Frequently Asked Questions

They are used for different jobs. The real value of three- and four-dimensional ultrasound is that it shows what two-dimensional cannot: the view of the womb from above, exactly aligned sections in examining the brain, and reconstruction of the spine. Routine screening, on the other hand, is done with two-dimensional ultrasound.

Because the difference is large. In diagnosing congenital differences of the womb, the accuracy is 97.1% with three-dimensional; with two-dimensional it is 51.4% on first assessment and 82.9% in experienced hands. Distinguishing a septum inside the womb from a double womb is particularly critical — the treatment of the two is entirely different, and the distinction matters in infertility and recurrent pregnancy loss.

Ultrasound involves no radiation and is regarded as safe in clinical use; there is no independently confirmed study showing otherwise. Even so the ALARA principle is applied: the lowest power sufficient to make the diagnosis is used and the scan is kept as short as possible.

Yes. Doppler studies emit considerably more energy than standard imaging. For this reason the thermal index is kept below a certain limit in pregnancy and the time is limited to generally not more than 5–10 minutes. In the first 11 weeks of pregnancy Doppler should not be used unless there is a medical necessity.

That is not what the guidelines recommend. The recommendation of the international ultrasound society is clear: ultrasound should not be performed on its own solely to please the parents or to obtain a commercial keepsake image. The reasoning is that any scan without a medical purpose violates the ALARA principle and exposes the baby to unnecessary sound energy. This does not mean that images obtained during a medical examination cannot be shared.

Yes, and this is an important advantage of three-dimensional ultrasound. The volume data acquired can be stored digitally; the image can be reviewed from different angles and the measurements repeated even after you have left. This makes the assessment less dependent on the person performing it.

Guidelines look for the following criteria: being trained in diagnostic ultrasound and in safety, performing fetal ultrasound regularly, taking part in continuing medical education, having a referral pathway in place for doubtful findings, and carrying out quality audit regularly.

Guidelines do not define this in millilitres. The criterion is this: is the bleeding adversely affecting your quality of life physically, emotionally, socially or materially? Not being able to go to work, hesitating to go out, having to change pads frequently and feeling constantly weak are meaningful indicators. There is no need to compare with someone else's bleeding.

Yes. Every episode of bleeding after menopause is a finding that needs to be investigated; its amount and duration do not change that. In 5 to 10 per cent of women with this bleeding the underlying cause is cancer of the womb, and early diagnosis changes the outcome markedly.

Cycles without ovulation are common in adolescence, so a degree of irregularity is to be expected. But assessment is needed if the bleeding is excessive, produces symptoms of anaemia, or disrupts school and daily life; in that situation combined hormonal methods are recommended as first-line drug treatment.

It is the option guidelines place first in heavy menstrual bleeding and in thickening of the lining of the womb in which the cell structure is not disturbed. Because it acts locally inside the womb, the amount of hormone that passes into the body is small, which reduces the side effects seen throughout the body. Even so, as with every method, its suitability is assessed for the individual.

If you are of childbearing age, pregnancy is ruled out first. What follows depends on your age and the type of bleeding: after menopause, vaginal ultrasound comes first; before menopause, ultrasound is used mostly to look for structural causes such as fibroids and polyps. Anaemia is also looked for in everyone with abnormal bleeding.

Movement of the heart can generally be seen on ultrasound from weeks 5–6. The heart rate rises until week 10 (an average of 171 beats a minute), then falls to around 156 by week 14 — the rate falling after a while is to be expected and is not a cause for concern.

Movements in fact begin as early as week 12, but the mother does not feel them straight away. The time they are first felt is generally weeks 18–20. In those who have given birth before it can come as early as week 16; in a first pregnancy it may extend a little beyond week 20. Both are normal.

No — this is a widespread but false belief. From week 32 the frequency of movements reaches a level and stays there; it does not decrease. Because there is less room the character of the movements changes (strong kicks instead of large turns), but their frequency does not fall. If you notice a reduction in movements, do not wait — tell your health service.

Yes. In the third trimester the baby has regular cycles of sleep and wakefulness lasting 20–40 minutes (up to 90 minutes at most). Short periods without movement may be related to these cycles; but if there is a marked reduction in your usual pattern of movements, it should be assessed.

Yes, and it is an important detail: part of the bowel protruding outside the abdomen is normal up to week 11 and is a stage of development that resolves on its own. The bowel returns to the abdominal cavity from week 12. For this reason, at the 11–14 week ultrasound this finding is distinguished from a true opening in the abdominal wall.

It is a drug treatment given to the mother when there is a risk of premature birth. Its purpose is to speed up the development of the baby's lungs and to reduce the risk of breathing difficulty after birth. The substance that allows the baby to breathe on its own begins to be produced rapidly in the third trimester; this treatment speeds up the process.

In the first trimester the crown–rump length is measured — in this period the baby almost doubles in size from week 11 to week 14. From week 14, measurements of the head, abdomen and thigh bone are taken and the estimated weight of the baby is calculated. In the last period growth is followed at the examination by measuring over the abdomen and, if there is a risk, by ultrasound at intervals of 2–3 weeks.

Body-identical hormones have a chemical structure similar to the hormones the human ovary produces. Compared with synthetic options they have been described as having more neutral effects on clot risk and on breast cancer risk. Micronised progesterone, for example, is plant-derived and similar in structure to ovarian progesterone.

No — this is an important misunderstanding. Compounded body-identical hormones are not subject to the same rigorous oversight as regulated (licensed) ones; there are concerns about purity and safety. The source guideline recommends avoiding these preparations and obtaining a prescription for a regulated preparation from your doctor.

Oestrogen given through the skin has a very neutral effect on the way the body breaks hormones down and does not increase clot risk compared with not being on treatment. For people at higher risk of clots — for example those who are overweight — the skin route is the one to prefer. The decision is individual.

No. For people whose womb has not been removed, progesterone or a progestogen is always given as well, to protect the lining of the womb from the effect of oestrogen. If you are still having periods it can be given so as to produce a monthly bleed; if you have reached the menopause it can be given continuously without a bleed.

Combined (oestrogen + progestogen) treatment is associated with a small increase in breast cancer risk, low both medically and statistically. With oestrogen-only treatment, little or no increase has been shown. For context: the risk from two units of alcohol every evening is higher than that from hormone therapy, and the risk from being overweight is markedly higher.

Timing affects the outcome. Hormone therapy started under the age of 60 or within the first 10 years after the menopause has been shown to produce a clear reduction in the risk of heart disease and in deaths from cardiovascular disease.

Usually not, over the age of 45. The diagnosis is made by assessing symptoms together with the change in the pattern of periods. Because the FSH level fluctuates from month to month it can be misleading in this age group. Under 40, FSH is measured if premature ovarian insufficiency is suspected and repeated if unclear; between 40 and 45 it may help. A single test may not give the diagnosis.

Complementary methods may help with symptoms, but most are less effective than hormone therapy at controlling them and are not expected to have a clear effect on bone strength or heart health. Some herbal products may also contain substances with oestrogen-like activity, so they are unsuitable for people for whom hormone therapy would be inadvisable. Cognitive behavioural therapy, by contrast, is an effective option for hot flushes and night sweats.

No. Its licensed uses include excessive sweating of the armpits, spasticity of the arm after a stroke, dynamic equinus foot deformity in cerebral palsy, blepharospasm (spasm of the eyelid) and hemifacial spasm. Long before its cosmetic use it began to be used in the 1960s and 1970s in the treatment of squint.

There are many areas considered for cosmetic purposes — the forehead, between the eyebrows, crow's feet, the lower eyelid, the side of the nose, around the mouth, a downturned corner of the mouth, the jaw muscle, neck lines and so on. But some of these areas are outside the list of licensed uses. Which area is suitable for you should be decided together with your doctor.

No. Pregnancy and breastfeeding are a contraindication (a situation in which a treatment is inadvisable); that is, they are among the situations that are an obstacle to treatment.

Some may. Aminoglycoside antibiotics, penicillamine, quinine, calcium channel blockers, magnesium and ciclosporin are among the situations listed as obstacles. For this reason you need to declare all the medicines you take before treatment. Nerve–muscle diseases such as ALS, myasthenia gravis and Eaton-Lambert syndrome are also an obstacle.

Photographs before and after treatment are taken sitting upright, and the muscles are assessed both relaxed and contracted. This is so that the injection points and the dose can be determined correctly and the result can be compared. The photographs and the record of the procedure are filed together with the batch number of the product.

Temporary drooping of the eyelid (ptosis) is one of the possible side effects and is a manageable situation. Eye drops with an alpha adrenergic action can be used 3–4 times a day at intervals of 3–4 hours; radiofrequency, ozone and PRP treatments are also among the options. This is a decision for the doctor — do not use drops on your own; see your doctor.

Yes. In people who are not mentally stable and who have excessive expectations — in conditions such as body image disorder, borderline personality, obsessive-compulsive disorder or narcissism — treatment is not considered appropriate. For this reason the assessment before treatment covers not only the skin but how realistic the expectation is.

It is most often seen as part of the picture of the genitourinary syndrome that appears with menopause. Tissue changes after childbirth, episiotomy scars and skin conditions such as lichen sclerosus can also affect the quality of the tissue in the area.

