How to Approach Menstrual Irregularities: A Symptom-Based Diagnostic Guide for Gynecological Disorders

“My periods have been all over the place lately…”
“I haven’t had my period for months now…”

Menstrual irregularities are more than just a nuisance—they can be a sign of serious underlying conditions. For clinicians, they offer a gateway to exploring a broad spectrum of gynecological and systemic disorders.

In this article, we’ll walk through a practical and structured approach to evaluating menstrual irregularities, covering everything from initial history taking to physical exams and targeted investigations. Whether you’re preparing for OSCEs or managing real clinical cases, this guide is designed for junior doctors and generalists alike.

🎓 What You’ll Learn in This Article

• How to classify different types of menstrual irregularities (e.g., amenorrhea, menorrhagia, intermenstrual bleeding) and narrow down the differential diagnoses
• A structured approach to gynecological history taking and physical examination using OPQRST and PAM HITS FOSS frameworks
• How to identify and manage underlying causes including hormonal imbalance, structural abnormalities, and gynecological cancers

🩺 Case Introduction – A Real-World Scenario

👤 Patient Profile (Doorway Information):
Age/Sex: 32-year-old woman
Chief Complaint: Heavy periods and irregular spotting
Vitals: BP 122/76 mmHg, HR 78/min, Temp 36.7°C, SpO₂ 99% (RA)

🗣️ Patient’s Words:
“Over the past few months, my periods have become extremely heavy. I’m soaking through pads every hour. On top of that, I’ve also had some light bleeding between my periods. I’m really worried…”

🧭 First Impressions: How Should We Approach This?

In a woman in her 30s presenting with abnormal menstruation, it’s essential to approach the case using a structured diagnostic framework. Here are the key steps we should take:

1. Always start by ruling out pregnancy.
   For any woman of reproductive age presenting with bleeding, excluding pregnancy is the top priority. This includes evaluating for ectopic pregnancy or miscarriage when appropriate.
2. Classify the bleeding pattern: Is it AUB (Abnormal Uterine Bleeding)?
   If the patient is not pregnant, we should categorize the bleeding using the PALM-COEIN system:
   • PALM (Structural Causes): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy and hyperplasia
   • COEIN (Non-Structural Causes): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified
3. Generate differential diagnoses based on this classification and clinical context.
   Menstrual irregularities are often just the starting point. From here, we build hypotheses that cover gynecological, endocrine, and even systemic conditions.

Let’s now apply the FPH model—Fact, Problem, Hypothesis—to this patient.

• ✅ Fact:
  32-year-old woman with progressively heavier periods over several months.
  Soaking through pads every hour.
  Intermenstrual bleeding present.
  Stable vital signs. No pain or fever.
• 🔍 Problem:
  Menstrual cycle remains regular, but with sustained menorrhagia and new intermenstrual spotting.
  No signs of infection or systemic illness.
• 🧠 Hypothesis (Prioritized Differentials):
  • 🎯 High Priority: Leiomyoma (fibroids), endometrial hyperplasia or early malignancy, endometrial polyp, anovulatory bleeding
  • 🟡 Moderate Priority: Adenomyosis, coagulopathy, iatrogenic causes (e.g., OCPs, IUD)
  • 🔵 Low Priority: Infection (e.g., PID), endocrine disorders (e.g., hypothyroidism, hyperprolactinemia)

We’ll need more information on her menstrual pattern, contraceptive history, anemia symptoms, and sexual history. For that, let’s proceed to the interview using the OPQRST and PAM HITS FOSS frameworks.

🗣️ Step 1: History Taking – Clarifying Menstrual Concerns

When a patient presents with menstrual irregularities, thorough history-taking is crucial to formulate differential diagnoses. In clinical practice and OSCEs alike, using structured tools like OPQRST and PAM HITS FOSS can ensure no important clues are missed.

🧩 OPQRST – Understanding the Bleeding Pattern

Start the conversation naturally with expressions like:

• “Now I’d like to ask you some questions about your menstrual cycle.”
• “These questions help us better understand your overall health.”

Then structure your inquiry using the OPQRST framework:

• O (Onset): When did the bleeding pattern change? Age at menarche?
• P (Provocation/Palliation): Any triggers like stress, weight loss, new medications?
• Q (Quality): Volume (pads per hour), color, presence of clots, pain?
• R (Region/Radiation): If painful, where is the pain? Does it radiate?
• S (Severity): How heavy is the bleeding? How many pads per day?
• T (Time course): How long does each period last? Regular or irregular? Compared to previous cycles?

