There is not enough evidence to recommend any specific treatment for recurrent BV in primary care. However, in women with an intrauterine contraceptive device and persistent BV, it may be advisable to remove the device and suggest an alternative form of contraception.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

The correct answer is to double the dose of levonorgestrel to 3 mg by mouth for this patient, as she has a weight of over 70kg, despite having a healthy BMI. This information is based on the BNF guidelines.

Inserting a copper intrauterine device would not be the best option for this patient, as she already has plans for levonorgestrel device insertion and may be using it for additional hormonal benefits, such as reducing the heaviness of her bleeding.

Inserting the levonorgestrel uterine system would not provide the emergency contraception required for this patient, as it takes about 7 days to become effective. Therefore, it is not appropriate in this situation.

The standard dose of levonorgestrel 1.5mg would be given to females who weigh less than 70 kg or have a BMI less than 26. However, in this case, it would be inappropriate due to the patient’s weight being over 70kg.

It would be risky to suggest to this patient that she doesn’t need to take another form of emergency contraception, as the initial pill may not have prevented ovulation during this cycle.

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, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

The patient is likely experiencing genital ulcers and systemic symptoms due to a primary herpes simplex genital infection, which commonly causes painful ulcers. While waiting for swab results, treatment should be initiated with an antiviral such as valaciclovir for a longer course in an initial infection.

If a simple urinary tract infection is suspected, trimethoprim for 3 days may be appropriate. However, dysuria and trace leukocytes can also be indicative of primary herpes simplex infection.

Valaciclovir is the correct treatment for this patient, but a 3-day course is insufficient for a primary infection and would be more appropriate for a recurrence of genital herpes.

If lymphogranuloma venereum is suspected, doxycycline daily for 7 days may be appropriate. However, this is less likely in this case as it typically leads to painless ulceration and is uncommon.

If a complicated urinary tract infection is suspected, trimethoprim for 7 days may be appropriate. However, given the presence of painful ulceration, herpes infection is the most likely cause regardless of urinalysis results and dysuria.

Understanding STI Ulcers

Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most well-known causes is the herpes simplex virus (HSV) type 2, which can cause severe primary attacks with fever and subsequent attacks with multiple painful ulcers. Syphilis, caused by the spirochaete Treponema pallidum, has primary, secondary, and tertiary stages, with a painless ulcer (chancre) appearing in the primary stage. Chancroid, a tropical disease caused by Haemophilus ducreyi, causes painful genital ulcers with a sharply defined, ragged, undermined border and unilateral, painful inguinal lymph node enlargement. Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis, has three stages, with the first stage showing a small painless pustule that later forms an ulcer, followed by painful inguinal lymphadenopathy in the second stage and proctocolitis in the third stage. LGV is treated with doxycycline. Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale (previously called Calymmatobacterium granulomatis). Understanding the different causes of STI ulcers is crucial in diagnosing and treating these infections.

When starting the combined oral contraceptive pill, it is important to inform women that there is a slight increase in the risk of breast and cervical cancer. However, it is also important to note that the pill is protective against ovarian and endometrial cancer.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

Women and men who are taking leflunomide must use effective contraception for a minimum of 2 years and 3 months respectively after discontinuing the medication, similar to the requirements for thalidomide.

Leflunomide: A DMARD for Rheumatoid Arthritis

Leflunomide is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage rheumatoid arthritis. It is important to note that this medication has a very long half-life, which means that its teratogenic potential should be taken into consideration. As such, it is contraindicated in pregnant women, and effective contraception is essential during treatment and for at least two years after treatment in women, and at least three months after treatment in men. Caution should also be exercised in patients with pre-existing lung and liver disease.

Like any medication, leflunomide can cause adverse effects. Some of the most common side effects include gastrointestinal issues such as diarrhea, hypertension, weight loss or anorexia, peripheral neuropathy, myelosuppression, and pneumonitis. To monitor for any potential complications, patients taking leflunomide should have their full blood count (FBC), liver function tests (LFT), and blood pressure checked regularly.

If a patient needs to stop taking leflunomide, it is important to note that the medication has a very long wash-out period of up to a year. To help speed up the process, co-administration of cholestyramine may be necessary. Overall, leflunomide can be an effective treatment option for rheumatoid arthritis, but it is important to carefully consider its potential risks and benefits before starting treatment.

