Step 1 Express 2022 workbook: REPRODUCTIVE page 1

Reproductive

Questions

EMBRYOLOGY
1. Place a checkmark in the appropriate column for the embryologic origin of the organs. (p 637)

Embryologic
Ectoderm Mesoderm Endoderm
Derivative

Adenohypophysis
Muscle
Gut tube epithelium
Brain
Wall of gut tube
PNS ganglia
Most of urethra and
lower vagina
Bone
Kidneys
Oligodendrocytes
Spleen
Parathyroid

2. Describe the physical findings in a newborn suffering from Fetal alcohol syndrome. (p 639)

______________________________________________________________________________

______________________________________________________________________________

3. What symptoms might a newborn suffering from neonatal abstinence syndrome display? (p 639)

______________________________________________________________________________

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

page 2 Step 1 Express 2022 workbook: REPRODUCTIVE

4. What two structures does the urachus connect? What two structures does the vitelline duct connect?
What are the clinical consequences of either of these ducts failing to close? (p 642)
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. Describe the genetic signal that directs differentiation along the male pathway rather than the female
(default) pathway, naming specific cell types and factors. (p 646) __________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

ANATOMY
6. Describe the venous drainage flow from the left ovary/testicle. Describe the venous drainage flow
from the right ovary/testicle. To which lymph nodes do these structures drain? (p 648)
______________________________________________________________________________

______________________________________________________________________________

7. On which side are varicoceles more common and why? (p 648) ___________________________

______________________________________________________________________________

8. Match the female reproductive system ligament to the structures it connects. (p 649)

_____ A. Connects cervix to side wall of pelvis 1. Broad ligament

_____ B. Connects ovaries to lateral pelvic wall 2. Cardinal (transverse cervical) ligament
_____ C. Connects medial pole of ovary to uterine horn 3. Ovarian ligament
_____ D. Connects uterine horn to labia majora 4. Round ligament
_____ E. Connects uterus, fallopian tubes, and 5. Infundibulopelvic ligament
ovaries to pelvic side wall

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 3

9. A female patient presents with acute pelvic pain, adnexal mass, and nausea/vomiting. What does
she likely have? (p 649) _________________________________________________________

______________________________________________________________________________

10. What pathway do sperm follow during ejaculation? (p 650) _______________________________

______________________________________________________________________________

11. Why aren’t gametes attacked by a man’s immune system? (p 652) _________________________

______________________________________________________________________________

12. Which cells in the male reproductive tract secrete inhibin B? Which secrete testosterone? (p 652)

______________________________________________________________________________

PHYSIOLOGY
13. What are the three major forms of estrogen? How do they compare in potency? (p 654) ________

______________________________________________________________________________

14. What are the three major sources of estrogens? (p 654) _________________________________

______________________________________________________________________________

15. Which estrogen is used as an indicator of fetal well-being? (p 654) ________________________

16. List the four functions of estrogen. (p 654) ____________________________________________

______________________________________________________________________________

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

page 4 Step 1 Express 2022 workbook: REPRODUCTIVE

17. Identify the hormone levels shown on the image. (p 656)

18. What are the structural and non-structural causes of abnormal uterine bleeding? (p 657) ________

______________________________________________________________________________

______________________________________________________________________________

19. Where is hCG synthesized? When is hCG first detectable in the blood? In the urine? (p 657)

______________________________________________________________________________

______________________________________________________________________________

20. In what pathologic states can hCG levels be elevated? (p 658) ____________________________

______________________________________________________________________________

21. What cells synthesize HPL and what is its main function? (p 658) __________________________

______________________________________________________________________________

22. A newborn with pink arms and torso, irregular respirations, pulse of 64, no movement and weakly

crying has an APGAR score of? (p 658) _____________________________________________

