Module 3 Kelsey Chapter 4

Question 1

Estrogen is released by the ovary in response to:

A) FSH.
B) GnRH.
C) hCG.
D) LH.

Answer 1

FSH.

FSH is released by the anterior pituitary gland in response to GnRH from the hypothalamus. FSH stimulates ovarian follicular growth, resulting in increased levels of the estradiol.

Question 2

Which of the following androgens can be converted to estradiol?

A) Androstenedione
B) Cortisol
C) DHA
D) Testosterone

Answer 2

Testosterone

Testosterone is produced in the adrenal gland, in the ovarian stroma, and through conversion of androstenedione and DHA in peripheral tissues. Testosterone is aromatized to estradiol in peripheral tissues.

Question 3

Increased production of ____________ is associated with primary dysmenorrhea.

A) androstenedione
B) arachidonic acid
C) cortisol
D) prostaglandin

Answer 3

prostaglandin

Prostaglandins act at target sites near areas of secretion. They regulate contraction and relaxation of smooth muscle. Prostaglandins are produced by the endometrium, with peak levels occurring in the late secretory phase. They stimulate uterine myometrial contractions.

Question 4

Which of the following actions does the estrogen in COCs include?

A) Inhibits ovulation through suppression of the LH surge
B) Inhibits sperm penetration by thickening cervical mucus
C) Provides most of the contraceptive effect for COCs
D) Stabilizes the endometrium for less unscheduled bleeding

Answer 4

Stabilizes the endometrium for less unscheduled bleeding

The estrogen in COCs stabilizes the endometrium, so less unscheduled bleeding occurs. Estrogen contributes to the inhibition of ovulation through suppression of FSH; however, it mainly potentiates the action of progestin, which has the most contraceptive effect.

Question 5

Which of the following statements is true concerning the luteal phase of the menstrual cycle?

A) It begins at the time of the LH surge.
B) It corresponds with the uterine proliferative phase.
C) There is thickened cervical mucus.
D) It lasts an average of 10 days from the time of ovulation to menses.

Answer 5

There is thickened cervical mucus.

The luteal phase of the menstrual cycle begins after ovulation occurs, lasts approximately 14 days (± 2 days), and ends with the first day of menses. Progesterone secreted from the corpus luteum causes thickened cervical mucus. The luteal phase corresponds with the uterine secretory phase.

Question 6

Instructions for progestin-only oral contraceptive users should include which of the following statements?

A) If you are more than 3 hours late taking a pill, use a backup method for 48 hours.
B) If you miss taking two pills in the third week of the pack, throw away the pack and start a new one.
C) If you miss pills in the fourth week of the pack, you do not have to use a backup method.
D) If you miss two pills in the first week of the pack, make them up and use a backup method for 7 days.

Answer 6

If you are more than 3 hours late taking a pill, use a backup method for 48 hours.

The major mechanism of action of progestin-only pills is the thickening of cervical mucus. Progestin-only pills must be taken at the same time each day to maintain adequate progestin for this effect. Progestin levels peak shortly after taking a pill and decline to nearly undetectable levels 24 hours later.

Question 7

Which of the following statements about prolactin is correct?

A) It is produced by the placenta during pregnancy.
B) It is secreted by the posterior pituitary gland.
C) It stimulates the breastmilk ejection reflex with suckling.
D) It stimulates synthesis of milk proteins in mammary glands.

Answer 7

It stimulates synthesis of milk proteins in mammary glands.

Prolactin is secreted by the anterior pituitary gland. During pregnancy, prolactin stimulates synthesis of milk proteins in the mammary glands. Oxytocin is secreted by the posterior pituitary gland in response to suckling and stimulates the breastmilk ejection reflex.

Question 8

A menopausal client experiencing discomfort with sexual intercourse related to vaginal dryness wants to know whether she should use a vaginal lubricant or a vaginal moisturizer. Correct information to provide would include all of the following except:

A) lubricants are intended to reduce friction during sex.
B) lubricants may take several weeks of use before becoming effective.
C) moisturizers provide longer-term relief of vaginal dryness than do lubricants.
D) moisturizers are typically applied several times weekly.

Answer 8

lubricants may take several weeks of use before becoming effective.

Vaginal lubricants have an immediate effect and are intended to reduce friction on atrophic vulvovaginal structures during sex. Vaginal moisturizers are applied several times weekly for longer-term relief of vaginal dryness. Moisturizers help maintain vaginal moisture and lower vaginal pH.

Question 9

The lymph nodes that drain directly into the infraclavicular nodes are the:

A) central nodes.
B) lateral nodes.
C) subscapular nodes.
D) supraclavicular nodes.

Answer 9

central nodes.

The pectoral, subscapular, and lateral axillary lymph nodes drain into the central nodes that are located high in the axilla between the anterior and posterior axillary nodes and are the most likely to be palpable. The central nodes drain into the infraclavicular and supraclavicular nodes.

Question 10

Drugs that increase production of cytochrome P-450 may decrease the effectiveness of COCs by which of the following mechanisms?

A) Decrease in absorption in the gastrointestinal tract
B) Decrease in enterohepatic recirculation
C) Increase in first-pass metabolism in the liver
D) Increase in protein binding at receptor sites

Answer 10

Increase in first-pass metabolism in the liver

Drugs that increase production of the liver enzyme cytochrome P-450 may cause more rapid clearance of COCs during first-pass metabolism in the liver.

