14.2 Women's Reproductive Health
Key Takeaways
- CDC Medical Eligibility Criteria grade contraception from 1 (no restriction) to 4 (unacceptable risk). Combined hormonal methods are category 4 in migraine with aura, SBP ≥160, age ≥35 plus ≥15 cigarettes a day, and prior VTE.
- LARCs — the copper IUD, levonorgestrel IUD, and implant — have the lowest typical-use failure rates. Emergency contraception is LNG, ulipristal, or a copper IUD.
- Pregnancy testing is the first step in amenorrhea and in PALM-COEIN abnormal uterine bleeding. PCOS is a Rotterdam diagnosis after other causes are excluded.
- Menopausal hormone therapy is most appropriate for bothersome vasomotor symptoms within about 10 years of menopause and before age 60 when contraindications are absent; prefer transdermal estradiol when VTE risk is higher.
- Screen sexually active women younger than 25 for chlamydia and gonorrhea. Treat gonorrhea with ceftriaxone and add chlamydia therapy when chlamydia has not been excluded. Cervical screening starts at 21.
The official TCO scores Reproductive as its own body system and scores the drugs you use for contraception, bleeding, menopause, and infection under genitourologic, endocrine, and anti-infective classes. Domain III Planning is the CDC Medical Eligibility Criteria (MEC) table. Domain IV Implementation is the method you hand over, the dual gonorrhea regimen, and the diagnostic — not screening — image for a breast mass.
Contraception by CDC MEC
CDC MEC categories are the exam language. Category 1 means no restriction. Category 2 means advantages generally outweigh risks. Category 3 means risks usually outweigh advantages and you need a careful, often specialist-informed decision. Category 4 means unacceptable health risk — do not start that method.
High-yield category 4 conditions for combined hormonal contraception (combined pill, patch, or ring) include:
- Migraine with aura at any age (ischemic-stroke risk)
- SBP ≥160 mm Hg or DBP ≥100 mm Hg
- Age ≥35 years and smoking ≥15 cigarettes a day
- Current or history of VTE, or a known thrombogenic mutation
- Current breast cancer
- Ischemic heart disease or prior stroke
- Less than 21 days postpartum
- Complicated valvular disease, peripartum cardiomyopathy with impaired function, and several severe liver conditions
Age ≥35 plus smoking fewer than 15 cigarettes is usually category 3, not a free pass. Migraine without aura at age ≥35 is also category 3 for combined hormones. Uncontrolled diabetes with nephropathy, retinopathy, neuropathy, or more than 20 years’ duration is another combined-hormone stop. When combined hormones are category 4, progestin-only pills, depot medroxyprogesterone, implants, and IUDs are often still category 1 or 2 — look the condition up rather than declaring “no contraception.”
LARCs — the copper IUD, levonorgestrel IUD, and etonogestrel implant — have typical-use failure rates under 1% and are first-line for most adolescents and adults who want highly effective reversible contraception, including nulliparous patients. Combined pills, the patch, the ring, and progestin-only pills fail about 7% per year in typical use because they require a daily or weekly behavior. Counsel effectiveness honestly. IUDs are not reserved for people who have already given birth.
Emergency contraception
Offer emergency contraception whenever a method failed or was not used. Three options belong on the FNP-BC:
| Method | Window | Notes |
|---|---|---|
| Levonorgestrel (LNG) 1.5 mg | Best within 72 hours; some effect to 120 | OTC. Less effective as BMI rises. Does not abort an established pregnancy. |
| Ulipristal acetate (UPA) 30 mg | Up to 120 hours | More effective than LNG after 72 hours and in higher BMI. Wait 5 days before restarting hormonal contraception; use a barrier in between. Needs a negative pregnancy test conceptually and a prescription. |
| Copper IUD | Up to 5 days | Most effective EC and then ongoing contraception. Not limited by body weight. |
Do not tell a patient it is “too late” at 80 hours if UPA or a copper IUD is still available. A copper IUD is also reasonable when she wants long-acting contraception anyway.
Abnormal uterine bleeding, amenorrhea, and PCOS
Pregnancy testing is first in any reproductive-age person with missed periods, irregular bleeding, or pelvic pain. After a negative test, FIGO’s PALM-COEIN framework keeps the differential honest. PALM is structural: Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia. COEIN is nonstructural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified. You do not need to recite every letter on the exam, but you do need to stop saying “dysfunctional uterine bleeding” as if it were a diagnosis.
Acute heavy bleeding is an ABCs problem: vitals, hemoglobin, pregnancy test, and a decision about the emergency department if she is orthostatic or soaking pads hourly. Endometrial sampling belongs in age ≥45 with AUB and in younger patients with unopposed estrogen, obesity, failed medical therapy, or persistent bleeding. Transvaginal ultrasound looks for structural PALM lesions. A 52-year-old with postmenopausal bleeding does not get a three-month trial of cyclic progesterone as the only plan — that bleeding is endometrial cancer until imaging and sampling say otherwise.
Amenorrhea is primary (no menses by 15 if secondary sexual characteristics are present, or by 13 if they are not) or secondary (no menses for three months if cycles were regular, or six months if they were irregular). After hCG, order TSH and prolactin. Add FSH when you suspect primary ovarian insufficiency or when age makes that likely. Look at BMI, energy availability, and exercise for hypothalamic amenorrhea. Ask about intrauterine procedures if Asherman syndrome is possible. Do not start combined pills as a “test of ovarian function” and call the workup done.
