Write short notes on three of the following:

a)	Intrauterine contraceptive device (IUCD).

b)	Hormone replacement therapy (HRT).

c)	Urinary incontinence.

d)	Colposcopy.

a)	IUCDs, as implied in the name, are contraceptive devices left in the uterine cavity. First generation IUCDs such as the Lippes loop and Dalkon’s shield are inert devices left in situ for more than 10 years. However, they are often embedded in the uterine wall and hysteroscope is required for its removal. Second generation IUCDs such as Copper T380, consists of a silver cord wound around with copper, copper on side arms and a fine thread left protruding from the cervix into the vagina and the IUCD can be removed in due course by traction on this thread. 

An IUCD is ideal for women who want a long-term method of contraception independent of intercourse and where regular compliance is not required. It can be left in the uterus for up to five years and is efficacious with a Pearl Index of 0.5 to 1. IUCDs can also be used for emergency contraception. An IUCD inserted within 72 hours of unprotected intercourse is effective in preventing contraception. 

A progestogen loaded IUCD, such as Mirena, is also used to treat dysfunctional uterine bleeding in women. The stem of the IUCD has a silastic rod impregnated with 52mg of levonorgestrol. Mirena is found to be effective in reducing menstrual loss, dysmenorrhoea, ectopic pregnancy, incidence and growth of fibroids and risk of PID. 

All IUCDs induce an inflammatory response in the endometrium that prevents implantation. Copper-bearing IUCDS work primarily by a toxic effect on sperm that prevents fertilization. Mirena causes uniform endometrial atrophy and thickening of the mucus, inhibits sperm motility and function inside the uterus and fallopian tubes.

IUCDs are usually inserted immediately after abortion or D&C following a spontaneous complete abortion or within 5 days of onset of menses at the request of the woman. They are usually recommended for women who have completed their families but do not want to take the irreversible step of sterilization, women over 35 years of age in whom the risks of oral contraceptive pill are increased and young women who do not have the motivation to use other methods of contraception.

The contraindications to IUCD use are as follows:

1.	Existing pregnancy.

2.	Previous pelvic inflammatory disease.

3.	Known malformation of the uterus.

4.	Existing pregnancy.

5.	Genital malignancy.

6.	Severe dysmenorrhoea.

7.	Menorrhagia.

Use of IUCDs can lead to the following complications:

1.	Immediate:
-	risk of expulsion within first 6 months especially during menstruation.
-	hypogastric discomfort during menses.
-	uterine perforation.

2.	Chronic:
-	3 – 4% failure rate.
-	increased risk of ectopic pregnancy.
-	increased risk of PID.
-	translocation to peritoneal cavity requiring laparotomic removal. 

3.	Pregnancy-related:
-	spontaneous abortion.
-	premature delivery.
-	still-birth. 

b)	Menopause is defined as the final menstrual period in a woman’s life and is associated with a genetically programmed loss of ovarian follicles leading to a hypoestrogenic state. This drop in the level of estrogen is responsible for short-term menopausal symptoms such as hot flushes, vaginal dryness and atrophy to long-term complications like osteoporosis and cardiovascular disease. The use of HRT is thought to reverse these unwanted effects of menopause by replenishing the body’s estrogen.

However, data from the WHI (2002) and HERS (1998) trials have led to changes in recommendations for HRT. Continuous estrogen-progestin therapy does not appear to protect against cardiovascular disease and increases the risk of breast cancer. As a result, the primary indication for HRT at present is for control of menopausal symptoms.

Goals of HRT:

1.	Ameliorate menopausal symptoms.

2.	Reduce atrophy and changes of aging in estrogen responsive tissues.

3.	Prevent or treat conditions such as osteoporosis-related fractures. 

Before initiating HRT, the following needs to be documented and discussed with the patient:

1.	Symptoms and signs of estrogen deficiency, with more than 6 months of amenorrhoea.

2.	Laboratory confirmation of decreased ovarian or abnormal pituitary function.

3.	Discuss the risks and benefits and mode of action of HRT.

4.	Screen for contraindications to HRT.

Contraindications to HRT:

1.	Undiagnosed vaginal bleeding.

2.	Suspected or known pregnancy.

3.	Suspected or known breast cancer or endometrial cancer.

4.	Coronary heart disease.

5.	Stroke.

6.	Venous thromboembolism.

7.	Active or chronic liver disease.

Prescribe according to uterine status:

1.	Intact uterus: use combination of estrogen and progestogen.

2.	Hysterectomy done: use estrogen alone.

Estrogen recommendations:

1.	Drug: conjugated equine estrogen (premarin) has been evaluated most and is most affordable.

2.	Dose: use low starting dose 0.625 – 2.5mg daily for 2 – 3 months and titrate up to minimum protective dose.

Progestogen recommendations:

1.	Drug: medroxyprogesterone acetate (Provera).

2.	Dose: start with 5mg or equivalent for 0 to 2 years post-menopausal or 2.5mg or equivalent for > 2 years post-menopausal and titrate down to dose that produces appropriate bleeding pattern. 