The main approach described in the sources is the person's own fat tissue (autologous fat graft). The fat is passed through filters and turned into microfat and nanofat forms; microfat is the one suitable for giving volume. Nanofat contains no mature fat cells but is rich in stem cells.

PRP is the plasma fraction obtained from the person's own blood with a high concentration of platelets (the cell fragments in blood that start clotting). When added to fat tissue it has been shown to preserve the structure of the fat cells better, to create a strong blood supply and to create a favourable environment for the multiplication of stem cells. Its purpose, in other words, is to improve the likelihood of the graft taking.

In one of the published examples the result at 18 months was reported in a 54-year-old person; in another, the volume gained was reported to have been maintained. But these are reports of a limited number of cases — that the long-term effects need to be assessed further is the source's own wording.

It is necessary to be clear: the source text states that the effectiveness of microfat and nanofat grafting in this field has not previously been assessed, and that further studies are needed for the results to be confirmed. Most of the favourable results reported rest on subjective scoring scales, and the source accepts that subjectivity as a limitation. This does not mean the method does not work — it means it has not yet been measured in large comparative studies.

The source states that the fat tissue integrates naturally with the host tissue and that no notable side effect has been reported. Even so, this is a report resting on a limited number of cases; as with every interventional procedure, results may vary from person to person.

This is called a pregnancy of unknown location. The guideline's warning is clear: until the location of the pregnancy is established, it must be accepted that it could be an ectopic pregnancy. This is why follow-up and reassessment are requested.

Because the pregnancy hormone in the blood (hCG) does not show where the pregnancy is — it shows how the process is progressing. Two measurements are made as close as possible to exactly 48 hours apart. A rise of more than 63% favours a pregnancy inside the womb (an ectopic pregnancy is still not ruled out), a fall of more than 50% favours the pregnancy not continuing; results in between require assessment within 24 hours.

No. The guideline emphasises this in particular: your symptoms are more important than your test results. If your complaints change or worsen, your situation must be reassessed whatever the previous results were. You should be told in writing how to reach emergency help 24 hours a day.

Yes, there are two further options. Expectant management: if your condition is stable, there is no pain, the pregnancy is smaller than 35 mm with no heartbeat, the hCG is below the threshold and you can attend for follow-up. Medical treatment: under similar conditions and if a pregnancy inside the womb has been ruled out. Which is appropriate is decided according to your findings.

The guideline reports, stating that it rests on limited evidence, that no difference appears between expectant and medical management in terms of the risk of the tube rupturing. Likewise no difference was found in the rate at which the ectopic pregnancy resolves on its own, the need for further treatment, or scores for mental state. But it should be known that emergency admission may be needed if the situation worsens.

hCG is repeated on days 2, 4 and 7 after the first test. If the value is falling by 15% or more at each measurement compared with the previous one, weekly follow-up continues until a negative result is reached. If it is not falling, stays the same or rises, the situation is reassessed and a senior opinion is obtained.

The guideline states that expectant and medical management are expected to be similar in terms of the time the ectopic pregnancy takes to resolve and future fertility outcomes. In addition, if you have any concern in the early stage of a future pregnancy, you can refer yourself directly to the early pregnancy assessment unit; you should be told about this.

For hyaluronic acid, the substance most often used, no allergy test is needed; it has been FDA approved since 2003. Even so, the medicines you take, the illnesses you have had and your history of allergy are assessed before treatment.

It depends on the substance: the effect of PLLA lasts on average 18–24 months and calcium hydroxylapatite on average 12–18 months. But the duration does not depend on the substance alone — how mobile the area is, the depth of injection, the amount of cross-linking, smoking, alcohol, excessive exercise and weight loss also affect it.

No, there are two different ways of working. Hyaluronic acid gives volume directly and holds water. PLLA, polycaprolactone and calcium hydroxylapatite work by stimulating the production of your own collagen — which is why their results appear later.

They are not recommended. The most important advantage of a fat (autologous) filler is that it does not cause an allergic or foreign-body reaction; but it is not preferred under the eyes or in the lip area. It is a suitable option for people with marked hollowing of the face after severe weight loss.

For fillers containing calcium hydroxylapatite, yes — calcium is radiopaque (visible on X-ray) and can be seen on imaging. This appearance is not permanent. Even so, if you are going to have imaging it is worth telling your doctor that you have previously had a filler.

PLLA has been found to carry a high risk of forming papules and nodules under the skin (small firm lumps) in the areas around the mouth and the eyes. For this reason care is advised in these areas and the choice of substance is made accordingly.

A filler is not a simple injection. The vascular structure of the face is complex, and injections made in the wrong direction can lead to a pulmonary embolism. For this reason the distribution of vessels and nerves in the area is assessed before treatment, and it is confirmed before injecting that the needle is not inside a vessel. The procedure being carried out by a doctor and in appropriate conditions is the basis of its safety.

No, and this should be known plainly. ACOG states that G-spot augmentation procedures have no medical justification whatsoever and that there is no long-term scientific evidence of their effectiveness and safety; it warns doctors not to offer these procedures under the name of "sexual rejuvenation". The FDA has given no official approval and regards the applications as off-label.

In the medical literature there is no agreement. While some studies report that a particular part of the front wall of the vagina is rich in nerves and vessels, many independent studies, including twin studies, argue that no such separate structure has a physiological reality and that the sensitivity arises from the proximity of the clitoris to this area.

No. Clinical data establish this plainly: the application may help increase intensity and duration only in people who have previously experienced vaginal orgasm but whose sensitivity has decreased over time. In people who have never experienced orgasm in their lives it cannot start a new orgasmic function.

It depends on the material used. Hyaluronic acid is the temporary material most often chosen and generally lasts between 4 and 9 months. Collagen is fully absorbed in 6–8 months. The person's own fat tissue and materials that are not absorbed can also be used.

Yes, and they should not be taken lightly. Although very rare, life-threatening pulmonary embolism has been reported after filler was inadvertently delivered into the network of veins in the area. Too much filler can also prevent urination and a temporary catheter may be needed. Lasting loss of sensation, pain during intercourse, infection and firm inflammatory lumps around the filler are also among the risks reported.

It is carried out in the outpatient setting, usually takes less than 30 minutes and requires no rest period. The area is prepared with local numbing. After the procedure, abstaining from intercourse for 2–3 days is advised.

Rather than choosing a procedure directly, the cause needs to be assessed first. ACOG recommends that before moving to surgery or filler, the psychosexual situation and the context of the relationship be examined carefully. There may also be causes such as the clitoris being covered by a thick hood, or dryness due to menopause — causes that have well-established treatments.

In the common method the starting point is not the day of conception but the first day of the last menstrual period. For this reason there is in fact no pregnancy yet in the first two weeks of "pregnancy" — that is how the calculation is set up.

Go back 3 months from the date of your last period and add 7 days. An example: if the last period was on 10 January, three months back is 10 October, and adding seven days gives an estimated due date of 17 October. This gives the same result as adding 280 days to the date of the last period.

The ultrasound is taken as the basis. According to the guidelines, the crown–rump length measured in the first trimester is the most reliable measurement for determining the week of pregnancy. If there is a difference, the week found by ultrasound is used and all subsequent care is planned according to it.

Because the calculation assumes that the menstrual cycle is 28 days and that ovulation takes place on day 14. In fact the length of the cycle varies from person to person and from month to month, ovulation does not always happen on day 14, and the date of the last period is not always remembered clearly.

Generally no. The estimated due date is not a target but the midpoint of a range. The birth is not expected to take place on exactly that day.

With an irregular cycle, a calculation based on the date of the last period is less reliable. In that case dating by an ultrasound done early becomes particularly important; use the calculator only to get a rough idea.

The standard recommendation is 400 micrograms a day; it is started before pregnancy and continued through the first 12 weeks of pregnancy. In some situations, however, 5 milligrams a day is needed and should be started at least 1–3 months before pregnancy. Your doctor decides which is appropriate for you.

Those with a history of a defect in the development of the spine or brain in themselves, their partner, a previous pregnancy or the family; those with excess weight (body mass index above 30), previous obesity surgery, diabetes, epilepsy and the use of medicines for it, sickle cell anaemia or thalassaemia.

In recurrent miscarriage of unexplained cause — where the special situations above (diabetes, epilepsy and so on) do not apply — high-dose folic acid is not routinely recommended. This is a common mistake.

The measles-mumps-rubella and chickenpox vaccines contain live virus and cannot be given during pregnancy. If you are not immune you need to complete these before pregnancy and to avoid pregnancy for at least 1 month after vaccination. The influenza and COVID-19 vaccines can safely be given before or during pregnancy; the whooping cough vaccine is repeated in every pregnancy.

First, know this: having been given a live vaccine while unknowingly pregnant is not a reason to end the pregnancy. Tell your doctor about it; your follow-up plan is then made accordingly.

Definitely do not stop it on your own. Epilepsy medicines must never be stopped suddenly without consulting a doctor — having a seizure can pose a greater risk than the medicine itself. The right course is for the type and dose of medicine to be reviewed with a specialist when a pregnancy is being planned.

Before pregnancy. Weight lost before pregnancy directly reduces the risk of pre-eclampsia, stillbirth and a large baby, and increases the chance of a normal birth after a previous caesarean. Medicines that help with weight loss are also not recommended during pregnancy — which is another reason the preparation needs to be done beforehand.

