Gynaecology: Fertility Contraception Menopause

💊 Menopause, fertility and contraception -these are everyday topics across a woman's life. Most menopausal women benefit from HRT if they choose it, and its risks are small for most women under 60. About 1 in 7 couples have difficulty conceiving. Long-acting reversible contraception (implant, IUD, IUS) is the most effective, and the UKMEC criteria help you choose safely.
Your four questions for every patient: What does she want -symptom relief, a pregnancy, or to avoid one? Are there contraindications (UKMEC, VTE, breast cancer, migraine with aura)? Is she or could she be pregnant? What will she find acceptable and use well?

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The Menopause

• Definitions:
  • Menopause -the last period, confirmed after 12 months without one. Average age 51 in the UK.
  • Perimenopause -the years of changing cycles and symptoms before and up to 12 months after the last period.
  • Premature ovarian insufficiency -menopause before 40; early menopause -40–45.
• Symptoms:
  • Vasomotor -hot flushes and night sweats (most women; median about 7 years).
  • Mood -low mood, anxiety, irritability; poor sleep; "brain fog" and poor concentration.
  • Genitourinary syndrome of menopause -vaginal dryness, painful sex, urinary frequency and urgency, recurrent UTIs.
  • Joint and muscle aches; low libido; changes in periods (irregular, heavier or lighter).
• Long-term effects of low oestrogen -osteoporosis, increased cardiovascular risk.
• Diagnosis (NICE NG23):
  • Age over 45 with typical symptoms -diagnose clinically; no blood tests needed.
  • FSH -consider if aged 40–45 with symptoms; use for suspected POI under 40. (FSH is unreliable on combined hormonal contraception or high-dose progestogens.)
• Contraception is still needed -until 1 year after the last period if over 50, or 2 years if under 50; or until age 55. HRT is not contraceptive.

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HRT -Choosing and Using

• Oestrogen treats symptoms. Women with a womb need a progestogen as well, to protect the endometrium from hyperplasia and cancer.
• Types:
  • No womb (after hysterectomy) -oestrogen only.
  • With a womb -combined HRT:
    • Sequential (cyclical) -oestrogen every day, progestogen for 10–14 days a month -a monthly bleed. For perimenopausal women (periods within the last 12 months).
    • Continuous combined -both every day, no bleed. For postmenopausal women (over 12 months since the last period, or after 1 year of sequential HRT). Irregular bleeding is common in the first 3–6 months.
• Routes:
  • Oestrogen -tablets, transdermal patches, gel or spray. Transdermal doesn't raise VTE risk -preferred if BMI over 30, VTE risk factors, migraine, or on enzyme-inducing drugs.
  • Progestogen -micronised progesterone (Utrogestan -lower breast cancer and VTE risk than synthetic progestogens), oral synthetic progestogens, or the LNG-IUS (Mirena -also gives contraception; licensed for 5 years for endometrial protection).
  • Tibolone -a synthetic steroid with combined effects (postmenopausal women).
• Starting -lowest dose that controls symptoms; review at 3 months, then yearly. There's no fixed time limit; individualise.
• Side effects -breast tenderness, nausea, headaches, bloating, irregular bleeding (usually settle in 3 months).
• Unscheduled bleeding on HRT (after the first 3–6 months, or after a period of no bleeding) -refer to exclude endometrial cancer.
• Testosterone -consider for low libido if HRT alone doesn't help (specialist, off-label for women).
• Contraindications -current or past breast cancer (or other oestrogen-sensitive cancer), undiagnosed vaginal bleeding, untreated endometrial hyperplasia, active VTE or arterial disease (oral), active liver disease, pregnancy.

