Ultimate Gynecology Exam Guide

• Amenorrhea is the absence of menstruation; it is a symptom, not a disease.
• Primary Amenorrhea is defined as the absence of menstruation by 16 years of age in the presence of normal secondary sexual characteristics, or by 14 years of age if secondary sexual characteristics have not developed.
• Normal menstruation requires five factors: 1) Normal 46,XX chromosomal pattern. 2) Coordinated Hypothalamic-Pituitary-Ovarian (HPO) axis. 3) Anatomical presence and patency of the outflow tract. 4) Responsive endometrium. 5) Active support of thyroid and adrenal glands.
• Frequencies of Etiologies: Hypergonadotropic hypogonadism (43%), Eugonadism (30%), Low FSH without breast development (27%).

• Before Puberty: Pituitary gonadotropins are inadequate to stimulate ovarian follicles, so estrogen is insufficient.
• During Pregnancy: Large amount of estrogens and hCG from trophoblasts suppress pituitary gonadotropins.
• During Lactation: High level of Prolactin inhibits ovarian response to FSH, preventing follicular growth. Menstruation returns by 6th week in 40% of non-breastfeeding, and by 12th week in 80%. Suspended in ~70% of breastfeeding women.
• Menopause: Ovaries run out of responsive follicles, causing cessation of estrogen and elevation of pituitary gonadotropins.

• Outflow Tract Obstruction is the most common cause in this category. Requires pelvic ultrasound to assess anatomy.
• Imperforate Hymen: Presents in early childhood as a mucocele, or later with cyclical abdominal pain (dysmenorrhea) and haematocolpos (blood in vagina). Shows a bulging bluish membrane at introitus. Treatment is a cruciate incision.
• Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome (Müllerian Agenesis): Second most common cause overall. Absent vagina and non-functioning uterus with normal ovaries (46,XX karyotype). Important: 40% have renal anomalies and skeletal abnormalities. Non-surgical vaginal dilators are successful in 85% of cases.
• Androgen Insensitivity Syndrome (AIS): 46,XY karyotype but phenotypically female due to absent/non-functioning androgen receptors. Breast development occurs via peripheral conversion of androgens to estrogen. Scanty pubic hair, short vagina, absent uterus. Gonadectomy is required due to 30% malignancy risk in testes.
• Transverse Vaginal Septum: Requires specialist surgical reconstruction.

• Normal Height:
  • Isolated GnRH Deficiency (Kallmann Syndrome): Absent GnRH neurons with partial/complete agenesis of the olfactory bulb. Characterized by anosmia (loss of smell) and color blindness. Treat with HRT (Estrogen alone for 2 years, then gradual progestogens over 3-5 years) for secondary characteristics.
  • Weight Loss / Anorexia: Fails to activate the gene initiating GnRH release.
  • Excessive Exercise: Decreased body fat (ballet dancers, athletes) leads to amenorrhea.
• Short Stature:
  • Turner Syndrome: 45,X0 karyotype. Short stature, ovarian failure (streak gonads), shield-shaped thorax, widely spaced nipples, elevated gonadotropins (High FSH).
• Diagnosis Pathway: Normal height + low gonadotropins = Hypogonadotropic hypogonadism. Normal height + high gonadotropins = gonadal failure (do karyotype). Short stature + high gonadotropins = Turner syndrome.

• Secondary Amenorrhea: Cessation of menstruation for six consecutive months in a woman who previously had regular periods.
• Asherman’s Syndrome: Intrauterine adhesions preventing normal endometrial growth, usually due to over-vigorous endometrial curettage (affecting basalis layer) or endometritis. Estrogen deficiency in breastfeeding women increases adhesion risk. Diagnosed via Hysterosalpingography (HSG) or Hysteroscopy. Treated with adhesiolysis followed by cyclical estrogen/progesterone for 3 months (can insert Foley catheter/IUD for 7-10 days to prevent recurrence).
• Cervical Stenosis: Occurs after cervical trauma (traditional cone biopsy or curettage). Treated by careful cervical dilatation.

