FNP Mastery Contraception
A 25-year-old female patient has been using Depo-Provera, but has experienced an 8-lb weight gain in the past year and is already significantly overweight. She asks if the weight gain is common. How should the NP respond? "This is, unfortunately, common with the use of Depo-Provera. If your weight has normalized and this is tolerable for you, you can continue it." "This is an abnormal side effect associated with the use of this drug, but if this weight is tolerable for you, you can continue it." "This is, unfortunately, common with the use of Depo-Provera." As she is already overweight, the NP should offer a switch to a different form of contraception like the nonhormone intrauterine device. "This is a very abnormal side effect associated with the use of this drug." The NP should advise that she switch to a different form of contraception.
"The weight gain is, unfortunately, common with the use of Depo-Provera." As she is already overweight, the NP should offer a switch to a different form of contraception like the nonhormone intrauterine device. It would not be wise to continue on an option that has caused weight gain if she is unhappy with it. This is not an abnormal side effect. It is common.
A 34-year-old patient has been using depot medroxyprogesterone acetate (Depo-Provera) for five years. She just moved to town and has asked you to continue her prescription. Which of the following should be your response? You will continue this medication as long as her cholesterol and other risk factors are low. You agree to continue the medication only until she turns 35 years old. You agree to continue the medication for a total of ten years because this drug may result in a loss of bone mineral density. You agree to prescribe it, but counsel her on the importance of adequate calcium and vitamin D, and regular exercise. She has been on this medication longer than is recommended; the NP should recommend another form of oral contraception.
A primary concern of depot medroxyprogesterone acetate (Depo-Provera) is the effect on bone density. Suppression of gonadotropin secretion suppresses production of ovarian estradiol, resulting in a decline in bone mineral density (BMD). The greatest loss is the first one to two years of use. Studies of women using Depo-Provera for up to five years showed that the decline in BMD reversed substantially after discontinuation. To promote bone health, providers should always advise patients to have an adequate intake of calcium and vitamin D, regular exercise, and to avoid cigarette smoking and excessive alcohol consumption. The FDA recommends Depo-Provera should not be used as a long-term birth control method (longer than 2 years) unless other birth control methods are considered inadequate.
Which of the following is true about therapy with Depo-Provera? Return of fertility may be delayed after discontinuing the drug. It may be prescribed up until age 35. It may be prescribed only for 2 years due to decreased bone mineral density. It is not appropriate for adolescents.
A primary concern of depot medroxyprogesterone acetate; (Depo-Provera) is the effect on bone density. Suppression of gonadotropin secretion suppresses ovarian estradiol production, resulting in a decline in bone mineral density (BMD). The greatest loss is during the first one to two years of use, after which BMD appears to plateau. Studies of women on Depo-Provera for up to five years showed that the decline in BMD reversed after substantially after discontinuation. To promote bone health, providers should advise patients to have adequate intake of calcium and vitamin D, regular exercise, and avoid cigarette smoking and excessive alcohol consumption. Return of fertility can be delayed after discontinuation, but within 10 months of the last injection, half of women who are trying to conceive will become pregnant. For some women, though, fertility is not reestablished until 18 months after the last injection. Rates of oral contraceptive failure are very high among adolescents. In contrast, Depo-Provera provides highly effective contraception for this population.
Your 30-year-old patient has been taking oral contraceptives for over ten years. She has recently stopped taking them and wonders how quickly she can safely conceive. How do you respond? She may conceive after one month off of the oral contraceptives. She may have over one year to return to safe fertility. She will only be able to safely conceive after three months off of the hormones. She can safely conceive immediately.
After having taken oral contraceptives for any length of time, it is safe to conceive immediately. It may take her up to a year's time to return to fertility; however, she may safely attempt to conceive immediately following the discontinuation.
Which of the following is false regarding emergency contraception? Levonorgestrel (Plan B) should be taken within 48 hours of intercourse. Oral emergency contraceptives work by delaying ovulation. A copper intrauterine device may be an effective emergency contraception if placed within 5-6 days of intercourse. Emergency contraception medication may cause nausea, vomiting, and headaches.
