CMN 572 COMPREHENSIVE EXAM UPDATED
QUESTIONS AND ANSWERS GRADED A+
✔✔categories of OC - ✔✔Combination oral contraceptives (COCs) have an estrogen
and a progestin
Progestin-only pills (POPs) have only progestin
Tri-phasic pills are COCs that have different doses for each of 3 weeks plus a placebo
week
Extended cycle pills are COCs that provide menses once every 3-12 months:
Seasonique or Seasonique Lo or you can use COCs (not tri-phasics) or POPs and drop
placebo pills to mimic this regimen.
Continuous cycling for a year: Lybrel
✔✔basic considerations prior to prescribing OCs - ✔✔[CVD, bleeding/clot disorders]
Don't use a medication strength stronger than 1/35 (progestin/estrogen); 1/50 pills are
reserved for ovarian suppression monitored by a specialist
Patients with family history of clotting disorders get testing first (factor V Leiden)
Patients with a family history of CVD before age 50 need to be evaluated by a specialist
before starting OCPs
Patients with heavy bleeding should get a platelet function test to r/o bleeding disorders
before OCP start
✔✔Normal Menstrual flow & suggested OC types - ✔✔Light flow/mild cramps: OCP with
low endometrial activity (Examples: Demulen 1/35, Alesse)
Moderate flow/average cramps: medium endometrial activity especially starting out
(Examples: Apri, LoOvral, Ortho Tri-cyclen, Necon 1/35, Ocella)
Heavy flow and severe cramps: high endometrial activity (Examples: Ovral)
✔✔Irregular menses OC types - ✔✔Irregular menses + PCOS or insulin resistance:
high progestin, low androgen (Examples: Apri, Demulen 1/35, Alesse, Yaz)
Irregular menses other than above: low estrogen/progestin (Examples: Micronor, Ortho
TriCyclen Lo, Alesse)
✔✔Symptoms of estrogen sensitive women - ✔✔Nausea or edema at midcycle
Enlarged uterus
Uterine fibroids
,Large or painful breasts
Fibrocystic breasts
Heavy menstruation
Severe cramps with menses
✔✔OC for estrogen sensitive women: - ✔✔Choose OC with low estrogen activity:
progestin-only pills or those with 20 mcg ethinyl estradiol (EE)
✔✔OC for progesterone sensitive women: - ✔✔Choose low progestational OCs or a tri-
phasic pill:
Progestin-only pills (POPs), Alesse, or Yasmin/Yaz
✔✔Symptoms of progesterone sensitive women: - ✔✔Premenstrual S/S: edema,
abdominal bloating, headache, depression
Or if they had these S/S during pregnancy: excessive appetite, weight gain or tiredness;
hypertension; varicose veins
✔✔Symptoms of estrogen deficiency & OC - ✔✔Scant menses
Small uterus
Small breasts
Midcycle spotting
Choose an combination oral contraceptive(COC) with 20 or 25 mcg EE
✔✔Symptoms of Progesterone deficiency & OC - ✔✔Prolonged menses
Heavy menses
Severe cramping
Premenstrual breakthrough bleeding or spotting
Premenstrual S/S
Similar to women with anovulatory cycles, corpus luteum insufficiency, endometriosis
and adenomyosis. Choose a COC with increased progestational and/or androgenic
activities such as: Loestrin, Seasonale, Seasonique
✔✔Migraine & OCP considerations - ✔✔Previous history of premenstrual migraines:
consider putting women on continuous regimens - drop placebos and start new pack; it
is usually the drop in estrogen which precipitates premenstrual migraines
DO NOT CONTINUE PILLS IN PATIENTS WITH NEW ONSET OR WORSENING
HEADACHES OR MIGRAINES [concern for stroke]
DO NOT START OCPs IN WOMEN WITH ANY TYPE OF MIGRAINE WITH AURA
✔✔most common side effect of OCP: - ✔✔Break Through Bleeding (BTB)
,Most common with low dose COCs and POPs
More common in overweight women and smokers
More common in extended use cycles
Will occur if patient misses pills or does not take at the same time daily
Eliminate possible pregnancy (do UCG or serum HCG)
✔✔breakthrough bleeding onset & estrogen levels - ✔✔Bleeding < 10th pill =
insufficient estrogen activity
Bleeding > 10th pill = insufficient progestin dose
bleeding starts after day 14: use higher progestational activity OC
If the patient is not a good historian as to when BTB occurs: higher androgenic activity
can be used
If bleeding starts before day 14 or if menses continues into the active pill cycle: switch to
a higher estrogen OC
✔✔breast feeding considerations/post partum and OCPs - ✔✔You can initiate POPs,
Depo-Provera, Implanon/ Nexplanon or Mirena IUD after six weeks postpartum (unless
high risk for pregnancy)
You should not use COCs since estrogen decreases the milk supply.
Consider switching mothers to COCs once breastfeeding is finished since this would
decrease the chance of failure
✔✔post partum OCP use & patient is not breastfeeding - ✔✔COCs can be started after
the sixth week postpartum-Starting hormonal methods before this time may increase the
chance of thromboembolism
Patients can use condoms and lubrication during the first three weeks postpartum or
abstinence
The mother is the one who determines the time for intercourse to resume - no one else!