If a woman is not starting her contraceptive method on the first day of her period, the only option that will be effective immediately is an intrauterine device (IUD). This device is a T-shaped plastic device that contains copper and is inserted into the uterus to provide contraception immediately.

Other methods, such as the contraceptive injection, implant, and combined oral contraceptive (COC), as well as the intrauterine system (IUS), require 7 days to become effective if not started on the first day of menstruation. The progesterone-only pill (POP) is also not the best choice as it requires 2 days before becoming effective and must be taken every day. It is important to consider the effectiveness and convenience of each method when choosing a contraceptive.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

Cervical screening is only available to women between the ages of 25 and 64, and cannot be offered to those outside of this age range. However, if a patient has never had a screening test or has not had one since age 50, they can have a one-off test. Unlike breast and bowel screening, patients cannot self-refer for cervical screening outside of the routine age range. This is because cervical cancer is unlikely to develop after this age if previous tests have been normal. Patients with symptoms of cervical cancer should be referred for colposcopy, while asymptomatic patients should not be referred as screening is designed to detect asymptomatic cases.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

The progestogen-only pill (POP) is available in different formulations including desogestrel, norethisterone, and levonorgestrel. The DSG pill may be more effective in suppressing ovulation and managing pain associated with endometriosis, menstruation, and ovulation. There is no evidence of increased risks of stroke, MI, VTE, or breast cancer associated with POP use. The traditional POP becomes more effective in older users. The UKMEC category for women over 45 years is 1 if there are no other contraindications.

Pros and Cons of the Progestogen Only Pill

The progestogen only pill, also known as the mini-pill, has its advantages and disadvantages. One of its main advantages is its high effectiveness, with a failure rate of only 1 per 100 woman years. It also doesn’t interfere with sex and its contraceptive effects are reversible upon stopping. Additionally, it can be used while breastfeeding and in situations where the combined oral contraceptive pill is contraindicated, such as in smokers over 35 years of age and women with a history of venous thromboembolic disease.

However, the progestogen only pill also has its disadvantages. One common adverse effect is irregular periods, with some users not having periods while others may experience irregular or light periods. It also doesn’t protect against sexually transmitted infections and has an increased incidence of functional ovarian cysts. Common side-effects include breast tenderness, weight gain, acne, and headaches, although these symptoms generally subside after the first few months. Overall, the progestogen only pill may be a suitable contraceptive option for some women, but it’s important to weigh its pros and cons before deciding to use it.

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 doesn’t 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 condition.

Management of Unscheduled Bleeding in a Young Lady on Depo-Provera Injection

This patient is a young lady who has been experiencing unscheduled bleeding after being put on the Depo-Provera injection. However, she has no red flag symptoms and is up-to-date with her cervical smears, which provides reassurance to her history. At this stage, blood tests and a pelvic ultrasound scan are not necessary, but may be considered later on. Referral to a gynaecologist is not indicated as there are no alarming symptoms present.

It is important to follow advice from the cervical screening hub regarding cervical smears and not order one sooner than indicated. If any alarming symptoms arise, referral to a gynaecologist is recommended. For women experiencing unscheduled bleeding while on a progesterone-only injectable and who are medically eligible, a combined oral contraceptive can be offered for three months in the usual cyclic manner. The longer-term use of the combined contraceptive pill with the injectable progesterone is a matter of clinical judgement.

The only recognized treatment option for premenstrual syndrome among the given choices is a low dose SSRI during the luteal phase. According to the NICE Clinical Knowledge Summary on Premenstrual Syndrome, lifestyle advice should be given to women with severe PMS, and treatment options for moderate PMS include a new-generation combined oral contraceptive, analgesics, or cognitive behavioral therapy. Additionally, an SSRI can be taken continuously or during the luteal phase (days 15-28 of the menstrual cycle, depending on its length).

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 doesn’t 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 condition.

The patient has vaginal candidiasis, indicated by itching, reddening, and ‘curdy’ discharge with pH <4.5. Treatment with vaginal clotrimazole is appropriate. Other treatments are used for bacterial vaginosis, Trichomonas vaginalis, Chlamydia, and gonorrhoea infections. Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions. Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

The appropriate HRT for Annie, who is postmenopausal and at risk of venous thromboembolism due to her smoking and obesity, is a continuous combined transdermal preparation. This is because she requires the progestogen component for endometrial protection and oral preparations should be avoided in her case. Cyclical preparations, both oral and transdermal, are not indicated as she has been amenorrhoeic for over 12 months.