Question 11

A 4-week-postpartum woman who is breastfeeding on demand without supplements presents in your office to discuss contraceptive options. She says she plans to continue breastfeeding for at least 6 months. Information for this client concerning the lactational amenorrhea method of contraception should include which of the following statements?

A) The expected failure rate for this method of contraception is about 20%.
B) This method is considered effective for only 3 months postpartum.
C) The patient can rely on this method as long as a period has not occurred.
D) Another method of contraception should be considered when the infant begins sleeping through the night.

Answer 11

Another method of contraception should be considered when the infant begins sleeping through the night.

Alternative contraception should be considered when any of the following occur—menses, regular supplementation, long periods without breastfeeding, baby is 6 months old.

Question 12

The predominant estrogen after menopause is:

A) estradiol.
B) estriol.
C) estrone.
D) estropipate.

Answer 12

estrone.

The predominant estrogen after menopause is estrone. Estrone is converted from androstenedione produced by the adrenal gland and ovarian stroma.

Question 13

Which of the following contraceptive choices should not be recommended for the perimenopausal individual who is having irregular menses?

A) COCs.
B) Diaphragm
C) Fertility awareness methods
D) LNG-IUS

Answer 13

Fertility awareness methods

The perimenopausal woman who is having irregular menses may have unpredictable ovulation, so she should not rely on fertility awareness methods for contraception.

Question 14

Which phase of the menstrual cycle is the most variable?

A) Follicular
B) Luteal
C) Ovarian
D) Secretory

Answer 14

Follicular

The follicular phase begins day 1 of menses and ends with ovulation. This phase is more variable in terms of time frame than the luteal phase, which is normally 14 days (± 2 days).

Question 15

A vaginal pH less than 4.5 is an expected finding in a:

A) healthy reproductive-age woman.
B) menopausal woman with atrophic vaginitis.
C) woman using the lactational amenorrhea method of contraception.
D) healthy prepubertal-age girl.

Answer 15

healthy reproductive-age woman.

An acidic vagina pH (less than 4.5) is an expected finding in a healthy reproductive-age woman. This acidic pH is the result of the prevalence of lactobacilli, which in turn reflects the influence of estrogen initiated during puberty. Menopausal women and women who are using the lactational amenorrhea method of contraception may have a more alkaline pH as a result of decreased estrogen levels.

Question 16

The ACS recommends yearly mammogram screening beginning at age:

A) 40
B) 45
C) 50
D) 55

Answer 16

The ACS recommends yearly mammograms for women starting at age 45.

Question 17

The most prevalent contraceptive method among married women in the United States is:

A) COCs.
B) condoms.
C) sterilization.
D) withdrawal.

Answer 17

sterilization.

The most prevalent contraceptive method among married women in the United States is sterilization (female and male).

Question 18

Instructions and/or information for a new user of COCs should include:

A) COCs may decrease the effectiveness of some antibiotics.
B) discontinue your pills immediately if you miss a period.
C) start the first pack of pills on the last day of your next period.
D) Sunday starters should use a backup method for the first week of the first pack of pills.

Answer 18

Sunday starters should use a backup method for the first week of the first pack of pills.

A first day of menses start does not require backup contraception. The quick-start method for COCs requires backup contraception for 7 days except if switching directly from one hormonal method to another. A Sunday start requires 7 days of backup method unless it corresponds with the first day of menses.

Question 19

A client calls the clinic on Monday morning. She had unprotected sex Friday night and is interested in emergency contraception. Appropriate information for this client would include which of the following statements?

A) Emergency contraception pills are very effective for a medication abortion in early pregnancy.
B) If she is not midcycle when she had sex, she does not need emergency contraception.
C) It is too late for emergency contraceptive pills, but insertion of an IUC is an option.
D) She can use emergency contraception pills even if she has had other unprotected sex since her last period.

Answer 19

She can use emergency contraception pills even if she has had other unprotected sex since her last period.

Emergency contraception pills should be taken as soon as possible after unprotected sex and within 120 hours for maximum effectiveness. If the woman has had previous unprotected sex since her last period and more than 120 hours ago, obtain a urine pregnancy test to rule out an existing pregnancy.

Question 20

Squamous metaplasia of the cervix occurs within the:

A) columnar epithelium.
B) internal cervical os.
C) squamous epithelium.
D) transformation zone.

Answer 20

transformation zone.

Squamous metaplasia is the process whereby columnar cells of the endocervix are replaced by mature squamous epithelium. The transformation zone is the area around the junction of squamous and columnar cells (squamocolumnar junction) where squamous metaplasia occurs.

Question 21

Advantages of the cervical cap over the diaphragm include which of the following?

A) It has a lower failure rate.
B) It is easier to insert.
C) It can remain in place for 48 hours.
D) Spermicide is not needed.

Answer 21

It can remain in place for 48 hours.

The diaphragm should not be left in place for more than 24 hours. The cervical cap may be left in place for up to 48 hours.

Question 22

Which of the following statements by a client indicates the need for the clinician to provide additional information about use of the contraceptive vaginal ring?

A) “I should insert a new ring every 7 days.”
B) “I should expect to have regular periods while using the ring.”
C) “My partner can use a male condom while I am wearing the ring.”
D) “The exact position of the ring in the vagina is not important.”

Answer 22

“I should insert a new ring every 7 days.”

The contraceptive vaginal ring is worn in the vagina for 3 weeks, followed by 1 week without the ring, when the woman will have a withdrawal bleed. The exact position of the ring in the vagina is not important to effectiveness. The male condom can be used with the contraceptive vaginal ring.

