Endometriosis affects around 1 in 10 women. Tissue similar to the womb lining grows outside the uterus — on ovaries, fallopian tubes, bowel, and bladder. It responds to hormones each cycle, causing inflammation, scarring, and often severe pain.

Symptoms: Painful periods (dysmenorrhoea), pain during sex (dyspareunia), pelvic pain throughout the cycle, painful bowel movements or urination during a period, fatigue, and difficulty conceiving.

Treatment: Hormonal suppression (combined pill, progestogen-only pill, Mirena IUS, GnRH analogues — e.g. Prostap), laparoscopic surgery (excision or ablation of deposits), pain management (NSAIDs, co-codamol). There is no cure — treatment manages symptoms.

PCOS affects 1 in 10 women and is the most common hormonal condition in women of reproductive age. Diagnosis requires 2 of 3 criteria (Rotterdam): irregular/absent periods, raised androgens (clinical or biochemical), polycystic ovaries on ultrasound.

Features: Irregular or absent periods, acne, excess hair growth (hirsutism), thinning scalp hair, weight gain, difficulty conceiving. Long-term risks include type 2 diabetes and endometrial cancer (due to unopposed oestrogen from irregular cycles). Management: Combined pill (regulates cycle, reduces androgens), metformin (insulin resistance), lifestyle (weight loss restores ovulation in many), clomifene or letrozole for fertility.

Defined as blood loss ≥80mL per cycle, or bleeding that significantly impacts quality of life. Common causes: fibroids, adenomyosis, PCOS, endometrial polyps, or no identifiable cause (dysfunctional uterine bleeding).

Treatment options (NICE CG44): First-line — Mirena IUS (most effective medical treatment). Also: tranexamic acid (reduces loss by ~50%), NSAIDs, combined pill, norethisterone. Surgical options: endometrial ablation, myomectomy (for fibroids), hysterectomy.

PMS affects up to 40% of women — physical and emotional symptoms in the luteal phase (days 14–28) that resolve with menstruation. PMDD (Premenstrual Dysphoric Disorder) is a severe form causing disabling mood symptoms. Management: SSRIs (continuous or luteal-phase dosing — first-line for PMDD), combined pill (Yasmin/Eloine — drospirenone-containing), CBT. Referral to specialist PMS clinic if severe.

The NHS Cervical Screening Programme uses HPV primary screening. A sample of cells is taken from the cervix (smear). If high-risk HPV is detected, the sample is checked for abnormal cells. If HPV is not found, no further action is needed until the next routine screen.

HPV not detected: Routine recall at next screening interval — no further action.
HPV detected, no abnormal cells: Repeat smear in 12 months.
HPV detected + abnormal cells (CIN1/2/3): Referred for colposcopy.

CIN grading: CIN1 — mild changes, often clear spontaneously (watchful waiting). CIN2 — moderate changes, usually treated. CIN3 — severe changes (pre-cancer), always treated. CIN is NOT cancer — it means cells that could potentially develop into cancer if left untreated.

Colposcopy is a closer examination of the cervix using a magnifying instrument. A biopsy may be taken. Treatment for CIN2/3: LLETZ (Large Loop Excision of the Transformation Zone) — removes abnormal tissue under local anaesthetic, takes ~15 minutes. LLETZ is both diagnostic and curative in most cases. Follow-up smear at 6 months post-treatment, then annual for up to 10 years depending on result.

The NHS HPV vaccine (Gardasil 9) is offered to all Year 8 pupils (aged 12–13). It protects against HPV types 16, 18 (cause ~70% of cervical cancers), 31, 33, 45, 52, 58, and types 6 & 11 (genital warts). Vaccination does not replace screening — vaccinated women must still attend cervical screening.

NHS breast screening is offered every 3 years to women aged 50–71. Mammograms detect cancers too small to feel. Around 1 in 25 women screened are recalled for further assessment — most of these do NOT have cancer. Recall for further imaging (ultrasound, magnification views, biopsy) is not a diagnosis.

