FNP women's health: contraception, menopause, and reproductive health management

The CDC Medical Eligibility Criteria for Contraceptive Use (MEC) provides a framework for determining which contraceptive methods are appropriate based on medical conditions. Category 1 = no restriction; 2 = advantages outweigh risks; 3 = risks outweigh advantages; 4 = unacceptable health risk (contraindicated).

Combined hormonal contraceptives (CHC — pills, patch, ring): Absolute contraindications (Category 4): Current DVT/PE, history of DVT/PE (not on anticoagulation), migraine with aura (stroke risk), smoking age ≥35, history of ischaemic heart disease, known thrombogenic mutations. Efficacy: 91–99% with correct use. Pearls: start any day of cycle; backup 7 days; reduces dysmenorrhoea, endometriosis, acne, ovarian cysts, PMS.

Progestin-only methods: IUDs (levonorgestrel — Mirena/Kyleena/Liletta) and implant (etonogestrel — Nexplanon) are the most effective methods (>99%). Can use in most women where oestrogen is contraindicated. Levonorgestrel IUD also treats heavy menstrual bleeding — FDA-approved for menorrhagia.

Emergency contraception: Levonorgestrel (Plan B) within 72 hours (decreasing efficacy to 120 h). Ulipristal acetate (Ella) — up to 120 hours, superior efficacy especially in obese women. Copper IUD: most effective EC (within 5 days), also provides ongoing contraception for 10+ years.

USPSTF 2018 cervical cancer screening guidelines:

• Ages 21–29: Pap smear alone every 3 years (HPV testing not recommended under 25)
• Ages 30–65: Pap + HPV co-testing every 5 years (preferred), OR Pap alone every 3 years, OR high-risk HPV testing alone every 5 years
• Stop screening at 65 if adequate prior screening (3 consecutive negative Paps or 2 consecutive negative co-tests in past 10 years)
• After hysterectomy with cervix removed: do not screen if no history of CIN2/3 or cervical cancer

Abnormal results — ASCCP algorithm (simplified for FNP exams): ASCUS + HPV negative → resume routine screening. ASCUS + HPV positive → colposcopy. LSIL → colposcopy (most women). HSIL → colposcopy with endocervical sampling. ASC-H, adenocarcinoma in situ → immediate colposcopy. Refer abnormal cytology per ASCCP guidelines; FNP manages routine screening and co-testing, gynaecology manages abnormal results.

HPV vaccination: ACIP recommends HPV vaccine through age 26. Shared decision-making for ages 27–45 (lower benefit due to prior exposure). 2 doses (Gardasil 9) if series started before age 15; 3 doses if age ≥15 or immunocompromised.

Definition: Natural menopause = 12 consecutive months of amenorrhoea without other cause. Average age 51.4 years in US. Perimenopause begins years earlier with irregular cycles and vasomotor symptoms.

Hormone therapy (HT) — current evidence: Menopausal hormone therapy is the most effective treatment for vasomotor symptoms and genitourinary syndrome of menopause (GSM). The Women's Health Initiative (WHI) overestimated risks in healthy peri/early-postmenopausal women — current evidence supports HT as generally safe for women aged 50–59 or within 10 years of menopause without contraindications.

Absolute contraindications to systemic HT: History of breast cancer, history of oestrogen-sensitive cancer, unexplained vaginal bleeding, active DVT/PE, active liver disease, known BRCA1/2 mutation with intact breast tissue.

Non-hormonal options for vasomotor symptoms: SSRIs (paroxetine 7.5 mg — only FDA-approved non-hormonal option for VMS; escitalopram, venlafaxine also have evidence), gabapentin, oxybutynin, fezolinetant (neurokinin-3 receptor antagonist — Veozah, FDA approved 2023).