Yes. A body mass index below 18.5 increases the risk of miscarriage in the first three months and the likelihood of poor growth in the baby. A balanced weight matters in both directions.

Yes, particularly about smoking. Smoking is the most important modifiable risk factor for placental insufficiency, premature birth and stillbirth, and it is recommended that both partners stop when a pregnancy is being planned — in the father's case to prevent damage to sperm DNA. Alcohol should also be stopped completely when a pregnancy is being planned.

No. The approach guidelines recommend first is to wait 7–14 days, and most women need no other treatment. Surgery is only one of three options; you decide, on an informed basis, which is used.

Yes, in some situations the other options should be considered: a high risk of bleeding (for example being towards the end of the first trimester), a previous negative or traumatic experience relating to pregnancy (stillbirth, miscarriage, bleeding before birth), a clotting disorder or not being able to receive a blood transfusion, and signs of infection.

If waiting does not feel right for you, medical treatment is recommended. An approach coming first in a guideline does not mean you have to accept it — all three options should be discussed with you and the choice should be yours.

Where the pregnancy has stopped but the miscarriage has not started, two medicines are used; the second is given 48 hours after the first. In an incomplete miscarriage a single medicine is given as a single dose. You are given painkillers and anti-sickness medicine; the duration and heaviness of the bleeding and possible side effects such as pain, diarrhoea and vomiting should be explained beforehand. If bleeding does not start within 48 hours of the second medicine, tell your health service.

They are prescription medicines used under a doctor's supervision and are not appropriate for self-administration; for this reason no dose information is given on this page. The guideline also notes that some of these uses are outside the licence. The appropriate medicine and dose are decided by your doctor according to your situation.

No, options should be offered. The guideline requires that a choice be offered between two options: manual vacuum aspiration (drawing out by suction) under local anaesthesia, in outpatient or clinic conditions, or a surgical procedure under general anaesthesia in an operating theatre.

After both waiting and medical treatment, a urine pregnancy test is done at home 3 weeks later. If the test is positive you need to be seen, to rule out pregnancy tissue remaining in the womb, a molar pregnancy or an ectopic pregnancy. If the test is negative but heavy bleeding continues, or there are symptoms such as pelvic pain or fever, assessment is again needed.

Bleeding in a pregnancy inside the womb in which a heartbeat is seen does not always mean a miscarriage. If you have not had a miscarriage before: if the bleeding increases or lasts more than 14 days, reassessment is needed; if it stops, routine antenatal care continues. If you have had a miscarriage before, micronised progesterone by the vaginal route is recommended and, if a heartbeat is confirmed, continued until week 16 of pregnancy is completed.

No. This page describes the management of pregnancy loss (miscarriage). Elective termination of pregnancy has its own legal framework in Türkiye; you need to speak to your doctor about the conditions and the process.

In a pregnancy that runs without problems, about 10 check-ups are expected for those in a first pregnancy and 7 for those who have given birth before. It is recommended that the booking visit take place before week 10 (by week 14 at the latest).

Blood pressure is measured and the urine tested for protein (screening for pre-eclampsia), the baby's heart sounds are listened to, generally from week 28 the height of the womb is measured and plotted on a growth chart, and the baby's movements are asked about, particularly after week 28.

No. In those with a body mass index above 35 or with a large fibroid in the womb, this measurement can be misleading. These women are followed up directly by ultrasound.

Blood group and antibody screening, a full blood count, screening for HIV, hepatitis B and syphilis, a urine culture, measurement of exposure to smoking and assessment of mental health. Guidelines do not recommend routine screening in the general pregnant population for chlamydia, bacterial vaginosis, genital herpes and hepatitis C — these are requested according to the level of risk.

In the guidelines the test is carried out in those with risk factors between weeks 24 and 28: excess weight, diabetes in the family, gestational diabetes in a previous pregnancy and so on. National programmes differ; ask your doctor about your own situation.

Antibody screening is repeated in this week, and there is a critical order: the blood sample must be taken immediately before the anti-D injection is given. Getting the order wrong makes the result difficult to interpret.

In the last three months growth is followed at the examination by measuring the height of the womb; ultrasound is used to complete the assessment. The situations in which it is particularly requested: a plateau or deviation from the chart in the measurement, a reduction in the baby's movements, a newly developed condition in the mother (high blood pressure, bleeding), and situations in which the measurement is not reliable.

Because the volume of blood increases in pregnancy, so the values naturally fall. In the first three months a haemoglobin below 11 g/dL is regarded as anaemia, while around week 28 the figure is below 10.5 g/dL. For this reason the same value is interpreted differently at different weeks.

No, that is a common misunderstanding. The nuchal translucency is only one of the values measured. This examination also looks at the head and brain, face, heart, abdominal organs, arms and legs and the placenta; it confirms that the pregnancy is viable and how many babies there are, establishes the gestational age and assesses the risk of pre-eclampsia.

Because the crown–rump length measured at this stage is the most reliable measurement for determining gestational age. The accuracy of all subsequent care and tests rests on this dating.

This is an indicator of risk, not a diagnosis. In about 50–60% of babies with Down syndrome the nasal bone is not seen — so its not being seen does not by itself mean a conclusion, and its being seen does not remove the risk altogether. The result is assessed together with the other findings and tests.

For two separate purposes: in the baby, the flow in certain vessels going to the heart and at a heart valve is examined to assess markers of risk for chromosomal differences and heart defects. In the mother, the flow in the uterine arteries is measured and, together with blood pressure and blood tests, a risk calculation for pre-eclampsia is made.

All the baby's organ systems are examined in detail: head and brain, face, heart, lungs, abdominal organs, kidneys and bladder, spine, arms and legs. Growth measurements are also taken, the amount of amniotic fluid is assessed and the relation of the placenta to the cervix is established.

Counting fingers is not a required part of routine screening. The symmetry, length, position and movement of the bones in the arms and legs are assessed. This is a point worth knowing so that expectations are set correctly.

If the placenta is closer than a certain distance to the cervix, a repeat look in the third trimester is recommended. This does not mean there is a problem at the time — the placenta can move upwards as the pregnancy progresses. If you have had surgery on the womb, additional findings are also looked for with regard to a problem of attachment.

Dilatation of the renal pelvis is one of the findings looked at in the detailed ultrasound. If it is above a certain measurement, follow-up is needed — in most cases it is managed by monitoring. Your doctor decides how often checks are needed according to the degree of the finding.

On the surgical side Labiaplasty, Clitoral Hood Reduction, Vaginoplasty and Hymenoplasty; on the energy and filler side Genital Laser, Labia Majora Filler, PRP to the Genital Area and G-Spot Injection. Their levels of evidence differ greatly from one another.

It helps to think in three groups. Those correcting a functional problem (discomfort from the size of the inner labia, repair of support after childbirth) have defined findings and established techniques. For changes caused by the menopause, moisturisers, local oestrogen and hormone therapy come first. For injections aimed at sexual function there are explicit warnings from ACOG and the FDA.

Because whether a result is found acceptable depends not only on the anatomical finding but on the balance between that finding and the distress it causes. In people whose finding is small but who perceive it as very large, no result may feel sufficient. This assessment is meant to protect you from possible disappointment.

Because it is not rare: its frequency among people presenting for aesthetic surgery has been found to be 13.2%. The critical finding is that more than 90% of people with this condition are still not happy after surgery, and surgery can make the situation worse. The right course is psychological assessment and treatment first.

Yes. One of the source texts puts it this way: “A patient cannot consent to a flawed procedure.” If the examination findings do not support it, the procedure is not recommended — the scarring and risks would outweigh the change that could be achieved. This stands however keen the person may be.

For two reasons. First, the sources' own warning: images must not be presented in a way that suggests an “expected result”; healing and scarring vary from person to person. Second, the regulation in force: information about the cost of procedures, promotional announcements, accounts of other people's experiences, before-and-after images and product brands do not appear on this site.

A chaperone who is a health professional must always be present during the examination; this rule applies to female doctors and female patients too. A family member is not considered suitable for this role.

The main condition is the genitourinary syndrome of menopause (GSM): vaginal dryness, burning, irritation, reduced lubrication, laxity and pain during intercourse. These in turn can lead to vaginal infection, inflammation of the bladder and burning on passing urine.

Up to 50% of women who have gone through menopause experience at least one GSM complaint. After menopause, vaginal dryness is reported at 27–55%, pain during intercourse at 32–42% and urinary tract infection at 4–15%. So it is not rare — but because it is a difficult subject to talk about, it is seldom mentioned.

No, and this matters. The source lists moisturisers and lubricants, hormone therapy (if nothing stands in the way) and local oestrogen preparations as the conventional treatments. Hyaluronic acid, PRP and laser are among the tools that can be used. Laser is not described as replacing the others or as being superior to them.

Medical lasers work through a photo-thermal effect: the beam is absorbed by the tissue component able to absorb it (the chromophore) and heat is released. The target chromophore of the CO2 and Er:YAG lasers used in genital applications is water. In their fractional forms (which deliver the energy to spot areas) the energy is given not to the whole surface but to spot areas; the intact tissue in between acts as the source of healing.