Before commencing on HRT, the patient should be advised on the following complications:

1.	Short-term:
-	nausea.
-	breast engorgement and tenderness.
-	physiological vaginal discharge.
-	irregular vaginal bleeding.
-	fluid retention leading to leg cramps.

2.	Long-term:
-	may increase the risk of heart disease and stroke.
-	may increase risk of breast and endometrial cancer. 

Principles of management:

1.	Regimen: continuous estrogen, if mastalgia persists beyond 3 months, try cyclic regimen with pill-free interval 5 to 7 days.

2.	Use lowest, effective dose whenever possible.

3.	For women at least one year post-menopause, use continuous combined estrogen and progestogen preparation.

4.	Discontinue HRT periodically for a few weeks to determine whether symptoms are still present.

5.	Always taper therapy over a few weeks to prevent withdrawal symptoms and to obtain accurate assessment of further need.

6.	Do not use HRT for more than 5 years. 

Follow-up assessment:

1.	Evaluate tolerance to HRT every 3 months until stable. 

2.	Evaluate any unscheduled bleeding and refer for vaginal ultrasound, hysterectomy and endometrial sampling.

3.	Weight and blood pressure checks.

4.	Blood sugar and lipid level evaluation.

5.	Annual breast and pelvic examination.

6.	Mammogram every two to three years.

7.	Repeat BMD in two years if BMD is low and to assess adequacy of osteoporosis treatment. 

c)	Urinary incontinence is defined as the voluntary loss of urine that is objectively demonstrable and is a social or hygienic problem. It is a common problem in women as a result of aging and is an inevitable problem they must contend with. It has multiple and broad-reaching effects that influence their daily activities, social interactions and self-perception of health.

The prevalence increases with age, with approximately 5 per cent of women between 15 and 44 years of age being affected, rising to 10 per cent of those aged between 45 and 64 years and approximately 20 per cent of those greater than 65 years. 

Common symptoms:

1.	Stress incontinence: loss of urine on physical effort.

2.	Urge incontinence: an involuntary loss of urine associated with a strong desire to void.

3.	Overflow incontinence: occurs without any detrusor activity when the bladder is over-distended.

4.	Frequency: the passing of urine seven or more times a day, or being awoken from sleep more than once a night to void.

Genuine stress incontinence is the commonest form of urinary incontinence and it is more common between the ages of 45 and 54. It is defined as the involuntary loss of urine occurring when, in the absence of a detrusor contraction, the intravesical pressure exceeds the maximal urethral pressure. The common causes are increased intra-abdominal pressure due to obesity, chronic cough, heavy exercises, pelvic tumors or chronic constipation, urethral hypermotility due to childbirth and intrinsic sphincter deficiency due to pelvic surgery or aging. Treatment can be conservative with the use of physiotherapy, vaginal pessaries and drugs or surgical procedures like Burch colposuspension and tension-free vaginal tape (TVT).

Detrusor instability is a disorder of filling in which involuntary bladder contractions are demonstrated while the patient is attempting to inhibit. The overall prevalence in the general population is 10%. 90% of women have no recognizable pathology. The less common causes are neurologic disease, bladder neck obstruction due to pelvic organ prolapse and previous pelvic surgery. It can be managed with bladder retraining drills, drugs such as oxybutynin, tolterodine and imipramine and as a last resort, surgery, e.g. bladder distention, subtrigonal injection of phenol, transvaginal denervation of bladder.

d)	The colposcope is a binocular operating microscope with magnification of between five to 20 times used to examine the cervix in detail to identify dysplastic abnormalities on the ectocervix. A satisfactory colposcopy is one in which the entire squamo-columnar junction is demonstrated. 

1.	Indications:
-	abnormal Pap smear: CIN I, II, III and AGUS.
-	exclude invasive disease.
-	identify site, size and extent of any abnormality.
-	decide between targeted or excisional biopsy to obtain reliable histological diagnosis.
-	discrepancy between histology and cytology findings.
-	biopsy shows microinvasive disease.

2.	Procedure:
-	magnified examination with green filter or saline.
-	apply acetic acid 3 – 5% precipitate nuclear proteins.
-	Lugol’s iodine stains glycogenated epithelium (Schiller’s test).

3.	Features of abnormal epithelium:
-	acetowhite change: spread of uptake and intensity.
-	punctation: stippled vascular pattern within a well demarcated area.
-	alterations in surface contour: raised, peeling edges, contact bleeding.
-	variations in blood vessel patterns: mosaicism.