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📚 GNM Exam - Important Gynecology Questions & Answers
Sources: Berek & Novak's Gynecology | Costanzo Physiology | Medical Physiology (Boron) | Textbook of Family Medicine | Swanson's Family Medicine Review | Goldman-Cecil Medicine
1. MENSTRUAL CYCLE
Q1. What are the two phases of the menstrual cycle and which hormones dominate each?
A. The menstrual cycle (typically 28 days) has two phases:
- Follicular (Proliferative) phase - Days 1-14, dominated by estrogen (17β-estradiol). Estrogen stimulates endometrial growth, elongates spiral arteries, and makes cervical mucus copious, watery, and elastic (shows "ferning" pattern on a glass slide).
- Luteal (Secretory) phase - Days 14-28, dominated by progesterone. Progesterone makes uterine glands tortuous with glycogen vacuoles, thickens cervical mucus (no ferning), and raises basal body temperature slightly (basis for rhythm method). (Costanzo Physiology)
Q2. What is the "ferning" sign and its significance?
A. Cervical mucus from the follicular phase, when spread on a glass slide, forms a fern-like crystallization pattern. This happens because estrogen makes the mucus watery, allowing sperm channels to form - signifying the fertile window around ovulation.
Q3. What is ovulation and what triggers it?
A. Ovulation is the release of a mature ovum from the Graafian follicle, occurring around Day 14 of a 28-day cycle. It is triggered by a LH (luteinizing hormone) surge from the anterior pituitary. After ovulation, the ruptured follicle becomes the corpus luteum, which secretes progesterone.
2. MENOPAUSE
Q4. Define menopause. At what age does it typically occur?
A. Menopause is the permanent cessation of menstruation marking the end of reproductive function. It occurs at a mean age of 51.5 years in the United States. It is diagnosed after 12 consecutive months without menstruation.
Q5. What are the symptoms of menopause (Menopausal Syndrome)?
| Menopausal Syndrome | Physical Changes |
|---|---|
| Vasomotor instability | Atrophy of vaginal epithelium |
| Hot flashes | Changes in vaginal pH |
| Night sweats | Decreased vaginal secretions |
| Mood changes | Pelvic relaxation |
| Sleep disturbances | Loss of vaginal tone |
| Short-term memory loss | Cardiovascular disease risk |
| Headaches | Osteoporosis |
| Loss of libido | Risk of Alzheimer disease |
(Medical Physiology, Boron)
Q6. What is HRT? When is it given?
A. Hormone Replacement Therapy (HRT) consists of estrogen + progestin given to menopausal women to relieve menopausal syndrome and prevent osteoporosis. Progestin is added to protect the endometrium from unopposed estrogen (risk of neoplasia). Women who have had a hysterectomy receive estrogen alone (no progestin needed).
Q7. What are SERMs?
A. Selective Estrogen Receptor Modulators - drugs that act as estrogen agonists or antagonists depending on the target tissue (e.g., Tamoxifen, Raloxifene). Useful in managing menopausal symptoms and osteoporosis while reducing breast cancer risk.
3. UTERINE FIBROIDS (Leiomyomas)
Q8. What are uterine fibroids? How common are they?
A. Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. They are present in approximately 1 in 3 reproductive-age women and are the most common reason for hysterectomy in the US.
(Textbook of Family Medicine)
Q9. What are the symptoms of uterine fibroids?
A.
- Heavy/irregular vaginal bleeding (most common)
- Pelvic pain and pressure
- Urinary symptoms (frequency, urgency due to bladder compression)
- Infertility (though causation is not clearly established)
- Pregnancy complications
Q10. How are fibroids classified by location?
A.
- Submucosal - beneath the endometrium; causes most bleeding
- Intramural - within the myometrium; most common type
- Subserosal - on the outer surface of the uterus; causes pressure symptoms
- Pedunculated - attached by a stalk (can be submucosal or subserosal)
Q11. What are the treatment options for fibroids?
A.
- Watchful waiting - for asymptomatic women; most fibroids shrink after menopause
- Medical: NSAIDs, OCPs, levonorgestrel IUD (Mirena - reduces bleeding), Mifepristone (reduces bleeding and improves quality of life), GnRH agonists (pre-op to shrink fibroids)
- Surgical: Myomectomy (uterus-sparing, but 50% recurrence within 5 years), Hysterectomy (definitive), Uterine artery embolization, Endometrial ablation
4. PELVIC INFLAMMATORY DISEASE (PID)
Q12. What is PID and what organisms cause it?
