Physician Assistant National Certifying Examination (PANCE) Reproductive System and Women's Health Syllabus

Which virus causes the majority of cervical dysplasia and cervical cancer, and which serotypes are highest-risk?

Human papillomavirus (HPV); high-risk types 16 and 18 cause about 70% of cervical cancers.

What is the most common histologic type of cervical cancer?

Squamous cell carcinoma (arising at the transformation zone), accounting for the majority of cases; adenocarcinoma is the second most common.

According to current guidelines, at what age does routine cervical cancer screening (Pap testing) begin, and how often is it done from ages 21–29?

Screening begins at age 21 regardless of sexual history. From ages 21–29, cytology (Pap) alone is done every 3 years.

What are the preferred cervical cancer screening options for women aged 30–65?

Primary HPV testing every 5 years (preferred), OR co-testing (cytology + HPV) every 5 years, OR cytology alone every 3 years.

Name the classic clinical findings of pelvic inflammatory disease (PID) on exam.

Lower abdominal/pelvic pain plus cervical motion tenderness ('chandelier sign'), uterine tenderness, and adnexal tenderness. Often with mucopurulent cervical discharge and fever.

Which organisms most commonly cause PID, and what is the recommended outpatient antibiotic regimen?

Neisseria gonorrhoeae and Chlamydia trachomatis. Recommended regimen: ceftriaxone 500 mg IM once PLUS doxycycline 100 mg PO BID for 14 days PLUS metronidazole 500 mg PO BID for 14 days.

What is Fitz-Hugh-Curtis syndrome?

Perihepatitis (inflammation of the liver capsule causing RUQ pain and 'violin-string' adhesions) as a complication of PID, classically from chlamydial or gonococcal infection.

What is Naegele's rule for estimating the estimated date of delivery (EDD)?

EDD = first day of last menstrual period $-$ 3 months $+$ 7 days $+$ 1 year (assuming a regular 28-day cycle).

Which prenatal screening tests are recommended at the first prenatal visit?

Blood type and Rh, antibody screen, CBC, rubella immunity, hepatitis B surface antigen, HIV, syphilis (RPR/VDRL), urinalysis/urine culture, Pap if due, and gonorrhea/chlamydia testing.

When is the maternal serum quad screen performed, and what four analytes does it measure?

Performed at 15–22 weeks. It measures AFP, hCG, unconjugated estriol (uE3), and inhibin A.

On a quad screen, what analyte pattern suggests Down syndrome (trisomy 21)?

Low AFP, low estriol, high hCG, and high inhibin A.

When is the routine fetal anatomy ultrasound performed, and when is screening for gestational diabetes done?

Anatomy ultrasound at 18–20 weeks. Gestational diabetes screening at 24–28 weeks (1-hour 50 g glucose challenge).

Distinguish gestational hypertension, preeclampsia, and chronic hypertension in pregnancy by timing.

Chronic hypertension: present before 20 weeks. Gestational hypertension: new BP $\geq 140/90$ after 20 weeks WITHOUT proteinuria/end-organ damage. Preeclampsia: new hypertension after 20 weeks WITH proteinuria or end-organ dysfunction.

What blood pressure and laboratory findings define preeclampsia with severe features?

BP $\geq 160/110$, platelets $< 100{,}000/\mu L$, doubling of creatinine or $> 1.1$ mg/dL, elevated liver enzymes ($2\times$ normal) with RUQ pain, pulmonary edema, or new cerebral/visual symptoms.

What does HELLP syndrome stand for?

Hemolysis, Elevated Liver enzymes, and Low Platelets — a severe variant/complication of preeclampsia.

What medication is used for seizure prophylaxis in severe preeclampsia/eclampsia, and what is the definitive treatment?

Magnesium sulfate for seizure prophylaxis/treatment. Definitive treatment of preeclampsia is delivery of the fetus and placenta.

What are the diagnostic thresholds for gestational diabetes using the 3-hour 100 g oral glucose tolerance test (Carpenter-Coustan)?

Fasting $\geq 95$ mg/dL, 1-hour $\geq 180$ mg/dL, 2-hour $\geq 155$ mg/dL, 3-hour $\geq 140$ mg/dL. Two or more abnormal values confirm GDM.

