Contraceptives and HRT

The primary care NP sees a woman who has been taking HT for menopausal symptoms for 3 years. The NP decreases the dosage, and several weeks later, the woman calls to report having several hot flashes each day. The NP should: a. Increase the HT dose. b. Discontinue HT. c. Recommend black cohosh to alleviate symptoms. d. Reassure her that these symptoms will diminish over time.

a. Increase the HT dose. The Women's Health Initiative results indicate that HT use for 3 to 5 years is safe and recommend slow weaning after women review HT with their providers at annual visits. If symptoms recur, the dose should be increased until symptoms improve.

A woman who lives in Seattle is preparing to take a plane trip to London. She has been taking the SERM raloxifene (Evista) for 6 months. The nurse will provide which instructions to this patient? a. She needs to stop taking the drug at least 72 hours before the trip. b. She must remember to take this drug with a full glass of water each morning. c. She will not take the drug while traveling on the plane. d. No change in how the drug is taken will be needed.

a. She needs to stop taking the drug at least 72 hours before the trip. A patient taking a SERM must be informed to discontinue the drug 72 hours before and during prolonged immobility so as to prevent the development of a thrombosis.

A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should: a. Tell her that starting HT now may reduce her risk of breast cancer. b. Advise a short course of HT now may decrease her risk for CHD. c. Tell her that HT will not help control her symptoms during postmenopause. d. Recommend herbal supplements for her symptoms to avoid HT side effects.

a. Tell her that starting HT now may reduce her risk of breast cancer. The current gap hypothesis regarding breast cancer supports initiating HT 5 years or more after menopause. To decrease risk for CHD, HT should begin at the time of menopause. HT will relieve vasomotor symptoms at all stages of menopause. Herbal supplements have estrogenizing effects and carry the same risks as estrogen therapy.

The nurse recognizes that the risk of osteoporosis is higher in an individual with which risk factor? a. White or Asian race b. African-American race c. History of participation in active sports d. Obesity

a. White or Asian race Risk factors for postmenopausal osteoporosis include white or Asian descent, slender body build, early estrogen deficiency, smoking, alcohol consumption, low-calcium diet, sedentary lifestyle, and family history of osteoporosis.

A woman who has been taking a COCP tells the primary care NP that, because of frequent changes in her work schedule, she has difficulty remembering to take her pills. The woman and the NP decide to change to a vaginal ring. The NP will instruct her to insert the ring: a. Within 7 days after her last active pill. b. And use a backup contraceptive for 7 days. c. And continue the COCP for one more cycle. d. On the same day she stops taking her COCP.

a. Within 7 days after her last active pill. Patients should be switched from a COCP to a vaginal ring by insertion within 7 days after the last active pill. No backup method is needed. Patients do not need to continue one more cycle of COCPs. Women taking progestin-only pills insert the ring on the last day of the pill pack.

The nurse is preparing to administer the contraceptive form of medroxyprogesterone (Depo-Provera). What route is appropriate? a. Subcutaneous b. Intramuscular c. Vaginal d. Transdermal

b. Intramuscular Depo-Provera is a progestin-only injectable contraceptive that is given by the intramuscular route. The other options are incorrect.

The nurse is reviewing the use of uterine tocolytics, such as indomethacin (Indocin). Which statement best describes the indication for these drugs? a. Prevention of preterm labor in the 15th week of pregnancy b. Prevention of preterm labor in the 22nd week of pregnancy c. Stimulation of contractions in prolonged labor d. Stimulation of ovulation as part of infertility treatments

b. Prevention of preterm labor in the 22nd week of pregnancy Tocolytics relax uterine smooth muscles and stop the uterus from contracting and are used along with nonpharmacologic measures to prevent preterm labor between 20 and 37 weeks of pregnancy.

Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She has a positive family history of breast cancer. The primary care NP should recommend: a. Testosterone therapy. b. Estrogen-only therapy. c. Nonhormonal drugs for osteoporosis. d. Estrogen-progesterone therapy for 1 to 2 years.

c. Nonhormonal drugs for osteoporosis. Although estrogen slows the progression of osteoporosis, it also increases the risk of breast cancer when initiated early in menopause. This woman should receive a nonhormonal treatment for osteoporosis and may receive HT in 5 years if menopausal symptoms persist. Testosterone therapy, estrogen-only therapy, and estrogen-progesterone therapy are not indicated.

A 52-year-old woman reports having hot flashes and intense mood swings. After a year of having irregular menstrual periods, she has not had a period for 6 months. The primary care NP should diagnose: a. Menopause. b. Dysmenorrhea. c. Perimenopause. d. Postmenopause.

c. Perimenopause. Perimenopause usually occurs between ages 42 and 55 and is characterized by erratic ovulation and irregular periods, hot flashes, and intensified PMS symptoms. Menopause begins when periods have been absent for 12 months. Postmenopause describes the 5-year period after menopause. Dysmenorrhea is painful periods.

A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman's mother had CHD. She has no family history of breast cancer. The NP should prescribe: a. Estrogen-only HT now. b. Estrogen-only HT in 5 years. c. Estrogen-progesterone HT now. d. Estrogen-progesterone HT in 5 years.

a. Estrogen-only HT now. HT relieves symptoms of menopause and prevents osteoporosis. When started soon after menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5 years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only therapy is indicated.

A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe: a. Estrogen-only HT. b. Low-dose oral contraceptive therapy. c. Selective serotonin reuptake inhibitor therapy until menopause begins. d. Estrogen-progesterone HT.

a. Estrogen-only HT. Estrogen-only regimens are used in women without a uterus and may be initiated to treat perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat irregular menstrual bleeding in perimenopausal women.

A man who has secondary hypogonadism associated with pituitary dysfunction will begin exogenous testosterone therapy. The patient asks the primary care NP about future chances of fathering children. The NP should tell him that: a. Fertility may improve with testosterone therapy. b. Exogenous testosterone therapy will shut down sperm production. c. Fertility can be restored when testosterone therapy is discontinued. d. He should store sperm ahead of the initiation of testosterone therapy.

a. Fertility may improve with testosterone therapy. Men with secondary hypogonadism may become fertile with exogenous testosterone.

The nurse is teaching a patient about the adverse effects of fertility drugs such as clomiphene (Clomid). Which is a potential adverse effect of this drug? a. Headache b. Drowsiness c. Dysmenorrhea d. Hypertension

a. Headache Headache is one of the possible adverse effects of the fertility drugs. They may also cause vomiting, restlessness, and urticaria. Drowsiness, dysmenorrhea, and hypertension are not potential adverse effects. See Table 34-5 for other adverse effects.

A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she: a. Is having vomiting or diarrhea. b. Delays taking a pill by 5 or 6 hours. c. Takes nonsteroidal antiinflammatory drugs several days in a row. d. Has recurrent headaches or insomnia.

a. Is having vomiting or diarrhea. Vomiting and diarrhea may cause oral contraceptive failure, so women should be advised to use backup contraception if they experience these. The other conditions do not lead to oral contraceptive failure.

The nurse is providing patient education for a patient taking an oral contraceptive. Which drugs may cause interactions with oral contraceptives? (Select all that apply.) a. Cephalexin (Keflex) b. Guaifenesin (Robitussin) c. Warfarin (Coumadin) d. Ibuprofen (Motrin) e. Theophylline (Uniphyl)

ANS: A, C, E Patients must be educated about the need to use alternative birth control methods for at least 1 month during and after taking any of these drugs: antibiotics (especially penicillins and cephalosporins); barbiturates; isoniazid; and rifampin. The effectiveness of other drugs, such as anticonvulsants, beta blockers, hypnotics, antidiabetic drugs, warfarin, theophylline, tricyclic antidepressants, and vitamins, may be reduced when they are taken with oral contraceptives.

