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 30-year-old primiparous woman delivers a healthy baby vaginally. One hour postpartum, she starts bleeding heavily from the vagina. On examination, she is pale, hypotensive (BP 90/50 mmHg), and her pulse is 110 bpm. The uterus is palpable above the umbilicus and feels soft and boggy. What is the most immediate and crucial initial step in her management?
A 32-year-old nulliparous woman requests contraception. She has a history of migraines with aura and essential hypertension, well-controlled on medication. She smokes 5 cigarettes a day. She reports regular, heavy, and painful periods. She wants a highly effective method.
A 25-year-old P1 woman delivered a healthy baby vaginally 1 hour ago. The placenta was delivered complete. She is now experiencing heavy vaginal bleeding, and on examination, her uterus is soft and boggy, palpable above the umbilicus. Her blood pressure is 90/50 mmHg, and pulse rate is 110 bpm. What is the most appropriate initial pharmacological intervention?
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