GYN-Problem-Based Questions

Table of Contents

• Problem-Based Questions
  • CD 1: Third Trimester Bleeding
  • CD 2: Intrauterine Fetal Demise (IUFD)
  • CD 3: Surgical Conditions during Pregnancy
  • CD 4: Premenstrual Syndrome (PMS)
  • CD 5: Pelvic Inflammatory Disease (PID)
  • CD 6: Ectopic Pregnancy
  • CD 7: Abortion
  • CD 8: Pelvic Prolapse
  • CD 9: Polycystic Ovarian Syndrome (PCOS)
  • CD 10: Menopause

Problem-Based Questions

R1-Boys

CD 1: Third Trimester Bleeding

Problem:

A 31-week pregnant woman, P3+0, with a history of 3 previous C/S, presents with painless vaginal bleeding. Her vitals are stable, there’s no ongoing bleeding, and ultrasound confirms placenta previa.

Guiding Questions:

1. What is your initial approach to a patient with third-trimester bleeding?

   • ABCs stabilization: Assess airway, breathing, circulation; establish IV access (two large-bore cannulas).
   • Vital signs & resuscitation: Monitor BP, HR, O₂ saturation; administer O₂ if hypoxic; fluid resuscitation if unstable.
   • Fetal assessment: Immediate continuous CTG to evaluate fetal well-being and uterine activity.
   • History & exam: Detailed history (onset, volume, pain, trauma); avoid digital vaginal exam until placenta previa is ruled out.
   • Investigations: Complete blood count, coagulation profile, blood group/crossmatch (4 units); urgent ultrasound to identify placental location. - Catheter? z
   • Admission: Hospitalize for monitoring even if bleeding stops, due to risk of recurrence.

2. Based on the history and examination, what are the likely causes of her bleeding?

   • Placenta previa (most likely): Confirmed by ultrasound; painless bleeding in a patient with prior uterine scars (3 C/S → high risk for previa). - increased heart rate of placenta + fetal heart sound

   • Vasa previa: Possible given prior C/S (abnormal placental cord insertion), but less common.

   • Unlikely causes:

     • Abruptio placentae (typically painful bleeding, uterine tenderness).
     • Uterine rupture (severe pain, instability; rare without labor).
     • Cervical/vaginal lesions (e.g., polyps, trauma; usually minor bleeding).

3. How would you differentiate placenta previa from abruptio placenta clinically?

Feature	Placenta Previa	Abruptio Placentae
Pain	Painless vaginal bleeding.	Severe abdominal or back pain, often sudden.
Bleeding	Bright‑red, sudden and intermittent.	Dark red/maroon; may be concealed (≈25 % of cases).
Uterus	Soft, non‑tender, relaxed.	Firm, tender with a characteristic “woody” hardness.
Fetal presentation	Frequently malpresented (e.g., breech).	Usually a normal presentation.
FHR changes	Late decelerations only if severe blood loss occurs.	Early decelerations, reflecting hypoxia.
Ultrasound	Shows placenta overlying or adjacent to the internal os.	May reveal a retro‑placental clot (often absent).

4. What are the maternal and fetal complications of placenta previa?

   • Maternal:
     • Hemorrhage → shock, disseminated intravascular coagulation (DIC).
     • Emergency cesarean delivery (risk of intraoperative hemorrhage, hysterectomy).
     • Infection (from prolonged hospitalization/procedures).
     • Increased risk of placenta accreta (given 3 prior C/S → up to 40% risk).
   • Fetal:
     • Preterm delivery → respiratory distress syndrome, NICU admission.
     • Fetal hypoxia/anemia from acute blood loss.
     • Intrauterine growth restriction (IUGR) from placental dysfunction.
     • Stillbirth (if severe undiagnosed hemorrhage).

5. Outline your management plan for this patient.

   • Immediate:
     • Admit to antepartum unit; strict bed rest.
     • Continuous fetal monitoring (CTG) and maternal vitals q15min until stable, then q1-2h.
     • Type and crossmatch 4-6 units PRBCs; initiate IV fluids.
     • Administer corticosteroids (e.g., betamethasone) for fetal lung maturity (31 weeks).
   • Monitoring:
     • Serial Hb/Hct (q6-12h initially); ultrasound to reassess placental location (if bleeding recurs).
     • Rule out placenta accreta (MRI if suspicion high due to prior C/S).
   • Delivery planning:
     • Expectant management until 36–37 weeks if stable.
     • Cesarean delivery scheduled at 36–37 weeks (earlier if active bleeding, distress, or accreta suspected).
     • Multidisciplinary team (OB, anesthesia, NICU, blood bank); consider cell salvage if accreta risk.
     • Avoid labor induction (placenta covers internal OS).