Women at higher risk (family history, BRCA gene) may be offered annual mammograms and/or MRI from age 30–40, arranged via a Familial Breast Cancer clinic.

BRCA1 and BRCA2 are tumour suppressor genes. Pathogenic variants significantly increase lifetime risk: BRCA1 — ~72% lifetime risk of breast cancer, ~44% ovarian cancer. BRCA2 — ~69% breast cancer, ~17% ovarian cancer (also increases male breast and prostate cancer risk).

Management options: Increased surveillance (annual MRI/mammogram), chemoprevention (tamoxifen or raloxifene), risk-reducing mastectomy (~90% risk reduction), risk-reducing salpingo-oophorectomy (also reduces ovarian cancer risk). Genetic counselling is offered before and after testing.

Breast cancer is the most common cancer in the UK — around 1 in 7 women will be diagnosed. Most (80%) are oestrogen-receptor positive (ER+) and respond to hormonal treatment (tamoxifen, aromatase inhibitors). Survival has improved dramatically — 85% survive 10+ years. HER2-positive and triple-negative cancers require targeted treatments (trastuzumab/Herceptin, chemotherapy).

Check breasts monthly — look and feel for: a new lump or thickening (especially if only on one side), change in size, shape, or outline, skin changes (dimpling, puckering, redness), nipple changes (inversion, discharge, rash), or pain in one area. Report anything new to your GP promptly — don't wait for your next screening appointment.

Non-cancerous growths within the muscle of the uterus. Found in up to 70% of women by age 50, though most cause no symptoms. More common in Black women (who also tend to present at a younger age with more severe symptoms).

Symptoms: Heavy/prolonged periods, pelvic pain or pressure, urinary frequency, bloating, fertility problems (depending on location). Treatment: Watchful waiting (if asymptomatic), Mirena IUS, ulipristal acetate (Esmya — note MHRA restrictions), uterine artery embolisation (UAE), myomectomy (removes fibroids, preserves uterus), hysterectomy.

The endometrial tissue (womb lining) grows into the muscle wall of the uterus. Causes a bulky, tender uterus. Symptoms mirror endometriosis: heavy painful periods, pelvic pain throughout the cycle. Often coexists with endometriosis. Definitive diagnosis is histological (from hysterectomy), though MRI is highly suggestive. Management: Hormonal suppression (Mirena IUS most effective), GnRH analogues, or ultimately hysterectomy.

Most ovarian cysts are functional (related to the normal ovulation cycle) and resolve spontaneously within 1–3 months. Persistent, large, or complex cysts require further assessment.

Risk of malignancy index (RMI) guides management. Benign-appearing cysts <5cm in premenopausal women: repeat ultrasound in 3 months. Suspicious features (solid areas, septations, bilateral, ascites): urgent 2-week wait gynaecology referral. Emergency: Sudden severe abdominal pain may indicate ovarian torsion — go to A&E immediately.

Affects up to 1 in 3 women. Includes: stress urinary incontinence (leaking on coughing/sneezing/exercise), urgency incontinence (overactive bladder), pelvic organ prolapse (bladder, uterus, or bowel descending into the vaginal canal). Treatment: Pelvic floor physiotherapy (first-line for most), bladder training, pessaries (for prolapse), surgical repair. Pelvic floor exercises (Kegels) are effective if done correctly — a physiotherapist can assess and teach proper technique.

AMH (Anti-Müllerian Hormone): Indicates ovarian reserve (the pool of remaining eggs). Can be measured at any point in the cycle. Low AMH suggests diminished reserve — relevant for IVF planning. Does not predict ability to conceive naturally.

Day 21 progesterone: Confirms ovulation has occurred (level >30 nmol/L is considered ovulatory in a 28-day cycle — adjust for cycle length).

HSG (Hysterosalpingography): X-ray with dye to check the uterine cavity and fallopian tubes for blockages. Performed as an outpatient procedure. Some women find it painful — take ibuprofen beforehand.

