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Module 7010 lessonsDAST IV gynecologic disorders and medicinal chemistry lectures, RxPrep foundations, ACOG guidance, ASRM guidance, NICE NG88, FDA labeling, and DailyMed

Menstrual and Gynecologic Disorders

Move from menstrual pattern and diagnostic triage to evidence-based care for abnormal uterine bleeding, dysmenorrhea, premenstrual disorders, endometriosis, and symptomatic uterine fibroids.

01

Describe menstrual-cycle physiology and recognize bleeding patterns that require urgent or targeted evaluation.

02

Classify abnormal uterine bleeding with the PALM-COEIN framework while excluding pregnancy and instability first.

03

Build an initial plan for acute abnormal uterine bleeding based on hemodynamic status, contraindications, and reproductive goals.

04

Select chronic heavy-menstrual-bleeding therapy using cause, uterine anatomy, comorbidities, patient preference, and fertility goals.

05

Distinguish primary dysmenorrhea from pain that suggests endometriosis, adenomyosis, fibroids, infection, or another secondary cause.

06

Diagnose premenstrual disorders prospectively and compare SSRI, hormonal, behavioral, and supportive treatment strategies.

07

Explain endometriosis as a chronic inflammatory disease and use symptoms, examination, imaging, and response to treatment without requiring surgery before every diagnosis.

08

Compare NSAIDs, hormonal suppression, progestogens, GnRH agonists, GnRH antagonists, and add-back therapy for endometriosis-associated pain.

09

Connect fibroid location and symptom burden to medical, procedural, and surgical options.

10

Monitor bleeding response, anemia, bone health, thrombotic risk, mood, fertility priorities, and the need for escalation over time.

70.01

Lesson

Menstrual Pattern and Diagnostic Triage

Menstrual symptoms become clinically useful when timing, flow, pain, pregnancy possibility, systemic effects, and quality-of-life impact are assessed together.

What to learn
  • Cycle pattern
  • Pregnancy exclusion
  • Hemodynamic status
  • Anemia
  • Red flags
Clinical triageStart with the threat, then define the pattern
01FirstStability and pregnancy

Identify shock or pregnancy-related bleeding before routine classification

02NextPattern and burden

Map timing, flow, pain, anemia, and daily-life impact

03ThenCause-directed workup

Select examination, laboratory testing, imaging, or tissue assessment

Describe the pattern

Record frequency, regularity, duration, volume clues, intermenstrual or postcoital bleeding, pain, medications, and functional impact. Patient-defined burden matters more than an impractical attempt to measure exact blood loss.

Exclude urgent threats

Assess vital signs, orthostasis, syncope, chest pain, dyspnea, severe unilateral pain, pregnancy possibility, and the rate of blood loss. Unstable bleeding requires emergency stabilization and gynecologic involvement.

Target the workup

Pregnancy testing, complete blood count, and focused testing follow the presentation. Pelvic examination, ultrasound, hysteroscopy, coagulation evaluation, endocrine testing, and endometrial sampling are selected by age, symptoms, risk, and suspected cause.

Quick check

0 of 1 answered
01A patient with heavy bleeding is dizzy, tachycardic, and has a positive pregnancy test. What is the priority?
Answer every question to submit.
70.02

Lesson

Classifying Abnormal Uterine Bleeding

PALM-COEIN separates structural causes from nonstructural causes so the workup and treatment follow the mechanism rather than an outdated bleeding label.

What to learn
  • PALM
  • COEIN
  • Ovulatory dysfunction
  • Iatrogenic bleeding
  • Malignancy risk
Cause mapSeparate structure from function
01PALMStructural causes

Polyp, adenomyosis, leiomyoma, malignancy or hyperplasia

02COEINNonstructural causes

Coagulopathy, ovulatory, endometrial, iatrogenic, not classified

03OverlapMore than one cause

Update the working diagnosis as evidence accumulates

Find structural causes

PALM represents polyp, adenomyosis, leiomyoma, and malignancy or hyperplasia. Location matters because a small submucosal lesion can cause more bleeding than a larger lesion elsewhere.

Find nonstructural causes

COEIN represents coagulopathy, ovulatory dysfunction, endometrial causes, iatrogenic causes, and not otherwise classified. More than one cause may be present.