6. When is blood transfusion indicated, and what are its possible complications?

   • Indications:
     • Hemodynamic instability (tachycardia, hypotension) despite fluid resuscitation.
     • Symptomatic anemia (e.g., dyspnea, tachycardia at rest).
     • Hb <7 g/dL (or <8 g/dL if active bleeding, cardiac disease, or ongoing loss).
     • Note: Transfuse before Hb reaches critical levels in pregnancy due to physiological anemia.
   • Possible complications:
     • Acute: Febrile non-hemolytic reaction, allergic reaction, TRALI (transfusion-related acute lung injury), TACO (transfusion-associated circulatory overload).
     • Delayed: Hemolytic reaction (if ABO mismatch), iron overload (with massive transfusion), infections (e.g., hepatitis, HIV; rare with modern screening).
     • Special in obstetrics: Alloimmunization (risk in future pregnancies), hypocalcemia (from citrate in massive transfusion).

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CD 2: Intrauterine Fetal Demise (IUFD)

Problem:

A 39-week pregnant patient, P2+5, with diabetes, presents with absent fetal movements for 1 week. There’s no fluid loss or bleeding, and ultrasound confirms absent fetal heart.

Guiding Questions:

What are the etiologies and risk factors for IUFD in this patient? Etiologies/Risk Factors:

• Diabetes mellitus: Pre-gestational or poorly controlled gestational diabetes increases risk due to fetal macrosomia, stillbirth, vasculopathy, and placental insufficiency.
• Advanced maternal age: Patient is likely ≥35 years (P2+5 implies multiparity, often with older age).
• Hypertensive disorders: Preeclampsia or chronic hypertension (common in diabetics).
• APA ?CC
• Placental pathology: Abruption, infarction, or insufficiency.
• Fetal growth restriction (FGR): Associated with diabetic vasculopathy.
• Prolonged pregnancy: 39 weeks approaches post-term risk (though not yet ≥40 weeks).
• Prior obstetric history: “P2+5” suggests prior losses (embryonic/fetal), increasing recurrence risk.

Which clinical features raise suspicion of IUFD?

• Absent fetal movements for 1 week: A critical red flag (normal reduction is gradual; complete absence >24 hours warrants urgent evaluation). - fetal hydroms, infections, absent heart sound.
• Maternal risk factors: Diabetes (micro/macrovascular complications), advanced maternal age, and history of prior losses (“P2+5” indicates 2 live births + 5 pregnancy losses). - hypertensive, soker, drug abuser, truama - milk ejection,
• Placental: -
• Note: Lack of bleeding/fluid loss does not rule out IUFD, as these are absent in ~50% of cases.

cholestasis during pregnancy sudden IUFD with itching

*How do you confirm the diagnosis of IUFD? *

• Ultrasound (US) is definitive:
  • Absent fetal cardiac activity on real-time US (visualization of heart motion).
  • Additional findings: Lack of fetal movement, placental thickening/calcifications, oligohydramnios.
• Confirmatory steps:
  • Repeat US after 5–10 minutes if initial study is equivocal.
  • Use Doppler if standard US is inconclusive (absent umbilical artery flow).
  • Not diagnostic: Fetal kick counts, auscultation, or maternal symptoms alone.

collapse fetal abd, robert sign; presence of gasses in abdomen of child, doda sign?CC, amntiotic fluid index, <2cm fluid, fetal membrane skull

*What are the management options once IUFD is confirmed? *

• Immediate goals: Expedite delivery (avoid maternal coagulopathy, infection, or psychological harm from prolonged retention).
• Delivery methods:
  • Induction of labor (preferred at 39 weeks):
    • Cervical ripening: Misoprostol (vaginal/sublingual) ± Foley catheter.
    • Oxytocin: For active labor once cervix is open/favorable.
    • Avoid: Prostaglandins (e.g., dinoprostone) if prior cesarean (increased rupture risk). CC
  • Dilation & evacuation (D&E): Rarely used at 39 weeks; typically for <24 weeks.
• Critical adjuncts:
  • Thromboprophylaxis: LMWH/heparin (IUFD increases VTE risk).
  • Postpartum pathology: Placental examination, fetal autopsy (if consented), maternal labs (e.g., HbA1c, thrombophilia screen).
  • Antibiotics: If >48 hours since demise (risk of intra-amniotic infection).

