Step 3 · 7–9%

Pregnancy, Female Reproductive & Breast

Prenatal care to postpartum, then contraception, menses, menopause, infections and breast.

See it in the Brain

Prenatal care & screening

In the Brain

Date the pregnancy well, run each screen in its window, and stop harmful drugs and exposures early.

Rules to know

First prenatal visit labs → CBC, blood type and antibody screen, rubella IgG, HBsAg, HIV, syphilis, hepatitis C, urine culture; chlamydia and gonorrhea if under 25 or at risk
Dating the pregnancy → first-trimester crown-rump length wins; change the due date if period dates differ by >5 days before 9 weeks or >7 days through 13 weeks
Routine prenatal visit schedule → every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, then weekly until birth
Aneuploidy screening → offer to every patient at any age; cell-free DNA from 10 weeks is the most sensitive screen but is not diagnostic
Positive cell-free DNA or serum screen → genetic counseling and diagnostic testing (CVS at 10–13 weeks or amniocentesis from 15 weeks) before any irreversible decision
Cell-free DNA returns no result (low fetal fraction) → counsel about higher aneuploidy risk; offer detailed ultrasound and diagnostic testing
Open neural tube defect screening → maternal serum AFP at 15–22 weeks or a detailed anatomy scan; cell-free DNA does not detect these
High maternal serum AFP → confirm dates by ultrasound first, then a targeted scan for neural tube or abdominal wall defect, twins or fetal death
Quad screen with low AFP and estriol, high hCG and inhibin → trisomy 21 pattern; all low except inhibin points to trisomy 18
Carrier screening → offer cystic fibrosis, spinal muscular atrophy and hemoglobinopathy screening (CBC with MCV, electrophoresis if indicated) to everyone; a carrier's partner is tested next
Gestational diabetes screening at 24–28 weeks → 50-g 1-hour challenge then 100-g 3-hour test if high, or a single 75-g 2-hour test
Overweight with prior gestational diabetes, PCOS or strong family history → screen for diabetes at the first visit; repeat at 24–28 weeks if normal
Group B strep screening → rectovaginal culture at 36–37 weeks; skip it when GBS bacteriuria this pregnancy or a prior infected infant already mandates labor prophylaxis
Rh-negative, antibody screen negative → anti-D immune globulin at 28 weeks, after bleeding, trauma or procedures, and within 72 h of birth if the newborn is Rh-positive
Rh-negative with anti-D antibodies already present → immune globulin no longer helps; follow titers, then serial MCA Doppler for fetal anemia once titers are critical
Syphilis screening in pregnancy → first visit, again near 28 weeks and at delivery, given rising congenital syphilis
Bacteriuria on first-visit culture without symptoms → treat per sensitivities (cephalexin, nitrofurantoin, fosfomycin) and repeat the culture; untreated it can progress to pyelonephritis
Each pregnancy → Tdap at 27–36 weeks, inactivated influenza in season, RSV vaccine at 32–36 weeks September–January unless the infant will receive nirsevimab
Nonstress test after 32 weeks → reactive if two accelerations of 15 bpm lasting 15 seconds within 20 minutes; nonreactive → biophysical profile or contraction stress test
Biophysical profile score → 8–10 reassuring; 6 equivocal (deliver at term, otherwise repeat within 24 h); 4 or less usually means delivery
Decreased fetal movement in the third trimester → same-day nonstress test and amniotic fluid check, not reassurance by phone
Fundal height off by >3 cm at 24–38 weeks → ultrasound for fetal growth and amniotic fluid
Planning pregnancy on ACE inhibitor, ARB, warfarin, valproate, methotrexate, mycophenolate or isotretinoin → switch or stop before conception
Antibiotics in pregnancy → penicillins, cephalosporins, azithromycin and clindamycin are safe; avoid tetracyclines and fluoroquinolones, and TMP-SMX in the first trimester and near term
Pain or fever in pregnancy → acetaminophen at the lowest effective dose; avoid NSAIDs from 20 weeks (oligohydramnios, early ductus closure)
Needed CT or x-ray during pregnancy → proceed; fetal doses under 50 mGy carry no measurable anomaly risk; iodinated contrast is acceptable, gadolinium is avoided
Opioid use disorder in pregnancy → buprenorphine or methadone rather than withdrawal; plan ahead for neonatal opioid withdrawal care
Alcohol, tobacco or cannabis use in pregnancy → advise stopping all; no amount of alcohol is known safe; counseling first for smoking, nicotine replacement if that fails

Traps that cost points

Offering amniocentesis or CVS only to patients 35 and older→ Every patient is offered screening and diagnostic testing; age changes the risk, not the eligibility.
Treating a positive cell-free DNA result as a diagnosis→ False positives occur, especially in low-risk patients; confirm with CVS or amniocentesis before any decision.
Giving anti-D globulin to an Rh-negative patient who is already sensitized→ Once antibodies exist the globulin cannot help; follow titers and screen the fetus for anemia with MCA Doppler.
Working up a high AFP before checking the dates→ Wrong gestational age is the most common explanation; date by ultrasound first, then do a targeted anatomy scan.
Withholding a needed CT from a pregnant patient with trauma or suspected PE→ Diagnostic doses sit far below harmful thresholds; a missed diagnosis is the greater danger to mother and fetus.
Advising a pregnant patient with opioid use disorder to taper off→ Withdrawal raises relapse, overdose and fetal stress; start or continue buprenorphine or methadone.
Stopping a needed SSRI or antiseizure drug as soon as pregnancy is confirmed→ Untreated illness carries its own risk; continue effective drugs and switch only clear teratogens such as valproate.
Ordering routine TSH and vitamin D panels at the first visit for everyone→ Test thyroid only with symptoms or risk factors; the core panel is blood type, antibodies, infections and urine culture.

Medical complications of pregnancy

In the Brain

Hypertensive disorders and diabetes dominate: know the thresholds, the drug of choice and the week to deliver, plus the key infections.

