2.8 Ovarian, Testicular & Reproductive Endocrine Disorders

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

2.8 Ovarian, Testicular & Reproductive Endocrine Disorders

Key Takeaways Explain This Topic AI

Polycystic ovary syndrome, premature ovarian insufficiency, female infertility and hormonal therapy comprise the ovarian and female reproductive health blueprint subsection.

Male hypogonadism, male infertility, erectile dysfunction and gynecomastia comprise the testes and male reproductive health subsection.

Polycystic ovary syndrome is a diagnosis of exclusion requiring two of three Rotterdam criteria after thyroid disease, hyperprolactinemia and non-classic adrenal hyperplasia are ruled out.

Testosterone must be measured on a morning fasting sample and confirmed on a second occasion before hypogonadism is diagnosed.

A low testosterone with a low or inappropriately normal luteinizing hormone indicates secondary hypogonadism and requires prolactin measurement and pituitary imaging.

Last updated: August 2026

1. Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive-age women and the most commonly tested item in this subsection. The Rotterdam criteria require two of three features:

• Oligo- or anovulation (cycles longer than 35 days or fewer than eight per year)
• Clinical or biochemical hyperandrogenism (hirsutism, acne, androgenic alopecia, or elevated free testosterone)
• Polycystic ovarian morphology on ultrasound

The examination trap is that PCOS is a diagnosis of exclusion . Before applying the criteria you must exclude:

• Mimic Discriminating test
• Thyroid disease Thyroid-stimulating hormone
• Hyperprolactinemia Prolactin
• Non-classic congenital adrenal hyperplasia Early-morning 17-hydroxyprogesterone
• Cushing syndrome Clinical features; overnight dexamethasone suppression if suspected
• Androgen-secreting tumor Rapid virilization, testosterone markedly elevated

Rapidly progressive virilization — clitoromegaly, voice deepening, male-pattern balding over months — is not PCOS. It signals an androgen-secreting ovarian or adrenal tumor and requires imaging.

Management by patient goal

Not seeking pregnancy: combined hormonal contraception is first line, treating menstrual irregularity, hirsutism and acne simultaneously while providing endometrial protection.

Seeking pregnancy: letrozole is the preferred first-line ovulation induction agent, having surpassed clomiphene for live-birth rate in this population.

Metabolic risk: weight reduction improves ovulatory function; metformin addresses insulin resistance and glucose intolerance but is not a primary fertility agent.

Endometrial protection is mandatory. Chronic anovulation exposes the endometrium to unopposed estrogen, raising endometrial hyperplasia and carcinoma risk. A woman with PCOS who has gone many months without a withdrawal bleed needs cyclic progestin or continuous contraception.

2. Premature Ovarian Insufficiency

Cessation of ovarian function before age 40, defined by amenorrhea with elevated follicle-stimulating hormone on two occasions and low estradiol. Distinguish it from hypothalamic amenorrhea, in which gonadotropins are low or normal .

Evaluation includes karyotype (Turner syndrome and mosaicism), FMR1 premutation testing (fragile X carriers), and screening for autoimmune adrenal insufficiency and thyroid disease. Systemic estrogen with a progestin is offered until the average age of natural menopause to protect bone and cardiovascular health — this is replacement of a physiologic deficit, not the same risk calculus as postmenopausal hormone therapy in an older woman.

3. Amenorrhea: A Working Sequence

Exclude pregnancy. Always the first test.

Measure thyroid-stimulating hormone and prolactin.

Measure follicle-stimulating hormone to separate ovarian failure (high) from hypothalamic-pituitary causes (low or normal).

Assess for hyperandrogenism if hirsutism or virilization is present.

Functional hypothalamic amenorrhea — from low energy availability, excessive exercise or psychological stress — produces low gonadotropins with low estradiol and is a recognized cause of premature bone loss.

4. Male Hypogonadism

Testosterone deficiency requires both symptoms and confirmed low levels. Symptoms include reduced libido, erectile dysfunction, reduced morning erections, loss of body hair, gynecomastia, reduced muscle mass and low mood.

Testing rules that generate exam points:

Draw testosterone in the early morning (levels have a marked diurnal rhythm) and in the fasting state .

Confirm a low value on a second morning sample before diagnosing.

Do not test during acute illness, which transiently suppresses the axis.

If sex hormone-binding globulin is likely to be abnormal — obesity, diabetes, advanced age, hepatic or thyroid disease — measure free testosterone .

Then localize with luteinizing hormone (LH) and follicle-stimulating hormone (FSH):

Pattern Level Causes

Primary (hypergonadotropic) Low testosterone, high LH/FSH Klinefelter syndrome, orchitis, trauma, chemotherapy, radiation

Secondary (hypogonadotropic) Low testosterone, low or inappropriately normal LH/FSH Hyperprolactinemia, pituitary mass, opioids, glucocorticoids, obesity, hemochromatosis, obstructive sleep apnea

Secondary hypogonadism mandates prolactin measurement and pituitary imaging , because a prolactinoma or other sellar mass may be the cause. Opioid-induced androgen deficiency is common and frequently overlooked.

Testosterone therapy: contraindications and monitoring

Testosterone is contraindicated in men desiring fertility — exogenous testosterone suppresses gonadotropins and therefore spermatogenesis, and is a cause of male infertility rather than a treatment for it. Other contraindications include untreated obstructive sleep apnea, an elevated hematocrit, and known prostate or breast cancer. Monitoring includes hematocrit (erythrocytosis is the most common adverse effect) and prostate-specific antigen in age-appropriate men.

5. Male Infertility

Evaluation begins with semen analysis , repeated if abnormal. Azoospermia is separated by FSH:

High FSH — primary testicular failure.

Normal or low FSH with normal testicular volume — consider obstruction, including congenital bilateral absence of the vas deferens, which warrants cystic fibrosis transmembrane conductance regulator testing .

Varicocele is the most common surgically correctable cause. Exogenous anabolic steroid use is a common and reversible cause that must be asked about directly.

6. Erectile Dysfunction

Erectile dysfunction is enumerated in this blueprint subsection and is frequently a sentinel marker of endothelial dysfunction , often preceding a coronary event by several years. New erectile dysfunction warrants cardiovascular risk assessment.

Preserved nocturnal and morning erections suggest a psychogenic contribution.

Gradual loss of all erections suggests a vascular, neurogenic or endocrine cause.

Review medications: thiazides, beta-blockers, selective serotonin reuptake inhibitors, antiandrogens.

Phosphodiesterase-5 inhibitors are absolutely contraindicated with nitrates in any form, because the combination causes profound hypotension.

7. Gynecomastia

True gynecomastia is glandular tissue — a firm, concentric, often tender subareolar disc — and must be distinguished from lipomastia (fatty tissue without a discrete disc) and from male breast cancer (hard, eccentric , fixed, possibly with nipple retraction or discharge; unilateral).

It reflects a rise in the estrogen-to-androgen ratio . Causes to consider:

Physiologic: puberty, aging

Drugs: spironolactone, cimetidine, ketoconazole, antiretrovirals, antipsychotics, anabolic steroids, marijuana, alcohol

• Cirrhosis (impaired estrogen clearance) and chronic kidney disease
• Hypogonadism of either type; hyperthyroidism
• Tumors: human chorionic gonadotropin-secreting germ cell tumors, adrenal or Leydig cell tumors

Rapid-onset gynecomastia in a young man should prompt testicular examination and measurement of human chorionic gonadotropin, because a testicular germ cell tumor is the diagnosis not to miss. Drug withdrawal and treatment of the underlying cause are first line; longstanding fibrotic gynecomastia does not regress medically.