In women aged 50-59 who do not use HRT, the background incidence of VTE is 5 cases per 1,000. The use of oestrogen-only HRT increases the incidence by 2 cases per 1,000, while combined HRT increases it by 7 cases per 1,000. According to the BNF, tibolone doesn’t elevate the risk of VTE when compared to combined HRT.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

Polycystic ovarian syndrome is among the risk factors for endometrial cancer.

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. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. 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 of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be 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.

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.

Polycystic ovarian syndrome (PCOS) is diagnosed based on the Rotterdam criteria, which requires the presence of at least two of the following: oligo/anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovaries on ultrasound scanning. Patients may be asymptomatic or present with menstrual disturbance, infertility, obesity, male pattern hair loss, hirsutism, and acne. Blood tests can support the diagnosis, with elevated LH and testosterone levels being common findings. Mild prolactinaemia and insulin resistance may also be present. Ultrasound scanning is not necessary if the diagnosis is obvious on clinical and biochemical grounds. Confirming the diagnosis is important to rule out other potential causes and to monitor for associated health problems such as diabetes, cardiovascular disease, and endometrial cancer. Women with PCOS should have regular periods or progesterone-induced withdrawal bleeds to reduce the risk of endometrial hyperplasia and cancer.

Guidelines for Referral of Suspected Breast Cancer

Current NICE guidelines focus on symptoms and signs of breast cancer in individuals aged 30 and over. Referral for an appointment within two weeks is recommended for those with an unexplained breast lump with or without pain, or for those aged 50 and over with nipple discharge, retraction, or other changes of concern. Non-urgent referral may be considered for those under 30 with an unexplained breast lump. However, in cases where the cause of the problem may be an ill-fitting bra, conservative management is recommended. Topical NSAIDs may be given for symptom relief, but evening primrose oil has no evidence to support its use for cyclical mastalgia. Re-examination should be considered if symptoms persist.

Contraception Options for Patients with Past Breast Cancer

Patients with a past history of breast cancer should be advised to use barrier contraception or the intrauterine device (IUD) only. Hormonal containing contraception, including progestogens, are UKMEC 3 in these patients. This means that the benefits of using hormonal contraception may outweigh the risks, but caution should be taken and alternative options should be considered.

The IUD and implant are also UKMEC 3 in patients with past breast cancer, while the IUD and progesterone-only pill are also considered UKMEC 3. It is important for patients to discuss their options with their healthcare provider and weigh the potential benefits and risks of each method before making a decision. By considering all options and taking precautions, patients with past breast cancer can still have access to effective contraception while minimizing potential risks.

If a patient experiences reddening and thickening of the nipple and areola, it is important to consider the possibility of Paget’s disease of the breast. However, it is also possible that the symptoms are caused by nipple eczema, especially if the patient has a history of atopy and no personal or family history of breast disease. It is important to rule out Paget’s disease, as it typically presents unilaterally and may be accompanied by bloody nipple discharge and an underlying breast lump.

Understanding Paget’s Disease of the Nipple

Paget’s disease of the nipple is a condition that affects the nipple and is associated with an underlying breast cancer. It is present in only 1-2% of patients with breast cancer, but it is important to note that half of these patients have an underlying mass lesion, and 90% of them will have an invasive carcinoma. Even patients without a mass lesion may still have an underlying carcinoma, which is found in 30% of cases. The remaining patients will have carcinoma in situ.

Unlike eczema of the nipple, Paget’s disease primarily affects the nipple and later spreads to the areolar. Diagnosis is made through a combination of punch biopsy, mammography, and ultrasound of the breast. Treatment options will depend on the underlying lesion.

If a woman is 55 years or older and experiences postmenopausal bleeding (i.e. bleeding occurring more than 12 months after her last menstrual cycle), she should be referred through the suspected cancer pathway within 2 weeks to rule out endometrial cancer. As this woman is over 50 years old and has not had a menstrual cycle for over a year, she has reached menopause and doesn’t require blood tests to confirm it. The recent vaginal bleeding she has experienced is considered postmenopausal bleeding and requires further investigation to eliminate the possibility of endometrial cancer.

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. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. 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 of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be 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.

For women over 40, it is recommended to consider a COC pill containing less than 30 µg ethinylestradiol as the first-line option due to the potentially lower risks of VTE, cardiovascular disease, and stroke compared to formulations with higher doses of estrogen. COCP can also help reduce menstrual bleeding and pain, which may be beneficial for women in this age group. However, it is important to consider special considerations when prescribing COCP to women over 40.