*How would you address the psychosocial aspects of care in IUFD? *

• Immediate approach:
  • Deliver diagnosis with empathy: “I’m so sorry; your baby has died. We’ll support you through this.”
• Family-centered care:
  • Offer options: psychologist, or grief counsellor.
  • Include partners in decision-making; screen for perinatal mood disorders.
• Long-term support:
  • Provide written resources (e.g., Star Legacy Foundation, March of Dimes).
  • Schedule follow-up within 1–2 weeks for grief counseling and mental health referral.
  • Address guilt (“Was it my diabetes?“): Reassure that IUFD is rarely preventable despite optimal care.
• Documentation: Note psychosocial needs in records for coordinated care.

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CD 3: Surgical Conditions during Pregnancy

Problem:

A 25-year-old woman at 20 weeks of gestation presents with acute left lower quadrant pain, tachycardia, and localized tenderness. Ultrasound suggests ovarian torsion.

Guiding Questions:

1. How do you conduct a focused history and examination for acute abdomen in pregnancy?
2. What are the differential diagnoses of acute abdomen during pregnancy?
3. Which investigations would you order, and how do you interpret them?
4. What is your management plan for ovarian torsion in this case?
5. What are the potential complications of surgical intervention during pregnancy?

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CD 4: Premenstrual Syndrome (PMS)

Problem:

A 34-year-old woman reports symptoms of hot flushes, mastalgia, irritability, and depression 5 days before menses, resolving after menstruation begins.

Guiding Questions:

1. How would you define PMS?
   Premenstrual Syndrome (PMS) is a cyclical disorder characterized by physical, behavioral, and emotional symptoms that occur specifically during the luteal phase (post-ovulation) of the menstrual cycle, typically 5–7 days before menses, and resolve within 4 days after menstruation begins. Symptoms must be absent during the follicular phase (post-menses) and significantly interfere with daily functioning. It affects 20–40% of women of reproductive age.

2. What history and examination are essential in evaluating PMS?

   • Essential History:
     • Daily symptom diary tracking for ≥2-3 cycles (to confirm cyclical pattern, timing, severity).
     • Specific symptoms: Physical (mastalgia, bloating, headaches), mood (irritability, depression, anxiety), behavioral (food cravings, fatigue).
     • Duration/timing: Symptom onset (luteal phase), resolution (post-menses), and symptom-free interval.
     • Impact: Effect on work, relationships, and daily activities.
     • Exclusion of mimics: Perimenopause (hot flushes), thyroid dysfunction, depression, anxiety disorders.
     • Medication/substance use: Hormonal contraceptives, SSRIs, caffeine, alcohol.
   • Essential Examination:
     • Physical: BP, BMI, breast exam (for mastalgia), pelvic exam (to rule out pathology).
     • Mental health screening: PHQ-9 for depression, GAD-7 for anxiety.
     • Laboratory tests only if indicated: TSH (rule out thyroid disorder), pregnancy test.

3. What are the possible causes and pathophysiology of PMS?

   • Primary mechanism: Abnormal neuroendocrine response to normal ovarian hormone fluctuations (estrogen/progesterone), not hormone deficiency/excess.
   • Key pathways:
     • Serotonin dysregulation: Reduced serotonin activity during luteal phase → mood/behavioral symptoms.
     • Allopregnanolone sensitivity: Abnormal GABA-A receptor response to progesterone metabolites → anxiety, irritability.
     • Fluid retention: Elevated aldosterone/ADH → bloating, mastalgia.
     • Inflammation: Prostaglandin-mediated symptoms (headaches, cramps).
   • Risk factors: Genetic predisposition, stress, prior depression.

4. What are the diagnostic criteria for PMS?
   Diagnosis requires ALL of the following (per DSM-5 for Premenstrual Dysphoric Disorder, the severe subtype; PMS follows similar principles):

   • Symptom timing: ≥5 luteal-phase symptoms (physical/mood) recurring in most menstrual cycles over the past year.
   • Symptom resolution: Symptoms end within a few days after menses starts; symptom-free week in follicular phase.
   • Severity: Symptoms cause significant distress/impairment in work, social, or relationships.
   • Confirmation: Prospective daily ratings (diary) for ≥2 cycles to exclude non-cyclical disorders (e.g., major depression).
   • Exclusion: Symptoms not attributable to another medical/psychiatric condition.
     Note: PMS requires ≥1 physical + 1 mood symptom; PMDD requires ≥5 symptoms (including 1 mood symptom).

