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Reproductive System: High-Yield PANCE Review

The reproductive system carries one of the heavier weights on the PANCE (~8% of the blueprint, covering both female and male genitourinary/reproductive disorders), spanning STIs, menstrual and pregnancy disorders, gynecologic and prostate/testicular malignancies, and breast disease. This guide targets the most-tested first-line diagnoses, thresholds, and therapies aligned to the current NCCPA blueprint and standard board references (CDC 2021 STI guidelines, USPSTF/ACOG current recommendations).

Sexually Transmitted Infections

  • ◆Chlamydia (most common reportable STI): often asymptomatic; treat with doxycycline 100 mg BID x7 days (now preferred over azithromycin per CDC 2021); azithromycin 1 g single dose in pregnancy (doxycycline contraindicated). Screen all sexually active women <25 annually.
  • ◆Gonorrhea: treat with ceftriaxone 500 mg IM once (1 g if >=150 kg); no longer co-treat for chlamydia unless chlamydial infection has not been excluded. Can cause disseminated GC (tenosynovitis, migratory polyarthritis, pustular rash) and PID.
  • ◆Syphilis: primary = painless chancre; secondary = diffuse rash including palms/soles + condyloma lata; tertiary = gummas/tabes dorsalis/aortitis. Screen with RPR/VDRL, confirm with FTA-ABS/treponemal. Treat with benzathine penicillin G IM (single dose for early; weekly x3 for late/latent or unknown duration).
  • ◆Trichomonas: frothy green-yellow discharge, 'strawberry cervix,' motile flagellates on wet mount, pH >4.5. Treat with metronidazole 500 mg BID x7 days for women (CDC 2021; men can still receive 2 g single dose); treat partners.
  • ◆Genital herpes (HSV-2 > HSV-1): painful grouped vesicles/ulcers; treat with acyclovir, valacyclovir, or famciclovir. HPV causes condyloma acuminata and cervical dysplasia (types 16/18 oncogenic; 6/11 warts).

Menstrual, Pelvic, and Benign Gyn Disorders

  • ◆PCOS: hyperandrogenism + oligo/anovulation + polycystic ovaries (Rotterdam 2 of 3); LH:FSH often elevated, insulin resistance. First-line: weight loss + OCPs (for menses/hirsutism), metformin, letrozole is first-line for ovulation induction/fertility.
  • ◆Endometriosis: cyclic pelvic pain, dysmenorrhea, dyspareunia, infertility; classic 'chocolate cysts' and fixed retroverted uterus. Definitive dx by laparoscopy (powder-burn lesions); treat with NSAIDs, OCPs/progestins, GnRH agonists.
  • ◆PID: cervical motion/adnexal/uterine tenderness; treat empirically with ceftriaxone 500 mg IM + doxycycline 100 mg BID x14 days + metronidazole 500 mg BID x14 days (CDC 2021 adds metronidazole to all regimens). Fitz-Hugh-Curtis = perihepatitis (RUQ pain).
  • ◆Leiomyoma (fibroids): most common benign uterine tumor; enlarged irregular uterus, menorrhagia, bulk symptoms; estrogen-dependent, regress after menopause. Options: expectant, GnRH agonists, UAE, myomectomy/hysterectomy.
  • ◆Abnormal uterine bleeding: use PALM-COEIN. Postmenopausal bleeding is endometrial cancer until proven otherwise -> transvaginal US (>4 mm) + endometrial biopsy.
  • ◆Bacterial vaginosis: thin gray discharge, positive whiff test, clue cells, pH >4.5 (Amsel criteria); treat with metronidazole. Candida: thick white 'cottage cheese,' pH normal, treat fluconazole/topical azoles.