In-Vitro Fertilisation (IVF) involves: ovarian stimulation (gonadotrophin injections, ~10–14 days), egg collection (under sedation), fertilisation in the laboratory, embryo culture (3–5 days), and embryo transfer (fresh or frozen). NHS funding criteria vary by CCB/ICB — typically offered to women under 40 after 2 years of trying, up to 3 cycles.

Success rates (HFEA 2022): Under 35 — ~32% live birth rate per embryo transfer. 35–37 — ~25%. 38–39 — ~19%. 40–42 — ~11%. 43–44 — ~5%.

Start folic acid 400mcg daily at least 3 months before trying to conceive (5mg daily if previous NTD, on antiepileptics, diabetic, or BMI >30). Stop smoking and limit alcohol. Review all medications with your GP — some are teratogenic (methotrexate, warfarin, ACE inhibitors, valproate). Achieve a healthy BMI (19–30) if possible — obesity significantly reduces fertility and increases pregnancy complications. Ensure rubella immunity is confirmed before conception.

1. Ovarian stimulation (10–14 days): Daily self-injections of gonadotrophin hormones stimulate the ovaries to produce multiple follicles. Regular monitoring scans and blood tests track progress. The dose may be adjusted as you respond.

2. Egg collection: Done under sedation or light general anaesthetic. A fine needle guided by ultrasound passes through the vaginal wall to aspirate follicles. Takes 20–30 minutes. Cramping and spotting are normal afterwards. Rest is advised for the remainder of the day.

3. Fertilisation: Eggs and sperm are combined in the laboratory (IVF) or a single sperm is injected directly into each egg (ICSI). The lab will call the next day with a fertilisation report. Not all eggs will fertilise — this is normal.

4. Embryo development: Embryos are cultured for 3–6 days. Many clinics culture to blastocyst stage (day 5–6) as this allows better embryo selection. Not all fertilised eggs will reach blastocyst — further attrition at every stage is expected and normal.

5. Embryo transfer: One (or occasionally two) embryos are placed in the uterus via a thin catheter — similar to a smear test. No anaesthetic needed. Remaining suitable embryos are frozen (vitrified) for future use.

6. The two-week wait: The hardest part for most people. Progesterone support (pessaries, injections, or gel) is taken to support implantation. A pregnancy test is taken 9–14 days after transfer. This period can be intensely anxious — this is a completely normal response to an incredibly high-stakes wait.

IVF: Eggs and sperm are placed together in a dish and fertilisation happens naturally. Used when sperm quality is sufficient and there are no fertilisation failure concerns. ICSI: A single sperm is selected and injected directly into each egg using a micro-needle. Used for male factor infertility, previous fertilisation failure, low egg yield, or frozen/surgically retrieved sperm. ICSI does not improve pregnancy rates over IVF when sperm quality is normal — it is not automatically "better."

NICE guidelines recommend up to 3 full cycles of IVF on the NHS for women under 40 who have been trying to conceive for 2 years (or 12 failed IUI cycles). Women aged 40–42 may be offered 1 cycle if certain criteria are met. In practice, NHS funding varies enormously by ICB (Integrated Care Board) — some areas fund 3 cycles, others fund 1 or none.

A frozen embryo transfer (FET) using embryos created during a funded cycle is usually also funded. Check your local ICB policy or ask your GP for a referral to a fertility clinic for a funding assessment. Fertility Network UK (fertilitynetworkuk.org) provides up-to-date local funding information.

OHSS occurs when the ovaries over-respond to stimulation — fluid leaks from blood vessels into the abdomen. Mild OHSS (bloating, mild discomfort) is common and self-limiting. Severe OHSS (breathing difficulty, severe abdominal pain, reduced urination, rapid weight gain) is rare but serious — seek urgent medical attention.

Risk factors: PCOS, previous OHSS, young age, low AMH (paradoxically — very high response possible), large number of follicles. In high-risk women, clinics may freeze all embryos (freeze-all cycle) and transfer in a later natural or medicated FET cycle — this completely prevents severe OHSS.

