AC is a 28 year-old female with lupus-induced nephropathy.

Her renal function has

declined and her creatinine clearance is currently estimated as 23 mL/minute. Her
serum potassium is 4.8 mEq/L. Her medications include lisinopril 10 mg twice daily,
methotrexate once weekly, a vitamin D supplement and simvastatin. AC has met a
young man she likes, and went to her physician to get a contraceptive method.
AC should not receive any of these contraceptive options: (Select ALL that apply.)
A. Mirena (IUD)
B. Condoms and foam
C. Ortho Cyclen
D. Yaz
E. Yasmin

A pregnancy test kit is positive if this hormone is present in the urine:

Human chorionic gonadotropin

If a case indicates human Chorionic Gonadotropin positive (hCG+), the

patient is pregnant and teratogenic drugs should be discontinued, if possible.

With a regular estrogen-progestin birth control pill formulation, when is the

highest risk time for pregnancy if a pill is missed?

Week 1 and Week 3

While there is no time that is 100% fool proof to miss pills, missed pills on
either side of the placebo week is the highest risk.

Week 4 is the week of the placebo, highest risk when you are on either side,
not on period and on either side of week 4 since hormones will either out of
the body or is before in week 3 which could allow the egg to release into
uterus

HG is a 30 year-old woman who just had a baby. She has been prescribed the
progestin-only mini-pill, Camila. Her physician told her that she will use this
type of birth control pill until she is done breastfeeding her baby. Which of the
following counseling points on the "mini pill" should be relayed to the patient?

The mini pill can be started at any time.

A young female enters the pharmacy. She asks for the best over-the-counter
option to protect against sexually transmitted infections (STIs). Which of the
following represents the best option for STI protection?
Latex male condom

Consistent and correct use of male latex condoms, or female condoms, can
reduce (though not eliminate) the risk of STI transmission.

If a patient finds that she cannot tolerate estrogen for any reason, which
products might be used as alternatives?

Depo-Provera

Depo-Provera contains the progestin medroxyprogesterone; it is an

acceptable option as there is no estrogen. The shot lasts for three months. All
of the other products containe estrogen.

NOT Loestrin 24 Fe (ethinyl estradiol, norethindone, and ferrous fumarate), 1 st

pill on Sunday after starting, when run out start the new pack the next day,
24 tabs of ethinyl estradiol and norethindone and 4 ferrous fumerate
reminder pills , Xulane (patch, once a week, Se constistnet with high
estrogen,norelgestromin-ethinyl-estradiol), Ortho Evra (patch, once a week,
norelgestromin-ethinyl-estradiol), Seasonique (1 tab every day,
levonorgestrol, ethinyl estradiol, do not remove the tab from the blister pack
until you are ready to take Seasonique. Begin taking Seasonique on the first
Sunday following the start of your period, unless otherwise directed by your
doctor. If your period begins on a Sunday, begin taking Seasonique on that
day. Nausea (esp. when 1st starting), 84 days straight of levonorgestrol and
ethynyl estradiol (light blue-green tabliet, then followed by one yellow
estradriol tablet for 7 days.

MH has entered the pharmacy to get emergency contraception (EC) for his
girlfriend. Which statements regarding EC are correct? (Select ALL that
apply.)

If the period is more than a week late, a pregnancy test should be taken.
There is no age restrictions to purchasing EC over-the-counter
Emergency contraception is a form of contraception that prevents pregnancy
after sexual intercourse.
The levonorgesterel EC formulations are indicated for use up to 3 days (72
hours) after unprotected intercourse.

Plan B One Step and generic formulations contain one 1.5 mg tab of
levonorgesterol. There are no age restrictions to purchase these products
over-the-counter.

Which of the following products requires that the pharmacist dispense a

patient package insert (PPI) with each prescription and refill?
Nexplanon (etonogestrel), implanted in the arm, lasts for 3 years, has to be
done by a trained PCP, you will get a USER CARD, w/ date of the implant on it
and the date for it to be removed (3 yr), remove if liver dis., breast cancer,
sensitive to progestin, blood clots, and unexplained vaginal bleeding.
Major SE is change in bleeding pattern of menstrual cycle. Use other form for
1st week after plantation. Have to feel and check to see if the plantation is
successful. Cysts, blood clots, call dr if pain develops in lower leg.