A patient wants to try an oral soy product to relieve perimenopausal symptoms. The nurse will assess the patient's medication history for which potential drug interaction? a. Thyroid replacement therapy b. Oral anticoagulant therapy c. Nonsteroidal anti-inflammatory drugs d. Beta blockers

a. Thyroid replacement therapy Orally administered soy may interfere with thyroid hormone absorption, so concurrent use must be avoided. The other options are incorrect.

A woman who began taking a COCP 2 months ago calls the primary care NP to report having nausea every day. She takes a pill at the same time each morning. The NP should tell her to: a. Try taking the pill in the evening each day. b. Come to the clinic for a urine pregnancy test. c. Take the pill on an empty stomach with water. d. Stop taking the pill for 7 days and then restart.

a. Try taking the pill in the evening each day. If nausea occurs when taking the pill, patients should be instructed to switch to the opposite time of day or to take with food. A urine pregnancy test is not indicated. If nausea occurs, patients should take the pill with food. Patients stop taking pills for 7 days at the end of each 21-day pack.

The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen? a. "I have to take a pill only every 3 months." b. "I should expect to have only four periods each year." c. "I will need to use condoms for only 7 more days." d. "This type of pill has fewer side effects than other types."

b. "I should expect to have only four periods each year." The extended-cycle pills have fewer pill-free intervals, so women have only four periods a year. Patients take pills every day. Because this patient has multiple partners, she should continue to use condoms. This type of pill has the same side effects as other types.

The nurse is providing patient teaching about the oral bisphosphonate alendronate (Fosamax). Which statement by the patient indicates a good understanding of when this drug should be taken? a. "I will take it in the evening just before bedtime." b. "I will take it in the morning with an 8-ounce glass of water." c. "I will take it with the first bite of the morning meal." d. "I will take it between meals on an empty stomach."

b. "I will take it in the morning with an 8-ounce glass of water." Bisphosphonates must be taken in the morning, with 6 to 8 ounces of plain water, to prevent esophageal erosion. In addition, the patient must sit upright for 30 minutes after taking them.

A 50-year-old woman reports severe, frequent hot flashes and vaginal dryness. She is having irregular periods. She has no family history of CHD or breast cancer and has no personal risk factors. The primary care NP should recommend: a. Estrogen-only HT. b. Low-dose oral contraceptive therapy. c. Selective serotonin reuptake inhibitor therapy until menopause begins. d. Estrogen-progesterone HT.

b. Low-dose oral contraceptive therapy. Oral contraceptive pills are not approved by the U.S. Food and Drug Administration for management of perimenopausal symptoms except to treat irregular menstrual bleeding. This patient has a low risk for CHD and breast cancer, so oral contraceptive pills are relatively safe. She is also at risk for pregnancy, so oral contraceptive pills can help to prevent that.

An adolescent girl has chosen Depo-Provera as a contraceptive method and tells the primary care NP that she likes the fact that she won't have to deal with pills or periods. The primary care NP should tell her that she: a. Should consider another form of contraception after 1 year. b. May have irregular bleeding, especially in the first month or so. c. Will need to take calcium and vitamin D every day while using this method. d. Will have to take oral contraceptive pills in addition to Depo-Provera when she takes antibiotics

b. May have irregular bleeding, especially in the first month or so. Because of strong progestational effects on the endometrium, irregular bleeding or spotting is common in the early months of use. Because of concerns about the effect of depot medroxyprogesterone acetate on bone density, it is recommended that woman change to another birth control method after 2 years, not 1 year. Calcium and vitamin D supplements have not been shown to prevent bone density loss. It is not necessary to take oral contraceptive pills when taking antibiotics.

