--- module: 053-01 language: en chapter: 53 title: "Gynaecological Disease, Menstruation, Fertility, and Contraception" module_title: "Foundations" source_sha256: a8aa7e8948755413efd905efb123b870a024eec296918396432ae9e353fff5a3 --- # Gynaecology, menstruation, fertility, and contraception ## Orientation ### Endocrine physiology meets bleeding, pain, infection, cancer ### Explain, consent, offer chaperone, allow stopping ### Urgent: instability, ectopic, torsion, infection, haemorrhage ## Menstrual physiology and history ### Follicular oestradiol proliferates endometrium #### Sustained high oestradiol triggers luteinising-hormone surge ##### Ovulation ### Corpus luteum progesterone makes endometrium secretory #### No implantation: hormone withdrawal causes menstruation ### Ovulation inconsistent after menarche and before menopause ### History: interval, volume, pain, pregnancy, goals ### Product counts imperfect #### Anaemia, leakage, restriction, experience matter ## Abnormal uterine bleeding ### Causes: structural lesions, coagulopathy, ovulatory, drugs ### Adolescents: anovulation, but consider bleeding disorders ### Perimenopause: anovulation, but cancer risk rises with age ### Stability and pregnancy first #### Blood count and iron define consequence ### Biopsy with age, unopposed oestrogen, obesity, tamoxifen ### Acute: resuscitation, tranexamic acid, hormones, surgery ### Chronic: intrauterine system, hormones, non-steroidal drugs ### Ablation is not contraception #### Unsuitable if future pregnancy desired ## Pelvic pain and endometriosis ### Acute differentials: ectopic, torsion, cyst, infection ### Pregnancy test routine when biologically possible ### Sudden unilateral pain with nausea suggests torsion #### Normal Doppler misses intermittent or partial torsion ### Endometriosis: endometrium-like tissue outside cavity #### Inflammation, fibrosis, adhesions ##### Pain and infertility #### Burden does not track lesion extent #### Clinical diagnosis; laparoscopy not always required ### Adenomyosis: endometrium within myometrium #### Painful heavy bleeding, tender enlarged uterus ### Leiomyomas: benign smooth-muscle tumours #### Effects depend on size and location ## Infection and discharge ### Discharge: physiological, infective, atrophy, malignancy #### History alone unreliable; test by syndrome ### Pelvic inflammatory disease: ascending, often polymicrobial #### Pain plus cervical, uterine, adnexal tenderness #### Delay raises infertility, ectopic, abscess, pain #### Treat broadly, test, manage partners, reassess ### Human papillomavirus drives several cancers #### Vaccination and screening reduce, not remove, risk ### Trauma-informed care follows the person's choices ## Polycystic ovarian syndrome and amenorrhoea ### Ovulatory dysfunction, androgen excess, ovarian morphology #### Insulin resistance commonly contributes #### Unopposed oestrogen causes endometrial hyperplasia ### Management follows the person's priorities #### Cycle protection with combined pill or progestogen ### Cysts not required; ultrasound alone insufficient ### Amenorrhoea: exclude pregnancy first #### Hormone tests and imaging localise the axis #### Low-energy suppression threatens bone and fertility ##### Restore energy availability ## Infertility ### Assess earlier with age, irregular cycles, known disease ### Evaluate both partners concurrently ### Female factors: ovulation, reserve, tubes, uterus, age ### Confirm ovulation by cycle or timed progesterone ### Reserve tests predict stimulation, not natural fertility ### Treatment from timing to IVF, donor gametes, adoption ## Contraception ### Condoms reduce infection transmission ### Implants and intrauterine devices: low user failure ### Combined methods suppress ovulation #### Oestrogen raises thrombosis risk ### Progestogen-only avoids oestrogen, varied side effects ### Copper device: hormone-free, more bleeding and pain ### Emergency contraception does not end implanted pregnancy ### Enzyme inducers reduce some hormonal methods ## Menopause and pelvic-floor health ### Diagnosed retrospectively after sustained amenorrhoea ### Hormone therapy most effective for vasomotor symptoms #### Systemic oestrogen needs endometrial protection ### Local vaginal oestrogen: low systemic exposure ### Prolapse and incontinence: childbirth, ageing, tissue #### Physiotherapy, pessary, surgery by burden and goals ## Gynaecological cancer ### Postmenopausal bleeding needs endometrial assessment ### Cervical screening detects precancer before symptoms ### Ovarian cancer: persistent nonspecific symptoms ### Persistent warning features need biopsy and referral ### Tumour markers are not general screening tests