Rules to know

Aspirin to prevent preeclampsia → 81 mg daily started at 12–28 weeks, ideally before 16, and continued until delivery
Aspirin candidates in pregnancy → prior preeclampsia, chronic hypertension, pregestational diabetes, kidney disease, lupus or antiphospholipid syndrome, twins, or two or more moderate risks
New hypertension after 20 weeks without proteinuria or severe features → gestational hypertension (≥140/90 twice, 4 h apart); weekly labs, fetal testing, deliver at 37 weeks
Hypertension after 20 weeks plus proteinuria or end-organ signs → preeclampsia; protein/creatinine ≥0.3, or low platelets, rising creatinine, high transaminases, pulmonary edema, new headache
Severe features of preeclampsia → BP ≥160/110, platelets <100,000, transaminases twice normal, creatinine >1.1, pulmonary edema, persistent headache or visual changes
Preeclampsia without severe features → twice-weekly BP, weekly labs and fetal testing; deliver at 37 weeks
Preeclampsia with severe features at 34 weeks or later → magnesium, control BP, deliver after stabilizing; vaginal birth is acceptable
Severe preeclampsia before 34 weeks, mother and fetus stable → tertiary center, betamethasone, magnesium, daily labs; deliver if anything worsens
BP ≥160/110 for 15 minutes in pregnancy or postpartum → IV labetalol, IV hydralazine or oral immediate-release nifedipine within 30–60 minutes
Magnesium sulfate for seizure prophylaxis → 4–6 g IV load, then 1–2 g/h through delivery and 24 h after; reduce the dose with renal impairment
Lost reflexes, slow breathing or heart block on magnesium → stop the infusion, give IV calcium gluconate, support ventilation
Seizure after 20 weeks or postpartum without another cause → eclampsia; protect the airway, left lateral position, magnesium; deliver once the mother is stable
Hemolysis, rising transaminases, falling platelets, RUQ pain → HELLP; magnesium and delivery, with a steroid course first only if under 34 weeks and stable
Chronic hypertension in pregnancy → treat to below 140/90 with labetalol or long-acting nifedipine; baseline creatinine, LFTs, platelets and urine protein
Gestational diabetes → nutrition therapy and activity with 4-times-daily glucose checks; targets fasting <95, 1 h after meals <140 or 2 h <120
Gestational diabetes above target despite diet → insulin first-line; metformin is an alternative but crosses the placenta; glyburide is less preferred
After gestational diabetes → 75-g 2-hour glucose tolerance test at 4–12 weeks postpartum, then diabetes screening every 1–3 years for life
Pregestational diabetes planning pregnancy → A1c below 6.5% if safely reached, retinal exam and kidney tests; in pregnancy, aspirin from 12 weeks and fetal echocardiography
Pregnant patient on levothyroxine → raise the dose about 25–30% (two extra doses weekly) right away; TSH every 4 weeks through midpregnancy
DVT or PE in pregnancy → therapeutic LMWH through pregnancy and at least 6 weeks postpartum (3 months minimum); avoid warfarin and DOACs before delivery
Epilepsy in pregnancy → continue the drug that works and avoid valproate; lamotrigine levels fall, so monitor and adjust, then reduce after delivery
Antiphospholipid syndrome in pregnancy → low-dose aspirin plus prophylactic LMWH; therapeutic LMWH if there was a prior thrombosis
Itching of palms and soles in the third trimester, high bile acids → intrahepatic cholestasis; ursodiol, deliver at 36–39 weeks (36 if bile acids ≥100)
Third-trimester vomiting, jaundice, hypoglycemia and coagulopathy → acute fatty liver of pregnancy; correct glucose and clotting, deliver promptly
Pyelonephritis in pregnancy → admit, IV ceftriaxone after culture, oral once afebrile, then suppressive antibiotics for the rest of pregnancy
HIV in pregnancy → ART for all; viral load >1,000 near term → cesarean at 38 weeks plus IV zidovudine; suppressed → vaginal birth
HBsAg-positive mother → check HBV DNA; tenofovir from 28–32 weeks if >200,000 IU/mL; newborn gets HBIG plus vaccine within 12 hours
History of genital herpes → suppressive acyclovir or valacyclovir from 36 weeks; active lesions or prodrome in labor → cesarean
Nonimmune pregnant patient exposed to chickenpox → varicella-zoster immune globulin within 10 days; acyclovir if infection develops, IV for pneumonia
Parvovirus infection in pregnancy → serial MCA Doppler for 8–12 weeks; fetal anemia or hydrops → intrauterine transfusion

Traps that cost points

Waiting for proteinuria before calling preeclampsia in a hypertensive patient with low platelets→ Severe features alone define preeclampsia; proteinuria is not required once end-organ signs appear.
Relying on magnesium to bring down a severe-range blood pressure→ Magnesium prevents seizures only; severe-range BP needs labetalol, hydralazine or nifedipine within the hour.
Giving a benzodiazepine or phenytoin first for an eclamptic seizure→ Magnesium sulfate stops and prevents recurrence best; other drugs are backups when magnesium fails or is unavailable.
Rushing to emergency cesarean for fetal bradycardia during an eclamptic seizure→ The fetal heart usually recovers after the seizure; stabilize the mother first, then plan delivery.
Choosing glyburide as the first drug for gestational diabetes→ Insulin is preferred; metformin is the alternative. Glyburide causes more neonatal hypoglycemia and macrosomia.
Continuing an ACE inhibitor after a positive pregnancy test→ ACE inhibitors and ARBs injure fetal kidneys and cause oligohydramnios; switch to labetalol or nifedipine.
Starting warfarin for a DVT found at 20 weeks→ Warfarin crosses the placenta; LMWH is the antepartum drug. Warfarin is fine postpartum, including with breastfeeding.
Skipping postpartum glucose testing after gestational diabetes→ Later type 2 diabetes is common; do a 2-hour OGTT at 4–12 weeks, then screen every 1–3 years.

Early pregnancy: bleeding, ectopic, loss & vomiting

In the Brain

Every first-trimester bleed is an ectopic until proven otherwise: pair hCG with transvaginal ultrasound and let stability decide the path.

