First-Line Treatment for Menorrhagia

When it comes to treating menorrhagia, the levonorgestrel-releasing intrauterine system (LNG-IUS) is considered the first-line option by NICE. This is especially true for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis. While the combined oral contraceptive pill is also an option, it is not the preferred choice.

It is important to note that a repeat ultrasound may not be the next step in management, as the history of menorrhagia is the crucial point to consider. If menorrhagia is not present, the treatment plan may differ. Ulipristal acetate may be used for larger fibroids, but it is typically started in secondary care. Referral for surgical treatment should not be the first-line option, as more conservative measures should be tried initially.

Bacterial Vaginosis: Symptoms, Risk Factors, and Treatment

Bacterial vaginosis is a common condition among women of childbearing age. It is characterized by a thin, milky white discharge with a malodorous fishy smell. The discharge is not itchy, but the fishy odor can be detected by adding 10% potassium hydroxide to the vaginal discharge. The vaginal pH is usually greater than 4.5.

Risk factors for bacterial vaginosis include the use of intrauterine coil devices, vaginal douching, and having multiple sexual partners. If left untreated, bacterial vaginosis can lead to pelvic inflammatory diseases. Some patients may not experience any symptoms, but those who do should seek treatment, especially if they are pregnant.

In the UK, the first line treatment for bacterial vaginosis is metronidazole 400 mg twice daily for seven days. Alternatively, a single dose of oral metronidazole 2 g may be given if patient adherence is an issue. Azithromycin is used to treat Chlamydia, and ceftriaxone is used to treat gonorrhea.

In the US, the CDC has updated treatment recommendations for bacterial vaginosis. Metronidazole 500 mg orally twice a day for seven days is the recommended therapy, with alternatives including several tinidazole regimens or clindamycin (oral or intravaginal). Additional regimens include metronidazole (750 mg extended release tablets once daily for seven days) or a single dose of clindamycin intravaginal cream, although data on the performance of these alternative regimens are limited.

The use of SSRI medications, either continuously or during the luteal phase, may be beneficial in managing premenstrual syndrome (PMS). This is especially true for patients who have not seen improvement with first-line treatments such as combined oral contraceptive pills. Co-cyprindiol, levonorgestrel-releasing intrauterine systems, mirtazapine, and copper coils are not indicated for the management of PMS.

Understanding Premenstrual Syndrome (PMS)

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

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

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

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

Contraindications for Combined Oral Contraceptive Pill

The decision to prescribe the combined oral contraceptive pill is based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential cautions and contraindications on a four-point scale. UKMEC 1 represents a condition for which there is no restriction for the use of the contraceptive method, while UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, immobility, and a family history of thromboembolic disease in first-degree relatives under 45 years old. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension.

In 2016, the UKMEC was updated to reflect that breastfeeding between 6 weeks and 6 months postpartum is now classified as UKMEC 2 instead of UKMEC 3. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. It is important for healthcare providers to consider these contraindications when deciding whether to prescribe the combined oral contraceptive pill to their patients.

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

Understanding Cervical Cancer Screening in the UK

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

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

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

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

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

For women who are at high risk of STIs, have recently undergone a gynaecological or obstetric procedure (including delivery), or are pregnant, it is recommended to undergo an examination. In cases of new-onset vaginal discharge, an intimate examination is advised. If the patient has had an intrauterine system inserted recently and is experiencing a recurrence of bacterial vaginosis, an examination should be conducted before determining the next course of action.

Understanding Vaginal Discharge: Common and Less Common Causes

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

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

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

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

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

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

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

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

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

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

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

Comparison of Bacterial Vaginosis and Trichomonas Vaginalis

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

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

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

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

According to NICE, women who are at a high risk of developing VTE and are seeking HRT should be referred to haematology before starting any treatment, even if it is transdermal.

While there is no evidence to suggest that transdermal HRT preparations such as patches or gels increase the risk of VTE, it is recommended to seek specialist advice before starting treatment if there are any risk factors present.

For patients with a high risk of VTE, oral HRT, whether it is combined or oestrogen-only, would be risky. Although per vaginal oestrogen would be a safer option, it would only provide local relief and may not alleviate all of the patient’s symptoms.