🔍 Associated Symptoms → Possible Conditions

When patients report additional symptoms, these may serve as red flags or diagnostic clues. Here’s a symptom-based reverse index to guide your clinical reasoning:

Associated Symptom	Possible Conditions
Severe menstrual cramps (dysmenorrhea)	Adenomyosis, Endometriosis, PID
Pelvic pressure / fullness	Uterine fibroids (leiomyoma), ovarian mass
Intermenstrual spotting	Endometrial polyp, anovulatory cycles, hormonal imbalance, cervical pathology
Postcoital bleeding	Cervical polyp, cervical cancer, STI, vaginal atrophy
Galactorrhea	Hyperprolactinemia (e.g., pituitary adenoma)
Hirsutism / acne	PCOS, androgen-secreting tumor, CAH
Fatigue, dizziness, pallor	Iron-deficiency anemia from chronic menorrhagia
Fever + lower abdominal pain	PID, endometritis, tubo-ovarian abscess
Visual changes + headache	Macroprolactinoma, intracranial lesion
Weight change, hair loss, mood swings	Thyroid dysfunction
Sudden sharp pelvic pain + amenorrhea	Ectopic pregnancy, ovarian torsion, ruptured cyst
Easy bruising, heavy bleeding elsewhere	Bleeding diathesis, Von Willebrand disease

This reverse symptom map can help guide your OPQRST and review of systems during history taking, especially in complex menstrual cases.

💡 Tip: Even if the patient says “It’s normal,” always ask follow-up questions like, “How does it compare to your last or previous periods?”

📚 PAM HITS FOSS – Background Factors That Matter

This framework helps explore underlying conditions that might be driving menstrual abnormalities:

• P – Previous Medical History: Thyroid disorders, PCOS, diabetes, hyperprolactinemia
• A – Allergy
• M – Medications: OCPs, SSRIs, antipsychotics, GnRH agonists
• H – Hospitalizations
• I – Injuries
• T – Trauma
• S – Surgeries: D&C, gynecologic procedures
• F – Family History: Early menopause, breast or uterine cancer
• O – OBGYN History: Menarche, LMP, cycle pattern, GPAC (gravida, para, abortion, cesarean)
• S – Sexual History: Postcoital bleeding, contraception use, STI history
• S – Social History: Weight loss, excessive exercise, stress, sleep, alcohol, smoking

🩺 Key Diagnostic Clues From History

• Ovulatory dysfunction: Irregular or delayed cycles, galactorrhea, hirsutism, eating disorders
• Structural lesions (e.g., fibroids, polyps): Regular cycles with heavy bleeding, intermenstrual spotting, palpable masses
• Endocrine or malignant conditions: Age over 40, obesity, anovulation, high estrogen state

💡 OSCE Tip: Always confirm LMP and ask about GPAC status.
Clinical Tip: Don’t miss red flags like rapid weight loss, SSRI use, or postcoital bleeding.

With the patient’s history now clarified, let’s move on to physical examination in Step 2 and see how we can validate or rule out our working hypotheses.

🩺 Step 2: Physical Examination – What to Look For

After taking a thorough history, the next step is physical examination to narrow down differentials and detect red flags. In menstrual irregularities, your exam should focus on both systemic and gynecologic findings.

🔎 1. General Appearance and Systemic Clues

• Body habitus: Obesity (suggestive of PCOS), low BMI (suggestive of hypothalamic amenorrhea)
• Skin and hair: Hirsutism, acne, alopecia → Androgen excess
• Thyroid gland: Enlargement, tenderness, nodules → Thyroid dysfunction
• Galactorrhea: Check for nipple discharge → Hyperprolactinemia
• Pallor of mucous membranes: Suggests anemia from chronic blood loss

🧠 2. Gynecologic Examination (When Appropriate)

• External inspection: Vulvar lesions, ulcers, abnormal discharge or bleeding
• Speculum exam: Cervical polyps, friability, contact bleeding, mucopurulent discharge
• Bimanual exam: Uterine size and tenderness, cervical motion tenderness, adnexal masses

⚠️ Tip: Always explain the procedure beforehand and obtain verbal consent. Avoid invasive exams if the patient is uncomfortable or has trauma history.