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 5

23. Describe the benefits of breastfeeding for the newborn and the mother. (p 659) _______________

______________________________________________________________________________

______________________________________________________________________________

24. What hormonal changes occur during menopause? (p 659) _______________________________

______________________________________________________________________________

25. What are the sequelae of menopause? (p 659) ________________________________________

______________________________________________________________________________

26. What are the three major forms of androgens? How do they compare in potency? (p 659) _______

______________________________________________________________________________

27. List the five functions of testosterone. (p 659) _________________________________________

______________________________________________________________________________

______________________________________________________________________________

28. Compare the causes of central vs. peripheral precocious puberty. (p 660) ___________________

______________________________________________________________________________

______________________________________________________________________________

PATHOLOGY

29. Klinefelter syndrome is associated with which karyotype? What are the clinical findings? (p 661)

______________________________________________________________________________

30. Turner syndrome is associated with which karyotype? What are the clinical findings? (p 661) ____

______________________________________________________________________________

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

page 6 Step 1 Express 2022 workbook: REPRODUCTIVE

31. For each diagnosis below, indicate whether the lab findings are elevated, decreased, or normal.
(p 662)

Diagnosis LH Testosterone
Defective androgen receptor
Hypogonadotropic hypogonadism
Hypergonadotropic
hypogonadism
Testosterone-secreting tumor or
exogenous steroids

32. Define the following terms and list the risk factors. (p 664)

A. Abruptio placentae __________________________________________________________

__________________________________________________________________________

B. Placenta accreta ____________________________________________________________

__________________________________________________________________________

C. Placenta increta _____________________________________________________________

__________________________________________________________________________

D. Placenta percreta ___________________________________________________________

__________________________________________________________________________

E. Placenta previa _____________________________________________________________

__________________________________________________________________________

33. What are the most common risk factors for ectopic pregnancy? (p 665) _____________________

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 7

34. Match these gynecologic conditions with their associated findings. (pp 666, 669, 671-672)

_____ A. Dysplasia and carcinoma in situ 1. Too little amniotic fluid

_____ B. Choriocarcinoma 2. Too much amniotic fluid
_____ C. Dysgerminoma 3. Call-Exner bodies
_____ D. Endometriosis 4. Chocolate cysts
_____ E. Granulosa cell tumor 5. Dermoid cyst
_____ F. Fibromas 6. HPV-16 and HPV-18
_____ G. Mature cystic teratoma 7. AFP tumor marker
_____ H. Oligohydramnios 8. CA 125 levels
_____ I. Ovarian neoplasms 9. Increased hCG level
_____ J. Polyhydramnios 10. hCG and LDH tumor markers
_____ K. Yolk sac tumor 11. Meigs syndrome

35. What are the risk factors for preeclampsia/eclampsia? (p 667) ____________________________

______________________________________________________________________________

36. What is HELLP syndrome? (p 667) __________________________________________________

______________________________________________________________________________

37. Rank the incidence of gynecologic tumors in the United States from most common to least common:

cervical, endometrial, and ovarian. Then rank the prognosis of these tumors from worst to best.

(p 667) _______________________________________________________________________

______________________________________________________________________________

38. A 68-year-old female patient presents with porcelain-white plaques on her vulva with a red border.

What is her most likely diagnosis, and what disease could follow in later years? (p 668) ________

______________________________________________________________________________

39. If left untreated, what can imperforate hymen lead to? (p 668) _____________________________

______________________________________________________________________________

40. Which condition is associated with eating disorders and “female athlete triad”? (p 669)

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

page 8 Step 1 Express 2022 workbook: REPRODUCTIVE

41. What hormonal changes occur in polycystic ovarian syndrome? (p 669) ____________________

_____________________________________________________________________________

42. What symptoms does primary dysmenorrhea cause and how is it treated? (p 670)
_____________________________________________________________________________

43. Match these breast tumors with their associated diagnostic findings. (pp 673-674)
_____ A. Ductal carcinoma in situ 1. Often bilateral
_____ B. Fibroadenoma 2. Ductal atypia
_____ C. Inflammatory carcinoma 3. Eczematous patches over nipple, areola
_____ D. Intraductal papilloma 4. Hard mass with sharp margins
_____ E. Invasive ductal carcinoma 5. Increased tenderness prior to menstruation
_____ F. Invasive lobular carcinoma 6. Nipple discharge; benign
_____ G. Paget disease of breast 7. Peau d’orange