• Polycystic Ovary Syndrome (PCOS): Common cause of ovarian amenorrhea.
• Premature Ovarian Failure (POF): Cessation of periods with raised gonadotropins (High FSH/LH) before the age of 40 years. Often accompanied by low estradiol (<150pmol/L).
• Most common cause of POF is autoimmune disease (screen for thyroid, gastric parietal cells, and adrenal autoantibodies).
• Chromosomal abnormalities found in 2-5% of secondary amenorrhea (e.g., Turner mosaic 46,XX/45,X0 or 47,XXX in adolescents losing function soon after menarche).
• Must treat with Hormone Replacement Therapy (HRT) to prevent long-term osteoporosis and cardiovascular disease.

• Pituitary: Hyperprolactinemia is the most common pituitary cause. Caused by prolactinoma, drugs (phenothiazines, metoclopramide), or hypothyroidism. Galactorrhea in 1/3 of patients. Prolactin is an excellent tumor marker (>5000-8000 IU/L suggests macroadenoma).
• Treatment for Prolactinoma: Dopamine agonists like Bromocriptine (take with food at night to minimize nausea/hypotension) or Cabergoline. Surgery (trans-sphenoidal adenectomy) if drug-resistant, intolerable side effects, or suprasellar extension desiring pregnancy.
• Sheehan’s Syndrome: Hypogonadotropic hypogonadism due to profound hypotension and pituitary infarction following a major obstetric hemorrhage.
• Weight-related: BMI <19 kg/m2. At least 22% body fat is needed to maintain ovulatory cycles (allows extraovarian aromatization of androgens to estrogens). Anorexia nervosa drastically increases risk of severe osteoporosis.
• Exercise-related: 10-20% of intensive athletes (e.g., ballet dancers, runners) suffer oligomenorrhea/amenorrhea.

• Paramesonephric (Müllerian) Ducts: Form the fallopian tubes, uterus, cervix, and upper 4/5 of the vagina. The lower 1/5 comes from the urogenital sinus (sinovaginal bulbs).
• Mesonephric (Wolffian) Ducts: Regress in females. Form male structures. Also form ureteric buds (trigone, kidneys, ureters), explaining the high urinary tract anomaly association (up to 40%).
• SRY Gene: On the Y chromosome, dictates testis development. Testes secrete testosterone (from Leydig cells) and Anti-Müllerian Hormone (AMH) (from Sertoli cells) which causes Müllerian duct regression.

• Müllerian Agenesis (MRKH Syndrome): Complete failure to form. Painless primary amenorrhea, absent/dimple vagina, normal ovaries/secondary characteristics. Treat via vaginal dilation first, surgical vaginoplasty second.
• Imperforate Hymen: Cyclical pain, primary amenorrhea, bluish bulging introitus. Treat with cruciate incision.
• Transverse Vaginal Septum: Failure of Müllerian ducts to fuse with urogenital sinus. Presents with cyclical pain, haematocolpos, endometriosis (due to retrograde menstruation). Excision required.
• Uterine Anomalies (Bicornuate, Septate): Failure of midline fusion. Often asymptomatic, but associated with primary infertility, recurrent miscarriage, preterm labor, or abnormal lie.

• Congenital Adrenal Hyperplasia (CAH): 46,XX. Virilizing forms. Check urgent serum 17-hydroxyprogesterone (elevated). Treat salt-losing crisis urgently.
• Androgen Insensitivity Syndrome (AIS): 46,XY. Tissues do not respond to testosterone. Phenotypically female.
• 5-alpha-reductase deficiency: 46,XY. Inability to convert testosterone to highly active Dihydrotestosterone (DHT). Presents with virilization at puberty.
• Swyer Syndrome: 46,XY pure gonadal dysgenesis. Presents with primary amenorrhea.
• Gonadectomy is needed in gonadal dysgenesis or presence of Y fragment due to a 30% lifetime risk of malignancy.

