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25 yo nuliparous white woman has CC of heavy and frequent menstrual bleeding for the past year. she has never been sexually active; is moderately overwright; and has hirsutism and acne. She denies vaginal dryness, mood swings, or hot flashes. She also denies hot or cold intolerance, diarrhea, or heart palpitations. Which part of this history suggests PCOS?


weight, skin and hair changes

  • PCOS is suggested by her being moderately overweight and having hirsutism and acne. as has been claimed, 80 - 90% of the diagnosis can be made from medical history.*
  • essential parts of the history when investigating the causes of DUB are age of menarche, menstrual history, date of the first day of the last normal menstrual period, contraceptive use, signs and symptoms of coagulopathy (nosebleeds, petechiae, and ecchymoses), endocrine symptoms, menopause symptoms, weight changes and stress*

a man and a woman in their 20s have been trying unsuccessfully to conceive for the last year. the woman has regular menses and a 28-day cycle. In the initial eval, which of the following tests or evaluations should be considered first line?


semen analysis

generally, infertility is defined as the inability for a couple to conceive after reasonably frequent unprotected intercourse for 1 year. In approaching the work-up, with a thorough PE and history of both partners, the clinician should establish the following points:

  1. does the woman ovulate (if not, why not)
  2. does the semen have normal characteristics?
  3. is there a female reproductive tract abnormality?

noninvasive tests should be done first line

for the male partner, semen analysis is noninvasive and helpful, though not diagnostic.

In the initial eval of the female partner, noninvasive procedures, such as measurement of LH and mid-luteal phase progesterone (to determine ovulatory function) and TVUS (to rule out the possibility of fibroids or PCOS) are first line

pelvic US should also be part of the routine gynecologic eval because it allows a more precise evaluation of the position of the uterus within the pelvis and provides more info about its size and irregularities

hysterosalpingography is an invaseive procedure and therefore NOT first line.

Endometrial biopsy and postcoital testing are no longer recommended for the routine infertility evaluation because they have poor predictive value


In the U.S., what is the most common gynecologic cancer?


endometrial cancer


What is the hallmark history component for endometrial cancer?


more than 90% of patients with endometrial cancer present with post-menopausal bleeding, thus making it the hallmark history component.

  • there are several risk factors for developing type 1 endometrial cancer, but in general excessive estrogen is the cause*
  • (therefore women who are postmenopausal taking unopposed estrogen replacement or tamoxifen and women who are above 50 lbs abode their ideal weight, are at risk for endometrial hyperplasia and endometrial cancer)*
  • Type II endometrial cancers tend to occur in older, thinner women without exogenous estrogen exposure*

examples of times when OCPs are contraindicated


smokers older than 35

woman at risk for VTEs


36 yo G2 P2 female complains of heavy menstrual bleeding for the past year. patient is bleeding through super tampons and a heavy pad every hour. Her PE and lab work-up are normal (negative B-hCG, LH, FSH, prolactin, clotting times, liver function, and renal function tests), except for the CBC and labs indicating that she has iron deficiency anemia. the patient’s weight is 298 lbs.

In addition to iron supplementation, which of the following is the BEST INITIAL therapy for this patient?


oral contraceptives

OCPs are the best treatment for this patient. treatment


treatment for patient with uncomplicated mastitis (not severe). pt has no allergies

what if they have a penicillin allergy?

what if they have severe infection with systemic symptoms?

what if you suspect MRSA?


dicloxacillin x 14 days

PCN allergy: clindamycin

severe infection: clindamycin or trimethoprim-sulfamethoxazole

MRSA: vancomycin


what other suggestions (other than antibiotic treatment) should you give a woman with mastitis?


continue pumping/breastfeeding

warm compresses/hot showers

increase water intake

manual decompression


What is Hegar’s sign?


Hegar’s sign is the softening of the cervix that often occurs with pregnancy