44. Match these testicular conditions with their associated diagnostic findings. (pp 675-677)
_____ A. Acquired hydrocele 1. Androblastoma
_____ B. Choriocarcinoma 2. Associated with lack of circumcision
_____ C. Leydig cell tumor 3. Dilated epididymal duct
_____ D. Seminoma 4. Dilated vein in pampiniform plexus
_____ E. Sertoli cell tumor 5. Increased scrotal fluid
_____ F. Spermatocele 6. Increased hCG level
_____ G. Squamous cell carcinoma 7. Most common testicular tumor
_____ H. Testicular lymphoma 8. Most common testicular tumor in older men
_____ I. Varicocele 9. Reinke crystals
_____ J. Yolk sac tumor 10. Schiller-Duval bodies

45. What hormone levels are elevated in choriocarcinomas? In teratomas? (p 677) _______________

______________________________________________________________________________

46. What are the differences between epididymitis and orchitis? How do they each present? (p 678)
______________________________________________________________________________

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 9

47. Which lobes are affected in benign prostatic hyperplasia compared to prostatic adenocarcinoma?

(p 678) _______________________________________________________________________

_____________________________________________________________________________

48. How are most prostate cancers diagnosed? (p 678) ____________________________________

PHARMACOLOGY
49. Continuous leuprolide has _______________ (agonist/antagonist) properties, whereas pulsatile

leuprolide has ______________ (agonist/antagonist) properties. (p 680)

50. What is the clinical use for Degarelix? What are the adverse effects? (p 680) _________________

______________________________________________________________________________

51. How does clomiphene stimulate ovulation? (p 680) _____________________________________

______________________________________________________________________________

52. What is the main clinical use of Tamoxifen? (p 680) _____________________________________

53. How does Raloxifene differ from Tamoxifen? (p 680) ____________________________________

_______________________________________________________________________________

______________________________________________________________________________

54. How do oral contraceptive pills prevent pregnancy? (p 681) _______________________________

______________________________________________________________________________

55. In which patients are oral contraceptive pills contraindicated? (p 681) _______________________

______________________________________________________________________________

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

page 10 Step 1 Express 2022 workbook: REPRODUCTIVE

56. What drugs are commonly used to treat BPH? (p 682) ___________________________________

______________________________________________________________________________

57. Name a medication that can be used for male-pattern baldness. What is its MOA? (p 682) ______

______________________________________________________________________________

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 11

Answers

EMBRYOLOGY
1.

Embryologic
Ectoderm Mesoderm Endoderm
Derivative

Adenohypophysis √
Muscle √
Gut tube epithelium √
Brain √
Wall of gut tube √
PNS ganglia √
Most of the urethra and
√
lower vagina
Bone √
Kidneys √
Oligodendrocytes √
Spleen √
Parathyroid √

2. Pre- and postnatal developmental retardation, microcephaly, facial abnormalities (eg, smooth
philtrum, thin vermillion border, small palpebral fissures), limb dislocation, and heart defects.

3. Uncoordinated sucking reflexes, irritability, high-pitched crying, tremors, tachypnea, sneezing,

diarrhea, and possibly seizures.

4. The urachus connects the fetal bladder and the umbilicus; the vitelline duct connects the yolk sac to
the midgut lumen. Patent urachus leads to urine discharge from the umbilicus, and a vitelline fistula
leads to meconium discharge from the umbilicus.

5. The SRY gene on the Y chromosome produces testis-determining factor, which leads to
development of testes. Within the testes, Sertoli cells secrete Müllerian inhibitory factor, suppressing
development of the paramesonephric ducts (which develop into female reproductive structures), and
Leydig cells secrete androgens that stimulate development of the mesonephric ducts (which develop
into male internal structures).

© First Aid for the USMLE Step 1, 2022 edition

page 12 Step 1 Express 2022 workbook: REPRODUCTIVE

ANATOMY
6. Left ovary/testis → left gonadal vein → left renal vein → inferior vena cava (IVC). Right ovary/testis
→ right gonadal vein → IVC. The ovaries/testes drain to the para-aortic lymph nodes.

7. Left side. Because of the right angle created at the left gonadal-renal vein junction, there is an
increase of high resistance flow, which can lead to backup. Enough backup leads to blood pooling
in the left gonadal veins.

8. A-2, B-5, C-3, D-4, E-1.

9. Adnexal torsion - twisting of the ovary and fallopian tube around infundibulopelvic ligament and
ovarian ligament, causing compression of ovarian vessels in infundibulopelvic ligament, leading to
blockage of lymphatic and venous outflow.