Er:YAG has a wavelength of 2940 nm and acts mainly on the upper skin layer. The CO2 laser reaches both the upper and the middle skin layer; it is a stronger laser that works more deeply. Both have fractional forms.

This should be known clearly: the US Food and Drug Administration (FDA) and the American College of Obstetricians and Gynecologists (ACOG) have stated that there is no official approval for marketing energy-based devices for "vaginal rejuvenation" or for the treatment of menopausal complaints, urinary incontinence and sexual function problems, and that unsupervised use may carry a risk of burns, scarring and lasting pain. Clinical studies, on the other hand, report favourable results in GSM complaints. The picture is not one-sided — you need to know both sides when you decide.

The common protocol is 3 sessions 4–6 weeks apart; in some situations this may go up to 5 sessions. But it is not done once and finished: because the collagen production stimulated by the laser declines over time, a reminder session once a year is recommended, and depending on the state of the tissue the whole course may need to be repeated every two years. It is worth taking sustainability into account when you decide.

In the first 24 hours there may be mild redness, swelling and pinpoint bleeding; in the first 7–10 days mild stinging, itching and mild burning on passing urine. Discharge is expected: a light pink watery discharge for the first few days, then a heavy, clear discharge lasting 7–15 days — this is the result of the shedding surface cells, not a sign of infection. On the day of the procedure there may also be flu-like symptoms such as tiredness and a slight fever.

So as not to suppress the process that starts the healing, paracetamol is recommended during this period rather than medicines such as ibuprofen or aspirin. Ask your doctor about the medicine you are going to use.

Active infection (vaginitis, urinary tract infection, thrush, herpes), an abnormal smear result within the past year, gynaecological cancer or bleeding whose cause has not been established, pregnancy and the first 3 months after birth, moderate to advanced prolapse (in which case the tears cannot be repaired with a laser and the only option is surgery), active inflammatory skin disease in the area, uncontrolled diabetes, use of blood thinners, use of oral isotretinoin within the past 12 months, and unrealistic expectations.

With tissue-removing (ablative) lasers the healing time may be longer, and there is a risk of darkening of colour and of scarring. For this reason cooling before and after the procedure is important. The procedure also needs to be carried out by an operator trained in the protective measures appropriate to the wavelength used.

Yes. The function of the outer lips is to surround and protect the other external genital structures. When they lose volume and flatten with age, the inner lips, the vagina and the urinary tract are left unprotected; this contributes to infection, inflammation of the bladder and discomfort. For details you can see the Labia Majora Filler page.

The application is referred to in promotional material by a brand name. Because the Turkish Regulation on Advertising and Information Activities in Health Services excludes the advertising of products and brands (Article 5/1-h) and popular-culture names (Article 5/1-c), the clinical name is used on this page. The content describes the same application.

PRP (platelet-rich plasma) is obtained from the person's own blood. The blood is separated by rapid spinning (centrifugation); first the red cells are separated, then the platelets are concentrated. Platelets contain growth factors able to stimulate mesenchymal stem cells (cells able to turn into different tissues); this is the reasoning on which the application rests.

The aim is to deliver the growth factors to the clitoral area and to the Skene glands around the urinary tract, in order to stimulate the formation of new nerves in the clitoris and an increase in the secretion-producing cells in the Skene glands. These are the intended mechanisms — it has not been shown in large studies that they actually occur.

The source gives no clear answer to this question: it states that it is very difficult to say how long it will take for new nerve formation or an increase in secretion, and therefore a change in sexual satisfaction, to appear.

No. According to the report of the authors who perform the method, at 3 months about 10% of patients reported no improvement at all in their sexual satisfaction. The source also states plainly that this datum is unpublished.

It is limited. In the source's own words, follow-up studies with larger numbers of patients and over longer periods are needed for the results to be established more soundly. In addition, whether one of the areas the application targets — the G-spot — is a real anatomical structure present in every woman is disputed in the literature; the same literature contains reviews describing it as "a modern gynaecologic myth".

The source states that the legislation governing PRP injection differs from country to country and that in some places it is not permitted in the outpatient setting. You need to consult your doctor about your own situation and the current legislation.

The first step is not to choose a procedure but to have the cause of the complaint assessed. There may be genitourinary syndrome due to menopause, vaginal dryness, hormonal changes or other conditions causing pain — most of these have well-established treatments. After assessment, the appropriate course is decided together.

No. In 2018 the FDA announced that it had not approved the safety and effectiveness of energy-based devices for this purpose; ACOG also stated that cosmetic vaginal procedures are not based on adequate evidence. There are studies reporting favourable results, but specialist societies say broader and longer-term studies are needed.

The two work differently. The laser produces controlled peeling at the tissue surface, reaches a higher temperature, and because it depends on the tissue components that absorb light it carries a risk of burns in darker skin types. Radiofrequency does not peel the surface, goes deeper and works at a lower temperature. Which is suitable depends on the complaint, the state of the tissue and the person's other health problems; the evidence for both is limited in a similar way.

The number of sessions varies with the device used: in some systems three sessions 4–6 weeks apart, in others a single session. The main part of the effect does not appear immediately; it begins to be felt after the third week and continues to develop over 3–4 months.

No. Because the device produces an electromagnetic current, it is not applied to those with a pacemaker or another implanted electronic device. An intrauterine device (coil), on the other hand, is not an obstacle; it does not need to be removed.

The type and degree of the leakage need to be established first. Pelvic floor exercises, for which the evidence is stronger, come first. Radiofrequency may come up only in mild cases and after the other options have been assessed; in second-degree prolapse and above it is inadequate, and in that situation surgical repair is recommended.

The types that cause genital warts are the low-risk HPV 6 and 11. The types that cause cancers are different — most often 16 and 18. So having warts does not mean you are infected with a cancer-causing type. Even so, the screening recommendations should be followed.

They take the form of rounded bumps or plaques (raised patches) that may be skin-coloured, light and shiny, or dark grey, brown or purple; they are described as "cauliflower-like". They do not cause pain, but they may itch or become irritated.

The diagnosis is mostly made by examination. 3–5% acetic acid may be applied as an aid — it makes mucosal cells (the thin tissue lining the inner surface) infected with HPV turn white and so visible. HPV DNA can also be looked for by PCR in the samples taken. Because there are other conditions that look like warts (skin tags, moles, seborrhoeic keratosis, molluscum, condylomata lata and some skin cancers), assessment is necessary.

Partly. Used correctly and consistently they are quite effective, but they do not give complete protection: HPV can also be transmitted by skin-to-skin contact and from areas outside the barrier. It has also been documented that HPV can be transmitted without sexual intercourse — through intermediate objects such as clothing, medical equipment and surfaces, and through non-sexual skin contact.

There are two families. Tissue-destroying procedures: freezing (cryotherapy), cautery, surgical removal and laser vaporisation. Topical treatments: podofilox and imiquimod (which you apply yourself) and sinecatechin ointment (applied by the doctor). The choice is made according to the site, size and extent of the warts. Surgical removal, for example, provides tissue for pathological examination, while laser is useful for widespread lesions (tissue changes) that are difficult to reach.

Yes, recurrence is common and most people need more than one treatment session. This does not mean the treatment has not worked — it is the nature of the condition. Using tissue-destroying and topical methods together can increase clearance and reduce recurrence, particularly in widespread disease.

These heat-based methods can release virus particles into the air, and this carries a possible risk of warts forming in the throat. For this reason an appropriate respirator mask and a surgical smoke extractor need to be used during the procedure. That is why it matters that the procedure be carried out in a properly equipped setting.

HPV infection is mostly cleared by the immune system. But in people whose immune system is suppressed — those with systemic lupus (affecting the whole body), HIV infection or a history of organ transplant — the risk of the infection persisting is higher. Tobacco use is also among the factors that increase the risk.

No. It is direct visualisation of the inside of the womb with a fine telescope, but treatment can also be carried out in the same session — this is called the "see and treat" approach. Removing polyps and fibroids, dividing adhesions, cutting a septum, removing a lost coil and removing pregnancy tissue remaining in the womb can all be done this way.

The guideline prefers mechanical tissue-removal systems to small electrical tips, and recommends this at the highest level of evidence. In a comparative study the mechanical system was found to be less painful, faster and to have a higher success rate.

This is a real risk, because surgery on the womb is itself a cause of adhesions. For this reason treatment does not end with dividing the existing adhesion; protective measures such as barrier gels containing hyaluronic acid, absorbable medical membranes or an intrauterine device must be used to prevent a new one from forming.

In people who have experienced recurrent pregnancy loss, correction of the septum with hysteroscopy is reported to reduce the rates of pregnancy loss markedly. Mechanical mini-scissors that use no electricity are preferred in the procedure; they are significantly less painful than electrical tips.

No, routine preventive antibiotics are not recommended. In a large randomised study no significant difference was found in the infection rate between those given antibiotics and those not given them (1.0% versus 1.3%). The exception: if an active infection is suspected before the procedure it is postponed and treated; if pus is found in the womb during the procedure, intravenous antibiotics are started immediately.

It is rare but serious; the reported rate is between 0.002% and 1.7%. In a diagnostic procedure it is less than one in a thousand, and a little more frequent when a polyp or fibroid is removed. Factors that increase the risk: the need to dilate the cervix by more than 6 mm, narrowing of the cervix, a tortuous canal and an excessively angled womb.