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HRT Benefits and Risks

Outcome	Effect (for women starting around the menopause)
Symptoms	Most effective treatment for flushes, sweats, mood and sleep; vaginal symptoms
Bone	Reduces osteoporosis and fractures while taken
Breast cancer	Combined HRT -small increase, related to duration, falls after stopping. Oestrogen-only -little or no increase. Micronised progesterone may carry less risk
VTE	Oral oestrogen raises risk; transdermal does not (at standard doses)
Stroke	Small increase with oral oestrogen (low baseline risk under 60); not with transdermal
Heart disease	No increase if started under 60 (may reduce it)
Endometrial cancer	Raised with oestrogen alone in women with a womb -prevented by adequate progestogen
Ovarian cancer	Very small increase
Dementia	Not shown to prevent or cause it when started around the menopause

• For most women under 60 (or within 10 years of menopause), the benefits outweigh the risks.
• Use tools such as decision aids and discuss individual risk (breast cancer family history, BMI, VTE).

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Non-hormonal Options and Vaginal Symptoms

• Lifestyle -regular exercise, weight loss, cool environment, layered clothing, reduce caffeine, alcohol and spicy food, stop smoking.
• CBT -helps flushes, low mood, anxiety and sleep (NICE).
• Non-hormonal drugs for vasomotor symptoms (when HRT is unsuitable, e.g. after breast cancer):
  • SSRIs or SNRIs (e.g. venlafaxine, citalopram) -avoid fluoxetine and paroxetine with tamoxifen (they reduce its effect).
  • Gabapentin; clonidine.
  • Neurokinin-3 receptor antagonists (e.g. fezolinetant) -newer licensed options; check current NICE status.
• Complementary therapies (black cohosh, isoflavones) -limited evidence; interactions and quality concerns.
• Genitourinary syndrome of menopause:
  • Vaginal oestrogen (cream, pessary, ring) -safe long term, no progestogen needed; can be used alongside systemic HRT.
  • Vaginal moisturisers and lubricants.
  • Ospemifene; vaginal DHEA (prasterone).
  • After breast cancer -non-hormonal first; vaginal oestrogen after discussion with the oncology team.
• Bone health -calcium, vitamin D, weight-bearing exercise; FRAX assessment; bisphosphonates if indicated (see the Bone Medicine chapter).

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Premature Ovarian Insufficiency

• Definition -loss of ovarian function before 40; affects about 1 in 100 women under 40.
• Diagnosis -irregular or absent periods for 4 months or more plus raised FSH (over 25 IU/L on two samples at least 4 weeks apart).
• Causes:
  • Idiopathic (most).
  • Autoimmune -with thyroid disease, Addison's, type 1 diabetes, coeliac disease.
  • Genetic -Turner syndrome, fragile X premutation (FMR1).
  • Iatrogenic -chemotherapy, pelvic radiotherapy, surgery (oophorectomy).
  • Infections (mumps, TB); galactosaemia.
• Tests -karyotype, fragile X, thyroid and adrenal antibodies, TFTs, DEXA scan.
• Management:
  • Hormone replacement until at least the average age of menopause (51) -HRT or combined hormonal contraception -to protect bone, heart and brain, as well as treat symptoms. (The usual HRT breast cancer risk data don't apply -it is replacing normal hormones.)
  • Fertility -spontaneous pregnancy still possible in about 5–10% (contraception if needed); egg donation IVF is the main option.
  • Psychological support; bone and cardiovascular monitoring.
• Fertility preservation (egg, embryo or ovarian tissue freezing) before cancer treatment.