YT is using an estrogen-progestin oral contraceptive. She is started on

Trileptal for seizures by her primary care physician. Despite perfect
adherence with the daily birth control pills, she became pregnant within a few
months of starting the Trileptal. What is the likely cause of the pregnancy?

Triliptal (oxcarbazepine)- HLA-B-1502-Asian people-

CYP 2C19- STRONG INHIBITOR-phenytoin, citalopram, diazepam, imipramine,
omeprazole, propranolol, amitriptyline and progesterone. Will INCREASE
levels when admin together
CYP3A4 INDUCER- DHP CCB and oral contraceptives are dec. due to them
being a substrate of CYP3A4.

Phenobarbital and phenytoin are CYP2C19 inducers and dec. Triliptal levels.
Phenobarbital is also CYP2B6, 2C9 inducers, CYP2C19 substrate
Phenytoin inducer 2C9, 2C19, 3A4, CYP2C19 substrate

RW has started to use the oral contraceptive Ortho Tri-Cyclen. Which medical
conditions should the pharmacist screen for to make sure the use of this
medication is safe for RW?

Hypertension

Estrogen products should be avoided in patients with certain medical

conditions, including uncontrolled hypertension. Estrogen can elevat blood
pressure. Refer to p. 634 of the 2017 RxPrep Course Book. Estrogen products
can have a positive effect on bone mass, acne and heavy menses.

Elevated clotting risk Avoid drospirenone, avoid the Ortho Evra,

Xulane (35 mcg) patch, Use lower dose estrogen content, Choose
POP or non-hormonal method.

Which of the following contraception formulations would have a higher risk of

clotting than the Loestrin Fe 1.5/30 formulation? (Select ALL that apply.)
Xulane

Yaz or Yasmin (drospirenone)

35 mcg ethynyl estradiol/
A pharmacist remembers that he was taught in school to warn patients using
oral contraceptives about watching for severe leg pain, chest pain or trouble
breathing. This is due to a risk of:

Clots

JG has just received a NuvaRing at the pharmacy. It is a good choice for her
because she sometimes forgets to take the pill. Counseling points for the
NuvaRing should include all of the following recommendations:

The ring does not protect against sexual transmitted diseases.

The ring is refrigerated at the pharmacy but can be kept at room temperature
by the patient for up to 4 months. It should be inserted on the first day of
menstrual bleeding. Leave it in for 3 weeks then have a period of 7 days with
nothing then insert again when menstration begins.

CL is started on the contraceptive Ortho Tri-Cyclen Lo five months ago.

Initially, she had spotting over several weeks but was instructed by the
pharmacist to wait 2-3 months to see if the spotting went away. CL feels it
has improved but she continues to spot around days 7-8. What is the likely
cause of the spotting?

Too little estrogen (needs to go up to cause the egg to be released to the

utereus, when it does not get enough estrogen it will cause spotting).

If low-dose estrogen pills are used, or if there is insufficient estrogen (the

patient may be a fast metabolizer, or be using an enzyme inducer),
then spotting may occure early-mid cycle.

What is the primary reason that Yaz and Yasmin became best-selling drugs
(and this reason could also be considered a "side effect" of the drug)?

They cause less wt. gain. (due to K sparing)- less bloating-water comes off-
weight down

Refer to p. 638 of the 2017 RxPrep Course Book. These formulations, and
others, that contain drospirenone are popular because they have less
bloating, acne, weight gain and other PMS symptoms. Drospirenone does
have a higher clotting risk however than other progestins.

A woman is hoping to become pregnant. Choose the correct statement.

(Select ALL that apply.)
If a couple is attempting pregnancy, it should occur in about 25% of couples
within a month, and most become pregnant with a year (85%).
Women attempting to become pregnant should begin to take folic acid 400-
800 mcg/daily.

Refer to p. 642 of the 2017 RxPrep Course Book. Folic acid is necessary to
prevent neural tube defects in the fetus.

When do patients begin a combination oral contraceptive?