A negative IVF result is a genuine bereavement — not an overreaction. The grief is real, the loss is real, and the physical and hormonal crash after a failed cycle is real. There is no right way to feel. You do not need to "stay positive" or "stay strong." Allow yourself to grieve.

Miscarriage after IVF is not more common than natural conception — the rates are similar. But it can feel more devastating when so much effort, money, and hope went into getting there. The Miscarriage Association (miscarriageassociation.org.uk, 01924 200799) offers support specifically for loss after fertility treatment.

Support resources: Fertility Network UK (fertilitynetworkuk.org) — patient charity, forums, local groups. Infertility Network UK helpline: 0800 008 7464. The Fertility Counsellors Register (BICA) can help find a specialist fertility counsellor. Many clinics offer counselling as part of treatment — you are entitled to ask for it.

Embryos can be stored for up to 55 years under UK law (extended from 10 years in 2022 — HFEA amendment). Annual storage fees apply — typically £200–£400/year at private clinics. NHS clinics may cover storage costs during the funded treatment period.

Important: You will be asked to renew consent annually. If you do not renew, the clinic must contact you before taking any action. Keep your contact details up to date with your storage clinic. If your relationship status changes (separation, divorce), both partners' consent may be required to use the embryos — discuss this with your clinic in advance.

Combined screening (11–14 weeks): NT ultrasound + blood tests (PAPP-A, free beta-hCG) — calculates risk of trisomy 21 (Down's), 18 (Edwards'), and 13 (Patau's). A high-risk result (typically >1:150) is offered diagnostic testing.

NIPT (Non-Invasive Prenatal Testing): Analyses cell-free foetal DNA in maternal blood. Highly accurate (>99% sensitivity for T21) but is a screening test, not diagnostic. Available via NHS (England 2023) following high-risk combined screening result, or privately.

Diagnostic tests: Amniocentesis (16+ weeks) or CVS (chorionic villus sampling, 11–14 weeks) — give definitive chromosomal diagnosis but carry ~0.5–1% miscarriage risk.

Pre-eclampsia: High blood pressure + proteinuria after 20 weeks. Symptoms: severe headache, visual disturbances, epigastric pain, sudden oedema. Can progress to eclampsia (seizures) — medical emergency. Women at high risk are offered aspirin 150mg daily from 12 weeks.

Gestational diabetes (GDM): Glucose intolerance first identified in pregnancy. Diagnosed by OGTT (oral glucose tolerance test) at 24–28 weeks if risk factors present. Increases risk of macrosomia, shoulder dystocia, stillbirth. Managed with diet, metformin, or insulin. Usually resolves after birth — but increases lifetime T2DM risk.

Obstetric cholestasis: Liver condition causing intense itching (especially palms/soles) without rash. Raised bile acids — increases risk of stillbirth. Managed with ursodeoxycholic acid; elective delivery usually offered at 37 weeks.

Epidural: Most effective pain relief — local anaesthetic infused into the epidural space. Requires anaesthetist. May slow labour and increase instrumental delivery rate. Gas & air (Entonox): 50% nitrous oxide/oxygen — takes the edge off, no effect on baby, but can cause nausea/dizziness. Diamorphine/pethidine: IM opioid — may cause nausea and can affect baby's breathing if given close to delivery (reversed with naloxone). TENS: Electrical stimulation — works best in early labour. Warm water/pool: Effective for pain and relaxation in established labour.

Around 1 in 4 confirmed pregnancies end in miscarriage — the majority in the first 12 weeks. Most are caused by chromosomal abnormalities in the embryo and are not caused by anything the parent did. After 3 or more miscarriages (recurrent miscarriage), NHS investigation is offered.

Management options: Expectant (wait for natural passage), medical (misoprostol pessaries), surgical (ERPC — evacuation of retained products of conception, under general anaesthetic). All are equally safe — choice depends on gestational age, medical history, and personal preference.

Medical emergency if ruptured. The fertilised egg implants outside the uterus — usually in a fallopian tube. Symptoms: one-sided pelvic pain, vaginal bleeding, shoulder tip pain (if internal bleeding). Ruptured ectopic causes collapse — call 999. Treatment: methotrexate injection (if unruptured, hCG <3000, no fetal heartbeat), salpingostomy or salpingectomy (surgical, laparoscopic). One previous ectopic increases risk of recurrence to ~10%.