Question 23

Instructions for the use of nonoxynol-9 spermicide should include which of the following?

A) Place the spermicide close to the opening of the vagina for maximal effectiveness.
B) Remove excess spermicide from the vagina within 6 hours to reduce vaginal irritation.
C) When used with a condom, spermicide will further decrease the risk of STIs.
D) Frequent use of spermicide may cause vaginal changes, making you more susceptible to HIV infection.

Answer 23

Frequent use of spermicide may cause vaginal changes, making you more susceptible to HIV infection.

Frequent spermicide use (two or more times per day) may cause vulvovaginal epithelium disruption and, theoretically, increase susceptibility to HIV infection. Spermicide should be placed deep in the vagina close to the cervix and left there for at least 6 hours after sexual intercourse. When spermicide is used along with a condom, there is an increased contraceptive efficacy, but it will not further decrease the risk for STIs.

Question 24

Which of the following individuals should have an endometrial biopsy/evaluation?

A) Individual on continuous-cyclic HT regimen with amenorrhea
B) Individual on continuous-cyclic HT regimen with bleeding starting on the last few days of progestogen administration each month
C) Individual on continuous-combined HT regimen with irregular bleeding in the first year of use
D) Individual on continuous-combined HT regimen with spotting that occurs after several months of amenorrhea

Answer 24

Individual on continuous-combined HT regimen with spotting that occurs after several months of amenorrhea

Individuals using continuous-combined HT may initially have some unpredictable spotting and bleeding. After several months of use, the endometrium atrophies and amenorrhea usually results. If spotting or bleeding recurs after several months of amenorrhea, endometrial evaluation is warranted.

Question 25

A 25-year-old woman who has had an IUC for 2 years has a Pap test showing actinomycosis. She has no symptoms of infection. Appropriate management would include:

A) removing the IUC and repeating the Pap test in 6 months.
B) removing the IUC, treating with doxycycline, and repeating the Pap test in 1 year.
C) keeping the IUC and repeating the Pap test in 3 years.
D) keeping the IUC, treating with doxycycline, and repeating the Pap test in 3 months.

Answer 25

keeping the IUC and repeating the Pap test in 3 years.

Actinomyces is a normal female genital tract organism. IUC users are more likely to have colonization. Pelvic infection from Actinomyces is very rare, although it is a serious infection if it occurs. The Pap test does not diagnose actinomycosis infection. The asymptomatic IUC user should be informed of the Pap test result and should be advised that the IUC does not need to be removed and that she does not need any antibiotic treatment unless infection occurs.

Question 26

According to CDC recommendations, which of the following is considered to be a category 4 condition for use of the indicated contraceptive method?

A) Use of emergency contraceptive pills by a woman who has history of DVT
B) Insertion of an IUC in a woman with a history of PID
C) Use of COC by a 40-year-old woman who has migraine headaches without aura
D) Use of progestin-only pills by a woman who has type 2 diabetes

Answer 26

Use of COC by a 40-year-old woman who has migraine headaches without aura

The use of COCs by a woman who is 35 years or older and who has migraine headaches with or without aura is a CDC category 4 condition. The use of COCs by a woman of any age who has migraine headaches with aura is also a CDC category 4 condition.

Question 27

An advantage of the female condom is that it:

A) can be used with a male condom for added protection.
B) can be used for repeated acts of intercourse.
C) may be used by individuals with latex allergy.
D) has a lower failure rate than the male condom does.

Answer 27

may be used by individuals with latex allergy.

The female vaginal condom is made of nitrile, and previously was made of polyurethane, so it may be used by individuals with latex allergy.

Question 28

For which of the contraceptive methods is there the least difference between the perfect use and typical use failure rates?

A) COCs
B) Diaphragm
C) Intrauterine contraceptive
D) Male condom

Answer 28

Intrauterine contraceptive

The perfect use and typical use failure rates are the same or very close to the same for both levonorgestrel-releasing and copper-releasing intrauterine contraceptives. These methods do not require the woman to remember to do something each day or to have to have supplies available and use them at the time of sexual intercourse.

Question 29

The levonorgestrel-releasing IUC may be a better choice than the copper-releasing IUC for a woman who:

A) has never been pregnant.
B) has dysmenorrhea.
C) is currently breastfeeding.
D) is sure she does not want more children.

Answer 29

has dysmenorrhea.

The levonorgestrel-releasing IUC may cause reduced menstrual bleeding or amenorrhea and reduce dysmenorrhea. The copper-releasing IUC may increase dysmenorrhea.

Question 30

The structure in the breast that is responsible for milk production is the:

A) areola.
B) alveoli.
C) lobule.
D) lactiferous sinus.

Answer 30

alveoli.

Alveoli within the breast lobules are responsible for milk production.

Question 31

Healthy sperm can survive in the female reproductive tract and retain the ability to fertilize an egg for:

A) 12–24 hours.
B) 24–48 hours.
C) 3–5 days.
D) up to 7 days.

Answer 31

3–5 days.

Healthy sperm can survive in the female reproductive tract and retain ability to fertilize an egg for 3–5 days. An egg can be fertilized for 12–24 hours after release from the ovary.

Question 32

The hormone that stimulates synthesis of milk is:

A) aldosterone.
B) estrogen.
C) progesterone.
D) prolactin.

Answer 32

prolactin.

Prolactin is released from the anterior pituitary gland in increasing amounts during pregnancy. Prolactin stimulates synthesis of milk proteins in mammary tissue.