📷 3. Consider Transvaginal Ultrasound (TVUS)

If available and appropriate, TVUS can provide key information:

• Evaluate for fibroids, polyps, thickened endometrium, and ovarian cysts or tumors
• TVUS is preferred over abdominal ultrasound for accuracy in gynecologic evaluation

🚩 4. Red Flags on Physical Exam

• Uterine tenderness + fever → Consider PID
• Enlarged, mobile uterus → Likely leiomyoma (fibroids)
• Cervical ulceration or bleeding → Consider cervical cancer or polyp
• Pelvic/adnexal mass → Evaluate for ovarian neoplasm or ectopic pregnancy

🦠 5. STI Screening and Pelvic Infection Workup

If patient reports postcoital bleeding, discharge, or dyspareunia, evaluate for sexually transmitted infections:

Pathogen	Typical Signs	Diagnosis
Chlamydia / Gonorrhea	Cervicitis, discharge, may be asymptomatic	Speculum exam + PCR swab
HSV	Painful vesicles or ulcers, inguinal LAD	Visual exam + PCR or Tzanck smear
Syphilis	Painless ulcer (chancre)	RPR / TPHA serology
Trichomonas	Frothy yellow-green discharge, foul smell	Wet mount, microscopy, vaginal pH > 5
Candida	Thick, white discharge, severe itching	Microscopy, low pH (< 4.5)

📌 STI suspicion warrants combined testing (PCR, HIV, syphilis), especially in sexually active or younger women.

📎 Column: Dyspareunia (Pain During Intercourse)

If a patient complains of pain during intercourse, consider:

• Superficial pain: Vaginal atrophy, HSV, vulvovaginitis, vaginismus
• Deep pain: Endometriosis, adenomyosis, pelvic adhesions, PID

Be sure to ask:

• “Is the pain during penetration or deeper inside?”
• “What kind of pain is it – sharp, burning, or cramping?”
• “How long does it last?”

💡 Red Flag: Deep dyspareunia may suggest endometriosis or pelvic pathology.

🔬 Step 3: Investigations – Tailoring Tests to Hypotheses

Once the history and physical exam point toward likely causes, the next step is to confirm your hypotheses with targeted investigations. The key is to avoid ordering all tests indiscriminately—choose based on clinical reasoning.

🧪 1. Basic Labs – Always Rule Out Pregnancy First

• β-hCG (serum): Mandatory in all cases of menstrual irregularity
• Complete Blood Count (CBC): To assess anemia or infection
• TSH and Prolactin: For thyroid dysfunction and hyperprolactinemia

💡 Note: Serum hCG is more sensitive than urine tests and detects pregnancy earlier (≥5 IU/L vs. ≥50 IU/L for urine).

🧬 2. Hormonal Evaluation – Based on Clinical Clues

• FSH, LH, Estradiol (E2): Evaluate ovarian reserve or hypothalamic amenorrhea
• Anti-Müllerian Hormone (AMH): For ovarian reserve and possible PCOS
• Total Testosterone, DHEA-S: For signs of androgen excess (e.g., acne, hirsutism)

💡 Tip: Hormone levels should ideally be checked during days 3–5 of the menstrual cycle.

📷 3. Transvaginal Ultrasound (TVUS) – First-Line Imaging

• Evaluate for: Fibroids, polyps, endometrial thickening, ovarian cysts or tumors
• Endometrial stripe: >20 mm in the luteal phase may indicate hyperplasia
• PCOS findings: ≥10 small follicles per ovary (string-of-pearls pattern)

💡 Tip: Postmenopausal endometrium >4 mm may warrant biopsy.

🧫 4. Endometrial Biopsy / Hysteroscopy – When to Consider

• Age ≥40 with abnormal bleeding
• Younger patients with risk factors (e.g., obesity, diabetes, prolonged anovulation)
• TVUS shows thickened endometrium or suspicious polypoid lesions

🧠 Pearl: Have a low threshold for endometrial biopsy in AUB cases with unclear etiology.

🧪 5. STI Testing & Cervical Cancer Screening

• Chlamydia/Gonorrhea: Swab or urine PCR
• Pap smear: For cervical cytology, especially with postcoital bleeding
• HIV, RPR, TPHA: Screen based on risk factors

💡 Tip: Postcoital bleeding may be the first sign of cervical dysplasia or STI.