All emergency contraception is best used as soon as possible after unprotected intercourse. Levonorgestrel (Plan B) oral contraception should be taken up to 3 days (72 hours) after intercourse 0.75 mg is given twice, 12 hours apart or 1.5 mg may be given as a single dose. The following statements are true: A copper intrauterine device may be an effective emergency contraception if placed up to 5 days (120 hours) after intercourse. Direct laboratory evidence overwhelmingly supports the hypothesis that oral emergency contraceptives work primarily by delaying ovulation and may cause nausea, vomiting, and headaches.
Which of the following patients could be considered for use of combination oral contraceptives? A 25-year-old with thyroid disease A 35-year-old with cervical cancer A 40-year-old with a family history of breast cancer A 28-year-old with menorrhagia All of the above choices are candidates
All of the above are candidates. Though some risk factors should be considered, there are no absolute contraindications to use. The combination pill is not associated with an overall increased risk of cancer, though there are some specific risks associated with use. Thyroid disease is a risk factor that should be weighted, but not a contraindication. Any estrogen taken orally will raise the levels of thyroxine-binding globulin (TBG). In response, total thyroxine (T4) and triiodothyronine (T3) levels will increase, but serum concentrations of free T4 and T3 are not expected to change. The risk of cervical cancer appears to be increased with use of combination pills, warranting routine monitoring of cervical pap sears. A family history of breast cancer is not a risk factor. The incidence of breast cancer in combination pill users was similar to that of individuals who have never used oral contraceptives. In combination pill users compared with nonusers, cancer risks are significantly lower for colorectal, uterine, and ovarian cancer. Age ≥35 years and smoking ≥15 cigarettes per day is a relative risk factor.
When counseling a woman about the use of oral contraceptives, you should provide her with which of the following pieces of information? All of the answers are correct. They may worsen mood. They must be taken every day. Antibiotics may decrease their effectiveness and she should use a backup method of protection when taking them. They do not protect against sexually transmitted infections.
All of the above should be explained when counseling a woman on the use of oral contraceptives: Antibiotics may decrease their effectiveness, and she should use a backup method of protection when taking them They do not protect against sexually transmitted infections They must be taken every day They may worsen mood
Which of the following is a known contraindication to the prescription of oral contraceptives? All of the answer choices are correct Undetermined uterine bleeding Known or suspected estrogen-related cancer Current pregnancy History of blood clots
All of the answer choices are contraindications. Oral contraceptive hormones may influence the development and growth of cancer. An existing cancer is certainly a contraindication for oral contraceptives. Breakthrough bleeding and spotting may be encountered in patients on oral contraceptives, especially during the first three months of use. The cause of uterine bleeding should be determined before starting an individual on oral contraceptives. Oral contraceptives may increase the risk of thrombosis and should not be given to individuals with a history of blood clots. Oral contraceptives are contraindicated in pregnancy due to the potential abortive effect.
Which of the following is not true about the use of Depo-Provera? May result in a delayed return to fertility for up to one year May reduce low-density lipoprotein cholesterol Must be injected May cause menstrual irregularities
Although reducing low-density lipoprotein would be beneficial, it does not have this effect. Instead, it may reduce high-density lipoprotein cholesterol. The remaining answers are disadvantages: It must be injected It may result in a delayed return to fertility for up to one year It may cause menstrual irregularities
One of your patients is pleased that her acne has diminished on her oral contraceptives (ethinyl estradiol 30 mcg/drospirenone 3 mg). You advise her that this is likely due to which of the following? The androgen-reducing effects of the medication Her bleeding reduction The estrogenic effects of the medication Her cycles normalizing, giving her fewer hormonal fluctuations that trigger her acne
Androgen reducing effect Acne can be related to higher than normal androgen levels. Androgen can contribute to acne by overstimulating stimulating the growth and secretory function of sebaceous glands and altering the development of skin cells that line hair follicles in the skin. Androgen excess may be suspected in women with acne accompanied by excess facial or body hair or irregular or infrequent menstrual periods. Combined oral contraceptives containing both estrogen and progestin are effective therapies for acne vulgaris in women. All generations of progestins can be effective, but some have antiandrogenic properties. Ethinyl estradiol 30 mcg/drospirenone 3 mg (Yasmin) and ethinyl estradiol 20 mcg/drospirenone 3 mg (Yaz) are the two drospirenone-containing oral contraceptives with antiandrogenic progestins that are prescribed in the United States. The estrogenic effects of the medication, normalizing cycles, and bleeding reduction have no effect on acne.
