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Female Reproductive & Breast — USMLE Step 2 CK Notes

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Shared for free public use by a practising clinician who has sat the exam, with their permission. These notes are a revision aid and are not editorially reviewed, so verify against a primary source before relying on anything clinically.

The reflex that saves you marks

Any woman of reproductive age with abdominal or pelvic pain gets a pregnancy test. There are no exceptions, and stems are written to punish skipping it.

Acute pelvic pain

Diagnosis	Clue	Action
Ectopic pregnancy	Positive hCG, no intrauterine pregnancy	Unstable → surgery; stable → methotrexate criteria
Ovarian torsion	Sudden pain, vomiting, mass over 5 cm	Laparoscopy — preserved Doppler flow does not exclude it
PID	Cervical motion tenderness, discharge	Treat empirically, do not await cultures
Ruptured cyst	Mid-cycle, free fluid	Usually conservative

Abnormal uterine bleeding

Structure it with PALM-COEIN. The examinable skill is knowing who needs an endometrial biopsy:

Any postmenopausal bleeding — cancer until proven otherwise, even with a thin stripe
Age 45 and over with abnormal bleeding
Under 45 with unopposed oestrogen risk (obesity, PCOS, anovulation)

PCOS

Rotterdam: two of oligo-ovulation, hyperandrogenism, polycystic ovaries — after excluding pregnancy, thyroid disease, hyperprolactinaemia and non-classical CAH.

Treatment follows the goal. Wanting pregnancy → weight loss then letrozole. Not wanting pregnancy → combined pill for cycle control and hirsutism. Either way the endometrium must be protected against unopposed oestrogen.

Breast

Triple assessment: clinical examination + imaging + biopsy
Under 30 → ultrasound first; 30 and over → mammogram plus ultrasound
Core biopsy, not FNA — you need histology and ER/PR/HER2
A suspicious lump with normal imaging still gets biopsied
Mastitis not responding to antibiotics → consider inflammatory breast cancer

Menopause

Clinical diagnosis over 45; no hormone testing needed. Uterus present means a progestin is mandatory alongside systemic oestrogen. Isolated genitourinary symptoms → vaginal oestrogen.

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