The best treatment option for chlamydial urethritis in pregnancy is Azithromycin 1g as a single dose orally. This is the preferred option as the drug is coming under category B1 in pregnancy.

Tetracycline antibiotics, including doxycycline, should never be used in pregnant or breastfeeding women.

Erythromycin Estolate is contraindicated in pregnancy due to its increased risk for hepatotoxicity. Ciprofloxacin is not commonly used for treating chlamydial urethritis and its use is not safe during pregnancy.

Fibroids are a common gynaecological condition found in many women above the age of 35. They are however uncommon before puberty. They are most common in black women vs white women, and its prevalence increases from puberty to menopause. Risk factors for fibroids include increasing age, obesity and infertility. Protective factors, on the other hand, include pregnancy, as the risk of fibroids decreases with increasing numbers of pregnancies.

An assessment of amniotic fluid in pregnancy can be done by taking ultrasound measurements of the depth of amniotic fluid pockets. The combination of the measurements in four quadrants is called the amniotic fluid index (AFI), one of the major determinants of the biophysical profile which predicts pregnancy outcome. An AFI of less than 5 cm, or less than the 5th percentile is defined as oligohydramnios while an AFI of more than 25 cm is considered polyhydramnios.

Fetal position and presentation is best evaluated by Leopold’s manoeuvre. It will determine which part of the foetus is in the uterine fundus.
Cullen’s sign is found in ruptured ectopic pregnancy characterised by bruising and oedema of the periumbilical region.
Mauriceau-Smelli-Veit manoeuvre is done during a breech delivery.

Placental abnormalities such as placenta previa and placenta accreta are the most common reasons for considering hysterectomy as an inevitable treatment option in postpartum hemorrhage.

Placental villi normally invade only the superficial layers of endometrial deciduas basalis, but when the invasion is too deep into the uterine wall, the condition is termed as placenta accreta, increta or percreta depending on the depth of invasion.
– When the villi invade the deeper layers of the endometrial deciduus basalis, but not the myometrium it is called as Placenta accreta. This is the most common type of decidual invasion and accounts for approximately 75% of the cases.
– When the villi invade the myometrium, but do not reach the uterine serosa or the bladder is called Placenta increta. This type accounts for nearly 15% of cases.
– In cases were the villi invades into the uterine serosa or the bladder is it called as Placenta percreta and this happens in 5% of cases.

Prior uterine surgery is the main risk factor for placenta accreta and the best management is elective cesarean hysterectomy.
postpartum hemorrhage can also be caused by conditions like genital lacerations, uterine atony, retained products of conception and uterine inversion. In most of these above mentioned cases, hysterectomy is not required and remains as the last resort in extremely desperate situations.

NOTE– Though uterine atony is the most common cause of postpartum hemorrhage, it is often manageable medically.

COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.

(13-20 weeks). If a mother has chickenpox in late pregnancy (5 days prior to delivery) then there is risk of neonatal varicella infection which may be severe.

Uncontrolled endometrial proliferation due to excess and unregulated estrogen is the reason for intermenstrual bleeding and irregular menses along with abnormal uterine bleeding (AUB) in this patient. The condition is mostly associated with an increased risk of endometrial hyperplasia
ancer.
The absolute risk of endometrial hyperplasia
ancer is very low in women aged <45, therefore they can be started on combination medication with estrogen/progestin contraception (ie, medical management) without the evaluation of endometrium.  The estrogen component of medication regulates the menstrual cycle by build up the endometrium; whereas the progestin component helps in shedding of the endometrium.
However, patients who have continued irregular menstrual bleeding even while on combination contraceptives require further evaluation as they have failed to improve with medical management. In such patients, the endometrial lining will be too thick for the progestin to completely shed during menstruation and this unshed endometrium continues to undergo dysregulated proliferation, leading to an increased risk of endometrial hyperplasia
ancer. Therefore, patients age below 45 with AUB who have failed medical management require an endometrial biopsy.
AUB persistent above 6 months, obesity, and/or tamoxifen therapy are the other indications for endometrial biopsy in women age <45, as all of these will increase the amount of unopposed endometrial estrogen exposure. In patients with heavy menstrual bleeding and anemia, coagulation studies are performed to evaluate for bleeding disorders like von Willebrand disease. It is not necessary in this patient as she have a normal hemoglobin level. In patients with heavy, but regular (ovulatory) bleeding an endometrial ablation, which is a procedure used to remove the excess endometrium, can be considered as the treatment option. Endometrial ablation is contraindicated in undiagnosed cases of AUB as it prevents evaluation of the endometrium in patients with possible endometrial hyperplasia
ancer.