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Subfertility -Assessment

• Definition -failure to conceive after 1 year of regular unprotected sex (every 2–3 days). About 80% of couples conceive within a year, and 90% within 2 years.
• Refer earlier (NICE CG156) if:
  • Woman aged 36 or over.
  • Known cause -irregular or absent periods, previous PID or pelvic surgery, endometriosis, undescended testes, previous chemotherapy.
• Causes (roughly):
  • Male factor -about 30%.
  • Ovulation disorders -about 25% (mostly PCOS).
  • Tubal damage -about 20%.
  • Unexplained -about 25%.
  • Endometriosis; uterine problems.
  • Often more than one factor.
• Advice for both partners:
  • Folic acid 400 micrograms (5 mg if indicated) for the woman.
  • Healthy weight -BMI 19–30 for the woman (fertility treatment may not be offered over 30–35); weight loss improves ovulation in PCOS.
  • Stop smoking; limit alcohol (up to 1–2 units once or twice a week for women; within limits for men).
  • Avoid recreational drugs and anabolic steroids; loose underwear; avoid heat for testes.
  • Check rubella immunity and cervical screening.
• Initial tests:
  • Woman -mid-luteal progesterone (7 days before the expected period -over 30 nmol/L confirms ovulation); FSH and LH (if irregular cycles); prolactin and TFTs if symptoms; chlamydia test; AMH or antral follicle count (ovarian reserve).
  • Man -semen analysis (repeat after 3 months if abnormal; sooner if severe).
  • Tubal patency -hysterosalpingography (HSG) or HyCoSy (ultrasound) if no known pelvic disease; laparoscopy and dye if known risk (endometriosis, previous PID).

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Female Causes and Treatment

• Ovulation disorders (WHO groups):
  • Group I -hypothalamic–pituitary failure (low FSH, LH and oestrogen: low weight, excess exercise, Kallmann syndrome) -restore weight; pulsatile GnRH or gonadotrophins.
  • Group II -hypothalamic–pituitary–ovarian dysfunction (normal FSH and oestrogen: mainly PCOS) -weight loss; letrozole or clomifene (with ultrasound monitoring -multiple pregnancy risk); metformin; laparoscopic ovarian drilling; gonadotrophins; IVF.
  • Group III -ovarian failure (high FSH: POI) -egg donation.
  • Hyperprolactinaemia -dopamine agonists (cabergoline, bromocriptine).
  • Thyroid disease -treat.
• Tubal disease (from PID, previous ectopic, surgery, endometriosis):
  • Tubal surgery for some; IVF for most.
  • Hydrosalpinx -remove or clip before IVF (fluid reduces success).
• Endometriosis -surgical treatment of endometriosis may help; IVF.
• Uterine problems -submucosal fibroids, polyps, septum, adhesions -hysteroscopic surgery.
• Age -the most important factor; fertility falls from the early 30s and more steeply after 37.
• Unexplained subfertility -try for 2 years in total, then IVF (NICE doesn't recommend clomifene for unexplained subfertility).

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Male Factor Subfertility

• Semen analysis (WHO 2021 lower reference limits -approximately):
  • Volume 1.4 mL or more.
  • Concentration 16 million/mL or more.
  • Total motility 42% or more; progressive motility 30% or more.
  • Normal forms 4% or more.
• Causes:
  • Testicular -undescended testes, mumps orchitis, trauma, torsion, chemotherapy or radiotherapy, varicocele, Klinefelter syndrome (47,XXY -small firm testes, azoospermia, gynaecomastia), Y chromosome microdeletions.
  • Hormonal -hypogonadotrophic hypogonadism (Kallmann), high prolactin, anabolic steroids and testosterone use (suppress sperm production).
  • Obstructive -vasectomy, infection (epididymitis), congenital absence of the vas deferens (cystic fibrosis gene variants).
  • Erectile or ejaculatory dysfunction; retrograde ejaculation (diabetes, prostate surgery, alpha-blockers).
  • Drugs and lifestyle -sulfasalazine, smoking, alcohol, obesity, cannabis, heat.
• Tests -FSH, LH, testosterone, prolactin; karyotype and Y microdeletion (severe oligospermia or azoospermia); CF testing (absent vas); scrotal ultrasound.
• Treatment:
  • Stop anabolic steroids and testosterone; lifestyle.
  • Gonadotrophins for hypogonadotrophic hypogonadism.
  • ICSI (intracytoplasmic sperm injection) -for severe male factor; surgical sperm retrieval if azoospermia.
  • Donor sperm.
• Sperm banking before cancer treatment.