• A diagnosis of exclusion. Prevalence is 3% to 30%. Heavy Menstrual Bleeding (HMB) is the most common symptom (50-60% of AUB).
• Intermenstrual Bleeding (IMB): Between periods (suspect polyps). Post-Coital Bleeding (PCB): After sex (suspect cervical pathology). Postmenopausal Bleeding (PMB): >1 year after cessation (suspect endometrial pathology/atrophy).
• Structural Causes (PALM): Polyps, Adenomyosis (70% have HMB), Leiomyomas (Fibroids - 30% of HMB), Malignancy/Hyperplasia.
• Non-Structural (COEIN): Coagulopathy (e.g., von Willebrand - found in 20% of unexplained HMB), Ovulatory (PCOS), Endometrial, Iatrogenic, Not otherwise classified (e.g., AVMs).

• Transvaginal Ultrasound Scan (TVUSS) and Full Blood Count (FBC).
• Endometrial Biopsy is mandatory if: Age >45 years, PMB with thickness >4mm, persistent PMB, treatment failure, or HMB with IMB.
• Hysteroscopy: For viewing/resecting submucosal fibroids or polyps.
• Coagulation screen only if HMB since menarche or positive family history.

• Medical:
  • Levonorgestrel Intrauterine System (LNG-IUS / Mirena): Releases measured doses of levonorgestrel daily (52mg total), reduces loss by 90%. ~30% amenorrheic at 12 months.
  • Tranexamic Acid: Antifibrinolytic, non-hormonal, 1g three times daily on days 1-4, reduces blood loss by 40-50%. Side effects: leg cramps, minor GI upset.
  • NSAIDs (Mefenamic Acid): Inhibits prostaglandins, 500mg three times daily days 1-5, reduces loss by 20-30% and treats dysmenorrhea.
  • Combined Oral Contraceptive Pill (COCP) or Cyclical Progestogens (norethisterone day 6-26).
  • GnRH agonists/antagonists: Used short-term to shrink fibroids before surgery (causes temporary menopause/bone loss).
• Surgical:
  • Endometrial Ablation: Destroys basalis layer. 80-90% improved, 30% amenorrheic. Only for women who have completed their family (risk of placenta accreta if pregnancy occurs). Uterus must be <10 weeks size and fibroids <3cm.
  • Myomectomy: For fibroids in patients desiring future fertility (risk of uterine rupture in pregnancy).
  • Uterine Artery Embolization (UAE): Symptoms improve in >80%.
  • Hysterectomy: Only guaranteed cure, but higher morbidity. Vaginal route preferred over abdominal. 25% risk of premature ovarian failure.

• Menopause: 12 consecutive months of amenorrhea due to loss of ovarian follicular activity. Average age is 52 years.
• Premature Ovarian Failure (POF): Menopause occurring <40 years. High FSH/LH, low estradiol (<150 pmol/L). Can be due to autoimmune, genetics, or surgery.
• Prolactin inhibits gonadotropin drive during lactation (physiological menopause).

• Short-Term: Vasomotor symptoms (Hot flushes/night sweats, highest in 1st year). Female Sexual Dysfunction (FSD) (dryness, dyspareunia, affects 42% to 88%). Psychological (mood swings, anxiety).
• Long-Term:
  • Osteoporosis: Estrogen loss decouples bone remodeling (resorption > formation), severely affecting trabecular bone (vertebrae, distal radius/Colles', femoral neck). Diagnosed by BMD scan (T-score ≤ -2.5).
  • Cardiovascular Disease (CVD): Most common cause of death >60 yrs. Estrogen loss increases Total/LDL cholesterol and decreases HDL. Oophorectomized women have 2-3x higher Coronary Heart Disease (CHD) risk.
  • Urogenital Atrophy: Frequency, urgency, dyspareunia.