Defined as loss of a baby at or after 24 weeks gestation. Around 1 in 250 pregnancies in the UK. Causes include placental problems, infections, fetal abnormalities, and umbilical cord complications — in many cases, no cause is found. Reducing movement should always be reported promptly — never wait until the next day. Bereavement support is available via SANDS (stillbirth and neonatal death charity) — 0808 164 3332.

Menopause is confirmed after 12 consecutive months without a menstrual period. The average age in the UK is 51. Perimenopause (the transition) typically begins 4–8 years before the last period. Over 30 symptoms have been identified — including vasomotor symptoms (hot flushes, night sweats), psychological symptoms (anxiety, low mood, brain fog), and genitourinary symptoms (vaginal dryness, UTIs).

Premature Ovarian Insufficiency (POI): Menopause before age 40 — affects ~1% of women. Requires HRT until at least the average age of menopause (51) to protect bone density and cardiovascular health, regardless of symptoms.

Oestrogen protects bone density. After menopause, bone loss accelerates — women can lose up to 20% of bone density in the 5–7 years after menopause. Osteoporosis (T-score ≤ −2.5 on DEXA) significantly increases fracture risk.

Prevention: HRT (most effective in early menopause), weight-bearing exercise, calcium (1000mg/day from diet), vitamin D (400–800IU/day). Treatment: Bisphosphonates (alendronate 70mg weekly — first-line), denosumab, raloxifene, romosozumab. DEXA scan offered to high-risk women — use FRAX tool to estimate 10-year fracture risk.

GSM (formerly called vaginal atrophy) affects up to 50% of postmenopausal women and does not improve without treatment — unlike vasomotor symptoms, which may ease over time. Symptoms: vaginal dryness, soreness, painful sex, recurrent UTIs, urinary urgency. Treatment: Vaginal oestrogen (pessaries, cream, ring — e.g. Vagifem, Estriol cream, Vagirux ring) is safe even for most women who cannot take systemic HRT, including many breast cancer survivors. Can be used long-term.

The risks of HRT were significantly overstated by the 2002 WHI study (which used oral conjugated equine oestrogen + medroxyprogesterone acetate). Current evidence (NICE NG23, BMS guidance) shows that body-identical HRT (transdermal oestradiol + micronised progesterone/Utrogestan) carries no increased risk of VTE and a significantly lower (possibly neutral) breast cancer risk compared to older synthetic progestogens.

Transdermal oestrogen (patches, gel, spray) does not increase clot (DVT/PE) risk — unlike oral oestrogen. This is important for women with a history of VTE or at elevated cardiovascular risk.

Sequential (cyclical) HRT: Oestrogen daily + progestogen for 12–14 days/month — causes a monthly withdrawal bleed. Used in perimenopause / within 1 year of last period.

Continuous combined HRT: Oestrogen + progestogen daily — no bleed. Used once confirmed postmenopausal (12+ months since last period). Initial irregular spotting may occur for 3–6 months.

Testosterone: Licensed for women with low libido not responding to HRT. Applied as a small daily amount to the inner thigh or abdomen. Levels should be monitored to remain within the female physiological range.

Absolute contraindications include: oestrogen-sensitive cancers (e.g. ER+ breast cancer — specialist advice needed, vaginal oestrogen may still be appropriate), unexplained vaginal bleeding, active liver disease, untreated endometrial hyperplasia, and pregnancy. HRT is not a contraceptive — contraception is needed until 2 years after the last period if under 50, or 1 year if over 50.

A chronic inflammatory skin condition affecting the vulva (and sometimes anus). Causes white, thinned, fragile skin with itching, soreness, fissuring, and — if untreated — architectural changes (loss of labia minora, burying of the clitoris). Can occur at any age but most common post-menopause and in girls before puberty.

