Hello, and welcome to the Physician Assistant Exam Review Podcast. Today’s episode is 158, and we’re moving through reproduction, talking about menstrual disorders, PCOS, infertility, contraception, menopause, all kinds of fun things. Remember, this isn’t just about medical facts. It’s about how to think, how to study, and how to perform on a high-stakes exam. Our motto is think different, work different, score different. Each episode, we take real medical content and break it down to show you how it actually shows up on exams, how to organize it, how to study it, and how to avoid the thinking traps that cost you points. That’s the most important thing.

We want to turn the knowledge you have into as many points as possible on your exam. Before we jump in today, the next 33 Days to Pass the PANCE cohort begins registration on March 19th. We’re going to run an April 1st cohort. If you’re interested in the 33 Days to Pass the PANCE, we recommend you do it as early as possible because of how the content we cover allows you to utilize it throughout didactic, throughout clinical year, and on your PANCE. There’s so many different ways you can apply this stuff. So the sooner the better. But we are running cohorts every other month now.

We’ve increased it from five to six cohorts per year because I’ve brought on some new coaches, some ways to make things work. But anyway, the important point for you is March 19th, registration will open for the April cohort. So if your scores aren’t reflecting all the work that you’re doing, it may be worth checking out. You can find out more information at physicianassistantexamreview.com/33. Or be sure to get on the email list at physicianassistantexamreview.com/daily. And that way you’ll be sure to find out when things happen.

All right, so we’re going to jump in today with our priming questions moving on to some reproductive issues. Remember, our priming questions are to get your brain functioning and moving. This is not passive. This is not just letting this wash over you, although you could use it that way. It doesn’t make the most sense to use it that way. You want to be thinking about this as engaged study. And that’s what the priming questions are for.

You may not know these. I’m fine with that. You don’t need to know them. We’re going to go over them. It just gives you a place to start looking for the information. It gives your subconscious mind a place to start finding gaps and look to fill those gaps. So it’s actually more important if you don’t know these.

All right, so what is the first step in evaluating a 28-year-old with irregular menses? First step in evaluating a 28-year-old female with irregular menses. Irregular cycles plus acne and hirsutism should make you think of what underlying problem? Irregular cycles plus acne and hirsutism should make you think of what underlying problem? A patient with heavy prolonged menses presents with fatigue. What lab helps assess severity? A patient with heavy prolonged menses presents with fatigue.

What lab helps you to assess severity. A 52-year-old with hot flashes and one year of amenorrhea asks, what test confirms the diagnosis? What do you tell her? A 52-year-old with hot flashes and one year of amenorrhea asks, what test confirms the diagnosis? What do you tell her? A patient with a migraine with aura requests birth control. Which category of contraception should you avoid?

A patient with a migraine with an aura requests birth control. Which category of contraception should you avoid?

All right, let’s jump into, we’re going to start with menstrual disorders, which is a little bit bigger topic. It’s kind of like saying we’re going to cover arrhythmias and making that sound like it’s just one line. It doesn’t work that way. It’s a little bigger and more complicated. There’s also some pieces of this that aren’t going to come until later episodes and later content. I’m not going to go deep into them, but we’ll just touch on them here so that you can see where they’re relevant. So what’s important is considering how you think through a menstrual disorder, how you think through the problem, both in the clinic and on your test.

So what you’re looking for is the patterns, the frequency, the timing, those are your keys. So whenever you come across a menstrual problem, patient complaining about their cycle, the amount of blood flow, etc., there’s pretty much a standard system. And number one is always, well, what is always number one? Think for a second. What’s always the first step? First step is always rule out pregnancy. Because pregnancy can present with bleeding, it can present with amenorrhea.

So always, always, always first step is a pregnancy test. It’s simple, it’s easy, and it’s your number one cause of issues.

Next, you’re going to characterize the bleeding pattern. So we have amenorrhea. What’s amenorrhea? Well, it’s the absence of menses. Amenorrhea. So oligomenorrhea is infrequent cycles. So instead of every month, maybe it’s every two months or every three months, something like that.

