In hyperemesis gravidarum, IV corticosteroids can be given to reduce vomiting, if the patient is not responding to standard anti emetics.

Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighbouring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess.

Lower abdominal pain is the cardinal presenting symptom in women with PID. The abdominal pain is usually bilateral and rarely of more than two weeks’ duration. The character of the pain is variable, and in some cases, may be quite subtle. The recent onset of pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID. The onset of pain during or shortly after menses is particularly suggestive.

Other non-specific complaints include urinary frequency and abnormal vaginal discharge.

Ovarian cyst, uterine leiomyoma, appendicitis or ectopic pregnancy do not present with fever and vaginal discharge although tenderness is noted in appendicitis and ectopic pregnancy. Therefore, these options do not explain the patient’s symptoms.

As the most likely diagnosis, this woman meets diagnostic criteria for premenstrual syndrome (PMS).
Affective and physical symptoms that begin one week before menstruation and end four days after menstrual flow begins are diagnostic criteria for premenstrual syndrome. The symptoms must be present for at least three menstrual cycles and must not occur during the preovulatory period.
It’s critical to note that these symptoms are not caused by any medical or psychological condition, medications, drugs, or alcohol.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent tears, and a lack of interest in daily activities. To put it another way, emotional impairment is the most prominent trait.

This woman does not meet the diagnostic criteria for PMDD because she only has psychological symptoms of irritation and anxiety, as well as physical symptoms of headache and breast soreness (five symptoms).

PMDD diagnostic criteria include:
Symptoms and their timing
A) At least 5 symptoms must be present in the final week before menses, improve within a few days after menses, and become mild or non-existent in the week after menses in the majority of menstrual cycles.
Symptoms
B) At least one of the symptoms listed below must be present:
1) Affective lability that is noticeable (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
2) Excessive irritation, wrath, or interpersonal conflicts
3) Depressed mood, hopelessness, and self-depreciating thoughts
4) Severe anxiety, tension, and/or a sense of being tense or on edge
C) In addition to the symptoms listed in criterion B, one (or more) of the following symptoms must also be present to reach a total of five symptoms.
1) Loss of enthusiasm for customary activities
2) Subjective concentration problems
3) Lethargy, fatigability, or a noticeable lack of energy
4) Significant changes in appetite, such as binge eating or specific food desires
5) Insomnia or hypersomnia
6) A feeling of being overwhelmed or powerless
7) Physical signs and symptoms include breast discomfort or swelling, joint or muscle pain, bloating, or weight gain.
Severity
D)The symptoms are linked to clinically substantial distress or interfere with employment, school, regular social activities, or interpersonal relationships.
E) Think about other mental illnesses. The disturbance isn’t only a sign of another disorder, like major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
Confirmation of the condition
F)Prospective daily ratings throughout at least two symptomatic cycles should be used to confirm Criterion A. (although a provisional diagnosis may be made prior to this confirmation)
Other medical explanations are ruled out.
G) The symptoms aren’t caused by the physiological consequences of a substance (e.g., drug misuse, medication, or other treatment) or a medical condition (e.g., hyperthyroidism).
The severity of the symptoms cannot be explained by normal menstrual physiology.
Generalized anxiety disorder and depression are improbable diagnoses because these symptoms are temporally tied to menstrual cycles.

In a postmenopausal woman, the ovaries should not be palpable; if they are, it should raise the concern that an ovarian malignancy is present. Before one would perform an operative evaluation, radiologic assessment should be done.

– Although this is an accepted regimen for oestrogen replacement therapy, the palpable ovaries need to be evaluated to rule out malignancy.
– Dual photon densitometry will give a reliable measure of bone density. Again, however, the palpable ovary is the first thing that needs to be worked up.
– Although surgical exploration may be warranted, initial workup of the adnexal mass should include an ultrasound along with tumour markers. A CT scan may also be warranted.

The CDC recommends that:
If diarrhoea occurs within 24 hours of taking oral birth control or continues for 24 to 48 hours after taking a pill, an additional dose is not needed.
If diarrhoea lasts more than 48 hours Use backup birth control, such as condoms, or avoid sexual intercourse until pills have been taken for seven diarrhoea-free days.

