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.

This patient meets the diagnostic criteria for premenstrual syndrome.
Affective and somatic symptoms over the five days before menses in each of the three previous menstrual cycles are diagnostic criteria for premenstrual syndrome.
Affective symptoms include:
– Depression.
– Anger outbursts.
– Irritability.
– Anxiety.
– Confusion.
– social withdrawal.
Somatic symptoms include:
– breast tenderness
– abdominal bloating
– headache and swelling of extremities.
Symptoms normally disappear within four days of menstruation and are present even when no medical therapy, drugs, or alcohol are used.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent crying, loss of interest in daily activities, reduced focus, exhaustion, sleeplessness, and a sense of being overwhelmed or out of control.
Symptoms must have been present for the majority of the previous 12 months, interfering with daily activities.

The diagnoses of generalised anxiety disorder and depression alone are doubtful.

A complication of bilateral salpingo-oophorectomy and hysterectomy is the formation of adhesions in the GIT that can cause intestinal obstruction. Abdominal X-ray is sufficient to visualize any obstruction in the GIT.

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.

Luteal phase is always fixed to 14 days. In this patient, ovulation will occur between days 12-15. Sexual encounter must be ceased until 24-36 hours before day 15 (day 17). The start date of abstinence, calculated by decreasing 6 days (life span of the sperm) from the earliest possible day of ovulation (12-6=6). Hence from day 6-17, sexual encounter must be avoided.

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.

If abnormal cells are found high up in the cervical canal, it is critical to consider doing a cone biopsy to rule out any cervical malignancy. A cone-shaped section of the cervix containing the abnormal cells is removed under general anaesthesia.
Loop Electrosurgical Excision Procedure is a way of removing the abnormal cells from the cervix using a wire loop. First a speculum is inserted to open the vagina so the uterus can be seen. Then a solution is applied to the surface of the cervix to make the areas of abnormal cells easier to see. It is done under local anaesthesia.

Cone biopsy is the only acceptable option to rule out malignancy. Cryotherapy, chemotherapy and radiotherapy are management options once malignancy has been confirmed.

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.

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 the patient should use backup birth control, such as condoms, or avoid sexual intercourse until pills have been taken for seven diarrhoea-free days.

Options to stop pills are incorrect as it increases risk of pregnancy.

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.

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

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extra pelvic endometriosis may rarely occur.

Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Though ESR maybe elevated due to the presence of inflammation, it is not specific for endometriosis and has no role in preoperative staging. The same holds true for any possible CBC finding.

Transvaginal ultrasound is preferred for diagnosis but doesn’t aid in preoperative staging of endometriosis.

CA125 values are elevated in severe infiltrative endometriosis but unchanged in mild disease. Relaying on CA125 cause a high rate of false negatives.

On reflex liquid-based cytology, this patient had a cervical screening test that revealed HPV non-16 and 18 kinds, as well as a low-grade squamous intraepithelial lesion. In a year, she should be provided a cervical screening test. If HPV non-16/18 kinds are discovered in 12 months, she will need a colposcopy.

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.

Premenstrual dysphoric disorder (PMDD) is a more serious form of premenstrual syndrome (PMS). PMS causes bloating, headaches, and breast tenderness a week or two before your period.

With PMDD, you might have PMS symptoms along with extreme irritability, anxiety, or depression. These symptoms improve within a few days after your period starts, but they can be severe enough to interfere with your life.

PMDD symptoms appear a week or two before menstruation and go away within a few days after your period starts. In addition to PMS symptoms, you may have:

Anger or irritability.
Anxiety and panic attacks.
Depression and suicidal thoughts.
Difficulty concentrating.
Fatigue and low energy.
Food cravings or binge eating.
Headaches.
Insomnia.
Mood swings.

The following treatments have been shown to relieve symptoms:

Sertraline, escitalopram, paroxetine, and fluoxetine are SSRIs (selective serotonin reuptake inhibitors). SSRIs are the first-line treatment and are extremely effective.
The second line of defence is alprazolam (a short course recommended due to its addictive potential).
The use of temazepam has little advantage because it only aids with sleep and is relatively short-acting.
Lifestyle modifications-weight loss, exercise, quitting smoking, and relaxation therapies for less severe PMS.
Danazol-suppresses the ovulation and helps with mastalgias associated with PMS.

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

Urge incontinence is involuntary pee loss accompanied by a strong desire to urinate. The most common cause of urge incontinence is detrusor or bladder dyssynergia, which is characterized by an involuntary contraction of the bladder during urine distension.

Bladder training, eliminating excess coffee and fluid intake, biofeedback, and pharmacological therapy are all options for treating urge incontinence. Treatment with anticholinergic medicines (oxybutynin chloride), -sympathomimetic agonists (metaproterenol sulphate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) has proven successful if conservative approaches fail.