Question 33

Which hormone is dominant during the proliferative phase of the menstrual cycle?

A) Estrogen
B) LH
C) Progesterone
D) Prolactin

Answer 33

Estrogen

Estrogen is the predominant hormone during the uterine proliferative phase of the menstrual cycle, which correlates with the ovarian follicular phase. Under the influence of estrogen, the endometrium grows/thickens in the proliferative phase.

Question 34

The main mechanism of action of misoprostol in medically induced abortion is:

A) blocking the action of progesterone.
B) inhibiting enzymes necessary for DNA synthesis.
C) stimulating synthesis of prostaglandin by cells of the early decidua.
D) stimulating uterine contractions.

Answer 34

stimulating uterine contractions.

Misoprostol is commonly used in conjunction with mifepristone or methotrexate for medical abortions. Misoprostol, a prostaglandin analogue, softens the cervix and stimulates uterine contractions.

Question 35

When evaluating cervical mucus, the term spinnbarkeit refers to:

A) amount.
B) cellularity.
C) clarity.
D) elasticity.

Answer 35

elasticity.

Spinnbarkeit refers to the elasticity of cervical mucus (ability to be stretched between two fingers) seen at ovulation and under the influence of estrogen.

Question 36

The anatomic area that contains the urethral/vaginal openings, hymen, Skene’s glands, and Bartholin’s glands is called the:

A) labia majora.
B) perineum.
C) vestibule.
D) vulva.

Answer 36

vestibule.

The vestibule is enclosed by the labia minora. This area contains the urethral and vaginal openings; hymen; Skene’s glands on each side of the urethral meatus; and Bartholin’s glands, with openings located posteriorly on either side of the vaginal orifice.

Question 37

Contraindications to the use of medication abortion with mifepristone and misoprostol include all of the following except:

A) current use of an anticoagulant medication.
B) greater than 7 weeks’ gestation.
C) known or suspected ectopic pregnancy.
D) use of long-term systemic corticosteroid therapy.

Answer 37

greater than 7 weeks’ gestation.

The FDA has approved the use of mifepristone and misoprostol for medication abortion for up to 70 days after an LMP.

Question 38

An advantage of the transdermal patch over oral delivery of estrogen for the individual experiencing menopausal symptoms is that the transdermal delivery method:

A) does not require addition of a progestogen.
B) has fewer adverse effects on coagulation factors.
C) improves vulvovaginal symptoms more quickly.
D) increases HDL-C levels and decreases LDL-C levels.

Answer 38

has fewer adverse effects on coagulation factors.

Estrogen delivered via a transdermal patch has no effect on cardiovascular markers (HDL-C, LDL-C, triglycerides, C-reactive protein). There is less effect on coagulation factors and a lower risk of venous thromboembolism with transdermal estrogen compared with oral estrogen in the menopausal woman.

Question 39

Which of the following is not an FDA-approved indication for the use of HT?

A) Prevention of cardiovascular disease
B) Prevention of osteoporosis
C) Relief of moderate to severe symptoms of vulvovaginal atrophy
D) Relief of moderate to severe vasomotor symptom

Answer 39

Prevention of cardiovascular disease

The FDA-approved indications for HT include relief of moderate to severe menopausal symptoms related to estrogen deficiency (vasomotor instability, vulvar/vaginal atrophy), and prevention of osteoporosis.

Question 40

A 24-year-old female presents to your office with a request for COCs. Her current medications include a bronchodilator for asthma. Management for this client should include advising her that:

A) COCs are not recommended for women with asthma.
B) COCs may potentiate the action of her bronchodilator.
C) she should use a backup method if using the bronchodilator several days in a row.
D) progestin-only contraceptive injections may reduce her asthma attacks.

Answer 40

COCs may potentiate the action of her bronchodilator.

COCs may potentiate the action of some drugs, including benzodiazepines, tricyclic antidepressants, and theophylline.

Question 41

Which of the following list of events is in the correct chronological order?

A) LH surge, ovulation, rise in BBT, thickened cervical mucus
B) Ovulation, LH surge, thickened cervical mucus, rise in BBT
C) Rise in BBT, thickened cervical mucus, ovulation, LH surge
D) Thickened cervical mucus, rise in BBT, LH surge, ovulation

Answer 41

LH surge, ovulation, rise in BBT, thickened cervical mucus

The LH surge occurs in the follicular phase and peaks about 10 to 12 hours before ovulation occurs. BBT increases at the time of ovulation. After ovulation, the corpus luteum formed from the ruptured follicle secretes progesterone, which causes thickening of cervical mucus and a sustained increase in BBT.

Question 42

A 53-year-old female asks you if increasing her soy product intake or taking an isoflavone supplement has any benefit for her now that she is menopausal. Information you would want to provide would include evidence showing that increasing soy product intake may help:

A) improve memory and concentration in menopausal women.
B) prevent osteoporosis in menopausal women.
C) prevent the skin changes that typically occur with aging.
D) reduce hot flash frequency and severity for some women.

Answer 42

reduce hot flash frequency and severity for some women.

Data from a meta-analysis of 17 small randomized controlled trials (Taku, Melby, Kronenberg, Kurzer, & Messina, 2012) support the efficacy of soy products in reducing hot flash frequency and severity for some women. Inform women that soy products vary in composition and concentration.

