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Fatima Altaiy and Abdullah El-badawey Endometriosis Fibroids PCOS Ovarian torsion Atrophic vaginitis Amenorrhoea Menopause Urinary incontinence STIs/infections ContraceptionSBA A 25 year old female is being investigated for dysmenorrhoea and dyspareunia. She is trying to conceive but has been unable to do so for 8 months. On examination there is tenderness in the posterior vaginal fornix. The doctor suspects an underlying gynaecological pathology. Which of the following investigations below is the gold standard in diagnosing this condition? A) Transvaginal US B) Laparoscopy C) Abdomen US D) Pregnancy test E) Abdominal CTSBA A 25 year old female is being investigated for dysmenorrhoea and dyspareunia. She is trying to conceive but has been unable to do so for 8 months. On examination there is tenderness in the posterior vaginal fornix. The doctor suspects an underlying gynaecological pathology. Which of the following investigations below is the gold standard in diagnosing this condition? A) Transvaginal US B) Laparoscopy C) Abdomen US D) Pregnancy test E) Abdominal CTSBA A 23 year old female presents to her GP complaining of heavy menstrual bleeding for the last year. Her blood tests and examination results are shown below: Platelets: 160 (150-400 * 109/L) Examination: Boggy enlarged uterus A) Endometriosis B) PCOS C) Adenomyosis D) Bleeding disorder E) EndometritisSBA A 23 year old female presents to her GP complaining of heavy menstrual bleeding for the last year. Her blood tests and examination results are shown below: Platelets: 160 (150-400 * 109/L) Examination: Boggy enlarged uterus A) Endometriosis B) PCOS C) Adenomyosis D) Bleeding disorder E) Endometritis Endometriosis Growth of ectopic endometrial tissue outside of uterine cavity. Oestrogen makes it worse, by increasing the growth Management in primary care: -First line: NSAIDs/paracetamol (pain relief is Features attempted) -pelvic pain -COCP or progestogens (trying to reduce oestrogen levels) -dysmenorrhoea: pain during period -dyspareunia: pain during intercourse Management in secondary care: -GnRH analogues (downregulate HPG axis, -subfertility leading to decreased oestrogen release) -Surgery https://guotaitcm.com/zh/treatments/endometriosis/ On pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal Enlarged boggy uterus fornix Menorrhagi Dysmenorrhoea a Deep Dysmenorrhoea dyspareunia subfertility https://www.pantai.com.my/medical-specialties/maternity- services/endometriosis-vs-adenomyosisSBA A 32 year old woman attends for a regular blood check up for her work. She has no symptoms and feels generally fine. Her results are shown below. Which of the following could be an explanation for the findings shown? Hb: 120 (115 - 160) RBC: 6 (4.2-5.4 cells/mcL) A) Cervical cancer MCV: 88 (82-100 fl) C) Ovarian cysts WBC: 3.3 (4.0-11.0 * 109/L)09/L) D) Uterine fibroid TSH: 5 (0.5-5.5 mu/L) E) Adenomyosis T4: 15 (9-18 pmol/L)SBA A 32 year old woman attends for a regular blood check up for her work. She has no symptoms and feels generally fine. Her results are shown below. Which of the following could be an explanation for the findings shown? Hb: 120 (115 - 160) RBC: 6 (4.2-5.4 cells/mcL) A) Cervical cancer MCV: 88 (82-100 fl) C) Ovarian cysts WBC: 3.3 (4.0-11.0 * 109/L)09/L) D) Uterine fibroid TSH: 5 (0.5-5.5 mu/L) E) Adenomyosis T4: 15 (9-18 pmol/L) Fibroids Benign smooth muscle tumours of uterus, which occur with higher oestrogen and progesterone levels Management: If under 3cm, not distorting cavity, Features medical treatment can be tried May be asymptomatic or may Asymptomatic - no treatment needed cause lower abdominal pain Menorrhagia secondary to fibroids: mirena coil Menorrhagia -> iron-deficiency anaemia or may cause Treatment to shrink/remove fibroids: polycythaemia (benign tumour Medical: GnRH (analogues) agonists may produce EPO) (inducing a menopause) Diagnosis: transvaginal ultrasound Surgical: myomectomy (surgical ases/9130-uterine-fibroids.org/procedure removing fibroids)SBA A 23 year old female presents to her GP complaining of facial hair acne. She was recently diagnosed with PCOS. She