A. PID is infection and inflammation of the upper genital tract (uterus, fallopian tubes, ovaries). Causative organisms include:
- Neisseria gonorrhoeae (most common)
- Chlamydia trachomatis
- Anaerobes, gram-negative bacteria, streptococci (Swanson's Family Medicine Review)
Q13. What are the diagnostic criteria for PID?
A. Minimum criteria (at least one must be present):
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
Supportive criteria:
- Oral temperature >38.3°C
- Abnormal mucopurulent cervical/vaginal discharge
- WBCs on wet prep
- Elevated ESR or CRP
- Lab confirmed gonorrhea/chlamydia
Q14. What are the risk factors for PID?
A.
- Age < 25 years (most common age group)
- Multiple sexual partners
- No barrier contraception
- History of previous PID
- High-prevalence area for gonorrhea/chlamydia
- Note: IUD use increases risk only in the first 21 days post-insertion; after that, risk depends on sexual behavior
Q15. What is the treatment for PID?
A.
- Inpatient: IV cefotetan or cefoxitin + doxycycline (oral or IV) OR IV clindamycin + IV gentamicin
- Outpatient: IM ceftriaxone + oral doxycycline ± metronidazole
Indications for hospitalization: surgical emergency cannot be excluded, pregnancy, failed outpatient therapy, severe illness (high fever, vomiting), tubo-ovarian abscess (TOA)
Q16. What is a tubo-ovarian abscess (TOA)?
A. A serious complication of PID where infection causes an abscess involving the fallopian tube and ovary. It requires hospitalization and IV antibiotics; may need surgical drainage if it doesn't respond to antibiotics.
5. CONTRACEPTION
Q17. What are the types of contraception?
A.
| Category | Methods |
|---|---|
| Hormonal | Combined OCP, Progestin-only pill (POP/mini-pill), Injectable (Depo-Provera), Implant, Patch, Vaginal ring |
| Intrauterine | Copper IUD (most effective emergency contraception), Levonorgestrel IUD (Mirena) |
| Barrier | Male condom, Female condom, Diaphragm, Cervical cap |
| Permanent | Tubal ligation (female), Vasectomy (male) |
| Emergency | Copper IUD, Levonorgestrel pill (Plan B), Ulipristal acetate |
| Natural | Rhythm/calendar method, Basal body temperature, Lactational amenorrhea |
(Textbook of Family Medicine)
Q18. What is the mechanism of action of combined OCPs?
A.
- Primary: Suppress ovulation by inhibiting FSH and LH via negative feedback on the hypothalamic-pituitary-ovarian (HPO) axis
- Secondary: Thicken cervical mucus (impedes sperm), thin endometrial lining, alter tubal motility
Q19. Which is the most effective emergency contraceptive?
A. The copper IUD is the most effective emergency contraception (>99% effective if inserted within 72-120 hours of unprotected intercourse). It also provides ongoing contraception.
6. CERVICAL CANCER & PAP SMEAR SCREENING
Q20. What causes cervical cancer?
A. Cervical cancer is caused by persistent infection with Human Papillomavirus (HPV), particularly high-risk strains HPV 16 and HPV 18, which together account for ~70% of cases.
Q21. What are the Pap smear screening guidelines?
A. (USPSTF guidelines)
- Start at age 21 years (regardless of sexual history or HPV vaccination)
- Ages 21-30: Pap smear every 3 years
- Ages 30-65: Pap smear every 3 years OR Pap + HPV co-testing every 5 years
- After 65: Discontinue if adequate screening history and not high risk
- Women with total hysterectomy for benign disease: No screening needed (Goldman-Cecil Medicine)
Q22. What is the HPV vaccine and who gets it?
A. The HPV vaccine (Gardasil 9) protects against HPV strains causing cervical cancer and genital warts. Recommended for girls and boys at age 11-12 years (can be given 9-45 years). It does not eliminate the need for Pap screening.
7. OVARIAN CYSTS
Q23. What is an ovarian cyst? How is it evaluated?
