Contraception and fertility under the 2024 CDC guidance

A patient using the lactational amenorrhea method is 4 months postpartum. Which change means she needs to start another contraceptive method?

1. She begins regular formula feeds
   Lactational amenorrhea depends on full or nearly full breastfeeding; regular formula feeds reduce suckling, ovulation can return, and another method is needed now.
2. She has resumed sexual intercourse
   Resuming intercourse is when contraception matters, but it is not one of the criteria that end the method's reliability.
3. Her infant is now 5 months old
   The method stays valid until the infant is 6 months old; reaching 5 months does not end it.

Item 422717 · Flag an error

A 27-year-old with opioid use disorder stable on buprenorphine wants to avoid pregnancy and often forgets daily medications. The most appropriate contraceptive is

1. Transdermal contraceptive patch
   The patch needs a weekly change and has typical-use failure close to the pill, so it does not remove the adherence problem the way a LARC does.
2. Progestin-only pill
   Progestin-only pills need a dose every day at the same time; for someone who often forgets daily medications, this is the least forgiving choice.
3. Etonogestrel implant
   The implant provides 3 or more years of protection without any daily action and has no interaction with buprenorphine, so it suits a patient who forgets pills.

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A healthy 30-year-old nonsmoker has migraine without aura and wants combined oral contraceptives. Under US MEC 2024, this is

1. Category 3; risks usually outweigh benefits
   Category 3 overstates the risk for migraine without aura in a healthy nonsmoker; the stroke concern centers on migraine with aura.
2. Category 3 if she is 35 or older
   Age does not change the category for migraine without aura; current MEC keeps it at category 2 at any age, so turning 35 does not move it to category 3.
3. Category 2; COCs may be used
   In US MEC 2024, migraine without aura is category 2 for combined hormonal contraception at any age; aura, not age, is what moves it to category 4.

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A patient with regular 28-day cycles is scheduled for a hysterosalpingogram as part of an infertility evaluation. The test should be performed on cycle days

1. 6 to 11
   A hysterosalpingogram is done after menses stop and before ovulation, about cycle days 6 to 11, so the cavity is clear and an early pregnancy is not exposed.
2. 1 to 3
   On cycle days 1 to 3 menstrual blood and clots can mimic filling defects and raise the risk of pushing endometrial tissue into the tubes.
3. 21 to 25
   Days 21 to 25 are after ovulation, when a conceptus may already be present; the thick secretory endometrium also obscures the cavity.

Item 423046 · Flag an error

A patient with cycles that vary from 24 to 40 days wants a fertility awareness method. The most appropriate method is

1. Calendar rhythm method
   Calendar rhythm subtracts from her shortest and longest cycles, giving a fertile window of more than 3 weeks with irregular cycles, which is impractical and less effective.
2. Standard Days method
   The Standard Days method assumes cycles of 26 to 32 days; her shorter and longer cycles fall outside its rule for days 8 to 19.
3. TwoDay method
   The TwoDay method uses daily checks for cervical secretions and works whatever the cycle length, so it fits cycles that vary from 24 to 40 days.

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A patient taking a norethindrone 0.35-mg progestin-only pill took today's pill 5 hours late. The nurse practitioner should advise her to

1. Take it now and use backup for 7 days
   Seven days of backup is the rule for missed combined pills; the progestin-only rule is 2 days of on-time pills.
2. Take it now and use backup for 2 days
   A norethindrone pill more than 3 hours late is taken as soon as possible, and condoms or abstinence are used until pills have been taken on time for 2 days (US SPR).
3. Take it now; no backup is needed
   No backup fits only a delay of 3 hours or less; at 5 hours the cervical mucus effect may already have waned.

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A 27-year-old presents 100 hours after sexual assault and wants emergency contraception. She declines an IUD. Her BMI is 24. The most effective option is

1. No oral option is effective after 72 hours
   The 72-hour limit is a levonorgestrel label; ulipristal is approved up to 5 days, so refusing an oral method leaves her unprotected.
2. Levonorgestrel 1.5 mg orally
   Levonorgestrel is labeled for 72 hours and loses efficacy as time passes; at 100 hours it is less effective than ulipristal.
3. Ulipristal acetate 30 mg orally
   When a copper IUD is declined, ulipristal is the most effective oral emergency option up to 120 hours, and it keeps its efficacy at 100 hours better than levonorgestrel.

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A 29-year-old with systemic lupus erythematosus and positive antiphospholipid antibodies requests contraception. Which method is contraindicated?

