Consider referral if the cyst remains after 12 weeks.

When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.

For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.

Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.

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.

A woman under 30 years old who presents with an unexplained breast lump, with or without pain, may not meet the 2-week-wait referral criteria but can still be referred for further evaluation. The most likely diagnosis is a fibroadenoma, which is a common benign breast lump that often occurs in younger women. These lumps are typically firm, smooth, and highly mobile, and can be described as a breast mouse due to their tendency to move away from the examiner’s hand. While a referral to a breast clinic is necessary, routine referral is appropriate given the low likelihood of cancer. There is no need to arrange mammograms or ultrasounds as these will be done by the breast clinic. Reviewing the patient in one month is unnecessary as the lump has persisted for two months and is not cyclical. Urgent referral to a breast clinic is not necessary given the patient’s age and low likelihood of breast cancer. According to NICE CKS, a 2-week-wait referral is recommended for those over 30 years old with an unexplained breast lump, or over 50 years old with unilateral nipple changes. Consideration of a 2-week-wait referral is also recommended for those over 30 years old with an unexplained lump in the axilla or skin changes suggestive of breast cancer.

In 2015, NICE released guidelines for referring individuals suspected of having breast cancer. If a person is 30 years or older and has an unexplained breast lump with or without pain, they should be referred using a suspected cancer pathway referral for an appointment within two weeks. Similarly, if a person is 50 years or older and experiences discharge, retraction, or other concerning changes in one nipple only, they should also be referred using this pathway. If a person has skin changes that suggest breast cancer or is 30 years or older with an unexplained lump in the axilla, a suspected cancer pathway referral should be considered for an appointment within two weeks. For individuals under 30 years old with an unexplained breast lump with or without pain, a non-urgent referral should be considered.

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.

Breast Cancer Screening and Familial Risk Factors

Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

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.

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.

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.

In cases of recurrent vaginal candidiasis, it is important to consider a blood test to rule out diabetes as a potential underlying cause. This is because poorly controlled diabetes can increase the risk of Candida growth. While it is important to treat the symptoms of the infection, it is also crucial to investigate any predisposing factors that may be contributing to the recurrence.

Measuring TSH, free T3 and T4 levels to rule out hyperthyroidism is not necessary as there is no link between an overactive thyroid and Candida infections. Similarly, mid-stream urine to rule out UTI is not necessary unless the patient’s symptoms suggest a urinary tract infection. Referral to a specialist is also not necessary as recurrent vaginal candidiasis can be managed in primary care with an induction-maintenance regimen of antifungals. Specialist referral may only be necessary if the infective organism is resistant to treatment or if it is a non-albicans Candida species.

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.

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 Endometrial Cancer in postmenopausal Woman with Abnormal Bleeding

According to the 2015 NICE guidelines, women aged 55 and over with postmenopausal bleeding should be referred for suspected cancer pathway referral within two weeks. This includes women who experience unexplained vaginal bleeding more than 12 months after menstruation has stopped due to menopause.

In this case, the patient’s periods stopped 18 months ago, making her postmenopausal. Her recent bleeding episode, along with her nulliparity, obesity, menopause after 52, and family history of hereditary nonpolyposis colon cancer, all increase her risk for endometrial cancer. Although bleeding can occur when using HRT, the patient began bleeding six months after initiating HRT, and the bleeding persisted four weeks after stopping HRT, making it less likely that the medication is the cause.

Re-initiating HRT would be contraindicated until endometrial cancer is ruled out. While the patient has not experienced post-coital bleeding and has a normal-looking cervix with normal smear results, referral for colposcopy would not be the most appropriate next step. Inserting a Mirena coil may be useful in managing troublesome bleeding associated with HRT, but it would not be appropriate until the patient is investigated for endometrial cancer.

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.

Investigation is necessary for any ovarian mass found in a woman who has undergone menopause.

When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.

For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.

Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.

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.

The individual is suffering from thrush. Pregnancy prohibits the use of oral antifungal treatments, so a Clotrimazole pessary should be administered instead.

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.

Urgent Action Required for Haemodynamically Unstable Patient

The most appropriate course of action in this case is to call 999 and request an ambulance. This patient may have an ectopic pregnancy or may be miscarrying, and is therefore unstable and requires immediate resuscitation and transfer to hospital. While waiting for the ambulance, an attempt at IV cannulation and fluid resuscitation should be made.

Arranging an assessment at the EPAU within 24 hours is inappropriate, as the patient is haemodynamically unstable and requires urgent admission via ambulance. Conducting a pelvic exam is not appropriate as this patient is haemodynamically unstable and has abdominal tenderness. Similarly, conducting a urine pregnancy test or taking blood for a serum βHCG would only cause unnecessary delay.