Menorrhagia is heavy menstrual bleeding, excessive blood flow. Metrorrhagia is intermenstrual bleeding, bleeding between cycles. And my spell check isn’t finding that one. Dysmenorrhea is painful periods.

Okay, so first you’re going to get a pregnancy test, then you’re going to think about, all right, is this amenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, or dysmenorrhea. You want to characterize it. After that, you’re going to look at, is this stable? So is this person having a life-threatening bleed and significant anemia? Or are they just hanging out talking to me in the office? One of the other things on your list is to consider how old the patient is. So are they reproductive age?

Are they in menopause? Are they in perimenopause? It’s obviously going to affect your decision-making tree. And then lastly, it’s what’s causing this problem. Is it a hormonal issue? Is it a structural problem? Is it a systemic problem?

Or is it iatrogenic? Those tend to be the four things that can cause menstrual disorders. So we said hormonal, so you have issues like menopause, right? If it’s structural, you have things like fibroids and polyps. If it’s systemic, what we’re talking about here is you may have a coagulopathy, right? If you have excessive bleeding, it could be a reproductive issue, but it could be a coagulopathy. You also can have some endocrine issues that can cause this.

And then iatrogenic, so that’s us giving medications or contraceptives that can cause it, right? So that’s sort of the decision-making tree I want you to go down. You should be thinking about or come up with your own for how to walk through a patient who comes in with a menstrual disorder. Number one is always rule out pregnancy. So what is a menstrual disorder? It’s abnormal timing, frequency, or volume of menstrual bleeding. Exam focuses on pattern recognition and what’s the next step.

That’s what you’re usually looking for. So we’re going to go through each of these and then we’ll do sort of the workup at the end because I don’t want to repeat it every time. It’s just mostly repetitive for this whole section, which is nice because now you only have to remember one set of labs and just what they do. So first we have amenorrhea. Amenorrhea is the absence of menstruation. Common causes here, what’s the number one cause? Pregnancy.

Other common causes are polycystic ovarian syndrome, hyperprolactinemia, hypothalamic dysfunction, ovarian insufficiency, or menopause. But always, always, always think pregnancy first. Oligomenorrhea is infrequent or unpredictable cycles. We just talked about some of these. We talked about all of these actually. I’m just going to breeze through them. Common causes here are PCOS, perimenopause, stress or energy imbalance.

So this is where you could get your patient who is running her training for her first marathon may find that her cycle is, the timing is off. Menorrhagia is that prolonged bleeding during menses. Most common causes here are anovulation, fibroids, and then we have that coagulopathy. Here you’re going to want to assess for hemodynamic stability and anemia. Menorrhagia is bleeding between expected menstrual periods. Here you may have some sort of hormonal imbalance, a structural lesion, or a complicated pregnancy. Dysmenorrhea may be associated with structural diseases like endometriosis or fibroids, but you’re going to want to work this up.

Now, what does the workup for all this look like? Well, what do we start with? What’s our first, when we talk about physical exam labs and studies, what’s our first lab we’re going to get on all of these patients? Well, we’re going to get a pregnancy test, right? Depending on age, I guess, but pregnancy test. You’re going to get a CBC. Why are we getting a CBC?

Well, we’re going to assess for anemia, especially if this person has heavy, prolonged bleeding. We’re going to get a TSH and screen for any thyroid issues. Hypo and hyperthyroid both can screw up ovulation. You’re going to want to get a prolactin level. We’re looking for a hyperprolactinemia, which suppresses ovulation and causes amenorrhea. Especially if you have galactorrhea or headaches present. You can do an androgen test to look for PCOS.

Especially if you have physical signs like acne or hirsutism or obesity. And we’ll get into PCOS in just a second. Pelvic ultrasound evaluates for structural causes such as fibroids, polyps, or ovarian pathology. We’re not going to get too deep into those this week because we have a show coming up on structural issues. So we’re going to get to that there. This is more hormonal today. And then you’re going to want to get an endometrial evaluation.

