Women's Health Board Prep

Contraception, prenatal care, menstrual disorders, and menopause make up the bulk of OB/GYN questions on the ABFM. Daily practice from current ACOG guidance.

Women's health, including obstetrics and gynecology content delivered in a family medicine context, makes up 7 to 9 percent of the ABFM. The exam reflects the breadth of women's health that family physicians manage: contraception, routine prenatal care, common menstrual and gynecologic complaints, sexually transmitted infections, breast complaints, and menopause management. The dominant guideline sources are ACOG (American College of Obstetricians and Gynecologists), the CDC (especially for STI treatment), USPSTF (for screening), and the US Medical Eligibility Criteria for Contraceptive Use.

Contraception is the single most-tested topic. The CDC US MEC categorizes contraceptive methods by safety in various medical conditions. Long-acting reversible contraception (LARC) — IUDs and implants — has the highest efficacy and the lowest typical-use failure rate. The exam tests whether you understand which methods are safe in specific conditions: combined hormonal contraceptives are MEC category 4 (do not use) in women with migraine with aura, history of VTE, or smokers over 35; progestin-only methods (POPs, implants, IUDs) are safer in these scenarios. Emergency contraception options include levonorgestrel (up to 72 hours, less effective with higher BMI), ulipristal acetate (up to 120 hours, most effective oral option), and copper IUD (most effective overall, can be placed up to 5 days after intercourse).

Prenatal care follows ACOG schedules: visits every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, weekly until delivery. Key screening points: dating ultrasound and risk assessment in the first trimester; aneuploidy screening (cell-free DNA, sequential or quad screen) by 12 to 22 weeks; anatomy ultrasound at 18 to 22 weeks; gestational diabetes screening at 24 to 28 weeks (1-hour 50 g glucose challenge with 140 cutoff); GBS culture at 36 to 37 weeks; Tdap with each pregnancy at 27 to 36 weeks; influenza any time during pregnancy; COVID-19 and RSV vaccines per current ACIP guidance. The ABFM tests both the timing and the individual screening choices.

Cervical cancer screening overlaps with preventive care but is heavily tested in women's health context. Ages 21 to 29: cytology alone every 3 years. Ages 30 to 65: cytology every 3 years, HPV alone every 5 years, or co-testing every 5 years. Stop at 65 with adequate prior screening. Stop after total hysterectomy for benign disease. ASCCP management guidelines drive what to do with abnormal results.

Menstrual disorders, abnormal uterine bleeding, polycystic ovary syndrome, endometriosis, and menopause round out the high-yield content. PCOS uses Rotterdam criteria (two of three: oligo/anovulation, hyperandrogenism, polycystic ovaries on ultrasound). Menopause hormone therapy is reasonable for symptomatic women under 60 or within 10 years of menopause onset, with shared decision-making about risks. Bone health and breast cancer screening intersect with menopause care.