To check for abnormalities of the uterus like didelphys or of the Fallopian tube like scarring, a hysterosalpingogram is used but it is not useful to evaluate AUB. In addition, as the procedure could spread cancerous endometrial cells into the abdominal cavity, hysterosalpingogram is contraindicated in cases of undiagnosed AUB.

To evaluate secondary amenorrhea, ie. absence of menses for >6 months in a patient with previously irregular menses, a progesterone withdrawal test is used to determine whether amenorrhea is from low estrogen level, in negative cases there will be no bleeding after progesterone. This test is not indicated or relevant in this case as patient had continued bleeding while on oral contraceptives suggestive of high estrogen levels.

Evaluation for endometrial hyperplasia
ancer with an endometrial biopsy is required for those women age <45 with abnormal uterine bleeding who have failed medical management with oral contraceptives.

Breast milk contains around 4% fat, 7% sugar and 1% proteins. The rest is water and minerals.

First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour is having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.

Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.

Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.

Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.

Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).

Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.

The most suitable step would be to wait for spontaneous onset of labour. This woman would be able to deliver vaginally in 3 situations. The first would be if the foetus is estimated to weigh less than 3800g (first child weight 3800g). Another would be if the foetus is in a frank or complete breech presentation and lastly if the rate of labour progress is satisfactory and breech extraction is unnecessary. RCOG (Royal College of Obstetricians & Gynaecologists) guidelines recommends that women should be informed that elective Caesarean section for the delivery of a breech baby would have a lower risk of perinatal mortality than a planned vaginal delivery. This is because with an elective Caesarean section, we would be able to avoid stillbirth following 39 weeks of gestation as well as intrapartum and vaginal breech delivery risks. The ideal mode of delivery of a breech foetus when labour starts or at least close to term is a Caesarean section as the risks towards the foetus would be significantly increased in a vaginal delivery. The obstetrician is responsible to ensure that there are no other abnormalities that could complicate this even further such as footling presentation, low estimated birth weight (less than 10th centile), hyperextended neck on ultrasound, evidence of fetal distress and high estimated birth weight (>3.8kg). Provided that there is a normal progression of events, fetal risks during both labour and delivery should be low if such factors are absent. Hence, it is right to await the onset of labour to occur spontaneously in this case. In order to exclude a knee presentation with fetal head extension or a footling breech, ultrasound examination has to be done. These are linked to a high fetal risk if the mother attempts vaginal delivery. X-ray pelvimetry is advisable but is not essential in fetal size assessment since its accuracy is roughly 20%. In this case, it is not indicated since there is evidence that her pelvis is of adequate size as she had already delivered a 3.9kg baby prior. It is best to avoid induction of labour in breech cases for numerous reasons (need for augmentation, cord prolapse).

In stage III cervical cancer there is involvement of the pelvic wall and ureter which may result in abdominal pain and hydronephrosis.

2010 FIGO classification of cervical carcinoma

Stage
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, Greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis
4A – Invades mucosa bladder and rectum
4B – Distant Metastasis

Oogonium become Primary Oocyte via Growth/Maturation. This process is called oocytogenesis Primary Oocyte undergoes 2 meiotic divisions to become Ootids. This process is called Ootidogenesis Ootids differentiate into Ovum

Urodynamics is a broad term that comprises cytometry, urethral pressure measurement, leak point pressure, pressure flow studies, EMG and videourodynamics. They assess the function of the bladder and urethra as a functional unit. This may provide information such as the site of bladder outlet obstruction, overactivity of the detrusor and sphincter weakness. In muscular terms the detrusor and sphincter muscles are being assessed.

Genital folds lead to the formation of the scrotum in males while in females they form the posterior labial commissure. Genital tubercles form the labia majora whereas the tubercle itself becomes the mons pubis. The labia minora is formed by the urogenital folds.

Diagnosis can be made using the Amsel’s criteria:
1. Presence of clue cells on microscopic examination (these cells are epithelial cells covered with the bacteria).
2. Creamy greyish discharge.
3. Vaginal pH of more than 4.5.
5. Positive whiff test – release of fishy odour on addition of alkali solution. Other criteria include the nugent score and the Hay/Ison criteria. The Nugent score estimates the relative proportions of bacterial morphotypes to give a score between 0 and 10 (<4 = normal, 4-6 = intermediate, >6 = BV)
The Hay/Ison criteria
Grade 1 (Normal): Lactobacillus morphotypes predominate
Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
Grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli.

