Compounds with both agonist and antagonist properties on the progesterone receptor (PR) and fewer antiglucocorticoid properties are classified as selective progesterone receptor modulators (SPRMs). SPRMs have been shown to have an antagonistic effect on endometrial and breast tissue PRs without influencing the effect of oestrogen on endometrial and breast tissue. Mifepristone and ulipristal acetate are the only SPRMs currently licensed for use in the UK; however, other SPRMs have been or are currently being developed and undergoing trial. Raloxifene and ormeloxifene are SERMs (selective oestrogen receptor modulators). Misoprostol and dinoprostone are prostaglandins.

Murdoch M, Roberts M. Selective progesterone receptor modulators and their use within gynaecology. Obstet Gynaecol. 2014;16:46–50.

Uterine fibroids (leiomyomas or myomas) are benign tumours of smooth muscle cells and fibrous tissue that develop within the wall of the uterus. They are the most common tumours of the female genital tract present in 20–40 % of women in the reproductive age group. Treatment is often only required if the woman is symptomatic and is dependent on symptoms. If the woman has heavy menstrual bleeding, the National Institute for Health and Care Excellence (NICE) recommends consideration of pharmaceutical treatment when fibroids are less than 3 cm in diameter and causing no distortion of the uterine cavity

National Institute for Health and Care Excellence. Heavy menstrual bleeding. (CG44) London: National Institute for Health and Care Excellence; 2007.

Chronic pelvic pain (CPP) is a common condition in women of reproductive age. Current data from the USA and UK suggest that it occurs in 14–24 % of women aged between 18 and 50 years. It is a common condition at the population level. Further work has indicated that rates of consultation for CPP in general practice are similar to those for asthma and migraine. The USA and UK population-based studies, together with data from UK hospital settings, demonstrate a substantial impact of CPP on health-related quality of life. The differences in estimated prevalence may be due to the design and type of study performed, for example, the use of different definitions of the condition.

Cheong Y, Stones RW. Management of chronic pelvic pain: evidence from randomised controlled trials. Obstet Gynaecol. 2006;8:32–8.

Typical laparoscopic findings in women investigated for CPP are, in increasing order of frequency, adhesions (24 %), endometriosis (33 %) and ‘no pathology’ (35 %). Patterns of symptoms and received diagnosis in the population-based studies cited above suggest a broad pattern of pathophysiology, with urinary (31 %) and gastrointestinal (37 %) problems being more common than specifically gynaecological (20 %) problems.

Cheong Y, Stones RW. Management of chronic pelvic pain: evidence from randomised controlled trials. Obstet Gynaecol. 2006;8:32–8.

Incidentally detected ovarian pathology at the time of caesarean section is rare. However, when detected, it is necessary to differentiate benign from malignant. Ultrasound is the commonly used tool, and complex, septate mass with mural nodules and papillary projections is highly suggestive of malignancy. Unilocular thin-walled anechoic cysts, measuring <5 cm in diameter, have a 90–100 % chance of regression. If suspected to be benign, a policy of ‘wait and watch’ can be adopted keeping in mind the complications that may occur. And these include cyst rupture, cyst haemorrhage, torsion (up to 5 %), obstructed labour and fetal malpresentation.

Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. Obstet Gynaecol. 2006;8:14–9.

The indications for surgery will depend on the degree of suspicion of malignancy in the mass or the development of cyst complications. If there is doubt regarding the diagnosis, MRI can prove useful as a tool to help distinguish dermoids and endometriomas from malignant neoplasms. If elective surgery is embarked upon, this should be done after 14 weeks’ gestation to minimise the risk of fetal loss due to miscarriage, although this risk is very small. This recommendation is based on the principle that the developing pregnancy is dependent on the corpus luteum during the first trimester and much less so after 12 weeks. The standard approach is to perform the surgery via a laparotomy, but laparoscopic surgery has been used, although it is skill dependent and more time-consuming than open surgery.

Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. Obstet Gynaecol. 2006;8:14–9.

