Study guide
13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
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
13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
Key Takeaways Explain This Topic AI
Dysmenorrhea, amenorrhea and abnormal uterine bleeding are enumerated under menstrual disorders, and fibroids and endometriosis under uterine disorders.
Ectopic pregnancy is an enumerated topic under the pregnancy blueprint subsection.
Any reproductive-age woman with abdominal pain requires a pregnancy test before the differential is narrowed.
A positive pregnancy test with human chorionic gonadotropin above the discriminatory zone and no intrauterine gestation on ultrasound suggests ectopic pregnancy.
Uterine fibroids are the most common cause of structural abnormal uterine bleeding and are classified by their relationship to the endometrial cavity.
Last updated: August 2026
1. Amenorrhea
Primary amenorrhea: no menses by age 15 with secondary sexual characteristics, or by age 13 without them. Secondary amenorrhea: absence of menses for three months in a previously regular woman, or six months if irregular.
The evaluation sequence is fixed and is the exam content:
Pregnancy test. Always. Pregnancy is the most common cause of secondary amenorrhea.
Thyroid-stimulating hormone and prolactin.
Follicle-stimulating hormone , to separate ovarian from central causes.
Assess for hyperandrogenism if hirsutism or virilization is present.
FSH Localization Causes
High Primary ovarian insufficiency Premature ovarian insufficiency, Turner syndrome, chemotherapy, radiation, autoimmune
Low or normal Hypothalamic-pituitary Functional hypothalamic amenorrhea , hyperprolactinemia, pituitary tumor, infiltrative disease, Sheehan syndrome
- Normal with hyperandrogenism Ovarian Polycystic ovary syndrome
- Normal with outflow obstruction Uterine Asherman syndrome , cervical stenosis
Functional hypothalamic amenorrhea results from low energy availability — restrictive eating, excessive exercise, psychological stress — and produces low gonadotropins with low estradiol. It is a cause of premature bone loss , and the treatment is restoring energy availability, not prescribing an oral contraceptive to induce withdrawal bleeding, which masks recovery without protecting bone.
Asherman syndrome — intrauterine adhesions after instrumentation, usually dilation and curettage — produces amenorrhea with normal hormones and no withdrawal bleed after progestin.
2. Dysmenorrhea
Primary dysmenorrhea is prostaglandin-mediated cramping beginning with menarche, occurring with ovulatory cycles, starting just before or with flow and lasting one to three days. Examination is normal. NSAIDs started before or at the onset of flow are first-line, because they inhibit prostaglandin synthesis rather than merely blunting established pain; hormonal contraception is the other first-line option.
Secondary dysmenorrhea implies underlying pathology and is suggested by onset years after menarche , progressive worsening, pain outside menses, dyspareunia, abnormal bleeding, infertility or an abnormal examination. Causes include endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, ovarian cysts and an intrauterine device.
3. Endometriosis
Endometrial-like tissue outside the uterus. The classic triad is dysmenorrhea, dyspareunia and infertility , often with cyclic bowel or bladder symptoms and chronic pelvic pain.
Key features:
Symptom severity correlates poorly with disease extent — extensive disease may be nearly asymptomatic and minimal disease severely painful
Diagnostic delay averages years , because symptoms are normalized as bad periods
Examination may show uterosacral nodularity, a fixed retroverted uterus or an adnexal mass ( endometrioma , the chocolate cyst)
Definitive diagnosis is by laparoscopic visualization , but empiric medical therapy is appropriate first — surgery is not required before treating
Treatment: NSAIDs plus continuous combined hormonal contraception or a progestin; second-line options include GnRH agonists or antagonists with add-back therapy. Surgery is reserved for refractory pain, endometrioma or infertility.
4. Uterine Fibroids (Leiomyomas)
The most common pelvic tumor in women and the leading structural cause of abnormal uterine bleeding. Classification by location predicts the symptom:
- Location Dominant symptom
- Submucosal (distorting the cavity) Heavy menstrual bleeding , infertility, recurrent loss
- Intramural Bleeding and bulk symptoms
- Subserosal Bulk symptoms — pressure, urinary frequency, constipation
- Pedunculated Torsion, acute pain
Fibroids are estrogen-responsive : they enlarge in pregnancy and regress after menopause. A fibroid that enlarges after menopause, or grows rapidly, warrants evaluation — leiomyosarcoma is rare but this is the presentation that should not be dismissed.