🌀 6. Amenorrhea – Stepwise Diagnostic Flow

1. Rule out pregnancy with β-hCG
2. Check TSH and prolactin
3. Measure FSH and E2:
   • High FSH, low E2 → Ovarian failure (e.g., POI)
   • Low FSH, low E2 → Hypothalamic suppression
4. Consider progesterone challenge test (P-test) and estrogen-progesterone test (E+P test)

📎 Note: In primary amenorrhea, also consider anatomical abnormalities like MRKH or AIS.

🧮 7. Rational Testing Strategy

• Thin, stressed patient: Prioritize hypothalamic axis (TSH, PRL, FSH)
• Regular cycles + heavy bleeding: Think structural – prioritize TVUS
• ≥40 years + abnormal bleeding: Biopsy sooner rather than later

💡 Clinical Tip: Choose “just enough” testing based on your working hypotheses—this is what defines sound clinical judgment.

🔁 Clinical Reflection – Applying the Approach to the Case

Now that we’ve gone through Steps 1–3, let’s return to our original case and apply each step to see how this structured approach works in practice.

🟢 Step 1: History Taking

Doctor: “What brings you in today?”
Patient: “My periods have been much heavier than usual for a few months. I’m soaking pads every hour. Also, I’ve had some spotting between periods.”

Alright… so the bleeding is cyclic but clearly heavier, and now there’s intermenstrual spotting too. First, I need to rule out pregnancy—but she says her cycles have been regular. Still, I’ll definitely check β-hCG.

Using OPQRST and PAM HITS FOSS, we find:

• Heavy bleeding lasting over 7 days, no severe pain
• No recent weight loss, stress, or new meds
• No history of thyroid disease or PCOS, no galactorrhea
• No IUD use, no history of STIs or PID
• Normal BMI, no tobacco use, stable social background

Fact: 32-year-old woman with progressively heavy menstruation and intermenstrual spotting

Problem: Regular but prolonged/heavy cycles, new spotting, no signs of infection or systemic illness

Hypotheses:

• 🎯 Leiomyoma (fibroids)
• 🎯 Endometrial polyp or hyperplasia
• 🎯 Ovulatory dysfunction
• 🟡 Adenomyosis
• 🟡 Iatrogenic (e.g., SSRI or OCP-related)

🟡 Step 2: Physical Examination

She appears healthy, no pallor or weight change. On abdominal exam, no masses or tenderness.

On bimanual exam, the uterus feels mildly enlarged and mobile—no adnexal masses. Speculum exam shows a healthy cervix with no contact bleeding or lesions.

→ This suggests a structural cause like fibroids or a polyp, rather than an inflammatory or infectious etiology. No cervical red flags noted.

🔬 Step 3: Investigations

• ✅ β-hCG: Negative → pregnancy ruled out
• ✅ CBC: Hemoglobin slightly low (anemia from blood loss)
• ✅ TSH/Prolactin: Normal
• ✅ TVUS: Revealed a 3-cm intramural fibroid and thickened endometrium (~18 mm)

That explains the heavy bleeding. The endometrial thickness might also suggest hyperplasia. Considering her age and symptoms, I’ll consider endometrial biopsy to rule out early malignancy.

Conclusion: This patient likely has AUB due to a combination of leiomyoma and possible endometrial hyperplasia. No signs of infection or hormonal disruption were found.

→ I’ll arrange for a biopsy and discuss initial treatment options, including medical management and possible referral to gynecology depending on the histology results.

🏥 When to Refer to a Gynecologist

📌 1. Indications for Referral

Consider referring the patient to a gynecologist in the following situations:

• Persistent or recurrent abnormal uterine bleeding (AUB) with suspicious imaging (e.g., fibroids, thickened endometrium, masses)
• Primary amenorrhea: No menarche by age 15, especially with signs of anatomical abnormalities
• Secondary amenorrhea: ≥6 months without menstruation, especially if the cause remains unclear after basic labs
• Postcoital bleeding or abnormal discharge suggesting cervical pathology
• Recurrent pelvic or dyspareunic pain indicating endometriosis, adenomyosis, or pelvic adhesions
• Adnexal masses: >5 cm, complex or solid, or associated with elevated CA-125