The nurse practitioner receives a phone call from an 18-year-old female patient on combined oral contraceptive pills, stating that she missed the previous two days of her birth control pill. She is inquiring as to what she should do now, as these are the "active pills". The NP advises her to: Discard the current pack and begin with a new one the following day. Resume taking the pills as scheduled the following day. Take two active pills today and two active pills tomorrow, then resume the regular schedule. Take the most recent missed active pill as soon as possible, discard other missed pills, and continue with the regular schedule, even if it means taking two pills in one day. Use backup contraception or avoid intercourse for 7 days.
Based on the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (CDC) Recommendations for providers for 2 missed pills-for combined progestin and estrogen OCPs: Currently, if two or more pills are forgotten (more than 48 hours late) only the last 'forgotten' pill is taken, other missed pills are discarded and the next pill taken at the usual time - often this means taking two pills in one day. • A back-up method (condoms or avoid intercourse) is needed for the next 7 consecutive pill days. • If pills were missed in the last week of hormonal pills (days 15-21 for 28-day packs) Omit the hormone-free interval by finishing the hormonal pills in the current pack and starting a new pack the next day. If unable to start a new pack immediately, use a back-up contraception until hormonal pills from a new pack have been taken for 7 consecutive days. • Consider emergency contraception: if hormonal pills were missed during the first week and unprotected sexual intercourse occurred in the previous 5 days or at other times as appropriate. • If the patient missed the inactive pills, the pack should be finished and a new pack started the next day missing out the break.
Your patient is currently menstruating and forgot to take her combined oral contraceptive pill yesterday. She calls the clinic. You advise her of which of the following? Take two today and get back on schedule tomorrow by taking one again If she missed a nonactive, nonhormonal pill, that is okay. She should resume taking her pills as scheduled again tomorrow. Discard this pack and start a new pack Resume taking her pills as scheduled again tomorrow
Because she is menstruating, you realize she is currently taking her nonactive, nonhormonal pills. You advise her that in this case, it is okay to resume taking her pills as scheduled tomorrow. You should not advise her to simply resume taking her pills tomorrow unless you have confirmed they were the inactive pills. If she missed an active pill, she should take two today. Incorrect options: The take two rule applies to active hormone pills There is no need to start a new pack yet
Which of the following risk factors should be considered when prescribing a combination of oral contraceptives? Aged >35 years One month postpartum Caution should be taken with all of the answer choices Smoker Current gallbladder disease
Caution is advised with any of the above risk factors. Oral contraceptives can increase the risk for gallbladder disease and thus should not be used if a patient has a history of gallbladder disease. Studies have reported an increased lifetime relative risk of gallbladder surgery in users of oral contraceptives. Combination oral contraceptives may increase the risk of thrombosis, as can smoking. Therefore, these should not be combined. The risk for thromboembolic disorders increases with age. Prescribing an oral contraceptive to an individual above the age of 35 increases this risk and should be used with caution. Individuals should wait four weeks after delivery to start using birth control methods that use estrogen, such as a combination birth control pill. Estrogen increases the risk for blood clots during the early postpartum weeks. Many women are recommended progesterone-only pills as estrogen may also reduce the quantity and quality of breast milk.
The NP is seeing a new patient, an adult female, who recently discovered that she is HIV positive. This patient is asking about the best method of contraception as well as preventing transmission of HIV to her partner. What would be the most appropriate contraceptive for this patient? Levonorgestrel Intrauterine Device (IUD) Condom Cervical Cap Transdermal Contraceptive Patch
Condoms are the best contraceptive method available for reducing the transmission of sexually transmitted infections—such as HIV. • In general, IUDs are not recommended in patients with a positive history for sexually transmitted diseases, due to the relatively increased risk of pelvic inflammatory disease—however, this is a relative, not an absolute contraindication. • Additionally, while the progestin within the levonorgestrel and transdermal contraceptive patch will increase cervical mucus thickness—which may marginally reduce the risk of contracting certain sexually transmitted infections, this does not provide adequate protection against sexually transmitted diseases. • The cervical cap is a relatively effective barrier contraceptive, however, it does not protect well against the transmission of sexually transmitted diseases.
