Welcome to PNP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for 90 students studying to pass their PNP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
Which of the following is a MEC category or where use represents an unacceptable health risk to the use of CHC combined hormonal contraceptive method such as combined oral contraceptive or COC?
Would it be:
A. A mother with a history of breast cancer
B. A personal history of hepatitis A at age ten years.
C. Presence of Factor V Leiden mutation.
D. Cigarette smoking of one pack per day in a 22-year-old.
Where should you start? First, determine what kind of a question this is. Given this is focused on CHC use, this is a plan or an intervention question. Next, let's take a look at the background information. Combined hormonal contraceptive options often abbreviated CHC, include standard birth control pills, patch, and ring have been available for more than five decades, with the patch and the ring being a little bit newer, but birth control pills have been around for literally more than half a century.
These products are referred to as combined because they have both an estrogen and progestin form in a hormonal contraception method. With appropriate use, this is a highly effective form of contraception working through multiple mechanisms, including ovulation suppression, endometrial thinning, as well as a few other ways, including thickening of the endocervical mucus plug, acting as a barrier to keep sperm from entering the uterus.
When considering prescribing a hormonal contraceptive option, the U.S. medical eligibility criteria for contraceptive use, or MEC, recommendations should be considered. These recommendations include helpful advice for using specific contraceptive methods by women who have select characteristics or certain health issues.
The U.S. MEC can be used to identify safe and effective contraceptive choices above and beyond barrier methods for nearly all women.
The MEC categories are as follows:
Category one: no restriction to the use of this contraceptive method. And by the way, many of the hormonal contraceptive options are, in fact, category one.
Category two: advantages outweigh the risk potentially associated with the contraceptive method. And again, many hormonal contraceptive options are category two. So just to recap, the vast majority of clinical scenarios and contraceptive methods that are hormonally based are either category one or category two. Many, not all, and that’s the purpose of this question.
Category three: Exercise caution. There are theoretical or proven risks for this contraceptive method, and those risks usually outweigh the benefit. And what I have to remind you of course is one of the benefits of contraceptive use is avoiding an unintentional pregnancy.
Category four: the use of the contraceptive method represents an unacceptable health risk. Now, it might be really daunting to consider all these MEC recommendations, but as I said, most of the currently available hormonal contraceptive forms and the majority of women will be MEC one or two. There's a really helpful app available from the CDC that allows plugging in patient characteristics and the contraceptive method under consideration. And voila. As it is with most apps, a little bit of magic occurs, and it will kick up and tell you what the MEC category is. I doubt that a day goes by in my practice that I don't use that app.
The app is available for download iPhone Android desktop and it is free of charge. I shouldn't say it's free of charge from the CDC. It's our taxpayer money at work and it’s money that's very well spent. So, make sure you have that.
Now, let's go back then and look at the question and the potential answers.
Which of the following is a MEC category four where use represents an unacceptable health risk to the use of CHC combined hormonal contraceptive method such as a combined oral contraceptive or standard birth control pill?
Answer A: mother with a history of breast cancer. This is incorrect. While a current personal history of breast cancer in the woman who would be taking the CHC is a contraindication to CHC use, a maternal history of the disease is not.
Option B. A personal history of hepatitis A at age ten years. Hepatitis A is caused by a liver specific virus. While current acute liver disease, including hep A is MEC category four a contraindication for CHC COC use, a past history of this disease is not. There's no chronic form of hepatitis A and the liver, especially when HAV infection is in childhood, makes a full recovery. What I will often say when I'm talking to patients or teaching a class that involves talking about hepatitis A, I'll remind folks it's a one and done condition. You get it. Once you get over it, you'll never get it again. Of course we can immunize against it, but people seldom die from hepatitis A unless there's so profound underlying liver disease.
Option C: Presence of Factor V Leiden mutation. This is the correct answer and Factor V Leiden mutation results in an increased tendency to form blood clots, also known as thrombophilia, resulting in a marked increase in venous thromboembolic events such as DVT and PE. An estimated 3 million people in the United States have this condition, adding prothrombotic medications, particularly the estrogen found in COC or CHC, increases that risk even more to a minimum of 10 to 30 times greater when compared with a woman without the gene mutation and not taking CHC, and in heterozygous patients where there's one mutated factor V gene. And up to 80 to 100 times greater in patients who are homozygous those with two mutated factor V genes.
At the same time, other highly effective forms of contraception can be used in women with Factor V Leiden mutation, and this includes copper containing IUD, which is MEC one, a levonorgestrel IUD, as well as a progestin implant, DMPA, which would be Depo-Provera injections, and progestin only pills. Those are all MEC two.
So, it's not like the Woman's Factor V Leiden mutation who desires to use a highly effective form of contraception is left out in the cold. There are many, many, many options.
Factor V Leiden mutation screening prior to combined hormonal contraceptive prescribing in an otherwise healthy person without DVT history is not currently recommended. Although I must say in my many, many, many years of practice, there have been a variety of thoughts on whether thrombophilia screening should be done before CHC prescribing is done. I will say, at the same time, the risk of clot is always the highest in pregnancy, including in women with Factor V Leiden mutation that pregnancy in the first two weeks postpartum are a highly prothrombotic state to be in.
Option D. Cigarette smoking one pack per day in a 22-year-old. That's obviously incorrect because we've identified with the correct answer is. That's category two condition where benefit outweighs risk. Certainly, cigarette smoking anyone of any age increases DVT risk. However, the significant increase in clot risk with CHC and smoking is most often noted in individuals greater than 35 years of age, where it's MEC three or MEC four depending on the number of cigarettes smoked per day.
Key takeaway prescribing combined hormonal contraception is a key part of health care where highly effective family planning options can be offered in a single clinical encounter. Being aware of the major, though infrequently, encountered clinical scenarios where CHC use is not advised is important to safe practice.
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