Rules to know

Positive pregnancy test with bleeding or pain → vital signs, transvaginal ultrasound, quantitative hCG, CBC, blood type and Rh
Pregnant, hypotensive, peritoneal signs or free fluid on FAST → ruptured ectopic; fluids, blood and surgery without waiting for hCG
No intrauterine pregnancy on transvaginal scan with hCG above about 3,500 → ectopic or failed pregnancy likely; if stable and pregnancy wanted, repeat hCG before treating
Pregnancy of unknown location, stable → repeat hCG in 48 hours with ultrasound; a viable pregnancy usually rises at least 35%
Methotrexate for ectopic → stable, unruptured, reliable follow-up, no intrauterine pregnancy, normal blood counts, liver and kidney tests, not breastfeeding
Ectopic with high hCG, cardiac activity or large mass → methotrexate likely to fail (hCG >5,000, embryonic heartbeat, mass >3.5 cm); laparoscopic surgery preferred
After single-dose methotrexate → hCG on days 4 and 7; a fall of 15% or more → weekly until undetectable; less → second dose or surgery
On methotrexate for ectopic → no folate supplements, NSAIDs, alcohol or strong sun; new severe pain → evaluate for rupture
Surgery for ectopic with a healthy opposite tube → salpingectomy; salpingostomy keeps the tube but needs weekly hCG for persistent trophoblast
Rh-negative patient with ectopic or molar pregnancy → give anti-D immune globulin
Rh-negative with miscarriage or abortion before 12 weeks → current guidance allows omitting anti-D; give it from 12 weeks on
Nonviable pregnancy criteria → crown-rump length ≥7 mm without a heartbeat, or mean sac diameter ≥25 mm without an embryo; below these, rescan in 7–14 days
Bleeding, closed os, live intrauterine pregnancy → threatened miscarriage; reassure, bed rest does not help, most pregnancies continue
Open os, tissue in the canal, heavy bleeding → inevitable or incomplete miscarriage; uterine aspiration if unstable or bleeding heavily
Early pregnancy loss, stable → expectant care, medication or uterine aspiration are all reasonable; the patient chooses
Medical management of early loss → mifepristone 200 mg, then misoprostol 800 mcg vaginally a day later; better than misoprostol alone
Fever, uterine tenderness and foul discharge after loss or abortion → septic abortion; blood cultures, broad IV antibiotics and prompt uterine evacuation
Single first-trimester loss → usually fetal aneuploidy; reassure that work, exercise and sex did not cause it; no workup needed
Two or more pregnancy losses → antiphospholipid antibodies, parental karyotypes, uterine cavity imaging, TSH and A1c
Vomiting with weight loss >5%, ketonuria, electrolyte changes → hyperemesis gravidarum; ultrasound for twins or molar pregnancy, check electrolytes, TSH and LFTs
Nausea and vomiting of pregnancy → pyridoxine with or without doxylamine first; add an antihistamine, metoclopramide or ondansetron if needed
Hyperemesis needing IV fluids → thiamine before dextrose; admit if fluids cannot be kept down or ketosis persists after outpatient therapy
Hyperemesis with low TSH, high free T4, no Graves signs → gestational transient thyrotoxicosis; no antithyroid drugs, settles by midpregnancy
Uterus large for dates, very high hCG, snowstorm ultrasound → molar pregnancy; suction curettage after baseline hCG and chest x-ray
Preeclampsia before 20 weeks or hyperthyroidism with very high hCG → suspect a molar pregnancy
After molar evacuation → weekly hCG until undetectable, then monthly checks for several months, with reliable contraception throughout
hCG plateaus or rises after molar evacuation → gestational trophoblastic neoplasia; chest imaging and staging, methotrexate for low-risk disease
Abnormal bleeding or lung nodules months after any pregnancy → check hCG for choriocarcinoma

Traps that cost points

Sending home a patient with pain because hCG is below the discriminatory level→ Ectopics occur at any hCG; with an empty uterus follow hCG every 48 hours and give strict return precautions.
Giving methotrexate after one hCG value in a stable patient who wants the pregnancy→ Confirm nonviability with a repeat hCG or scan first; methotrexate would end an early viable pregnancy.
Choosing methotrexate for a breastfeeding patient or one with liver disease→ These are contraindications; laparoscopic surgery is the safer option.
Prescribing bed rest for threatened miscarriage→ It does not prevent loss and adds clot risk; normal activity is fine.
Running dextrose before thiamine in a patient vomiting for weeks→ Glucose without thiamine can precipitate Wernicke encephalopathy; give thiamine first.
Starting methimazole for low TSH in hyperemesis→ hCG stimulates the thyroid temporarily; it resolves by about 20 weeks. Treat only true Graves disease.
Stopping hCG follow-up once a patient feels well after molar evacuation→ Persistent trophoblastic disease is silent; follow hCG to undetectable and beyond, and prevent a new pregnancy meanwhile.

Breast & gynecologic cancers and screening

In the Brain

Pick the first image by age, biopsy anything suspicious whatever the imaging says, and follow current screening intervals.

Rules to know

Average-risk woman 40–74 → screening mammography every 2 years; beyond 75 decide by health and life expectancy
Palpable breast mass under age 30 → targeted ultrasound first; mammogram only if ultrasound is suspicious
Palpable breast mass at 30 or older → diagnostic mammogram plus targeted ultrasound
Suspicious breast imaging (BI-RADS 4 or 5) → image-guided core needle biopsy
Clinically worrisome lump with normal mammogram and ultrasound → biopsy anyway; normal imaging never clears a suspicious mass
Simple breast cyst on ultrasound → aspirate only if painful; bloody fluid or a mass remaining after aspiration → biopsy
Smooth, mobile, rubbery mass in a young woman → fibroadenoma; ultrasound with core biopsy or follow-up; large, fast-growing → excise for phyllodes tumor
Spontaneous one-sided bloody discharge from a single duct → mammogram and ultrasound; usually intraductal papilloma, excise to exclude cancer
Red, swollen, peau d'orange breast that does not settle on antibiotics → inflammatory breast cancer; imaging plus core and skin punch biopsy
Scaly, eroded nipple that will not heal → Paget disease of the breast; mammogram and full-thickness nipple biopsy
Family history of breast or ovarian-type cancers, or BRCA-linked ancestry → familial risk tool; positive → genetic counseling, then testing
BRCA1 or BRCA2 carrier → yearly breast MRI from 25, add mammography at 30; salpingo-oophorectomy at 35–40 (BRCA1) or 40–45 (BRCA2)
Lifetime breast cancer risk ≥20% or chest radiation in youth → yearly MRI plus mammography, usually starting by 30
Increased breast cancer risk, age 35+, low clot risk → offer tamoxifen, raloxifene or an aromatase inhibitor; tamoxifen raises endometrial cancer and VTE
Hormone receptor–positive breast cancer → 5–10 years of endocrine therapy: tamoxifen before menopause, aromatase inhibitor after (with DXA monitoring)
Breast cancer survivor without symptoms → yearly history, exam and mammogram; no routine tumor markers, bone scans or CT
Cervical screening ages 21–29 → cytology every 3 years; nothing before 21
Cervical screening ages 30–65 → primary HPV test every 5 years preferred; cotesting every 5 or cytology every 3 years acceptable
Over 65 with adequate negative screening and no CIN2+ in 25 years → stop; total hysterectomy for benign disease → stop
HIV or organ transplant → cervical screening from diagnosis, cytology yearly for 3 years then every 3 years, continuing past 65
ASC-US at 25 or older → reflex HPV; HPV-negative → repeat testing in 3 years; HPV-positive → colposcopy
HPV 16 or 18 positive even with normal cytology → colposcopy; other high-risk types with normal cytology → repeat in 1 year
LSIL → colposcopy; HSIL → colposcopy, or immediate LEEP if 25 or older and not pregnant
ASC-US or LSIL at ages 21–24 → repeat cytology in 1 year instead of colposcopy
Abnormal cervical cytology in pregnancy → colposcopy is safe; no endocervical curettage, defer treatment of precancer until after delivery
Atypical glandular cells → colposcopy with endocervical sampling, plus endometrial biopsy if 35 or older or at risk
Visible cervical lesion or postcoital bleeding with a mass → biopsy the lesion; cytology is not a diagnostic test
Postmenopausal bleeding → transvaginal ultrasound (endometrium ≤4 mm reassuring) or endometrial biopsy; persistent bleeding → biopsy regardless of thickness
Endometrial hyperplasia with atypia → hysterectomy; without atypia → progestin, preferably levonorgestrel IUD, and repeat sampling
Bloating, early satiety, pelvic mass after menopause → transvaginal ultrasound and CA-125; refer to a gynecologic oncologist for surgery

