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.

This chapter discusses the biology of and therapeutics for gynaecological cancers such as vulval cancer, cervical cancer and ovarian cancer. The most common type of ovarian cancer, high-grade serous cancer, is characterised by mutation of the p53 (TP53) gene. All women with newly diagnosed high-grade serous ovarian carcinoma should have an accurate family history taken, and be referred for genetic assessment and considered for BRCA1 and BRCA2 mutation testing if appropriate. Within clinical trials, central pathological review is needed when treatment depends on morphological sub-type or other pathological parameters. Functional imaging in multicentre trials should be implemented with strict quality control to ensure standardisation and reproducibility. Evaluation of novel surgical strategies, such as robotics, should occur through well-conducted clinical trials. In surgery for ovarian cancer, whether carried out as a primary or a delayed procedure, the aim should be to remove all visible disease.

Vulval cancer is rare and constitutes approximately 3% of gynaecological cancers worldwide. The incidence of vulval cancer has increased since the mid-1990s owing to the increased incidence in younger women, which has doubled over the past 30 years. Clinical trials in vulval cancer can be divided into two categories-trials in women with vulval cancer and, more recently, trials on the prevention of vulval cancer by preventing or treating human papillomavirus (HPV)-related vulval intraepithelial neoplasia (VIN). Numerous studies have tried to evaluate the role of neoadjuvant radiotherapy and/or chemotherapy in this disease to reduce the extent of surgery. Early studies involving the medical treatment of VIN with imiquimod, cidofovir and especially therapeutic vaccines appear promising in the prevention of vulval cancer. However, the greatest effect on preventing cancer is likely to arise as a result of vaccination programmes of the prophylactic HPV vaccines, assuming adequate uptake of the vaccine.

The investigation and management of uncommon gynaecological cancers is made based mainly on cohort studies, case series and expert opinion. Risk factors for gestational trophoblastic disease (GTD) include: maternal age, race, reproductive history, parental blood groups, and genetic predisposition. Staging for fallopian tube carcinoma is analysed by the surgical pathological system. Surgery has a limited role in the management of women with vaginal cancer. Uterine sarcomas are mesodermal tumours and account for 3-5% of all uterine cancers. FIGO has only recently introduced a staging system for these tumours to separate them from the corpus uteri staging. Uterine sarcomas are more common in black women and women who have undergone previous pelvic irradiation. Gynaecological malignancy is uncommon in childhood and adolescence. The most common malignant ovarian tumours in childhood are germ-cell carcinomas: dysgerminoma, endodermal sinus tumour, malignant teratoma and, more rarely, embryonal carcinoma, primary ovarian choriocarcinoma and mixed germ-cell tumour.