The life time risk of breast cancer in BRCA 1 gene is 70% and of ovarian cancer is 40%.

The risk of transplacental transmission from mother to foetus is greater in later pregnancy i.e. 26-40 weeks. Although the risk of transmission is lower in early pregnancy, if infection does occur earlier, particularly before 10 weeks, then complications are typically more severe.

In pregnancy, term refers to the gestational period from 37 to 41+6 weeks. Preterm births occur between 24 and 36+6 weeks. Only 1% of women who go into PROM have risk of having serious neonatal infections.

Management of PROM:
60% of patients with PROM will go into labour within 24 hrs
Induction is appropriate if >34 weeks gestation and more than 24 hours post rupture when labour hasn’t started.
If < 34 weeks, induction of labour should not be carried out unless there are additional obstetric indications e.g. infection

TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

Combined oral contraceptive pills (COCPs) can be started immediately following abortion or miscarriage. Note following childbirth COCPs should not be restarted for 3 weeks (assuming the patient is not breastfeeding).

During pregnancy, anaemia increases more than fourfold from the first to third trimester. It is a well established fact that there is a physiological drop in haemoglobin (Hb) in the mid trimester. This physiological drop is attributed to increase of plasma volume and hence decrease of blood viscosity lead to better circulation in placenta.

PMNs phagocytise debris and kill bacteria via free radicals (AKA respiratory burst). They also break down damaged tissue. PMNs typically undergo apoptosis after 48 hours. They are then engulfed and degraded by macrophages. Macrophages therefore become the predominant cell type in the wound on days 3-4.

The uterine artery arises from the internal iliac artery, in particular the anterior division of the internal iliac artery. Some older texts refer to the internal iliac as the hypogastric artery. The vaginal artery typically arises as its own branch of the internal iliac artery. The ovarian arteries are branches of the aorta

Oxytocin stimulates the myoepithelial cells in the breast causing the milk production. It also helps augment contractions in labour and cause uterine involution after childbirth.

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

The most likely cause of her postcoital bleeding is cervical ectropion as suggested by her postcoital bleeding, normal pap smears and use of oral contraceptive pills.

Cervical ectropion is a benign condition that occurs as a result of overexposure to oestrogen. Here, glandular cells (the columnar epithelium) lining the endocervix, begin to grow on the ectocervix, leading to exposure of the columnar cells to the vaginal environment.

These columnar cells are prone to trauma and bleeding during coitus.

The maternal mortality rate starts low and raises steeply after the age of 30 years. The lowest mortality rate recorded among women is between 19-30 years of age group.

A brow presentation in a nulliparous woman is associated with high risk of obstructed labour and the need for delivery by Caesarean section.

Brow presentation occurs when the presenting part of the fetal head is the part between the orbital ridge and anterior fontanelle.

In multiparous women, the indications differ as vaginal manipulation or spontaneous flexion to a vertex presentation or extension to a face presentation can occur after full cervical dilatation.

Early fetal heart decelerations are indicative of a mild abnormality on cardiotocograph (CTG). It does not indicate obstructive labour or need for delivery by Caesarean section.

The slow descent of the fetal head can be controlled subsequently by good uterine contractions and allow for vaginal birth.

Prolonged labour can cause maternal fever, but that in isolation is not an indication for Caesarean section.

Caput and head moulding are associated with a ‘tight fit’ of the fetal head in the pelvis, but does not contraindicate vaginal birth.

Factors that increase the risk of ovarian cancer include nulliparity, IUD, endometriosis, cigarette smoking, HRT and obesity.

The presentation is antepartum haemorrhage. Ultrasound should be performed to find the reason for bleeding and assess the fetal well being.

Oxytocin is the primary stimulus for uterine involution following childbirth.

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.

Stress incontinence is characterized by the involuntary loss of urine with increases in intra-abdominal pressure. It is the most common type of incontinence in younger women, but also occurs in older women. Key risk factors include childbirth, medications that relax the urethral sphincter, obesity, lung disease (from chronic cough), and prior pelvic surgeries. Numerous treatments are available, although few studies compare one treatment with another.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Routine urodynamic tests are not recommended for urinary incontinence. Surgery is reserved for refractory incontinence.