Traps that cost points

Reassuring a woman with a firm lump because her mammogram was normal→ Mammography misses some palpable cancers, especially in dense breasts; image with ultrasound and biopsy a suspicious lump.
Ordering mammography first for a 24-year-old with a breast lump→ Young dense tissue images poorly on mammography; ultrasound is the first test.
Repeating antibiotics for persistent breast redness in a nonlactating woman→ If it does not clear quickly, image and biopsy for inflammatory carcinoma.
Doing yearly cervical cytology in a healthy 35-year-old with normal results→ Over-screening detects transient HPV changes and leads to needless procedures; primary HPV every 5 years.
Sending a 22-year-old with LSIL straight to colposcopy→ Low-grade changes usually regress in young women; repeat cytology in a year.
Stopping cervical screening at 65 in a woman with HIV or no documented negatives→ Stop only after an adequate negative history; immunocompromised patients continue lifelong.
Screening an average-risk woman for ovarian cancer with CA-125 and ultrasound→ It does not lower deaths and false positives lead to surgery; screening is for high-risk genetic pathways only.
Ignoring recurrent postmenopausal bleeding because the stripe measured 3 mm→ A thin stripe lowers risk, but persistent bleeding still needs tissue sampling.

Labor & delivery

In the Brain

Know normal labor's timelines, answer fetal heart tracings in order, and recognize the delivery-room emergencies.

Rules to know

Long latent phase below 6 cm → not a cesarean indication; rest, oxytocin or amniotomy, since active labor starts at 6 cm
No cervical change at ≥6 cm with ruptured membranes → active-phase arrest after 4 h of adequate or 6 h of oxytocin-augmented contractions; cesarean
No descent despite prolonged pushing → second-stage arrest after ≥3 h (nullipara) or ≥2 h (multipara), longer with epidural; operative vaginal birth or cesarean
Third stage of labor → placenta usually within 30 minutes; oxytocin right after the birth lowers hemorrhage risk
Category I fetal heart tracing → baseline 110–160, moderate variability, no late or variable decelerations; continue routine monitoring
Early decelerations mirroring contractions → fetal head compression; benign, no action needed
Late decelerations → uteroplacental insufficiency; left lateral position, stop oxytocin, IV fluid, correct hypotension; persistent with minimal variability → deliver
Recurrent variable decelerations → cord compression; reposition, check for cord prolapse, consider amnioinfusion
Category III tracing (absent variability with recurrent decelerations or bradycardia, or sinusoidal) → in-utero resuscitation and prepare for immediate delivery
More than 5 contractions per 10 minutes with tracing changes → tachysystole; stop oxytocin, give terbutaline if the tracing does not recover
Prolonged deceleration right after epidural placement → maternal hypotension; IV fluid, phenylephrine or ephedrine, lateral position
Fever in labor with fetal tachycardia or uterine tenderness → intraamniotic infection; ampicillin plus gentamicin, acetaminophen, deliver; cesarean only for usual reasons
Cord felt or seen after membranes rupture → hold the presenting part up off the cord, knee-chest position, emergency cesarean
Head delivers then retracts against the perineum → shoulder dystocia; call for help, McRoberts with suprapubic pressure, then deliver the posterior arm; no fundal pressure
Intrapartum GBS prophylaxis → IV penicillin G; low-risk penicillin allergy → cefazolin; high-risk allergy → clindamycin if susceptible, otherwise vancomycin
Unknown GBS status in labor → prophylaxis if preterm, membranes ruptured ≥18 h, temperature ≥38 °C, or positive rapid intrapartum test
Membranes ruptured at term without labor → induce with oxytocin rather than wait; GBS prophylaxis as indicated
Breech at 37 weeks → offer external cephalic version; if declined or unsuccessful, planned cesarean in most settings
Bishop score ≤6 before induction → cervical ripening with misoprostol, Foley balloon or dinoprostone; no misoprostol with a uterine scar
Low-risk pregnancy at 39 weeks → elective induction is reasonable and does not raise cesarean rates; at 41 weeks offer induction and start fetal testing
One or two prior low transverse cesareans → trial of labor is reasonable; prior classical incision or rupture → repeat cesarean at 36–37 weeks
Fetal bradycardia and lost station in labor after cesarean → uterine rupture; emergency laparotomy
Estimated fetal weight ≥5,000 g, or ≥4,500 g with diabetes → offer planned cesarean
Twin delivery timing → dichorionic at 38 weeks, monochorionic-diamniotic at 34–37 weeks; first twin not head-down → cesarean
Patient on LMWH approaching delivery → no neuraxial block within 12 h of a prophylactic or 24 h of a therapeutic dose
Cesarean prophylaxis → cefazolin within 60 minutes before incision; add azithromycin if laboring or membranes ruptured

Traps that cost points

Calling arrest of labor at 4–5 cm after two hours without change→ That is still latent labor; arrest requires ≥6 cm, ruptured membranes and the 4- or 6-hour criteria.
Applying fundal pressure for shoulder dystocia→ It wedges the shoulder harder behind the pubis; use McRoberts and suprapubic pressure, then posterior arm or rotation.
Keeping oxytocin running through recurrent late decelerations→ Stop oxytocin first, reposition, give fluid, fix hypotension; deliver if the tracing does not improve.
Ripening the cervix with misoprostol after a prior cesarean→ Prostaglandins raise uterine rupture risk with a scar; use a Foley balloon or oxytocin.
Going to cesarean because of intraamniotic infection alone→ Infection calls for antibiotics and delivery, not surgery; deliver vaginally unless usual obstetric indications arise.
Pushing a prolapsed cord back into the uterus→ Elevate the presenting part off the cord and keep it there until the cesarean is underway.
Choosing clindamycin for GBS in a patient whose penicillin allergy was a mild rash→ Low-risk allergy → cefazolin, which reliably covers GBS; clindamycin only for high-risk allergy with proven susceptibility.
Scheduling a repeat cesarean for every patient with a prior low transverse incision→ Trial of labor is a safe, reasonable choice for most; counsel and let the patient decide.

Preterm birth, ruptured membranes & late-pregnancy bleeding

In the Brain

Buy time for steroids when it helps, keep fingers out until previa is excluded, and deliver when mother or fetus cannot wait.