• Types:
  • Estrogen only: For hysterectomized women.
  • Estrogen + Progestogen: For women with an intact uterus to prevent endometrial cancer. Can be cyclical (perimenopausal) or continuous combined (postmenopausal "no bleed").
• Routes: Oral (first-pass liver metabolism, higher VTE risk). Transdermal patch/gel (avoids liver, maintains E2:Estrone ratio 2:1, lower VTE risk). Implants (1000 pmol/L limit). Vaginal.
• Minimum bone-sparing doses: Estradiol oral 1–2mg, patch 25–50mcg, gel 1–5g, implant 50mg/6mths, CEE 0.3–0.625mg.
• Risks: Breast Cancer (increased with combined HRT duration; 3 extra cases per 1000). Venous Thromboembolism (VTE) (doubled risk, highest in 1st year). Endometrial Cancer (if unopposed estrogen given to a woman with a uterus, RR 9.5 for >10 yrs). Gallbladder disease.
• Alternatives: Tibolone (synthetic steroid with estrogenic/progestogenic/androgenic activity, dose 2.5mg, improves libido). SSRI/SNRI (Fluoxetine/Venlafaxine for vasomotor). Bisphosphonates. Raloxifene (a SERM that blocks AF-2 in breast/uterus but protects bone via AF-1, does not help flushes).
• Contraindications (Absolute): Breast/endometrial cancer, acute active liver disease, uncontrolled hypertension, confirmed VTE, pregnancy.

• Hirsutism: Male pattern (terminal) hair growth in females due to increased androgens or skin sensitivity. Differs from hypertrichosis (generalized vellus hair).
• Hair phases: Anagen (growing), Catagen (ceasing), Telogen (resting). Hirsutism shortens the anagen phase (face hair has long anagen, takes 6-9 months to treat).
• Androgens: Ovaries produce testosterone/androstenedione (LH driven). Adrenals produce DHEA. Free testosterone converts to highly active Dihydrotestosterone (DHT) via 5-alpha reductase in the hair follicle.
• Sex Hormone Binding Globulin (SHBG) binds and inactivates testosterone. Hyperinsulinemia lowers SHBG, increasing free testosterone.
• Causes: Polycystic Ovary Syndrome (PCOS) accounts for 95%. Others: Congenital Adrenal Hyperplasia (CAH) (<1%), Cushing’s (<1%), Androgen-secreting tumors (<1%), Iatrogenic (Danazol).
• HAIR-AN Syndrome: Hirsutism + Acanthosis Nigricans + Insulin Resistance.

• Assessed by the Ferriman–Gallwey scoring system (Score ≥8 indicates hirsutism across 9 areas).
• Virilism: Hirsutism + defeminization (clitoromegaly, male baldness, deep voice, secondary amenorrhea). Indicates severe pathology like Ovarian/Adrenal Tumors or adult-onset CAH.
• Investigations: Free Androgen Index (FAI), Serum testosterone (>5 mmol/L suspects tumor), 17-OH progesterone (CAH, do Synacthen test), Dexamethasone suppression (Cushing's).

• Requires 6-9 months to see clinical effect.
• Combined Oral Contraceptive Pill (COCP): First-line. Increases SHBG. Best types contain Cyproterone acetate (Dianette) (2mg) or Drospirenone (Yasmin) which have anti-androgenic effects. Higher doses of Cyproterone (50-100mg) use a reverse sequential regimen (days 5-15). Avoid Levonorgestrel/Norethisterone.
• Anti-androgens:
  • Spironolactone: Blocks androgen receptor and 5-alpha reductase. Side effects: diuresis, hyperkalemia.
  • Flutamide: Potent (250-500mg/day) but hepatotoxic.
  • Finasteride: 5-alpha reductase inhibitor (5mg/day). Highly teratogenic (must use reliable contraception).
• Topical: Eflornithine (Vaniqa) inhibits ornithine decarboxylase, slows growth.
• Metformin: Improves insulin resistance, indirectly reducing androgens.
• Last Resort: Ketoconazole (400mg daily) induces hepatic clearance but is hepatotoxic. GnRH agonists (causes bone loss).

