USMLE Step 2 Quiz: Reproductive Endocrinology Contraception And Gynecologic Oncology

What this quiz covers

This quiz focuses on Reproductive Endocrinology Contraception And Gynecologic Oncology, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Stop OCPs and manage with NSAIDs alone until attempting conception
2. Begin GnRH agonist therapy for 12 months without add-back therapy
3. Laparoscopic cystectomy with excision/ablation of endometriosis lesions (correct answer)
4. Total hysterectomy with bilateral salpingo-oophorectomy
5. Switch to cyclic OCPs to allow withdrawal bleeding and reduce pain

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on surgical management of endometriosis with future fertility desires. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the worsening symptoms despite medical therapy and presence of endometrioma guide the most appropriate clinical decision. The correct choice, laparoscopic cystectomy with excision/ablation of endometriosis lesions, aligns with ASRM guidelines and directly addresses pain relief while preserving fertility. A common mistake is selecting total hysterectomy with bilateral salpingo-oophorectomy, which fails because the patient desires pregnancy in the near future. Teaching strategies include reviewing current guidelines on endometriosis surgery, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 2

1. Referral to gynecologic oncology for surgical evaluation given postmenopausal complex mass (correct answer)
2. Reassure and repeat ultrasound in 12 months
3. Start combined oral contraceptives to shrink the mass
4. Treat with methotrexate for suspected ectopic pregnancy
5. Order PET scan as the next diagnostic step

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on management of complex adnexal masses in postmenopausal women. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the postmenopausal status and complex adnexal mass guide the most appropriate clinical decision. The correct choice, referral to gynecologic oncology for surgical evaluation given postmenopausal complex mass, aligns with ACOG guidelines and directly addresses the malignancy risk. A common mistake is selecting reassure and repeat ultrasound in 12 months, which fails because it delays evaluation of a potentially malignant lesion. Teaching strategies include reviewing current guidelines on adnexal mass assessment, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 3

1. Polycystic ovary syndrome
2. Functional hypothalamic amenorrhea (correct answer)
3. Primary ovarian insufficiency
4. Hyperprolactinemia due to pituitary adenoma
5. Late-onset congenital adrenal hyperplasia

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on diagnosis of amenorrhea in underweight athletes. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the low BMI, exercise history, and low gonadotropins guide the most appropriate clinical decision. The correct choice, functional hypothalamic amenorrhea, aligns with Endocrine Society guidelines and directly addresses the energy deficiency etiology. A common mistake is selecting polycystic ovary syndrome, which fails because it typically presents with hyperandrogenism and normal/high gonadotropins. Teaching strategies include reviewing current guidelines on amenorrhea classification, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 4

1. Image-guided biopsy of the adnexal mass before any surgery
2. Laparoscopic cyst drainage and observation
3. Referral for exploratory laparotomy with staging by gynecologic oncology (correct answer)
4. Start oral progestin therapy and repeat ultrasound in 3 months
5. Treat with antibiotics for presumed tubo-ovarian abscess

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on management of suspected ovarian malignancy in postmenopausal women. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the complex adnexal mass, ascites, and elevated CA-125 guide the most appropriate clinical decision. The correct choice, referral for exploratory laparotomy with staging by gynecologic oncology, aligns with NCCN guidelines and directly addresses the high malignancy risk. A common mistake is selecting image-guided biopsy, which fails because it risks tumor seeding in potential ovarian cancer. Teaching strategies include reviewing current guidelines on ovarian cancer staging, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 5

1. Endometrial biopsy (correct answer)
2. Serum progesterone level
3. Pap test with HPV cotesting
4. Pelvic MRI as the next step
5. Repeat ultrasound in 3 months

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on evaluation of thickened endometrium in postmenopausal bleeding. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the endometrial thickness of 9 mm and risk factors like obesity guide the most appropriate clinical decision. The correct choice, endometrial biopsy, aligns with ACOG guidelines and directly addresses the risk of hyperplasia or malignancy. A common mistake is selecting repeat ultrasound in 3 months, which fails because it delays necessary tissue diagnosis in a high-risk patient. Teaching strategies include reviewing current guidelines on endometrial sampling, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 6

1. Endometrial biopsy to rule out hyperplasia or malignancy
2. Reassurance and outpatient follow-up if bleeding resolves (correct answer)
3. Hysterosalpingogram to evaluate uterine cavity
4. Start combined oral contraceptives for bleeding control
5. Routine Pap test as the next diagnostic step

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on management of postmenopausal bleeding with thin endometrium. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the endometrial thickness of 3 mm on ultrasound guides the most appropriate clinical decision. The correct choice, reassurance and outpatient follow-up if bleeding resolves, aligns with ACOG guidelines and directly addresses the low risk of malignancy. A common mistake is selecting endometrial biopsy, which fails because biopsy is not indicated when thickness is below 4 mm in asymptomatic cases. Teaching strategies include reviewing current guidelines on endometrial evaluation, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 7