Rules to know

Preterm contractions with cervical change at 24–34 weeks → betamethasone, nifedipine tocolysis for 48 h, GBS prophylaxis if status unknown
Antenatal steroid timing → betamethasone when birth is likely within 7 days at 24–34 weeks; one rescue course if the first was ≥14 days earlier
Birth likely at 34–36 weeks, no prior steroids → late preterm betamethasone may be given; watch newborn glucose
Delivery likely before 32 weeks → magnesium sulfate for fetal neuroprotection against cerebral palsy
Indomethacin for tocolysis → only before 32 weeks and no longer than 48 h (ductal constriction, oligohydramnios)
Preterm contractions with negative fetal fibronectin or cervix >30 mm → birth within 2 weeks unlikely; avoid tocolysis and long admission
Prior spontaneous preterm birth → cervical length every 1–2 weeks from 16 to 24 weeks; cerclage if it falls below 25 mm
Short cervix ≤20 mm in midpregnancy, no prior preterm birth → vaginal progesterone
Painless second-trimester dilation or prior painless midtrimester losses → cervical insufficiency; cerclage, history-indicated placement at 12–14 weeks
Fluid leaking before labor → sterile speculum for pooling, nitrazine and ferning, no digital exam; ultrasound fluid volume if unclear
PPROM before 34 weeks → admit, ampicillin plus erythromycin or azithromycin, betamethasone, magnesium if <32 weeks; deliver at 34 weeks or sooner for infection
PPROM with fever, uterine tenderness, abruption or abnormal tracing → deliver regardless of gestational age
Painless bright-red bleeding in the third trimester → placenta previa until proven otherwise; ultrasound before any digital exam
Placenta previa → pelvic rest; cesarean at 36–37 weeks if stable, emergency cesarean for heavy bleeding or fetal compromise
Low-lying placenta at the anatomy scan → repeat ultrasound around 32 weeks; most move away from the cervix
Previa over a prior cesarean scar → placenta accreta spectrum; plan cesarean hysterectomy at 34–35 weeks at a specialty center
Painful bleeding, tense tender uterus after trauma, cocaine or hypertension → abruption; large IVs, CBC, fibrinogen, type and cross; deliver if unstable
Abruption with fetal death → expect DIC; replace fibrinogen and blood products, vaginal delivery usually preferred
Bleeding at membrane rupture with fetal bradycardia or sinusoidal pattern → vasa previa; emergency cesarean
Pregnant trauma patient past 20 weeks → left uterine displacement, at least 4 h fetal monitoring, Kleihauer-Betke if Rh-negative to dose anti-D
Maternal cardiac arrest with uterus at or above the umbilicus → manual uterine displacement during CPR; perimortem cesarean if no pulse by 4 minutes
Estimated fetal weight below the 10th percentile → umbilical artery Doppler; absent or reversed end-diastolic flow moves delivery earlier
Deepest fluid pocket <2 cm → oligohydramnios; check for ruptured membranes, growth restriction or renal anomalies; isolated at 36–37 weeks → deliver
Deepest fluid pocket ≥8 cm → polyhydramnios; test for diabetes and look for fetal swallowing problems such as GI obstruction or neural tube defects
Monochorionic twins → ultrasound every 2 weeks from 16 weeks to catch twin-twin transfusion
Stillbirth evaluation → Kleihauer-Betke, antiphospholipid antibodies, fetal autopsy, placental pathology and genetic testing by microarray

Traps that cost points

Doing a digital cervical exam for painless third-trimester bleeding→ Fingers can tear a previa and trigger hemorrhage; locate the placenta by ultrasound first.
Starting tocolysis at 35 weeks to buy time→ Past 34 weeks tocolysis does not improve outcomes; allow delivery.
Continuing tocolysis beyond 48 hours→ Its only purpose is finishing steroids or transfer; maintenance tocolysis adds harm without benefit.
Checking the cervix digitally in suspected PPROM→ It raises infection risk and shortens latency; use a sterile speculum exam.
Discharging a pregnant patient soon after a minor car crash→ Abruption can declare itself hours later; monitor the fetus at least 4 hours at viable gestation.
Using Kleihauer-Betke to diagnose abruption→ It measures fetal blood in maternal circulation to dose anti-D; abruption is a clinical and ultrasound-supported diagnosis.
Giving magnesium for neuroprotection at 34 weeks→ The neuroprotective benefit is shown only before 32 weeks.

Vaginitis, STIs & acute pelvic pain

In the Brain

Diagnose vaginitis at the microscope, treat STIs and partners with current regimens, and never miss torsion or ectopic in pelvic pain.

Rules to know

Thin gray discharge, fishy odor, pH >4.5, clue cells → bacterial vaginosis; oral metronidazole for 7 days or vaginal gel; male partners not treated
Thick white discharge, itching, normal pH, hyphae on KOH → vulvovaginal candidiasis; single-dose oral fluconazole, topical azole in pregnancy
Four or more yeast infections a year → confirm by culture, then weekly fluconazole for 6 months after an initial course
Frothy discharge, strawberry cervix, positive trichomonas NAAT → metronidazole 500 mg twice daily for 7 days; treat partners, retest in 3 months
Cervicitis or positive chlamydia NAAT → doxycycline 100 mg twice daily for 7 days; azithromycin 1 g if pregnant, with test of cure
Gonorrhea → ceftriaxone 500 mg IM once (1 g if ≥150 kg); add doxycycline unless chlamydia has been excluded
After chlamydia, gonorrhea or trichomonas → retest in 3 months for reinfection; offer expedited partner therapy where allowed
Chlamydia and gonorrhea screening → yearly for sexually active women under 25 and older women at increased risk
Painless genital ulcer with firm edges → primary syphilis; benzathine penicillin G 2.4 million units IM once, nontreponemal titers at 6 and 12 months
Syphilis of unknown duration or late latent → benzathine penicillin weekly for 3 weeks; neurologic, eye or ear symptoms → IV penicillin for neurosyphilis
Fever, myalgia and headache hours after syphilis treatment → Jarisch-Herxheimer reaction; antipyretics and continue therapy
Painful grouped vesicles or shallow ulcers → genital HSV; lesion PCR, antivirals 7–10 days for a first episode; frequent recurrences → daily suppression
Painful ulcer with tender suppurative nodes → chancroid (azithromycin or ceftriaxone); small painless ulcer then large tender nodes → LGV (doxycycline 21 days)
Genital warts → patient-applied imiquimod or podofilox, or office cryotherapy; in pregnancy use cryotherapy or excision
Sexually active patient with cervical motion, uterine or adnexal tenderness → treat empirically for PID; do not wait for NAAT results
Outpatient PID → ceftriaxone 500 mg IM once plus doxycycline and metronidazole for 14 days; reassess in 72 h
PID needing admission → pregnancy, tubo-ovarian abscess, high fever, vomiting, failed oral therapy or possible surgical emergency; IV antibiotics
Tubo-ovarian abscess → IV antibiotics; drainage if large, no response in 48–72 h, or rupture
PID with right upper quadrant pain and normal liver tests → perihepatitis (Fitz-Hugh-Curtis); same PID treatment
Pelvic pain in a reproductive-age woman → pregnancy test first, then pelvic ultrasound
Sudden one-sided pelvic pain, nausea, adnexal mass → ovarian torsion; Doppler ultrasound, but normal flow does not exclude it; laparoscopic detorsion saving the ovary
Brief one-sided pain at midcycle, normal exam → mittelschmerz; reassurance
Ruptured hemorrhagic cyst with mild free fluid, stable → pain control and observation; unstable → surgery
Simple ovarian cyst up to 10 cm without symptoms → expectant care, even after menopause; repeat ultrasound for larger ones
Painful swelling at the lower vaginal opening → Bartholin abscess; drain with a Word catheter or marsupialization, biopsy if 40 or older
Itchy, thin white vulvar skin in a figure-of-8 pattern → lichen sclerosus; high-potency topical steroid, biopsy persistent or atypical areas, lifelong cancer follow-up
Sexual assault survivor → consent-based exam and evidence collection, emergency contraception, empiric ceftriaxone, doxycycline and metronidazole, HIV PEP within 72 h, hepatitis B vaccine
Doxycycline post-exposure prophylaxis → gay or bisexual men and transgender women with a bacterial STI in the past year: doxycycline 200 mg within 72 h after condomless sex