10. Remember SEVEN-UP: Seminiferous tubules → Epididymis → Vas deferens → Ejaculatory ducts
→ (Nothing) → Urethra → Penis.

11. Tight junctions between adjacent Sertoli cells form a blood-testis barrier that isolate gametes from
autoimmune attack.

12. Inhibin B: Sertoli cells. Testosterone: Leydig cells.

PHYSIOLOGY
13. Estradiol, estrone, and estriol. Estradiol is more potent than estrone, which is more potent than estriol
(estradiol > estrone > estriol).

14. Ovary (17β-estradiol), placenta (estriol), and adipose tissue (estrone via aromatization).

15. Estriol is used as a marker of fetal well-being.

16. Development of genitalia and breast, female fat distribution; growth of follicle, endometrial
proliferation, increased myometrial excitability; upregulation of estrogen, luteinizing hormone (LH),
and progesterone receptors and feedback inhibition of FSH and LH, then LH surge; stimulation of
prolactin secretion; and increased transport of proteins, SHBG; ↑ HDL; ↓ LDL.

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 13

17.

18. Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, or Malignancy/hyperplasia. Non-

structural causes (COEIN): Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not yet classified.
Remember PALM-COEIN.

19. In syncytiotrophoblasts of the placenta; 1 week after conception (in blood); 2 weeks after conception
(in urine).

20. hCG levels can be elevated in multiple gestations, hydatidiform moles, choriocarcinomas, and Down
syndrome.

21. HPL is synthesized by the syncytiotrophoblasts of the placenta, and functions to stimulate insulin
production as well as increase overall insulin resistance in an effort to shunt nutrients across the
placenta to the developing fetus.

22. APGAR score: 5.

23. Breast milk is the ideal nutrition for infants up to 6 months old. It contains immunoglobulins, which
confer passive immunity to the baby, macrophages, and lymphocytes. Breast milk reduces infant
infections and is associated with decreased risk for the child to develop asthma, allergies, diabetes
mellitus, and obesity. In the mother, it decreases the risk of breast and ovarian cancers and facilitates
mother-child bonding.

24. Decreased estrogen and increased FSH, LH, and GnRH levels.

25. Remember: HAVOCS: Hot flashes, Atrophy of Vagina, Osteoporosis, and Coronary artery disease,
Sleep disturbances.

© First Aid for the USMLE Step 1, 2022 edition

 page 14 Step 1 Express 2022 workbook: REPRODUCTIVE

26. Testosterone, dihydrotestosterone (DHT), and androstenedione. DHT is more potent than
testosterone, which is more potent than androstenedione (DHT > testosterone > androstenedione).

27. Differentiation of the epididymis, vas deferens, and seminal vesicles (internal genitalia, except
prostate); growth spurts: penis, seminal vesicles, sperm, muscle, RBCs; deepening of the voice,
closing of the epiphyseal plates, and libido.

28. Central precocious puberty results from an early activation of the HPG-axis from an increase in GnRH
secretion, such as from a CNS tumor. Peripheral precocious puberty occurs due to increased sex
hormone production or exposure, such as congenital adrenal hyperplasia, estrogen-secreting ovarian
tumor (eg, granulosa cell tumors), Leydig cell tumors, or McCune-Albright syndrome.

PATHOLOGY
29. 47, XXY; testicular atrophy, eunuchoid body shape, tall stature, long extremities, gynecomastia, and
female hair distribution. May present with developmental delay.

30. 45, XO; short stature (preventable with growth hormone therapy), ovarian dysgenesis, shield chest,
lymphatic defects (resulting in webbed neck or cystic hygroma), bicuspid aortic valve, coarctation of
the aorta, horseshoe kidney, high-arched palate, shortened 4th metacarpals, and primary
amenorrhea.

31.

Diagnosis LH Testosterone
Defective androgen receptor ↑ ↑
Hypogonadotropic hypogonadism
↓ ↓
(2°)
Hypergonadotropic
↑ ↓
hypogonadism (1°)
Testosterone-secreting tumor or
↓ ↑
exogenous steroids

© First Aid for the USMLE Step 1, 2022 edition

 Step 1 Express 2022 workbook: REPRODUCTIVE page 15

32. A. Abruptio placentae: premature separation (partial or complete) of placenta from uterine wall
before delivery of infant. Risk factors include trauma, smoking, hypertension, preeclampsia, and
cocaine abuse.