A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin. The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The primary care NP should recommend: a. Increasing the dose of warfarin. b. More frequent blood glucose monitoring. c. A higher than usual dose of testosterone. d. Increasing insulin doses to prevent hypoglycemia.

b. More frequent blood glucose monitoring. Patients with diabetes may require a decrease in insulin dose because of the metabolic effects of androgens. More frequent blood glucose monitoring should be performed. Warfarin doses may need to be decreased because androgens increase sensitivity to anticoagulants.

A woman who is taking a progestin-only pill has just stopped nursing her 9-month-old infant and tells the primary care NP that she would like to space her children about 2 years apart. The NP should: a. Discontinue the progestin-only pill. b. Prescribe a COCP and a folic acid supplement. c. Prescribe a progestin-only pill for another 6 months. d. Suggest that she use a barrier method of contraception.

b. Prescribe a COCP and a folic acid supplement. Serum folate levels may be decreased by oral contraceptives. Women who become pregnant shortly after stopping oral contraceptive use may have a greater chance of birth defects. This woman should become pregnant in about 6 months if she wants to space her children 2 years apart, so she needs an oral contraceptive. Progestin-only pills are used only during lactation.

During a follow-up visit, a patient who has been on estrogen therapy admits that she has continued to smoke cigarettes. The nurse will remind the patient that smoking while on estrogen may lead to increased: a. Incidence of nausea. b. Risk for thrombosis. c. Levels of triglycerides. d. Tendency to bleed during menstruation.

b. Risk for thrombosis. Smoking should be avoided during estrogen therapy because it adds to the risk for thrombosis formation. The other options are incorrect.

A patient who is taking the bisphosphonate alendronate (Fosamax) has been instructed to lie flat in bed for 2 days after having ophthalmic surgery. Which intervention is appropriate at this time? a. She will continue to take the alendronate with water. b. She cannot take the alendronate until she can sit up for 30 minutes. c. She can take the medication with breakfast. d. She will stop taking the medication 72 hours before her surgery.

b. She cannot take the alendronate until she can sit up for 30 minutes. The nurse must emphasize that the patient should remain upright in either a standing or sitting position for approximately 30 minutes after taking a bisphosphonate so as to help prevent esophageal erosion or irritation. Because this patient will be required to lie flat in bed for 2 days after the surgery, the prescriber will need to be notified that the patient cannot take the medication during this time.

The nurse is administering oxytocin (Pitocin). Which situation is an indication for the use of oxytocin? a. Decreased fetal heart rate and movements b. Stimulation of contractions during labor c. Cervical ripening near term in pregnant patients d. To reverse premature onset of labor

b. Stimulation of contractions during labor Oxytocin is used to induce labor at or near full-term gestation and to enhance labor when uterine contractions are weak and ineffective.

A primary care NP prescribes a COCP for a woman who has never taken oral contraceptives before. The woman is in a monogamous relationship, and she and her partner have been using condoms and wish to stop using them. Her last period was 1 week ago. The NP should: a. Perform an in-office pregnancy test before starting a COCP. b. Tell the patient to begin the first pill today and to continue using condoms for 7 days. c. Tell the patient to begin the first pill on the Sunday of or following her next menstrual period. d. Tell the patient to begin the first pill today and to return in 2 weeks for a pregnancy test.

b. Tell patient to begin the first pill today and to continue using condoms for 7 days To start COCPs using the quick start method, the woman takes the first pill on the day of her office visit and uses a barrier method such as condoms for the first 7 days. The patient should be reasonably sure she is not pregnant; she can take a pregnancy test in 2 to 3 weeks if pregnancy is suspected later. If she is pregnant, taking the COCPs would not negatively affect early pregnancy.

The nurse is providing teaching for a patient who is to receive estrogen replacement therapy. Which statement is correct to include in the teaching session? a. "If you miss a dose, double-up on the next dose." b. "There's no need to be concerned about breast lumps or bumps that occur." c. "Be sure to report any weight gain of 5 pounds or more per week." d. "Take the medication on an empty stomach to enhance absorption."

c. "Be sure to report any weight gain of 5 pounds or more per week." Patients taking oral estrogen therapy should report weight gain of 5 pounds or more per week to a physician. The other statements are not true for estrogen replacement therapy.

