Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management.

Absolute contraindications to endometrial ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In general, endometrial ablation should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm).

The best next step in her management is a colposcopy.

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

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

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

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

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.

Adolescents who fail to respond to first- or second-line treatment and have recurrent symptoms or have symptoms that worsen over time should be re-evaluated for other possible and serious causes of secondary dysmenorrhea such as endometriosis, uterine leiomyomas, polyps, or pelvic pathologies.

When pelvic pathology is suspected, abdominal and transvaginal ultrasonography should be used as first-line investigation. However, transvaginal ultrasound is more accurate and the preferred option if possible.

CT scan is not indicated in the assessment of dysmenorrhea.

D&C and laparoscopy can be considered as treatment options once a diagnosis has been established but can not be used as primary steps in diagnosis of dysmenorrhea.

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

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

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

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

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

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

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

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

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.

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.

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.

Paget’s disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. Symptoms may include redness of the nipple skin and crusting may occur around the area. In more advance cases, symptoms may include itching or a burning pain in the nipple.

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

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

This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).

When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.

Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.

The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.

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.

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.

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.

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.

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

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.

While on combination oral contraceptive tablets, this patient had a migraine. After a conversation about adverse effects, stop the combo medications and prescribe her progestogen-only pills.
The following are reasons why progestogen-only pills should be your first choice:
1-Age of 45 or more years
2-Smokers who are 45 years old or older
3-Oestrogen contraindications
4-Melitus Diabetes
5-A headache (combined oral contraceptive pills have absolute contraindication)
6-Hypertension under control
7-Lactation
8-Chloasma.

Pregnancy, undetected genital tract bleeding, and concurrent use of enzyme-inducing medications are all contraindications to using progestogen-only pills.

Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective hormonal contraceptives for obese women because they do not appear to be affected by body weight. Women using the combination contraceptive patch who weight 90 kg may experience decreased contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of pregnancy.

The management of low-grade squamous intraepithelial lesions (LSIL) on cervical cytology in women ages 25 years or older depends upon whether the patient underwent high-risk human papillomavirus (HPV) testing.

Women in this age group comprise two different populations in terms of cervical cancer screening strategies. Professional organizations recommend that women ages 25 to 29 years be screened with cytology alone, while women 30 years or older should be screened with cytology and HPV co-testing. Thus, the American Society for Colposcopy and Cervical Pathology (ASCCP) prefers that women ages 25 to 29 years are not managed based upon HPV results, even if an HPV test was performed at the time of screening. For women with ages 30 years or older and HPV positive, colposcopy must be performed.

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

Bacterial vaginosis (BV) is a clinical condition characterized by a shift in vaginal flora away from Lactobacillus species toward more diverse bacterial species, including facultative anaerobes. The altered microbiome causes a rise in vaginal pH and symptoms that range from none to very bothersome. Future health implications of BV include, but are not limited to, increased susceptibility to other sexually transmitted infections and preterm birth. Fifty to 75 percent of women with BV are asymptomatic. Symptomatic women typically present with vaginal discharge and/or vaginal odour. The discharge is off-white, thin, and homogeneous; the odour is an unpleasant fishy smell that may be more noticeable after sexual intercourse and during menses.

The best strategy is to commence cyclical hormone therapy using continuous daily oestrogen therapy, with medroxy progesterone acetate (MPA) given daily for 12 days each month.

This patient is most likely experiencing menopause, with symptoms caused by her oestrogen deficiency state.

Diazepam will help her to sleep and possibly alleviate her irritability, but would be unlikely to relieve the hot flushes.

Continuous therapy with oestrogen and MPA provides continuous progestogen therapy and has a high risk of causing unpredictable breakthrough vaginal bleeding, as it is only three months since the last menstrual period. This treatment is not recommended to be given within 1 – 2 years of the last period.

Oestrogen alone is not recommended for women who still have their uterus.

Progestogen alone would only be indicated in cases with contraindications to oestrogen administration.

Staph aureus is the most common causative organism of skin and soft tissue infections.

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.

Since the car crash happened two weeks prior, breast trauma is suggested and thus fat necrosis is the most probable diagnosis. Phyllodes tumours are typically a firm, palpable mass. These tumours are very fast-growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50, prior to menopause.

Eisenmenger’s syndrome is one where there is communication between the systemic and pulmonary system, along with increased pulmonary vascular resistance, either to systemic level or above systemic level (right to left shunt). A would-be mother must be informed that to become pregnant would incur a 50% risk of dying. Even if she survives, fetal mortality approaches 50% as well.

– Severe symptomatic aortic stenosis has a mortality in pregnancy of about 20%. Prevention of reduction in preload is necessary in all obstructive cardiac lesions. Balloon valvuloplasty can be done in pregnancy.
– Due to the increased blood volume and cardiac output in pregnancy, mitral stenosis can lead to severe pulmonary oedema. Balloon valvuloplasty can be done in pregnancy.
– Ebstein anomaly is a malformation of the tricuspid valve- It is usually not associated with maternal mortality.
– Atrial-septal defects rarely cause complications in pregnancy, labour, or delivery.

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

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

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

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.