13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening

ABIM Internal Medicine Exam

Track your progress as you read

Finished sections get a check mark.

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

13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening

Key Takeaways Explain This Topic AI

Abnormal uterine bleeding is enumerated under menstrual disorders, and uterine fibroids, endometriosis, endometrial cancer and cervical cancer under uterine disorders.

Any postmenopausal bleeding requires endometrial evaluation because endometrial carcinoma is the primary concern.

The PALM-COEIN system classifies abnormal uterine bleeding into structural and non-structural causes.

Cervical cancer screening begins at age 21, and management of abnormal results follows risk-based guidelines rather than cytology grade alone.

Ovarian cancer screening is not recommended in average-risk women because it does not reduce mortality and causes harm from false positives.

Last updated: August 2026

1. Abnormal Uterine Bleeding (AUB) & Postmenopausal Bleeding
FIGO PALM-COEIN Classification for Premenopausal AUB

The International Federation of Gynecology and Obstetrics (FIGO) categorizes abnormal uterine bleeding in non-pregnant reproductive-aged women into structural ( PALM ) and non-structural ( COEIN ) etiologies:

Structural Causes (PALM):

P - Polyp: Endometrial or endocervical polyps; diagnosed via transvaginal ultrasound (TVUS), saline infusion sonohysterography (SIS), or hysteroscopy. Managed with hysteroscopic polypectomy.

A - Adenomyosis: Presence of ectopic endometrial glands and stroma within the myometrium. Presents with heavy menstrual bleeding, severe dysmenorrhea, and a uniformly enlarged, globular, boggy, symmetrically tender uterus on bimanual pelvic examination. First-line medical: Levonorgestrel IUD, continuous combined OCPs, or tranexamic acid; definitive: total hysterectomy.

L - Leiomyoma (Uterine Fibroids): Benign myometrial smooth muscle neoplasms. Classified as Submucosal (protrude into cavity, cause heavy bleeding and subfertility), Intramural (within wall), or Subserosal (external surface, cause pelvic pressure/bulk). Medical: NSAIDs, tranexamic acid, combined OCPs, LNG-IUD, GnRH agonists (Leuprolide), or oral GnRH antagonists with add-back (Relugolix/Elagolix); Surgical: hysteroscopic myomectomy, abdominal/laparoscopic myomectomy, uterine artery embolization (UAE), or hysterectomy.

M - Malignancy & Hyperplasia: Endometrial adenocarcinoma or endometrial intraepithelial neoplasia (EIN).

Non-Structural Causes (COEIN):

C - Coagulopathy: von Willebrand disease (vWD, most common inherited bleeding disorder, presenting as severe menorrhagia at menarche), platelet dysfunction, or anticoagulant therapy.

O - Ovulatory Dysfunction: Anovulatory bleeding characterized by irregular, unpredictable, heavy bleeding due to lack of progesterone and continuous unopposed estrogen stimulation. Etiologies: PCOS, perimenopause, hypothyroidism, hyperprolactinemia, anorexia, extreme exercise.

E - Endometrial: Primary endometrial vasoconstrictor deficiency (endothelin-1, prostaglandin F2a) with regular ovulatory cycles.

I - Iatrogenic: Copper IUD, progestin implants/IUDs (breakthrough bleeding), psychotropic medications causing hyperprolactinemia, anticoagulants.

N - Not otherwise classified.

Evaluation of Postmenopausal Bleeding (PMB)

Cardinal Clinical Rule: ANY uterine bleeding occurring >=12 months after amenorrhea in a postmenopausal woman is ENDOMETRIAL CANCER until proven otherwise (~10% of PMB represents endometrial adenocarcinoma; ~60-80% is due to vulvovaginal or endometrial atrophy).

Diagnostic Protocol:

Initial investigation: Transvaginal Ultrasound (TVUS) OR office Endometrial Biopsy (EMB) .

TVUS Interpretation:

Endometrial Thickness <= 4 mm: High negative predictive value (>99%) for endometrial cancer. If the endometrial stripe is <=4 mm, uniform, thin, and no focal lesion is present, endometrial cancer is reliably excluded. Reassure the patient; if bleeding recurs, proceed to EMB.

Endometrial Thickness > 4 mm, Heterogeneous Stripe, or Fluid in Cavity: Mandatory immediate Endometrial Biopsy (EMB) .