• Bleeding occurring after menopause. Always abnormal if not on sequential HRT.
• Causes: Atrophic vaginitis (most common, due to low estrogen), Endometrial/cervical polyp, Endometrial hyperplasia, Endometrial carcinoma (10% of cases), Cervical carcinoma.
• Investigations: Transvaginal Ultrasound (TVS) is the first step. If endometrial thickness is ≥3mm (or ≥5mm if on HRT), an Endometrial Biopsy (Pipelle) is required to rule out cancer. Hysteroscopy allows direct visualization and targeted biopsy. (Dilatation & curettage is an old method).

• Tamoxifen: Non-steroidal drug used for breast cancer. Has anti-estrogenic effects on the breast but mild estrogenic effects on the endometrium, risking hyperplasia, polyps, or carcinoma. If PMB occurs on Tamoxifen, biopsy via Hysteroscopy is mandatory regardless of ultrasound findings.
• Treatments:
  • Atrophic vaginitis: Local estrogen cream/pessary.
  • Cervical polyp: Removed via speculum using polyp forceps.
  • Simple/Complex hyperplasia without atypia: Progesterone (oral or Mirena IUS).
  • Atypical hyperplasia / Endometrial cancer: Total hysterectomy + bilateral salpingo-oophorectomy (BSO).

• CIN (Dysplasia) is a premalignant histological abnormality in squamous epithelium (basement membrane is NOT breached). Significant features: cellular immaturity, disorganization, nuclear abnormality (dyskaryosis), increased mitosis.
• Grades (WHO): CIN 1 (lower 1/3), CIN 2 (basal half to 2/3), CIN 3 (full thickness, Carcinoma in Situ).
• Bethesda system: ASCUS, LSIL (CIN 1), and HSIL (CIN 2/3).
• Driven by Human Papillomavirus (HPV) high oncogenic risk types 16, 18, 31, 33, 35, 45, 56 (>99.7% of CIN/cancer cases).
• Anatomy: The Squamocolumnar Junction (SCJ) is dynamic. Metaplasia occurs when vaginal acidity converts columnar cells to squamous. The area between original and current SCJ is the Transformation Zone (TZ), the exact site where CIN and cancer develop. Retention of mucus creates Nabothian follicles.

• Liquid-Based Cytology (LBC): Collects whole sample in liquid medium. Reduces inadequate smears, increases dyskaryosis detection, and allows HPV/STD testing from the same vial.
• HPV DNA Testing: Polymerase chain reaction (PCR) and hybrid capture (HC). 80% clear infection naturally. Positive test in >30 yrs suggests colposcopy.
• Screening Interval: 3-yearly from 25-49 years old. 5-yearly thereafter to 64 years.
• HPV Vaccines: Bivalent (Cervarix 16,18) and Quadrivalent (Gardasil 16,18,6,11). Given IM to girls 12-18 years. Prevents ~90% of cervical cancer.
• Colposcopy: Clinical assessment (magnification x4-x25) viewing terminal vascular networks (punctation/mosaicism, bizarre shapes suggest malignancy).
• Colposcopic Tests:
  • Acetic Acid (3-5%): Coagulates nucleoproteins. High cell turnover areas (CIN) appear Acetowhite.
  • Schiller's Test (Lugol's Iodine): Normal glycogen-rich squamous cells stain dark brown. Premalignant cells lack glycogen and remain unstained (Schiller Positive).

• Low-grade (CIN 1): ~60% spontaneously regress without treatment via immune defense. Follow up with cytology/colposcopy at 6 months.
• High-grade (CIN 2/3): Requires treatment. 36% progress to cancer if untreated.
• LLETZ (Large Loop Excision of the Transformation Zone): The favored method using a diathermy wire loop under local anesthetic (takes 15 mins). Excision must be up to 10mm deep to remove deep crypt involvement. 95% effective. Large excisions risk preterm delivery (cervical weakness).
• Cold Coagulation: A hot probe (misnomer) destroys tissue but yields no histological specimen.
• Cone Biopsy: General anesthetic required, 5% risk of cervical stenosis/incompetence. Mostly superseded by LLETZ.