A patient is receiving oxytocin (Pitocin) to induce labor. During administration of this medication, the nurse will also implement which action? a. Giving magnesium sulfate along with the oxytocin b. Administering the medication in an intravenous (IV) bolus c. Administering the medication with an IV infusion pump d. Monitoring fetal heart rate and maternal vital signs every 6 hours

c. Administering the medication with an IV infusion pump Oxytocin is infused via an infusion pump, not via an IV bolus. Magnesium sulfate is not administered with oxytocin. Fetal heart rate and maternal vital signs should be monitored continuously.

An older adult female patient is receiving the progestin drug megestrol (Megace). Which is the most likely reason megestrol is ordered for this patient? a. Migraine headaches b. Osteoporosis c. Appetite stimulant d. Reduction of hot flashes

c. Appetite stimulant Megestrol can cause appetite stimulation and weight gain, and therefore is used in the management of anorexia, cachexia, or unexplained substantial weight loss in patients with acquired immunodeficiency syndrome (AIDS) and in patients with cancer. The other options are incorrect.

A sexually active patient tells the primary care NP that she has been unable to get her new COCP pill pack until today and has missed 3 days of pills. The NP should tell her to: a. Use backup contraception and take 2 pills each day for the next 2 days. b. Begin a new pack of pills today and use backup contraception for 7 days. c. Begin a new pack of pills today, take a Plan B pill, and use backup contraception for 7 days. d. Take a pregnancy test, begin a new pack of pills today, and use backup contraception for 7 days.

c. Begin a new pack of pills today, take a Plan B pill, and use backup contraception for 7 days. Patients who miss 2 or more pills at the beginning or end of a pack should use emergency contraceptive pills, such as the Plan B pill, restart a new pill pack, and use backup contraception for 7 days.

When considering the various types of contraceptive drugs, the nurse is aware that which type most closely duplicates the normal hormonal levels of the female menstrual cycle? a. Monophasic b. Biphasic c. Triphasic d. Short acting

c. Triphasic The triphasic drugs most closely duplicate the normal hormonal levels of the female menstrual cycle. The other options are incorrect.

A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and: a. Take one cycle of COCPs. b. Take a home pregnancy test. c. Use condoms for the next 7 days. d. Contact the clinic if she misses a period.

c. Use condoms for the next 7 days. If a transdermal patch has been discovered to be loose or has come off, patients should use a backup method of contraception. It is not necessary to use oral contraceptives. A home pregnancy test is not indicated.

The nurse recognizes that use of estrogen drugs is contraindicated in which patient? a. A patient who has atrophic vaginitis b. A patient who has inoperable prostate cancer c. A woman who has just given birth and wants to prevent postpartum lactation d. A woman with a history of thrombophlebitis

d. A woman with a history of thrombophlebitis Estrogenic drugs are contraindicated in people who have active thromboembolic disorders and in those with histories of thromboembolic disease. Atrophic vaginitis and inoperable prostate cancer are potential indications for estrogen therapy. Estrogen is not used to prevent lactation.

A woman with a family history of breast cancer had her last menstrual period 12 months ago and is experiencing hot flashes. She has not had a hysterectomy. The primary care NP should recommend: a. Black cohosh. b. Estrogen-only therapy. c. Progesterone-only therapy. d. Limiting alcohol and caffeine intake.

d. Limiting alcohol and caffeine intake. Hot flashes can be triggered by environmental conditions such as stress, excitement, anxiety, and alcohol and caffeine consumption. Black cohosh carries the same risks as estrogen. Estrogen-only therapy is not recommended for women with an intact uterus. Progesterone therapy is not recommended.