Levonorgestrel or norethisterone-containing COCP preparations should be considered as the first-line option for women over 40 due to the potentially lower risk of VTE compared to formulations containing other progestogens. The UKMEC criteria for women over 40 is 2, while for women from menarche until 40, it is 1. The faculty of sexual and reproductive health recommends the use of COCP until age 50 if there are no other contraindications. Women aged 50 and over should be advised to use an alternative, safer method for contraception.

Extended or continuous COCP regimens can be offered to women for contraception and to control menstrual or menopausal symptoms. COCP is associated with a reduced risk of ovarian and endometrial cancer that lasts for several decades after cessation. It may also help maintain bone mineral density compared to non-use of hormones in the perimenopause.

Although meta-analyses have found a slightly increased risk of breast cancer among women using COCP, there is no significant risk of breast cancer ten years after cessation. Women who smoke should be advised to stop COCP at 35 as this is the age at which excess risk of mortality associated with smoking becomes clinically significant.

Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

According to NICE guidelines for cervical cancer screening, if a person’s first repeat smear at 12 months is still positive for high-risk human papillomavirus (hrHPV), they should have another smear test 12 months later (i.e. at 24 months after the initial test). If the person remains hrHPV positive but has negative cytology results at 12 and 24 months, they should be referred to colposcopy. However, if they become hrHPV negative at 24 months, they can return to routine recall.

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.

If a patient refuses a chaperone for an intimate examination and you are not comfortable performing the examination without one, it is necessary to make alternative arrangements for the patient to be examined.

As per the current guidelines of the Faculty of Sexual and Reproductive Healthcare, a speculum examination is necessary for a patient who has been experiencing problematic per vaginal bleeding with hormonal contraception for more than three months. It is crucial to examine and visualize the cervix. However, in this case, the patient has declined a male chaperone, making it a challenging situation.

While referring the patient to another service for the examination is an option, it is not appropriate for an urgent same-day admission as this is a longstanding problem. Additionally, some accident and emergency departments may not be comfortable performing speculum examinations and would refer the patient to the gynaecology department if necessary.

Referring the patient to the two-week wait clinic without examining is not appropriate as the referral may not be necessary.

Continuing with the examination without a chaperone is not advisable, especially if the clinician is uncomfortable doing so, as there is no indication of an emergency presentation.

Proceeding with the examination with a female receptionist chaperoning is not recommended as the patient has declined this and has the capacity to do so. This would be without her consent.

The most appropriate course of action would be to arrange for a suitable colleague to examine the patient the following day. As there is no indication of an acute emergency or evidence of ectopic pregnancy, deferring the examination to the following day is entirely appropriate.

GMC Guidelines on Intimate Examinations and Chaperones

The General Medical Council (GMC) has provided comprehensive guidance on how to conduct intimate examinations and the role of chaperones in the process. Intimate examinations refer to any procedure that a patient may consider intrusive or intimate, such as examinations of the genitalia, rectum, and breasts. Before performing such an examination, doctors must obtain informed consent from the patient, explaining the procedure, its purpose, and the extent of exposure required. During the examination, doctors should only speak if necessary, and patients have the right to stop the examination at any point.

Chaperones are impartial individuals who offer support to patients during intimate examinations and observe the procedure to ensure that it is conducted professionally. They should be healthcare workers who have no relation to the patient or doctor, and their full name and role should be documented in the medical records. Patients may also wish to have family members present for support, but they cannot act as chaperones as they are not impartial. Doctors should not feel pressured to perform an examination without a chaperone if they are uncomfortable doing so. In such cases, they should refer the patient to a colleague who is comfortable with the examination.

It is not mandatory to have a chaperone present during an intimate examination, and patients may refuse one. However, the offer and refusal of a chaperone should be documented in the medical records. If a patient makes any allegations against the doctor regarding the examination, the chaperone can be called upon as a witness. In cases where a patient refuses a chaperone, doctors should explain the reasons for offering one and refer the patient to another service if necessary. The GMC guidelines aim to ensure that intimate examinations are conducted with sensitivity, respect, and professionalism, while also protecting the interests of both patients and doctors.

Understanding Mastitis: Symptoms, Management, and Risks

Mastitis is a condition that occurs when the breast tissue becomes inflamed, and it is commonly associated with breastfeeding. It affects approximately 1 in 10 women and is characterized by symptoms such as a painful, tender, and red hot breast, as well as fever and general malaise.

