindication to her restarting the combined pill is an incorrect answer, as it is equivalent to UKMEC 1.

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.

Differential diagnosis for a woman with typical PCOS phenotype and biochemical markers

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that affects reproductive-aged women. Its diagnosis is based on the presence of at least two of the following criteria: oligo-ovulation or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. However, other conditions can mimic or coexist with PCOS, making the differential diagnosis challenging. Here are some possible explanations for a woman who presents with the typical PCOS phenotype and biochemical markers:

– Cushing syndrome: This rare disorder results from chronic exposure to high levels of cortisol, either endogenously (e.g., due to a pituitary or adrenal tumour) or exogenously (e.g., due to long-term glucocorticoid therapy). Cushing syndrome can cause weight gain, central obesity, moon face, buffalo hump, purple striae, hypertension, glucose intolerance, and osteoporosis. However, it is not associated with a high LH: FSH ratio, which is a hallmark of PCOS.
– Androgen-secreting tumour: This is a rare cause of hyperandrogenism that can arise from the ovary, adrenal gland, or other tissues. The excess production of androgens can lead to virilization, hirsutism, acne, alopecia, menstrual irregularities, and infertility. However, the testosterone level in this case would be expected to be higher than 3.5 nmol/l, which is the upper limit of the normal range for most assays.
– Simple obesity: This is a common condition that can affect women of any age and ethnicity. Obesity can cause insulin resistance, hyperinsulinemia, dyslipidemia, inflammation, and oxidative stress, which can contribute to the development of PCOS. However, the abnormal testosterone and LH: FSH ratio suggest an underlying pathology that is not solely related to excess adiposity. Moreover, at a BMI of 28, the patient’s weight is not within the range for a clinical diagnosis of obesity (BMI ≥ 30).
– Complete androgen insensitivity syndrome: This is a rare genetic disorder that affects the androgen receptor, leading to a lack of response to androgens in target tissues. As a result, affected individuals have a female phenotype despite having XY chromosomes. They typically present with primary amenorrhea

If a patient with primary amenorrhea has elevated FSH/LH levels, it may indicate gonadal dysgenesis, such as Turner’s syndrome.

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.

Diagnosis of Fibroids: Ultrasound vs CT Scan vs MRI

Fibroids, or leiomyomatas, are common tumours of smooth muscle origin found in the uterus and cervix. They can cause symptoms such as heavy periods, dysmenorrhoea, and lower abdominal pain. Risk factors include Afro-Caribbean origin, obesity, nulliparity, and family history. Clinical examination may reveal a palpable abdominal mass or a uterus palpable on bimanual examination, but ultrasound is the preferred diagnostic tool. CT scans are reserved for complex cases, while MRI is used for localisation and characterisation of fibroids. A full blood count is also important to diagnose and treat anaemia associated with heavy periods.

Hormones Involved in Pregnancy Testing

Pregnancy testing relies on the detection of specific hormones in the body. One such hormone is human chorionic gonadotropin (hCG), which is secreted by the syncytiotrophoblast of a developing embryo after implantation in the uterus. The unique subunit of hCG, β, is targeted by antibodies in blood and urine tests, allowing for early detection of pregnancy. Luteinising hormone (LH) and follicle-stimulating hormone (FSH) also play important roles in female reproductive function, but are not measured in over-the-counter pregnancy tests. Progesterone, while important in pregnancy, is not specific to it and therefore not useful in diagnosis. The hCG subunit α is shared with other hormones and is not specific to pregnancy testing.

The effectiveness of different contraceptives varies in terms of the time it takes to become effective if not started on the first day of the menstrual cycle. The intrauterine device is the only method that is instantly effective at any time during the cycle as it reduces sperm motility and survival. The progesterone only pill takes at least 2 days to work if started after day 5 of the cycle and is immediately effective if started prior to day 5. The combined oral contraceptive pill, injection, implant, and intrauterine system take 7 days to become effective and work by inhibiting ovulation, thickening cervical mucous, and preventing endometrial proliferation. Side effects of the progesterone only pill may include menstrual irregularities, breast tenderness, weight gain, and acne.

