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).

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.

Tenderness is usually suggestive of a benign breast mass such as a breast abscess. Ultrasound is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage.

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.

Women aged 25-49 years living in England are routinely recalled for screening every three years. Women receive their first invitation for cervical screening at 25 years of age. They are not invited earlier as changes in the young cervix can be normal and result in unnecessary treatment. Provided the smears remain negative and there are no symptoms to suggest cervical cancer, the routine recall is three years for women aged 25-49 years. Women aged 50-64 years old are routinely recalled for a smear every five years. After the age of 65 years, women are only screened if they have not had a smear since the age of 50 years (including those who have never had a smear) or those who have had recent abnormal smears. This is because due to the natural history and progression of cervical cancer, it is highly unlikely that women over 65 years old will go on to develop the disease. 

This lady should be admitted to hospital for early surgical exploration. Taking into account her age, mild abdominal discomfort and a palpable lower abdominal mass, it is imperative that ovarian malignancy be ruled out as soon as possible. Patients with ovarian malignancy often present in advanced stages of cancer as the symptoms tend to be occult and non-specific. Other things to include in her workup would be her CA125 level. Any form of hormonal therapy is contraindicated until ovarian malignancy has been ruled out. A pap smear is not relevant here since we are suspecting an ovarian malignancy rather than cervical. Evaluation of her mass takes priority over an assessment for osteoporosis.

OCPs which contain oestrogen and progesterone are contraindicated in women who have migraines associated with a neurological deficit or aura (pins and needles in this case). In such cases, the alternative would be Implanon (etonogestrel), however, there are mixed reviews and opinions regarding whether or not there is a decreased efficacy in heavier women. The absolute contraindication for Implanon is active breast cancer. Therefore, the best advice for her case would be some form of barrier contraceptive.

When choosing a COCP (combined oral contraceptive pill), it is recommended that a formulation containing 20-30ug of ethinyl oestradiol is chosen. The progestogen part is responsible for prevention of conception and can be norgestrel or any other progestogens although the formulations containing norgestrel tend to be cheaper than more novel progestins such as cyproterone acetate as well as drospirenone. If the patient is known to have issues with excessive fluid retention, OCPs that has drospirenone would be the most suitable. However, if the patient is suspected to have PCOS, the best choice would be one that contains cyproterone acetate.

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.

The signs and symptoms of premenstrual dysmorphic disorder are well-known in this patient. Fluoxetine is the greatest therapeutic option among the available options.
For severe symptoms, clomipramine and danazol can be used interchangeably.
Bromocriptine, like oral contraceptives and evening primrose, has no scientific evidence to support its use in this syndrome.
NSAIDs are helpful for painful symptoms, but they only address a limited number of them.

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.

There are 3 stages of labour. The 1st stage of labour starts from labour contractions till the time the cervix is fully dilated. Stage 2 is from complete cervical dilatation until the baby is born. The 3rd stage is from the birth of the baby, until the time the placenta is expelled.

CA-125 has found application as a tumour marker or biomarker that may be elevated in the blood of some patients with specific types of cancers, or other conditions that are benign. Increased level of CA125 appears in fifty percent of stage 1 ovarian cancer patients and more than 90% with stages 2-4 ovarian cancer. CA-125 is therefore a useful tool for detecting ovarian cancer after the onset of symptoms as well as monitoring response to treatment and for predicting a patient’s prognosis after treatment.

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.

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.

There is high possibility of her being pregnant. Urine B-hCG has to be checked to exclude pregnancy.

Although a dilatation and curettage (D&C) is frequently recommended as part of a woman’s menorrhagia examination.
D&C is not indicated in a woman who had a normal hysteroscopy and laparoscopy only two years ago, and who experienced comparable symptoms when not taking the OCP in the past, especially after the age of 40.
The Filshie clips should not be removed because they will not improve the symptoms.

Although an endometrial ablation or possibly a hysterectomy may be required in the future to address the symptoms, the first line of treatment should be a nonsteroidal anti-inflammatory drug (NSAID), which will reduce the loss in up to half of the women treated.

A local exam might not help in locating the cause of the bleeding because it might be underneath the superficial structures. A thorough examination should be done under GA to accurately locate the source of bleeding.

IUCD is a risk factor for PID and PID has the clinical picture already described. However, fibroids should also be excluded since they may present in the same way.

The uterus needs support in order to remain centered inside the pelvic cavity. The support it receives comes in two forms: dynamic and passive. The ligaments of the uterus have an important role in both.

Dynamic support is provided by the pelvic diaphragm through tonic contractions while standing and sitting and active contractions during moments of increased abdominal pressure, such as coughing or sneezing. During these moments, the ligaments of the uterus transmit the force of the diaphragm towards the organ itself, maintaining its position.

The ligaments are also crucial in providing passive support. By minimizing movement of the body and the cervix, they maintain the uterus in the typical anteverted and anteflexed position directly on top of the bladder. This provides a support for the uterus when the abdominal pressure increases.

Hence, even though the broad ligament, round ligament and ovarian ligament have some role in the suspension of the uterus, the uterosacral ligament plays the most significant role. It is also the ligament used for surgical suspension of POP.

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.

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.

The most likely cause of her bleeding is an endometrial polyp formation due to the tamoxifen.

Tamoxifen is often prescribed to decrease risk of breast cancer recurrence in premenopausal women with oestrogen receptor-positive cancers.

As with any medication, it has known side effects, which include endometrial polyp formation, subendometrial oedema and, rarely, endometrial carcinoma.