A. A fluid-filled sac on or within the ovary. Initial evaluation is by transvaginal ultrasound.
- Simple cysts: thin-walled, fluid-filled - usually benign, managed expectantly
- Complex cysts: thick walls, irregularity, papillations, internal echoes, septa - higher malignancy risk
- Cysts > 10 cm or with increased vascularity on Doppler are concerning for malignancy
Q24. What is CA-125 and when is it used?
A. CA-125 is a tumor marker for ovarian cancer. Indications for referral to a gynecologic oncologist:
- Premenopausal: CA-125 > 200 U/mL, ascites, metastases, first-degree relative with breast/ovarian cancer
- Postmenopausal: any elevated CA-125, ascites, nodular/fixed pelvic mass, family history
8. ENDOMETRIOSIS
Q25. What is endometriosis?
A. Endometriosis is the presence of endometrial-like tissue (glands and stroma) outside the uterus - commonly on ovaries, fallopian tubes, peritoneum, and bowel. It causes cyclic (menstrual-related) pelvic pain and is a major cause of infertility.
Q26. What are the symptoms of endometriosis?
A.
- Dysmenorrhea (painful periods) - most common, especially cyclic pain
- Dyspareunia (painful intercourse)
- Dyschezia (painful defecation) if bowel involved
- Infertility
- Irregular menses
- Urinary symptoms if bladder involved
Q27. What is the treatment of endometriosis?
A.
- Medical (pain relief): Combined OCPs, progestins, GnRH agonists (e.g., leuprolide), danazol, NSAIDs
- Surgical: Laparoscopy with excision/ablation of lesions (gold standard for diagnosis AND treatment)
- Definitive treatment: hysterectomy ± bilateral salpingo-oophorectomy (for women who have completed childbearing)
9. VAGINITIS (Quick Comparison)
Q28. Compare the three common types of vaginitis:
| Feature | Bacterial Vaginosis | Candidiasis (Thrush) | Trichomonas |
|---|---|---|---|
| Organism | Gardnerella vaginalis + anaerobes | Candida albicans | Trichomonas vaginalis |
| Discharge | Thin, grey-white, fishy odor | Thick, white, "cottage cheese" | Frothy, yellow-green, foul-smelling |
| pH | >4.5 (alkaline) | <4.5 (normal/acidic) | >4.5 (alkaline) |
| KOH test | Positive "whiff test" (amine odor) | Pseudohyphae/spores | Negative |
| Wet mount | Clue cells | Pseudohyphae | Motile trichomonads |
| Treatment | Metronidazole or Clindamycin | Fluconazole (oral) or clotrimazole (topical) | Metronidazole (treat both partners) |
(Textbook of Family Medicine)
10. HIGH-YIELD ONE-LINERS FOR GNM EXAMS
| Question | Answer |
|---|---|
| Normal menstrual cycle length | 21-35 days |
| Normal menstrual blood loss | 20-80 mL per cycle |
| Menorrhagia definition | > 80 mL blood loss per cycle OR > 7 days |
| Amenorrhea (primary) | No period by age 16 |
| Amenorrhea (secondary) | No period for > 3 months |
| Dysmenorrhea | Painful menstruation |
| Most common gynecological malignancy | Endometrial (uterine) cancer |
| Most common cause of postmenopausal bleeding | Endometrial atrophy (not cancer) |
| Hormone of pregnancy | hCG (from trophoblast cells) |
| Ovulation day in a 28-day cycle | Day 14 |
| Corpus luteum produces | Progesterone |
| Normal vaginal pH | 3.8-4.5 (acidic) |
| Bartholin gland location | 5 and 7 o'clock positions at vaginal introitus |
| Most common STI | Chlamydia trachomatis |
| Gonococcal treatment | IM Ceftriaxone + Azithromycin/Doxycycline |
| Most common uterine benign tumor | Fibroid (leiomyoma) |
| HPV strains causing cervical cancer | HPV 16 and HPV 18 |
| Emergency contraception (most effective) | Copper IUD |
| Pap smear starts at age | 21 years |
Tip for GNM exams: Focus especially on PID diagnostic criteria, fibroid treatments, menopause symptoms, vaginitis comparison table, contraception mechanisms, and cervical cancer screening guidelines - these are very frequently tested topics.
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