This patient has developed symptoms of ovulation discomfort, which is also known as Mittelschmerz syndrome. Lower abdominal and pelvic pain that arises around the middle of a woman’s menstrual cycle characterises this condition.
The discomfort usually appears suddenly and disappears within hours, though it can continue up to three days.

The symptoms of ovulation pain can include:
– Lower abdomen pain.
– The pain typically occurs about two weeks before the menstrual period is due.
– The pain is felt on the right or left side, depending on which ovary is releasing an egg.
– The pain may switch from one side to the other from one cycle to the next, or remain on one side for a few cycles.
The duration of pain ranges anywhere from minutes to 48 hours.

Consuming alcohol and risk of cervical cancer are not associated. Not even drinking often and in large amounts are risk factors for developing cervical cancer.

So drinking alcohol and risk of cervical cancer aren’t associated. Based on their analyses of the scientific research evidence, that is the conclusion of, among many others, the:
American Cancer Society.
Centres for Disease Control and Prevention (CDC).
National Cancer Institute.
UK’s National Health Service.
Canadian Cancer Society.
Cancer Council Australia.
World Health Organization (WHO).

All other options can increase the risk of acquiring cervical cancer.

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.

When cervical biopsy or colposcopy doesn’t explain the severity of the pap smear results cone biopsy is done. In 10% of biopsies, results will be different from that of the pap smear as in this patient with pap smear showing HSIL and colposcopy showing chronic cervicitis.

In such cases conization is indicated. Repeating the pap smear could risk prompt management of a serious problem. No destructive procedure, ablation or cryotherapy, should be done before diagnosis is certain.

PMS is a condition, which is associated with somatic, emotional and behavioural symptoms during the women menstruation. Oenothera biennis with the common name of “evening primrose” is containing a valuable fixed oil with commercial name of EPO. Evening primrose oil has two types of omega-6-fatty acid including linoleic acid (60%–80%) and γ-linoleic acid (8%–14%). Essential fatty acids are considered as essential compounds for body health, especially among women. Evening primrose oil’s is effective in women health, but the immediate response should not be expected from it, therefore, it should be regularly used up to 4 or 6 months.

Oral contraceptive pills are only used when other treatments fail.
SSRI are only indicated in cases of persistent mood changes like depression.
Local anaesthetics have no role in the management of PMS.

The clinical features of endometriosis include dyspareunia, dysmenorrhea, dysuria, dyschezia as well as infertility. Pain is characteristically long-term, cyclic (often occurring the same time as menses) and can get progressively worse over time. Laparoscopy remains the standard for diagnosis. There are many cases in which endometriosis is only discovered at the time of the workup for infertility.

Postinor-2 (levonorgestrel 750pg) is only an emergency contraceptive and is not designed to be a regular form of contraception. If taken within 24 hours, it is estimated to be able to prevent up 97-98% of pregnancies and 58% if given between 48-72 hours post-unprotected intercourse. It can cause vaginal bleeding within a few days of its administration if it is given before day 8-10 of her menstrual cycle. However, if given mid-cycle, it typically doesn’t affect the timing of her next period unless conception occurs. Nausea and vomiting were common when high doses of OCP were used as a post-intercourse contraceptive. Nausea and vomiting still can occur with Postinor-2, but not up to 50% of women. There is currently no evidence to suggest that the levonorgestrel dose would cause a virilising effect on female foetuses.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.

Trichomoniasis is a common sexually transmitted infection caused by a parasite. In women, trichomoniasis can cause a foul-smelling vaginal discharge which might be white, grey, yellow or green, genital itching and painful urination.

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.

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.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

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.

Combined oral contraceptive pills have an anti ovulatory function and also reduce the pain of menstruation.

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.

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.

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.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor.

These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

All other options are incorrect.

Sertoli-Leydig cell tumours constitute less than 0.5 percent of ovarian neoplasms. They may behave in a benign or malignant fashion, which correlates with the degree of differentiation in an individual case. Approximately 75 percent occur in women under the age of 40 years (mean age at diagnosis is 25), but they occur in all age groups. The neoplasms are characterized by the presence of testicular structures that produce androgens. This can result in virilization, although not all of these neoplasms are functionally active.

Pure Sertoli cell tumours are usually estrogenic and may also secrete renin, leading to refractory hypertension and hypokalaemia. In addition, these tumours may be associated with Peutz-Jeghers syndrome.

Pure Leydig cell tumours are androgen secreting; only a few cases have been reported. Virtually all of these rare tumours are unilateral and confined to the ovary at diagnosis.

Granulosa cell tumours typically present as large masses; the mean diameter is 12 cm. Women may present with an asymptomatic mass noted on abdominal or pelvic examination. Granulosa cell tumours often produce oestrogen and/or progesterone; consequently, symptoms related to hyperestrogenism are common at diagnosis.

Krukenberg tumour, also known as carcinoma mucocellulare, refers to the signet ring subtype of metastatic tumour to the ovary. The stomach followed by colon are the two most common primary tumours to result in ovarian metastases, pursued by the breast, lung, and contralateral ovary.

A rare tumour that is made up of more than one type of cell found in the gonads (testicles and ovaries), including germ cells, stromal cells, and granulosa cells. Gonadoblastomas are usually benign (not cancer), but they may sometimes become malignant (cancer) if not treated.

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.

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.

Pain upon movement of the cervix with the health care provider’s gloved fingers is suggestive of an inflammatory process of the pelvic organs. CMT, when present, is classically found on bimanual examination of the cervix and uterus. While CMT is often associated with pelvic inflammatory disease, it can be present in other disease entities such as ectopic pregnancy, endometriosis, ovarian torsion, appendicitis, and perforated abdominal viscus.

PID is not a singular disease entity but describes a spectrum of disease. It is an upper genital tract infection, which may affect the uterus, fallopian tubes, ovaries, and peritoneum. PID can begin as cervicitis, progress to endometritis, followed by involvement of the fallopian tubes as pyosalpinx, and ultimately involve the ovary as a tubo-ovarian abscess (TOA). The two most common causative pathogens are N. gonorrhoeae and C. trachomatis although the infection is often polymicrobial.

Documentation of infection with either of these two organisms must be done by cervical swabs for culture.

Transvaginal ultrasound or CT scan can be done to confirm diagnosis however the absence of findings in these investigations doesn’t rule out the possibility of PID.

Urinalysis can be done to exclude urinary tract infection, one of the possible differential diagnosis for PID.

Thyroid stimulating hormone has no role in the diagnosis of PID.

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.

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.

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.

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.

Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.

A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).

Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.

PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.

Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.

Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.

Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).

In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.

Multiple epidemiological risk factors have been identified in patients who have adenocarcinoma of the endometrium.
– Endogenous factors
– Obesity
– Nulliparity
– An individual who has had a late menopause (aged >52 y)
– Unopposed oestrogen
– Tamoxifen
– Family history
– Individuals with a family history of endometrial cancer appear to be at increased risk.

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.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

Before considering invasive procedures, a cervical smear must first be performed. Antibiotics can only be given when inflammation has been confirmed and culture results have identified the organism causing the inflammation. Endometrial ablation, colposcopy and vaginal US are all invasive procedures that are not relevant in the immediate management of this patient.