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.

The addition of progestogen to HRT has been found to increase the risk of breast cancer. However, this risk is dependent on the duration of treatment and decreases after discontinuing HRT. It is important to note that this increased risk doesn’t affect the likelihood of dying from breast cancer. HRT with oestrogen alone may have no or reduced risk of coronary heart disease, while combined HRT has little to no increase in the risk of CHD. It is worth noting that there is no HRT available that contains progestogen only. Although NICE doesn’t provide specific risk analysis for ovarian cancer in women taking HRT, a meta-analysis suggests an increased risk for both oestrogen-only and combined HRT preparations.

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.

Transdermal HRT is a safer option than oral HRT for women at risk of VTE, according to NICE guidelines. Sharon’s BMI puts her at risk of VTE, so prescribing oral HRT would not be appropriate. Recommending lifestyle changes would not be effective as Sharon has already tried this. Seeking specialist advice is unnecessary as starting transdermal HRT in primary care is safe and reasonable. While antidepressants can be considered for menopausal symptoms, it is not necessary in this case as HRT is a viable option for Sharon.

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.

According to NICE guidelines, women who are 30 years or older should be referred urgently to the local breast services if they have an unexplained breast lump with or without pain. As the woman in question is 28 years old, she should be referred to the local breast services, but it is not urgent.

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.

The patient’s gynaecomastia is likely caused by taking goserelin for prostate cancer. Goserelin is a GnRH agonist that increases luteinising hormone and testosterone levels, leading to a change in oestrogen: androgen ratio and resulting in gynaecomastia. Bisoprolol, a β-blocker, may cause bronchospasm and bradycardia, while lansoprazole, a proton pump inhibitor, may lead to hyponatraemia and hypomagnesaemia. Naproxen, a non-steroidal anti-inflammatory drug, may worsen asthma symptoms and cause upper gastrointestinal haemorrhage.

Understanding Gynaecomastia: Causes and Drug Triggers

Gynaecomastia is a condition characterized by the abnormal growth of breast tissue in males, often caused by an increased ratio of oestrogen to androgen. It is important to distinguish the causes of gynaecomastia from those of galactorrhoea, which is caused by the actions of prolactin on breast tissue.

Physiological changes during puberty can lead to gynaecomastia, but it can also be caused by syndromes with androgen deficiency such as Kallman’s and Klinefelter’s, testicular failure due to mumps, liver disease, testicular cancer, and hyperthyroidism. Additionally, haemodialysis and ectopic tumour secretion can also trigger gynaecomastia.

Drug-induced gynaecomastia is also a common cause, with spironolactone being the most frequent trigger. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids. However, it is important to note that very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.

In summary, understanding the causes and drug triggers of gynaecomastia is crucial in diagnosing and treating this condition.

The FSRH has issued UKMEC recommendations for the combined oral contraceptive pill (COCP) due to the heightened risk of cardiovascular disease. According to these guidelines, the COCP is classified as UKMEC 2 for individuals under the age of 35. For those over the age of 35 who smoke less than 15 cigarettes per day, the COCP is classified as UKMEC 3. However, for those over the age of 35 who smoke more than 15 cigarettes per day, the COCP is classified as UKMEC 4. Progestogen-only contraceptives, on the other hand, are not associated with an increased risk of cardiovascular disease and are therefore classified as UKMEC 1, regardless of the patient’s age or cigarette intake.

The choice of contraceptive for women may be affected by comorbidities. The FSRH provides UKMEC recommendations for different conditions. Smoking increases the risk of cardiovascular disease, and the COCP is recommended as UKMEC 2 for women under 35 and UKMEC 3 for those over 35 who smoke less than 15 cigarettes/day, but is UKMEC 4 for those who smoke more. Obesity increases the risk of venous thromboembolism, and the COCP is recommended as UKMEC 2 for women with a BMI of 30-34 kg/m² and UKMEC 3 for those with a BMI of 35 kg/m² or more. The COCP is contraindicated for women with a history of migraine with aura, but is UKMEC 3 for those with migraines without aura and UKMEC 2 for initiation. For women with epilepsy, consistent use of condoms is recommended in addition to other forms of contraception. The choice of contraceptive for women taking anti-epileptic medication depends on the specific medication, with the COCP and POP being UKMEC 3 for most medications, while the implant is UKMEC 2 and the Depo-Provera, IUD, and IUS are UKMEC 1. Lamotrigine has different recommendations, with the COCP being UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS being UKMEC 1.