All other options are incorrect.

The tests listed can all be performed during the work-up of a woman with secondary amenorrhoea. They are useful in that they cam diagnosis the most likely cause for the amenorrhoea as well as guide the treatment required if the patient wanted to become pregnant. Of these, the hormone test best able to predict a poor response to ovulation-induction therapy is the follicle-stimulating hormone (FSH) assay. If there are high levels of FSH, most of the ovulation-induction therapies are ineffective, although the rare spontaneous pregnancy can occur.

To maximise the chance of pregnancy in patients with elevated FSH levels, the most effective technique is an ovum donation from a young woman. The ovum would be fertilised in the laboratory and transferred to the uterus of the woman with the high FSH level after administering hormonal preparation of her uterus.

If the FSH level is normal, ovulation-induction therapy is usually effective. For these patients, correction of thyroid function will be necessary if the thyroid function is not normal. Dopamine agonist therapy is indicated if the prolactin level is elevated. Clomiphene or gonadotrophin therapy can be used where the luteinising and oestradiol levels are low, normal, or minimally elevated.

Turner syndrome is the clinical diagnosis for this patient. Turner syndrome affects women who are lacking all of one X chromosome (45, characterized by X gonadal dysgenesis).
Turner Syndrome is characterized by small stature and non-functioning ovaries, resulting in infertility and lack of sexual development. Other sexual and reproductive organs (uterus and vagina) are normal despite the inadequate or missing ovarian activity.

Webbing of the neck, puffy hands and feet, coarctation of the aorta, and cardiac anomalies are all physical symptoms of Turner Syndrome. Streak gonads are also a feature of Turner syndrome.

The ovaries are replaced with fibrous tissue and do not produce much oestrogen, resulting in amenorrhea.

Until puberty, when oestrogen-induced maturation fails, the external female genitalia, uterus, and fallopian tubes develop normally.

Postmenopausal haemorrhage has started in this patient. Menopause is defined as the permanent cessation of menstruation and fertility that occurs 12 months after the previous menstrual period.

Atrophic vaginitis caused by oestrogen insufficiency is the most likely reason for this woman’s postmenopausal haemorrhage. It can also induce vaginal dryness and soreness during sexual intercourse.

Endometrial hyperplasia is unlikely to develop without hormone replacement therapy or oestrogen stimulation of the endometrium.

Similarly, endometrial cancer is a less likely cause of this patient’s post-menopausal bleeding.

A year ago, this woman received a normal cervical screening test. Cervical cancer is extremely unlikely to occur. After 12 months of no oestrogen, it’s also unlikely that you’ll have any irregular periods.

Reported cure rates for an episode of acute BV vary but have been estimated to be between 70% and 80%. Unfortunately, more than 50% of BV cases will recur at least once within the following 12 months. Because the aetiology of BV is still not entirely understood, identifying the cause of recurrent cases is challenging. Reinfection may play a role in explaining recurrent BV, but
treatment failure is a more likely contributor. There are several theories that try to explain recurrence and persistent symptoms. The existence of a biofilm in the vagina is one such theory and is the subject of ongoing research. Biofilms occur when microorganisms adhere to surfaces. G vaginalis, one of the primary organisms

BV is not a sexually transmitted infection. The antibiotic of choice to treat BV is Metronidazole. Reassurance is not acceptable as a means of treatment.

Venous thromboembolism (VTE) during pregnancy and the postpartum window occurs at a 6-10-fold higher rate compared with age-matched peers and is a major cause of morbidity and mortality. Hypercoagulability persists for 6-8 weeks after delivery with the highest risk of PE being during the postpartum period. The lack of randomized trials in pregnant women leads to variability in practice, which are largely based on expert consensus or extrapolation from non-pregnant cohorts. The standard treatment of VTE in pregnancy is anticoagulation with low molecular weight heparin (LMWH), which like unfractionated heparin does not cross the placenta and is not teratogenic.

The clinical evaluation indicates that the patient is ovulating but has not started menstruating. These observations suggest that the pain she is experiencing on a monthly basis could be related to ovulation or there could be an obstruction preventing the flow of menstrual blood from the uterus.