Vaginal atrophy (thinning of vaginal tissue): Oestrogen helps to keep this tissue healthy. After menopause, low oestrogen levels can cause your vaginal walls to become thin, dry, and inflamed. That often leads to bleeding after sex.

Vaginal atrophy is the most common cause of post menopausal vaginal bleeding.

With a normal pap smear a year ago, this patient is unlikely to develop cervical cancer.

Cervical ectropions are not common in post-menopausal women.

Endometrial cancer and cervical polyps are possible causes of postcoital bleeding, however, they are not as common as vaginal atrophy.

Ovarian granulosa cells (GC) are the major source of oestradiol synthesis. Induced by the preovulatory luteinizing hormone (LH) surge, cells of the theca and, in particular, of the granulosa cell layer profoundly change their morphological, physiological, and molecular characteristics and form the progesterone-producing corpus luteum that is responsible for maintaining pregnancy. 

Turner syndrome patients have high FSH levels and low oestrogen levels. They have a short stature and buccal smear is chromatin negative.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. The primary host for the organism is the domestic cat. Humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection can lead to hydrocephalus, microcephaly, mental disability and vision loss.

The lower vagina drains to the inguinal nodes where as the upper vagina drains to the internal and external iliacs

Face presentation is the abnormal position of the fetal head in labour. In this position the neck is hyperextended.
Vertex position is the normal presentation of the foetus for delivery, in which the head is flexed and the position of the chin is towards the chest.

Although there have been some mixed results regarding the use of hormone replacement therapy (HRT) and the prevalence of Alzheimer’s disease (AD), there is little question that HRT started during menopause lowers cognitive decline, which is a common early symptom of AD.
This is in contrast to the effect shown when HRT is started at the age of 60-65, when the risk of Alzheimer’s disease rises.
There are no statistics on the effect of HRT on the incidence of Alzheimer’s disease when it is started before menopause, but it is apparent that it does not slow the progression of the disease or make advanced dementia less severe.

Miscarriage is a pregnancy that ends spontaneously before the foetus reaches the age of viability i.e. before 24 weeks of gestation. In a threatened miscarriage the USG findings are of a foetus present in the uterus and on speculum examination the cervical OS is closed, in an inevitable miscarriage the cervical OS is opened. In an incomplete miscarriage the uterus contains the retained products of conception and the cervical OS is open. complete miscarriage contains no retained products of conception and the cervix is closed as the bleeding as resolved.

Anti phospholipid syndrome is an autoimmune disorder in which abnormal antibodies are formed which increases the risk of blood clots to develop in vessels and leads to recurrent miscarriages to occurs. The changes of recurrent miscarriage in a previously known case of APL is 15%.

It utilizes the IgG class of the antibody.

Ureters are muscular tubes that run from the kidneys to the urinary bladder. It is lined by transitional epithelium.

Fetal urine contributes significantly to amniotic fluid production in the second trimester of pregnancy. As early as 8-11 weeks, urine production begins and can be observed in the fetal bladder on ultrasound scans. The urine creates a hypotonic fluid which contains increasing concentrations of urea and creatinine. By term, a foetus produces about 800 ml of urine a day, of which 250ml is eliminated through fetal swallowing.

Bacterial vaginosis is characterised by a foul smelling vaginal discharge without inflammation. The most common spp to cause this is gardnerella vaginalis. Other spp include mycoplasma hominis and bacteroides. It occurs due to growth and increase in anaerobic spp with simultaneous reduction in lactobacilli in vaginal flora causing an increase in vaginal pH. It is the most common cause of abnormal vaginal discharge in women of childbearing age.

IgM rise is typically seen with acute infection. IgG is produced in response to infection but is produced later than IgM. IgG is also produced in response to vaccination. If IgG and IgM are negative the patient is susceptible to Rubella infection. If IgG +ve and IgM -ve the patient should be considered immune. If IgM +ve this suggests acute infection or false positive IgM (not uncommon)

Normal position of the foetus in relationship to the mother is always a longitudinal lie and a cephalic presentation. Transverse lie means that the baby is sideways. The foetus lies transverse till 26-28th week of gestation, after which it usually changes its position from transverse to a longitudinal lie with head down. A transverse lie can occur in conditions like grand multiparity, preterm foetus, placenta previa and pelvic contraction.

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.

Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.

Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.

BV recurrence rates are high, approximately 80% three months after effective treatment.