🧾 2. Recommended Workup Before Referral

To ensure a smooth consultation process, consider completing the following tests before referral:

• Serum β-hCG – to rule out pregnancy (mandatory)
• CBC – to assess for anemia or infection
• Hormone panel: TSH, Prolactin, FSH, LH, Estradiol (± AMH, Testosterone)
• STI screening: Chlamydia, Gonorrhea, HIV, Syphilis (as indicated)
• Pap smear: If postcoital bleeding or abnormal cervical appearance is present
• TVUS: To evaluate uterine and adnexal structures if possible

⚠️ Important: If the patient has pain or bleeding with pelvic exams, avoid invasive procedures unless absolutely necessary. Always prioritize comfort and consent.

💊 3. What Generalists Can Do – Initial Management with OCPs

In selected cases, general practitioners may initiate treatment with low-dose oral contraceptive pills (OCPs) prior to referral:

• Indications: Anovulatory bleeding, menorrhagia, cycle control, PMS/PCOS-related symptoms, endometriosis pain
• Contraindications: Age ≥35 + smoking, history of thromboembolism, severe hypertension, liver disease

📝 How to Start:

• Use low-dose LEPs (e.g., Yaz, Luviol) if covered by insurance
• Typical regimen: 21 days active + 7 days withdrawal
• Educate about common side effects (e.g., nausea, spotting) and when to seek help

🤝 4. Special Considerations – Sexual Assault Cases

If menstrual irregularity is associated with possible non-consensual intercourse, immediate support is critical:

• Ensure safety and provide emotional support
• Consider HIV PEP if within 72 hours
• Offer emergency contraception (levonorgestrel or ulipristal)
• Do not attempt forensic collection unless trained—refer to SANE (Sexual Assault Nurse Examiner) or dedicated support centers

📎 Referrals: Sexual assault support centers, women’s health hotlines, or local advocacy groups may be essential partners in care.

💡 Clinical Tips & Pearls – Don’t Miss These!

🔍 Practical Tips for History Taking & Physical Exam

• Always ask about LMP: “When was the first day of your last period?” – essential in all menstrual complaints
• Clarify “irregular periods”: Don’t settle for vague terms—explore cycle length, duration, and flow in detail
• Use GPAC framework: Gravida, Para, Abortion, Cesarean – helps assess reproductive history systematically
• Approach sexual history with care: Start broad: “Are you sexually active? With men, women, or both?”
• Screen for weight loss and stress: Especially in younger patients – may indicate hypothalamic amenorrhea
• Don’t overuse pelvic exams: Ask yourself: “Is it necessary right now?” and always explain and obtain consent
• Urine β-hCG first: In any case of bleeding or amenorrhea, pregnancy must be ruled out first
• Red Flags to remember: Postmenopausal bleeding, postcoital bleeding, abnormal cervical findings
• Use PALM-COEIN to classify AUB: Helps frame structural vs. non-structural causes systematically

🧠 OSCE Tips

• Lead with empathy: “Would it be alright if I ask you some questions about your periods?”
• Explain every step clearly before physical exam – especially for speculum and bimanual exams
• In OSCEs, remember to verbalize your reasoning: “I’d like to order a pregnancy test to rule out ectopic pregnancy.”

💬 Clinical Pearls – Words to Remember

“Half of all patients with infertility have male factors — it’s not just her issue.”
– OBGYN Clinical Teaching

“A good gynecologist listens to the cycle, not just the complaint.”
– Residency Wisdom

🗣️ OET Speaking Session – Menstrual Irregularities

👥 Scenario

You are a doctor in a general practice clinic. A 32-year-old woman presents with complaints of heavy menstrual bleeding and spotting between periods over the past few months. She is not taking any medications and has no history of hormonal therapy.

You suspect uterine fibroids or endometrial pathology, and need to rule out pregnancy and hormonal causes.

🎯 Your Task

• Take a focused menstrual and gynecologic history
• Reassure the patient and explain the need for certain tests
• Discuss potential causes and address her concerns empathetically
• Provide information on the next steps including referrals or follow-up

💬 Common Patient Cues & Sample Doctor Responses

🧠 Challenging Questions & Sample Doctor Responses

✉️ OET Writing Task – Sample Referral Letter

Today’s Date

Dr. Sophia Lin
Gynecology Department
City Women’s Health Center

Re: Ms. Yuki Nakamura, 32 years old

Dear Dr. Lin,

I am referring Ms. Yuki Nakamura, a 32-year-old woman, for further evaluation of abnormal uterine bleeding. She reports progressively heavy periods over the past three months, requiring pad changes every 1–2 hours, along with intermenstrual spotting.

