--- module: 053-02 language: en chapter: 53 title: "Gynaecological Disease, Menstruation, Fertility, and Contraception" module_title: "Menstrual mechanisms, pelvic emergencies, reproductive planning, and contraceptive safety" source_sha256: ee2fc2a4d6acc664e626b49e100a41d62057e57aa5ac1f7abcfa5614d192a49f --- # Menstrual mechanisms, emergencies, and contraceptive safety ## First questions and early pregnancy ### Pregnant, unstable, or losing blood supply? ### Pregnancy test whenever biologically possible #### Ectopic and miscarriage mimic other conditions ### Privacy, consent, trauma-informed explanation ### Pregnancy of unknown location, not simply too early #### Integrate haemodynamics, ultrasound, gonadotropin trend #### No single value proves normal or abnormal ### Shoulder-tip pain, syncope, peritonism suggest rupture ### Management safety depends on assured follow-up ## Menstrual cycle mechanism ### Falling steroids release gonadotropin drive #### Follicle-stimulating hormone recruits follicles ### Dominant follicle raises oestradiol and inhibin #### Negative switches to positive feedback ##### Luteinising-hormone surge ### Luteal progesterone stabilises secretory endometrium ### No implantation: luteal regression #### Spiral arterioles constrict, mediators activate ##### Functional layer sheds ## Bleeding history and mechanisms ### Quantify rather than label heavy or irregular ### Intermenstrual, postcoital, postmenopausal differ ### Normal haemoglobin does not exclude iron depletion ### Structural: polyps, fibroids, adenomyosis, neoplasia ### Non-structural: coagulopathy, ovulatory, drugs ### Anovulation prolongs unopposed oestrogen #### Unstable endometrium sheds irregularly ## Acute bleeding and endometrial sampling ### Treat by circulation and ongoing loss ### Tranexamic acid reduces fibrinolysis ### Hormones stabilise endometrium when appropriate #### Avoid oestrogen with thrombotic or vascular risk ### Once stable, find cause and restore iron ### Sample by cancer probability, not thickness alone ### Postmenopausal bleeding always assessed ### Hysteroscopy finds focal lesions blind biopsy misses ## Torsion and ruptured cyst ### Unilateral pain with nausea raises torsion ### Twisted pedicle blocks venous before arterial flow #### Oedema then infarction ### Doppler flow can persist #### Dual blood supply or intermittent torsion ### Urgent laparoscopy detorses and preserves ovary ### Ruptured haemorrhagic cyst bleeds intraperitoneally ## Pelvic inflammatory disease ### Low threshold clinical diagnosis #### Prevents tubal injury ### Fever and raised markers may be absent ### Negative nucleic-acid tests do not exclude it ### Treatment reduces infertility, ectopic, abscess ## Endometriosis ### Inflammatory, fibrotic disease outside the cavity ### Pain reflects location, nerves, sensitisation #### More than visible lesion volume ### Normal ultrasound misses superficial disease ### Empirical hormonal suppression if no warning features ### Laparoscopy if uncertain, fertility, or resistant ## Amenorrhoea and polycystic ovarian syndrome ### High gonadotropins, low oestradiol: ovarian insufficiency ### Low or normal gonadotropins: central suppression ### Prolactin inhibits gonadotropin-releasing hormone ### Functional hypothalamic amenorrhoea: low energy #### Low oestradiol harms bone, heart, fertility #### Pill bleeds do not correct energy deficit ### Polycystic ovarian syndrome after exclusions #### Rapid virilisation demands urgent investigation #### Progestogen reduces endometrial hyperplasia ## Infertility and contraception ### Infertility is a couple assessment #### Reserve tests are not an egg-quality score ### Separate perfect-use from typical-use failure ### Condoms reduce infection transmission ### Avoid unnecessary examinations delaying initiation ### Leg swelling, chest pain, headache: urgent review ### Combined methods raise venous and arterial thrombosis ### Enzyme inducers weaken hormonal, not intrauterine ### Emergency contraception acts before implantation ## Menopause and warning signs ### Follicular depletion causes menopause ### Unopposed oestrogen causes endometrial hyperplasia ### Local vaginal oestrogen: low systemic exposure ### Persistent warning symptoms need examination ### Screening is not a diagnostic test for symptoms ### Vulval symptoms need direct skin inspection #### Presumed candidiasis can delay diagnosis