Pregnancy and Prenatal Care

  • ◆Confirm with beta-hCG; suspect ectopic if hCG above the discriminatory zone (classically 1500-2000; ACOG now favors a more conservative ~3500 to avoid disrupting a viable IUP) without intrauterine pregnancy on TVUS -> classic triad: amenorrhea, vaginal bleeding, unilateral pelvic pain. Methotrexate (stable/unruptured) vs surgery.
  • ◆Preeclampsia: new HTN >=140/90 after 20 weeks + proteinuria (or end-organ signs); severe features BP >=160/110, headache, RUQ pain, HELLP. Treat with magnesium sulfate (seizure ppx) + antihypertensives (labetalol, hydralazine, nifedipine); delivery is definitive.
  • ◆Gestational diabetes: screen 24-28 weeks (1-hr 50 g -> 3-hr 100 g). Rh(D)-negative moms get RhoGAM at 28 weeks and postpartum if baby Rh+.
  • ◆Prenatal labs: first visit CBC, blood type/Rh/antibody, rubella, HIV, HBsAg, syphilis, urine culture, Pap. Folic acid 400 mcg (4 mg with prior NTD). GBS screen 36-37 weeks (36 0/7 to 37 6/7) -> intrapartum penicillin.
  • ◆Abruption = painful bleeding + rigid tender uterus (risk: HTN/cocaine/trauma). Previa = painless bleeding, no digital/vaginal exam -> TVUS.
  • ◆First-trimester dating by crown-rump length is most accurate. Avoid ACE inhibitors, warfarin, isotretinoin, tetracyclines, valproate.

Gynecologic Malignancies and Screening

  • ◆Cervical cancer (HPV 16/18): USPSTF screens with cytology starting age 21; ages 21-29 Pap q3y; ages 30-65 primary HPV q5y (preferred) or co-test (Pap+HPV) q5y or cytology q3y — 2024-2025 USPSTF now also endorses self-collected HPV samples (ACS alternatively starts at 25 with primary HPV q5y). Presents with postcoital bleeding. HPV vaccine 9-valent.
  • ◆Endometrial cancer (most common gyn malignancy): unopposed estrogen risk (obesity, nulliparity, tamoxifen, late menopause, PCOS); postmenopausal bleeding -> endometrial biopsy. Type 1 endometrioid most common.
  • ◆Ovarian cancer: usually late-stage (bloating, early satiety, pelvic pressure); CA-125 elevated (epithelial); no effective screening. BRCA1/2 confer risk. Risk reduced by OCPs, multiparity.
  • ◆Breast cancer: USPSTF (2024) recommends biennial mammography starting age 40 through 74. Suspicious findings: fixed hard mass, skin dimpling, nipple retraction/discharge, peau d'orange (inflammatory). Work up with US (young) or mammogram + core biopsy; check ER/PR/HER2.
  • ◆Molar pregnancy: markedly elevated hCG, 'snowstorm' US, hyperemesis, uterus large for dates; treat with D&C and serial hCG monitoring for GTN.

Male Reproductive Disorders

  • ◆Testicular torsion: sudden severe pain, high-riding testis, absent cremasteric reflex, negative Prehn sign; SURGICAL emergency -> detorsion + orchiopexy within 6 hours. US shows decreased flow.
  • ◆Testicular cancer: painless firm testicular mass in young men (15-35); germ cell tumors; tumor markers AFP, beta-hCG, LDH. Do NOT biopsy -> radical inguinal orchiectomy.
  • ◆BPH: lower urinary tract symptoms, smooth enlarged prostate; treat with alpha-blockers (tamsulosin) for rapid relief and 5-alpha-reductase inhibitors (finasteride) to shrink gland. Avoid anticholinergics/decongestants.
  • ◆Prostate cancer: hard nodular prostate; PSA elevated; adenocarcinoma of peripheral zone, metastasizes to bone (osteoblastic). USPSTF: shared decision PSA screening ages 55-69.
  • ◆Epididymitis: gradual pain, positive Prehn sign, present cremasteric reflex; <35 = chlamydia/gonorrhea (ceftriaxone 500 mg IM + doxycycline), >35 or insertive intercourse = enteric organisms (levofloxacin). Erectile dysfunction first-line PDE-5 inhibitors (avoid with nitrates).
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