Fainting, nausea and dizziness can occur: reported at 1.1% in a diagnostic procedure and at 5.8–12% in treatment procedures such as polyp and fibroid removal. Using salt water instead of carbon dioxide to distend the inside of the womb reduces this reaction significantly.

It generally takes 10–15 minutes; it may take longer if an additional procedure is carried out. Taking a painkiller 1–2 hours before the appointment is recommended. Afterwards use a pad, not a tampon. Bleeding for a few days that is lighter than a period is normal.

If you have abdominal pain that does not settle with a simple painkiller, bleeding heavier than a period, or signs of infection such as fever, shivering and foul-smelling discharge, seek help without delay. You should be given telephone numbers you can reach, including an out-of-hours number.

Yes. The procedure can be stopped at any moment. If pain or discomfort becomes unbearable, telling the team is enough; the procedure is stopped immediately. The team is also obliged to take into account that you may not be in a position to say so.

No, it is definitely not. The sources make this distinction explicitly: clitoral hood reduction has nothing whatsoever to do with female genital cutting, infibulation, cultural or ceremonial practices, or genital piercing. Nor is it a procedure performed on the clitoris — only the excess of the hood skin covering it is reduced.

It can be done, but that is uncommon. According to the sources, hood reduction is rarely performed as a separate procedure; it is most often planned together with inner lip reduction. One reason is aesthetic balance: if the hood is not corrected while the inner lips are reduced, the clitoral area may look disproportionately prominent.

It is necessary to be honest here: according to the sources its functional results are not fully known and its effect on sexual function has not been established. For this reason it is regarded as predominantly a procedure to do with appearance. One exception: if the clitoris is completely covered by an excessively thick hood, this can prevent it from receiving adequate stimulation.

The source gives this list plainly: those expecting orgasm only in a particular position or with no other stimulation at all; those who are currently content and have no examination findings; those with reduced sexual desire (if the cause is psychological or hormonal, surgery does not help); those with pain in the clitoris; those seeking multiple orgasms — such a result cannot be promised.

In these two situations the likelihood of the problem recurring is high. With adhesions due to menopause, the problem recurs if the hormonal situation is not corrected. With scar tissue due to lichen sclerosus, the condition recurs within a few months almost every time. For this reason the underlying condition needs to be addressed first.

This is the most important technical concern of the procedure. The clitoris contains about 8,000 sensory nerves and the under-surface of the hood is also rich in nerves. For this reason surgery does not go down to the deep plane; the dissection is kept in the superficial layer. Aggressive incisions can lead to lasting loss of sensation or to pain during intercourse.

Those with unrealistic expectations, those with untreated psychosexual problems, those with an active infection or inflammatory disease of the external genital area, those with a clotting disorder, and those who smoke. ACOG also recommends that in people presenting with a complaint of sexual dissatisfaction, the psychosexual situation be assessed before surgery.

It is recommended that the excess of the hood be assessed standing. Tissue thickness, excess folds and symmetry are examined; the clitoris is examined by hand and its size assessed; adhesions, narrowing, scarring and pain are recorded. Previous genital surgery is always asked about. The appearance of the hood varies a great deal from person to person and is mostly not symmetrical — for this reason there is no definition of an "ideal" appearance.

No. There is broad agreement in the scientific literature: the assumption that virginity can be identified by examination of the external genitalia is a myth. In one study, 19% of sexually active adolescent girls had no tear, notch or cleft at all in the hymen.

No. It is reported that 40–50% of women from different cultural backgrounds have no blood loss at all at first intercourse. The absence of bleeding is something to be expected.

Yes. The insertion of objects such as tampons, strenuous sporting activity, surgical procedures and falling onto a sharp object are among the reasons listed. The elasticity of the structure also varies from person to person — in some situations it may be elastic enough to allow intercourse without tearing.

Looked at on purely medical grounds, no — the sources state that the procedure is not medically indicated, provides no medical benefit, and that the balance of benefit against risk is not in its favour. Given the World Health Organization's definition of health as "a state of physical, mental and social well-being", it is also noted that a health benefit can be spoken of.

The Royal College of Obstetricians and Gynaecologists (RCOG) strongly opposes both virginity testing and hymenoplasty; it states that neither is medically necessary under any circumstances and that both reinforce beliefs that wrongly attach a value to women on the basis of their sexual history. RCOG also emphasises that a clinical procedure should not be performed in order to protect someone, and that people at risk of violence should be referred to the relevant agencies.

You should have counselling — and there are data showing how decisive this is: of the 82 women who applied for hymenoplasty, only 24 (29%) decided to go ahead with surgery after detailed counselling. For most of them, the information and self-confidence gained in counselling meant they were able to give up the operation they had initially seen as the only solution.

Wound separation, infection, scarring, distortion of the shape of the vaginal entrance and over-narrowing of the entrance are the risks listed. Over-narrowing may lead to obstruction of the outflow of menstrual blood and to pain during intercourse. In the largest series of 518 people, bleeding requiring surgery in the early period was reported at 0.5%; in the same series no complication related to childbirth was reported.

No — no technique can predict or promise this. There is no accepted surgical standard aimed at restoring the bleeding property of the hymen. While the rate of reporting bleeding after the procedure with one method is given as about 69%, the rate of recalling bleeding at first intercourse among people who have had no procedure at all is only 34%.

No. Guidelines recommend treatments without medicines as the first step: in the stress and mixed types, supervised pelvic floor muscle training for at least 3 months; in the urge and mixed types, bladder training for at least 6 weeks. Surgery comes up after these and, where appropriate, drug treatment have been tried.

The programme should last at least 3 months, be supervised and include at least 8 contractions three times a day. Before starting, an examination is done to confirm that you can contract the muscles correctly — this step matters, because exercising the wrong muscle produces no result. Devices that show muscle activity on a screen are not routinely recommended.

At the first assessment, the Q-tip, Bonney and Marshall tests, and routine cystoscopy (examination of the bladder with a camera) and imaging methods (MRI, CT, X-ray) should not be used. What is needed: a detailed history, a urine dipstick test, an examination, a bladder diary for at least 3 days and, if necessary, measurement of the amount left after passing urine by ultrasound.

No. In people in whom the history and examination clearly identify the stress type or a stress-predominant mixed type, routine urodynamic testing before a first operation is not recommended. The situations in which it is needed: urge-predominant mixed type or uncertainty about the type, suspicion of difficulty emptying the bladder, accompanying pelvic organ prolapse, and a previous unsuccessful operation for stress incontinence (urinary leaking).

No, patience is needed. With medicines that relax the bladder (anticholinergics), at least 4 weeks are needed for the full benefit. Side effects such as dry mouth and constipation may indicate that the medicine is working. It should also be explained to you that the long-term effects on cognitive function are uncertain.

Hormone treatment that affects the whole body (systemic) has no place in the treatment of urinary incontinence. But if you have complaints such as dryness, painful intercourse and irritation due to menopause and also have an overactive bladder, local (vaginal) oestrogen should be offered. These two are different things.

Desmopressin may be considered for getting up at night where this affects your quality of life. But care is needed in patients with cystic fibrosis, and it should be avoided in those over 65 and those with cardiovascular disease.

The guideline recommends weight loss for women with a body mass index above 30. It also recommends reducing caffeine in overactive bladder, and fluid intake is adjusted if it is very high or very low.

No. Colposcopy is done not because a diagnosis of cancer has been made but to measure risk. Guidelines define colposcopy as a risk assessment tool: it guides whether treatment, biopsy or only follow-up is needed afterwards. Being able to show safely that there is no disease is also one of the benefits colposcopy provides.

First acetic acid at a concentration of 3–5% is applied; this is a dilute vinegar solution and makes suspicious areas turn white temporarily. Where necessary, Lugol's iodine solution is also used to see whether the tissue takes up the stain. These two applications guide the taking of the biopsy from the right point.

Not always. In low-risk people whose colposcopic appearance is normal, not taking a biopsy is an acceptable approach. When a suspicious area is seen, targeted biopsies are generally taken from 2 to 4 points so that the most advanced change is not missed.

No. The colposcopic impression is a visual assessment and is not accepted as definitive on its own; for this reason it is recommended that suspicious areas be sampled by biopsy. The definitive diagnosis is made by the pathology (tissue) examination of the biopsy.

In selected situations, yes. In high-risk people with strong evidence in favour of high-grade disease, removal of the transformation zone with a loop may be done immediately after the colposcopy, so that diagnosis and treatment take place in the same session. This is not a practice that applies to everyone; your own findings determine the decision.

Colposcopy has other uses as well, such as assessment of the vagina and the vulva. But what is described on this page is colposcopic assessment within the scope of preventing cervical cancer.

It is considered where the inner labia extend outwards, are thickened by mucosa or submucosal tissue, have excess length front to back, or have a ruffled appearance. In the sources it is described as the most frequently performed female genital aesthetic procedure. The decision, however, rests on examination findings — the request alone is not sufficient.

In edge trim, tissue is taken along the free edge of the labium. In the wedge technique a full-thickness slice is taken from the most protruding part. The wedge technique's notable feature is that it preserves the natural edge of the labium, leaves a shorter scar and produces less sensitivity in the scar area. It also preserves the important nerves and maintains the arterial blood supply.