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.

The failure rate of female sterilisation is 1 in 200.

Understanding Female Sterilisation

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

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

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 most common cause of brown-green nipple discharge is duct ectasia. This condition is often found in women around menopause and is caused by the dilation of the milk duct due to aging. It may or may not be accompanied by a small lump under the nipple.

While breast cancer can also cause nipple discharge, it is usually bloody and only comes from one nipple. A prolactinoma, a benign pituitary tumor that produces prolactin, can cause bilateral lactation and a cream-colored discharge.

Fat necrosis of the breast is typically caused by blunt trauma to the breast, resulting in a hard lump, but no nipple discharge. Paget’s disease of the nipple is characterized by a change in the skin of the nipple and areola, but there is usually no associated nipple discharge.

Understanding Nipple Discharge: Causes and Assessment

Nipple discharge is a common concern among women, and it can be caused by various factors. Physiological discharge may occur during breastfeeding, while galactorrhea may be triggered by emotional events or certain medications. Hyperprolactinemia, pituitary tumors, mammary duct ectasia, and intraductal papilloma are other possible causes of nipple discharge.

To assess patients with nipple discharge, a breast examination should be conducted to determine the presence of a mass lesion. If a mass is detected, triple assessment is recommended to evaluate the condition. Reporting of investigations should follow a system that uses a prefix denoting the type of investigation, such as M for mammography, followed by a numerical code indicating the findings.

For non-malignant nipple discharge, endocrine disease should be excluded, and smoking cessation advice may be given for duct ectasia. In severe cases of duct ectasia, total duct excision may be necessary. Nipple cytology is generally unhelpful in diagnosing the cause of nipple discharge.

Understanding the causes and assessment of nipple discharge is crucial in providing appropriate management and treatment for patients. Proper evaluation and reporting of investigations can help in identifying any underlying conditions and determining the best course of action.

Elevated Ca125 and Normal Examination: What to Do Next?

This patient has an elevated Ca125 but a normal examination. Although the elevated result was detected during screening, she admits to experiencing bloating, which can be an early symptom of ovarian cancer. However, it’s important to note that Ca125 can be elevated for non-malignancy reasons, and if the ovarian cancer is not epithelial in origin, the Ca125 can be normal.

According to NICE guidelines, if a woman has symptoms that suggest ovarian cancer, serum CA125 should be measured in primary care. If the serum CA125 is 35 IU/ml or greater, an ultrasound scan of the abdomen and pelvis should be arranged. If the ultrasound suggests ovarian cancer, the woman should be referred urgently for further investigation.

If a woman has a normal serum CA125 (less than 35 IU/ml) or a CA125 of 35 IU/ml or greater but a normal ultrasound, she should be assessed carefully for other clinical causes of her symptoms and investigated if appropriate. If no other clinical cause is apparent, she should be advised to return to her GP if her symptoms become more frequent and/or persistent.

Hot flashes are a common side-effect of tamoxifen, as stated in the BNF. Although alopecia and cataracts are also listed as possible side-effects, they are not as frequently observed as hot flashes, particularly in women who have not yet reached menopause.

Tamoxifen and its Adverse Effects

Tamoxifen is a medication used in the treatment of breast cancer that is positive for oestrogen receptors. It is classified as a Selective oEstrogen Receptor Modulator (SERM) and works by acting as an antagonist and partial agonist of the oestrogen receptor. However, the use of tamoxifen can lead to several adverse effects. These include menstrual disturbances such as vaginal bleeding and amenorrhoea, as well as hot flashes which can cause 3% of patients to stop taking the medication due to climacteric side-effects. Additionally, tamoxifen increases the risk of venous thromboembolism and endometrial cancer.

To manage breast cancer, tamoxifen is typically prescribed for a period of 5 years following the removal of the tumour. However, due to the risk of endometrial cancer associated with tamoxifen, an alternative medication called raloxifene may be used. Raloxifene is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer. It is important for patients to discuss the potential risks and benefits of tamoxifen and other medications with their healthcare provider before starting treatment.