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IVF and Assisted Conception

• Intrauterine insemination (IUI) -prepared sperm placed in the womb: for donor sperm, same-sex couples, people unable to have vaginal sex.
• In vitro fertilisation (IVF):
  • Ovarian stimulation (injections of FSH) with a GnRH agonist or antagonist to prevent early ovulation.
  • Trigger (hCG or GnRH agonist), then egg collection by transvaginal needle under sedation.
  • Fertilisation in the lab (or ICSI), embryo culture, then embryo transfer (usually a single embryo to avoid twins).
  • Spare embryos can be frozen.
• NHS access (NICE CG156) -women under 40: up to 3 full cycles after 2 years of trying (or 12 cycles of IUI); 40–42: 1 cycle if certain criteria are met. Local commissioning rules vary.
• Success -falls with age (about 30–35% live birth per transfer under 35, under 5% over 44 with own eggs).
• Risks:
  • Ovarian hyperstimulation syndrome.
  • Multiple pregnancy (reduced by single embryo transfer).
  • Ectopic pregnancy (including heterotopic).
  • Slightly higher risk of pregnancy complications (pre-eclampsia, preterm birth, placenta praevia).
  • Emotional and financial strain.
• Regulation -the Human Fertilisation and Embryology Authority (HFEA) licenses clinics; donor-conceived people can learn the donor's identity at 18.
• Surrogacy and fertility preservation (egg and embryo freezing) are other options.

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Ovarian Hyperstimulation Syndrome

• What it is: An exaggerated response to ovarian stimulation -enlarged ovaries release vasoactive substances (VEGF), and fluid leaks out of the blood vessels.
• Risk factors -PCOS, young age, high AMH, many follicles, high oestradiol, hCG trigger, pregnancy (worse if pregnant).
• Features (days after egg collection or in early pregnancy):
  • Abdominal bloating and pain, nausea, vomiting.
  • Ascites, pleural effusion, breathlessness.
  • Haemoconcentration (raised haematocrit), low sodium, reduced urine output, AKI.
  • VTE (including unusual sites -neck veins).
  • Ovarian torsion.
• Management:
  • Mild -outpatient: analgesia (paracetamol, avoid NSAIDs), fluids to thirst, daily weight and fluid monitoring.
  • Moderate to severe -admit: fluid balance, IV fluids (careful), LMWH, analgesia, paracentesis for tense ascites, albumin, ITU if critical.
• Prevention -GnRH antagonist protocols, GnRH agonist trigger, freezing all embryos.

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Choosing Contraception

Method	Failure in first year -typical use (perfect use)
Implant	Under 1 in 1,000 (0.05%)
LNG-IUS	About 0.2%
Copper IUD	About 0.8%
Sterilisation (female / vasectomy)	About 0.5% / 0.15%
Injection (DMPA)	About 4–6% (0.2%)
Combined pill, patch, ring; progestogen-only pill	About 7–9% (0.3%)
Male condom	About 13–18% (2%)
Fertility awareness	About 2–23%

• Long-acting reversible contraception (LARC) -implant, IUD, IUS, injection -most effective because they don't rely on daily use.
• UKMEC (UK Medical Eligibility Criteria) categories:
  • 1 -no restriction.
  • 2 -benefits generally outweigh risks.
  • 3 -risks generally outweigh benefits (use only with specialist advice if no alternative).
  • 4 -unacceptable health risk -don't use.
• Consultation -medical history, BP and BMI (for combined methods), drug interactions, STI risk (condoms protect against STIs), future fertility plans, side effects, the woman's preferences.
• Quick starting -most methods can be started any day if pregnancy is reasonably excluded; use condoms for 7 days (combined methods, implant, injection) or 2 days (POP), and repeat a pregnancy test at 3 weeks if there was recent unprotected sex.