Uterine or vaginal anomalies that can obstruct menstrual flow include imperforate hymen, absent vagina, a transverse vaginal septum, or cervical obstruction.

If the cause was an obstruction to the flow, the retained menstrual products would have developed into a suprapubic mass (hematometra/ haematocolpos). However, no palpable mass was detected on abdominal examination.

Mullerian (paramesonephric) agenesis (correct answer) is the only condition that would result in no endometrial development; consequently there was no palpable mass observed and no menstrual loss that could be shed was present. A pelvic (lower abdominal) ultrasound examination can confirm the diagnosis.

Menorrhagia in a 45-year-old woman is most likely caused by an ovulation issue, most likely anovulatory cycles, particularly if the periods have grown irregular.

Endometrial carcinoma is a rare cause of menorrhagia that usually occurs after menopause.

Menorrhagia can be caused by fibroids, endometrial polyps, and adenomyosis, although the cycles are normally regular, and a dramatic change from normal cycles six months prior would be exceptional.
If fibroids or adenomyosis are the source of the menorrhagia, the uterus is usually enlarged.

Biochemical features suggest that this patient has polycystic ovary syndrome (PCOS). It is associated with signs and symptoms of hyperandrogenism (oligomenorrhea, irregular menstruation, hirsutism, hair loss, and acne) and elevated testosterone. PCOS patients are often overweight or obese, have insulin resistance (treated with Metformin) and an adverse risk profile for cardiovascular disease.

In pregnancy, progesterone is produced by the corpus luteum followed by the placenta- Exogenous progesterone will not lead to withdrawal bleeding. In ovarian failure as well as pituitary failure, no oestrogen stimulation of the endometrium exists, and progesterone cannot cause withdrawal bleeding. With Mullerian agenesis, there is no endometrium. Polycystic ovarian syndrome has an abundance of circulating oestrogen, so the endometrium will proliferate.

→ In pregnancy progesterone withdrawal will not occur since the corpus luteum is producing progesterone- The placenta will take over, starting at 7 weeks, and will be the sole producer of progesterone by 12 weeks.
→ In ovarian failure no oestrogen will be produced; no proliferation of the endometrium will occur.
→ Pituitary failure is an incorrect answer because without gonadotropin stimulation, there will not be enough oestrogen to stimulate the endometrial lining.
→ Mullerian agenesis is an incorrect answer – there is no uterus, thus no bleeding.

Testing for beta hCG should be the first test in this case. It will rule out any pregnancy that is strongly suspected based on the patient’s history and physical examination.

Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.

Women with polycystic ovary syndrome (PCOS) have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed oestrogen that results from anovulation.

Additionally, secretory endometrium of some women with PCOS undergoing ovulation induction or receiving exogenous progestin exhibits progesterone resistance accompanied by dysregulation of gene expression controlling steroid action and cell proliferation.

Other risk factors include nulliparity, early menarche and late menopause, obesity and family history of endometrial cancer. Which rules out all the other options.

This patient had postmenopausal vaginal haemorrhage and an 8mm endometrial thickness. Endometrial thickness of 4mm or more in a postmenopausal woman with vaginal bleeding necessitates an endometrial biopsy to rule out endometrial cancer, and this patient should be referred to a gynaecologist for this procedure.
All of the other choices are incorrect.

Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Approximately 30-40% of women with endometriosis will be sub fertile. About one third of women with endometriosis remain asymptomatic. When they do occur, symptoms, such as the following, typically reflect the area of involvement:
– Dysmenorrhea
– Heavy or irregular bleeding
– Pelvic pain
– Lower abdominal or back pain
– Dyspareunia
– Dyschezia (pain on defecation) – Often with cycles of diarrhoea and constipation
– Bloating, nausea, and vomiting
– Inguinal pain
– Pain on micturition and/or urinary frequency
– Pain during exercise

Pregnancy, appendicitis, ureteral colic and ruptured ectopic pregnancy all do not present with dysmenorrhea, pain on defecation and dyspareunia. Presence of a non tender, soft abdomen also rules out these conditions.