Traps that cost points

Treating the male partner of a woman with bacterial vaginosis→ Partner therapy does not prevent recurrence; trichomonas is the vaginitis that needs partner treatment.
Using azithromycin first for chlamydia in a nonpregnant patient→ Seven days of doxycycline cures more, especially rectal infection; azithromycin is for pregnancy or adherence concerns.
Waiting for NAAT results before treating suspected PID→ Delay raises infertility and ectopic risk; minimal exam criteria justify immediate empiric therapy.
Ruling out torsion because Doppler shows flow→ Flow can be intermittent or preserved; strong clinical suspicion means laparoscopy.
Removing a dark ovary at torsion surgery→ Most dusky ovaries recover after detorsion; untwist and preserve it.
Treating syphilis in a penicillin-allergic pregnant patient with doxycycline→ Only penicillin reliably prevents congenital syphilis, and doxycycline harms fetal teeth and bone; desensitize and give penicillin.
Giving a single 2 g metronidazole dose for trichomonas in a woman→ The 7-day course cures more often in women; the single dose is kept for men.
Skipping HIV PEP after assault because 60 hours have passed→ PEP is offered up to 72 hours; start it at once.

Contraception, abortion care & infertility

In the Brain

Match the method to the medical history, give emergency contraception fast, and work up infertility in a set order.

Rules to know

Most effective reversible contraception → implant and IUDs; appropriate first-line choices for adolescents and nulliparous patients
Starting contraception → same-day start once pregnancy is reasonably excluded; backup for 7 days unless started within 5 days of period onset; no pelvic exam needed
Migraine with aura, smoker over 35, prior VTE or thrombophilia → no estrogen (same for lupus with antiphospholipid antibodies); progestin-only method or copper IUD
BP ≥160/100, ischemic heart disease, stroke or diabetes with vascular disease → avoid combined hormonal methods
Current breast cancer → no hormonal method of any kind; copper IUD
On rifampin, carbamazepine, phenytoin or other enzyme inducers → pills, patch, ring and implant may fail; choose an IUD or DMPA
Lamotrigine plus a combined estrogen pill → estrogen lowers lamotrigine levels; monitor levels or choose a non-estrogen method
After malabsorptive bariatric surgery → avoid oral contraceptives; use a non-oral method
DMPA every 13 weeks → reversible bone density loss (no DXA needed), weight gain, fertility may take 10 or more months to return
Heavy menstrual bleeding and wants contraception → levonorgestrel IUD; the copper IUD tends to worsen bleeding and cramps
Unprotected sex within 5 days → IUD (copper or 52-mg levonorgestrel) most effective; ulipristal to 120 h; oral levonorgestrel to 72 h, weaker with BMI >30
After ulipristal emergency contraception → wait 5 days before starting hormonal contraception, using condoms meanwhile
Pregnancy with an IUD in place → exclude ectopic; intrauterine pregnancy with visible strings → remove the IUD
IUD strings not seen → pregnancy test, backup method, ultrasound; not in the uterus → abdominal x-ray and laparoscopic removal if perforated
PID with an IUD in place → treat with antibiotics and leave the IUD unless there is no improvement in 48–72 h
Wants permanent contraception → vasectomy is safer and more effective; tubal sterilization by full salpingectomy also lowers ovarian cancer risk
Unintended pregnancy → nondirective options counseling (continuing and parenting, adoption, abortion) and timely referral for the care chosen
Medication abortion through about 10–11 weeks → mifepristone, then misoprostol 24–48 h later; confirm completion by hCG, ultrasound or symptom check
Before medication abortion → exclude ectopic when there are risk factors or uncertain dates; remove any IUD first
When to start infertility evaluation → after 12 months of trying if under 35, 6 months at 35–39, at once if 40 or older or with known problems
Infertility workup → semen analysis, ovulation check (cycle history, midluteal progesterone), tubal patency by hysterosalpingogram, ovarian reserve (AMH, antral follicle count)
Anovulatory infertility from PCOS → letrozole first-line for ovulation induction, plus weight loss if obese
Blocked tubes, severe male factor or failed simpler treatment → IVF, with ICSI for severe male factor
Abdominal swelling, ascites and hemoconcentration after ovulation induction → ovarian hyperstimulation syndrome; severe → admit, fluids, VTE prophylaxis, paracentesis if tense
Cancer diagnosis in a reproductive-age patient → fertility preservation referral before chemotherapy or pelvic radiation
Scant or absent periods and infertility after a D&C → Asherman syndrome; hysteroscopy to confirm and lyse adhesions
Turner syndrome planning pregnancy with donor eggs → cardiology review and aortic imaging first, because of dissection risk

Traps that cost points

Requiring a pelvic exam or Pap test before prescribing the pill→ Blood pressure and history are enough; exams are a barrier, not a requirement.
Prescribing a combined pill to a smoker over 35 or a patient with migraine with aura→ Estrogen raises stroke and clot risk here; offer a progestin-only method or an IUD.
Choosing oral levonorgestrel for a patient with BMI 35 seen 4 days after sex→ It is weaker with obesity and after 72 h; an IUD or ulipristal works better.
Pulling the IUD as soon as PID is diagnosed→ Treat with the device in place; remove it only if there is no clinical response.
Ordering DXA scans for patients on DMPA→ The bone loss reverses after stopping and does not justify scans or limit use.
Starting a long female workup before checking the partner's semen→ Male factor contributes in about half of couples; semen analysis is cheap and comes early.
Using clomiphene first for PCOS-related infertility→ Letrozole yields more ovulation and live births in PCOS.
Asking a 38-year-old to try for a full year before evaluation→ From 35, evaluate after 6 months; from 40, evaluate right away.