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Combined Hormonal Contraception

• Forms -combined oral contraceptive pill (COC), patch (weekly), vaginal ring (monthly). Contain an oestrogen (usually ethinylestradiol) and a progestogen.
• How it works -stops ovulation; also thickens cervical mucus.
• How to take -21 days on, 7-day break (withdrawal bleed), or tailored regimens (shorter breaks, or continuous use with no break) -fewer bleeds and less risk of escape ovulation (FSRH supports these).
• Benefits:
  • Lighter, less painful, regular bleeds; helps PMS, endometriosis and acne.
  • Reduced ovarian, endometrial and bowel cancer risk (lasting for years after stopping).
  • Fewer functional ovarian cysts and benign breast disease.
• Risks:
  • VTE -about 2–3 times baseline (still lower than in pregnancy); higher with some progestogens (desogestrel, gestodene, drospirenone) than levonorgestrel or norethisterone.
  • Arterial disease -stroke and MI (small; higher with smoking, migraine with aura, hypertension).
  • Breast cancer -small increase while using, returns to baseline 10 years after stopping.
  • Cervical cancer -small increase with long-term use.
  • Side effects -nausea, breast tenderness, headaches, mood change, breakthrough bleeding.
• UKMEC 4 (don't use) -examples:
  • Migraine with aura (any age).
  • Age 35 or over and smoking 15 or more cigarettes a day.
  • BP 160/100 or more (or vascular disease).
  • Current or previous VTE; known thrombogenic mutation (e.g. factor V Leiden).
  • Ischaemic heart disease, stroke, complicated valvular heart disease.
  • Current breast cancer.
  • Major surgery with prolonged immobilisation.
  • Under 6 weeks after birth if breastfeeding (under 21 days if not breastfeeding).
  • SLE with positive antiphospholipid antibodies; severe cirrhosis; liver tumours.
• UKMEC 3 -examples: BMI 35 or more; age 35 or over and smoking under 15 a day or stopped under a year ago; controlled hypertension; multiple cardiovascular risk factors; breast cancer over 5 years ago; immobility.
• Stop 4 weeks before major elective surgery or surgery causing immobility.

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Missed Pills and Interactions

• Combined pill (FSRH):
  • One pill missed (24–48 hours since the last pill should have been taken) -take it as soon as possible (even if two in one day), continue as normal. No extra precautions.
  • Two or more pills missed (48 hours or more) -take the most recent missed pill now, continue the rest, and use condoms or abstain for 7 days.
    • In week 1 -consider emergency contraception if unprotected sex in the pill-free interval or week 1.
    • In week 2 -no EC needed if pills taken correctly in the previous 7 days.
    • In week 3 -skip the pill-free interval (start the next pack straight away).
• Progestogen-only pill:
  • Desogestrel (and drospirenone POP) -12-hour window (24 hours for drospirenone); traditional POPs -3-hour window.
  • Late -take it as soon as possible, continue, use condoms for 2 days; EC if sex in those 2 days.
• Vomiting within 2 hours or severe diarrhoea -treat as a missed pill.
• Enzyme-inducing drugs (reduce effectiveness of pills, patch, ring, implant, POP):
  • Rifampicin, rifabutin.
  • Carbamazepine, phenytoin, phenobarbital, topiramate, oxcarbazepine.
  • St John's wort.
  • Some HIV drugs (efavirenz, ritonavir-boosted).
  • Modafinil; bosentan.
  • Effect lasts 28 days after stopping. Use an IUD, IUS or injection instead.
• Lamotrigine -combined methods lower lamotrigine levels (seizure risk), especially in the pill-free week.
• Antibiotics (non-enzyme-inducing) don't reduce effectiveness.

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Progestogen-only Methods

• Progestogen-only pill (POP):
  • Desogestrel -inhibits ovulation; taken every day with no break; available from pharmacies without prescription.
  • Safe for most women who can't take oestrogen (migraine with aura, smokers over 35, VTE history, breastfeeding).
  • Side effects -irregular bleeding (the main reason people stop), headache, acne, breast tenderness, mood change.
• Implant (Nexplanon -etonogestrel rod in the upper arm):
  • 3 years; the most effective reversible method.
  • Irregular bleeding (about a third amenorrhoea, a fifth frequent or prolonged bleeding).
  • Fertility returns quickly after removal.
  • Rare -deep insertion, nerve damage, migration.
• Injection (DMPA -medroxyprogesterone acetate):
  • Every 13 weeks -IM (Depo-Provera) or SC self-injection (Sayana Press).
  • Weight gain (especially in under-18s with obesity), irregular bleeding then often amenorrhoea.
  • Reduced bone density (recovers after stopping) -caution under 18 and over 45; review every 2 years.
  • Delayed return of fertility -up to a year.
• Progestogen-only methods are UKMEC 4 only in current breast cancer (and UKMEC 3 for some other conditions, e.g. severe liver disease, IHD or stroke on the method).
• Bleeding problems -exclude pregnancy, STIs and cervical pathology; a short course of COC (if suitable) or NSAIDs can help.