This will rule out hyperplasia or malignancy in a postmenopausal bleeding or patients with prolonged unopposed estrogen exposure. So that’s the overall view. I didn’t want to get into the specifics of each diagnosis. That is the run through of what menstrual disorders look like. What variations in bleeding and volume and patterns all look like. And how you want to work it up and what you want to be thinking about. That moves us into our first diagnosis here, which is going to be polycystic ovarian syndrome, PCOS.

And this is relatively common. And it’s caused by chronic anovulation and hyperandrogenism, often driven by insulin resistance. That’s the major key here. Clinical presentation is irregular or infrequent menstrual cycle. You get those signs of hyperandrogenism, like acne, hirsutism, which means hair. I think it’s like facial hair. You can even get androgenic alopecia.

You usually have obesity or weight gain that goes along with this. But generally speaking, infertility is your presenting complaint. So your question stem is going to be something like a, you know, a 32-year-old woman comes in with irregular periods. She has some acne, is a little overweight, and she’s having difficulty conceiving. So this is generally a clinical diagnosis based on pattern and exclusion of other causes. You’re going to rule out pregnancy, right? You’re going to do thyroid checking.

You’re going to do a prolactinemia check. You’re going to do androgen levels. And then you’re going to do the pelvic ultrasound to look for those polycystic ovaries. But it’s not required for diagnosis to see those cysts in the ovaries. It’s not required. That’s important. Treatment here is going to be lifestyle modification and weight loss are first line.

You can do a combined hormonal contraceptive, so regulate cycles and reduce androgen effect. Metformin can be helpful for insulin resistance and may restore ovulation. It’s sort of tied together here. And you can do ovulation induction if fertility is the main outcome the patient is looking for. So as far as exam keys, what I’m looking for, irregular menses plus hyperandrogenism is PCOS until proven otherwise. So if I come across those things, I’m thinking PCOS. The ultrasound is supportive but not diagnostic.

That’s the other main key here. I think that people will mix up. And it’s a very common issue for infertility. Speaking of infertility, it’s the inability to conceive after 12 months of regular unprotected intercourse. However, we change that if the patient’s over 35. If we have a female over 35 and there’s an inability to conceive after six months, we start the workup because time’s a factor. Clinical presentation is the inability to conceive despite regular intercourse, which we just talked about.

They might have associated menstrual irregularities. You’re going to look in the history for anything that may be an issue with fertility, right? So if they have a, if they’ve had their tubes out, for example, if they’ve had an ectopic in the past, if they’ve had PID in the past, those kind of things. But the question stem will likely describe a couple trying to conceive for over a year and asking what to do next. So a significant portion of the issue falls upon the males. So you’re going to want to do a sperm count. You can also obviously have female issues.

So ovulatory dysfunction, most common here is PCOS. Again, I just said if you have prior PID or surgery or some issue with the tubes. You can also have issues with the uterus. So if you have fibroids filling up the uterine cavity, that’s going to prevent you from carrying a pregnancy. Or some other congenital anomalies. I don’t know why my inability to speak today. Lab studies and imaging, you’re going to evaluate both partners, right?

Both partners. Seems like it should be obvious, but just to be clear. You’re going to look through their menstrual history and targeted hormone testing when indicated. You’re going to do semen analysis. You can do a pelvic ultrasound, again, looking for those fibroids or something that’s structurally a problem. You can also do tubal evaluations. And we actually do this in the OR, not infrequently.

It’s called chromotubation. And you put a, I’m trying to think of how to describe it, a device up through the vagina, through the cervix, into the uterus. And you’re actually looking laparoscopically. Usually we’re doing something laparoscopically and we’re doing this in addition. So maybe we’re lysing adhesions because we have a patient who is looking to get pregnant. And they’re struggling and they had previous surgery. So we, or there are some other issues.