Diagnosis: Clinical (by specialist), confirmed by biopsy if uncertain. Treatment: Ultra-potent topical steroid (clobetasol propionate 0.05%) — applied as directed (typically daily for 4 weeks, then tapering). This is a long-term condition requiring ongoing management — not a cure, but symptoms are well-controlled with regular treatment. Annual review to check for VIN (pre-cancerous changes).

Important: Untreated LS carries a small (~4%) lifetime risk of vulval squamous cell carcinoma. Report any persistent ulcers, lumps, or new lesions promptly.

Vulvodynia is chronic vulval pain lasting 3+ months with no identifiable cause. Vestibulodynia (vulvar vestibulitis) is pain specifically at the vaginal opening (vestibule) triggered by touch or pressure. Both are real, recognised conditions — not "in the mind" — and affect up to 8% of women.

Management: Pelvic floor physiotherapy (most effective — addresses muscle hypertonicity), topical lidocaine (short-term), low-dose tricyclic antidepressants or gabapentin (neuropathic pain), CBT, psychosexual therapy. A multidisciplinary approach gives the best outcomes. Avoid soap and scented products — use emollient wash (Dermol, Cetraben) and unperfumed moisturiser.

Recurrent vulvovaginal candidiasis (thrush): 4+ episodes per year. Confirmed by swab culture before starting prophylactic treatment — not all itching is thrush. Prophylaxis: oral fluconazole 150mg weekly for 6 months (BASHH guideline). Identify and address triggers: antibiotics, tight synthetic clothing, diabetes, immunosuppression.

Bacterial vaginosis (BV): Most common cause of vaginal discharge in women of reproductive age — caused by imbalance of vaginal flora (not an STI). Characteristic fishy odour, thin grey-white discharge, high vaginal pH. Treatment: metronidazole 400mg BD for 5 days, or metronidazole 2g single dose. Recurrent BV: intravaginal lactic acid gel (Balance Activ), intravaginal boric acid (unlicensed), prophylactic metronidazole gel twice weekly.

Involuntary spasm of the pelvic floor muscles making penetration painful or impossible. Can be lifelong (primary) or develop after a period of pain-free sex (secondary — often following LS, vulvodynia, trauma, or childbirth). Highly treatable: graded vaginal trainers (dilators) combined with pelvic floor physiotherapy and psychosexual therapy. Success rates are high with a supported programme — this is not a permanent condition.

STI testing is free on the NHS and confidential. You can attend a GUM (genitourinary medicine) clinic without a GP referral. Many areas also offer free home test kits by post — order via SH:24 or your local sexual health service. Annual testing is recommended for anyone who is sexually active with more than one partner, and after any unprotected sex with a new partner.

Standard screen includes: Chlamydia, gonorrhoea (throat, genital, anal), syphilis, HIV, hepatitis B and C. Herpes is not routinely screened — diagnosis is usually clinical or by swab of an active lesion.

Modern antiretroviral therapy (ART) suppresses HIV to undetectable levels in the blood. Someone with an undetectable viral load (<200 copies/mL) cannot transmit HIV sexually — this is proven by major clinical trials (PARTNER, PARTNER2, Opposites Attract). Life expectancy on effective ART is comparable to the general population.

For clinicians: Standard infection control precautions apply for all patients regardless of HIV status. Disclosure of HIV status is the patient's choice — it does not change routine care for most procedures. HIV is not a contraindication to surgery, immunotherapy, or most treatments.

Affects around 1 in 8 adults in the UK — most don't know they have it. HSV-1 (typically oral) and HSV-2 both cause genital herpes. After the primary episode, the virus lies dormant and may reactivate. Recurrences become less frequent over time for most people.

Treatment: Aciclovir or valaciclovir reduce severity and duration of outbreaks. Daily suppressive therapy (valaciclovir 500mg daily) reduces frequency by ~70–80% and reduces transmission risk. Herpes is very common and manageable — it does not affect long-term health for most people.