All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

The clinical picture, unusually high LH-to-FSH ratio (which should ordinarily be around 1:1), and higher androgens but normal DHAS all point to polycystic ovarian syndrome (PCOS). DHAS is an indicator of adrenal androgen production; when normal, it rules out adrenal hyperandrogenism. Several drugs have been used to treat PCOS-related hirsutism. Contraceptives were the most often used medications for many years; they can decrease hair growth in up to two-thirds of individuals. They work by decreasing ovarian steroid production and increasing hepatic-binding globulin production, which binds circulating hormones and lowers metabolically active (unbound) androgen concentrations. Clinical improvement, on the other hand, can take up to 6 months to show.
Medroxyprogesterone acetate, spironolactone, cimetidine, and GnRH agonists, all of which decrease ovarian steroid synthesis, have also shown potential. GnRH analogues, on the other hand, are costly and have been linked to severe bone demineralization in some patients after only 6 months of treatment. Given the efficacy of pharmacologic medications and the ovarian adhesions that were usually linked with this surgery, surgical wedge resection is no longer regarded as an appropriate therapy for PCOS.

Taking into consideration that she had only missed one pill and that they were going to be stopped the next day anyway, the rate of pregnancy would be low; hence all of the responses would be acceptable and effective. However, the most appropriate step would be to initiate her hormone-free interval starting from the time she missed her pill i.e. 11pm the night before. This would make tonight the 2nd lactose pill day and hence she should commence the next course of hormone pills on the 5 nights from tonight. In doing this, her hormone-free period would be the usual length of 7 days. Although the risk of pregnancy is low after missing only one pill, this opposite occurs when the missed pill causes a longer than normal hormone-free duration between the end of the current cycle and the starting of the subsequent one.

The best regimen would be to have no intercourse in the follicular phase of the cycle and then commence it two days after a temperature rise of 0.3C and continue then onwards. When deciding the best contraceptive method, one has to consider two factors-the duration of survival of sperm in the uterus and body temperature in relation to ovulation. For this case, since her cycle length varies from 24 to 30 days, the earliest time in which ovulation would occur would be 14 days before her shortest cycle i.e. day 10. Intercourse has to be avoided from day 4 of her cycle just in case the current cycle is short because sperm can survive up to 6 days in the uterus. Day 4 would be the day her menses would end and as this couple avoids intercourse during her menstruation, there would be no intercourse during the follicular phase of her cycle.

During ovulation, her serum progesterone levels would start to increase, causing a 0.3°C to 0.4°C increase in her body temperature within 2-3 days of ovulating. This elevation in temperature would remain until close to when her period starts. The ovum can only be fertilised for roughly 24 hours after ovulation has taken place. Resuming sexual intercourse once her temperature has risen for 2 days would suggest that ovulation had already taken place 3-4 days earlier and so it is unlikely for pregnancy to occur.

Options that include intercourse during any part of her follicular phase is not correct. Hence, the only option that satisfies the above criteria would be intercourse avoidance during her follicular phase and to resume 2 days following a rise of 0.03°C in body temperature.

This patient has a regular and long menstrual period. The most crucial thing in this case is to rule out anovulation.
Serum progesterone concentration is the best test for detecting ovulation.
Ovulation has occurred if the level is greater than 20nmol/L.
This test should be performed 3 to 10 days prior to the start of the next anticipated period.

Endometrioid endometrial carcinoma is oestrogen-responsive, and the main risk factor for this disease is long-term exposure to excess endogenous or exogenous oestrogen without adequate opposition by a progestin.

Early age at menarche is a risk factor for endometrial carcinoma in some studies; late menopause is less consistently associated with an increased risk of the disease. Both of these factors result in prolonged oestrogen stimulation and at times of the reproductive years during which anovulatory cycles are common

Other risk factors include
obesity,
nulliparity,
diabetes mellitus, and
hypertension.

The risk of endometrial hyperplasia and carcinoma with oestrogen therapy can be significantly reduced by the concomitant administration of a progestin. In general, combined oestrogen-progestin preparations do not increase the risk of endometrial hyperplasia.

Endometrial carcinoma usually occurs in postmenopausal women (mean age at diagnosis is 62 years). Women under age 50 who develop endometrial cancer often have risk factors such as obesity or chronic anovulation.