5. What is your management plan for PMS?
   Stepwise approach (evidence-based):

   • First-line (non-pharmacological):
     • Lifestyle: Aerobic exercise (30 min/day), reduce caffeine/alcohol/salt, balanced diet (complex carbs, calcium 1200 mg/day).
     • Cognitive Behavioral Therapy (CBT): For mood symptoms (≥12 sessions).
     • Supplements: Pyridoxine (B6) 50–100 mg/day, calcium 500–1200 mg/day (modest evidence).
   • Second-line (pharmacological):
     • SSRIs (first-choice drugs): Sertraline 50–150 mg/day or fluoxetine 20 mg/day luteal-phase dosing only (days 14–28 of cycle).
     • Hormonal: Combined oral contraceptives (e.g., Yaz®: drospirenone/EE, FDA-approved for PMDD). Avoid if migraines with aura/thrombosis risk.
   • Third-line/refractory cases:
     • GnRH agonists (e.g., leuprolide) + “add-back” therapy (for severe, disabling symptoms).
     • Diuretics (spironolactone 50–100 mg/day) for fluid retention (limited evidence).
   • Patient education: Reassurance, realistic expectations, symptom diary monitoring.
     Avoid: Unproven therapies (herbal remedies like chasteberry require more evidence); opioids/sedatives.
     Follow-up: Reassess in 2–3 cycles; adjust therapy based on response.

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Answers align with ACOG (2021), NICE (2022), and DSM-5 guidelines. Hot flushes in this case warrant ruling out perimenopause/thyroid dysfunction.**

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CD 5: Pelvic Inflammatory Disease (PID)

Problem:

A 20-year-old woman presents with 3 days of worsening lower abdominal pain, fever (39°C), and cervical motion tenderness. Swab is positive for chlamydia.

Guiding Questions:

1. What is the pathophysiology of PID? PID results from an ascending polymicrobial infection originating in the cervix/vagina. Pathogens (commonly Chlamydia trachomatis <25 y in western country, Neisseria gonorrhoeae, Trachomosis is common in middle east or anaerobes) ascend through the endometrium into the fallopian tubes, causing salpingitis. This triggers inflammation, edema, and microabscess formation in the tubal mucosa. Severe cases lead to tubal occlusion, pyosalpinx, or tubo-ovarian abscess. Rupture can cause peritonitis or Fitz-Hugh-Curtis syndrome (perihepatitis).

2. What are the key history, examination, and investigations for PID?

   • History: Acute/persistent lower abdominal pain, fever, abnormal vaginal discharge, dysuria, postcoital/intermenstrual bleeding, recent STI exposure or IUD insertion.
   • Examination: Lower abdominal tenderness, cervical motion tenderness, adnexal tenderness, mucopurulent cervical discharge. Fever (>38.3°C) may be present. - types of inflammations?CC Adenexal, uterine, and… cervical?
   • Investigations:
     • Exclusion: Pregnancy test (rule out ectopic), urine culture (rule out UTI).
     • Swab; NAAT for C. trachomatis and N. gonorrhoeae (vaginal/cervical swab).
     • Wet mount (to exclude Trichomonas), complete blood count (leukocytosis), CRP/ESR (elevated).
     • Pelvic ultrasound (to rule out TOA or ectopic pregnancy; not required for diagnosis). ; tubual ovarian abcess, pouch fluids

3. What are the diagnostic criteria for PID?
   CDC Minimum Criteria (require ≥1):
   - Lower abdominal tenderness.
   - Adnexal tenderness.

   • Cervical motion tenderness.
     Additional Supportive Criteria:
     • Oral temperature >38.3°C (as in this case: 39°C).
     • Abnormal cervical mucopurulent discharge.
     • Elevated ESR/CRP.
   • C. trachomatis or N. gonorrhoeae positivity (confirmed here via swab).
     Note: Laparoscopy is diagnostic gold standard but not routinely used.