The detrusor muscle will be relaxed by these pharmacologic drugs. Oestrogen therapy may improve urine control in postmenopausal women who are not on oestrogen replacement therapy. Kegel exercises can help women with stress urinary incontinence strengthen their pelvic musculature and improve bladder control.

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.

This patient has been unable to conceive for over a year, and her fallopian tubes are blocked. Her body mass index is 42.
Because she has obstructed Fallopian tubes, in-vitro fertilisation (IVF) is an alternative to getting pregnant for this patient.
A woman with a BMI over 35, on the other hand, will need twice as many IVF rounds to conceive as a woman of normal weight.
As a result, the greatest advise for successful IVF would be to decrease weight as the first step in management.
Obese (BMI less than 40) patients’ IVF success chances are reduced by 25% and 50%, respectively.

Adenomyosis or dysfunctional uterine haemorrhage are the most likely causes of heavy periods.
Because she refuses to have a hysterectomy or endometrial ablation, hormonal therapy must be administered in addition to the iron therapy she is already receiving.
Any of the choices could be employed, but using therapy only during the luteal phase of the cycle in someone who is virtually surely ovulating (based on her typical monthly cycles) is unlikely to work.

Danazol is prone to cause serious adverse effects (virilization), especially when used for a long period of time.
GnRH agonists would cause amenorrhoea but are more likely to cause substantial menopausal symptoms, and the °fa contraceptive pill (OCP) is generally best avoided in someone using hypertension medication.

Treatment with norethisterone throughout the cycle is likely to be the most successful of the treatments available.
If a levonorgestrel-releasing intrauterine device (Mirena®) had been offered as an alternative, it would have been acceptable.

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.

Despite the fact that pregnancy at her age is uncommon, the best advise you can give her is to take a pregnancy test.

If the test results show she is not pregnant, she can next decide whether to restart the oral contraceptive pill (0CP) or simply weep until the post-pill amenorrhoea goes away.

Although an increased follicle-stimulating hormone (FSH) level may indicate ovarian failure, it does not guarantee that no more periods will occur and does not rule out the possibility of a future pregnancy.

Obviously, she should be recommended to use a contraceptive method like condoms until the cause of her amenorrhoea is determined.
Other hormonal tests, such as luteinizing hormone and prolactin testing, may be required.

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.

A ruptured ectopic pregnancy is the most probable diagnosis. As she is in shock (tachycardia and hypotension) immediate laparotomy is needed.

This patient is above 35 and smokes more than 15 cigarettes per day, which is an absolute contraindication to using a combined oral contraceptive pill. A BMI of greater than 35 is a relative contraindication to the usage of the combined oral contraceptive pill.
Progestogen-only contraception, such as etonogestrel implant, levonorgestrel intrauterine device, and depot medroxyprogesterone, should be offered to her.
Without initially attempting lifestyle changes, a referral for weight loss surgery is not required. Also, nicotine replacement therapy may aid in quitting smoking, but it may take time.

With the high level of sensitivity and specificity of current tests to measure hCG in serum and urine, pregnancy can now be diagnosed before the time of the first missed menstrual period- For current serum hCG assays, the low threshold for detection is 10-25 IU/L, while for urine assays it is 25-50 IU/L, which corresponds to approximately the seventh day after conception. Because the levels of hCG in the blood and urine are very similar, the tests are equivalent. Urine testing may reveal a positive result as early as 3-4 days after implantation. By the time of the expected menstrual period, the test will be positive 98% of the time- If a test is negative more than 1 week after the expected time of the menstrual period, it is almost certain the patient is not pregnant. To cover these rare instances where a woman has a low hCG and conceived later than expected, the test should be repeated in 1 week for a definitive result.

Since ectopic pregnancy is not a life-threatening problem for the mother until 2 months after conception, a patient with a negative urine hCG does not require ultrasonography to exclude ectopic pregnancy. Patients with a suspected ectopic pregnancy and a negative urine hCG should be followed closely, as early laparoscopic intervention can improve the chances of future fertility.

Gardnerella vaginalis is one of the bacteria implicated in the development of bacterial vaginosis , many women (>50%) with this vaginal infection have no signs or symptoms, when these are present they are most often :
Vaginal discharge, grey, white or green, with a strong unpleasant odour
Strong vaginal odour and fishy smell after sex
Vaginal itching
Burning during urination
Vaginal bleeding after sex
Gardnerella vaginalis can also be responsible for serious infections (sepsis, wound infections) in locations other than those associated with the genital tract or obstetrics, these cases are very rare but have been reported, including in men.

Mycoplasma Hominis is one of the organisms involved in the pathogenesis of BV but it appears normal on wet mount.

Candida presents with white cottage cheese like discharge.

Chlamydia is not seen on wet mount and produces clear vaginal discharge.

Trichomonas shows clue cells on wet mount.

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.

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.

The most appropriate test for a hydatiform mole is serum beta hCG levels, which are consistently raised in these patients. The levels return to normal when the pregnancy is terminated.