So we go in laparoscopically and we look at the tubes, look at the ovaries, make sure there are no adhesions, nothing structurally a problem. Maybe free up some of those structures. And at the same time, you can inject some dye into the uterus. And then the, it’ll actually leak out through the tube. So you can see that the tubes are patent is what you’re looking for. And you can get evidence of that or the, or the, or that they’re not. And that that’s your problem.

Treatment depends on underlying cause, ovulation induction for anovulatory infertility. You’re going to treat endocrine disorders if they’re there, that kind of thing. And then you’re going to refer to a reproductive endocrinologist for advanced eval if this problem persists. So exam keys. PCOS is the most common cause of anovulatory infertility. Keep an eye out for PCOS. Always evaluate both partners.

And that infertility is a 12 month or six months depending on age.

All right, let’s go into menopause. Permanent cessation of menstruation due to loss of ovarian follicular activity. This is diagnosed retrospectively after 12 months of amenorrhea. So if a woman around the age of 50 has amenorrhea for the past 12 months, has other symptoms and signs, is not pregnant, we believe that it’s menopause. Clinical presentation is irregular cycles progressing to amenorrhea. So if the story fits, this is a clinical diagnosis. Vasomotor symptoms like hot flashes and night sweats, sleep disturbances and mood changes, vaginal dryness, dyspareunia.

Your question stem is going to be something like a woman in her late 40s or 50s with missed periods and hot flashes. So they’re kind of probably described the individual. Lab studies and imaging diagnosis is clinical in the appropriate age group. I keep saying diagnosis. It’s sort of a diagnosis, but it’s a natural progression. So I’m not sure that that’s the right term. FSH may be elevated, but it is not required for diagnosis.

Pregnancy test. If amenorrhea occurs earlier than expected, so if you have a 42-year-old, might be menopause, but might be that they’re pregnant. Always think pregnancy first. Again, it’s so easy to test for. Further evaluation if symptoms are atypical or occur at a younger age. Treatment is symptom-driven and not required for every patient. If you’ve got mild symptoms, they can be managed with lifestyle modification, including dressing in layers and keeping cool environment to deal with the hot flashes.

Avoiding certain triggers like hot beverages, alcohol, and spicy foods. Regular exercise and weight management can help. Sleep hygiene can help. Sleep hygiene is good, and exercise are good for everything. Quite literally everything. If you’re not recommending them to all your patients and you’re not participating in those two things, this would be step one for literally when you get off the show today. Figure out a way to get some exercise and start working on your sleep hygiene.

Moderate to severe vasomotor symptoms may be treated with systemic hormone therapy if there are no contraindications. We’ll get to that in just a second. The primary agent for symptom relief is estrogen. The primary agent for symptom relief is estrogen. If the uterus is present and you’re giving estrogen, you must also give progestin. This prevents endometrial hyperplasia. Let me say it again.

If you’re giving estrogen and the uterus is present, you must give progestin. Patients without a uterus can get estrogen alone. Locally applied vaginal estrogen can help with dryness or dyspareunia. And then if they’re contraindicated, if a patient can’t have hormonal therapy and they’re having symptoms, there are SSRIs may be helpful, SNRIs may be helpful. Gabapentin might be helpful.

Now, why wouldn’t a patient be able to get hormone therapy? Well, if they have a history of breast cancer, if they have a history of endometrial cancer, if they have a history of DVT, right? You all know that OCPs increase your risk for DVTs. If they have a history of stroke or MI, if they have active liver disease, if they have unexplained vaginal bleeding. So there are reasons why you’re not going to give hormone therapy. So just a quick recap. Menopause is a clinical diagnosis.

Hormone therapy is available and optional based upon symptoms. Estrogen treats those symptoms and progestin protects the uterus. FSH testing is usually unnecessary. So you can get it, but you don’t need it.