In this case, the fundus height appears to be smaller than the suggested dates of gestation. However, this is uncertain as the exact gestation dates are not known. Head-sparing intrauterine growth restriction needs to be excluded or managed appropriately if detected.

The best initial management step would be to perform an ultrasound examination (correct answer). This would enable complete assessment of the foetus and all the measurable parameters can be determined. This would aid in identifying any discrepancy in size of the abdomen, limbs and head, and the liquor volume (amniotic fluid index) could be evaluated.

If asymmetrical growth restriction was detected via ultrasound examination, further evaluations such as cardiotocography (CTG) and umbilical arterial wave form analysis by Doppler could be initiated.

Additionally, foetal movement counting could then be commenced and evaluation of foetal lung maturity by amniocentesis could be considered.

If the ultrasound was normal (no evidence of asymmetrical growth restriction, normal amniotic fluid), repeat ultrasound should be performed after two weeks to evaluate the foetal growth.

If normal growth is observed on the repeat ultrasound, the estimated due date can be calculated (assuming normal foetal growth around the 50th percentile for the population).

Post coital literally means “after intercourse” which is when this fertility test is conducted. The patient has intercourse at home usually between cycle days 12 and 15 (or a day around the LH surge as measured by urinary ovulation predictor kits). Afterwards, the female comes to the office and a sample of the cervical mucus is taken for microscopic examination.

The post coital fertility test (PCT) allows for evaluation of sperm in the cervical mucus and to determine the consistency of the mucus. Sperm must swim through the cervical mucus from the vagina, through the cervix, and into the uterus. Normal sperm will be active and swim in approximate straight lines through the mucus. If the mucus is too thick, sperm impedance can be observed.

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

Only little volumes of urine are lost when her intra-abdominal pressure is elevated during coughing, laughing, jumping, and straining, which is the only symptom associated with real stress incontinence.
The other reactions are significantly more compatible with a detrusor instability diagnosis (also called urge incontinence).
If she had incontinence throughout pregnancy, it would have been stress in nature, which is what her current incontinence is.

Mammary duct ectasia occurs when the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

Pregnant women with high-grade squamous intraepithelial lesions (HSIL) on cervical cytology should be evaluated with colposcopy. Principles of management of pregnant women include the following:
– An immediate diagnostic excisional procedure should NOT be performed.
– When colposcopy is performed during pregnancy:
– Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy; however, the endocervical canal may be sampled gently with a cytobrush.
– Cervical biopsy should be performed only if a lesion is present that appears to be high grade or suspicious for cancer.
– If the examination is unsatisfactory, repeating the colposcopy after 6 to 12 weeks should allow visualization of the entire squamocolumnar junction.

There is no indication for inducing abortion or performing a hysterectomy.

Because of the high possibility of spontaneous resolution and the fact that if the cystic mass was verified ultrasonically, a conservative policy would almost probably be proposed for at least another six weeks, an ultrasound examination is not necessary at this time. If the cyst is still present at the six-week check, an ultrasound examination is required, as it is likely that the cyst is a benign tumour or possibly endometriosis. It’s quite improbable that it’s cancer.
Additional tests, such as computed tomography (CT) examination and potentially surgical removal or drainage, may be required in the future, although not at this time.
This cyst in a young lady is almost probably of physiological origin, especially given its size. The woman should be informed, but a follow-up examination is required. The most suitable next action is to return in six weeks, as the cyst is most likely physiologic and will most likely dissipate naturally by then. The following appointment should not take place during the same menstrual cycle.

The best next step in her management is a colposcopy.

Patients diagnosed with high-grade lesions (CIN 2 or 3) or adenocarcinoma in situ (AIS) during pregnancy should undergo surveillance via colposcopy and age-based testing (cytology/HPV) every 12-24 weeks.

Cone biopsy and long loop excision of the transformation zone (LLETZ biopsy) are not recommended if the lesion extends up the canal and out of the vision of the colposcope.
It is not necessary to terminate the pregnancy.

Because repeat colposcopic examination during pregnancy offers all of the information needed, the repeat Pap smear is best done after the pregnancy has ended.

Unless colposcopy indicates aggressive cancer at an earlier time, the ultimate therapy required is usually not decided until the postpartum visit.

