10.5 Female Reproductive Disorders & Gynecology

Female Reproductive Disorders on Step 2 CK

The official Step 2 CK content specifications group Renal & Urinary System & Reproductive Systems at 7–13% of items. Female reproductive pathology outside pregnancy is tested heavily within Obstetrics & Gynecology clinical science (10–20% of the exam when combined with obstetric content). Vignettes emphasize diagnosis, first-line pharmacotherapy, surgical indications, and emergency triage.

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Pelvic Inflammatory Disease & Tubo-Ovarian Abscess

Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the upper genital tract involving the endometrium, fallopian tubes, and/or ovaries. Common pathogens include Neisseria gonorrhoeae, Chlamydia trachomatis, and vaginal anaerobes/facultative organisms.

Clinical Diagnosis

Minimum diagnostic criteria (treat empirically if present and no alternative diagnosis is more likely):

• Sexually active patient at risk for STIs
• Pelvic or lower abdominal pain
• Cervical motion tenderness, uterine tenderness, or adnexal tenderness on bimanual exam

Supportive findings include fever, mucopurulent cervical discharge, abundant WBC on wet mount, elevated ESR/CRP, and laboratory documentation of gonorrhea or chlamydia.

Management Algorithm

Fitz-Hugh–Curtis syndrome is perihepatitis from ascending gonococcal/chlamydial infection presenting as right-upper-quadrant pain with normal LFTs or mild transaminase elevation and "violin-string" adhesions at laparoscopy.

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Polycystic Ovary Syndrome (PCOS)

PCOS is the most common endocrine cause of anovulatory infertility. Diagnosis uses Rotterdam criteria (need 2 of 3 after excluding mimics such as nonclassic CAH, hyperprolactinemia, and thyroid disease):

1. Oligo-ovulation or anovulation
2. Clinical and/or biochemical hyperandrogenism (hirsutism, acne, elevated total/free testosterone)
3. Polycystic ovarian morphology on ultrasound (≥20 follicles per ovary or ovarian volume ≥10 mL; not required if other two criteria met)

High-Yield Management

• Lifestyle / weight loss: First intervention in overweight patients; modest weight loss can restore ovulation.
• Menstrual regulation / endometrial protection: Combined oral contraceptives (COCs) are first-line for irregular menses and hyperandrogenism in patients not seeking pregnancy.
• Insulin resistance / diabetes risk: Screen for diabetes; metformin is adjunctive, especially with impaired glucose tolerance.
• Anovulatory infertility: Letrozole is first-line ovulation induction (preferred over clomiphene in many guidelines).
• Anti-androgen therapy: Spironolactone may be added for hirsutism after reliable contraception is established (teratogenic risk).

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Endometriosis

Endometriosis is ectopic endometrial glands and stroma outside the uterine cavity, driven by estrogen. Classic symptoms are cyclic pelvic pain, dysmenorrhea, dyspareunia, and infertility. Exam may show uterosacral nodularity or fixed retroverted uterus, but physical findings can be normal.

• Ovarian endometrioma ("chocolate cyst"): Complex ovarian cyst with ground-glass appearance on ultrasound.
• Diagnosis: Clinical therapy may begin empirically; definitive diagnosis is laparoscopic visualization (± histologic confirmation).
• Medical therapy: Continuous or cyclic COCs, progestins (norethindrone, medroxyprogesterone, levonorgestrel IUD), or GnRH agonists/antagonists with add-back therapy for refractory pain.
• Surgery: Laparoscopic excision/ablation for failed medical therapy, endometrioma management, or infertility evaluation.

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Abnormal Uterine Bleeding (AUB)

Always exclude pregnancy first (urine or serum β-hCG). Structural and nonstructural causes are organized by PALM-COEIN:

Postmenopausal bleeding is endometrial cancer until proven otherwise—perform endometrial sampling (office biopsy or hysteroscopy/D&C). Transvaginal ultrasound endometrial thickness ≤4 mm has high negative predictive value but does not replace sampling when clinical suspicion is high or bleeding persists.

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Ovarian Emergencies & Ectopic Pregnancy

Ovarian Torsion

Sudden severe unilateral pelvic pain, nausea/vomiting, and adnexal mass (often cyst or dermoid). Doppler ultrasound may show decreased/absent ovarian flow, but normal Doppler does not exclude torsion. Management is emergent surgical detorsion (ovary-sparing when viable), not delay for prolonged imaging.

Ectopic Pregnancy (Non-Obstetric Overlap)

Classic triad: amenorrhea, unilateral abdominal/pelvic pain, vaginal bleeding. Risk factors include prior ectopic, PID/tubal damage, prior tubal surgery, and assisted reproduction.

        [ Positive β-hCG + pelvic pain/bleeding ]
                         |
              [ Transvaginal ultrasound ]
                         |
     +-------------------+-------------------+
     |                                       |
[ IUP visualized ]                 [ No IUP / adnexal mass or free fluid ]
     |                                       |
[ Manage as IUP ]              [ Hemodynamically unstable or rupture? ]
                                               |
                          +--------------------+--------------------+
                          |                                         |
                        [ Yes ]                                   [ No ]
                          |                                         |
                 [ Emergent laparoscopy /      [ Stable: methotrexate criteria? ]
                   laparotomy ]                         |
                                         +--------------+--------------+
                                         |                             |
                                  [ Meets criteria ]          [ Does not meet / refuses ]
                                         |                             |
                              [ IM methotrexate ]            [ Surgical management ]
                              + serial β-hCG follow-up

Methotrexate candidates (typical criteria): hemodynamic stability, no rupture, β-hCG below institutional threshold (commonly <5,000 mIU/mL), ectopic mass usually <3–4 cm, no fetal cardiac activity, normal LFTs/CBC/creatinine, reliable follow-up, and no breastfeeding/immunodeficiency/active pulmonary disease. Absolute contraindications include intrauterine pregnancy, immunodeficiency, baseline blood dyscrasias, active peptic ulcer disease, hepatic/renal dysfunction, and inability to comply with follow-up.

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Contraception Counseling Pearls

• Combined hormonal contraceptives: Contraindicated with migraine with aura, prior VTE, smoking age ≥35 with ≥15 cigarettes/day, uncontrolled hypertension, and known thrombophilia.
• Progestin IUD / implant: Highly effective long-acting reversible contraception; levonorgestrel IUD also treats heavy menstrual bleeding and endometriosis-associated pain.
• Copper IUD: Nonhormonal; most effective emergency contraception when placed within 5 days of unprotected intercourse.
• Emergency contraception pills: Levonorgestrel OTC most effective within 72 hours; ulipristal more effective up to 5 days and with higher BMI.