Avoid obsolete shortcuts

Terms such as dysfunctional uterine bleeding or menorrhagia can obscure mechanism. Describe the bleeding pattern and attach a suspected or confirmed cause when possible.

Quick check

0 of 1 answered
01Which PALM-COEIN category includes anticoagulant-associated bleeding?
Answer every question to submit.
70.03

Lesson

Acute Abnormal Uterine Bleeding

Acute abnormal uterine bleeding is a time-sensitive syndrome in which stabilization, rapid cause assessment, and bleeding control occur in parallel.

What to learn
  • Stabilization
  • Medical therapy
  • Contraindications
  • Transfusion
  • Escalation
Acute responseControl bleeding without losing diagnostic sight
01StabilizePerfusion and access

Resuscitate and prepare blood support when indicated

02ControlPatient-specific medical therapy

Choose hormonal or antifibrinolytic treatment only when safe

03EscalateProcedural readiness

Move quickly when instability or treatment failure persists

Stabilize first

Establish access, assess perfusion, obtain urgent laboratory studies, prepare blood products when indicated, and involve gynecology early for instability or ongoing severe bleeding.

Choose medical control

Options for stable nonpregnant reproductive-aged patients can include multidose combined hormonal therapy, oral progestin therapy, intravenous estrogen in selected cases, or tranexamic acid. The best choice depends on thrombotic risk, contraindications, severity, and the suspected cause.

Know when to escalate

Failure of medical therapy, instability, suspected retained tissue or structural disease, or contraindications to medical treatment may require tamponade, hysteroscopy, dilation and curettage, embolization, or surgery.

Quick check

0 of 1 answered
01A hemodynamically unstable patient has ongoing brisk uterine bleeding. What is the best next step?
Answer every question to submit.
70.04

Lesson

Chronic Heavy Menstrual Bleeding

Chronic heavy menstrual bleeding treatment aims to restore daily function, correct iron loss, reduce bleeding, and preserve the reproductive choices important to the patient.

What to learn
  • LNG-IUS
  • Tranexamic acid
  • NSAIDs
  • Hormonal therapy
  • Iron deficiency
Treatment selectionMatch bleeding control to anatomy and goals
01NonhormonalTranexamic acid or NSAID

Preserve ovulation while targeting fibrinolysis or prostaglandins

02HormonalLNG-IUS or systemic therapy

Suppress endometrial growth when acceptable and safe

03StructuralProcedure or surgery

Address cavity distortion, large fibroids, or refractory symptoms

Treat the person, not a volume

Ask how bleeding affects work, school, sleep, exercise, sexual health, and access to supplies. Check for iron deficiency and anemia when indicated and replace iron while controlling the source.

Compare first options

For patients without cavity distortion or another contraindication, a levonorgestrel intrauterine system often provides strong bleeding reduction. Tranexamic acid is taken during menses and preserves ovulation. NSAIDs can reduce prostaglandin-mediated flow and pain. Combined hormonal therapy or cyclic progestogens may be appropriate for selected patients.

Use anatomy and goals

Persistent intermenstrual bleeding, pressure, a mass, significant pain, infertility concerns, or poor response should prompt targeted evaluation. Structural disease may change both drug effectiveness and the need for a procedure.

Quick check

0 of 1 answered
01Which option reduces heavy menstrual bleeding without suppressing ovulation and is taken only during menses?
Answer every question to submit.
70.05

Lesson

Dysmenorrhea and Secondary Pain

Primary dysmenorrhea reflects prostaglandin-driven uterine contractions, while secondary dysmenorrhea signals an underlying pelvic disorder that requires a different plan.

What to learn
  • Prostaglandins
  • NSAID timing
  • Hormonal suppression
  • Secondary causes
  • Escalation
Pain pathwaySeparate prostaglandin pain from secondary disease
01PrimaryCyclic prostaglandin excess

Start NSAID early and on schedule when safe

02SuppressReduce menstrual activity

Use a suitable hormonal strategy when desired

03InvestigateAtypical or refractory pain

Evaluate endometriosis, adenomyosis, fibroids, or infection

Interrupt prostaglandins

NSAIDs work best when started just before expected menses or at symptom onset and taken on a scheduled basis for the highest-burden days, assuming no contraindication.

