Gynecology
Gynecology in the OEOG tests benign conditions that present in clinic: abnormal uterine bleeding, contraception, pelvic infection, menopause, and early pregnancy complications. Management questions often hinge on the next diagnostic step rather than a rare syndrome.
Core rules
- Abnormal uterine bleeding is classified with PALM-COEIN: structural causes are polyp, adenomyosis, leiomyoma, and malignancy/hyperplasia; nonstructural causes are coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified.
- Postmenopausal bleeding always needs endometrial assessment; transvaginal ultrasound thickness >4 mm warrants sampling, and persistent bleeding needs sampling even if the endometrium is thin.
- Pelvic inflammatory disease is diagnosed on minimum criteria: lower abdominal pain plus cervical motion, uterine, or adnexal tenderness. CDC 2021 treatment is ceftriaxone 500 mg IM once plus doxycycline 100 mg twice daily and metronidazole 500 mg twice daily for 14 days.
- Ectopic pregnancy: a stable patient with an unruptured mass, no fetal cardiac activity, and hCG below the discriminatory zone (often 3,500 IU/L with transvaginal scan) may be treated with methotrexate.
- Menopause: hormone therapy is the most effective treatment for vasomotor symptoms; use the lowest effective dose and add a progestogen if the uterus is present.
Worked example
A 54-year-old postmenopausal woman has one episode of vaginal bleeding; endometrial thickness is 9 mm. Reasoning: postmenopausal bleeding with thickness >4 mm needs endometrial sampling by pipelle or hysteroscopy and curettage. Do not reassure because it was a single episode. Cancer must be excluded before attributing bleeding to atrophy.
Traps
- Calling postmenopausal bleeding atrophic without imaging and sampling.
- Using CA-125 to screen asymptomatic women.
- Missing an ectopic pregnancy when hCG is below the discriminatory zone but symptoms are present.