Counselling for Women Considering the progesterone-Only Pill

Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

Investigation is necessary for any postmenopausal bleeding. The first step is to conduct a transvaginal ultrasound scan to examine the thickness of the endometrium. To diagnose endometrial cancer, a Pipelle biopsy is used to sample the endometrium, which is effective in most cases. Hysteroscopy with directed sampling (dilation and curettage) can be used to detect lesions or when Pipelle has been inconclusive. CT scan is not required as a pre-operative imaging test nor is it used to diagnose endometrial cancer.
Reference: Colombo N, Preti E, Landoni F, Carinelli S, Colombo A, et al. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013; 24 (6): vi33-vi38.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

Diagnosis of Androgen Insensitivity Syndrome: A Case Study

The presented case strongly suggests the presence of androgen insensitivity syndrome, a condition where a patient’s phenotype and secondary sexual characteristics differ from their karyotype and gonads. In this case, the patient is likely to have a karyotype of 46,XY and be a male pseudohermaphrodite. Androgen insensitivity syndrome is associated with mutations in the AR gene, which codes for the androgen receptor. In complete androgen insensitivity, the body cannot respond to androgens at all, resulting in a female phenotype, female secondary sexual characteristics, no uterus, and undescended testes.

Karyotyping is the key diagnostic investigation to confirm the diagnosis of androgen insensitivity syndrome. Serum oestradiol levels may vary according to the type of androgen insensitivity disorder and are unlikely to aid the diagnosis. Pituitary MRI may be a second diagnostic investigation if karyotype abnormalities are ruled out. Transvaginal ultrasound is not necessary if an abdominal ultrasound has already been performed and showed an absent uterus.

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.

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.

Squamous cell carcinoma of the cervix is often caused by the human papillomavirus (HPV), particularly strains 16 and 18. HPV infects the host and interferes with genes that regulate cell growth, leading to uncontrolled growth and inhibition of apoptosis. This results in precancerous lesions that can progress to carcinoma. Risk factors for cervical carcinoma include smoking, low socio-economic status, use of the contraceptive pill, early sexual activity, co-infection with HIV, and a family history of cervical carcinoma. HIV is not the cause of cervical squamous cell carcinoma, but co-infection with HIV increases the risk of HPV infection. Epstein-Barr virus (EBV) is associated with other types of cancer, but not cervical squamous cell carcinoma. Chlamydia trachomatis is a bacterium associated with genitourinary infections, while herpes simplex virus (HSV) causes painful ulceration of the genital tract but is not associated with cervical carcinoma.

The current guidelines for cervical cancer screening recommend using hrHPV as the first screening test. If the result is negative, the patient can return to routine recall. However, if the result is positive, the sample is examined for cytology. If the cytology is normal, the patient is asked to return for screening in 12 months instead of the usual 3 years. If the hrHPV result is negative at the 12-month follow-up, the patient can return to routine recall. But if the result is positive again, as in this scenario, and the cytology is normal, the patient should attend another screening in 12 months. If the cytology is abnormal at any point, the patient should be referred for colposcopy. If the patient attends a third screening in another 12 months and the hrHPV result is still positive, she should be referred for colposcopy regardless of the cytology result.

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.

Understanding Vaginal Discharge: Common Causes and Key Features

Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a pathological condition. There are various causes of vaginal discharge, including physiological factors and infections. Some of the common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. However, less common causes such as gonorrhea, chlamydia, ectropion, foreign body, and cervical cancer can also lead to vaginal discharge.

It is important to note that the key features of each cause of vaginal discharge can vary. For instance, Candida infection may present with a discharge that resembles cottage cheese, accompanied by vulvitis and itch. On the other hand, Trichomonas vaginalis infection may cause an offensive, yellow/green, frothy discharge, along with vulvovaginitis and a strawberry cervix. Bacterial vaginosis, another common cause of vaginal discharge, may present with an offensive, thin, white/grey, ‘fishy’ discharge.

According to NICE guidelines, an endometrial biopsy should be performed if necessary to rule out endometrial cancer or atypical hyperplasia. The biopsy is recommended for women who experience persistent intermenstrual bleeding and for those aged 45 and above who have had unsuccessful or ineffective treatment. In the case of the patient mentioned above, her treatment has not been successful and she has a thickened endometrium. Although there is some debate about the thickness of the endometrium in premenopausal women, this patient qualifies for a biopsy based on her failed medical treatment alone, making it the most appropriate option.

Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.

Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.