The first-line management of mastitis is to continue breastfeeding, and simple measures such as analgesia and warm compresses can also be helpful. However, if a woman is systemically unwell, has a nipple fissure, or if symptoms do not improve after 12-24 hours of effective milk removal, treatment with antibiotics may be necessary. The most common organism causing infective mastitis is Staphylococcus aureus, and the first-line antibiotic is oral flucloxacillin for 10-14 days. It is important to note that breastfeeding or expressing should continue during antibiotic treatment.

If left untreated, mastitis can lead to the development of a breast abscess, which may require incision and drainage. Therefore, it is crucial to seek medical attention if symptoms persist or worsen. By understanding the symptoms, management, and risks associated with mastitis, women can take proactive steps to address this condition and ensure their overall health and well-being.

Management of Asymptomatic Fibroids in Women

The absence of menorrhagia is an important point to note in the management of asymptomatic fibroids in women. According to guidelines, annual follow-up to monitor size and growth is recommended for such cases. However, routine referral to a gynaecologist is not required unless there are symptoms that have not improved despite initial treatments, complications, fertility or obstetric problems associated with fibroids, or a suspicion of malignancy. Treatment options for menorrhagia associated with fibroids are available but have no role in the management of small asymptomatic fibroids. NSAIDs and/or tranexamic acid should be stopped if symptoms have not improved within three menstrual cycles. It is important to consider these factors when managing asymptomatic fibroids in women.

Norethisterone taken orally is a viable solution for quickly halting heavy menstrual bleeding on a temporary basis.

Managing Heavy Menstrual Bleeding

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

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

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

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.

Management of Suspicious Bleeding in a High-Risk Patient

This patient has several risk factors for endometrial dysplasia and cancer, including obesity, polycystic ovarian syndrome, and long-term amenorrhea. Recently, she has experienced a change in her bleeding pattern from amenorrhea to spotting, which requires ruling out any suspicious causes. According to NICE guidelines, women aged 55 years and over with postmenopausal bleeding should be referred for an appointment within 2 weeks for endometrial cancer. For women under 55 years, a suspected cancer pathway referral should be considered. A direct access ultrasound scan may also be considered for women aged 55 years and over with unexplained symptoms of vaginal discharge, thrombocytosis, haematuria, low haemoglobin levels, thrombocytosis, or high blood glucose levels.

In this case, checking a day 21 progesterone is not useful as the patient is amenorrheic. The FSH:LH ratio may be helpful in diagnosing polycystic ovarian syndrome, but it will not guide management in this case. The use of a coil may be considered after a TVUS to measure endometrial thickness if the patient is deemed low risk. Overall, it is important to promptly investigate any suspicious bleeding in high-risk patients to ensure early detection and management of any potential malignancies.

The recommended hormone replacement therapy (HRT) for this patient is a transdermal, combined sequential preparation. This is because she has erratic periods, indicating an intact uterus that requires protection of the endometrium with both oestrogen and progesterone. Therefore, an oestrogen-only HRT is not suitable.

Using a Mirena coil, which releases levonorgestrel into the uterus, is unlikely to alleviate the emotional lability and hot flashes associated with menopause. Additionally, using it alone without an oestrogen component is not an option for this patient. As she is still having periods at the age of 49, a sequential preparation is more appropriate than a continuous one, which is typically used after menopause.

Given the patient’s family history of unprovoked deep vein thrombosis (DVT), a transdermal preparation may be preferable as it significantly reduces the risk of venous thromboembolism associated with HRT.

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.

No additional contraception is needed if an LNG-IUS or Levonorgestrel-IUS is inserted on day 1-7 of the cycle. However, if it is inserted outside this timeframe, 7 days of additional contraception is required. Since the patient is currently on day 6 of her cycle, there is no need for extra precautions.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Injectable progesterone contraceptives are not recommended for individuals with current breast cancer due to contraindications. This applies to all hormonal contraceptive options, including Depo-Provera, which are classified as UKMEC 4. As a result, the copper intrauterine device is the only suitable contraception option available.

Injectable Contraceptives: Depo Provera

Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150 mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucous thickening and endometrial thinning.

However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

It is important to note that Noristerat, another injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks. The BNF gives different advice regarding the interval between injections, stating that a pregnancy test should be done if the interval is greater than 12 weeks and 5 days. However, this is not commonly adhered to in the family planning community.