In labia thickened by excess submucosal tissue, edge trim is difficult: thinning the tissue would require removing almost the whole labium. The result is remnants that are very short and have lost their natural edge. The wedge technique, by contrast, allows the amount of submucosal tissue removed to be adjusted.

The wedge technique is usually performed under local anaesthetic and most often takes less than an hour. People are reported to tolerate the procedure well under these conditions.

Notching of the edge, separation of the stitches and a collection of blood are the complications listed, and they are uncommon. Even so, as with any surgical procedure, healing and scarring vary from person to person; possible outcomes should therefore be discussed as a range.

Yes, that is possible. The source states plainly that labiaplasty should not be performed on people whose inner labia are already small on examination: the scarring and risks would outweigh the change in appearance that could be achieved. This assessment stands however keen the person may be.

Because whether a result is found acceptable depends not only on the anatomical finding but on the balance between finding and distress. In people whose finding is small but who perceive it as very large, no result may feel sufficient. This assessment is part of the procedure and is meant to protect you from possible disappointment.

Body dysmorphic disorder is when a person perceives an aspect of their appearance as ugly, although the appearance is usually ordinary. Its frequency among people presenting for aesthetic surgery has been found to be 13.2% — so it is not rare. What matters is this: more than 90% of people with this condition are still not happy after surgery, and surgery may make the situation worse. The right course is psychological assessment and treatment first.

Yes. A chaperone who is a health professional must always be present during the examination; this rule applies to female doctors and female patients too. A family member is not considered suitable for this role.

There is less pain and less need for painkillers after the operation, the hospital stay is shorter and the return to work is faster. Wound infection is less frequent, there is less blood loss and the scar is very small. One of the most important: fewer adhesions form — which is particularly valuable for those thinking of a pregnancy later.

The great majority pass without problems. In diagnostic laparoscopy the risk of a serious complication is about two in a thousand. Bowel injury is 0.4–1.1 in a thousand; major vessel injury 0.1–0.2 in a thousand; injury to the bladder or urinary tract 0.3 in a thousand. Death is very rare (3–8 in a hundred thousand). The risks increase if an additional treatment procedure is carried out.

This is very important: about 15% of bowel injuries cannot be noticed during the operation and show themselves days later, often after you have been discharged. Increasing abdominal pain — particularly if accompanied by fever, loss of appetite and vomiting — means you should seek help without delay.

Shortness of breath, chest pain or coughing up blood — this may indicate that a clot has travelled to the lung; call for emergency help. Pain, redness, swelling or warmth in the leg, or difficulty putting weight on it, may also be a sign of a clot in a vein. Redness and pain around the scars suggest a wound infection.

This is expected and temporary: part of the gas used to inflate the abdomen during the operation remains behind and irritates the diaphragm, causing pain at the tip of the shoulder. Similarly, trapped wind can occur because the bowels slow down temporarily; walking relieves it.

Move as early as possible. Even while resting, move your ankle and pump each foot briskly up and down for 30 seconds. Also take your painkiller regularly — if the pain is under control you will get up earlier, which both speeds up healing and prevents clots.

This is assessed beforehand. The rate of adhesions around the navel can be as high as 50% after a midline incision and 23% after a low transverse incision. For this reason the surgeon may prefer to make the entry at a different point. Excess weight and being very thin also affect the entry plan.

Because when the abdominal wall is thin, the deep structures come very close to the skin. In young, very thin women with well-developed abdominal muscles who have never given birth in particular, the main artery may be only 2.5 cm below the skin. Because this is known, the entry method is chosen accordingly in this group.

Yes, this is a known possibility and it should be explained to you before the operation. It is also part of the information given that laparoscopy (viewing the abdomen with a camera) may not find the cause of your complaint.

A biopsy takes a small piece in order to make a diagnosis. LEEP removes the whole transformation zone; that is, it both treats and provides pathology with a complete tissue sample. That sample makes it possible to see whether there is a more advanced change than expected and whether the surgical margins are clear.

As a rule treatment is recommended for CIN 2; but follow-up can also come up — if your concerns about the effect of treatment on future pregnancies outweigh your concern about cancer. This is a matter for shared decision making. There are also situations in which follow-up is not accepted: if the upper border of the transformation zone cannot be seen, or if the sample taken from the canal shows CIN 2 or above. With CIN 3, follow-up is not accepted in those who are not pregnant.

Guidelines prefer removal methods for high-grade changes — but the reason is not a definite superiority in success. A Cochrane review comparing the surgical techniques concluded that no technique is clearly superior in terms of treatment failure or side effects. What LEEP actually provides is a tissue sample to send to pathology and information about the surgical margins; with burning methods this information cannot be obtained.

No. For high-grade cell changes, topical medicines, therapeutic vaccines and similar non-surgical methods are not acceptable outside the setting of a clinical trial. This is what the guidelines state plainly.

In some situations, yes; this is called expedited treatment. The decision depends on the current risk of CIN 3 or worse: if the risk is 60% or more, direct treatment is preferred; in the 25–59% range both direct treatment and colposcopy with biopsy first are acceptable. This decision should be taken together with your doctor, particularly if you are planning a pregnancy.

In glandular cell change in the cervical canal (AIS), removing the piece in one piece is preferred so that the margins can be interpreted correctly. A length of at least 10 mm is preferred; in those who have no concerns about the effect on future pregnancies it can be increased to 18–20 mm. Deliberately dividing the piece is not acceptable.

Generally no. CIN 1 is the appearance of HPV infection in the tissue and the rate of it regressing on its own is high, particularly at younger ages. Even in those aged 25 and over in whom CIN 1 has been found for at least two years in succession, follow-up is preferred; treatment is an acceptable option only as a personal preference after shared decision making.

A scan at least once is advised for all postmenopausal women aged 65 and over, even with no other risk factor. Under 65, going straight to DEXA is not considered appropriate as general screening — the 10-year fracture probability is first calculated with a tool such as FRAX, and DEXA follows if the risk is high.

In early menopause and ovarian insufficiency a DEXA scan must be done at the time of diagnosis, to establish a baseline. Because cardiovascular risk is markedly higher in this group, blood pressure, weight, cholesterol and blood sugar should also be checked once a year.

No. If the baseline scan is normal and adequate oestrogen therapy has been started, there is little clinical value in repeating it within 5 years. If osteoporosis or reduced bone mass has been found, it is checked every 1–3 years; in women taking bone-losing medicines who are not on hormone therapy, every 2 years is advised.

Current advice for women at average risk of breast cancer is to begin screening with mammography every two years from the age of 40. In women on hormone therapy follow-up is closer; clinical protocols include breast imaging together with a gynaecological examination once a year.

Yes. After the menopause the protective effect of oestrogen is lost, so risks relating to the heart and metabolism increase. In natural menopause a baseline risk profile is established during the transition, lifestyle changes are supported, and regular cholesterol and blood pressure monitoring follows according to risk. In early menopause this monitoring should be annual.

In those at high risk of bone loss, measuring the vitamin D level at the outset, or considering supplementation directly, is advised. The amount of supplement is decided individually, so no dose is given on this page.

If 12 consecutive months have passed since your periods stopped, you are considered to have reached the menopause; the date of your last period is taken retrospectively as the moment of menopause. The stage before those 12 months are complete, when periods become irregular and symptoms can begin, is called perimenopause.

Usually not, if you are over 45 — an FSH test is not useful for diagnosis in that age group, because the level fluctuates from month to month. The diagnosis is made from your symptoms and the change in your periods. Under 40, FSH is measured if ovarian insufficiency is suspected; between 40 and 45 it may help. A single test may not give the diagnosis.

No. About one in four women has no symptoms at all. Hot flushes and night sweats are the most common symptoms and occur in 70–80% of women. Of those who do have symptoms, 25% describe them as severe and disruptive to daily life.

On average more than 7 years. More than a third of women have long-lasting symptoms that can continue for years. During perimenopause symptoms may come and go; some ease while others become more noticeable.

Yes. Because hormone receptors are found throughout the body, symptoms can look unrelated to each other. Disturbed sleep, fatigue, anxiety, difficulty with memory and concentration ("brain fog"), joint pains, palpitations and headaches are all recognised. In perimenopause the first hormone to fall is usually progesterone; because it has a calming, sleep-promoting effect, sleep can suffer as it declines.

Yes. Menopause under the age of 40 is called premature ovarian insufficiency (POI) and affects about 1 in 100 women under 40 (1 in 1,000 under 30, 1 in 10,000 under 20). Periods stopping permanently between 40 and 45 is described as early menopause.

Removing both ovaries at operation is called surgical menopause; loss of ovarian function through radiotherapy or chemotherapy is called medical menopause. In these situations the menopause begins abruptly. You should be told about the effects in detail before the operation or treatment, and have access to continuing support afterwards.

Falling oestrogen has long-term effects in two areas: an increased risk of osteoporosis and of heart disease. Osteoporosis has no clear symptom — the first sign may be a fracture. The menopause is therefore a good time to review lifestyle and health screening.

No. Guidelines describe several non-hormonal options: neurokinin receptor blockers, antidepressant-group medicines (SSRIs/SNRIs), gabapentin and pregabalin, oxybutynin and clonidine. Cognitive behavioural therapy is also recommended with the strongest level of evidence. None is as effective as hormone therapy, but they can reduce symptoms appreciably.