Suppress cycling when useful

Combined hormonal contraception or a progestin method can reduce endometrial proliferation and menstrual activity. Selection follows contraceptive goals and patient-specific safety criteria.

Recognize secondary pain

Pain that begins later, worsens over time, persists outside menses, occurs with intercourse, infertility, abnormal bleeding, fever, discharge, or examination findings should prompt evaluation for endometriosis, adenomyosis, fibroids, infection, or another cause.

Quick check

0 of 1 answered
01Why are NSAIDs effective for primary dysmenorrhea?
Answer every question to submit.
70.06

Lesson

PMS and Premenstrual Dysphoric Disorder

Premenstrual disorders are cyclic symptom syndromes whose diagnosis depends on timing, prospective confirmation, functional impairment, and exclusion of another disorder that simply worsens premenstrually.

What to learn
  • Prospective charting
  • Functional impairment
  • SSRIs
  • Hormonal options
  • Multimodal care
Symptom timingThe cycle is part of the diagnosis
01LutealSymptoms emerge

Track mood, cognition, behavior, and physical burden daily

02MensesSymptoms improve

Look for a reproducible transition near menstrual onset

03FollicularMinimal symptoms

Persistent symptoms suggest another disorder or comorbidity

Prove the timing

Symptoms emerge in the luteal phase, improve around the onset of menses, and are minimal after menses. Prospective daily ratings across at least two symptomatic cycles help distinguish PMDD from persistent depression or anxiety.

Use effective treatment

SSRIs have evidence for continuous or luteal-phase dosing and can act faster in PMDD than in major depression. Selected combined hormonal regimens, cognitive behavioral therapy, exercise, sleep support, and symptom-directed care can be combined.

Protect safety

Severe depression, self-harm thoughts, mania, psychosis, or major functional collapse requires immediate mental-health assessment. Calcium or complementary approaches should not delay evidence-based care for severe disease.

Quick check

0 of 1 answered
01What best distinguishes PMDD from major depressive disorder with premenstrual worsening?
Answer every question to submit.
70.07

Lesson

Recognizing Endometriosis

Endometriosis is a chronic inflammatory condition with endometrial-like tissue outside the uterus, variable lesion burden, and symptoms that do not reliably track anatomic stage.

What to learn
  • Cyclic pain
  • Dyspareunia
  • Infertility
  • Imaging
  • Clinical diagnosis
Disease mapSymptoms can exceed what imaging reveals
01SurfaceSuperficial disease

Normal ultrasound cannot exclude small peritoneal lesions

02OvaryEndometrioma

Ultrasound can identify a characteristic ovarian lesion

03DeepInfiltrating disease

Map bowel, bladder, and pelvic involvement when symptoms suggest it

Recognize the pattern

Dysmenorrhea, chronic pelvic pain, deep dyspareunia, painful bowel or bladder symptoms, infertility, and family history can raise suspicion. A normal examination or ultrasound does not exclude superficial disease.

Use imaging purposefully

Ultrasound can identify endometriomas and some deep disease and can evaluate competing structural causes. MRI is reserved for selected mapping questions. Imaging cannot rule out all endometriosis.

Share diagnostic decisions

Current ACOG guidance supports a clinical diagnostic pathway for appropriate patients. Laparoscopy remains useful when diagnosis is uncertain, symptoms persist, fertility planning requires it, or surgery is chosen.

Quick check

0 of 1 answered
01A patient has classic cyclic pelvic pain but a normal ultrasound. Which statement is correct?
Answer every question to submit.
70.08

Lesson

Endometriosis Pharmacotherapy

Endometriosis therapy controls pain and suppresses disease activity, but it does not create a permanent cure and must be aligned with pregnancy goals and long-term tolerability.