1. Combined ethinyl estradiol/levonorgestrel oral contraceptive
2. Copper intrauterine device
3. Levonorgestrel-releasing intrauterine device (correct answer)
4. Transdermal combined hormonal contraceptive patch
5. Combined hormonal vaginal ring

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on contraceptive selection in patients with migraine with aura. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the patient's history of migraine with aura and desire for lighter periods guide the most appropriate clinical decision. The correct choice, levonorgestrel-releasing intrauterine device, aligns with US MEC guidelines and directly addresses the patient's need for a non-estrogen method that reduces menstrual flow. A common mistake is selecting combined ethinyl estradiol/levonorgestrel oral contraceptive, which fails because estrogen-containing methods are contraindicated in migraine with aura due to increased stroke risk. Teaching strategies include reviewing current guidelines on contraceptive safety, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 8

1. Letrozole (correct answer)
2. Combined oral contraceptives
3. Gonadotropin injections as initial therapy
4. Bromocriptine
5. Bilateral oophorectomy

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on ovulation induction in polycystic ovary syndrome. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the clinical features of PCOS and desire for ovulation induction guide the most appropriate clinical decision. The correct choice, letrozole, aligns with ACOG recommendations and directly addresses first-line therapy for anovulatory infertility in PCOS. A common mistake is selecting combined oral contraceptives, which fails because they suppress ovulation rather than induce it. Teaching strategies include reviewing current guidelines on fertility treatments in PCOS, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 9

1. MRI of the pituitary with contrast (correct answer)
2. CT scan of the abdomen to evaluate adrenal mass
3. Hysteroscopy to evaluate the endometrial cavity
4. Serum CA-125 level
5. Karyotype analysis for Turner syndrome

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on evaluation of hyperprolactinemia in infertility. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the elevated prolactin, galactorrhea, and headaches guide the most appropriate clinical decision. The correct choice, MRI of the pituitary with contrast, aligns with Endocrine Society guidelines and directly addresses the suspicion for pituitary adenoma. A common mistake is selecting serum CA-125 level, which fails because it is irrelevant to hyperprolactinemia without ovarian pathology. Teaching strategies include reviewing current guidelines on prolactin disorders, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 10

1. Combined oral contraceptive pill
2. Levonorgestrel-releasing intrauterine device (correct answer)
3. Combined hormonal patch
4. Combined hormonal vaginal ring
5. Diethylstilbestrol for contraception

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on contraception in patients with thrombosis history and migraine with aura. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the prior DVT and migraine with aura guide the most appropriate clinical decision. The correct choice, levonorgestrel-releasing intrauterine device, aligns with US MEC guidelines and directly addresses the need for a progestin-only method that lightens bleeding. A common mistake is selecting combined oral contraceptive pill, which fails because estrogen is contraindicated due to thrombotic risk. Teaching strategies include reviewing current guidelines on high-risk contraception, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 11

1. Combined oral contraceptive pill started today
2. Levonorgestrel-releasing intrauterine device (correct answer)
3. Transdermal combined hormonal contraceptive patch
4. Combined hormonal vaginal ring
5. Ethinyl estradiol emergency contraception as ongoing method

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on postpartum contraception in breastfeeding women with migraine with aura. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the history of migraine with aura and breastfeeding status guide the most appropriate clinical decision. The correct choice, levonorgestrel-releasing intrauterine device, aligns with US MEC guidelines and directly addresses the need for a progestin-only method safe for lactation. A common mistake is selecting combined oral contraceptive pill, which fails because estrogen is contraindicated in migraine with aura and may affect milk supply. Teaching strategies include reviewing current guidelines on postpartum contraception, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 12

1. Total hysterectomy with bilateral salpingo-oophorectomy and surgical staging (correct answer)
2. High-dose combined oral contraceptives as definitive therapy
3. Observation with repeat biopsy in 6 months
4. Endometrial ablation to control bleeding
5. Dilation and curettage only, without further surgery

Explanation: This question tests knowledge in reproductive endocrinology, contraception, and gynecologic oncology, specifically focusing on surgical management of endometrial cancer with adnexal involvement. Understanding the nuances in choosing appropriate diagnostic and management strategies is crucial in patient care. In this scenario, the biopsy-proven endometrioid adenocarcinoma and complex adnexal mass guide the most appropriate clinical decision. The correct choice, total hysterectomy with bilateral salpingo-oophorectomy and surgical staging, aligns with NCCN guidelines and directly addresses comprehensive oncologic treatment. A common mistake is selecting observation with repeat biopsy, which fails because it delays definitive therapy in confirmed malignancy. Teaching strategies include reviewing current guidelines on endometrial cancer staging, understanding the indications and contraindications of various treatments, and practicing with similar clinical scenarios to reinforce learning.

Question 13

1. Hysterosalpingogram
2. Mid-luteal phase progesterone level
3. Semen analysis (correct answer)
4. Trial of clomiphene citrate

Explanation: The initial evaluation of an infertile couple should include an assessment of ovulatory function, tubal and uterine anatomy, and male factors. Semen analysis is a simple, noninvasive, and cost-effective test that can identify male factor infertility, which accounts for up to 50% of cases. Given its high yield and low risk, it is a crucial first step. Hysterosalpingogram is more invasive and is typically performed after semen analysis. A mid-luteal phase progesterone level assesses ovulation, which is likely normal given the patient's regular cycles. Clomiphene citrate is a treatment, and therapy should not be initiated before a diagnosis is established.