✔✔Pre-existing HTN & OCP use - ✔✔pre-existing hypertension, even if it is controlled
with medication, they are at risk. Let the OB-GYN make this call and then you can follow
the plan after their okay.
COCs increase angiotensin II and may cause fluid retention. Some patients may do fine
on POPs, but let the specialist make that call.
Consider other forms of non-hormonal birth control: Copper IUD (Paragard) or barrier
methods.
, ✔✔Obesity & OCPs - ✔✔Consultation with a OB/GYN
Depo Provera injections can cause weight gain, use with caution.
Cooper or Mirena IUD-May be a higher failure with some hormonal methods due to
absorption and dosing issues
✔✔Teen education & OCPs - ✔✔Spend time teaching: same time every
day, what to do if they forget; common SE
first three months. Written reinforcement goes
with the patient.
Do parents know teen is using contraceptive? If
teen needs to hide the pills, they are more likely to forget to take them=Suggest
another method.
Emphasize that pills and condoms go together. Reinforce safe sex practices.
✔✔Acne considerations & OCPs - ✔✔COCs with low androgenic-to-progestin activity
ratios and those with moderate-to-high estrogen contents will most likely help.
Still important to follow acne care directions.
Patients on Accutane will have you sign a form indicating the usage of two forms of birth
control.
Good types to use:
Yasmin (generic is Ocella), Yaz,
Cyclessa, Ortho Tri-Cyclen
✔✔smoking considerations & OCPS - ✔✔No COCs ages 35 or over: POPs only or non-
hormonal method such as copper IUD.
Under 35: Proceed with caution - use low dose pills or POPs. Consider all the factors in
the patient's history.
Remember to reiterate the message to quit smoking at every single opportunity. Have
smoking cessation resources available
✔✔depression considerations & OCPs - ✔✔Proceed with caution.
Here are a few things to consider:
Continuous cycling (no placebo pills) may be helpful.
Avoid Depo Provera injections - once it's injected it can't be removed. Try POPs in oral
form first to see how tolerated.
Yaz is indicated for PMDD
Use low dose COCs and re-evaluate in 3 months or sooner if you are really concerned.
✔✔routine assessment of initial OCP start - ✔✔Have patient return in 3 months for BP
check and assessment of SEs and ACHES, new medications. If all is okay, proceed
with another six month Rx. Do not give more than six months of OCPs at one time
QUESTIONS AND ANSWERS GRADED A+
✔✔categories of OC - ✔✔Combination oral contraceptives (COCs) have an estrogen
and a progestin
Progestin-only pills (POPs) have only progestin
Tri-phasic pills are COCs that have different doses for each of 3 weeks plus a placebo
week
Extended cycle pills are COCs that provide menses once every 3-12 months:
Seasonique or Seasonique Lo or you can use COCs (not tri-phasics) or POPs and drop
placebo pills to mimic this regimen.
Continuous cycling for a year: Lybrel
✔✔basic considerations prior to prescribing OCs - ✔✔[CVD, bleeding/clot disorders]
Don't use a medication strength stronger than 1/35 (progestin/estrogen); 1/50 pills are
reserved for ovarian suppression monitored by a specialist
Patients with family history of clotting disorders get testing first (factor V Leiden)
Patients with a family history of CVD before age 50 need to be evaluated by a specialist
before starting OCPs
Patients with heavy bleeding should get a platelet function test to r/o bleeding disorders
before OCP start
✔✔Normal Menstrual flow & suggested OC types - ✔✔Light flow/mild cramps: OCP with
low endometrial activity (Examples: Demulen 1/35, Alesse)
Moderate flow/average cramps: medium endometrial activity especially starting out
(Examples: Apri, LoOvral, Ortho Tri-cyclen, Necon 1/35, Ocella)
Heavy flow and severe cramps: high endometrial activity (Examples: Ovral)
✔✔Irregular menses OC types - ✔✔Irregular menses + PCOS or insulin resistance:
high progestin, low androgen (Examples: Apri, Demulen 1/35, Alesse, Yaz)
Irregular menses other than above: low estrogen/progestin (Examples: Micronor, Ortho
TriCyclen Lo, Alesse)
✔✔Symptoms of estrogen sensitive women - ✔✔Nausea or edema at midcycle
Enlarged uterus
Uterine fibroids
,Large or painful breasts
Fibrocystic breasts
Heavy menstruation
Severe cramps with menses
✔✔OC for estrogen sensitive women: - ✔✔Choose OC with low estrogen activity:
progestin-only pills or those with 20 mcg ethinyl estradiol (EE)
✔✔OC for progesterone sensitive women: - ✔✔Choose low progestational OCs or a tri-
phasic pill:
Progestin-only pills (POPs), Alesse, or Yasmin/Yaz
✔✔Symptoms of progesterone sensitive women: - ✔✔Premenstrual S/S: edema,
abdominal bloating, headache, depression
Or if they had these S/S during pregnancy: excessive appetite, weight gain or tiredness;
hypertension; varicose veins
✔✔Symptoms of estrogen deficiency & OC - ✔✔Scant menses