Menstrual disorders, PCOS & endometriosis

In the Brain

Pregnancy test first, then sort bleeding by age and structure, and amenorrhea by uterus, breasts and FSH.

Rules to know

Abnormal uterine bleeding in reproductive years → pregnancy test first, then CBC, TSH and pelvic ultrasound guided by structural vs nonstructural causes
Abnormal bleeding at 45+, or younger with unopposed estrogen → endometrial biopsy (also after failed medical therapy); obesity and PCOS count as unopposed estrogen
Heavy bleeding since menarche, or bleeding with dental work or surgery → screen for von Willebrand disease
Acute heavy uterine bleeding, unstable → resuscitate; IV conjugated estrogen or high-dose combined pill, tranexamic acid; D&C if medical therapy fails
Chronic heavy menstrual bleeding without a structural cause → levonorgestrel IUD, combined pills, tranexamic acid or NSAIDs during menses
Heavy bleeding with an enlarged irregular uterus → fibroids; ultrasound; LNG IUD, GnRH antagonist with add-back, myomectomy if fertility wanted, embolization, hysterectomy
Submucosal fibroid with heavy bleeding or infertility → hysteroscopic resection
Uniformly enlarged, soft, tender uterus with heavy painful periods → adenomyosis; ultrasound or MRI, hormonal therapy, hysterectomy is definitive
Primary amenorrhea → no menses by 15, or 3 years after breast budding; start with pregnancy test and exam for breasts and uterus
Breasts present, uterus absent → müllerian agenesis (female testosterone) vs androgen insensitivity (male-range testosterone, gonadectomy usually after puberty)
No breast development with high FSH → gonadal failure; karyotype for Turner syndrome; low FSH → hypothalamic or pituitary cause
Secondary amenorrhea → pregnancy test, then TSH, prolactin and FSH; add androgen levels if hirsute
Amenorrhea in an athlete or with low weight → functional hypothalamic amenorrhea; low FSH and estrogen; restore energy balance and check bone density
Amenorrhea before 40 with menopausal-range FSH on repeat → primary ovarian insufficiency; karyotype, FMR1 premutation, adrenal antibodies; hormone therapy until about 51
Irregular cycles with hirsutism or acne → likely PCOS; exclude pregnancy, thyroid disease, high prolactin and nonclassic CAH (17-hydroxyprogesterone)
PCOS diagnosis → two of three: oligo-ovulation, clinical or lab hyperandrogenism, polycystic ovaries or high AMH in adults
PCOS not seeking pregnancy → combined hormonal contraception for cycles, hirsutism and endometrial protection; add spironolactone after 6 months if needed
PCOS long-term care → screen for diabetes (OGTT or A1c), lipids, sleep apnea and depression; modest weight loss improves ovulation
Rapid virilization or testosterone >200 ng/dL → androgen-secreting tumor; pelvic ultrasound, DHEAS and adrenal CT
Painful periods beginning with ovulatory cycles, normal exam → primary dysmenorrhea; NSAIDs, then hormonal contraception
Cyclic pelvic pain, dyspareunia, painful defecation, infertility, uterosacral nodules → endometriosis; NSAIDs plus continuous hormonal suppression empirically
Endometriosis failing hormonal therapy or with infertility → laparoscopy to confirm and excise; GnRH antagonist or agonist with add-back is second-line
Luteal-phase mood symptoms that impair function and lift with menses → PMDD; SSRI daily or luteal-only, or a drospirenone pill
Postcoital bleeding → cervical screening if due, chlamydia and gonorrhea testing, and speculum look for polyp or lesion

Traps that cost points

Ordering hormone levels before a pregnancy test in amenorrhea→ Pregnancy is the most common cause at every age; test first.
Skipping endometrial sampling in an obese 38-year-old with irregular heavy bleeding→ Unopposed estrogen raises risk regardless of age; biopsy the endometrium.
Requiring laparoscopy before treating suspected endometriosis→ Empiric NSAIDs and hormonal suppression come first; surgery is for failure or infertility.
Using metformin as the main treatment for PCOS cycles and hirsutism→ Combined hormonal contraception is first-line; metformin helps metabolic risk.
Starting spironolactone for hirsutism without contraception→ It can feminize a male fetus; pair it with reliable contraception.
Telling a patient with primary ovarian insufficiency she cannot conceive→ Intermittent ovulation persists in some; counsel contraception if pregnancy is unwanted.
Treating an amenorrheic athlete with calcium and vitamin D alone→ Low estrogen from low energy availability drives bone loss; restoring intake and weight is the treatment.

Postpartum care & complications

In the Brain

Bleeding first, then fever, mood and feeding: know the uterotonic order and which postpartum symptoms are emergencies.

Rules to know

Postpartum hemorrhage (≥1,000 mL or bleeding with hypovolemia) → call for help, two large IVs, bimanual massage, IV oxytocin, find the cause: tone, trauma, tissue, thrombin
Boggy uterus despite oxytocin → add methylergonovine (not with hypertension), carboprost (not with asthma) or misoprostol
Postpartum hemorrhage within 3 hours of birth → tranexamic acid 1 g IV alongside uterotonics
Firm uterus but ongoing bleeding → inspect for cervical, vaginal or perineal lacerations and hematoma; repair
Placenta not out by 30 minutes or missing pieces → manual removal under anesthesia; no cleavage plane suggests accreta, prepare for hysterectomy
Bleeding persisting after uterotonics → balloon or vacuum tamponade, then embolization or surgery (compression sutures, artery ligation, hysterectomy); activate massive transfusion
Shock out of proportion to bleeding, fundus not palpable → uterine inversion; stop uterotonics, replace the uterus manually, then oxytocin
Sudden hypoxia, hypotension and DIC during or just after delivery → amniotic fluid embolism; CPR, ventilation, pressors and blood products
No milk and no periods after massive postpartum hemorrhage → Sheehan syndrome; check cortisol first, then thyroid and other pituitary hormones
Fever after cesarean with uterine tenderness and foul lochia → endometritis; IV clindamycin plus gentamicin until afebrile 24–48 h, no oral step-down needed
Postpartum fever persisting despite antibiotics → CT for pelvic abscess or septic pelvic thrombophlebitis; thrombophlebitis needs anticoagulation
Nursing mother with tender red wedge of breast and fever → mastitis; keep emptying that breast, dicloxacillin or cephalexin; MRSA risk → clindamycin
Fluctuant tender breast mass while nursing → breast abscess; ultrasound-guided aspiration or drainage plus antibiotics; breastfeeding can continue
Tearful mood swings that resolve within 2 weeks of birth → postpartum blues, peaking around days 3–5; reassure and recheck
Depressive symptoms beyond 2 weeks in the year after birth → postpartum depression; screen with a validated tool at postpartum and infant visits
Postpartum depression → psychotherapy and/or an SSRI (sertraline is well studied in breastfeeding); zuranolone is an oral 14-day option
Confusion, hallucinations or bizarre thoughts in the first postpartum weeks → postpartum psychosis; emergency psychiatric admission and an infant safety plan
Palpitations months after birth, painless thyroid, low uptake → postpartum thyroiditis; beta-blocker only, then watch for a hypothyroid phase
Heart failure late in pregnancy or up to 5 months postpartum → peripartum cardiomyopathy if EF <45%; standard heart failure therapy, ACE inhibitors only after delivery
Headache or BP ≥160/110 within 6 weeks after birth → postpartum preeclampsia; magnesium and antihypertensives, even after a normotensive pregnancy
Hypertensive disorder of pregnancy → BP check within 72 h of discharge if severe, otherwise within 7–10 days
Postpartum follow-up → contact within 3 weeks and a comprehensive visit by 12 weeks
Nonimmune to rubella or varicella → vaccinate before discharge; safe with breastfeeding, avoid pregnancy for 1 month
Rh-negative mother of an Rh-positive newborn → rosette screen, Kleihauer-Betke if positive to size the dose, anti-D within 72 hours
Postpartum contraception → implant, IUD and progestin-only methods can start right away; combined estrogen waits at least 21 days, longer with clot risk or breastfeeding
Exclusive breastfeeding, no periods, infant under 6 months → lactational amenorrhea is about 98% effective; add contraception when any condition lapses
Pain relief while breastfeeding → ibuprofen and acetaminophen first; avoid codeine and tramadol (ultrarapid metabolism can harm the infant)
Medications while breastfeeding → most antibiotics, SSRIs, heparin, warfarin and antiseizure drugs are compatible; avoid DOACs, radioactive iodine and chemotherapy