1. Copper intrauterine device
   The copper IUD is hormone-free and US MEC category 1 in SLE with antiphospholipid antibodies, so it is the safest choice rather than a contraindication.
2. Levonorgestrel IUD
   A levonorgestrel IUD is category 3 in SLE with antiphospholipid antibodies; the risks usually outweigh benefits but it is not an outright contraindication like estrogen.
3. Combined vaginal ring
   The ring contains estrogen, and in US MEC 2024 combined hormonal methods are category 4 for SLE with positive or unknown antiphospholipid antibodies because of thrombosis risk.

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A 30-year-old with bipolar disorder stabilized on lamotrigine asks about birth control. Which method is most likely to lower her lamotrigine level?

1. Combined oral contraceptive
   Ethinyl estradiol induces glucuronidation of lamotrigine and can cut its level by about half, risking loss of mood control; levels also rebound in the hormone-free week.
2. Copper IUD
   The copper IUD is hormone-free and has no drug interactions, which makes it a good option rather than a risk here.
3. Levonorgestrel IUD
   The levonorgestrel IUD acts mainly locally and has no estrogen, so it does not lower lamotrigine levels.

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A mother requests permanent sterilization for her 19-year-old daughter, who has moderate intellectual disability and can express preferences. The nurse practitioner's most appropriate initial action is to

1. assess the patient's own capacity and wishes
   Sterilization of a person with intellectual disability starts with her own understanding and preferences; a parent's request alone is not consent, and less permanent methods are considered first.
2. recommend endometrial ablation instead
   Ablation is a bleeding treatment, not contraception, and it is still a permanent procedure chosen without hearing the patient.
3. schedule tubal occlusion with the mother's consent
   A parent cannot consent to an adult daughter's sterilization; scheduling it on the mother's word bypasses the patient's rights and legal safeguards.

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A 24-year-old transgender man has taken testosterone for 1 year and has amenorrhea. He has receptive vaginal intercourse with a cisgender male partner. The nurse practitioner should advise that

1. testosterone-induced amenorrhea prevents pregnancy
   Amenorrhea on testosterone is not contraception; pregnancies occur in transgender men on therapy.
2. he still needs contraception during testosterone therapy
   Testosterone suppresses menses but does not reliably stop ovulation, and it is teratogenic, so a patient with a sperm-producing partner still needs effective contraception.
3. testosterone is stopped before IUD placement
   Testosterone does not need to be stopped for an IUD; the IUD is compatible with gender-affirming therapy and is a common choice.

Item 423234 · Flag an error

Which finding confirms that ovulation has already occurred?

1. A sustained basal temperature rise
   Progesterone after ovulation raises basal temperature about 0.4 °F (0.2 °C) for the luteal phase, so a sustained rise shows ovulation has already happened.
2. Midcycle unilateral pelvic pain
   Mittelschmerz can occur around ovulation, but it is inconsistent and nonspecific and cannot confirm that ovulation occurred.
3. A positive urine LH test
   A positive LH test predicts ovulation within about 24 to 36 hours; it shows the surge, not that the egg has been released.

Item 423315 · Flag an error

A 41-year-old has had unprotected intercourse for 2 months without conceiving. She asks when to begin an infertility evaluation. The nurse practitioner should advise

1. evaluation after 6 months of trying
   Six months is the threshold for women aged 35 to 40; at 41 waiting loses time when treatment success is falling month by month.
2. evaluation starting now
   ASRM and ACOG advise infertility evaluation without delay for women over 40, after 6 months of trying at 35 to 40, and after 12 months under 35, because fecundity falls quickly with age.
3. evaluation after 12 months of trying
   Twelve months is the standard definition of infertility for women under 35; applying it at 41 delays care the most.

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Before IVF for tubal-factor infertility, a 32-year-old is found to have bilateral hydrosalpinges on ultrasound. To improve IVF success, the nurse practitioner anticipates

1. tubal reconstruction to restore patency
   Reconstruction of hydrosalpinges rarely restores function and keeps the fluid problem; with IVF planned, the tubes are not needed.
2. salpingectomy before embryo transfer
   Hydrosalpinx fluid is embryotoxic and lowers IVF implantation rates, and removing or occluding the affected tubes before transfer restores success rates.
3. proceeding with IVF without intervention
   Going ahead untreated accepts a markedly lower pregnancy rate and a higher miscarriage risk from fluid flowing into the cavity.

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