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Intrauterine Methods

• Copper IUD:
  • Hormone-free; copper is toxic to sperm and eggs and prevents implantation.
  • Lasts 5–10 years (depending on device); if fitted at 40 or over, it can stay until after the menopause.
  • Works immediately; the most effective emergency contraception.
  • Side effects -heavier, longer, more painful periods.
• Levonorgestrel IUS:
  • Releases progestogen locally -thins the lining, thickens mucus.
  • 52 mg (Mirena, Levosert, Benilexa) -contraception for up to 8 years (Mirena; check the specific device); 5 years for endometrial protection in HRT.
  • Lower-dose devices -Kyleena (5 years), Jaydess (3 years).
  • Lighter periods (often amenorrhoea); irregular spotting at first; treats heavy periods.
  • If fitted at 45 or over (52 mg), can stay until age 55 for contraception.
• Risks of both:
  • Pain at insertion; vasovagal reaction.
  • Infection -small risk in the first 20 days (screen for STIs if at risk).
  • Expulsion (about 1 in 20), most in the first 3 months.
  • Perforation -about 1 in 1,000 (higher when breastfeeding or soon after birth).
  • If pregnancy occurs, a higher proportion are ectopic (though overall ectopic risk is lower than using no contraception).
• Lost threads -use other contraception, pregnancy test, ultrasound to locate (X-ray if not in the womb -perforation).
• Contraindications -pregnancy, current PID or untreated STI, unexplained bleeding, distorted cavity, cervical or endometrial cancer, Wilson's disease (copper).

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Emergency Contraception

Method	Key points
Copper IUD	Most effective (over 99%). Up to 120 hours (5 days) after the first unprotected sex in the cycle, or up to 5 days after the earliest likely ovulation date. Offer to everyone. Ongoing contraception.
Ulipristal acetate 30 mg (ellaOne)	Up to 120 hours. More effective than levonorgestrel. Delay starting hormonal contraception for 5 days after (it reduces ulipristal's effect); use condoms. Reduced by enzyme inducers. Avoid with severe asthma on oral steroids. Breastfeeding -avoid for 1 week.
Levonorgestrel 1.5 mg	Up to 72 hours (less effective after). Double dose (3 mg) if BMI over 26 or weight over 70 kg, or on enzyme inducers. Hormonal contraception can be started straight away.

• Oral EC delays ovulation -it won't work if ovulation has already happened; it is not an abortifacient.
• Vomiting within 3 hours -repeat the dose.
• Follow-up -pregnancy test at 3 weeks; STI testing; start ongoing contraception (quick start).
• Available free from sexual health clinics, many pharmacies and GPs; can be given in advance.
• Safeguarding -consider coercion, sexual assault, or child sexual exploitation, especially in young people.

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Barrier Methods and Sterilisation

• Condoms (male and female) -the only methods that also protect against STIs; advise using with other methods ("double Dutch"). Oil-based lubricants damage latex.
• Diaphragm or cap with spermicide -less effective; left in for 6 hours after sex.
• Fertility awareness methods -tracking temperature, mucus and cycle; needs commitment and regular cycles; apps vary in accuracy.
• Female sterilisation -laparoscopic clips (Filshie) or salpingectomy:
  • Permanent; about 1 in 200 lifetime failure (higher ectopic proportion if it fails).
  • General anaesthetic; use contraception until the next period after the procedure.
  • LARC is as effective -discuss as an alternative.
• Vasectomy:
  • Local anaesthetic, quicker and safer than female sterilisation.
  • Not effective immediately -use contraception until semen analysis is clear (about 12 weeks after).
  • Failure about 1 in 2,000 after clearance; chronic testicular pain in a few.
• Counselling -both are intended to be permanent; regret is more common in those under 30 or making the decision at a time of crisis (e.g. at caesarean).

