Gynecology
Domain overview
The Gynecology domain tests preventive care, contraception, menstrual disorders, menopause, and common infections. It emphasizes age-based screening and evidence-based evaluation of abnormal uterine bleeding.
Core rules
- Cervical cancer screening starts at 21. Cytology alone every 3 years is acceptable for ages 21–29. For ages 30–65, co-testing every 5 years or cytology every 3 years is acceptable. Stop screening at 65 after adequate prior negative screening and no high-risk history.
- Classify abnormal uterine bleeding with PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy/hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified).
- Postmenopausal bleeding requires endometrial biopsy or transvaginal ultrasound to exclude endometrial cancer; do not attribute it to atrophy without evaluation.
- Use U.S. MEC categories for contraception. Category 4 means unacceptable health risk-e.g., combined hormonal contraceptives in migraine with aura, uncontrolled hypertension, or history of VTE.
- Menopause is clinical (12 months of amenorrhea). Hormone therapy is for vasomotor symptoms at the lowest effective dose; any bleeding on therapy needs evaluation.
Worked example
A 54-year-old postmenopausal woman reports one episode of vaginal bleeding. Reasoning: postmenopausal bleeding is endometrial cancer until proven otherwise. Obtain transvaginal ultrasound; if endometrial thickness is >4 mm, proceed to endometrial biopsy. If ≤4 mm, biopsy may still be considered based on risk factors. Do not use a Pap smear to evaluate bleeding.
Traps
Attributing postmenopausal bleeding to atrophic vaginitis without tissue sampling is a classic error. Also, do not screen before age 21 regardless of sexual history, and do not use co-testing in women younger than 30.