Question 43

A client calls the office to ask what to do because her contraceptive patch had come off, although it was easily reapplied. She knows it was fully attached last evening before having sex. Appropriate advice would include:

A) remove the current patch, apply a new one, and use a backup method for 7 days.
B) keep the current patch on if it adheres well and consider emergency contraception.
C) remove the current patch, start her patch-free week now, and then apply a new patch.
D) keep the current patch on if it adheres well and keep the same patch-change day.

Answer 43

keep the current patch on if it adheres well and keep the same patch-change day.

If a contraceptive patch is detached for less than 24 hours, it can be reattached if it adheres well or a new patch can be applied. The client should keep the same patch-change day. As long as it has been less than 48 hours since the patch detached, she does not need to use emergency contraception or a backup method.

Question 44

The predominant vaginal organism responsible for an acidic pH is:

A) Doderlein bacillus.
B) Gardnerella.
C) Haemophilus.
D) Lactobacillus.

Answer 44

Lactobacillus.

Lactobacillus is the predominant vaginal organism responsible for an acidic pH in the reproductive-age woman.

Question 45

Potential disadvantages of progestin-only implants include which of the following?

A) Side effects may be increased in individuals who are underweight.
B) They may cause a significant decrease in bone mineral density.
C) They may cause irregular bleeding and spotting.
D) Return to fertility after discontinuation may take several months.

Answer 45

They may cause irregular bleeding and spotting.

Users of progestin-only implants may experience irregular, prolonged, and more frequent bleeding, especially in the first few months of use. Progestin-only implants do not cause any decrease in bone mineral density. Most users ovulate within 6 weeks after removal.

Question 46

According to USPSTF recommendations, an 80-year-old female should have:

A) a clinical breast examination and a screening mammogram annually.
B) a clinical breast examination annually but no screening mammogram.
C) neither a clinical breast examination nor a screening mammogram.
D) a screening mammogram biennially but no clinical breast examination.

Answer 46

neither a clinical breast examination nor a screening mammogram.

The USPSTF recommends against routine clinical breast examination at any age and recommends biennial mammograms from age 50 to 74.

Question 47

Urine ovulation tests detect:

A) estrogen levels.
B) FSH surge.
C) LH surge.
D) progesterone levels.

Answer 47

LH surge.

Urine ovulation prediction tests detect an LH surge. Ovulation occurs within 32–44 hours after LH surge begins.

Question 48

Which of the following lab values would be expected with menopause?

A) Decreased FSH, increased LH, decreased estradiol
B) Decreased LH, increased FSH, increased estradiol
C) Increased FSH, increased LH, decreased estradiol
D) Increased LH, decreased FSH, increased estradiol

Answer 48

Increased FSH, increased LH, decreased estradiol

During the menopausal transition, production of estradiol decreases as the number of responsive ovarian follicles decreases. This decrease in estradiol triggers the increased release of FSH and LH from the anterior pituitary gland.

Question 49

A 68-year-old woman had cervical cancer screening done at age 65 and results were normal. She has no history of abnormal screenings. She has recently started having sexual intercourse with a new male partner and asks if she should start having cervical cancer screening again. An appropriate answer would be that she:

A) does not need Pap tests but should have HPV testing every 5 years.
B) does not need to resume either Pap tests or HPV testing.
C) should have a Pap test with HPV co-testing in 5 years and, if it is negative, can stop screening.
D) should resume Pap tests with HPV co-testing every 5 years.

Answer 49

does not need to resume either Pap tests or HPV testing.

The ACS, ACOG, and USPSTF recommend no further cervical cancer screening in women age 65 and older following adequate negative prior screening and no history of CIN2 or more serious diagnosis. Screening should not be resumed even if the woman reports a new sexual partner.

Question 50

A woman taking UPA for emergency contraception because she was late starting a new pack of her COC and had unprotected sex should be advised to:

A) abstain from sex or use a barrier method for 5 days and then restart her COCs.
B) abstain from sex or use a barrier method until her menses and then restart her COCs.
C) restart her COCs the next day; no backup method is needed.
D) restart her COCs the next day and use a backup method for 7 days.

Answer 50

abstain from sex or use a barrier method for 5 days and then restart her COCs.

There is theoretical concern that hormonal contraception may reduce the effectiveness of UPA as emergency contraception. The woman should be advised not to start hormonal contraception for at least 5 days after taking UPA. She should also use a backup method for the first 7 days after restarting her COCs.

Question 51

Which endogenous estrogen is known as the “estrogen of pregnancy”?

A) Estradiol
B) Estriol
C) Estrone
D) Estropipate

Answer 51

Estriol

Estriol is the least potent of the estrogens. It is derived from the conversion of estrone and estradiol in the liver, uterus, placenta, and fetal adrenal gland.

Question 52

A 20-year-old female who has a BMI of 38 (obese) presents for her first DMPA injection. Concerns in administering DMPA to this woman include which of the following?

A) She may need a larger dose than the usual 150 mg.
B) She should return for repeat injections every 2 months.
C) You should massage the injection site well to ensure absorption.
D) You should choose a site that ensures deep IM injection.

Answer 52

You should choose a site that ensures deep IM injection.

The IM formulation of DMPA must be given as a deep injection in the deltoid or gluteal muscle. For obese women, the deltoid may be preferable.

Question 53

Which of the following would not be an expected pelvic examination finding in a 70-year-old woman?

A) Narrow vaginal canal
B) Palpable ovaries
C) Small uterus
D) Thin vaginal walls

Answer 53

Palpable ovaries

Three to five years after menopause, ovaries are atrophic and are usually not palpable.