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

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

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

Breastfeeding Problems and Management

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

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

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

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

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

The combined oral contraceptive pill (COC) is not recommended for individuals with current gallbladder disease as per the United Kingdom Medical Eligibility Criteria (UKMEC) 3. This is because the risks of using COC outweigh the benefits, as it may increase the risk of gallbladder disease and worsen existing conditions. However, if the patient has undergone cholecystectomy or is asymptomatic, COC may be considered as per UKMEC 2.

The patient’s age is not a factor in determining the suitability of COC in this scenario, as being aged 40 or over is the only age-related UKMEC 3.

The patient’s BMI is within an acceptable range for COC use.

Breastfeeding less than six weeks postpartum is not recommended as per UKMEC 4, as it poses an unacceptable risk to health. From two weeks to six months, it is UKMEC 2, and from six months onwards, it is UKMEC 1.

Smoking ten cigarettes per day is only a UKMEC 3 if the patient is over 35 years of age.

Contraindications for Combined Oral Contraceptive Pill

The decision to prescribe the combined oral contraceptive pill is based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential cautions and contraindications on a four-point scale. UKMEC 1 represents a condition for which there is no restriction for the use of the contraceptive method, while UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, immobility, and a family history of thromboembolic disease in first-degree relatives under 45 years old. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension.

In 2016, the UKMEC was updated to reflect that breastfeeding between 6 weeks and 6 months postpartum is now classified as UKMEC 2 instead of UKMEC 3. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. It is important for healthcare providers to consider these contraindications when deciding whether to prescribe the combined oral contraceptive pill to their patients.

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 only those who need further investigation and treatment, as low-grade abnormalities often resolve on their own.

If a woman tests negative for high-risk HPV, she is simply returned to routine screening recall. However, if she tests positive, she is 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 who are HPV negative are returned to 3 yearly recall. This new approach ensures that women receive the appropriate level of care and reduces unnecessary referrals for colposcopy.

According to the NICE guidelines on cervical cancer screening, if an individual’s second repeat smear at 24 months is still positive for high-risk human papillomavirus (hrHPV), they should be referred for colposcopy. Prior to this, if an individual is positive for hrHPV but receives a negative cytology report, they should have the HPV test repeated at 12 months. If the HPV test is negative at 12 months, they can return to routine recall. However, if they remain hrHPV positive and cytology negative at 12 months, they should have a repeat HPV test in a further 12 months. If they become hrHPV negative at 24 months, they can safely 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.

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.

Breast cancer treatment often involves hormonal therapy, particularly for those with estrogen receptor-positive tumors (which account for about 80% of all breast cancers). Aromatase inhibitors like anastrozole are commonly used in postmenopausal women to target estrogen production.

However, one of the major concerns with hormonal therapy is the risk of osteoporosis. Women should undergo bone mineral density testing before starting treatment and regularly thereafter.

Tamoxifen, another drug commonly used to treat breast cancer, has been associated with side effects such as deep vein thrombosis, endometrial cancer, and vaginal bleeding. However, urinary incontinence is not a known side effect of anastrozole.

Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen may cause adverse effects such as menstrual disturbance, hot flashes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors may cause adverse effects such as osteoporosis, hot flashes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

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.

Diagnosing Menopause According to NICE NG23

According to NICE NG23 guidelines, menopause can be diagnosed without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms. Perimenopause can be diagnosed based on vasomotor symptoms and irregular periods, while menopause can be diagnosed in women who have not had a period for at least 12 months and are not using hormonal contraception. Menopause can also be diagnosed based on symptoms in women without a uterus.

However, in women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle, and in women aged under 40 years in whom menopause is suspected, a FSH test may be considered to diagnose menopause.

In the case of a woman aged over 45 years with amenorrhoea for over 12 months, a clinical diagnosis of menopause can be made without the need for blood tests. It is important to note that premature ovarian failure is not a concern in this case as the woman is aged 48.

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.

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

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

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

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

Understanding Cervical Cancer Screening in the UK

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

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

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

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

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