Past or active breast cancer, hormone-sensitive gynaecological tumours, vaginal bleeding of unexplained cause, active or past blood clot, active liver disease, a recent heart attack or coronary heart disease, past stroke, and high blood pressure that is not under control.

If you take tamoxifen, paroxetine and fluoxetine must not be used — they block the enzyme that activates tamoxifen in the body. The preferred option is venlafaxine. St John's wort is also not recommended because it interacts seriously with chemotherapy, and phytoestrogen supplements are not suitable with a history of a hormone-sensitive tumour.

It is important to set the right expectation: CBT does not remove the number of hot flushes. It changes how you perceive them, strengthens your belief that you can cope, and lessens the sense of being overwhelmed. In studies, 4–6 weekly sessions clearly improved distress, sleep problems and anxiety, and the effect persisted at 26 weeks.

In a randomised controlled trial aerobic exercise, yoga and omega-3 supplements could not be shown to be superior to placebo for the frequency of hot flushes. That does not make exercise unnecessary — it is always recommended for muscle mass, mood and bone health. It should just not be done with the sole expectation of reducing hot flushes.

Being “natural” does not mean being safe. For black cohosh a Cochrane review found no clear superiority over placebo, and cases of serious liver toxicity have been reported. St John's wort interacts seriously with many medicines. Phytoestrogen supplements are not recommended with a history of a hormone-sensitive tumour.

Neurokinin receptor blockers are the newest group; they have been reported to reduce the frequency of hot flushes by more than 50%, with the effect beginning within the first week. However licensing and availability differ from country to country. These medicines also require regular liver function tests before and during treatment.

If non-hormonal treatments do not relieve your symptoms, or troublesome side effects persist, guidelines recommend referral to a health professional experienced in the menopause. The treatment options are then reassessed individually.

Earlier than most people think: loss begins 1–2 years before the last period and continues for a further 3–4 years. The fastest loss is in the three-year window from one year before to two years after the last period — in that short time an average of 10.6% of bone mass is lost from the lumbar spine and 9.1% from the femoral neck.

No, and this is the most common mistake in assessment. The great majority of fractures after the menopause occur not at the “osteoporosis” threshold but one step above it, in people whose bone mass is only mildly reduced. Bone health should therefore be judged with whole-person risk assessment tools, not the score alone.

Oestrogen keeps blood vessels flexible and supports the healthy working of the vessel lining; when it is withdrawn the vascular bed is left unprotected. In the same period total cholesterol, “bad” cholesterol and triglycerides rise while “good” cholesterol falls. This increases arterial stiffness and the risk of heart disease.

Because the benefit depends on it. When treatment is started within the first 10 years of the menopause or before the age of 60, coronary heart disease, heart failure and cardiovascular deaths are reported to fall by roughly half. The same treatment started later does not show this benefit.

Yes, and it has a measurable basis. Oestrogen governs how the brain uses glucose, its main fuel; with the menopause the brain's use of glucose falls temporarily by 20–25% and the brain shifts to a different fuel arrangement. Difficulty finding words and trouble concentrating follow from that shift — they are not imagined.

No. Although protective effects of oestrogen in the brain have been described, guidelines do not recommend starting hormone therapy solely to prevent dementia in women going through a natural menopause. The decision to treat is made on other grounds and individually.

With the menopause the distribution of fat changes permanently: fat collects around the abdomen and the internal organs rather than at the hips. Muscle mass and strength also decline. Where the weight sits matters more than the weight itself — fat inside the abdomen drives insulin resistance and the risk of type 2 diabetes.

Yes, markedly. In women with early menopause who do not use hormone therapy, life expectancy is reported to be shortened; the main reason is rapidly progressing cardiovascular disease. Each year spent without oestrogen independently increases cardiovascular risk. Menopause caused by surgery takes a faster and more severe course than spontaneous early menopause.

If this is early menopause or ovarian insufficiency, yes. The strongest recommendation in the guidelines is that these women take hormone therapy even if they have no symptoms at all, at least until the age of natural menopause (on average 50–51), to protect heart, bone and brain health. In this age group the benefits are far greater and the risks far lower than in older women.

It is a method carried out with small-volume injections into the skin and beneath it. In skin rejuvenation it is one of the approaches that aim to stimulate the production of collagen — it appears on the same list as microneedling, chemical peels, energy-based devices, hyaluronic acid injections and biostimulant agents.

With these methods a period of 3–4 months is needed for results to be seen. The reason is this: biostimulation does not give volume immediately as a filler does; it stimulates the production of your own collagen, and that takes time. Not seeing a result straight away does not mean the treatment has not worked.

The slowing of collagen production begins after the twenties; in the same period its breakdown also starts to increase. After the thirties and forties there is a loss of 1–1.5% of collagen each year. In women this process speeds up with menopause.

It is a regenerative treatment carried out with biocompatible substances that stimulates the fibroblast (collagen-producing) cells responsible for the production of collagen and elastin in the skin and the tissues beneath it to increase in number and in their capacity to produce. The substances used are biologically degradable and absorbable; their end products are water and carbon dioxide.

On the contrary, it matters even more. Among the external factors that speed up skin ageing, sun damage caused by ultraviolet rays is the greatest threat. Smoking, alcohol and stress also speed up the biological clock. The result of treatment is determined together with daily habits.

Ageing of the face is not only about the skin. It is the combined result of changes in the skin, the fat tissue beneath it, the muscles, the deep fat pads, the connective tissue and the bone — with age there is also marked loss in the bone of the face, and this reduces the support for the tissues above. For this reason the assessment looks at the whole rather than a single layer.

The HPV test is more sensitive and, when negative, gives stronger reassurance that there is no cancer. For this reason screening with the HPV test alone (primary HPV screening) has become the preferred method in guidelines. A smear looks at cells, while an HPV test looks for the presence of the virus that can lead to cancer.

According to the American Cancer Society guideline, primary HPV screening is the preferred method, to be done every 5 years from the age of 25. If the sample was taken by a doctor and the result is negative, it is repeated every 5 years. National screening programmes differ between countries; ask your doctor about your own plan.

Yes, this is now an approved option and does not require an examination instrument (speculum). But a sample taken by a doctor is preferred; a self-collected sample is considered acceptable for people aged 25–65 at average risk. An important difference: if a test on a self-collected sample is negative, the repeat interval is not 5 years but 3 years. In some higher-risk people a doctor-taken sample continues to be recommended.

No. An HPV test is not a cancer test; it shows the presence of the virus that can lead to cancer. Most of those whose test is positive need further assessment steps — this usually means examination of the cells and, where necessary, Colposcopy. Your findings determine the next step.

For screening to be brought to an end in a person at average risk, the HPV tests done at ages 60 and 65 must be negative; it is a condition that the last HPV test not be at an age younger than 65. If these tests are not available, three consecutive negative examinations of the cells done at the recommended interval, the last of them at the age of 65, is acceptable.

It is recommended routinely at age 11 or 12 and can be started from the age of 9. The American Cancer Society encourages recommending it from the age of 9 or 10, because the vaccine is more effective at younger ages — being vaccinated at 12–13 is markedly more effective than at 14–15.

It is recommended up to the age of 26 for everyone who has not been adequately vaccinated. Between 27 and 45 it may be considered through a shared decision with the doctor; but it is stated that most adults in this age group will not benefit from the vaccine. The vaccine is not licensed for those over 45.

No. Doing a smear or HPV test before vaccination in order to decide whether the vaccine is appropriate is not recommended. The recommendations apply to everyone, regardless of behavioural or medical risk factors for HPV.

No. The vaccine does not take the place of screening. People who have been vaccinated also need to continue following the cervical cancer screening recommendations.

In pregnancy HPV vaccination is postponed until after the pregnancy; but there is no need for a pregnancy test before vaccination. People who are breastfeeding can be vaccinated.

No. In an adult woman with both irregular periods and excess male hormone, two of the three criteria are already met — there is no need for an ultrasound or an AMH test. An ultrasound is needed only if just one of these two findings is present, in order to assess the third criterion.

In young girls within the first 8 years after their first period, the use of ultrasound and AMH is not recommended. The reason is this: having many small follicles in the ovaries can be normal at this stage, and looking at an ultrasound leads to unnecessary diagnoses. In this age group, excess male hormone and irregular periods must be present together for the diagnosis.

The guideline states plainly: there is no single diet or exercise programme specific to PCOS. The general principles of healthy eating apply, and the form you can keep up and prefer yourself should be chosen. Approaches claiming that "this diet solves PCOS" have no counterpart in the guideline.

The first step is contraceptive pills; they are also the first option for irregular periods and acne. If an adequate response is not obtained from these or from cosmetic methods for at least 6 months, anti-androgen medicines are considered. Laser and light-based treatments are also effective in reducing unwanted hair.

You must use a highly effective method of contraception. These medicines can cause a developmental problem in a male baby. For this reason contraception must not be neglected during treatment.

Everyone at diagnosis — regardless of age and weight — should have fasting blood lipids checked and their blood sugar situation assessed. Blood pressure is measured every year. Lipid and sugar screening is repeated every 1–3 years if there are risk factors. The most sensitive test for sugar is the glucose tolerance test.