Question 54

Individuals who are going to take ospemifine for treatment of dyspareunia related to vulvovaginal atrophy should be advised that they:

A) will need to take a progestogen in addition to prevent endometrial hyperplasia.
B) may also use vaginal estrogen to further enhance the medication’s effect.
C) may experience hot flashes as a side effect of this medication.
D) should take the medication 2 to 3 hours before having sexual intercourse.

Answer 54

may experience hot flashes as a side effect of this medication.

Ospemifine is a SERM taken as a daily oral dose to treat moderate to severe dyspareunia related to vulvovaginal atrophy. Hot flashes are a common side effect. Estrogen should not be used in combination with ospemifine. No studies have looked at using a progestogen with ospemifine.

Question 55

Which of the following contraceptive methods would be best for a woman with a seizure disorder who is taking phenytoin?

A) COCs
B) Transdermal contraceptive patch
C) Progestin-only oral contraceptives
D) Progestin-only contraceptive injections

Answer 55

Progestin-only contraceptive injections

Some anticonvulsant medications, including phenytoin, induce cytochrome P-450 enzyme activity and can cause increased first-pass metabolism of COCs as well as progestin-only pills. Although no first-pass metabolism occurs with the transdermal contraceptive patch, the FDA applies the same warning about possible reduced efficacy. The effectiveness of DMPA injections is not affected by anticonvulsant medications and may decrease the incidence of seizures in affected individuals.

Question 56

Findings on a pelvic examination of a 25-year-old nulliparous female include uterus 8 cm in length, right ovary 3 cm × 2 cm, and left ovary not palpable. These findings indicate a(n):

A) normal uterus and normal ovaries.
B) normal uterus and enlarged right ovary.
C) enlarged uterus and, normal ovaries.
D) enlarged uterus and enlarged right ovary.

Answer 56

normal uterus and normal ovaries.

In a reproductive-age woman, the uterus is approximately 8 cm in length, 5 cm in width, and 2.5 cm in thickness, with slightly larger dimensions in the multiparous woman than the nulliparous woman. Ovaries are approximately 3 cm × 2 cm × 1 cm.

Question 57

A 58-year-old female with vaginal dryness causing irritation and dyspareunia has no problem with hot flashes. Of the following treatment choices, the best for her would be:

A) continuous-combined regimen hormone therapy (HT).
B) continuous-cyclic HT with added testosterone.
C) low-dose estrogen vaginal ring.
D) progestin-only therapy.

Answer 57

low-dose estrogen vaginal ring.

The menopausal woman who has symptoms related to vulvovaginal atrophy and no vasomotor symptoms is best treated with local low-dose vaginal estroge

Question 58

According to the CDC, initiating progestin-only contraceptive injections (DMPA) is a category 3 when which of the following conditions exists?

A) Age 35 years or older and smoking more than 15 cigarettes daily
B) History of DVT or pulmonary emboli
C) Unexplained vaginal bleeding prior to evaluation
D) Use of drugs that alter liver enzymes

Answer 58

Unexplained vaginal bleeding prior to evaluation

Unexplained vaginal bleeding prior to evaluation is a CDC category 3 condition for initiation of DMPA. Current and/or history of DVT or pulmonary emboli is a category 2 condition; drugs that alter liver enzymes do not influence effectiveness of DMPA, and smoking at any age is a category 1 condition for use of DMPA.

Question 59

The area located between the fourchette anteriorly and the anus posteriorly is the:

A) levator ani.
B) perineum.
C) prepuce.
D) vestibule.

Answer 59

perineum.

The area located between the fourchette anteriorly and the anus posteriorly is the perineum.

Question 60

A client who is requesting contraception and who also wants to get pregnant in one year should avoid using:

A) COCs.
B) fertility awareness methods.
C) progestin-only oral contraceptives.
D) progestin-only contraceptive injections.

Answer 60

progestin-only contraceptive injections.

Return to fertility after discontinuing progestin-only injections (DMPA) may take 6 to 12 months.

Question 61

A woman who has been using a copper-releasing IUC presents with a positive pregnancy test. After determining that the pregnancy is intrauterine and the IUC is in place, the woman should be informed that:

A) removing the IUC may increase the chance of a spontaneous abortion.
B) the baby is at risk for congenital defects related to copper exposure.
C) the IUC should be removed promptly regardless of her plans for the pregnancy.
D) there is no risk to the baby if she leaves the IUC in place until delivery.

Answer 61

the IUC should be removed promptly regardless of her plans for the pregnancy.

Removing the IUC reduces the risk for spontaneous abortion. There is no risk of congenital defects from copper exposure. If the IUC is left in place, the woman is at risk for spontaneous septic abortion as well as preterm delivery.

Question 62

Which of the following structures produces GnRH?

A) Anterior pituitary gland
B) Hypothalamus
C) Posterior pituitary gland
D) Ovaries

Answer 62

Hypothalamus

GnRH is released from the hypothalamus in a pulsatile fashion. GnRH stimulates the anterior pituitary gland to release FSH and LH.

Question 63

The polypeptide hormone produced by the ovaries that stimulates FSH production is:

A) activin.
B) follistatin.
C) inhibin.
D) prolactin.

Answer 63

activin.

Activin is a polypeptide hormone produced by the ovaries that stimulates FSH production. Inhibin, which is also a polypeptide hormone, inhibits FSH production. Follistatin binds with activin to inactivate it, thereby inhibiting FSH production.