Small uterus
Small breasts
Midcycle spotting
Choose an combination oral contraceptive(COC) with 20 or 25 mcg EE
✔✔Symptoms of Progesterone deficiency & OC - ✔✔Prolonged menses
Heavy menses
Severe cramping
Premenstrual breakthrough bleeding or spotting
Premenstrual S/S
Similar to women with anovulatory cycles, corpus luteum insufficiency, endometriosis
and adenomyosis. Choose a COC with increased progestational and/or androgenic
activities such as: Loestrin, Seasonale, Seasonique
✔✔Migraine & OCP considerations - ✔✔Previous history of premenstrual migraines:
consider putting women on continuous regimens - drop placebos and start new pack; it
is usually the drop in estrogen which precipitates premenstrual migraines
DO NOT CONTINUE PILLS IN PATIENTS WITH NEW ONSET OR WORSENING
HEADACHES OR MIGRAINES [concern for stroke]
DO NOT START OCPs IN WOMEN WITH ANY TYPE OF MIGRAINE WITH AURA
✔✔most common side effect of OCP: - ✔✔Break Through Bleeding (BTB)
,Most common with low dose COCs and POPs
More common in overweight women and smokers
More common in extended use cycles
Will occur if patient misses pills or does not take at the same time daily
Eliminate possible pregnancy (do UCG or serum HCG)
✔✔breakthrough bleeding onset & estrogen levels - ✔✔Bleeding < 10th pill =
insufficient estrogen activity
Bleeding > 10th pill = insufficient progestin dose
bleeding starts after day 14: use higher progestational activity OC
If the patient is not a good historian as to when BTB occurs: higher androgenic activity
can be used
If bleeding starts before day 14 or if menses continues into the active pill cycle: switch to
a higher estrogen OC
✔✔breast feeding considerations/post partum and OCPs - ✔✔You can initiate POPs,
Depo-Provera, Implanon/ Nexplanon or Mirena IUD after six weeks postpartum (unless
high risk for pregnancy)
You should not use COCs since estrogen decreases the milk supply.
Consider switching mothers to COCs once breastfeeding is finished since this would
decrease the chance of failure
✔✔post partum OCP use & patient is not breastfeeding - ✔✔COCs can be started after
the sixth week postpartum-Starting hormonal methods before this time may increase the
chance of thromboembolism
Patients can use condoms and lubrication during the first three weeks postpartum or
abstinence
The mother is the one who determines the time for intercourse to resume - no one else!
✔✔Pre-existing HTN & OCP use - ✔✔pre-existing hypertension, even if it is controlled
with medication, they are at risk. Let the OB-GYN make this call and then you can follow
the plan after their okay.
COCs increase angiotensin II and may cause fluid retention. Some patients may do fine
on POPs, but let the specialist make that call.
Consider other forms of non-hormonal birth control: Copper IUD (Paragard) or barrier
methods.
, ✔✔Obesity & OCPs - ✔✔Consultation with a OB/GYN
Depo Provera injections can cause weight gain, use with caution.
Cooper or Mirena IUD-May be a higher failure with some hormonal methods due to
absorption and dosing issues
✔✔Teen education & OCPs - ✔✔Spend time teaching: same time every
day, what to do if they forget; common SE
first three months. Written reinforcement goes
with the patient.
Do parents know teen is using contraceptive? If
teen needs to hide the pills, they are more likely to forget to take them=Suggest
another method.
Emphasize that pills and condoms go together. Reinforce safe sex practices.
✔✔Acne considerations & OCPs - ✔✔COCs with low androgenic-to-progestin activity
ratios and those with moderate-to-high estrogen contents will most likely help.
Still important to follow acne care directions.
Patients on Accutane will have you sign a form indicating the usage of two forms of birth
control.
Good types to use:
Yasmin (generic is Ocella), Yaz,
Cyclessa, Ortho Tri-Cyclen
✔✔smoking considerations & OCPS - ✔✔No COCs ages 35 or over: POPs only or non-
hormonal method such as copper IUD.
Under 35: Proceed with caution - use low dose pills or POPs. Consider all the factors in
the patient's history.
Remember to reiterate the message to quit smoking at every single opportunity. Have
smoking cessation resources available
✔✔depression considerations & OCPs - ✔✔Proceed with caution.
Here are a few things to consider:
Continuous cycling (no placebo pills) may be helpful.
Avoid Depo Provera injections - once it's injected it can't be removed. Try POPs in oral
form first to see how tolerated.
Yaz is indicated for PMDD
Use low dose COCs and re-evaluate in 3 months or sooner if you are really concerned.
✔✔routine assessment of initial OCP start - ✔✔Have patient return in 3 months for BP
check and assessment of SEs and ACHES, new medications. If all is okay, proceed
with another six month Rx. Do not give more than six months of OCPs at one time