Simple cysts smaller than 5 cm regress in 90–100 % of cases and can be safely observed. These cysts do not need further evaluation, and rescanning is only required if there is a clinical indication, such as pelvic pain. Adnexal masses that undergo torsion are usually dermoids or cystadenomas. If this complication occurs, it does so during the first trimester or in the immediate puerperium (up to 14 days after delivery). Ovarian dermoids that measure less than 6 cm are unlikely to grow significantly in pregnancy and can be managed conservatively as the risk of complications, such as torsion, is thought to be low. The woman should be rescanned in the postnatal period to determine further management of any ovarian dermoid that has not resolved spontaneously.

Persistent, simple, unilocular cysts without any solid elements that are larger than 10 cm can be aspirated either transvaginally or abdominally under ultrasound guidance using a fine needle (greater than 20 gauge). This procedure is only indicated if the cyst is causing pain or thought to be increasing the risks of fetal malpresentation or obstructed labour due to its location in the pelvis. Although not commonly employed, this technique seems to be a reasonable alternative to surgery in suitable women. The woman should be subsequently rescanned to determine whether cyst recurrence has taken place, and the risk of this is thought to be 33–50 %, and the mother should therefore be counselled that further aspirations can be required during the rest of the pregnancy.

Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. Obstet Gynaecol. 2006;8:14–9.

Nipple discharge is a common presentation to a breast clinic. In one study over 32 years, 4.8 % of women presented with nipple discharge, although only 2.6 % occurred spontaneously. Controversy surrounds the management of such patients including their initial investigations through to the requirement and type of surgery. The surgical options for the treatment of nipple discharge are either single or multiple duct excision. It is recommended that major duct excision in women over 45 years is a safe, effective procedure with good cosmesis when performed well and provision of maximal histological information. However, several studies advocate microdochectomy as the treatment of choice with minimal morbidity and few missed cases of malignancy and may be performed under local anaesthetic. Studies demonstrate that 3.8 % of patients may have associated malignancy.

Burton S, Li W-Y, Himpson R, Sulieman S, Ball A. Microdochectomy in women aged over 50 years. Ann R Coll Surg Engl. 2003; 85:47–50

Women presenting with PCOS (particularly if they are obese, have a strong family history of type 2 diabetes or are over the age of 40 years) are at increased risk of type 2 diabetes and should be offered a glucose tolerance test. Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later carcinoma. It is good practice to recommend treatment with progestogens for at least 12 days to induce a withdrawal bleed at least every 3–4 months. 60–85 % of patients will ovulate on clomiphene citrate.

Royal College of Obstetricians and Gynaecologists. Long term consequences of polycystic ovary syndrome. Green-Top guideline No. 33. London: RCOG Press. 2007. Available at http://​www.​rcog.​org.​uk/​files/​rcog-corp/​uploaded-files/​GT33_​LongTermPCOS.​pdf

SOGC Clinical Practice Guideline. Ovulation induction in polycystic ovary syndrome. 2010. Available at http://​sogc.​org/​wp-content/​uploads/​2013/​01/​gui242CPG1005E_​000.​pdf

Pregnancy outcomes in patients post-UAE include increased preterm delivery rate up to 20 % and caesarean section rates up to 80 %. Only about 1/3 of the patients deliver vaginally. In addition there are increased chances of malpresentations and postpartum haemorrhage. There is significantly higher miscarriage rate following UAE for fibroids than for women with untreated fibroids, thought to be due to relative endometrial ischaemia and distortion of uterine cavity.

Pregnancy outcomes after uterine artery embolisation for fibroids. TOG. 2009;11:265–70.

While the diagnosis of molar pregnancy is rare, there are two groups of women who have significantly elevated risks of developing a molar pregnancy. At the extremes of the reproductive age, girls under the age of 15 years have a risk approximately 20 times higher than women aged 20–40, while women aged over 45 have a several hundredfold higher risk than those aged 20–40. The increased risk for these groups is mainly for complete molar pregnancy, with the incidence of partial molar pregnancy changing less across the age groups.