Hormone Replacement Therapy: Uses and Varieties

Hormone replacement therapy (HRT) is a treatment that involves administering a small amount of estrogen, combined with a progestogen (in women with a uterus), to alleviate menopausal symptoms. The indications for HRT have changed significantly over the past decade due to the long-term risks that have become apparent, primarily as a result of the Women’s Health Initiative (WHI) study.

The most common indication for HRT is vasomotor symptoms such as flushing, insomnia, and headaches. Other indications, such as reversal of vaginal atrophy, should be treated with other agents as first-line therapies. HRT is also recommended for women who experience premature menopause, which should be continued until the age of 50 years. The most important reason for giving HRT to younger women is to prevent the development of osteoporosis. Additionally, HRT has been shown to reduce the incidence of colorectal cancer.

HRT generally consists of an oestrogenic compound, which replaces the diminished levels that occur in the perimenopausal period. This is normally combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer. The choice of hormone includes natural oestrogens such as estradiol, estrone, and conjugated oestrogen, which are generally used rather than synthetic oestrogens such as ethinylestradiol (which is used in the combined oral contraceptive pill). Synthetic progestogens such as medroxyprogesterone, norethisterone, levonorgestrel, and drospirenone are usually used. A levonorgestrel-releasing intrauterine system (e.g. Mirena) may be used as the progestogen component of HRT, i.e. a woman could take an oral oestrogen and have endometrial protection using a Mirena coil. Tibolone, a synthetic compound with both oestrogenic, progestogenic, and androgenic activity, is another option.

HRT can be taken orally or transdermally (via a patch or gel). Transdermal is preferred if the woman is at risk of venous thromboembolism (VTE), as the rates of VTE do not appear to rise with transdermal preparations.

If the results of the 2nd repeat smear at 24 months show that the patient is now negative for high-risk human papillomavirus (hrHPV), the appropriate action is to return to routine recall in 3 years. This is based on the assumption that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but with normal cytology. The patient then had a repeat test at 12 months, which also showed hrHPV positive but with normal cytology. If the patient had still been hrHPV positive, she would have been referred for colposcopy. However, since she is now negative, there is no need for further testing or repeat smear in 4 weeks or 12 months. It is also not necessary to check cytology on the sample as the latest cervical screening programme doesn’t require it if hrHPV is negative. It is important to note that transient hrHPV infection is common and doesn’t necessarily indicate a high risk of cervical cancer.

Understanding Cervical Cancer Screening Results

The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

Urgent Referral for Unexplained Vulval Lump or Non-Responsive Ulceration

Any woman who discovers a new, unexplained lump or experiences ulceration that doesn’t respond to treatment should be referred urgently. It is important to note that the term pressure sore should be used with caution, as it may not accurately describe the condition.

If the ulcer appears to be caused by thrush, fluconazole may be considered. However, if the ulcer doesn’t arise from typical intertriginous areas and lacks satellite lesions or white discharge, a fungal infection is unlikely.

While primary syphilis can cause a solitary painless genital ulcer, it tends to resolve within four to eight weeks. Therefore, it is unlikely that this would be the first presentation of a lady with primary syphilis.

If the condition is suspected to be a pressure ulcer on the sacrum or another pressure point, a tissue viability nurse may be consulted. However, based on the given history, this seems unlikely. Referring to dermatology is not appropriate for a strongly suspected case of vulval carcinoma.

To ensure reliable contraception, it is recommended to take a two-month course of Cerazette (desogestrel) as Nexplanon may not be dependable.

Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

Although cervical cancer screening is effective in detecting squamous cell cancer, it may not be as effective in detecting adenocarcinomas. Even with the switch to liquid based cytology, the detection rate for adenocarcinomas has not improved.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

Women under the age of 25 years cannot receive cervical screening. Before considering referral to colposcopy, other possible causes should be ruled out first.

As she is currently on day 2 of her menstrual period, pregnancy is unlikely. Given her new boyfriend and symptoms of increased vaginal discharge and occasional post-coital bleeding, a speculum examination and STI screening would be the most appropriate course of action.