• Squamous Cell Carcinoma: 85-90%, arises from ectocervix (SCJ or metaplasia).
• Adenocarcinoma: 10-15%, arises from endocervical canal (lining or glands). Infiltrative, causes barrel-shaped cervix.
• Risk Factors: HPV, young age of first intercourse (<16 years), multiple partners, smoking, immunosuppression, high parity.
• Presentation: Can be asymptomatic (incidental on loop biopsy). Classic symptoms: Post-coital bleeding, intermenstrual/postmenopausal bleeding, blood-stained friable vascular vaginal discharge. Late stages involve pain (spinal cord infiltration), incontinence (Vesicovaginal fistulas), anemia, and uremia.

• Stage I: Confined to the cervix (83% 5-yr survival).
  • Ia: Microscopic (Ia1: ≤3mm depth, ≤7mm width; Ia2: >3mm to 5mm depth).
  • Ib: Clinical lesions (Ib1: ≤4cm; Ib2: >4cm).
• Stage II: Extends beyond cervix but NOT to pelvic sidewall or lower 1/3 of vagina (65% 5-yr survival).
  • IIa: Involves upper 2/3 of vagina.
  • IIb: Infiltrates the parametrium.
• Stage III: Extends to pelvic sidewall OR lower 1/3 of vagina (36% 5-yr survival).
  • IIIa: Lower 1/3 of vagina.
  • IIIb: Extends to pelvic wall, or causes hydronephrosis/non-functioning kidney.
• Stage IV: Extends beyond true pelvis or involves bladder/rectum mucosa (IVa) or distant metastasis (IVb) (10% 5-yr survival).

• Stage Ia: Excision/Cone biopsy (preserves fertility) or simple abdominal hysterectomy (if present in margins).
• Stage Ib - IIA: Radical Hysterectomy (Wertheim’s) + Pelvic Lymph Node dissection (removes uterus, upper vagina, parametrium). Complications: bladder/sexual dysfunction, lymphedema. Ovaries can be spared in premenopausal women.
• Radical Trachelectomy: Fertility-sparing alternative for early Ib1 (removes 80% cervix/parametrium). High mid-trimester miscarriage risk (40%).
• Stage IIB and above: Surgery is not suitable. Chemoradiation (External beam radiotherapy 45 Gy + Internal Brachytherapy + Cisplatin) is the standard. Brachytherapy uses selenium rods, targets 5mm radius.
• Major Causes of Death: Uremia (from bilateral ureteric obstruction/hydronephrosis is the leading cause), Hemorrhage, Sepsis, Cachexia, Metastases (Lung 36%, Lymph nodes 30%, Bone 16%).

• Contains Ethinylestradiol and a Progestogen. Acts primarily by inhibiting ovulation (suppresses FSH/LH). Failure rate 0.1-1 per 100 women years.
• Pill Types: Low-strength (20 µg), Standard (30-35 µg), High-strength (50 µg - obsolete). Third-generation progestogens (desogestrel, gestodene) have slightly higher thrombosis risk but better for acne/hirsutism.
• Non-contraceptive benefits: Controls heavy/painful periods, reduces Ovarian cancer risk (50%) & Endometrial cancer risk (40%) after 5 years, reduces functional cysts, improves acne/hirsutism, controls fibroids.
• Contraindications: Breastfeeding < 6 weeks postpartum, Smoking ≥15 cigs/day AND age ≥35, Migraine with aura, Hypertension (≥160/100), history of Deep Vein Thrombosis (DVT) / ischemic heart disease, Diabetes with severe vascular disease, Current breast cancer.
• Missed Pill Rules: 1 missed pill (<48h late): take ASAP, no backup needed. >2 missed pills (>48h): take most recent, use condom for 7 days. If missed in week 1: consider EC. If missed in week 3 (pills 15-21): omit the pill-free interval and start new pack.