Her cycles remain regular at 28–30 days. She denies pelvic pain, fever, or abnormal discharge. There is no known history of thyroid disorder, polycystic ovary syndrome, or prior gynecological surgery. She is not currently using hormonal contraception or anticoagulants. Her BMI is within normal range, and her general physical exam was unremarkable.

Initial investigations revealed a negative serum β-hCG, normal TSH and prolactin levels, and borderline anemia (Hb 10.8 g/dL). Transvaginal ultrasound showed a 3-cm intramural fibroid and an endometrial thickness of 18 mm. An endometrial biopsy has not yet been performed.

I would appreciate your expert assessment regarding the need for further diagnostic procedures (e.g., hysteroscopy or biopsy), and advice on possible hormonal or surgical treatment options.

Please feel free to contact me if you require further information.

Yours sincerely,

Dr. [Your Name]
General Practitioner

🧾 Summary – Seeing Beyond the Bleeding

Menstrual irregularities are not just a gynecological inconvenience — they are a message from the body, sometimes subtle, sometimes urgent. In this article, we explored how to approach this common but complex symptom from a structured and thoughtful perspective.

We began with a case of a 32-year-old woman experiencing heavy menstrual bleeding and spotting. Through a systematic approach — from taking a detailed history (OPQRST + PAM HITS FOSS), to performing a focused physical exam, to selecting targeted investigations — we demonstrated how to move from uncertainty to clinical clarity.

Along the way, we covered a broad spectrum of underlying causes: from hormonal imbalances and ovulatory disorders to fibroids, endometrial hyperplasia, and even gynecologic cancers. We also addressed essential adjacent topics, including STIs, fertility concerns, PMS, sexual trauma, and gender diversity in reproductive care.

Through Clinical Tips and OSCE-ready thinking, this guide was designed to support not only your clinical practice, but also your communication skills — especially in English-speaking settings through the OET Speaking & Writing session.

Ultimately, the most important lesson is this: Always ask, always listen, and always remember — the menstrual cycle is a vital sign of health, not just a calendar event.

Whether you’re preparing for exams, working on the frontlines of primary care, or counseling patients from all backgrounds, we hope this article serves as a reliable companion on your clinical journey.

📝 If any diseases or phrases caught your attention — take a moment now to jot them down in your own words. That’s how information becomes lasting knowledge.

🔗 Related Articles – Keep Exploring

Menstrual irregularities often overlap with other clinical presentations. Here are some symptom-based articles that can further deepen your understanding:

• 🩺 Abdominal Pain – Don’t Miss Gynecological Causes
• 💤 General Fatigue – Thyroid, Anemia, and PMS
• ⚖️ Unintentional Weight Loss – Endocrine, Malignancy, and Eating Disorders

🌍 Want to learn in Japanese?

この記事の日本語版はこちら：

• 月経異常で受診したら？考えるべき鑑別と診察の進め方【婦人科疾患まとめ】

📚 References

1. American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstetrics & Gynecology. 2012;120(1):197–206.
2. UpToDate. Evaluation of abnormal uterine bleeding in premenopausal women. Accessed 2024. Available at: https://www.uptodate.com
3. Japanese Society of Obstetrics and Gynecology. Gynecology Practice Guidelines – Outpatient Edition 2023. (日本産科婦人科学会『産婦人科診療ガイドライン 婦人科外来編2023』)
4. Centers for Disease Control and Prevention (CDC). HPV Vaccination Recommendations. Accessed 2024. Available at: https://www.cdc.gov/vaccines/vpd/hpv
5. Oats J, Abraham S. Oxford Handbook of Obstetrics and Gynaecology. 3rd ed. Oxford University Press; 2013.
6. 医歯薬出版. 標準産婦人科学 第4版（Standard Obstetrics and Gynecology, 4th ed. Ishiyaku Publishers, Japan）
7. 日本医事新報社. OSCEのための診察手技と臨床推論（Clinical Skills and Reasoning for OSCEs. Nihon Iji Shinpo-sha, Japan）