Question 64

Non-contraceptive benefits of COCs include all of the following except:

A) decrease in risk for benign breast disease.
B) decrease in risk for cervical cancer.
C) decrease in risk for endometrial cancer.
D) decrease in risk for ovarian cancer.

Answer 64

decrease in risk for cervical cancer.

Non-contraceptive benefits of COCs include decreased risks for benign breast disease, endometrial cancer, and ovarian cancer.

Question 65

An advantage of continuous-combined HT over continuous-cyclic HT regimens is:

A) no estrogen-free period during which vasomotor symptoms can occur.
B) predictable withdrawal bleeding each month.
C) lower cumulative dose of progestin.
D) less negative impact on triglyceride levels.

Answer 65

lower cumulative dose of progestin.

Estrogen and progestogen are taken every day with a continuous-combined HT regimen with lower cumulative dose of progestogen than continuous-cyclic HT regimen in which estrogen is taken every day and larger doses of progestogen are added 10 to 14 days each month.

Question 66

According to CDC recommendations, which of the following would be considered a category 4 condition for the indicated contraceptive method?

A) Levonorgestrel IUC for woman with endometriosis
B) Copper IUC for woman with history of breast cancer
C) Progestin-only pills for woman with past history of DVT
D) Vaginal contraceptive ring for woman older than 35 years of age who smokes one pack of cigarettes per day

Answer 66

Vaginal contraceptive ring for woman older than 35 years of age who smokes one pack of cigarettes per day

Smoking 15 or more cigarettes a day at age 35 years or older is a CDC category 4 condition for all of the CHCs.

Question 67

Which of the following estrogen therapy options does not require opposition by a progestogen in an individual with an intact uterus?

A) Bioidentical oral estrogen formulation
B) Estring vaginal ring
C) Plant-based (estriol) oral estrogen
D) Transdermal estrogen patch

Answer 67

Estring vaginal ring

The Estring vaginal ring has little or no systemic absorption and does not require opposition by a progestogen.

Question 68

A 4-week-postpartum woman who is breastfeeding now and plans to start weaning the baby in the next month is in your office to discuss her contraceptive options. She has a BMI of 35 (obese). Of the following, the best contraceptive choice for her at this time would be:

A) COCs.
B) fertility awareness method.
C) lactational amenorrhea method.
D) progestin-only pills.

Answer 68

progestin-only pills.

Progestin-only methods are classified as CDC category 1 for lactating women 30 or more days postpartum. CHCs are classified as CDC category 3 for the first 42 days postpartum for women with other venous thromboembolism risk factors, which include obesity. Fertility awareness methods are not recommended until the woman has resumed regular menses. She is weaning her baby, so she will not be able to rely on the lactational amenorrhea method for contraception.

Question 69

Level I evidence (i.e., high quality randomized controlled trials, systematic review of level I studies) supports the use of which of the following strategies for managing mild-moderate vasomotor symptoms related to menopause?

A) Acupuncture
B) Cognitive behavior therapy
C) Exercise
D) Yoga

Answer 69

Cognitive behavior therapy

Level I evidence (i.e., high quality randomized controlled trials, systematic review of level I studies) supports the use of cognitive behavioral therapy—group or self-guided and clinical hypnosis for managing mild-moderate vasomotor symptoms related to menopause. Data on long-term use are limited.

Question 70

A 51-year-old female asks you if she should take estrogen to help her memory because she is sometimes forgetful and has difficulty concentrating. Her mother developed dementia at age 65. The best initial response would be to:

A) advise her that she may benefit from taking estrogen for about 5 years.
B) ask about other menopausal symptoms such as hot flashes and night sweats.
C) tell her the WHIMS study showed an increase in dementia for women her age who took estrogen.
D) tell her that her memory changes are likely caused by depression.

Answer 70

ask about other menopausal symptoms such as hot flashes and night sweats.

Although more history and a physical examination may be warranted, the best answer choice is to initially ask about other menopausal symptoms such as hot flashes and night sweats. These vasomotor symptoms can contribute to memory impairment and difficulty concentrating as a result of sleep disturbance. If the client has vasomotor symptoms, short-term HT may be an option.

Question 71

A client is planning to use measurement of basal body temperatures as a means of contraception. Which of the following statements would indicate the need for further instruction about this method?

A) “I will take my temperature the same time each day before getting out of bed.”
B) “I know that I am about to ovulate when my temperature rises at least 0.4°F.”
C) “I will need to use a special thermometer to take my basal body temperature.”
D) “A rise of 0.4°F above my baseline for 3 days indicates that it is safe to have sex.”

Answer 71

“I know that I am about to ovulate when my temperature rises at least 0.4°F.”

The rise in BBT occurs at the time of ovulation. BBT cannot be used to predict ovulation, but it can be used to determine whether ovulation has occurred.

Question 72

The term for the anatomic abnormality in which a male has a tight foreskin that cannot be retracted is:

A) hypospadias.
B) Peyronie’s disease
C) phimosis.
D) varicocele

Answer 72

phimosis.

The term for the anatomic abnormality in which a male has a tight foreskin that cannot be retracted is phimosis. Phimosis may contribute to male infertility.

Question 73

A woman plans to use the calendar method for contraception. She has charted her menstrual cycles for several months and has noted her longest cycle to be 30 days and her shortest cycle to be 27 days. She should abstain from sexual intercourse each cycle from day _____ through day ____.