4. What is your initial management approach?CC Immediate empiric antibiotics (to cover N. gonorrhoeae, C. trachomatis, and anaerobes):

   • Parenteral: Ceftriaxone 1g IM/IV daily + Doxycycline 100mg oral twice daily ± Metronidazole 500mg oral twice daily (if anaerobic coverage needed).
   • Oral alternative (mild cases): Ceftriaxone 500mg IM once + Doxycycline 100mg oral twice daily × 14 days ± Metronidazole.
     Adjuncts:
   • Hospitalize if severe (e.g., fever >39°C, vomiting, pregnancy, TOA, or failed outpatient therapy).
   • Pain control (NSAIDs).
   • Expedited partner therapy (treat all sexual partners within 60 days).
   • Test for HIV/syphilis; repeat pregnancy test if symptoms persist.

5. What are the long-term complications of PID?

   • Tubal factor infertility (10-15% after 1 episode; 40-50% after 3 episodes).
   • Ectopic pregnancy (6-10× increased risk).
   • Chronic pelvic pain (due to adhesions/scarring).
   • Tubo-ovarian abscess (TOA) recurrence.
   • Fitz-Hugh-Curtis syndrome (perihepatitis causing right upper quadrant pain).
   • Increased risk of recurrent PID.

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CD 6: Ectopic Pregnancy

Problem:

A 27-year-old woman, 6 weeks post-LMP, presents with abdominal pain, vaginal bleeding, and an adnexal mass on ultrasound.

Guiding Questions:

1. How do you define ectopic pregnancy?
2. What risk factors predispose to ectopic pregnancy?
3. What is your differential diagnosis for first-trimester bleeding and pain?
4. Which investigations confirm the diagnosis of ectopic pregnancy?
5. What are the management options (medical vs. surgical)?

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CD 7: Abortion

Problem:

A 9-week pregnant woman presents with vaginal bleeding, clots, and cervical dilatation with tissue passage.

Guiding Questions:

• What is your differential diagnosis for first-trimester bleeding?

  1. Threatened abortion (viable fetus)Z
  2. Inevitable abortion (bleeding + dilated cervix)
  3. Incomplete abortion (tissue passage + residual material)
  4. Complete abortion (all tissue passed)
  5. Missed abortion (retained non-viable fetus)
  6. Septic abortion (infection superimposed)
  7. Ectopic pregnancyZ
  8. Molar pregnancyZ
  9. Cervical/vaginal pathology (e.g., polyps, trauma)

• How do you differentiate the types of abortion clinically (missed, threatened, incomplete, etc.)?

Type	Bleeding	Cervical OS	Pain	Ultrasound Findings
Threatened	Mild-mod	Closed	Mild	Viable IUP
Inevitable	Mod-sev	Open	Mod-severe	IUP, no cardiac activity
Incomplete	Mod-sev	Open	Severe	Retained products
Missed	Scant	Closed	Absent/mild	Non-viable fetus (>7 weeks)
Complete	Scant	Closed	Resolved	Empty uterus

• What are the possible etiologies of spontaneous abortion?

  • Chromosomal (50%, e.g., trisomies)
  • Maternal factors: Endocrinopathies (DM, thyroid), infections (listeria, toxoplasma), structural (uterine anomalies, fibroids)
  • Immunological: Antiphospholipid syndrome
  • Environmental: Teratogens (alcohol, radiation)
  • Luteal phase defect (low progesterone)

• What are the complications of spontaneous abortion? 1. Hemorrhagic shock 2. Infection → endometritis, sepsis 3. Disseminated intravascular coagulation (DIC) 4. Asherman’s syndrome (uterine synechiae) 5. Psychological trauma

• How would you manage each type of abortion?

• What are the methods of termination (surgical and non-surgical)? Non-Surgical

  • Medical: Mifepristone (anti-progesterone) + misoprostol (PGE1) ≤10 weeks
    Surgical
  • Vacuum aspiration (≤12-14 weeks)
  • D&C (≤12 weeks)
  • D&E (2nd trimester)

• What are the complications of induced abortion? Immediate:

• hemmorhage,

• uterine hemorrhage

• resulting in shock

• cerrvical injury

• antethesial?

• septic miscarriage

• PE

CC

Early (<48h)	Late (>48h)
Perforation/hemorrhage	Infection
Cervical laceration	Retained POC
Anesthetic complications	Asherman’s syndrome; uterine adhesions
Uterine atony	Rhesus sensitization
Incomplete abortion (~2%)	Future preterm birth/subfertility

Key Practice Point:

• Quantitative hCG + transvaginal US is diagnostic gold standard.
• RhoGAM for all Rh(−) women regardless of abortion type to prevent isoimmunization.
• Avoid curettage in desired pregnancies unless mandatory (e.g., hemorrhage).