A polyp or carcinoma can cause uterine bleeding, but a polyp is more likely to occur.

Routine endometrial thickness screening is not recommended in all women taking tamoxifen. However, in cases of abnormal bleeding, ultrasound assessment of endometrial thickness, hysteroscopy and curettage are indicated to assess the endometrium in more detail.

Tamoxifen is not associated with endometrial atrophy.

Endometrial metastasis from a breast cancer is rare, and tamoxifen would not usually induce follicular development in a woman who has had chemotherapy and resultant amenorrhoea.

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

An LSIL Pap test shows mild cellular changes. The risk of a high-grade cervical precancer or cancer after an LSIL Pap test is as high as 19 percent.

As with an ASC-US Pap test, an LSIL Pap test is evaluated differently depending upon age. For women ages 25 or older, follow-up depends upon the results of human papillomavirus (HPV) testing:

– Women who test positive for HPV or who have not been tested for HPV should have colposcopy.
– Women who test negative for HPV can be followed up with a Pap test and HPV test in one year.

All other options are not acceptable for the above mentioned reasons.

This woman has experienced a septic abortion. Therefore the first step is commencement of intensive antibiotic treatment as soon as cervical swabs have been taken.

The next step is evacuation of the uterus. Curettage can be performed after a few hours, to extract any remaining infected products of conception from the uterine cavity.

The choice of antibiotics depends on the most likely microorganism involved. Therefore, prior to commencing any other procedure, it is vital to take cervical swabs for microscopic examination to guide further antibiotic therapy (correct answer).

If curettage is performed immediately there is a risk that the infection would spread.

However, if Clostridium welchii infection is suspected from the cervical smear (particularly if encapsulation of the microorganisms is present), then curettage should be performed immediately along with commencing antibiotic treatment.

Curettage can be delayed for up to 12-24 hours if other microorganisms are suspected; unless a significant increase in bleeding occurs.

Ergometrine is not essential as an immediate treatment measure as the patient is not bleeding heavily and reports that her bleeding has decreased. However, ergometrine is commonly given when curettage is performed.

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).

This patient has experienced polycystic ovarian syndrome-like symptoms.
At least two out of three of the following criteria must be met to diagnose polycystic ovarian syndrome:
1- Hyperandrogenism suggesting an excess of androgens e.g. excess hair growth, acne etc.
2- Menstrual irregularities e.g. dysmenorrhea, oligomenorrhea, and amenorrhea.
3-The ovaries are polycystic if one ovary has 12 or more follicles or if the size of one or both ovaries has risen.

Low FSH, LH, and pituitary hormones are typically associated with hypothalamic dysfunction, however this is not the case here.
Similarly, with premature ovarian failure, FSH/LH levels rise while oestrogen levels decrease.

All of the other choices are incorrect.

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.

Paroxetine is an SSRI used for hot flushes in women with contraindication for hormonal therapy.

Hormonal or other pharmacotherapy is usually needed for women with bothersome hot flashes. For most women with moderate to very severe hot flashes and no contraindications, we suggest MHT. Women with an intact uterus need both oestrogen and a progestin, while those who have undergone hysterectomy can receive oestrogen only. For women interested in MHT, the first step is to determine the potential risks for the specific individual.

The majority of perimenopausal and recently menopausal women are good candidates for short-term hormone therapy for symptom relief. However, for women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event (VTE) or stroke, or those at moderate or high risk for these complications, alternatives to hormone therapy should be suggested. For women with moderate to severe hot flashes who are not candidates for hormone therapy based upon their breast cancer, CHD, or VTE risk and for those who choose not to take MHT, we suggest nonhormonal agents. The agents most commonly used include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs.

Black Cohosh is found to be no more significant than placebo.
Long-term use of mefenamic acid is controversial and not recommended.

An ectopic pregnancy is definitely present in this patient. An extrauterine pregnancy is referred to as an ectopic pregnancy. The fallopian tube accounts for 96% of ectopic pregnancies, but other sites include the cervical, interstitial (also called cornual; a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus), hysterotomy (caesarean) scar, intramural, ovarian, or abdominal. Furthermore, multiple gestations may be heterotopic in rare situations (including both a uterine and extrauterine pregnancy). Diabetes mellitus is not considered a risk factor for the development of an ectopic pregnancy.

Risk factors for ectopic pregnancy are summarized below:
High Risk: (Risk factors & Odds ratio)
Previous ectopic pregnancy 2.7 to 8.3
Previous tubal surgery 2.1 to 21
Tubal pathology 3.5 to 25
Sterilization 5.2 to 19
IUD – Past use 1.7 – Current use 4.2 to 16.4
Levonorgestrel IUD 4.9
In vitro fertilization in current pregnancy 4.0 to 9.3

Moderate:
Current use of oestrogen/progestin oral contraceptives 1.7 to 4.5
Previous sexually transmitted infections (gonorrhoea, chlamydia) 2.8 to 3.7
Previous pelvic inflammatory disease 2.5 to 3.4
In utero diethylstilbesterol (DES) exposure 3.7
Smoking – Past smoker 1.5 to 2.5 – Current smoker 1.7 to 3.9
Previous pelvic/abdominal surgery 4.0
Previous spontaneous abortion 3.0

Low:
Previous medically induced abortion 2.8
Infertility 2.1 to 2.7
Age ≥40 years 2.9
Vaginal douching 1.1 to 3.1
Age at first intercourse <18 years 1.6
Previous appendectomy 1.6