A) 9; 19
B) 10; 15
C) 11; 18
D) 12; 16

Answer 73

9; 19

The woman who plans to use the calendar method for contraception should chart her menstrual cycles for several months. She should subtract 11 days from her longest recorded cycle and 18 days from her shortest cycle to estimate when she would be fertile and infertile. The woman with 27- to 30-day cycles should abstain from sexual intercourse from day 9 (27 minus 18) through day 19 (30 minus 11).

Question 74

The sebaceous glands located within the areola are called:

A) Bartholin’s glands.
B) Cowper’s glands.
C) Montgomery’s glands.
D) Skene’s glands.

Answer 74

Montgomery’s glands.

Montgomery’s glands are the sebaceous glands that circle the nipple within the area of the areola.

Question 75

A woman who weighs 200 lb or more may have decreased effectiveness with which of the following contraceptive methods?

A) Progestin-only injectable contraception
B) Contraceptive vaginal ring
C) Levonorgestrel intrauterine system
D) Transdermal contraceptive system

Answer 75

Transdermal contraceptive system

The transdermal contraceptive patch may be less effective in women who weigh 90 kg (198 lb) or more.

Question 76

Which of the following factors may increase levels of SHBG?

A) Estrogen-containing oral contraceptives
B) Hyperinsulinemia
C) Increased androgen levels
D) Obesity

Answer 76

Estrogen-containing oral contraceptives

Factors that increase SHBG include hyperthyroidism, pregnancy, and use of estrogen-containing oral contraceptives. Factors that decrease SHBG include obesity, hyperinsulinemia, and androgens.

Question 77

Which of the following statements concerning coitus interruptus is false?

A) It has a lower perfect use failure rate than the cervical cap.
B) It may result in a decreased risk for HIV transmission to the female partner.
C) Men are typically not able to predict the timing of ejaculation.
D) There is a decreased chance for the presence of pre-ejaculatory sperm with repeat acts of intercourse.

Answer 77

There is a decreased chance for the presence of pre-ejaculatory sperm with repeat acts of intercourse.

This statement is false. In itself, pre-ejaculatory fluid contains no sperm. However, with repeat acts of intercourse close together, subsequent pre-ejaculatory fluid may have “carryover” sperm from the previous ejaculation.

Question 78

A 52-year-old female who had a hysterectomy 2 years ago for uterine bleeding caused by fibroids presents with complaint of severe hot flashes and night sweats for the past few months. Of the following treatment choices, the most appropriate for her vasomotor symptoms at this time would be:

A) continuous-combined oral HT.
B) ospemifine (estrogen agonist/antagonist).
C) transdermal estrogen patch.
D) vaginal estrogen cream.

Answer 78

transdermal estrogen patch.

HT is indicated for treatment of moderate to severe vasomotor symptoms. The individual who has had a hysterectomy does not need a progestogen, so estrogen only is appropriate. The estrogen agonist/antagonist (ospemifene) and vaginal estrogen cream are indicated for vulvovaginal atrophy and related symptoms, but will not relieve vasomotor symptoms.

Question 79

A woman using a diaphragm for contraception has sexual intercourse at 8:00 p.m. on Friday, at 2:00 a.m. on Saturday, and again at 8:00 a.m. on Saturday. When can she safely remove her diaphragm for effective contraception while minimizing problems related to leaving the diaphragm in for extended periods of time?

A) 10:00 a.m. on Saturday
B) 2:00 p.m. on Saturday
C) 10:00 p.m. on Saturday
D) 8:00 a.m. on Sunday

Answer 79

2:00 p.m. on Saturday

The diaphragm should be left in place for at least 6 hours after sexual intercourse and no longer than 24 hours.

Question 80

Which of the following occurs first during female puberty?

A) Beginning breast development
B) Beginning pubic hair development
C) Growth spurt peak
D) Menstruation

Answer 80

Beginning breast development

Breast development begins with breast budding around age 9; the growth of pubic and axillary hair usually starts after breast development begins; and the peak growth spurt occurs around age 12, just prior to onset of menses.

Question 81

When comparing conjugated estrogen combined with bazedoxifene (CEE/BZA) to conjugated estrogen combined with medroxyprogesterone acetate (CEE/MPA), data have shown:

A) better prevention of bone loss with CEE/BZA.
B) less prevention of hot flashes with CEE/BZA.
C) less unscheduled bleeding with CEE/BZA.
D) more breast tenderness with CEE/BZA.

Answer 81

less unscheduled bleeding with CEE/BZA.

Data indicate less unscheduled bleeding and less breast tenderness with CEE/BZA than with CEE/MPA.

Question 82

A woman who had an IUC placed 3 months ago returns to the office with complaint of cramping and states the IUC thread feels longer. You determine that she is likely has a partial IUC expulsion. Appropriate management if she wants to continue with an IUC for contraception includes the following steps:

A) remove the IUC, place a new IUC at the current visit, and start doxycycline for 5 to 7 days.
B) remove the IUC and instruct the client to return at the next menses for placement of a new IUC.
C) start doxycycline and have the client return in 1 week to remove the IUC and replace with a new IUC.
D) use sterile forceps to move the IUC so it is back at the fundus of the uterus.

Answer 82

remove the IUC, place a new IUC at the current visit, and start doxycycline for 5 to 7 days.

A partially expelled IUC should be removed. If the woman wants another IUC, it can be placed that same day after ruling out pregnancy. Doxycycline can be prescribed for 5 to 7 days to reduce the risk of infection.