• Ideal if estrogen is contraindicated. Mechanism: Thickens cervical mucus (hostile to sperm) and thins endometrium. High doses also inhibit ovulation.
• Progestogen-Only Pill (POP / Mini-pill): Must be taken at exact same time daily (>3 hours late reduces efficacy, except Desogestrel/Cerazette which is 3rd generation). May cause erratic bleeding and functional ovarian cysts. Failure rate 1-3.
• Injectables (Depo-Provera): 150mg medroxyprogesterone acetate every 12 weeks. High efficacy (0.1-2). Disadvantages: Delayed return of fertility (up to 18m), weight gain, risk of osteoporosis with long-term use (re-evaluate after 2 years).
• Subdermal Implant (Implanon): Etonogestrel rod in upper arm, lasts 3 years. Rapid return of fertility upon removal. Irregular bleeding in first year is common. Failure rate 0.1.

• Copper IUD: Toxic effect on sperm/egg prior to fertilization. Can cause heavier, more painful periods. Failure rate 1-2. Lasts up to 10 years.
• LNG-IUS (Mirena): Releases 52mg Levonorgestrel (20µg/day). Lasts 5 years. Causes endometrial atrophy resulting in dramatically lighter periods (or amenorrhea). Failure rate 0.5.
• Complications: Pelvic Inflammatory Disease (PID, highest risk in first 20 days - give azithromycin/doxycycline if suspected), Expulsion (1 in 20, often during menses in first 3 months), Perforation (0.3/1000 at insertion).
• Barrier Methods: Male condoms (failure 2-5), Diaphragms (failure 1-15, must be fitted by pro), Spermicides (Nonoxynol-9, high failure, frequent use may increase HIV risk).
• Natural Family Planning (NFP): Failure rate 2-3. Formula: First fertile day = shortest cycle minus 20. Last fertile day = longest cycle minus 10.

• Emergency Contraception (EC):
  • Levonorgestrel (Levonelle): 1.5mg single dose within 72 hours.
  • Ulipristal acetate (ellaOne): Progestogen receptor modulator, up to 120 hours.
  • Copper IUD: Most highly effective EC, inserted up to 5 days after ovulation or unprotected sex.
• Sterilization: Permanent. Female (clips, rings, Essure) failure 1/200. Male (Vasectomy) failure 1/2000.
• Vasectomy: Divides vas deferens. Not effective immediately; requires backup until 2 consecutive semen analyses at 12 & 16 weeks show azoospermia. Can cause sperm granulomas or anti-sperm antibodies (prevents reversal success).

• Lichen Sclerosus: Figure-of-8 white, shiny, "tissue paper" appearance around vulva/anus. Itchy, burns, leads to loss/fusion of labia minora. Autoimmune association (HLA-DQ7, thyroid, diabetes). Carries a 2% risk of Vulval Squamous Cell Carcinoma. Treat with potent topical steroids (Clobetasol propionate 0.05%).
• Lichen Planus: Purplish papules, white streaks (Wickham's striae), can cause severe desquamative vaginitis and ulcers. Also carries cancer risk.
• Vulval Dermatitis/Eczema: Erythema, no loss of architecture (no fusion of labia). Often due to irritants (soaps, creams). Treat by avoiding irritant + mild/moderate steroids + sedating antihistamine at night (Chlorphenamine 4mg).
• Vulvodynia/vestibulodynia: Dysaesthesia, neuropathic pain without specific cause. Treat with general care, local anesthetic, and Amitriptyline (start 10mg, increase to 80mg).