While cervical screening is not typically offered to women under 25, if the patient’s history strongly suggests cervical cancer and other possibilities have been eliminated, referral to colposcopy may be necessary.

Although cervical cancer is rare in young women, it is still important to investigate the cause of her symptoms.

Understanding Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

If Bartholin’s cysts are asymptomatic, there is no need for any intervention. However, if they cause symptoms or affect the appearance, they can be treated by incision and drainage. In women over 40, a biopsy may be recommended by some gynaecologists to rule out carcinoma.

If the cyst becomes infected and turns into an abscess, the initial treatment would be marsupialisation. Alternatively, a word catheter can be inserted. Antibiotics are not effective in managing a cyst that is not accompanied by an abscess.

Bartholin’s cyst occurs when the Bartholin duct’s entrance becomes blocked, causing mucous to build up behind the blockage and form a mass. This blockage is usually caused by vulval oedema and is typically sterile. These cysts are often asymptomatic and painless, but if they become large, they may cause discomfort when sitting or superficial dyspareunia. On the other hand, Bartholin’s abscess is extremely painful and can cause erythema and deformity of the affected vulva. Bartholin’s abscess is more common than the cyst, likely due to the asymptomatic nature of the cyst in most cases.

Bartholin’s cysts are usually unilateral and 1-3 cm in diameter, and they should not be palpable in healthy individuals. Limited data suggest that around 3000 in 100,000 asymptomatic women have Bartholin’s cysts, and these cysts account for 2% of all gynaecological appointments. The risk factors for developing Bartholin’s cyst are not well understood, but it is thought to increase in incidence with age up to menopause before decreasing. Having one cyst is a risk factor for developing a second.

Asymptomatic cysts generally do not require intervention, but in older women, some gynaecologists may recommend incision and drainage with biopsy to exclude carcinoma. Symptomatic or disfiguring cysts can be treated with incision and drainage or marsupialisation, which involves creating a new orifice through which glandular secretions can drain. Marsupialisation is more effective at preventing recurrence but is a longer and more invasive procedure. Antibiotics are not necessary for Bartholin’s cyst without evidence of abscess.

References:
1. Berger MB, Betschart C, Khandwala N, et al. Incidental Bartholin gland cysts identified on pelvic magnetic resonance imaging. Obstet Gynecol. 2012 Oct;120(4):798-802.
2. Kaufman RH, Faro S, Brown D. Benign diseases of the vulva and vagina. 5th ed. Philadelphia, PA: Elsevier Mosby; 2005:240-249.
3. Azzan BB. Bartholin’s cyst and abscess: a review of treatment of 53 cases. Br J Clin Pract. 1978 Apr;32(4):101-2.

Qlaira is taken daily for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and 2 inactive pills. The dose of estradiol decreases gradually while the dose of dienogest increases during the cycle.

Choice of Combined Oral Contraceptive Pill

The combined oral contraceptive pill (COCP) comes in different variations based on the amount of oestrogen and progestogen and the presentation. For first-time users, it is recommended to use a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone. However, two new COCPs have been developed in recent years, namely Qlaira and Yaz, which work differently from traditional pills.

Qlaira is a combination of estradiol valerate and dienogest with a quadriphasic dosage regimen designed to provide optimal cycle control. The pill is taken every day for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and two pills being inactive. The dose of estradiol is gradually reduced, and that of dienogest is increased during the cycle to give women a more natural cycle with constant oestrogen levels. However, Qlaira is more expensive than standard COCPs, and there is limited safety data to date.

On the other hand, Yaz combines 20mcg ethinylestradiol with 3mg drospirenone and has a 24/4 regime, unlike the normal 21/7 cycle. This shorter pill-free interval is better for patients with troublesome premenstrual symptoms and is more effective at preventing ovulation. Studies have shown that Yaz causes less premenstrual syndrome, and blood loss is reduced by 50-60%.

In conclusion, the choice of COCP depends on various factors such as cost, safety data, and missed pill rules. It is essential to consult a healthcare provider to determine the most suitable COCP based on individual needs and medical history.