Traps that cost points

Giving methylergonovine for hemorrhage in a patient with preeclampsia→ Ergots cause intense vasoconstriction and hypertensive crisis; use carboprost or misoprostol.
Giving carboprost to a patient with asthma→ Prostaglandin F2-alpha triggers bronchospasm; choose methylergonovine if normotensive, or misoprostol.
More massage and uterotonics when the uterus is already firm→ A firm uterus points to lacerations, retained tissue or coagulopathy; inspect and check clotting.
Telling a mother with mastitis to stop breastfeeding→ Continued emptying speeds recovery and the milk is safe for the infant.
Calling postpartum psychosis the baby blues→ Hallucinations or confusion threaten mother and infant; this needs emergency admission.
Starting methimazole for postpartum thyroiditis→ The thyroid is leaking stored hormone, not making more; treat symptoms with a beta-blocker.
Dismissing severe headache a week after a normotensive delivery→ Preeclampsia can first appear up to 6 weeks postpartum; check BP and labs, give magnesium if severe.
Prescribing codeine for post-cesarean pain to a nursing mother→ Ultrarapid metabolizers pass morphine to the infant; use NSAIDs and acetaminophen first.

Menopause & gender-affirming hormone care

In the Brain

Treat symptoms with the right hormone in the right patient, and monitor gender-affirming hormones on a steady lab schedule.

Rules to know

Over 45 with 12 months without periods and hot flashes → menopause is a clinical diagnosis; FSH testing is unnecessary
Bothersome hot flashes, under 60 or within 10 years of menopause → systemic hormone therapy is the most effective option if no contraindication
Hormone therapy with an intact uterus → add a progestogen to protect the endometrium; no uterus → estrogen alone
Hormone therapy candidate with clot or triglyceride concerns → transdermal estradiol rather than oral
Contraindications to systemic hormone therapy → breast or endometrial cancer, prior VTE or stroke, coronary disease, active liver disease, unexplained bleeding
Hot flashes when hormones are not an option → SSRI or SNRI (low-dose paroxetine, venlafaxine), gabapentin, or fezolinetant with liver test monitoring
Vaginal dryness, painful sex and urinary symptoms after menopause → genitourinary syndrome; moisturizers, lubricants, low-dose vaginal estrogen without a progestogen
Hormone therapy solely to prevent heart disease, dementia or fractures → not recommended; use it for symptoms
Years of combined estrogen-progestin → small rise in breast cancer risk; estrogen alone after hysterectomy has not shown this rise
Menopause before 40, natural or surgical → hormone therapy until about the usual age of menopause to protect bone and heart
Postmenopausal osteoporosis needing drug therapy → bisphosphonate first; hormone therapy protects bone but is chosen for symptoms
Irregular bleeding in perimenopause → still evaluate, and keep contraception until 12 months without periods after 50 or age 55
Before gender-affirming hormones → informed consent, baseline labs, and a fertility preservation discussion (sperm or egg banking)
Feminizing hormone therapy → estradiol (transdermal, oral or injectable) plus an androgen blocker such as spironolactone or a GnRH agonist; not ethinyl estradiol
On feminizing therapy → estradiol and testosterone every 3 months the first year, then 1–2 times yearly; aim estradiol 100–200 pg/mL, testosterone <50 ng/dL
Spironolactone as an androgen blocker → potassium and creatinine at baseline and after dose changes
Estrogen therapy with smoking, older age or prior VTE → highest clot risk; prefer transdermal estradiol and support quitting
Masculinizing hormone therapy → testosterone injection or gel; testosterone level and hematocrit every 3 months the first year, then 1–2 times yearly
Hematocrit above 54% on testosterone → lower the dose or lengthen the interval, look for sleep apnea and smoking
On testosterone with a uterus and ovaries → pregnancy is still possible and testosterone harms a fetus; counsel reliable contraception
Screening transgender patients → screen the organs present: cervix by usual schedule, breasts by tissue and hormone history, prostate by usual PSA discussion
After gonadectomy, or sex hormones stopped long-term → assess bone density, since sex steroids maintain bone

Traps that cost points

Ordering FSH to diagnose menopause in a 52-year-old with typical symptoms→ The diagnosis is clinical; FSH swings during the transition and adds nothing.
Prescribing estrogen alone to a woman with a uterus→ Unopposed estrogen causes endometrial hyperplasia and cancer; add a progestogen.
Refusing hormone therapy to a healthy 50-year-old with severe hot flashes→ Under 60 or within 10 years of menopause, benefits usually outweigh risks without contraindications.
Starting hormone therapy at 68 to prevent heart disease→ Late starts carry more cardiovascular and stroke risk, and hormones are not for disease prevention.
Avoiding vaginal estrogen for genitourinary syndrome because of systemic warnings→ Low-dose vaginal estrogen has minimal absorption and needs no progestogen.
Assuming testosterone prevents pregnancy→ Ovulation can still happen; counsel contraception because fetal exposure to testosterone is harmful.
Prescribing ethinyl estradiol for feminizing therapy→ It carries the highest clot risk; estradiol formulations are used instead.
Skipping cervical screening in a transgender man on testosterone→ A cervix still needs routine screening; HPV testing helps when atrophy makes cytology unsatisfactory.