Endometrial Biopsy (EMB): Office Pipelle aspiration biopsy has >90-95% sensitivity for detecting endometrial cancer.

Hysteroscopy with Dilation & Curettage (D&C): Indicated if office EMB is non-diagnostic, insufficient tissue is obtained, cervical stenosis prevents sampling, or persistent/recurrent bleeding occurs despite a benign biopsy.

2. Endometrial Hyperplasia & Endometrial Cancer
Pathology & Progression Risk

Endometrial hyperplasia results from prolonged, chronic unopposed estrogen stimulation without cyclic progestin opposition, driving abnormal glandular proliferation:

Classification Histopathological Characteristics Malignant Potential / Cancer Risk Primary Management

Atypical Hyperplasia / Endometrial Intraepithelial Neoplasia (EIN) Marked cytological atypia (nuclear enlargement, loss of polarity, prominent nucleoli), crowded glandular architecture with minimal intervening stroma 30% to 40% risk of concurrent invasive adenocarcinoma ; high progression rate Total Hysterectomy with Bilateral Salpingo-Oophorectomy (BSO) . (Progestin + q3-6m EMB only if fertility preservation desired or high surgical risk)

Non-Atypical Hyperplasia (Benign / Simple / Complex Hyperplasia without Atypia) Increased gland-to-stroma ratio without nuclear atypia Low risk of progression (<1% to 5%) Continuous Progestin Therapy (Levonorgestrel IUD 52 mg preferred; or oral Medroxyprogesterone 10 mg/d) + repeat EMB at 3-6 months

Endometrial Cancer Risk Factors
Obesity (peripheral aromatization of androstenedione to estrone by adipose tissue)
Polycystic Ovary Syndrome (PCOS) / chronic anovulation
Unopposed systemic estrogen therapy
Early menarche (<12y) / Late menopause (>55y) / Nulliparity
Tamoxifen therapy (agonist effect on endometrium)

Lynch Syndrome (HNPCC): Germline DNA mismatch repair gene mutations ( MLH1, MSH2, MSH6, PMS2 ); confers a 40% to 60% lifetime risk of endometrial cancer. Screening with annual endometrial biopsy starting at age 30-35, and prophylactic hysterectomy with BSO after childbearing is complete.

3. Cervical and Ovarian Cancer Screening & Prevention
Cervical Cancer Screening Guidelines (USPSTF / ASCCP)

Age < 21 Years: No screening recommended, regardless of sexual debut or risk factors.

Age 21 to 29 Years: Cervical cytology (Pap smear) alone every 3 years .

Critical Pearl: Do NOT perform HPV testing in women aged 21-29 because transient, oncogenically benign HPV infections are extremely prevalent and clear spontaneously.

Age 30 to 65 Years: Three acceptable screening strategies:

Primary High-Risk HPV (hrHPV) testing alone every 5 years (preferred by ASCCP and ACS), OR
Co-testing (hrHPV testing + cervical cytology) every 5 years , OR

Cervical cytology alone every 3 years .

Discontinuation at Age 65: Stop screening if the patient has adequate prior negative screening :

3 consecutive negative cytology results, OR 2 consecutive negative hrHPV/co-test results within the past 10 years, with the most recent test performed within the past 5 years;

AND no history of CIN 2, CIN 3, or cervical cancer within the past 20 years.

Hysterectomy Exception: Women who have had a total hysterectomy (removal of uterus and cervix) for benign indications and who have no prior history of CIN 2+ or cervical cancer do NOT require screening .

Management of Abnormal Cervical Screening Results (ASCCP Risk-Based Guidelines)

HPV Genotypes 16 or 18 Positive: Immediate Colposcopy regardless of cytology result (due to high risk of occult high-grade precancer).

Atypical Squamous Cells of Undetermined Significance (ASC-US):

If hrHPV positive -> Colposcopy .

If hrHPV negative -> Repeat co-test in 3 years.

High-Grade Squamous Intraepithelial Lesion (HSIL): Immediate Colposcopy with endocervical curettage (ECC) OR immediate Loop Electrosurgical Excision Procedure (LEEP) diagnostic excision in non-pregnant women aged >=25 years.

Atypical Glandular Cells (AGC): High risk of significant cervical adenocarcinoma or endometrial cancer. Mandatory evaluation includes Colposcopy + Endocervical Curettage (ECC) + Endometrial Biopsy (EMB) in all women aged >=35 years or in women <35 years with risk factors for endometrial neoplasia.