A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches. For this patient, the NP should prescribe: a. Condoms. b. Tubal ligation. c. Monophasic combined oral contraceptive pill (COCP). d. Low-estrogen COCP.

d. Low estrogen COCP Low-estrogen COCPs are recommended for women older than 40 with or without cardiovascular risk. Monophasic COCPs are recommended for women with migraine headaches. Condoms are more useful for preventing sexually transmitted diseases and not as reliable as contraception. Tubal ligation has surgical risks.

A patient is being treated for secondary amenorrhea. The nurse expects which drug to be used to treat this problem? a. Methylergonovine (Methergine) b. Estradiol transdermal (Estraderm) c. Raloxifene (Evista) d. Medroxyprogesterone (Provera)

d. Medroxyprogesterone (Provera) Medroxyprogesterone, a progestin, is one of the drugs most commonly used for secondary amenorrhea. Secondary amenorrhea is not an indication for the other drugs listed.

A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP's next action should be to: a. Order LH and FSH levels. b. Order a serum prolactin level. c. Prescribe testosterone replacement. d. Obtain a morning serum testosterone level.

d. Obtain a morning serum testosterone level. To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive.

A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should: a. Prescribe estrogen-only therapy. b. Initiate oral contraceptive pills now. c. Discuss using bioidentical HT. d. Plan to use estrogen-progesterone therapy when menopause begins.

d. Plan to use estrogen-progesterone therapy when menopause begins. The timing hypothesis suggests that initiating HT at or very near to the time of menopause, which begins when a woman has not had a period for 12 months, reduces CHD in postmenopausal women. Estrogen-only therapy is indicated only for women who do not have a uterus. Oral contraceptive pills increase the risk of CHD. Bioidentical HT is not indicated.

A woman visits a health center requesting oral contraceptives. Which laboratory test is most important for the nurse to assess before the patient begins oral contraceptive therapy? a. Complete blood count b. Serum potassium level c. Vaginal cultures d. Pregnancy test

d. Pregnancy test Pregnancy should be ruled out before beginning oral contraceptive therapy because the medications can be harmful to the fetus; they are classified as pregnancy category X.

A woman who has been taking a COCP for 2 months tells the primary care NP that she has had several headaches, breakthrough bleeding, and nausea. The NP should counsel the woman: a. To change to a progestin-only pill. b. To stop taking the COCP immediately. c. To use a backup form of contraception. d. That these effects will likely decrease in another month.

d. That these effects will likely decrease in another month. Breakthrough bleeding, nausea, and headaches are common during the first 3 months of therapy and should improve without intervention. Progestin-only pills are used for lactating women only. Prolonged bleeding and severe headache would warrant discontinuation of the COCP. Backup contraception is not indicated.

A postpartum woman will begin taking the minipill while she is nursing her infant. The primary care NP should instruct the patient: a. To use backup contraception while taking the minipill. b. To continue using the minipill for 6 months after she stops nursing. c. That irregular periods while taking the minipill may indicate she is pregnant. d. That this method does not increase her risk of thromboembolic events.

d. That this method does not increase her risk of thromboembolic events. Minipills are used primarily in breastfeeding women. There is no increased risk for thromboembolic events for women taking these pills. It is not necessary to use a backup method of contraception. Women should be advised to contact the provider when they stop nursing so that a COCP can be prescribed. The more disrupted the bleeding pattern, the more likely it is that ovulation is inhibited.

A 51-year-old woman will be taking selective estrogen receptor modulators (SERMs) as part of treatment for postmenopausal osteoporosis. The nurse reviews potential contraindications, including which condition? a. Hypocalcemia b. Breast cancer c. Stress fractures d. Venous thromboembolism

d. Venous thromboembolism SERMs such as raloxifene are contraindicated in women with a venous thromboembolic disorder, including deep vein thrombosis, pulmonary embolism, or a history of such disorders. The other options are incorrect.