Question 14

1. Copper intrauterine device (IUD)
2. Combined oral contraceptive pills (correct answer)
3. Levonorgestrel-releasing IUD
4. Progestin-only pill

Explanation: Combined hormonal contraceptives (containing both estrogen and progestin) are contraindicated in women with migraine with aura due to an increased risk of ischemic stroke. The estrogen component is believed to be responsible for this risk. Progestin-only methods, such as the progestin-only pill and the levonorgestrel-releasing IUD, as well as non-hormonal methods like the copper IUD, are safe and appropriate alternatives for this patient.

Question 15

1. Reflex human papillomavirus (HPV) testing (correct answer)
2. Immediate colposcopy
3. Repeat Pap smear in 1 year
4. Loop electrosurgical excision procedure (LEEP)

Explanation: The preferred management for a Papanicolaou (Pap) test result of ASC-US in a woman aged 25 or older is reflex HPV testing from the same sample. If the HPV test is positive, the patient should be referred for colposcopy. If the HPV test is negative, she can return to routine screening. Repeating the Pap smear in one year is an alternative if HPV testing is not available or was not performed. Immediate colposcopy is indicated for higher-grade lesions (e.g., HSIL) or if the ASC-US result is positive for high-risk HPV. LEEP is a treatment modality, not an initial diagnostic step for ASC-US.

Question 16

1. Polycystic ovary syndrome
2. Premature ovarian insufficiency
3. Asherman syndrome
4. Functional hypothalamic amenorrhea (correct answer)

Explanation: This patient's presentation of amenorrhea in the context of low body weight and intense physical exercise is classic for functional hypothalamic amenorrhea. This condition is caused by decreased pulsatile secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus, leading to low levels of LH, FSH, and consequently, estrogen. Polycystic ovary syndrome is associated with hyperandrogenism and often obesity. Premature ovarian insufficiency would present with elevated FSH levels. Asherman syndrome (intrauterine adhesions) typically follows uterine instrumentation.

Question 17

1. Percutaneous needle biopsy of the mass
2. Measurement of serum CA-125 (correct answer)
3. Diagnostic paracentesis
4. Initiation of empiric chemotherapy

Explanation: The patient's presentation is highly suspicious for epithelial ovarian cancer. Measurement of serum CA-125 is an essential part of the initial workup for a suspected ovarian malignancy in a postmenopausal woman, as it helps with risk stratification and can be used as a baseline to monitor treatment response. Percutaneous biopsy of an adnexal mass is contraindicated due to the risk of rupturing the capsule and seeding the peritoneum with malignant cells, which would upstage the cancer. Paracentesis is typically reserved for symptomatic relief of ascites. Chemotherapy is initiated only after a definitive tissue diagnosis is made, usually at the time of surgical staging.

Question 18

1. Levonorgestrel pill
2. Ulipristal acetate pill
3. Copper intrauterine device (correct answer)
4. Combined estrogen-progestin pills (Yuzpe method)

Explanation: The copper intrauterine device (IUD) is the most effective form of emergency contraception, with a failure rate of less than 0.1%. It can be inserted up to 5 days after unprotected intercourse. Ulipristal acetate is the most effective oral option and can also be used up to 5 days after intercourse, but it is slightly less effective than the copper IUD. The levonorgestrel pill is most effective within 72 hours and its efficacy decreases significantly after that time. The Yuzpe method (combined pills) is the least effective option and has more side effects.

Question 19

1. TP53
2. MLH1
3. BRCA1 (correct answer)
4. PTEN

Explanation: This family history is highly suggestive of Hereditary Breast and Ovarian Cancer (HBOC) syndrome, most commonly caused by mutations in the BRCA1 or BRCA2 genes. The constellation of early-onset breast cancer, ovarian cancer, and prostate cancer, along with Ashkenazi Jewish ancestry, strongly points toward a BRCA mutation. BRCA1 mutations carry a particularly high risk for both breast and ovarian cancer. MLH1 is associated with Lynch syndrome (colorectal, endometrial, ovarian cancer). TP53 is associated with Li-Fraumeni syndrome. PTEN is associated with Cowden syndrome.

Question 20

1. Immediate colposcopy
2. Repeat co-testing in 1 year (correct answer)
3. Endocervical curettage
4. Resume routine screening in 5 years

Explanation: According to current guidelines, for a woman aged 30 or older with a negative Pap test but a positive high-risk HPV test, the preferred management is to repeat co-testing in one year. This approach is based on the high likelihood that the HPV infection will clear spontaneously. If the repeat testing shows ASC-US or greater, or if the HPV test remains positive, colposcopy would then be recommended. Immediate colposcopy is not recommended for this specific combination of results, as it would lead to over-investigation. Resuming routine screening would be inappropriate given the positive HPV result.