wants to know if there is any treatment for this. She is currently only using barrier protection for contraception. Her bloods are shown below. Which of following below is the most appropriate treatment to be used for this patient? A) Doxycycline C) Clomifeneperoxide 1% D) COCP E) Mirena coilSBA A 23 year old female presents to her GP complaining of facial hair acne. She was recently diagnosed with PCOS. She wants to know if there is any treatment for this. She is currently only using barrier protection for contraception. Her bloods are shown below. Which of following below is the most appropriate treatment to be used for this patient? A) Doxycycline C) Clomifeneperoxide 1% D) COCP E) Mirena coil PCOS Features: Diagnosis criteria (needs 2/3) • Subfertility and infertility • infrequent or no ovulation (usually manifested as • Menstrual disturbances: infrequent or no menstruation) oligomenorrhoea and amenorrhoea • clinical and/or biochemical signs of • Hirsutism, acne (due to hyperandrogenism (such as hirsutism, acne, or hyperandrogenism) elevated levels of total or free testosterone) • Obesity • polycystic ovaries on ultrasound scan (defined as • Hyperinsulinaemia the presence of ≥ 12 follicles (measuring 2-9 mm • Acanthosis nigricans (due to insulin in diameter) in one or both ovaries and/or resistance) increased ovarian volume > 10 cm³) https://www.nhs.uk/conditions/acanthosis-nigricans/ PCOS Investigations • pelvic ultrasound: multiple cysts on the ovaries • raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis Management • Hirsutism and acne - COCP, topical eflornithine, spironolactone, flutamide and finasteride may be used under specialist supervision https://www.everydayhealth.com/pcos/ • Infertility - clomifeneSBA A 19 year old patient presents to the emergency department with an intense pain in her abdomen. She is crying and can’t give much of a history. She has vomited once already. On examination you find significant pain in the RIF. Some investigations are shown below. Temperature: 37.1, HR 110, RR 15, BP 133/85 Urine dip: NAD Pregnancy test: negative A) Appendicitis US: whirlpool sign B) Upper urine tract infection D) Pancreatitisnancy E) Ovarian torsion What is the most lkely diagnosis?SBA A 19 year old patient presents to the emergency department with an intense pain in her abdomen. She is crying and can’t give much of a history. She has vomited once already. On examination you find significant pain in the RIF. Some investigations are shown below. Temperature: 37.1, HR 110, RR 15, BP 133/85 Urine dip: NAD Pregnancy test: negative A) Appendicitis US: whirlpool sign B) Upper urine tract infection D) Pancreatitisnancy E) Ovarian torsion What is the most lkely diagnosis? https://visualsonline.cancer.gov/details.cfm?imageid=8262 Ovarian torsion https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.7310 Features: • Sudden onset of deep colicky abdominal pain • Vomiting and distress • In the iliac fossa (Twisting and untwisting) • Investigations: ultrasound shows whirlpool sign • Diagnosis: laparoscopy • Management: surgery https://www.childrenscolorado.org/conditions-and-advice/conditions-and- https://radiopaedia.org/articles/whirlpool-sign-mesenteryns/pediatric-ovarian-torsion/Ovarian torsion https://www.childrenscolorado.org/conditions-and-advice/conditions-and- symptoms/conditions/pediatric-ovarian-torsion/ Atrophic vaginitis Post-menopausal women It presents with vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used. IMPORTANT TO RULE OUT ENDOMETRIAL CANCER IF POST-MENOPAUSAL BLEEDINGSBA A 14 year old female presents to her GP with her mother, as she has not yet started menstruation. Her mother is concerned that there is an underlying problem. On examination the patient has a short stature. The GP organises a blood test which shows the following: Hb: 116 (115 - 160) A) Normal variant Platelets: 160 (150-400 * 109/L) B) Turners syndrome WBC: 3 (4.0-11.0 * 109/L) C) PCOS TSH: 4 (0.5-5.5 mu/L) D) Congenital adrenal T4: 11 (9-18 pmol/L) E) Imperforate hymen FSH and LH raisedSBA A 14 year old female presents to her GP with her mother, as she has not yet started menstruation. Her mother is