Ilioinguinal nerve injury is one of the most common nerve injuries associated with pelvic surgery.

Clotting factor problem. Some of the more common disorders of coagulation that occur during pregnancy are von Willebrand disease, common factor deficiencies, platelet disorders and as a result of anticoagulants.

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.

Providers should identify any known risk factors for ectopic pregnancy in their patient’s history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment.

Performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy.

Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration.

Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. The patient may have a cervical ectopic pregnancy and would thus run the risk of haemorrhage and potential hemodynamic instability if a dilation and curettage are performed.

The female pelvic inlet tilts at an inclination that is about 60 degrees from the anatomical horizontal plane. This tilt is maintained by muscles and fascia. The pelvic outlet slopes at an angle of 15 degrees.

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.

The maximum dose of lidocaine with adrenaline is 7mg/kg.

Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. It can be a sign of serious underlying pathology and is usually alarming for patients. About one-third of patients also have abnormal uterine bleeding that is not associated with coitus and about 15 percent have dyspareunia. The most serious cause of postcoital bleeding is cervical cancer. About 11 percent of women with cervical cancer present with postcoital bleeding. The patient should undergo cervical cancer screening according to local guidelines. Postcoital bleeding is not an indication for cervical cytology if previous screening tests are up-to-date and normal.

Cervical screening and liquid based cytology are superior to transvaginal ultrasound.

Coagulation profile can be done if cytology is normal to rule out bleeding diathesis.

Tranexamic acid can be considered once malignancy is ruled out and cause of bleeding has been established.

Leiomyomas uterine (fibroids)
Clinical features:
Menses that are heavy and last a long time, symptoms of pressure, pelvic discomfort, constipation, frequency of urination, complications during pregnancy, fertility problems, loss of pregnancy, premature birth, uterus enlargement and irregularity

Workup:
Ultrasound

Treatment:
Asymptomatic: monitoring
Surgical intervention, hormonal contraception

This patient has uterine leiomyomata, or fibroids, which are benign smooth muscle (myometrial) tumours that are very prevalent in adult women (up to 25%). These tumours can expand the endometrium’s surface area, the uterus’ overall size and thickness, and compress adjacent structures; nevertheless, some individuals have no symptoms and are identified by chance during a physical examination or imaging (as in this patient’s CT scan after a car accident).
Heavy, prolonged menses are among the indications for uterine leiomyomata treatment (particularly if associated with anaemia).
Pelvic discomfort that persists (e.g., dyspareunia).
Symptoms in abundance (e.g., pelvic pressure, hydronephrosis, constipation).
Recurrent miscarriages.
Medical or surgical treatment options are available for patients with these clinical characteristics (e.g., myomectomy).

This woman had mild menses and no pelvic discomfort or mass symptoms while having many big intramural and pedunculated leiomyomata (e.g., no ureter compression). There is no need for extra treatment in persons with asymptomatic fibroids. Only observation and reassurance are required.
In the treatment of symptomatic fibroids, a combination of oral contraceptive pills and progestin-containing intrauterine devices can be utilised, although they are not required in the management of asymptomatic fibroids. Furthermore, this patient has a minimal risk of unwanted pregnancy (e.g., monogamous, same-sex relationship), and the hazards of these contraceptives (e.g., venous thromboembolism, uterine perforation) outweigh the benefits.

GnRH agonist therapy (e.g., leuprolide) is a treatment for symptomatic uterine fibroids that works by inhibiting pulsatile FSH and LH production in the hypothalamus, lowering oestrogen levels. Low oestrogen levels cause a temporary reduction in leiomyoma size, which helps with heavy menses and bulky symptoms. Because long-term usage of GnRH agonists is linked to an increased risk of osteoporotic fractures, they are only administered preoperatively.

Tranexamic acid is a nonhormonal medicinal medication that reduces heavy menstrual bleeding by preventing fibrin breakdown (i.e., an antifibrinolytic drug). This patient’s menses are light.
Uterine leiomyomata (fibroids) are benign myometrial tumours that can produce a range of symptoms but are often identified by chance. Heavy menstrual blood, pelvic pain, and bulk symptoms are all indications for treatment. Patients with asymptomatic fibroids merely need to be monitored and reassured.

Most women lose about 35-40 ml of blood on average during each menstrual cycle. The maximum amount of blood loss is 80 ml after which blood loss of more than 80 ml is defined as heavy menstrual bleeding, formerly known as menorrhagia.