All right. Our last topic for today is contraceptive methods. Obviously, this is mostly for pregnancy prevention, but it can also be for cycle regulation and symptom control. So your exam is going to be looking for what’s the safest option based on the patient’s factor. So there’s reasons, again, why patients can get certain things and they can’t get certain things. So that’s the part of this that you should probably learn. So I went through this and I was thinking about rather than just reciting it to you, it’d be what’s the structure?

How do we look at this so that it makes sense when you’re either prescribing it or you’re thinking about it on an exam? So if the patient can safely take estrogen and wants cycle control or acne improvement, then a combined hormonal method will be your best choice, meaning estrogen and progestin. If estrogen is contraindicated, choose progestin only method. If hormones are contraindicated or not desired, choose a non-hormonal method, which we’ll get to in a second. So we have an estrogen and progestin pill. This is an oral pill, the patch, or a vaginal ring. This suppresses ovulation and stabilizes the endometrium.

Improves cycle regularity, improves dysmenorrhea, and improves acne. This is appropriate for healthy patients without estrogen risks. Progestin only contraceptives are like the Depo, medroxyprogesterone injections, the implant, hormonal IUD. These thicken the cervical mucus and variably suppress ovulation. They’re preferred when estrogen is contraindicated, like we talked about earlier. They may cause irregular bleeding patterns, though. What are some non-hormonal contraceptives?

Well, barrier methods for one, right? Like condoms. Permanent sterilization, either male or female. A copper IUD, but it may increase menstrual bleeding and cramping, so just watch out for that. So those are some non-hormonal contraceptives, if hormone treatment is not desired or contraindicated. So what are some contraindications to estrogen therapy here? Again, that history of a DVT, history of a stroke or MI, migraine with an aura, any kind of estrogen-dependent malignancy, so we’re talking about breast cancer, maybe, active liver disease, uncontrolled hypertension, and a smoker over age 35.

Fertility and cycle implications. Most methods are fully reversible, other than permanent sterilization, right? That’s not so reversible. But stopping the pill will reverse this, and often it does so quickly. Keep in mind for your exams that estrogen will increase your thromboembolic risk. Migraine with an aura is an absolute contraindication to estrogen. Progestin only is safe when estrogen is contraindicated.

And choose the contraception based on their profile, right? That’s what you’re going to be asked to do on your exam. Fantastic work. Good, good, good. We’re really moving through reproduction. We’re moving through so much material. I’m thrilled about how you guys are doing.

I’m thrilled about the way the show has been growing. Thank you for sharing it. Really appreciate that. It’s been… Really nice to see. Anyway, let’s jump in and talk about our study tip for today before we get to the answers to our priming questions. And I want to talk about something we talked about on last night’s 33 Days group coaching call.

Last night was the last coaching call that I’ll do. The coaches will host one more workshop on Wednesday. But as the… What is this? The February cohort comes to an end. Last night was my last call. So I talk about what to do next, where we’re heading, how to maintain everything that you learned, how to keep up with everything that you’ve done, and not to fall back into bad habits.

And inevitably, the question comes up about the NCCPA mock exams and when to take them and if to take them. And I’m not going to go into a lot of detail about what we talked about. I’m not going to go into a lot of detail about my overall thoughts on them. What I am going to say is if you’re getting ready for your PANCE and you’re thinking about taking the mock exam prior to your PANCE exam, consider the ramifications of doing well and consider the ramifications of doing poorly on that exam. I have seen so many students take the NCCPA mock PANCE exam in the week or two before, do poorly on it, and have it shatter their confidence. To where they go into their PANCE and they just can’t think straight and they think they’re going to fail. Or they push their PANCE back and then they push it back and then they push it back.

That concerns me a lot when people talk about taking it. I will also tell you that in my anecdotal experience, I have not seen a strong correlation between the mock exam and PANCE pass rates.

Now, they may have different data. I have no access to that. But just in talking with hundreds of students, I’ve talked with some who did terrible on the mock exam, went in and did just fine on the PANCE. I’ve talked with a lot who have done great on the PANCE. I’m sorry, on the mock exam and failed the PANCE. So all I’m saying is don’t let it eat up your ego. And if it’s going to, don’t use it.

