This chapter focuses on the non-oral combined hormonal contraceptive options, including the patch and more specifically the vaginal ring, which are underused in the UK and Australia. The clinical effectiveness unit of the faculty of sexual and reproductive healthcare developed a guideline to facilitate appropriate investigation of women presenting with unscheduled bleeding. For women with breakthrough bleeding in association with the use of hormonal contraception, lasting longer than three months, it is important to view the cervix. A pelvic examination should be undertaken to exclude pelvic pathology including ovarian cysts, fibroids and gynaecological cancers. In clinical trials, most users have been satisfied with the combined hormonal ring. The greatest barrier to this method is promoting the vagina as an ideal organ in which to place hormonal contraception and this remains a challenge to all providers of contraception.

The size of the mass in three dimensions, its location, consistency, and borders (well-/ill-defined) should be determined for a diagnostic approach to masses. Generally, most diagnoses can be made by transvaginal ultrasonography; however, a combination of transabdominal and transvaginal scan should be considered as they have different advantages and disadvantages. Follicular ovarian cysts comprise the most common cystic adnexal mass seen in women of reproductive age. Luteal cysts are characterized by peripheral blood flow at Doppler examination and menstrual disturbances. Recently three-dimensional (3D) or volume ultrasonography has been added to the gynecologic assessment armamentarium. The availability of noninvasive ultrasonography has resulted in improved care for infertile women. The ability to diagnose and decide on appropriate treatment is invaluable in helping women to achieve better fertility outcomes where identified pathology is detrimental, but also in improving patient well-being where this may be more serious, such as malignancy, and is dealt quickly.

There are many diagnostic dilemmas in gynaecological cellular pathology, spanning across all age groups. This chapter considers the six most challenging pathological entities in the reproductive age group. The dilemmas in ovarian cysts arises when the cyst is deemed to be complex as there may be a reluctance to aspirate in case of spillage of malignant cells. The most significant diagnostic dilemma with regard to cervical neoplasia is in the staging of microinvasive carcinoma. All the diagnostic difficulties in cervical neoplasia are compounded by the need to excise as small a piece of the cervix as possible to preserve fertility and prevent miscarriage. The problem with the diagnosis of atypical hyperplasia is in the vague criteria used for cytological atypia, rounding up of nuclei with clearing of chromatin and prominent nucleoli, which results in considerable variation of opinion among pathologists.