The levels of oestradiol (E2), progesterone, and prolactin (PRL) are all elevated during early pregnancy. However these elevations cannot be solely relied on to determine if pregnancy has occurred since increased levels of these hormones can also occur in pathologic states in non-pregnant women or, in some cases, even during menstrual cycles.

The levels of follicle stimulating hormone (FSH) are suppressed in pregnancy because of the elevated E2 and progesterone levels.

The correct answer is elevated levels of luteinising hormone (LH). This is because the beta sub-units of LH and human chorionic gonadotrophin (hCG) are almost identical and therefore, hCG is measured as LH in almost all LH assays (correct answer).

The LH levels can be slightly raised in polycystic ovarian syndrome; however, it is unlikely that the levels would increase above 30 mIU/mL in this condition.

The mid-cycle levels of LH can go up to 100-150 mIU/mL. If the levels are more than 200 mlU/mL, it usually indicates pregnancy.

In premenopausal women, watchful waiting usually involves monitoring for symptoms (pelvic pain or pressure) and repeating the pelvic ultrasound after six to eight weeks. If the ovarian cyst does not enlarge or if it resolves during the period of watchful waiting, it does not usually require surgical removal. Some premenopausal women will be advised to take a birth control pill during this time to help prevent new ovarian cysts from developing.

If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until your healthcare provider is certain that the cyst is not growing. If the cyst resolves, no further testing or follow-up is required.
Surgery may be recommended in the following situations:
– A cyst is causing persistent pain or pressure, or may rupture or twist.
– A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
– Large cysts (>5 to 10 cm) are more likely to require surgical removal compared to smaller cysts. However, a large size does not predict whether a cyst is cancerous.
– If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies, your healthcare provider may recommend surgery.
– If the suspicion for ovarian cancer is low but the cyst does not resolve after several ultrasounds, you may choose to have it removed after a discussion with your healthcare provider. However, surgical removal is not usually necessary in this case.

This patient should have an endometrial biopsy (SOR C). Approximately 7% of postmenopausal women with benign endometrial cells on a Papanicolaou smear will have significant endometrial pathology. None of the other options listed evaluate the endometrium for pathology. An asymptomatic premenopausal woman with benign endometrial cells would not need an endometrial evaluation because underlying endometrial pathology is rare in this group.

Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.

In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.

This is a case of a woman who presented with cyclical breast pain that is on an OCP and with a family history of breast cancer. Those with a family history of breast cancer in more than one blood relative (parent, sibling, grandparent) have a significantly higher chance of developing breast cancer than women with no family history. Regular six-monthly clinical review and yearly mammographic screening, with or without ultrasound screening, should start at least five years before the age of the diagnosis in the blood relatives.

The consensus now is that any additional risk of breast cancer from the oestrogen in the oral contraceptive pill (OCP) is less than the risk of unwanted pregnancy when using alternative, and perhaps less effective, contraception. Thus, the patient would not be advised to stop the OCP.

With two blood relatives that developed breast cancer before the age of 50, this patient is in a high-risk group of developing breast cancer. Even so, 50% of such high-risk women will not develop a breast cancer in their lifetime. There are specialised familial cancer screening clinics are available for high-risk women where genetic testing can be discussed further. Women at high risk may electively have a bilateral subcutaneous mastectomy performed prophylactically which will bring the risk of breast cancer development to an irreducible minimum.

The woman’s blood pressure was elevated at her visit; therefore she should be advised to immediately cease the oral contraceptive pill (OCP) so that the hypertension can resolve without the need for any hypotensive treatment. The blood pressure can then be reassessed in three months. Alternative, non-hormonal birth control methods such as condoms should be used instead.

If her high blood pressure does not resolve, any medication that would be commenced to reduce her blood pressure should be one that is safe to continue when she becomes pregnant.

It is inappropriate to continue the OCP even at a lower dosage or in combination with a hypotensive agent.

Methyldopa has been evaluated and used for treatment of hypertension during pregnancy. There is no clinical evidence to suggest that it causes harm to the foetus or neonate.

Angiotensin converting enzyme (ACE) inhibitors are not approved for use in pregnancy as they have been associated with fetal death in utero. Other antihypertensive agents such as beta-blockers and diuretics are also problematic in pregnancy and should be avoided.