Pregnant women with a BMI greater than 30 kg/m2 should be prescribed a high dose of 5mg folic acid instead of the standard 400 micrograms. Therefore, the lifestyle and dietary advice given to this patient is incorrect. Additionally, prescribing 75 mg of aspirin is not appropriate for this patient as it is typically given to women with one high-risk factor or two moderate-risk factors for pre-eclampsia, and a BMI over 35 would only qualify as a single moderate-risk factor. While 150 mg of aspirin is an alternative dose for pre-eclampsia prophylaxis, 75 mg is more commonly used in practice.

Folic Acid: Importance, Deficiency, and Prevention

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

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

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

On ultrasound imaging, the presence of a whirlpool sign and free fluid may indicate ovarian torsion. This sign occurs when a structure twists upon itself. It is important to note that appendicitis and ectopic pregnancy do not show this sign on imaging. Additionally, the pain associated with Mittelschmerz is typically less severe and would not be accompanied by the ultrasound finding.

Understanding Ovarian Torsion

Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.

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.

The risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

Understanding Ectopic Pregnancy: The Pathophysiology

Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

If a woman is not starting her contraceptive method on the first day of her period, the time until it becomes effective varies. The only option that is effective immediately is an intrauterine device (IUD), which is a T-shaped device containing copper that is inserted into the uterus. Other methods, such as the progesterone-only pill (POP), combined oral contraceptive (COC), injection, implant, and intrauterine system (IUS), require a certain amount of time before they become effective. The POP requires 2 days, while the COC, injection, implant, and IUS all require 7 days before they become effective. It’s important to consider the effectiveness and convenience of each method before choosing the best option.

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

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

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

Causes of postmenopausal Bleeding: Understanding the Different Aetiologies

postmenopausal bleeding (PMB) can be a concerning symptom for women, and it is important to understand the different causes that may be responsible. One of the most common causes is vaginal atrophy, which occurs due to a decrease in oestrogen levels after menopause. This can lead to thinning and drying of the vaginal mucosa, as well as other symptoms such as vaginal dryness and an increased risk of urinary tract infections. Treatment options include non-hormonal approaches such as lubricants and moisturisers, as well as hormonal treatments like topical preparations or systemic oestrogen replacement.

Another potential cause of PMB is endometrial hyperplasia, which involves abnormal proliferation of the endometrium and is associated with an increased risk of endometrial cancer. While this is not the most common cause of PMB, ruling it out is important in order to identify any potential issues. Endometrial cancer itself is also a significant concern, with a 10% probability of being the cause of PMB. Urgent referral to a gynaecology outpatient is necessary to exclude this possibility.

Cervical cancer is not typically the cause of PMB, but it is important to discuss the cervical cancer screening programme with patients and any history of abnormal smears. Finally, the use of hormone replacement therapy (HRT) can also trigger menstruation and lead to PMB, although this is not the most common cause. By understanding these different aetiologies, healthcare providers can better diagnose and treat PMB in their patients.

Even if a child is Gillick competent, they are still unable to consent to sexual intercourse if they are under the age of 13. Therefore, any interaction with this age group should prompt child protection measures to be taken. Simply prescribing medication or ignoring the situation would not be in compliance with this protocol.

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.

Hysterectomy is the most effective treatment for menorrhagia caused by large fibroids, which are benign tumors of smooth muscle that can grow in response to hormones. Risk factors for fibroids include obesity, early menarche, African-American origin, and a family history of fibroids. Symptoms of fibroids include heavy periods, anemia, abdominal discomfort, and pressure symptoms. Diagnosis is made through pelvic ultrasound. Medical management with NSAIDs or tranexamic acid can be tried first, but if it fails, surgical management is necessary. Uterine-sparing surgeries like myomectomy or uterine artery embolization can be considered for women who want to preserve their fertility, but hysterectomy is the definitive method of treatment for women who have completed their family or have severe symptoms. The levonorgestrel intrauterine system is not recommended for women with large fibroids causing uterine distortion. Mefenamic acid is less effective than tranexamic acid for fibroid-related menorrhagia. Myomectomy is not a definitive method of management as fibroids can recur. Uterine artery embolization is an option for women who want to preserve their uterus but not their fertility, but its effect on fertility and pregnancy is not well established.

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.

Ultrasound imaging may reveal a whirlpool sign in cases of ovarian torsion, which is strongly indicated by the patient’s history and examination. The beads-on-a-string sign is typically associated with chronic salpingitis, while hypoechoic masses are often indicative of fibroids. A snow-storm appearance is a characteristic finding in complete hydatidiform mole.

Understanding Ovarian Torsion

Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.