Your patient is worried about which contraceptive option would be best for her. She states that she often forgets to take her vitamins. For this particular candidate, you would discuss which of the following? Select all that apply. Which of the following is a known contraindication to the prescription of oral contraceptives? All of the answer choices are correct Undetermined uterine bleeding Known or suspected estrogen-related cancer Current pregnancy History of blood clots An intrauterine device Depot medroxyprogesterone Progestin-only pills NuvaRing
Depot medroxyprogesterone (Depo-Provera), Nuva Ring, or an intrauterine device are all options that would not require this patient to remember to take a pill every day. These should be offered to her in place of daily oral pills.
The Nurse Practitioner is providing teaching to a postpartum Catholic client who wishes to use natural family planning. Which of the following would the NP include in teaching about how to utilize this method? Select all that apply. Calendar charting Cervical mucous observation Extended breastfeeding Basal body temperature graphing The use of condoms with no spermicide
Each of the following choices should be included in natural family planning: Prolonged breastfeeding, monitoring of cervical mucus, basal body temperature graphing, and calendar charting. Using multiple NFP methods together increases the effectiveness. Monitoring cervical mucus to time ovulation has a failure rate of 3% with perfect use, but with typical use, the failure rate is 44% Typical user failure rates for all of these methods are much higher than the failure rates with correct use, as with all contraception. Incorrect: Condoms are a barrier method even without spermicide, and are contrary to the client's wishes.
Why does acne reduce with COCs?
Ethinyl estradiol 30 mcg/drospirenone 3 mg (Yasmin) and ethinyl estradiol 20 mcg/drospirenone 3 mg (Yaz) are the two drospirenone-containing oral contraceptives with antiandrogenic progestins that are prescribed in US
Which of the following statements should the Nurse Practitioner include in medication teaching about oral contraceptives? Select all that apply. Progestin-only contraceptive pills thicken the endocervical mucus, alter the endometrium, and suppress ovulation. Benefits of progestin-only pills include a daily schedule that's easy to remember and less nausea than with combined oral contraceptives. Benefits of combined oral contraceptives may include decreased menstrual cramps and PMS. Progestin-only pills are as effective as the combined pill with typical use. Progestin-only pills may be less effective than the combined pill.
Ethinyl estradiol is an example of a synthetic estrogen • Progestins thicken cervical mucous, interfering with sperm transport and implantation • Benefits of combined oral contraceptives (COC) include decreased menstrual cramps and PMS symptoms, decreased frequency of pelvic inflammatory disease (PID) due to thickened endocervical mucus, and thus lower rates of future ectopic pregnancies. COC user benefit from decreased rates of acne, hirsutism, and ovarian cysts. • Benefits of progestin-only pills include a daily schedule that's easy to remember and less nausea than with combined oral contraceptives. • It is likely that the progestin-only pill is less effective than the combined pill with typical use because the progestin-only pill is less forgiving of missed doses. It is not known whether the progestin-only pill is less effective with perfect use.
A patient visits the clinic with complaints of oral contraceptive side effects. Which one of the following is NOT a sign of excessive estrogen? Breast tenderness Increased blood pressure Decreased blood pressure Headache Melasma
Excessive estrogen has been known to cause breast tenderness, headaches, and melasma and can actually raise blood pressure. Increased, not decreased, blood pressure has been reported in women taking oral contraceptives.
All of the following are examples of excessive progesterone except: Depression Breast tenderness Increased libido Increased appetite
Excessive progesterone does not cause increased libido. It can cause decreased libido. Excessive progesterone can cause depression, breast tenderness, decreased libido, and fatigue.
Your 27-year-old patient who is suffering from chronic migraine headaches visits your clinic for contraceptives. She is otherwise healthy and does not smoke. You advise that the best option for her is: Combined estrogen and progestin pills Ortho Evra patch Progestin-only pills NuvaRing
Headaches are less commonly reported with progestin-only pills. Progestin-only pills would be the best option for a patient with migraine headaches. Combined hormone options like Nuva Ring and Ortho Evra would not be the best choice for this woman as they also contain estrogen, which is more likely to cause a headache than progestin.