Cardiotocography (CTG) helps to record the heartbeat of the foetus in parallel to measuring the contractions of the mother’s uterus, this is the most appropriate tool to assess this patient’s condition.

Urethral syndrome is characterized by dysuria and pyuria in the presence of a negative culture for uropathogens. Frequency and urgency are often absent. The infecting organism is typically Chlamydia trachomatis although other organisms such as Urea plasma urealyticum and Mycoplasma species may be involve- Effective medication choices include doxycycline, ofloxacin, levofloxacin, and macrolides such as erythromycin and azithromycin.

-Amoxicillin
lavulanate  and cephalexin  are incorrect. These would cover gram-positive bacteria but it would not cover gram-negative bacteria nor bacteria without a cell wall, which are the most common causes of this condition.
– Metronidazole is best for treating anaerobic infections and protozoa such as trichomonas vaginalis, it would not be the best for treating this condition, given the most likely causes.
-Pyridium is a phenazopyridine often used to alleviate the pain, irritation, discomfort, or urgency caused by urinary tract infections. While it would be beneficial for symptomatic relief, it is unlikely to completely resolve this patient’s condition, given her recent history.

IUS or Intra Uterine System/Device releases progestin. The progestin thickens the cervix, preventing the sperm from penetrating the cervix, and it also causes the uterine lining to become thinner, preventing any implantation. IUS may also prevent excessive bleeding and can help women with fibroids.

Absolute contraindications to OCs include breast cancer, history of deep venous thrombosis or pulmonary embolism, active liver disease, use of rifampicin, familial hyperlipidaemia, previous arterial thrombosis, and pregnancy, while relative contraindications include smoking, age over 35, hypertension, breastfeeding, and irregular spontaneous menstruation.

Progestin only pills are the safest and most effective contraceptive methods than the rest of the options.

Tubal sterilization is a safe and effective surgical procedure that permanently prevents pregnancy. However, pregnancy can occur in 1 in 200 cases, according to international sources. In the 1st year after tubal sterilization, the estimated failure rate is 0.1-0.8% respectively.

Fat necrosis may occur following a traumatic injury to the breast. The lump is usually firm, round, and painless.

An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary. Although the discovery of an ovarian cyst causes considerable anxiety in women owing to fears of malignancy, the vast majority of these lesions are benign.

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

However, meta-analyses have since shown that there is no difference between OCP use and placebo in terms of treatment outcomes in ovarian cysts and that these masses should be monitored expectantly for several menstrual cycles.

If a cystic mass does not resolve after this timeframe, it is unlikely to be a functional cyst, and further workup may be indicated.

Other methods of management maybe revisited if cyst increases in size or becomes complex upon follow up.

Women, who have never had sexual encounter, do not need cervical screening. However, any sort of sexual encounter (Lesbian or heterosexual) is considered a risk and the patient must be screened. Otherwise, routine cervical screening test can be performed every five years for woman 25-74 years who ever had sex with no evidence of cervical pathology. Perform a cervical screening test at the age of 25 or 2 years after first sexual intercourse-whichever is later in sexually active women. Perform cervical screening test in patients above 75 years if they request or if they never had any symptoms.

All other options are unacceptable.

This patient has got thrush or a fungal infection in the vaginal area. Candida infection is most likely based on the white discharge and itching. A vaginal clotrimazole antifungal treatment is required.

There are no interactions between the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone injections or levonorgestrel implants and the AEDs valproic acid (sodium valproate), vigabatrin, lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide, ethosuximide and the benzodiazepines. So she can use COCP along with Sodium valproate.

Approximately 75–80% of patients with PCOS will ovulate after Clomiphene citrate. Although there appears to be discrepancy between ovulation and pregnancy rates, life-table analysis of the largest and most reliable studies indicates a conception rate of up to 22% per cycle in those ovulating on CC.

Pelvic TB causes tubal occlusion by scarring leading to infertility. Once occlusion occurs, IVF is usually the only option for conception. This is also the case for women with Turner syndrome.

Azoospermia maybe treated with surgery or hormonal therapy based on the cause but the success rate is low.