High-yield women's health topics

• Contraceptive selection and US MEC. LARC (IUDs, implant) are most effective and recommended for most women. Combined hormonal contraceptives are MEC 4 (do not use) in: migraine with aura, smoking 15 cigarettes per day at age 35 or older, current breast cancer, severe hypertension, history of VTE, current ASCVD. Progestin-only options are safer alternatives.
• Emergency contraception options. Copper IUD: most effective, up to 5 days after intercourse, ongoing contraception. Ulipristal acetate (ella): up to 120 hours, most effective oral option. Levonorgestrel (Plan B): up to 72 hours, OTC, less effective with BMI over 30. Counsel that none cause abortion of an established pregnancy.
• Gestational diabetes screening. Two-step approach: 1-hour 50 g GCT at 24 to 28 weeks; if 140 or higher, proceed to 3-hour 100 g OGTT (fasting 95, 1-hour 180, 2-hour 155, 3-hour 140 — 2 abnormal values diagnoses GDM). Earlier screening at first prenatal visit for high-risk women (obesity, prior GDM, family history, certain ethnicities).
• Group B strep prevention. Universal vaginal-rectal culture at 36 0/7 to 37 6/7 weeks. Intrapartum antibiotics for: positive culture, prior infant with GBS disease, GBS bacteriuria in current pregnancy, unknown status with risk factors (preterm, ROM over 18 hours, intrapartum fever). Penicillin G first-line; cefazolin if low-risk penicillin allergy; clindamycin (if susceptible) or vancomycin if high-risk allergy.
• Cervical cancer screening and abnormal Pap follow-up. Ages 21 to 29: Pap every 3 years. Ages 30 to 65: Pap every 3, HPV alone every 5, or co-test every 5. ASCUS with positive HPV: colposcopy. LSIL: colposcopy (most ages). HSIL: colposcopy with possible LEEP. Apply ASCCP risk-based management guidelines for individual scenarios.
• Abnormal uterine bleeding workup (PALM-COEIN). Structural causes: Polyps, Adenomyosis, Leiomyoma, Malignancy. Non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified. Workup includes pregnancy test, CBC, TSH, prolactin if amenorrhea, transvaginal ultrasound, endometrial biopsy if 45 or older or risk factors for malignancy.
• Menopause hormone therapy. Reasonable for moderate to severe vasomotor symptoms in women under 60 or within 10 years of menopause onset. Estrogen plus progestin (combined) for women with intact uterus; estrogen alone for women post-hysterectomy. Contraindicated in: history of breast cancer, estrogen-sensitive cancers, undiagnosed vaginal bleeding, active VTE, active liver disease. Re-evaluate annually.
• Common STI treatment (CDC 2021 guidelines). Chlamydia: doxycycline 100 mg twice daily for 7 days (preferred) or azithromycin 1 g once. Gonorrhea: ceftriaxone 500 mg IM (1 g if over 150 kg) once. Trichomonas: metronidazole 500 mg twice daily for 7 days for women (single dose 2 g for men). Syphilis: benzathine penicillin G 2.4 million units IM once for early disease.

ABFM exam tips

For contraceptive questions, identify red flags first. Migraine with aura, smoking and age 35 or older, history of VTE, severe hypertension, breast cancer history — any of these makes combined estrogen-containing methods MEC category 4. The right answer is a progestin-only method or LARC.

For prenatal care, anchor on gestational age. First trimester: dating, aneuploidy screening, vaccines, basic labs. 24 to 28 weeks: gestational diabetes screen, RhoGAM if Rh-negative. 28 weeks: Tdap. 36 to 37 weeks: GBS culture. The exam loves to ask "what is due at this visit?"

Memorize the GDM cutoffs. 1-hour 50 g GCT screening: 140 (or 130 in higher-risk populations) triggers 3-hour confirmation. 3-hour 100 g OGTT: fasting 95, 1-hour 180, 2-hour 155, 3-hour 140. Two or more abnormal values diagnose GDM.

Recognize ectopic pregnancy presentations. Pregnancy with abdominal pain, vaginal bleeding, hemodynamic instability, or beta-hCG that is not rising appropriately (less than 53 percent in 48 hours). Transvaginal ultrasound at beta-hCG above 1500 to 2000 should show intrauterine pregnancy. Methotrexate or surgery for confirmed ectopic.

For STIs, follow CDC 2021 guidelines exactly. Doxycycline (not azithromycin) is now preferred for chlamydia. Ceftriaxone 500 mg (not 250 mg) is the current gonorrhea dose. These changed in the 2021 update and are testable.

For abnormal uterine bleeding, age determines workup. Under 45 with risk factors (obesity, PCOS, tamoxifen use, family history of Lynch syndrome): consider endometrial biopsy. Age 45 and older with abnormal bleeding: endometrial biopsy is generally indicated. Postmenopausal bleeding: always evaluate with TVUS and biopsy.

Common pitfalls

Do not prescribe combined hormonal contraceptives in migraine with aura. Stroke risk is elevated. Use progestin-only options or non-hormonal methods. Migraine without aura is not an absolute contraindication, but caution is still warranted, especially with risk factors.

Do not skip the 36-37 week GBS culture. Women without a culture at delivery are treated based on risk factors, but routine universal screening is the standard. Forgetting to order it is a tested miss.