What is the first-line management of gestational diabetes, and the first-line pharmacologic agent if needed?

First-line is dietary modification and exercise with glucose monitoring. If pharmacotherapy is needed, insulin is the preferred (first-line) agent.

What is the most common site of an ectopic pregnancy, and the classic symptom triad?

The ampulla of the fallopian tube. Classic triad: amenorrhea, vaginal bleeding, and unilateral lower abdominal/pelvic pain.

How does serum $\beta$-hCG behave in a normal intrauterine pregnancy versus an ectopic, and what is the discriminatory zone?

In a normal early IUP, $\beta$-hCG roughly doubles every 48 hours. A slow rise or plateau suggests ectopic. The discriminatory zone (~1500–2000 mIU/mL) is the $\beta$-hCG above which an IUP should be visible on transvaginal ultrasound.

What medication is used for medical management of an unruptured ectopic pregnancy, and its mechanism?

Methotrexate, a folic acid antagonist that inhibits dihydrofolate reductase and halts rapidly dividing trophoblastic tissue.

Define the major types of spontaneous abortion: threatened, inevitable, incomplete, and missed.

Threatened: bleeding, closed cervical os, viable. Inevitable: bleeding, open os, products not yet passed. Incomplete: some products passed, open os, retained tissue. Missed: fetal demise with closed os and no expulsion of products.

What are the three stages of labor?

First stage: onset of regular contractions to full cervical dilation (10 cm); divided into latent and active phases. Second stage: full dilation to delivery of the infant. Third stage: delivery of the infant to delivery of the placenta.

What is the most common cause of postpartum hemorrhage, and the first-line uterotonic treatment?

Uterine atony is the most common cause. First-line treatment is uterine massage plus oxytocin (Pitocin); additional agents include methylergonovine, carboprost, and misoprostol.

Differentiate shoulder dystocia management mnemonic and the first maneuver.

Mnemonic 'ALARMER' or 'HELPERR'; the first specific maneuver is the McRoberts maneuver (hyperflexion of maternal hips onto the abdomen) plus suprapubic pressure.

What is the most common benign breast condition and its typical presentation?

Fibrocystic changes — bilateral, often tender, lumpy breasts with cyclical pain that worsens premenstrually, most common in women 30–50.

What is a fibroadenoma, and in whom does it typically occur?

A fibroadenoma is the most common benign breast tumor in young women (teens–20s): a firm, smooth, rubbery, well-circumscribed, mobile, painless mass.

What is the most common histologic type of invasive breast cancer, and what features on exam are concerning for malignancy?

Invasive ductal carcinoma. Concerning features: a hard, fixed, irregular, nontender mass; skin dimpling/peau d'orange; nipple retraction; and bloody nipple discharge.

List the major categories of contraception from most to least effective (typical use), including LARC methods.

Most effective: implants and IUDs (LARC, $<1\%$ failure) and sterilization. Intermediate: injectables, pills, patch, ring ($\sim 7\%$ typical-use failure). Least effective: barrier methods, withdrawal, and fertility awareness.

What are the absolute contraindications to combined (estrogen-containing) hormonal contraception?

History of VTE/thromboembolism, known thrombophilia, migraine with aura, smoking at age $\geq 35$ ($\geq 15$ cigarettes/day), uncontrolled hypertension, active breast cancer, and active liver disease.

For sexually transmitted infections, contrast the discharge and treatment of gonorrhea versus chlamydia.

Gonorrhea: purulent discharge; treat with ceftriaxone 500 mg IM once. Chlamydia: mucopurulent/often asymptomatic; treat with doxycycline 100 mg PO BID $\times$ 7 days (azithromycin 1 g alternative). Empirically treat for both due to coinfection.

How long must a couple try to conceive before an infertility evaluation is warranted, and what is the first/most common cause to evaluate?

After 12 months of regular unprotected intercourse (or 6 months if the woman is $\geq 35$). Evaluation includes a semen analysis (male factor causes ~30–40%), ovulation assessment (mid-luteal progesterone), and tubal patency via hysterosalpingography.