concerned that there is an underlying problem. On examination the patient has a short stature. The GP organises a blood test which shows the following: Hb: 116 (115 - 160) A) Normal variant Platelets: 160 (150-400 * 109/L) B) Turners syndrome WBC: 3 (4.0-11.0 * 109/L) C) PCOS TSH: 4 (0.5-5.5 mu/L) D) Congenital adrenal T4: 11 (9-18 pmol/L) E) Imperforate hymen FSH and LH raised Amenorrhoea Primary: • Failure to establish menstruation Secondary: • Cessation of menstruation for 3-6 by 15 years of age in girls with months in women with previously normal secondary sexual characteristics (such as breast normal and regular menses, or 6- 12 months in women with development), or by 13 years of previous oligomenorrhoea age in girls with no secondary sexual characteristicsPrimary: Secondary: • gonadal dysgenesis (e.g. • hypothalamic amenorrhoea Turner's syndrome) - the (e.g. secondary stress, most common causes excessive exercise) • testicular feminisation • polycystic ovarian syndrome • congenital malformations of (PCOS) the genital tract • hyperprolactinaemia • functional hypothalamic • premature ovarian failure amenorrhoea (e.g. secondary • thyrotoxicosis to anorexia) • Sheehan's syndrome • congenital adrenal • Asherman's syndrome hyperplasia (intrauterine adhesions) • imperforate hymenSBA A 52 year old woman presents to the GP with symptoms of frequent hot flushes, mood swings, loss of libido, and depression. She is still getting periods, with her last period being 9 months ago. After researching treatment options she would like to discuss HRT. Which of the following is an appropriate option for her? A) COCP B) POP C) HRT combined continuous regime D) HRT combined cyclical regime E) Oestrogen patchSBA A 52 year old woman presents to the GP with symptoms of frequent hot flushes, mood swings, loss of libido, and depression. She is still getting periods, with her last period being 9 months ago. After researching treatment options she would like to discuss HRT. Which of the following is an appropriate option for her? A) COCP B) POP C) HRT combined continuous regime D) HRT combined cyclical regime E) Oestrogen patch Menopause The average women in the UK goes through the menopause when she is 51 years old. It is recommended to use effective contraception until the following time: • 12 months after the last period in women > 50 years • 24 months after the last period in women < 50 years https://www.everydayhealth.com/menopause/perimenopause-symptoms/ Menopause HRT 1.Uterus intact + LMP <12mo – cyclical combined HRT 2.Uterus intact + LMP >12mo – continuous combined HRT 3. Post-hysterectomy – oral or patch oestrogen Contraindications: Current or past breast cancer Any oestrogen-sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasiaSBA A 65 year old woman is complaining of leaking urine when she laughs or sneezes. Investigations are carried out, which are shown below. This is affecting her daily life as she feels embarrassed to go out in public. Which of the following could be a risk factor for developing this? Blood glucose: 5.6 (4-7) A) Early menarche Urine dip: NAD B) Not receiving HPV vaccine Blood test: NAD C) COPD background E) Low BMIon birthsSBA A 65 year old woman is complaining of leaking urine when she laughs or sneezes. Investigations are carried out, which are shown below. This is affecting her daily life as she feels embarrassed to go out in public. Which of the following could be a risk factor for developing this? Blood glucose: 5.6 (4-7) A) Early menarche Urine dip: NAD B) Not receiving HPV vaccine Blood test: NAD C) COPD background E) Low BMIon births Investigations: Urinary incontinence -bladder diaries for a minimum of 3 days -vaginal examination to exclude pelvic organ Risk factors: prolapse (where organs like womb or bladder • Older age • Previous pregnancies/vaginal childbirthmove out of place and press on vagina) -urine dipstick and culture • Fetal macrosomia • High coffee intake • Chronic cough Management in urge incontinence: bladder retraining -> oxybutynin (anti- Classification: muscarinic) or mirabegron (dementia -urge incontinence: wanting to go more often patients) due to detrusor overactivity -stress incontinence: leaking small amounts Management in stress incontinence: when coughing/laughing -overflow incontinence: if the bladder is still pelvic floor muscle training -> duloxetine (SNRI) palpable after urinationSBA An 18 year old women presents with 5 days of watery grey discharge which is particularly smelly after intercourse. Upon further questioning, she explains how she has had multiple sexual partners in the last week. Given the likely diagnosis, what is the first line treatment? A) Doxycycline B) Metronidazole C) Clindamycin D) Ceftriaxone E) CiprofloxacinSBA An 18 year old women presents with 5 days of watery grey discharge which is particularly smelly after intercourse. Upon further questioning, she explains how she has had multiple sexual partners in the last week. Given the likely diagnosis, what is the first line treatment? A) Doxycycline B) Metronidazole C) Clindamycin D) Ceftriaxone E) Ciprofloxacin Bacterial Vaginosis • Not an STI but increases risk of STI • Loss of lactobacilli (bacterial flora)-> reduction in lactic acid -> By Mikael Häggström, M.D. pH increases >4.5 -> anaerobe overgrowth ⚬ Gardneralla vaginalis (most common) Investigations: • Vaginal pH >4.5 (3.5 - 4.5) ⚬ Mycoplasma hominis • Clue cells on microscopy ⚬ Prevotella species Management: Risk factors: • Excessive cleaning especially with strong soaps • Self limiting (don’t need to treat) • Multiple partners • Metronidazole 1st line (oral/gel). Clindamycin 2nd line ⚬ Avoid alcohol (disulfram-like reaction) • Smoking • Antibiotics Complications: • Copper coil • Increased risk of STI’s Presentation: • Pregnant women • Fishy-smelling, watery, grey/white discharge ⚬ Miscarriage, preterm delivery, PROM, low birth weight • ~50% asymptomatic Trichomoniasis Vaginalis • An STI, Protozoan (type of parasite) - single celled with flagella Presentation: • ~50% asymptomatic Management: • Metronidazole 1st line • Frothy, yellow green discharge (can be fishy) • Itching (typically not in BV) Increase risk of: • Dysuria • Contracting HIV • Dyspareunia • BV https://my.clevelandclinic.org/health/diseases/4696-trichomoniasis • Balanitis • Cervical cancer • PID Investigations: • Vaginal pH >4.5 • Pregnancy related complications • Speculum: Strawberry cervix/colpitis macularis ⚬ Swab from posterior fornix Candidiasis/Thrush • Yeast of the candida family Investigations: • Most common Candida albicans • Vaginal pH <4.5 • Charcoal swab • Cultures Scanning electron microscopy was performed at CenSE, IISc, Bangalore Presentation: • Microscopy • Thick, white discharge • Itching/irritation/discomfort • Erythema Management: • Antifungal cream/pessary/tablets e.g. clotrimazole • Fissures • Dysuria • Dyspareunia NB: Can damage latex condoms and prevent spermicides from workingSBA A 36 year old women presents with green vaginal discharge and painful urination. A STI test shows she is positive for Chlamydia trachomatis and Neisseria gonorrhoeae. What are the most appropriate medications to give? A) Doxycycline & Ciprofloxacin B) Ciprofloxacin & Clindamycin C) Doxycycline & IM Ceftriaxone D) IM Ceftriaxone E) Co-amoxiclavSBA A 36 year old women presents with green vaginal discharge and painful urination. A STI test shows she is positive for Chlamydia trachomatis and Neisseria gonorrhoeae. What are the most appropriate medications to give? A) Doxycycline & Ciprofloxacin B) Ciprofloxacin & Clindamycin C) Doxycycline & IM Ceftriaxone D) IM Ceftriaxone E) Co-amoxiclav Chlamydia trachomatis • Gram-negative bacteria (intracellular) Management: https://visualsonline.cancer.gov/details.cfm?imageid=2331 • Most common STI • Doxycycline 100mg BD 7/7 1st line (contraindicated in pregnancy breast feeding) Presentation: ⚬ Warn pts about photosensitivity • Asymptomatic ~50% men, ~75% women • Azithromycin/erythromycin, amoxicillin • Abnormal PV discharge Complications: • Dysuria • PID • Abnormal PV bleeding • Chlamydial conjunctivitis • PID symptoms: Pelvic pain, dyspareunia etc. • Reactive arthritis • Lymphogranuloma venerum (LGV) Investigations: ⚬ Lymphoid tissue affected at site of CT infection • NAATs ￭ Primary stage -> Painless ulcer ⚬ Men: First catch urine/urethral