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CD 8: Pelvic Prolapse

Problem:

A 48-year-old multipara with 8 vaginal deliveries presents with pelvic heaviness and uterus protrusion. Examination confirms complete uterine prolapse.

Guiding Questions:

1. What are the types of pelvic organ prolapse?
2. What are the anatomic changes associated with prolapse?
3. What history and examination are important for pelvic prolapse?
4. How do you classify pelvic organ prolapse?
5. What are the confirmatory investigations?
6. What are the medical and surgical management options?

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CD 9: Polycystic Ovarian Syndrome (PCOS)

Problem:

A 28-year-old obese woman with irregular menses and hirsutism for 2 years. Ultrasound shows >10 follicles/ovary.

Guiding Questions:

1. What are the Rotterdam criteria for PCOS diagnosis?
   Diagnosis requires ≥2 of 3 criteria:

   • Oligo-/anovulation (e.g., irregular/absent menses).
   • Clinical and/or biochemical hyperandrogenism (e.g., hirsutism, acne, elevated serum androgens).
   • Polycystic ovaries on ultrasound (≥20 follicles per ovary or ovarian volume >10 mL). Note: The case states “>10 follicles/ovary,” but Rotterdam specifies ≥20 follicles (2–9 mm diameter) or volume >10 mL.

2. What are the etiologies and risk factors for PCOS?

   • Etiologies: Multifactorial; insulin resistance (leading to hyperinsulinemia) and hyperandrogenism are central. Genetic predisposition (e.g., DENND1A, THADA variants) and ovarian dysfunction amplify androgen production.
   • Risk factors:
     • Obesity (exacerbates insulin resistance).
     • Family history of PCOS, diabetes, or cardiovascular disease.
     • Sedentary lifestyle, high-glycemic diet.

3. What are the clinical features and physical findings?

   • Reproductive: Irregular/absent menses (oligoamenorrhea), infertility, recurrent miscarriage.
   • Dermatological: Hirsutism (face, chest, abdomen), acne, alopecia, acanthosis nigricans (insulin resistance sign).
   • Metabolic: Weight gain/obesity (50–80% of cases), increased risk of type 2 diabetes, dyslipidemia.
   • This patient exhibits irregular menses, hirsutism, and obesity—classic features.

4. Which investigations are appropriate for PCOS?

   • First-line:
     • Hormonal: Total/free testosterone, SHBG, LH:FSH ratio (often elevated LH), TSH, prolactin (to exclude mimics).
     • Metabolic: Fasting glucose, HbA1c, lipid panel.
     • Ultrasound: Transvaginal (confirms polycystic morphology; must meet Rotterdam’s ≥20 follicles/ovary).
   • Exclusion tests: 17-OH progesterone (rule out CAH), DHEA-S (if adrenal hyperandrogenism suspected).
   • Avoid: AMH (not diagnostic but often elevated; useful for research).

5. What is your management plan for PCOS?

   • Lifestyle modification (FIRST-LINE):
     • Weight loss (5–10% reduction): Calorie-restricted diet + aerobic exercise (improves insulin sensitivity, restores ovulation).
   • Symptom-specific treatment:
     • Hyperandrogenism/hirsutism: Combined oral contraceptive pills (COCPs; e.g., ethinyl estradiol + anti-androgen like drospirenone) or spironolactone (if COCP contraindicated).
     • Anovulation/infertility: Letrozole (first-line ovulation induction); metformin (if insulin resistance persists despite weight loss).
   • Metabolic monitoring: Annual screening for diabetes (HbA1c), lipids, BP.
   • For this patient: Prioritize weight loss + COCPs to regulate cycles and reduce hirsutism. Add metformin if prediabetes present.

Key Clarification: The case states “>10 follicles/ovary,” but Rotterdam criteria require ≥20 follicles per ovary. This discrepancy may indicate outdated imaging criteria; confirm follicle count meets current standards.

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CD 10: Menopause

Problem:

A 55-year-old woman presents with severe hot flushes and night sweats. FSH and LH are elevated, and her last menses was 6 months ago.

Guiding Questions:

1. How do you define menopause?
2. What are the physiological changes in the hypothalamic-pituitary-ovarian axis?
3. What are the common symptoms and exam findings of menopause?
4. What are the management options for peri-menopausal symptoms?
5. How would you counsel a patient regarding menopause?
6. What are the long-term complications associated with menopause?