Suspected Cervical Cancer

This patient should be suspected to have cervical cancer until proven otherwise, due to inflammation of the cervix that has been shown to be non-infective and no documented smear history, which puts her at higher risk. Empirical treatment for Chlamydia or gonorrhoea would not usually be suggested in general practice unless the patient has symptoms and signs of PID. Referring to an STD clinic is incorrect, as urgent investigation for cancer is necessary. Referring routinely to gynaecology is an option, but it doesn’t fully take into account the urgency of ruling out cervical cancer. Arranging a smear test for a lady with suspected cervical cancer would be inappropriate, as smear tests do not diagnose cancer, they only assess the likelihood of cancer occurring in the future.

Clonidine is the only option listed above that is recognized as a non-hormonal treatment for hot flashes during menopause. Amitriptyline is an antidepressant, Tibolone is a synthetic compound with estrogenic, progestogenic, and androgenic activity, Danazol is a synthetic steroid that suppresses gonadotropin production, and Clomiphene is a selective estrogen receptor modulator used in fertility treatments. According to the NICE Clinical Knowledge Summaries article on treating menopause symptoms, non-hormonal therapies for hot flashes include lifestyle changes, a trial of certain medications such as paroxetine, fluoxetine, citalopram, or venlafaxine, a 24-week trial of clonidine, or a progestogen like norethisterone or megestrol (with specialist advice).

Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

The hormonal factors are responsible for the risk of ovarian cancer. Women who experience ovulation without suppression are at a higher risk. Therefore, early menarche and late menopause, which increase ovulation, are considered risk factors for ovarian cancer. On the other hand, hormone replacement therapy (HRT) and obesity, not low body weight, are also risk factors.

Pregnancy, which suppresses ovulation, is a protective factor against ovarian cancer. Similarly, the use of combined oral contraceptives is also considered protective.

The media often highlights vague symptoms such as bloating as potential signs of ovarian cancer. However, it is important to reassure patients and conduct a thorough history and examination to identify any risk factors.

Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

The failure rate of female sterilisation is 1 in 200.

Understanding Female Sterilisation

Female sterilisation is a common method of permanent contraception for women. It has a low failure rate of 1 per 200 and is usually performed by laparoscopy under general anaesthetic. The procedure is generally done as a day case and involves various techniques such as clips (e.g. Filshie clips), blockage, rings (Falope rings) and salpingectomy. However, there are potential complications such as an increased risk of ectopic pregnancy if sterilisation fails, as well as general risks associated with anaesthesia and laparoscopy.

In the event that a woman wishes to reverse the procedure, the current success rate of female sterilisation reversal is between 50-60%. It is important for women to understand the risks and benefits of female sterilisation before making a decision.

Raynaud’s disease of the nipple can cause pain in women who are breastfeeding.

Symptoms of Raynaud’s disease of the nipple include intermittent pain during and after feeding, as well as nipple blanching followed by cyanosis and/or erythema. Pain subsides when the nipple returns to its normal color. Other possible causes of nipple pain, such as candidiasis or poor latch, should also be considered. Treatment options for Raynaud’s disease of the nipple include minimizing exposure to cold, using heat packs after feeding, avoiding caffeine, and quitting smoking. If symptoms persist, referral to a specialist for a trial of oral nifedipine may be necessary (although this is off-license).

Option one is the correct answer, as the clinical history is consistent with Raynaud’s disease of the nipple. Option two is incorrect, as pain would be more localized and may be accompanied by a white spot or tenderness. Option three is also incorrect, as pain is usually more generalized and occurs during the first few minutes of feeding. Option four is incorrect, as an infection would likely present with purulent nipple discharge, crusting, redness, and fissuring. Option five is also incorrect, as an eczematous rash would likely be present with itching and dry, scaly patches.

Breastfeeding Problems and Management

Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.

Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.

Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.

Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.

Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.

If a woman has symptoms of candidiasis or BV and is unlikely to have an STI or serious illness, vaginal examination may be unnecessary. However, if a woman has vaginal discharge and a history of BV or candidiasis, and is not pregnant or postnatal, and has not recently undergone a gynecological procedure, examination should not be omitted.

Understanding Vaginal Discharge: Common and Less Common Causes

Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a serious health issue. In fact, some amount of discharge is normal and helps to keep the vagina clean and healthy. However, when the discharge is accompanied by other symptoms such as itching, burning, or a foul odor, it may be a sign of an underlying condition.

The most common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. Candida is a fungal infection that can cause a thick, white discharge that resembles cottage cheese. Trichomonas vaginalis is a sexually transmitted infection that can cause a yellow or green, frothy discharge with a strong odor. Bacterial vaginosis is a bacterial infection that can cause a thin, gray or white discharge with a fishy odor.