swab ￭ Secondary stage -> Lymphadenitis ⚬ Women: Vulvovaginal swab ￭ Tertiary stage -> Proctocolitis/Proctitis ⚬ Can also do rectal/pharyngeal swab ⚬ Doxycycyline 100mg BD 3/52 Neisseria gonorrhoeae • Gram-negative diplococcus Management: https://www.vircell.com/en/diseases/40-neisseria-gonorrhoeae • High level of antibiotic resistance • 1 dose of IM Ceftriaxone 1g if no sensitivities Presentation: Complications: • Odourless purulent discharge, green/yellow • PID • Dysuria • Epididymo-orchitis • Pelvic pain • Conjunctivitis • Testicular pain/swelling, • Fitz-Hugh-Curtis syndrome • Disseminated gonococcal infection Investigations: ⚬ Untreated -> spreads to skin/joints • NAATs ⚬ Non -specific skin lesions ⚬ Men: First catch urine/urethral swab ⚬ Systemic symptoms e.g. pyrexia ⚬ Women: endocervical swab ⚬ Polyarthragia ⚬ Can also do rectal/pharyngeal swab ⚬ Migratory polyarthritis • Microscopy, culture and sensitivities ⚬ Tenosynovitis Pelvic Inflammatory Disease (PID) • Inflammation/Infection of pelvic organs (spreading from cervix) e.g.Endometritis, Salpingitis, Oophoritis, Parametritis, Peritonitis • Common causes: Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium (Mgen) • Non-STi causes: Gardnerella vaginalis, H. Influenzae, E. coli Presentation: Management: Signs: • Pelvic/lower abdo pain • Pelvic tenderness • IM Ceftriaxone (gonorrhoeae) • Abnormal vaginal discharge • Cervical excitation • Doxycyclyine (chlamydia/Mgen) • Abnormal bleeding • Cervicitis • Metronidazole (Anaerobes e.g. Gardnerella vaginalis) • Dyspareunia • Dysuria Complications: • Infertility • Fever Investigations: • Chronic pelvic pain • NAATs for Chlamydia, Gonorrhoeae + Mgen • Sepsis • Fitz-Hugh-Curtis Syndrome • HIV and syphilis blood test • Microscopy (pus cells) ⚬ Inflammation/infection of liver (Glisson’s) capsule • Pregnancy test (ectopic pregnancy) ⚬ Adhesions between liver + peritoneum ⚬ RUQ +/- shoulder tip pain • Inflammatory markersSBA An 18 year old male presents to the sexual health clinic with a 3 day history of a painless ulcer on his penis following unprotected receptive and insertive anal sex with a new male partner. On examination, there is a maculopapular rash on the chest/abdomen, inguinal lymphadenopathy and perianal papillomatous lesions. What is the most likely diagnosis that explains all his symptoms? A) Syphilis B) Condylomata lata C) Condylomata acuminata D) Herpes E) HIVSBA An 18 year old male presents to the sexual health clinic with a 3 day history of a painless ulcer on his penis following unprotected receptive and insertive anal sex with a new male partner. On examination, there is a maculopapular rash on the chest/abdomen, inguinal lymphadenopathy and perianal papillomatous lesions. What is the most likely diagnosis that explains all his symptoms? A) Syphilis B) Condylomata lata C) Condylomata acuminata D) Herpes E) HIV Anogenital Warts • Caused by HPV (mainly 6 &11) • Variable incubation period https://istockphoto.com/illustrations/hpv-warts Presentation: • Benign epithelial lesions with 4 key morphological Management: features: • Podophyllotoxin (anti-mitotic) ⚬ Exophytic + papillomatous (condylomata acuminata) • Imiquimod (cytokine inducer) ⚬ Thickened horny papules (keratotic) • Cryotherapy • Laser therapies ⚬ Flat warts (macular) ⚬ Papular Syphilis • Spirochete (spiral shaped) bacteria: Treponema pallidum Presentation: https://controllab.com/en/program/syphilis-immunology/ • Primary ⚬ Painless ulcer chancre as original infection site ⚬ Local lymphadenopathy Investigations: • Secondary • Testing for antibodies to T. pallidum ⚬ Maculopapular rash • Quantitative antibody testing: RPR/VDRL ⚬ Condylomata lata ⚬ Systemic symptoms e.g. fever Management: • Tertiary • Deep intramuscular dose of benzathine ⚬ Neurosyphilis benzylpenicillin ⚬ Frequency depends on stage of syphilis ￭ Tabes dorsalis ￭ Argyll-robertson pupil and follow up quantitative antibody test ⚬ Gummatous lesions (granulomatous lesions) results ⚬ Aortic aneurysmsSBA A 33 year old women would like emergency contraception after she forgot to take her COCP pill. The last pill she took was 75 hours ago (day 8 of the pack). She usually takes the