Chlamydia — most common STI in the UK. Often asymptomatic. If untreated, can cause pelvic inflammatory disease (PID), fallopian tube scarring, and fertility problems. Treat with doxycycline 100mg BD for 7 days (first-line) — single dose azithromycin no longer recommended (BASHH 2023). Gonorrhoea — increasing antibiotic resistance means treatment must be guided by culture sensitivity. Current first-line: ceftriaxone 1g IM single dose. Test-of-cure 2 weeks post-treatment is essential.

UTIs are the most common bacterial infection in women — around 50% of women will have at least one in their lifetime. Women are more susceptible due to a shorter urethra. Common symptoms: burning on urination, frequency, urgency, cloudy or smelly urine, pelvic discomfort. Fever, loin pain, and rigors suggest kidney involvement (pyelonephritis) — seek urgent medical attention.

Recurrent UTIs (3+ per year): A urine culture (not just a dipstick) should be sent to identify the organism and sensitivity before each treatment course. NICE NG112 supports self-start antibiotics for women who can reliably identify their symptoms. Low-dose prophylaxis (nitrofurantoin or trimethoprim at night) or post-coital single dose is effective. Vaginal oestrogen significantly reduces recurrence in postmenopausal women — often overlooked.

OAB affects around 1 in 6 adults — defined as urgency (sudden compelling urge to urinate) with or without urge incontinence. Not the same as stress incontinence (leaking on coughing/exercise). Many women have mixed incontinence (both types).

Management: First-line — bladder training (increasing intervals between voids), pelvic floor physiotherapy, fluid management (reduce caffeine, alcohol, carbonated drinks). Second-line — anticholinergics (solifenacin, tolterodine) or beta-3 agonist (mirabegron — fewer dry mouth side effects). Third-line — botulinum toxin bladder injection (under cystoscopy), sacral nerve stimulation.

A chronic condition causing bladder pain, pressure, and urgency without infection. Often misdiagnosed as recurrent UTIs — if cultures keep coming back negative but symptoms persist, IC should be considered. Affects women far more than men. Diagnosis is by exclusion (cystoscopy, urine culture, symptom history). Management: dietary triggers (caffeine, citrus, alcohol, spicy food), pentosan polysulfate sodium (Elmiron), bladder installations, pain management, physiotherapy. The Interstitial Cystitis Association (ichelp.org) is a useful resource.

Visible blood in urine (frank haematuria) should always be investigated urgently — refer via 2-week wait pathway to rule out bladder cancer, kidney cancer, or other serious causes. Non-visible haematuria (dipstick positive, no symptoms) in women under 40 is usually benign (menstruation, vigorous exercise) but persistent cases in those over 40 warrant investigation. Do not assume recurrent UTI without a urine culture — persistent symptoms with negative cultures need further assessment.

Mirena IUS (hormonal coil): >99% effective, lasts 5–8 years (licensed 5 years for contraception, 8 years off-label for perimenopausal women using it as the progestogen component of HRT). Reduces or stops periods. Best medical treatment for heavy periods. Insertion takes ~5 minutes — can be uncomfortable. Fertility returns immediately on removal.

Copper IUD: >99% effective, lasts 5–10 years (10-year device also licensed as emergency contraception if fitted within 5 days of unprotected sex). Completely hormone-free. May worsen periods, especially in the first 3–6 months. Fertility returns immediately on removal.

Implant (Nexplanon): >99% effective, lasts 3 years. Small rod inserted under the skin of the upper arm under local anaesthetic. Most common side effect: irregular bleeding (unpredictable, can be frequent). Fertility returns quickly after removal.

The COCP is safe for the vast majority of women under 35 who don't smoke. It is absolutely contraindicated in: migraine with aura (increases stroke risk), personal history of VTE (DVT/PE), current or past breast cancer, liver disease, uncontrolled hypertension, and in smokers over 35.

VTE risk: Third- and fourth-generation pills (drospirenone — Yasmin/Eloine; gestodene; desogestrel) carry a higher VTE risk than second-generation (levonorgestrel — Microgynon, Rigevidon). All COCPs increase VTE risk 3–4× compared to non-users — but absolute risk remains very low in healthy women. Progestogen-only methods do not increase VTE risk.