Which of the following is false regarding usage of the Ortho Evra patch? If the patch falls off and stays off for greater than 12 hours, restart a new four-week cycle and use a backup method of protection. After three applications, the patch is removed for seven days, allowing for menstruation. The patch is removed every seven days and another one is applied. The patch may be applied to the arm, buttocks, or abdomen.
If the patch falls off and stays off for >24 hours (not 12), restart a new four-week cycle and use a backup method of protection. The following are true: The patch may be applied to the arm, buttocks, or abdomen The patch is removed every seven days and another one is applied After three applications, the patch is then removed for seven days, allowing for menstruation
Which statement is false regarding the usage of NuvaRing? It is vaginally inserted. It is left in place for 21 days and then removed to allow for menstruation. It is a combination of synthetic estrogen and progestin. If the ring falls out, it should be reinserted within 24 hours.
If the ring falls out, it should be reinserted within three hours (not 24 hours). Otherwise, a backup method of protection must be used. The following are true: It is a combination of synthetic estrogen and progestin It is vaginally inserted It is left in place for 21 days and then removed to allow for menstruation
Which of the following contraceptive options are progestin-only? Choose three answers. Select all that apply. Paraguard intrauterine device Mirena intrauterine device NuvaRing Implanon Depo-Provera
Implanon, Mirena intrauterine device, and Depo-Provera are all progestin-only. NuvaRing is a combination of synthetic estrogen and progestin. Paraguard is a nonhormone copper-based intrauterine device.
The incidence of which of the following cancers are reduced with the use of oral contraceptives? Lung and ovarian Ovarian and endometrial Endometrial and breast Ovarian and breast
Ovarian cancers are reduced due to the suppression of ovulation. Endometrial cancers are also reduced, likely due to the reduction of endometrial hyperplasia. Breast cancers may be increased, especially among younger women, as hormones may influence the development and growth of cancer. However, the risk level returns to normal ten years or more after discontinuing oral contraceptive use. There is no association with lung cancer.
When counseling a patient on the risks associated with an intrauterine device, you include all of the following except: Intrauterine device use increases the risk for pelvic inflammatory disease All of the answer choices are true Risk of expulsion of the intrauterine device is 10% the first year of use Intrauterine device use increases the risk for candidiasis Intrauterine device strings may migrate due to poor positioning and become difficult to find
PID risk only for the first 3 weeks The intrauterine device (IUD) increases the risk for candidiasis as candida may cling or adhere to the parts of the IUD or string The risk of expulsion of the IUD is 10% in the first year of use The IUD string may migrate due to poor positioning and become difficult for the patient to find and feel to confirm the IUD is in place The risk of PID is primarily limited to the first three weeks after IUD insertion does not increase with prolonged IUD use. PID is most strongly associated with the insertion process and with STD infection.
Your 33-year-old patient is still breastfeeding her fourth child and wants to be reassured that she will not get pregnant again. Since she is breastfeeding, you recommend which of the following contraceptives? Ortho Evra patch Contraceptive ring (NuvaRing) Progestin-only pill She should avoid contraception until she has finished breastfeeding since breastfeeding offers protection
Progestin-only pills are the safest option when breastfeeding. Although breastfeeding may prevent pregnancy for a while, depending on the individual, it is not a reliable form of birth control. The NuvaRing and Ortho Evra patch contain estrogen and should be avoided when breastfeeding as the estrogen may reduce breast milk production.
One of the nurse practitioner's patients plans on using a diaphragm for contraception. While counseling her on how to use it, she asks when she should remove the diaphragm following intercourse. What would be the most appropriate answer to her question? 1 hour following intercourse Whenever is most convenient 6 hours following intercourse Immediately following intercourse
The diaphragm can be a very effective form of barrier contraception when used properly—motivated patients can expect to achieve about a 98% success rate at preventing pregnancy if they use a properly fitted diaphragm accordingly. • Proper usage involves applying about 5 ml of spermicidal lubricant to the side of the diaphragm which will directly contact the cervix and cover the cervix with the diaphragm. • If more than one instance of intercourse is had within 6 hours, the patient should apply additional spermicidal lubricant to the vagina—the patient should not break the seal of the diaphragm before 6 hours has elapsed since the last instance of intercourse. • The diaphragm should not be left in for an extended period of time—i.e. 12 hours or more—as there is an increased risk of developing bladder infections or toxic shock syndrome the longer the diaphragm is left in.