It is crucial to prioritize the patient’s immediate medical needs and take urgent action to ensure their safety and well-being.

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.

A labial lump and inguinal lymphadenopathy in an older woman may indicate the presence of vulval carcinoma, as these symptoms are concerning and should not be ignored. Although labial lumps are not uncommon, it is important to be vigilant and seek medical attention if a new lump appears.

Understanding Vulval Carcinoma

Vulval carcinoma is a type of cancer that affects the vulva, which is the external female genitalia. It is a relatively rare condition, with only around 1,200 cases diagnosed in the UK each year. The majority of cases occur in women over the age of 65 years, and the most common type of vulval cancer is squamous cell carcinoma, accounting for around 80% of cases.

There are several risk factors associated with vulval carcinoma, including human papillomavirus (HPV) infection, vulval intraepithelial neoplasia (VIN), immunosuppression, and lichen sclerosus. Symptoms of vulval carcinoma may include a lump or ulcer on the labia majora, inguinal lymphadenopathy, and itching or irritation.

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.

Mild cases of pelvic inflammatory disease do not require removal of intrauterine contraceptive devices.

Pelvic inflammatory disease (PID) is a condition where the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. It is typically caused by an infection that spreads from the endocervix. The most common causative organism is Chlamydia trachomatis, followed by Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and Gonorrhoea. However, these tests may often be negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole. In mild cases of PID, intrauterine contraceptive devices may be left in, but the evidence is limited, and removal of the IUD may be associated with better short-term clinical outcomes according to recent guidelines.

Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis, infertility (with a risk as high as 10-20% after a single episode), chronic pelvic pain, and ectopic pregnancy.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

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 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.

According to BASHH, recurrent vaginal candidiasis is characterized by experiencing four or more episodes per year. This criterion is significant as it helps determine the need for prophylactic treatment to prevent future recurrences.

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.

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.

The cause of endometrial hyperplasia is the lack of opposition to oestrogen by progesterone. This condition is linked to various factors such as taking unopposed oestrogen, obesity, late menopause, early menarche, being over 35 years old, smoking, nulliparity, and the use of tamoxifen. Tamoxifen is a risk factor because it has a pro-oestrogen effect on the uterus and bones, but it also has an anti-oestrogen effect on the breast.

Understanding Endometrial Hyperplasia

Endometrial hyperplasia is a condition characterized by the abnormal growth of the endometrium, which is the lining of the uterus. This growth is excessive compared to the normal proliferation that occurs during the menstrual cycle. There are different types of endometrial hyperplasia, including simple, complex, simple atypical, and complex atypical. Patients with this condition may experience abnormal vaginal bleeding, such as intermenstrual bleeding.

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

In summary, endometrial hyperplasia is a condition that requires proper diagnosis and management to prevent the development of endometrial cancer. Patients experiencing abnormal vaginal bleeding should seek medical attention to determine the underlying cause of their symptoms.

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.

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.

Contraception and Pregnancy

When a woman becomes pregnant while using contraception, it is usually recommended to stop or remove the method. However, it is important to note that contraceptive hormones do not typically harm the fetus.

If an intrauterine method is in place when pregnancy is diagnosed, the woman should be informed of the potential risks of leaving it in-situ, such as second-trimester miscarriage, preterm delivery, and infection. While removal in the first trimester carries a small risk of miscarriage, it may reduce the risk of adverse outcomes. If the threads of the intrauterine contraceptive are visible or can be retrieved, it should be removed up to 12 weeks gestation, but not after this point.

Overall, it is important for women to discuss their contraceptive options with their healthcare provider and to inform them if they suspect they may be pregnant.

Cervical Screening in the UK

Cervical screening is recommended for all women in England aged 25-64, and from 20 onwards in Wales and Scotland. This screening is important because certain human papillomavirus (HPV) subtypes underlie the development of almost all cases of cervical cancer. HPV is transmitted during sexual intercourse and intimate sexual contact, and even homosexual women can still pass the virus on to female partners.

Women who have been vaccinated as part of the national HPV programme will be protected against the main two HPV subtypes that cause the majority of cervical cancers, but there are other less common subtypes that can lead to cervical cancer that they are not vaccinated against. Women with a previously abnormal smear require follow up either with further smears or referral for colposcopy/treatment depending on the exact abnormalities detected.

Women who have never been sexually active would be very low risk so following discussion with their GP often may decide not to participate in cervical screening. However, they are eligible to be screened routinely and would be offered screening. The only group above who are not eligible for routine cervical screening are women over the age of 65. Routine screening runs up to the age of 64. However, if a woman has abnormalities that require further follow up smears then this would of course be done beyond the age of 65 if clinically indicated.

In summary, cervical screening is an important part of women’s health in the UK, and all women should consider participating in routine screening to help prevent cervical cancer.