Contraception is needed until 2 years after the last period if under 50, and 1 year after the last period if over 50. HRT is NOT a contraceptive — women on HRT still need contraception if they could conceive. The Mirena IUS can serve double duty: it provides the progestogen component of HRT whilst also acting as contraception. The combined pill can mask menopausal symptoms and mask the last period — making it harder to know when menopause has occurred; switching to progestogen-only methods at 50 is often advised.

Levonorgestrel (Levonelle): Up to 72 hours — effective if taken promptly (most effective within 12 hours). Available free from GP, sexual health clinic, or pharmacy. Ulipristal acetate (ellaOne): Up to 120 hours (5 days) — more effective than levonorgestrel, especially taken later. Available from GP or pharmacy (prescription required on NHS). Copper IUD: Most effective emergency contraception (>99%) — can be fitted up to 5 days after unprotected sex or 5 days after earliest likely ovulation. Also provides ongoing contraception for up to 10 years.

Hypothyroidism (underactive thyroid) affects around 2% of the UK population — the vast majority women. The most common cause is Hashimoto's thyroiditis, an autoimmune condition where the immune system attacks the thyroid gland. Symptoms develop gradually: fatigue, weight gain, feeling cold, constipation, dry skin, hair thinning, low mood, brain fog, heavy periods.

Diagnosis: TSH is the primary screening test. A raised TSH (above ~4.5 mIU/L) with low or low-normal Free T4 confirms hypothyroidism. TSH alone can be normal in the early stages of Hashimoto's — TPO antibodies confirm autoimmune cause. Treatment: Levothyroxine (T4) — taken on an empty stomach, 30–60 minutes before food. Target TSH is 0.5–2.5 mIU/L for most people on treatment (NICE guidance).

Persistent symptoms despite normal TSH: A significant minority of people on levothyroxine continue to have symptoms despite a "normal" TSH. Options include: optimising TSH to the lower end of the range, trialling combination T4+T3 therapy (liothyronine — available on NHS in some areas), or switching to NDT (natural desiccated thyroid — less commonly prescribed). This remains a debated area — specialist referral is recommended if symptoms persist.

Hyperthyroidism (overactive thyroid) causes: weight loss despite good appetite, palpitations, tremor, anxiety, heat intolerance, sweating, diarrhoea, and irregular periods. Graves' disease (autoimmune) is the most common cause — may also cause eye disease (Graves' ophthalmopathy) and skin changes.

Treatment options: Antithyroid drugs (carbimazole — first-line in the UK; PTU in pregnancy first trimester), radioiodine (RAI — most commonly leads to hypothyroidism, then lifelong levothyroxine), or thyroidectomy. Beta-blockers (propranolol) control palpitations and tremor while awaiting response to treatment. Many patients achieve remission on antithyroid drugs alone after 12–18 months.

Thyroid function changes significantly in pregnancy — TSH targets are lower (under 2.5 mIU/L in the first trimester). Women on levothyroxine often need a dose increase of 25–50mcg as soon as pregnancy is confirmed. Uncontrolled hypothyroidism in pregnancy increases risk of miscarriage, premature birth, and neurodevelopmental problems in the baby.

Important: If you are on levothyroxine and become pregnant, contact your GP immediately to have your dose reviewed. TSH should be checked every 4–6 weeks in the first half of pregnancy. Post-partum thyroiditis (temporary thyroid inflammation after childbirth) affects ~5–10% of women — causing a transient hyperthyroid phase followed by hypothyroidism before usually recovering.

Take on an empty stomach, 30–60 minutes before breakfast (or at bedtime, at least 4 hours after the last meal). Do not take with: calcium supplements, iron tablets, antacids, or dairy — all reduce absorption significantly. Take at least 4 hours apart from these. Consistency matters — take it at the same time every day. If you miss a dose, take it when you remember (same day) or double up the next day if you forget entirely. Do not split tablets unless prescribed — brand consistency can matter for some patients (do not switch between brands without GP advice).