B. Placenta accreta: defective decidual layer leads to abnormal attachment to myometrium without
penetrating it, and separation after delivery. Risk factors include prior C-section or uterine
surgery involving myometrium, inflammation, placenta previa, advanced maternal age, and
multiparity.

C. Placenta increta: placenta penetrates into the myometrium. Same risk factors as for placenta
accreta.

D. Placenta percreta: placenta penetrates (“perforates”) through myometrium into surrounding

uterine serosa (invades entire uterine wall); can result in placental attachment to rectum or
bladder. Same risk factors as for placenta accreta and increta.

E. Placenta previa: attachment of placenta over internal cervical os. Risk factors include multiparity
and prior C-section. (Low-lying placenta (< 2 cm from internal cervical os) is managed differently
from placenta previa.)

33. Prior ectopic pregnancy, history of infertility, salpingitis (pelvic inflammatory disease), ruptured
appendix, prior tubal surgery, smoking, and advanced maternal age.

34. A-6, B-9, C-10, D-4, E-3, F-11, G-5, H-1, I-8, J-2, K-7.

35. Preexisting hypertension, diabetes, chronic kidney disease, autoimmune disorders, maternal age >
40 years.

36. HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets. A manifestation of severe
preeclampsia.

37. For incidence: endometrial > ovarian > cervical. For prognosis: ovarian (worst) > endometrial >
cervical (best).

38. Lichen sclerosus; squamous cell carcinoma (SCC).

39. Primary amenorrhea, cyclic abdominal pain, hematocolpos (accumulation of menstrual blood in
vagina, leading to bulging and bluish hymenal membrane).

40. Functional hypothalamic amenorrhea.

41. ↑ LH:FSH ratio, ↑ androgens (eg, testosterone).

© First Aid for the USMLE Step 1, 2022 edition

page 16 Step 1 Express 2022 workbook: REPRODUCTIVE

42. Painful menses, caused by uterine contractions. Treatment: NSAIDs.

43. A-2, B-5, C-7, D-6, E-4, F-1, G-3.

44. A-5, B-6, C-9, D-7, E-1, F-3, G-2, H-8, I-4, J-10.

45. Choriocarcinomas typically present with an increase in beta-hCG, while teratomas normally do not
present with an elevation in any of the typical germ cell tumor markers (beta-hCG, PALP, and AFP).

46. Epididymitis is the inflammation of the epididymis. Presents with localized pain and tenderness over
posterior testis. Orchitis is the inflammation of testis. Presents with testicular pain and swelling.

47. In BPH, the periurethral lobes enlarge to compress the urethra into a vertical slit. Prostatic
adenocarcinoma occurs most commonly in the posterior lobe of the prostate gland.

48. Increased PSA and subsequent needle core biopsy.

PHARMACOLOGY
49. Antagonist; agonist.

50. To treat prostate cancer. It can cause hot flashes and liver toxicity.

51. By preventing normal feedback inhibition and increasing LH and FSH release from the pituitary.

52. To treat and prevent recurrence of estrogen receptor–positive ER/PR ⊕ breast cancer.

53. While both tamoxifen and raloxifene are antagonists at the breast and agonists at the bones, only
tamoxifen is an agonist at the uterus, which can increase a patient’s risk for endometrial cancer.
Because of this, raloxifene is more commonly used to treat osteoporosis. Both can cause an
increase in thromboembolic events.

54. OCPs prevent the estrogen surge, which in turn prevents the LH surge, and thus ovulation.

55. Smokers >35 years old, patients with a high risk of cardiovascular disease (including history of
venous thromboembolism, coronary artery disease, and stroke), and those with a history of
migraines (especially with aura), breast cancer, or liver disease.

56. Finasteride, tamsulosin, terazosin, and tadalafil.

57. Minoxidil. Potassium channel opener that leads to arteriole vasodilation.

© First Aid for the USMLE Step 1, 2022 edition