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Contraception for Young People

• Under 16 -contraception can be provided without parental consent if the young person is Gillick competent and the Fraser guidelines are met:
  • They understand the advice.
  • They can't be persuaded to tell their parents (or allow you to).
  • They are likely to have sex with or without contraception.
  • Their physical or mental health is likely to suffer without contraception.
  • It is in their best interests.
• Confidentiality -keep it, unless there is a risk of serious harm.
• Safeguarding:
  • Under 13 -cannot legally consent to sex; always discuss with the safeguarding lead and refer.
  • 13–15 -assess for exploitation (age gap, gifts, alcohol or drugs, coercion, missing from home), and act on concerns.
  • Spotting the signs of child sexual exploitation (CSE).
• Good choices -LARC is safe and effective at any age (including nulliparous); DMPA with caution under 18 (bone density); always promote condoms.

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Drug Reference Table

Drug	Key points
Transdermal oestradiol (patch, gel, spray)	HRT oestrogen without VTE increase; needs progestogen if womb present.
Micronised progesterone (Utrogestan)	HRT progestogen: 200 mg days 15–26 (sequential) or 100 mg daily (continuous).
Vaginal oestrogen (estriol cream, estradiol pessary)	Genitourinary syndrome of menopause; no progestogen needed.
Tibolone	Postmenopausal HRT alternative; stroke risk in over 60s.
Venlafaxine / citalopram / gabapentin / clonidine	Non-hormonal flush treatment; avoid fluoxetine/paroxetine with tamoxifen.
Letrozole / clomifene	Ovulation induction (PCOS); multiple pregnancy risk -monitor.
Cabergoline	Hyperprolactinaemia causing subfertility.
Combined pill (e.g. levonorgestrel/ethinylestradiol)	VTE, stroke; UKMEC 4 for migraine with aura, smokers 35+ (15+/day), VTE.
Desogestrel 75 micrograms	POP with 12-hour window; irregular bleeding.
Etonogestrel implant	3 years; most effective reversible method.
Medroxyprogesterone acetate	13-weekly injection; bone density, weight gain, delayed fertility.
Levonorgestrel IUS 52 mg	Contraception up to 8 years (Mirena); HMB; HRT endometrial protection.
Ulipristal acetate 30 mg	EC up to 120 hours; wait 5 days before hormonal contraception.
Levonorgestrel 1.5 mg (3 mg)	EC up to 72 hours; double dose if BMI over 26, weight over 70 kg, or enzyme inducers.

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Spot the Diagnosis

Clue	Diagnosis / answer
50-year-old with flushes, night sweats and irregular periods	Perimenopause -clinical diagnosis, no FSH needed
36-year-old with no periods for 6 months, FSH 68 twice	Premature ovarian insufficiency
Postmenopausal with a womb, last period 18 months ago, wants HRT	Continuous combined HRT
HRT user with BMI 34 and previous DVT	Transdermal oestrogen (specialist advice)
Vaginal dryness and recurrent UTIs at 62	Genitourinary syndrome of menopause -vaginal oestrogen
Mid-luteal progesterone 12 nmol/L, irregular cycles, acne	Anovulation from PCOS
Azoospermia, small firm testes and gynaecomastia	Klinefelter syndrome
Azoospermia with absent vas deferens	CF gene variants
Bodybuilder with low sperm count	Anabolic steroid suppression
Abdominal swelling, breathlessness and raised haematocrit after IVF	Ovarian hyperstimulation syndrome
Migraine with aura wanting the pill	Combined pill UKMEC 4 -offer progestogen-only or IUD
Missed two combined pills in week 3	Take the latest, condoms for 7 days, skip the pill-free interval
On carbamazepine wanting contraception	IUD, IUS or injection
Unprotected sex 4 days ago	Copper IUD (best) or ulipristal
BMI 32 needing EC 2 days after sex, no IUD wanted	Ulipristal, or levonorgestrel 3 mg

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Exam-style Scenarios

1. A 52-year-old with a womb has had no periods for 14 months. She has severe flushes and poor sleep, BMI 33, no other problems.
Answer: Postmenopausal vasomotor symptoms.