Do not use azithromycin as first-line for chlamydia anymore. The CDC 2021 update made doxycycline the preferred agent (100 mg twice daily for 7 days). Azithromycin remains an option but is second-line, especially for rectal infections where doxycycline is more effective.

Do not start HRT for prevention of cardiovascular disease. HRT is for symptomatic management of vasomotor symptoms in women under 60 or within 10 years of menopause. Using HRT for cardiovascular or osteoporosis prevention is not supported by evidence and is harmful in older women. The Women's Health Initiative results changed this paradigm decades ago.

Do not miss postmenopausal bleeding. Any bleeding after menopause requires evaluation: transvaginal ultrasound (endometrial stripe over 4 mm warrants biopsy) and consideration of endometrial sampling. Endometrial cancer risk rises substantially with age and obesity, and postmenopausal bleeding is its most common presentation.

Do not forget Tdap with every pregnancy. ACIP recommends Tdap with each pregnancy between 27 and 36 weeks regardless of prior history. This protects the newborn from pertussis through transplacental antibody transfer. Missing this is a tested error in prenatal care questions.

Do not test for ovarian cancer with CA-125 in average-risk women. Routine screening is not recommended (USPSTF Grade D) because it does not reduce mortality and leads to harm from false positives. CA-125 is appropriate in symptomatic patients or known BRCA mutation carriers, not as routine screening.

Frequently asked questions

How is contraception tested on the ABFM?

Heavily, through US MEC scenarios. The exam shows a patient with specific medical conditions (migraine with aura, smoking, hypertension, breast cancer, postpartum) and asks which methods are safe. LARC and progestin-only options are usually the right answers when combined hormonal contraceptives are contraindicated.

What prenatal labs and screenings should I memorize?

First visit: blood type and Rh, antibody screen, CBC, urinalysis and culture, rubella immunity, hepatitis B surface antigen, HIV, syphilis, gonorrhea and chlamydia, varicella immunity, Pap if due. 24 to 28 weeks: GDM screen, repeat antibody screen and CBC, RhoGAM if Rh-negative. 28 weeks: Tdap. 35 to 37 weeks: GBS culture.

When does cervical cancer screening start and stop?

Start at age 21 with Pap alone every 3 years. At age 30, options expand to HPV alone every 5 years or co-testing every 5 years. Stop at age 65 with adequate prior screening (3 negative cytology or 2 negative co-tests in past 10 years). Stop after total hysterectomy with cervix removal for benign disease.

How do I diagnose PCOS?

Rotterdam criteria require 2 of 3: oligo- or anovulation (irregular cycles), clinical or biochemical hyperandrogenism (acne, hirsutism, elevated free testosterone), and polycystic ovaries on ultrasound. Workup excludes other causes (TSH, prolactin, 17-OH progesterone for non-classical CAH). Evaluate metabolic risk: lipids, glucose, BMI.

When should I order an endometrial biopsy?

For postmenopausal bleeding (always), abnormal uterine bleeding in women 45 and older, abnormal bleeding in women under 45 with risk factors for endometrial cancer (obesity, PCOS, tamoxifen, Lynch syndrome family history), or persistently thickened endometrial stripe on ultrasound. The procedure is office-based and typically done with a Pipelle.

Is hormone therapy still used for menopausal symptoms?

Yes, for symptomatic women under age 60 or within 10 years of menopause onset, after shared decision-making about risks. Combined estrogen plus progestin for women with intact uterus; estrogen alone if post-hysterectomy. Avoid starting HRT in women over 60 or more than 10 years post-menopause. Reassess annually.

What are the current STI treatment doses?

Per CDC 2021: chlamydia is doxycycline 100 mg twice daily for 7 days (azithromycin 1 g is alternative). Gonorrhea is ceftriaxone 500 mg IM once (1 g if over 150 kg). Syphilis early is benzathine penicillin G 2.4 million units IM once. Trichomonas in women is metronidazole 500 mg twice daily for 7 days. Always treat partners and re-screen at 3 months.