Management ranges from observation for asymptomatic fibroids, through medical therapy for bleeding (tranexamic acid, hormonal contraception, a levonorgestrel intrauterine device for submucosal-sparing anatomy, GnRH modulators), to uterine artery embolization, myomectomy for fertility preservation, and hysterectomy.
Adenomyosis — endometrial glands within the myometrium — causes a diffusely enlarged, boggy, tender uterus with heavy painful periods, and is diagnosed on MRI or ultrasound.
5. Ovarian Cysts
Most cysts in premenopausal women are functional (follicular or corpus luteum) and resolve within one to two cycles. Features that raise concern for malignancy on ultrasound: solid components, thick septations, papillary projections, internal vascularity, ascites and large size.
Postmenopausal cysts require greater scrutiny , since functional cysts should not occur after ovulation ceases.
Ovarian torsion is the emergency: sudden severe unilateral pelvic pain with nausea and vomiting , usually with an ovarian mass over 5 cm. Doppler flow may be preserved because of dual blood supply, so normal Doppler does not exclude torsion , and surgical evaluation is required when clinical suspicion is high.
6. Ectopic Pregnancy
An enumerated blueprint topic and a leading cause of first-trimester maternal death.
The rule that governs the entire topic: every reproductive-age woman with abdominal pain, pelvic pain, syncope or abnormal bleeding gets a pregnancy test before anything else. Ectopic pregnancy has been missed innumerable times because the diagnosis was not considered in a woman who said she could not be pregnant.
Risk factors: prior ectopic pregnancy, prior pelvic inflammatory disease or chlamydial infection, tubal surgery or ligation, infertility and assisted reproduction, intrauterine device in place at the time of conception (which reduces absolute risk of pregnancy but raises the proportion that are ectopic), and smoking.
Presentation: amenorrhea, unilateral pelvic pain and vaginal bleeding — though the classic triad is often incomplete. Rupture presents with severe pain, peritoneal signs, shoulder-tip pain from diaphragmatic irritation by hemoperitoneum, and hemodynamic collapse.
Diagnostic approach:
- Quantitative beta-human chorionic gonadotropin and transvaginal ultrasound
- If hCG is above the discriminatory zone and no intrauterine gestation is seen, ectopic pregnancy is presumed
If hCG is below the discriminatory zone and the patient is stable, serial hCG measurements are used: a normal intrauterine pregnancy typically shows an appropriate rise over 48 hours, while an inappropriately rising or plateauing level suggests an abnormal pregnancy
A pseudogestational sac — a fluid collection in the endometrial cavity — must not be mistaken for an intrauterine pregnancy
Management:
Unstable, ruptured, or with contraindications to medical therapy: surgery. Laparoscopic salpingostomy or salpingectomy.
Stable, unruptured, low hCG, small mass, no fetal cardiac activity: methotrexate , with follow-up hCG measurements to confirm resolution. Contraindications include hemodynamic instability, immunodeficiency, significant hepatic or renal disease, cytopenias, breastfeeding, and an inability to attend follow-up.
Rh-negative women require Rh immune globulin.
A patient receiving methotrexate must be told to avoid folic acid supplements, NSAIDs and alcohol, and that transient abdominal pain is expected — although worsening pain requires reevaluation for rupture.
7. Other Early Pregnancy Considerations for the Internist
Hyperemesis gravidarum — intractable vomiting with weight loss, ketosis and electrolyte derangement. Thiamine must be given before glucose-containing fluids to prevent Wernicke encephalopathy, which has been reported in this setting.
Urinary tract infection in pregnancy — an enumerated blueprint topic. Unlike in non-pregnant adults, asymptomatic bacteriuria is screened for and treated in pregnancy , because it progresses to pyelonephritis and is associated with preterm birth.
Nutritional deficiencies — folic acid before conception and through the first trimester; iron; iodine; and vitamin B12 in patients with malabsorption or restrictive diets.
Venous thromboembolism — pregnancy and the puerperium are prothrombotic; the postpartum period carries the highest risk.
Medication review — the single most valuable preconception intervention an internist performs is stopping teratogens before conception rather than after a positive test.