• Offer HRT: continuous combined, transdermal oestrogen (BMI over 30) with micronised progesterone or LNG-IUS.
• Discuss benefits (symptoms, bone) and risks (small breast cancer increase with combined HRT).
• Review at 3 months; refer unscheduled bleeding after 6 months.

2. A couple have been trying to conceive for 14 months. The woman is 31 with regular cycles; she had chlamydia at 19.
Answer: Subfertility -possible tubal factor.

• Mid-luteal progesterone, chlamydia test, semen analysis.
• Laparoscopy and dye (history of infection) or HSG.
• Folic acid, lifestyle advice; IVF if tubal damage.

3. A 17-year-old forgot two combined pills in the first week of her pack and had unprotected sex 2 days ago.
Answer: Missed pills in week 1 with UPSI.

• Emergency contraception: copper IUD best; or levonorgestrel 1.5 mg (and continue the pill).
• Take the most recent missed pill, continue, condoms for 7 days.
• Pregnancy test in 3 weeks; consider LARC; STI screen; safeguarding check.

4. A 34-year-old who smokes 20 a day and has migraine with aura wants contraception.
Answer: Combined methods are UKMEC 4 (migraine with aura).

• Options: implant, IUS, copper IUD, desogestrel POP, injection.
• Smoking cessation support.

5. A 35-year-old 5 days after IVF egg collection has abdominal distension, vomiting and breathlessness. Haematocrit 48%, sodium 128.
Answer: Moderate to severe OHSS.

• Admit; strict fluid balance, careful IV fluids, LMWH, analgesia (no NSAIDs).
• Paracentesis for tense ascites; monitor kidney function; ITU if critical.

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Key Points

• Menopause over 45 is a clinical diagnosis -no FSH needed; contraception for 1 year after the last period over 50 (2 years under 50).
• Women with a womb need a progestogen with oestrogen; sequential if perimenopausal, continuous if postmenopausal.
• Transdermal oestrogen avoids the VTE increase; benefits outweigh risks for most women under 60.
• Vaginal oestrogen is safe long term without a progestogen.
• POI (under 40, FSH over 25 twice): HRT or COC until 51 to protect bone and heart.
• Subfertility: investigate after 1 year (earlier if 36 or over or known cause); mid-luteal progesterone, semen analysis, tubal patency.
• PCOS ovulation induction: weight loss, letrozole or clomifene.
• IVF risks: OHSS, multiple pregnancy, ectopic.
• LARC is most effective; UKMEC 4 means don't use.
• Combined methods: UKMEC 4 for migraine with aura, smokers 35+ (15+/day), BP 160/100+, VTE, breast cancer.
• Two or more combined pills missed: condoms for 7 days; EC if in week 1; skip the break if in week 3.
• Enzyme inducers: use an IUD, IUS or injection.
• EC: copper IUD most effective (up to 5 days); ulipristal (120 hours); levonorgestrel (72 hours, double dose if BMI over 26).
• Under 16: Fraser guidelines; under 13 -always safeguarding referral.

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Guidelines and Further Reading

• NICE NG23: Menopause -identification and management (2024 update)
• British Menopause Society: guidance and tools
• ESHRE guideline: Premature ovarian insufficiency
• NICE CG156: Fertility problems -assessment and treatment
• HFEA: information on fertility treatments
• RCOG Green-top Guideline 5: Ovarian hyperstimulation syndrome
• FSRH: UK Medical Eligibility Criteria for Contraceptive Use (UKMEC); clinical guidelines on combined, progestogen-only, intrauterine and emergency contraception; drug interactions
• BNF -for current doses

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