What to learn
  • NSAIDs
  • Combined hormonal therapy
  • Progestogens
  • GnRH therapy
  • Add-back
Suppression ladderEscalate while protecting long-term health
01RelieveNSAID and supportive care

Treat pain without claiming lesion suppression

02SuppressCombined or progestogen therapy

Reduce cycling when pregnancy is not currently desired

03IntensifyGnRH therapy with safeguards

Apply dose, duration, add-back, bone, mood, and pregnancy precautions

Begin with acceptable suppression

NSAIDs treat pain but do not suppress lesions. Continuous or cyclic combined hormonal therapy and progestogen options can reduce bleeding and pain. Choice depends on contraindications, preferences, and whether pregnancy is desired now.

Use GnRH therapy carefully

GnRH agonists cause an initial flare before pituitary desensitization. Oral GnRH antagonists suppress without flare. Product-specific dose and duration limits reflect bone loss and other hypoestrogenic effects.

Add back and monitor

Add-back therapy can reduce vasomotor symptoms and bone loss while preserving symptom control. Monitor mood, bleeding pattern, pregnancy risk, bone-health risk, drug interactions, and the exact label requirements.

Quick check

0 of 1 answered
01What distinguishes an oral GnRH antagonist from a depot GnRH agonist at initiation?
Answer every question to submit.
70.09

Lesson

Uterine Fibroids and Treatment Selection

Fibroids are benign smooth-muscle tumors whose location, size, number, bleeding burden, pressure symptoms, anemia, and fertility implications determine treatment.

What to learn
  • Submucosal
  • Intramural
  • Subserosal
  • Medical control
  • Procedures
Fibroid anatomyLocation changes the clinical problem
01SubmucosalToward the cavity

Bleeding and fertility effects can be disproportionate

02IntramuralWithin the myometrium

Bleeding, pain, and uterine bulk can coexist

03SubserosalToward the serosa

Pressure symptoms may dominate over bleeding

Let location explain symptoms

Submucosal fibroids can distort the cavity and drive bleeding or infertility. Intramural fibroids may cause bleeding, pain, or bulk. Subserosal fibroids more often cause pressure than cavity bleeding.

Control bleeding

LNG-IUS, hormonal therapy, tranexamic acid, and NSAIDs can reduce symptoms in selected patients. A GnRH agonist may be used short term, often before a procedure. Relugolix with estradiol and norethindrone is FDA approved for fibroid-associated heavy bleeding with label-defined duration and safety limits.

Choose a definitive path

Myomectomy preserves the uterus, hysteroscopic resection fits selected cavity lesions, uterine artery embolization and radiofrequency ablation have fertility uncertainties, and hysterectomy is definitive. Shared decisions should include recurrence and future pregnancy.

Quick check

0 of 1 answered
01Which fibroid location most directly distorts the endometrial cavity and can drive heavy bleeding?
Answer every question to submit.
70.10

Lesson

Monitoring, Counseling, and Escalation

Successful gynecologic pharmacotherapy is a monitored sequence that follows symptoms, bleeding, iron status, adverse effects, reproductive goals, and diagnostic uncertainty over time.

What to learn
  • Response tracking
  • Iron status
  • Safety
  • Fertility goals
  • Referral
Care loopReassess the patient, not only the prescription
01MeasureBleeding, pain, function, iron

Define success in terms the patient can feel

02ProtectToxicity and reproductive goals

Monitor the specific risks created by the regimen

03EscalateFailure or new red flags

Repeat the diagnostic process when the story changes

Measure outcomes

Track bleeding days, flooding, pain, missed activities, rescue medication use, quality of life, hemoglobin or ferritin when indicated, and patient-defined goals. A therapy that changes flow but not function may be inadequate.

Monitor the regimen

Review NSAID renal and gastrointestinal risk, tranexamic acid thrombotic context, hormonal contraindications, mood, blood pressure, bone risk with GnRH therapy, and product-specific interactions and duration limits.

Escalate with purpose

Refer or re-evaluate for persistent intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding, new mass or pressure, progressive pain, infertility, anemia despite therapy, treatment failure, or suspected malignancy.

Quick check

0 of 1 answered
01A patient has persistent heavy bleeding and worsening iron deficiency despite adherent therapy. What is the best response?
Answer every question to submit.

Module test

Check the connections.

Each attempt draws 10 questions from the complete 100 question bank.

100 questions in this module bank10 questions per attempt

Each attempt draws a fresh set and rearranges the answer choices.

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