In premenopausal women with PCOS the risk is increased 2- to 6-fold, but the actual risk is still low. Routine screening of thickness by ultrasound is not recommended. However, if you have not had periods for a long time, have abnormal bleeding or have risk factors such as excess weight, the threshold for investigation is kept low. The way to protect against it: weight management, establishing a regular menstrual cycle and regular progesterone treatment.

PCOS is regarded as high risk in pregnancy. When planning a pregnancy, blood pressure should be measured and a glucose tolerance test done. If this was not done beforehand it is done at the first antenatal visit and then repeated at weeks 24–28.

Yes, and this should not be overlooked. Anxiety, low mood, sleep disturbance and eating disorders are markedly more common in PCOS. Sleep apnoea is also more common; if there is snoring and excessive daytime sleepiness, it should be assessed.

Metabolic syndrome, type 2 diabetes and high blood pressure are more common in the fathers and brothers of women with PCOS. This means family members should not neglect their own check-ups either.

It means the pregnancy will be watched more closely. An important point: the level of risk is not fixed — it can change through the pregnancy and, according to the guidelines, is reassessed at every examination. It is not a label attached once and left.

No, do not wait. The sources describe a reduction in the baby's movements as one of the most important warning signs that the placenta is not working well enough and that the baby is under strain. Tell your health service as soon as you notice it.

It depends on the level of risk. At moderate risk, a growth ultrasound every 4 weeks from week 32; at high risk, every 2–4 weeks from weeks 24–28. If there is excess weight or a fibroid in the womb, the measurement over the abdomen is not reliable, so follow-up is done directly by ultrasound.

To assess the blood flow going to and returning from the baby. Different vessels are looked at for different questions: the uterine arteries for the risk of pre-eclampsia, the umbilical cord artery for how the placenta is working — this is the basic tool for telling whether the baby is "small but healthy" or genuinely under strain.

Those at high risk of pre-eclampsia are started on low-dose aspirin in the evening from week 12, continued until week 36. This is a preventive measure. Your doctor decides the dose and how it is used.

PCOS is among the conditions that increase the risk of pre-eclampsia, gestational diabetes, miscarriage and growth restriction in the baby during pregnancy. This does not mean you will have problems — it means you will be watched more closely. When planning a pregnancy, measuring blood pressure and a glucose tolerance test are recommended.

Twins sharing a single placenta in particular carry special risks, because the vessels of the placenta are shared. This can lead to problems with blood being shared between the twins. These pregnancies should be followed by a multi-specialty team and in centres with advanced neonatal intensive care.

Some situations require several specialties to work together — particularly growth restriction starting before week 32 and problems in twins sharing a single placenta. It is recommended that these pregnancies be managed by a team of obstetric, fetal medicine, neonatal and anaesthetic specialists, in centres with advanced neonatal intensive care.

The purpose is examination in pathology of a tissue sample taken from the lining of the womb. The situation in which it most often comes up is abnormal bleeding from the womb; assessment of the inside of the womb may also be needed when investigating reproductive problems.

Hysteroscopy is direct visualisation of the cavity of the womb with miniaturised endoscopic instruments. What matters about it is that the inside of the womb is assessed by seeing rather than blindly, and that where necessary the sample can be taken from the right point. Guidelines state that this assessment can be done as an outpatient, without an operating theatre or general anaesthesia.

In most cases no. In a randomised study comparing it with general anaesthesia, with the outpatient procedure the time to getting up was 0 minutes (105 minutes under general anaesthesia) and time away from work 0.8 days (3.3 days under general anaesthesia); people's ratings of their experience were high and equivalent with both methods. Even so, alternative anaesthetic options should be explained to you and you can choose them.

The guideline addresses this openly: the procedure is well tolerated by most people, but it can be associated with significant pain, anxiety and a feeling of embarrassment. Taking a painkiller by mouth an hour before the appointment is recommended. With the vaginoscopic approach (carried out without an examination instrument) routine local anaesthesia is not recommended; conscious sedation should also not be used routinely.

It is difficult to predict in advance, but you should be told beforehand that the procedure may be more difficult in these situations: having experienced faintness because of pain during periods; having experienced severe pain or anxiety during previous vaginal examinations (including a smear); traumatic experiences, particularly a history of sexual violence. Sharing these allows the procedure to be planned around you.

Yes. You can ask for the procedure to be stopped. If you are anxious, the appointment can be rearranged according to the anaesthetic method you prefer. If you want someone close to you to be with you, this should also be accommodated unless infection control prevents it.

Some procedures can be done as an outpatient: removing a polyp inside the womb, removing fibroids close to the lining of the womb, ablation of the lining of the womb, removing pregnancy tissue remaining in the womb and removing a lost intrauterine device. If treatment can also be carried out in the same session, this should be stated clearly in the information given.

Written information should be given before the appointment: what the procedure is, its benefits and its risks including pain, advice on painkillers, the care options and contact details you can use. You should also be told that other settings and anaesthetic options exist.

Yes, there is discharge in the vagina normally too. Normal discharge is small in amount, clear or white and has no smell; it is not accompanied by itching, burning or irritation. It is also normal for it to increase temporarily and become more watery in the middle of the menstrual cycle (at ovulation).

The smell is an important clue. A fishy smell — particularly if it becomes more noticeable after intercourse and during the period — suggests bacterial vaginosis. In thrush there is no smell. In trichomoniasis an unpleasant smell is seen together with frothy, yellow-green discharge.

Severe itching is the most typical feature of thrush; it is seen together with burning, irritation, swelling and redness of the external area, and the discharge is in clumps like cottage cheese. In bacterial vaginosis, by contrast, because there is no true inflammation, marked itching is generally not seen. Even so, the definite distinction is made by examination.

That is a risky route: according to the sources, more than half of the diagnoses people make themselves are wrong. The three conditions produce similar complaints but their treatments are completely different. Also, no response within 3 days to a medicine bought without prescription, or immediate recurrence, may point to a resistant species.

Simple and quick steps: the appearance of the discharge is assessed, the acidity (pH) is measured, a smell test is done and a sample is examined under the microscope. These few steps are enough to tell the three conditions apart. Because the detection power of the microscope is limited in trichomoniasis (51–70%), molecular testing may be preferred.

No. Bacterial culture has no place in this diagnosis — because the bacterium held responsible can be found in the normal flora of 50–60% of healthy women as well. The diagnosis is made by assessing certain criteria together.

That depends on the organism. In bacterial vaginosis treating the partner is not recommended — it has been shown not to reduce recurrence. In thrush it is not routinely recommended either. But in trichomoniasis it is essential: because it is transmitted sexually, partners need to be treated at the same time whether or not they have symptoms, and sexual contact should be avoided until the treatment is finished.

No, seek help without delay. Bacterial vaginosis and trichomoniasis during pregnancy can lead to the waters breaking early, premature birth and low birth weight.

No. Although it may look like cleaning, it removes the protective Lactobacillus bacteria, disturbs the natural acid balance of the vagina and prepares the ground for infection. Antibiotic use and hormonal changes are also among the factors that can disturb this balance.

Yes. Any vaginal discharge that starts after menopause must be investigated. It may be due to thinning of the tissues, but other causes need to be ruled out as well.

No — and the source explicitly criticises that idea. Narrowing simply by cutting and stitching skin creates an unnatural band of skin and leads to pain during intercourse. Narrowing with sutures may give a result in terms of appearance but cannot rebuild the perineum. The real aim is to repair the muscles and the supporting structures.

The main aim is to rebuild the perineal body — the point where the perineal muscles and the anal sphincter meet. Because pressure inside the abdomen stays high for a long time in pregnancy and vaginal birth, these muscles weaken, shift and descend; the operation aims to bring them back together.

Yes, this is a common reason. Removing tender scars remaining after repair of the cut made at delivery (episiotomy) is one of the defined uses of perineoplasty.

It is postponed in women planning a vaginal birth. Active infection and undiagnosed skin conditions of the external genital area must be treated first. Vulvodynia (persistent pain in the external genital area) is a relative contraindication — genital surgery may make it worse. If there are problems with bowel movements, the relevant specialist's opinion is obtained first.

Because the outcome depends on function, not only on appearance. Bladder, bowel and pelvic floor function are assessed; open questions are asked about sexual life, comfort, laxity and lubrication. The examination is done both gynaecologically and standing, with coughing and bearing down — because the true degree of prolapse is only seen on straining.

This is deliberately avoided. Over-narrowing leads to a tight introitus and pain during intercourse. The principle followed is "measure twice, cut once": if there is any doubt about how much tissue to remove, removing less is preferred. If a tight introitus does occur it is managed first with dilators and massage, and if that is not enough, with a small release procedure.

Rinse the perineum gently with soap and water four times a day and after every visit to the toilet; do not take sitting baths. Avoid heavy physical activity for 4 weeks, and tampons and intercourse for 6 weeks. Medicine to prevent constipation is given. Follow-up is at day 1, week 1, week 6 and month 3.

Delayed healing and superficial separation are the most common and do not require surgical repair. With deep separation the edges need to be refreshed and rejoined; if there is too much tension, letting the wound heal on its own is preferred. Swelling settles with cold application.