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USMLE Step 2 CK
Obstetrics-Gynecology
GYN Supplement – part 2

Elmar P. Sakala, MD, MA, MPH

Professor of Gynecology & Obstetrics
Loma Linda University School of Medicine
March, 2018
ÓElmar P. Sakala, MD, MPH (2017) No part of this document can be reproduced or transmitted,
in any form, or be any means, without the written permission of the author.

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MENSTRUAL HYPOTHALAMUS
CYCLE GnRh
Hormones
ANTERIOR PITUITARY
FSH LH

Inhibin OVARIAN FOLLICLE CORPUS LUTEUM

Estrogen Progesterone Progesterone
Withdrawal
ENDOMETRIUM ENDOMETRIUM
Proliferation Secretory changes
Spiral arteriolar
spasm

MENSTRUAL FLOW
Endometrial shedding

Changing effect of rising E2 levels on FSH secretion

Ovulation

LH surge ®
Ovulation ®
Corpus Luteum ®
PROGESTERONE
If no hCG 7 d after ovulation
corpus luteum regresses
& progesterone declines

Progesterone
Estradiol

50 hours

When prog ¯ below a critical level spiral

arterioles constrict ®menses
LH surge tend to occur at 3 am (midnight to 8 am) in 2/3 of women.
Ovulation occurs in morning (midnight to 11 am) during Spring time.
Ovulation occurs in evening (4 to 7 pm) during Autumn & Winter.

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Guidelines for MHT

Menopausal Hormone Therapy

E2 benefits best if: BENEFITS and ONLY Indications

Age <60 yrs or <10 yrs Vasomotor symptoms, vaginal dryness,
from menopause Premature menopause

BENEFITS but NOT Indications

Endometrial CA Prevention of Osteoporosis
Prevention: Coronary heart disease
E2 only if:
Uterus ABSENT
RISKS of MHT (E2 or E+P)
E+P both if: VTE & Ischemic stroke (E+P)
Uterus PRESENT
Breast cancer (P only)

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