PCOS is a Rotterdam diagnosis: two of three — oligo- or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology — after other causes are excluded. Exclude pregnancy, thyroid disease, hyperprolactinemia, and, when indicated, nonclassic congenital adrenal hyperplasia with a morning 17-hydroxyprogesterone. Lean PCOS still exists. Screen the metabolic cluster: blood pressure, A1c or OGTT, lipids, and sleep apnea symptoms. Treatment follows the goal. Lifestyle change is foundational. Combined hormones (if MEC allows) regulate cycles and help androgens. Metformin helps metabolic disease and ovulatory frequency; it is not a complete hirsutism drug. Spironolactone helps hirsutism and is teratogenic — pair it with contraception. If she wants pregnancy, letrozole is first-line ovulation induction, not a year of metformin as the only plan.
Menopause, STI treatment, cervix, and breast
Natural menopause is 12 months of amenorrhea at a typical age near 51. Vasomotor symptoms (VMS) and genitourinary syndrome of menopause (GSM) are the two symptom clusters you must separate. Systemic menopausal hormone therapy is the most effective treatment for bothersome VMS when there is no contraindication and she is generally within about 10 years of menopause and younger than 60. Use the lowest effective dose for the time it is needed. If the uterus is present, add a progestogen. Prefer transdermal estradiol when VTE risk, obesity, migraine without aura, or high triglycerides makes a first-pass oral estrogen less attractive. Contraindications include breast cancer, undiagnosed genital bleeding, active or high-risk VTE, active liver disease, and established coronary or cerebrovascular disease. Do not start hormone therapy at 72 “for the bones and the heart.”
GSM — dryness, dyspareunia, recurrent UTI — often responds to low-dose vaginal estrogen, which has negligible systemic absorption compared with pills or patches. Vaginal estrogen can still be discussed when systemic therapy is off the table; shared decision with oncology is required after hormone-sensitive breast cancer. Nonhormonal VMS options include SSRIs/SNRIs (paroxetine, venlafaxine, escitalopram), gabapentin, and the NK3 antagonist fezolinetant.
STI screening: USPSTF and CDC want chlamydia and gonorrhea screening in sexually active women younger than 25, and in older women when there is a new partner, multiple partners, a partner with STI, or other risk. Add HIV and syphilis per risk and local epidemiology. Treat gonorrhea with ceftriaxone 500 mg IM (1 g if weight ≥150 kg). Always cover chlamydia with doxycycline 100 mg twice daily for 7 days when chlamydia has not been excluded. Azithromycin 1 g remains the usual pregnancy alternative for chlamydia. Trichomoniasis in women is metronidazole 500 mg twice daily for 7 days. Expedited partner therapy — treating a partner of a documented chlamydia or gonorrhea case without a clinic visit when you cannot get that partner in — is legally permitted in most states and is an Implementation skill, not a loophole. Retest the index patient at about 3 months because reinfection is common. Test of cure is for pregnancy (chlamydia) and for persistent symptoms, not for every treated visit.
Cervical cancer screening (USPSTF):
| Age / situation | Test |
|---|---|
| Younger than 21 | Do not screen |
| 21–29 | Cytology every 3 years |
| 30–65 | Primary HPV every 5 years, or cotest every 5 years, or cytology every 3 years |
| After 65 | Stop if adequate prior negative screening and no CIN2+ history (adequate means three consecutive negative cytology results or two consecutive negative HPV/cotest results in the last 10 years, with the most recent within 5 years) |
| Hysterectomy with cervix removed for benign disease | No screening |
HIV and a recent CIN2+ history keep screening going on a different clock. HPV vaccination is routine through age 26 and shared decision at 27–45; it does not replace screening.
Breast mass versus screening. A palpable mass, skin change, or bloody nipple discharge is a diagnostic pathway — diagnostic mammography plus ultrasound by age, or ultrasound first if she is younger than about 30 — this week, not a scheduled screening mammogram in four months. Screening (USPSTF 2024: biennial mammography ages 40–74 for average risk) is for asymptomatic women. Do not reassure a dominant mass because last year’s screening film was normal.
FNP traps: starting an ethinyl-estradiol pill in migraine with aura; quoting perfect-use pill failure as if it were typical use; treating AUB without a pregnancy test; diagnosing PCOS from acne alone; starting oral estrogen at 68 for hot flashes and heart protection; treating gonorrhea with ceftriaxone and no chlamydia coverage; and parking a breast mass on the screening schedule.
A 32-year-old wants a combined oral contraceptive. She has migraine with visual aura about four times a year. Blood pressure is 118/74 and she does not smoke. Using CDC MEC, what is the correct counseling?
A 34-year-old with a 10-year history of normal cervical screening asks when she can switch away from cytology every 3 years. Which statement matches USPSTF cervical screening?
A 29-year-old reports 8 weeks of irregular heavy bleeding. She is sexually active and her last menstrual period was uncertain. What is the first diagnostic step?
A 53-year-old is 18 months past her final menstrual period and has frequent night sweats that wreck sleep. She has no history of breast cancer, VTE, coronary disease, or unexplained bleeding. Which counseling matches usual menopausal hormone-therapy principles?