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.

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 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.

The patient has breast engorgement and should be advised to feed the infant with no restrictions on frequency and length of feeds. Analgesia with opioids is not recommended, and support measures such as breast massage and cold gel packs are the mainstay of treatment. Mastitis is a differential diagnosis, but hospital admission is not necessary unless there are signs of sepsis or rapidly progressing infection. Other causes of breast pain or discomfort in breastfeeding women include a full breast, a blocked duct, mastitis, or a breast abscess. Deep breast pain may also be caused by ductal infection, spasm of the ducts, persistent reaction to nerve trauma, or prolactin-induced mastalgia.

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.

The use of Nexplanon® IMP is not limited by age and is licensed for contraception for a period of 3 years. It contains 68 mg etonogestrel and doesn’t pose an increased risk of VTE, stroke, or MI. Additionally, it has not been found to have a significant impact on bone mineral density (BMD). While the progesterone-only injectable contraceptive may initially decrease BMD, this effect is not exacerbated by menopause.

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.

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.

Referral for Colposcopy in HPV Positive and Abnormal Cytology Cases

According to national guidelines and summarised in NICE Clinical Knowledge Summaries, individuals who test positive for high-risk human papillomavirus (hrHPV) and have abnormal cytology should be referred for colposcopy. This means that if a woman has a borderline smear and is also HPV positive, she should be referred for colposcopy.

In this case, we have a 45-year-old female who would normally have cervical smears every 3 years. However, due to the presence of HPV positive and borderline smear, she requires further investigation through colposcopy. It is important to follow these guidelines to ensure early detection and treatment of any potential cervical abnormalities.

Screening for ovarian cancer in asymptomatic women should not be done using Ca-125 due to its poor sensitivity and specificity. Even when used in symptomatic patients, there is a high false negative rate, so an ultrasound scan should be considered if symptoms persist. CEA is a tumour marker for colorectal cancer, but it is not recommended for screening and is only used to monitor disease activity. Ultrasound is also not advised for screening for ovarian cancer in asymptomatic patients. Private whole-body scans for the worried well are available, but they carry the risk of incidental findings, and CT scans have a significant radiation risk.

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.

Importance of HPV Testing in Cervical Cancer Screening

The presence of high-risk HPV strains, such as 16 and 18, increases the likelihood of malignant changes in the cervical transmission zone. Therefore, a borderline change in this area is significant and should prompt a referral for colposcopy. In the past, before HPV testing was available, the advice would have been to repeat the smear test in six months. However, repeating the smear test after five years, as recommended for women over 50 in England, doesn’t take into account the abnormal result. It is important to understand that there is no antiviral treatment for HPV, so the use of aciclovir would be inappropriate. Currently, vaccination for HPV is only given to 12-13-year-old girls. Regular cervical cancer screening, including HPV testing, is crucial for early detection and prevention of cervical cancer.

The approach to managing secondary dysmenorrhoea varies depending on the root cause.

Understanding Dysmenorrhoea

Dysmenorrhoea is a medical condition that is characterized by excessive pain during the menstrual period. It is classified into two types: primary and secondary dysmenorrhoea. Primary dysmenorrhoea affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. It is caused by excessive endometrial prostaglandin production. The pain typically starts just before or within a few hours of the period starting and is felt as suprapubic cramping pains that may radiate to the back or down the thigh. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, while combined oral contraceptive pills are used second line.

On the other hand, secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but normal copper coils may worsen the condition.

HPV Triage in NHS Cervical Cancer Screening Programme

HPV triage is a new addition to the NHS cervical cancer screening programme. It involves testing cytology samples of women with borderline changes or mild dyskaryosis for high-risk HPV types that are linked to cervical cancer development. The aim is to refer women with abnormalities for colposcopy and further investigation, and if necessary, treatment. However, only a small percentage of women referred for colposcopy actually require treatment as low-grade abnormalities often resolve on their own. HPV testing provides additional information to help determine who needs onward referral for colposcopy and who doesn’t. Women who test negative for high-risk HPV are simply returned to routine screening recall, while those who test positive are referred for colposcopy. HPV testing is also used as a ‘test of cure’ for women who have been treated for cervical intraepithelial neoplasia and have returned for follow-up cytology. Those with ‘normal’, ‘borderline’, or ‘mild dyskaryosis’ smear results who are HPV negative are returned to 3 yearly recall.