Which is incorrect regarding the use of a vaginal diaphragm? It must be left in place for at least six hours after intercourse It should be refitted if one has a weight gain of greater than 10 lbs It may increase the risk for urinary tract infections All of the answer choices are true
The diaphragm should be refitted if one experiences a weight gain of greater than 20 lbs, not 10 lbs. All of the remaining answer choices are true: A vaginal diaphragm may increase the risk for urinary tract infections A vaginal diaphragm must be left in place for at least six hours after intercourse
True or false: 60% more estrogen is absorbed with the Ortho Evra patch than with oral contraceptives, increasing the risk for thromboembolic events. True False
The following statement is true: 60% more estrogen is released with the Ortho Evra patch than with oral contraceptives, increasing the risk for thromboembolic events. Hormones from topical estrogens are absorbed into the bloodstream and processed by the body differently than hormones from oral birth control pills.
The NP is seeing an adult female patient with 2 school-aged children in a monogamous relationship. She is asking about non-oral contraceptive methods but does not want to consider permanent sterilization for herself or her partner. This patient has no significant medical history but smokes 1 pack of cigarettes daily. Which of the following is the best contraceptive option for this patient? Transdermal Contraceptive Patch Etonogestrel Subdermal Implant Diaphragm Levonorgestrel Intrauterine Device (IUD)
The levonorgestrel IUD is the best choice because it is both an extremely effective birth control method, and does not have the heightened risk of thrombotic events in smokers-regardless of age. • Based on current studies, the levonorgestrel IUD does not appear to increase thrombotic risk in women. This is thought to be because the IUD only releases enough hormone to have local effects—rather than systemic effects. Therefore, the levonorgestrel IUD does not inhibit ovulation, but rather prevents pregnancy by thickening cervical mucus and thinning the endometrium—however the failure rate is still less than 1%—comparable to the failure rates of the etonogestrel subdermal implant or even surgical sterilization. • Transdermal contraceptive patches and the etonogestrel subnormal implant both carry an increased risk of thrombotic events in smokers, probably because there is a higher systemic level of hormone—causing the inhibition of ovulation. • The diaphragm does not carry increased risk of thrombotic events but is not nearly as effective as the levonorgestrel IUD in preventing pregnancy.
Your 32-year-old patient has been using Depo-Provera and recently received her shot before getting married. She would like to start planning to have a family. She visits your clinic hoping to get pregnant within the next three months. Your response to her is that: She will have an immediate return to fertility after three months since she just received a shot. She may have a delay in her return to fertility for up to one year or longer. She will have an immediate return to fertility as soon as her period is regular again. She should have an immediate return to fertility.
The patient should be advised that she may have a delayed return to ovulation and thus fertility of one year or longer, in some cases, for up to 18 months. Regardless of just receiving a shot, her return to fertility may still be delayed for longer than three months. She may not be fertile even when she begins cycling regularly again.
All of the following are examples of excessive androgens except: Weight gain and edema Acne and oily skin Syncope Hirsutism Increased libido
There are several causes for syncope, including estrogen excess and deficient progesterone, not excessive androgens. Acne and oily skin, weight gain, edema, increased libido, and hirsutism are often seen with androgen excess.
Which is a common side effect when using spermicides? All of the answers are correct Urinary tract infections Pelvic inflammatory disease Sexually transmitted infections Allergic reaction
Urinary tract infections and vaginal skin irritations are the most common side effects of spermicides. Sexually transmitted infections are not common side effects. They are simply not prevented with the use of spermicides. There is no risk for pelvic inflammatory disease from spermicides. Although vaginal skin irritation is common and allergic reactions can happen, allergic reactions are not common.
Androgen Excess examples
Weight Gain Edema Acne and oily skin Hirsutism Increased libido
Your patient asks you to prescribe her the most effective method of contraception. Which method has the highest failure rate? Depo-Provera Oral contraceptives Diaphragm Spermicides
You recommend she avoid using spermicides alone as they have the highest failure rate (21%). Diaphragm use has an 18% failure rate. For the first year of use, oral contraceptives have a <3% failure rate when used correctly. DepoProvera has a <1% failure rate.