• VIN: Premalignant squamous dysplasia associated with HPV 16 (>90%). Present with itch. Multicentric. High recurrence rate (40-70%) after excision. Can use Imiquimod (immune modifier cream, stimulates T-helper cells, 2-3 times weekly for 12 weeks).
• Paget’s Disease of the Vulva: Non-mammary adenocarcinoma in situ. Presents as an eczematous, velvety, weeping lesion. Extends beyond clinical lesion, difficult to excise completely. Associated with rectal adenocarcinoma.
• Vulval Cancer: 90% are Squamous Cell Carcinoma (SCC) presenting in older women (median age 74). Often arise on background of Lichen Sclerosus or VIN. Surgery is the mainstay: Wide local excision (>1cm margin) + groin lymphadenectomy (via triple incision to reduce morbidity compared to en bloc butterfly incision).
• Sentinel lymph node biopsy: Uses blue dye/radiolabel. High recurrence if node is positive and only radiotherapy used, so full groin node dissection is required if sentinel node is positive.

• Benign cysts: Gartner's cysts (mesonephric remnants in fornices). Treat with marsupialization, not excision.
• Vaginal Intraepithelial Neoplasia (VAIN): Usually an extension of CIN. Hard to treat if buried under vaginal vault suture line post-hysterectomy (requires partial vaginal colpectomy).
• Clear Cell Adenocarcinoma: Rare, occurs in young women exposed to Diethylstilbestrol (DES) in utero (critical exposure in first 20 weeks of pregnancy).
• Sarcoma Botryoides (Rhabdomyosarcoma): Derived from rhabdomyoblasts. Presents as a multicystic "grape-like" mass protruding from the vagina in female infants <3 years. Treated with neoadjuvant chemotherapy (vincristine, dactinomycin, cyclophosphamide) + fertility-preserving surgery. 90% survival.

• Enhanced Recovery After Surgery (ERAS): Protocol includes pre-op carbohydrate loading, avoiding overnight fasting/dehydration, using Minimally Invasive Surgery (MIS) where possible, avoiding unnecessary tubes/drains, avoiding opiates, and ensuring early mobilization and early resumption of fluids/normal diet.
• Consent: A continuous process, not just signing a form. Mental capacity is required. All risks, success rates, and alternatives must be explained in an understandable language.
• Thromboprophylaxis: VTE risk assessment is mandatory. Moderate/High risk dictates TED stockings and Low Molecular Weight Heparin (LMWH).

• Pfannenstiel Incision: Transverse, 2 fingers above pubic symphysis. Strong, low dehiscence risk, cosmetic, less painful. Disadvantage: Limited upper abdominal access.
• Midline Incision: Vertical. Excellent access, easily extended. Disadvantage: Higher hernia/dehiscence risk, very painful.
• Sutures:
  • Multifilament (braided): Secure knot tying due to friction (needs fewer throws). Example: Silk, Polyglactin (Vicryl 21 days). Disadvantage: harbors bacteria (higher infection risk).
  • Monofilament: Less tissue reaction, lower infection risk. Examples: Poliglecaprone (Monocryl 7 days), Polydioxanone (PDS 28 days), Nylon, Polypropylene (Prolene).

• Hysterectomy Routes:
  • Abdominal: For large fibroids or suspected cancer. Best oncological access, but longest recovery/highest pain.
  • Vaginal: No abdominal scar, rapid recovery. Suitable for spinal anaesthesia. Often combined with prolapse surgery. Ovaries usually not removed.
  • Laparoscopic: Includes Total Laparoscopic Hysterectomy (TLH) and Subtotal (leaves cervix behind). Quick recovery but difficult in dense adhesions or large uterus.
• Colporrhaphy: Anterior repair for cystocele (risk of bladder injury/retention), posterior repair for rectocele (can improve obstructed defecation, risk of rectal injury).
• Transvaginal Tape (TVT) / Transobturator Tape (TOT): Mesh for stress incontinence. Currently suspended in UK due to severe mesh erosion, bladder damage, and chronic pain.
• LLETZ: Under local anesthetic for CIN. Complications include primary and secondary hemorrhage (from infection), and preterm delivery.
• Myomectomy: "Shelling out" fibroids to preserve the uterus for future pregnancy. Risk of adhesion formation, intra-operative hemorrhage, and uterine rupture in future pregnancies.