Master Reproductive System (Obs & Gyn)
for PLAB 1
Access 40+ high-yield questions tailored for the 2026 syllabus. Includes AI-powered explanations and performance tracking.
Core Concepts
Menstrual Cycle: Regulated by the hypothalamic-pituitary-ovarian axis. Phases: Follicular (FSH, estrogen, follicle growth); Ovulation (LH surge); Luteal (progesterone, endometrial thickening). Average 28 days.
Key Hormones: FSH (follicle stimulating), LH (luteinizing), Estrogen (proliferation), Progesterone (secretion, pregnancy maintenance), hCG (maintains corpus luteum in early pregnancy).
Anatomy: Uterus (fundus, body, cervix), Fallopian tubes, Ovaries, Vagina, Vulva.
Clinical Presentation
- Abnormal Uterine Bleeding (AUB):
- Menorrhagia (heavy/prolonged), Metrorrhagia (intermenstrual), Post-coital bleeding, Post-menopausal bleeding.
- Causes: Fibroids, polyps, adenomyosis, endometrial hyperplasia/cancer, anovulation, coagulopathies.
- Pelvic Pain:
- Acute: Pelvic Inflammatory Disease (PID), ectopic pregnancy (ruptured), ovarian cyst rupture/torsion, miscarriage.
- Chronic: Endometriosis, adenomyosis, fibroids, adhesions, chronic PID. Dysmenorrhea (primary/secondary).
- Infertility: Inability to conceive after 1 year (or 6 months if >35 years). Causes: PCOS, tubal factor (PID, endometriosis), male factor, ovulatory dysfunction.
- Vaginal Discharge: Physiological vs. Pathological:
- Candidiasis: thick, white, 'cottage cheese' discharge, pruritus.
- Bacterial Vaginosis (BV): thin, grey, 'fishy' odor.
- Trichomoniasis: frothy, yellow-green, foul-smelling.
- Chlamydia/Gonorrhea: often asymptomatic, mucopurulent discharge.
- Breast Lumps: Often benign (fibroadenoma, cyst), but malignancy must always be excluded.
- Pregnancy Complications: Hyperemesis gravidarum, gestational hypertension/pre-eclampsia, gestational diabetes, miscarriage, ectopic pregnancy, Antepartum Haemorrhage (APH).
Diagnosis (Gold Standard)
AUB: Transvaginal Ultrasound (TVUS). Hysteroscopy with endometrial biopsy (for post-menopausal bleeding or suspected malignancy).
Pelvic Pain: TVUS. Laparoscopy for definitive diagnosis (endometriosis, adhesions).
Infertility: Male: Semen analysis. Female: Ovulation tracking, Hysterosalpingogram (HSG) for tubal patency, hormonal profile.
Vaginal Discharge: High Vaginal Swab (HVS) for microscopy/culture. NAAT for Chlamydia/Gonorrhea.
Breast Lumps: Triple Assessment: Clinical examination, imaging (Mammogram >40, USS <40), Biopsy (Fine Needle Aspiration Cytology/Core Biopsy).
Pregnancy: Urine hCG. USS for viability, dating, and location (rule out ectopic).
Pre-eclampsia: Blood Pressure (≥140/90 mmHg) & Proteinuria.
Ectopic Pregnancy: Positive hCG, empty uterus on TVUS, adnexal mass.
APH: USS for placental localisation (e.g., placenta praevia).
Management (First Line)
AUB:
- Menorrhagia: Mirena IUS (Levonorgestrel), Tranexamic acid, NSAIDs, COCs. Surgical: Endometrial ablation, Myomectomy, Hysterectomy.
- Post-menopausal bleeding: Urgent referral for hysteroscopy/biopsy.
Infertility: Ovulation induction (Clomiphene citrate, Letrozole). Assisted Reproductive Technology (ART) e.g., IVF. Lifestyle modifications.
Vaginal Discharge: Targeted antimicrobials: Candidiasis (Fluconazole), BV (Metronidazole), Trichomoniasis (Metronidazole for patient & partner), Chlamydia (Azithromycin/Doxycycline), Gonorrhea (Ceftriaxone + Azithromycin).
Breast Lumps: Reassurance (benign cyst/fibroadenoma), excisional biopsy if suspicious.
Pregnancy:
- Antenatal care: Folic acid (pre-conception & 1st trimester), Vitamin D.
- Hyperemesis: Antiemetics (Prochlorperazine, Ondansetron).
- Pre-eclampsia: Antihypertensives (Labetalol, Nifedipine), Magnesium Sulfate for eclampsia prophylaxis, planned delivery.
- Ectopic: Medical (Methotrexate) or surgical (salpingectomy).
- Postpartum Haemorrhage (PPH): Uterine massage, uterotonics (Oxytocin, Ergometrine, Carboprost). Fluid resuscitation.
Exam Red Flags
- Post-menopausal bleeding: ALWAYS requires urgent referral to rule out endometrial cancer.
- Persistent unilateral pelvic pain + positive pregnancy test: Ectopic pregnancy until proven otherwise. Rupture is a surgical emergency.
- Sudden onset severe abdominal pain with guarding/rebound: Suggests peritonitis (e.g., ruptured ectopic, ovarian torsion, ruptured appendix) - immediate surgical review.
- Painless, heavy vaginal bleeding in 3rd trimester: Suggests placenta praevia.
- Painful vaginal bleeding in 3rd trimester with tense, woody uterus: Suggests placental abruption.
- New onset hypertension (BP ≥140/90) AND proteinuria in pregnancy (>20 weeks gestation): Pre-eclampsia.
- "Turtle sign" (fetal head retracts) or inability to deliver shoulders: Shoulder dystocia - obstetric emergency.
- Visualization or palpation of umbilical cord presenting before the fetal head: Cord prolapse - obstetric emergency, immediate delivery required.
- Any breast lump in a woman >30, or with suspicious features (skin changes, nipple inversion, fixity): Urgent referral to breast clinic for triple assessment.
Sample Practice Questions
A 32-year-old primigravida attends her 36-week antenatal appointment. Her blood pressure is recorded as 155/98 mmHg. She reports no headache, visual disturbances, or epigastric pain. Urine dipstick shows 2+ proteinuria. Her previous blood pressures throughout pregnancy have been within the normal range.
A 28-year-old woman presents to the emergency department with a 6-week history of amenorrhea, followed by a sudden onset of left-sided lower abdominal pain and minimal vaginal spotting. She feels lightheaded. On examination, her pulse is 102 bpm, blood pressure is 90/60 mmHg. Abdominal examination reveals tenderness in the left iliac fossa. A urine pregnancy test is positive.
A 24-year-old nulliparous woman presents with a 3-year history of irregular menstrual cycles (oligomenorrhoea), increased facial and body hair (hirsutism), and difficulty losing weight despite diet and exercise. Her BMI is 32 kg/m². Blood tests reveal elevated testosterone and an increased LH:FSH ratio. Which of the following is the most appropriate initial management step for this patient's condition?
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