pill for 21 days and has a 7 day break. She has regular unprotected sex (UPSI). Which of the following would you recommend? A) Ullipristal B) Levonogestrel C) Take the most recent pill ASAP D) Copper coil E) Take the most recent pill ASAP and use barrier contraception for the next 7 daysSBA A 33 year old women would like emergency contraception after she forgot to take her COCP pill. The last pill she took was 75 hours ago (day 8 of the pack). She usually takes the pill for 21 days and has a 7 day break. She has regular unprotected sex (UPSI). Which of the following would you recommend? A) Ullipristal B) Levonogestrel C) Take the most recent pill ASAP D) Copper coil E) Take the most recent pill ASAP and use barrier contraception for the next 7 days Contraception Methods UKMEC • Family planning • UKMEC 1: No restriction to use • Barrier methods: Condom • UKMEC2: Benefits > Risks • Pills: COCP/POP • UKMEC 3: Risks > Benefits • IUD: Copper coil/IUS • UKMEC 4: Contraindicated • Injection/Implant: Depo-Provera • Surgery: Sterilisation • Emergency contraception Side effects COCP • Unscheduled bleeding, better after 3m • Small increased breast/cervical ca risk ⚬ reduced endometrial/ovarian/colon ca risk • Small increased risk of VTE/MI/stroke • Oestrogen and Progesterone • Licensed up to 50 y/o • Breast pain/tenderness/mood changes • Hypertension (HTN) Mechanism of action • Prevents ovulation Contraindications • Migraine with aura • Thicken cervical mucus • Inhibits endometrial proliferation • Uncontrolled HTN • Vascular disease • Hx of VTE Regime • SLE • 21d, 7d off • Smoking >15/day + >30 y/o • Continuous • Breast feeding ⚬ UKMEC 4 before 6 weeks postpartum ⚬ UKMEC 2 after 6 weeks postpartum COCP Key rules • Works instantly if started up to day 5. Taken OD. Missed pills (whilst on 21d on, 7d off regime) • After this it takes 7d of consistent pill taking to start • Always take the most recent missed pill ASAP ⚬ If only 1 pill missed, then that’s it! working ⚬ Theoretically once you do this you will be • If >1 pill missed additional contraception needed protected for the next 7 days whilst you consistently take 7 days of the pill • Day 1-7 • Missed pill = > 24hrs late = >48hrs since last pill • Missed 1 pill = 48 - 72hrs from last pill ⚬ Need emergency contraception (if UPSI) • Day 8-14 • Missed >1 pill = >72hrs from last pill ⚬ No emergency contraception needed • A day of vomiting/diarrhoea is considered a missed pill day • Day 15-21 ⚬ No emergency contraception needed ⚬ Skip pill free period, start next pack of pills COCP vs POP IUD vs IUS • POP missed pill is >12hrs late (vs 24hrs for COCP) • IUD contra-indicated in Wilson’s • POP has more unpredictable bleeding effects • IUD associated with irregular/heavy bleeding whilst IUS can reduce this and eventually stop this • Usually used when COCP contraindicated • IUD usually lasts longer • PID risk Injection vs Implant Emergency • Implant lasts longer than injection (yrs vs months) • Levonorgestrel - within 72 hrs of UPSI • Implant usually used in needle phobic pts • Ulipristal - within 120 hrs of UPSI • Implant does not effect fertility when stopped ⚬ Injection can effect this up to year after stopping ⚬ Avoid in severe asthma ⚬ Breastfeeding avoided for 1w after • Injection associated with osteoporosis ⚬ Wait 5 days before taking COCP/POP • Copper coil - within 5 d of UPSI, or within 5 d of the estimated date of ovulation• ZerotoFinals • Nice CKS • Passmedicine textbook • British assocation for sexual health and HIV https://guotaitcm.com/zh/treatments/endometriosis/ https://www.pantai.com.my/medical-specialties/maternity-services/endometriosis-vs-adenomyosis https://my.clevelandclinic.org/health/diseases/9130-uterine-fibroids https://www.nhs.uk/conditions/acanthosis-nigricans/ https://www.everydayhealth.com/pcos/ https://visualsonline.cancer.gov/details.cfm?imageid=8262 https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.7310 https://www.childrenscolorado.org/conditions-and-advice/conditions-and- symptoms/conditions/pediatric-ovarian-torsion/ https://radiopaedia.org/articles/whirlpool-sign-mesentery https://www.everydayhealth.com/menopause/perimenopause-symptoms/