You know yourself by now. You know what can send you into a spiral. You know it can upset you and make it so you can’t think straight. The chances of it giving you good news and boosting your confidence are there, but not huge. Because even so, you’ll still doubt something. But if you’re looking for a reason to doubt yourself and to be uncomfortable, getting a low score on this will help you with that. And that’s a terrible place to be.

So I’m not telling you not to take it, but I am telling you do not take it the week before your PANCE. Probably don’t take it two weeks before your PANCE. But more importantly than that is to understand what I’m saying and think about when you would take it, why you would take it, what the purpose is. You know, I had one student on the call who said, hey, I just don’t have access to a question bank, so I thought I would use it because I don’t have that access. And I said, great, I don’t have any problem with you using it. I think it’s a great question bank. But if it’s going to shake your ego, if you get a 45 on it, then I would recommend against it.

But if you can be outcome agnostic and you can just go through it and work your way through it, then I think it’s a fine question bank. I think it’s great. But just be careful in how much weight you put into things. In general, right? We want to kind of remain a little detached from the results. We want to put in the work and know that we did the work. Then we want to use the results of these things as feedback to adjust the work we’re doing, not as referendums on who we are as people, practitioners, how good we’re going to do, what a bad person I am, how you want to look at your work first and then use the rest as feedback to adjust the work.

All right, let’s jump into our priming questions. What’s the first step in evaluating a 28-year-old with irregular menses? Pregnancy test. Please tell me you got that right. Irregular cycles plus acne and hirsutism should make you think of what underlying problem? PCOS, that should be pretty straightforward. That was always one that seemed easy to me.

A patient with heavy, prolonged menses presents with fatigue. What lab helps assess severity? CBC, right? We’re looking for anemia. If she’s hemorrhaging. A 52-year-old with hot flashes and one year of amenorrhea asks, what test confirms the diagnosis? What do you tell her?

We say it’s a clinical diagnosis. You don’t need a test. We can do an FSH, but you don’t need it. A patient with a migraine, with an aura, request birth control. Which category of contraception should you avoid? Estrogen-containing contraceptives are contraindicated. That’s the kind of way that you’re going to see these questions on the exam, and that’s what you should be, how you should be studying them.

All right, if this helped at all, here’s the big takeaway. It’s not about cramming more facts into your brain. It’s about knowing how to see through the questions, see through the material, how to organize it, how to, so that you remember it when you’re under pressure. That’s part of the key here, remembering it when you’re under pressure. That’s also why I’ve seen the mock exam not reflected in the scores on the PANCE, because it’s a different day. The pressures are different. The situation is different.

You know, I talk a lot about sports, and I was talking with someone this weekend, and they were saying, you know, people get frustrated when a team that’s projected to lose, to win, loses. And it’s like, that’s why we play the games, because you can’t predict it. All the predictions in the world get you close. They don’t get you to the right answer, though. You have to play the game. And that’s why here, we talk about thinking different, working different, so that we can score different. And just a reminder before we go, March 19th, registration opens for the April cohort of 33 Days to Pass the PANCE.

If you’re struggling in PA school, and you want your studying to finally turn into points, then this is for you. Go to physicianassistantexamreview.com/33 for more information. We do not teach content inside of this program. It’s not what it’s for. That’s what this podcast does. It’s what your school does. Instead, we train you how to study, how to approach the questions, and how to manage yourself on exam day, which is so critically important.

So that all of your hard work turns into the scores you deserve. Again, if you want to know first when registration opens and everything that’s going on, register for the email list, physicianassistantexamreview.com/daily, and jump on the email list. And you’ll get all the details as soon as I send them out to the community. And we’ll start doing that actually pretty soon. Until next week, take care. Good luck on your exams. And I look forward to talking to you again.

Thank you so much for being here. Thank you so much for sharing the show. It’s been a really good 2026 so far. And good luck to you guys on your upcoming tests.