Less common causes of vaginal discharge include gonorrhea, chlamydia, ectropion, foreign bodies, and cervical cancer.

The use of combined hormonal contraceptive pills can lead to a decreased risk of ovarian and endometrial cancer that can last for many years even after discontinuation. However, for women under 35 years of age who smoke, the UKMEC category is 2, indicating that the benefits of using the method generally outweigh the potential risks. For women over 35 years of age who smoke, the UKMEC category is 3 if they smoke less than 15 cigarettes a day and 4 if they smoke more than 15 cigarettes a day.

While some meta-analyses have shown a slightly increased risk of breast cancer among women using COCP, there is no significant risk of breast cancer after 10 years of discontinuation. Additionally, COCP can help reduce menstrual bleeding and pain, as well as alleviate menopausal symptoms.

Pros and Cons of the Combined Oral Contraceptive Pill

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

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

Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

If you experience ovarian hyperstimulation syndrome, your chances of developing ovarian torsion are higher. This is because the ovary becomes enlarged, which increases the risk of torsion. If you experience sudden pelvic pain and vomiting on one side, it may be a sign of ovarian torsion.

While an ovarian cyst can cause pelvic pain, the sudden onset of pain suggests a cyst accident, such as rupture, haemorrhage, or torsion.

Pelvic inflammatory disease typically causes pelvic pain, fever, and abnormal vaginal bleeding.

Appendicitis usually causes pain in the right iliac fossa.

Understanding Ovarian Torsion

Ovarian torsion is a condition where the ovary twists on its supporting ligaments, leading to a compromised blood supply. This can result in partial or complete torsion of the ovary. When the fallopian tube is also affected, it is referred to as adnexal torsion. The condition is commonly associated with ovarian masses, pregnancy, and ovarian hyperstimulation syndrome. Women of reproductive age are also at risk of developing ovarian torsion.

The most common symptom of ovarian torsion is sudden, severe abdominal pain that is often colicky in nature. Other symptoms include vomiting, distress, and in some cases, fever. Adnexal tenderness may be detected during a vaginal examination. Ultrasound may reveal free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for ovarian torsion.

Special Situations for Combined Oral Contraceptive Pill

Concurrent Antibiotic Use:
In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

Switching Combined Oral Contraceptive Pills:
The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF.

Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite called Trichomonas vaginalis. It is more common in women than men, and many women with the infection do not experience any symptoms. In order to diagnose trichomoniasis, a sample of vaginal discharge is collected and examined under a microscope for the presence of motile trophozoites. Confirmation of the diagnosis can be done through molecular testing. Treatment typically involves taking oral metronidazole for a specified period of time. Other sexually transmitted infections, such as Chlamydia, gonorrhea, and candidiasis, require different treatments.

Comparison of Bacterial Vaginosis and Trichomonas Vaginalis

Bacterial vaginosis and Trichomonas vaginalis are two common sexually transmitted infections that affect women. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while Trichomonas vaginalis is caused by a protozoan parasite. Both infections can cause vaginal discharge and vulvovaginitis, but Trichomonas vaginalis may also cause urethritis in men.

The vaginal discharge in bacterial vaginosis is typically thin and grayish-white, with a fishy odor. The pH of the vagina is usually higher than 4.5. In contrast, the discharge in Trichomonas vaginalis is offensive, yellow/green, and frothy. The cervix may also appear like a strawberry. The pH of the vagina is also higher than 4.5.

To diagnose bacterial vaginosis, a doctor may perform a pelvic exam and take a sample of the vaginal discharge for testing. The presence of clue cells, which are vaginal cells covered in bacteria, is a hallmark of bacterial vaginosis. On the other hand, Trichomonas vaginalis can be diagnosed by examining a wet mount under a microscope. The motile trophozoites of the parasite can be seen in the sample.

Both bacterial vaginosis and Trichomonas vaginalis can be treated with antibiotics. Metronidazole is the drug of choice for both infections. For bacterial vaginosis, a course of oral metronidazole for 5-7 days is recommended. For Trichomonas vaginalis, a one-off dose of 2g metronidazole may also be used. It is important to complete the full course of antibiotics to ensure that the infection is fully treated.