Ovarian Cancer Screening & Prevention

Average-Risk Screening: The USPSTF gives a Grade D recommendation (recommends AGAINST routine screening) using serum CA-125, transvaginal ultrasound, or bimanual pelvic examination in asymptomatic, average-risk postmenopausal or premenopausal women. Clinical trials (PLCO, UKCTOCS) demonstrated that screening yields false-positive results leading to unnecessary major surgeries without reducing ovarian cancer mortality.

Hereditary Ovarian Cancer Syndromes:

BRCA1: ~40-50% lifetime risk of epithelial ovarian/fallopian tube cancer; ~70% lifetime breast cancer risk.

BRCA2: ~15-20% lifetime risk of ovarian cancer; ~70% lifetime breast cancer risk.

Risk-Reducing Bilateral Salpingo-Oophorectomy (RRSO): Standard-of-care prevention. Recommended at age 35 to 40 years for BRCA1 , and age 40 to 45 years for BRCA2 (or after childbearing is complete). RRSO reduces ovarian/tubal cancer risk by 80-90% and reduces all-cause mortality.

4. Polycystic Ovary Syndrome (PCOS)
Diagnostic Criteria & Differential Diagnosis

Rotterdam Diagnostic Criteria: Requires at least 2 of the following 3 features (after excluding mimickers):

Oligo- or Anovulation: Menstrual cycles >35 days apart or <8-9 periods per year.

Clinical and/or Biochemical Hyperandrogenism:

Clinical: Hirsutism (modified Ferriman-Gallwey score >=8), severe cystic acne, androgenic alopecia.

Biochemical: Elevated total or free serum testosterone, elevated androstenedione, or elevated DHEAS.

Polycystic Ovarian Morphology on Ultrasound: Presence of >=20 follicles per ovary (measuring 2 to 9 mm in diameter) and/or increased ovarian volume >=10 mL in either ovary.

Mandatory Exclusion of Secondary Causes:

Non-Classic Congenital Adrenal Hyperplasia (NCCAH): Check early morning fasting 17-hydroxyprogesterone (if >200 ng/dL, perform ACTH stimulation test; 21-hydroxylase deficiency).

Hyperprolactinemia: Check serum Prolactin .

Thyroid Dysfunction: Check serum TSH .

Cushing Syndrome: 24-hour urine free cortisol or 1-mg overnight dexamethasone suppression test if cushingoid features.

Androgen-Secreting Adrenal/Ovarian Neoplasms: Rapid virilization (clitoromegaly, voice deepening), total testosterone >200 ng/dL, or DHEAS >700 µg/dL warrants immediate CT adrenal and pelvic imaging.

Long-Term Complications & Comprehensive Management

Long-Term Risks: Endometrial adenocarcinoma (3-fold increased risk due to chronic unopposed estrogen), Type 2 Diabetes Mellitus (screen all PCOS patients with a 2-hour 75g OGTT ), MASLD, Dyslipidemia, Obstructive Sleep Apnea, and Cardiovascular Disease.

Management Pillars:

Lifestyle Modification & Weight Loss: 5% to 10% weight loss improves insulin sensitivity, increases SHBG, lowers free androgens, and restores ovulatory cycles.

First-Line for Cycle Regulation, Endometrial Protection & Hirsutism: Combined Oral Contraceptive Pills (COCPs) .

Estrogen increases hepatic Sex Hormone-Binding Globulin (SHBG), binding free circulating testosterone.

Progestin suppresses pituitary LH secretion (decreasing theca cell androgen production) and prevents endometrial hyperplasia.

Anti-Androgen Therapy for Persistent Hirsutism: Spironolactone (50-200 mg daily) .

Competitively blocks androgen receptors and inhibits 5-alpha-reductase.

Critical Rule: Add only after >=6 months of COCP therapy; MUST be co-prescribed with effective contraception due to the teratogenic risk of feminization of a male fetus.

Metformin (1500-2000 mg daily): Improves insulin sensitivity and glucose tolerance in patients with impaired glucose tolerance / T2D.

Ovulation Induction for Infertility: Letrozole (Aromatase Inhibitor) is first-line gold standard for ovulation induction in PCOS (PPCOS II trial demonstrated superior live-birth and ovulation rates compared to Clomiphene Citrate).