Start on the Sunday after the period has started

Most pills (including these formulations) are started on the Sunday following
the period. Other options are to start on the 1st day of menses or using the
"quick start" method (start as soon as pills are obtained and use a back-up
method for 7 days.

A pharmacist is filling a prescription for clomiphene for a woman who is

attempting pregnancy. Which of the following statements regarding
clomiphene are correct? (Select ALL that apply.)

This medication can cause hot flashes, which can make the user feel sweaty
and flushed.
The medication is a selective estrogen receptor modulator.
The medication can increase the chances of a multiple birth.

An ovulation predictor test kit is positive if this hormone is present in the

urine:

Luteinizing hormone

Ovulation predictor test kits are used to increase the chances of pregnancy; if
positive, the luteinizing hormone (LH) surge has occurred and it is best to
have intercourse the day of the LH surge and for two days afterwards.

Which of the following birth control pill formulations is a multiphasic

formulation?

Ortho-Novum 7/7/7

As indicated by the name, the Ortho-Novum 7/7/7 has three different weeks
of hormone levels; they change over time.

A physician is recommending Next Choice One-Dose to a young woman. The

physician is aware that nausea is the primary side effect of the emergency
contraceptive (EC) pills. He asks if she gets easily nauseated, and she replies
 that she does and states that she vomits easily. Choose the correct
recommendation for managing the nausea:

She can use OTC meclizine one hour before she use the EC.

The usual recommendation for nausea from the EC pills is OTC meclizine
(Bonine, Dramamine "Less Drowsy") but the catch is that these are sedating
and, if the patient is going to drive home from the pharmacy, it may be
unsafe.

KL comes into the pharmacy to pick up a prescription for Sarafem (fluoxetine)

for premenstrual dysphoric disorder (PMDD). Which birth control formulation
is approved for PMDD?

Yaz. Yaz (drospirenone/ethinyl estradiol tablets) provides an oral

contraceptive regimen consisting of 24 light pink active film-coated tablets
each containing 3 mg of drospirenone and 0.02 mg of ethinyl estradiol
stabilized by betadex as a clathrate (molecular inclusion complex) and 4
white inert film coated tablets. Monophasic Alesse, Ortho Cyclen.

NSAIDs (ibuprofen [Motrin, Advil], naproxen [Aleve and others] when taken long-term
and daily for treatment of arthritis or other problems)

Potassium-sparing diuretics (spironolactone and others)

Potassium supplementation

ACE inhibitors (Capoten, Vasotec, Zestril and others)

Angiotensin-II receptor antagonists (Cozaar, Diovan, Avapro and others)

Heparin

Aldosterone antagonists

Yasmin has 0.03 mg of ethynyl estradiol and 3 mg of drospirenone. More

ethinyl estradiol.

When the placebo period is shortened or low dose estrogen is given during
the placebo period, then physical and emotional withdrawal symptoms are
improved. Many women experience low mood when they have swings in
hormone levels and certain formulations can help stabilize mood.
Less estradiol and short placebo (4 days).

The pharmacist is dispensing the contraceptive patch to SE. The patient's

vitals today include a blood pressure of 106/68 mmHg, pulse 72 BPM, height
5'6" and weight 212 pounds. Select the correct statement:

The patient is not a good candidate for the contraceptive patch.

The patch is not recommended for women over 198 pounds due to lower
efficacy. The patch is linked to a higher risk of blood clots than low-dose oral
contraceptives.

Which of the following birth control pill formulations is not a mini-pill?

Cyclessa (Desogestrel, Ethinyl Estradiol), Mini-pill- Camila, Nora-BE, Errin,

Heather (ALL ARE NORETHINDRONE)

"Cycle" in the name indicates changing hormone dose. The POPs have the
same dose of a progestin only, taken daily.

A 24 year-old female patient uses the following medications on a daily basis:

Ortho Tri Cyclen (for contraception), sertraline (for depression) and buspirone
(for anxiety). She complains of nausea and weight gain. Which of the
following statements represents the most appropriate course of action?

Change the Ortho Tri Cyclen to Ortho Tri Cyclen Lo

Estrogen can cause nausea, breast tenderness, bloating and weight gain in
any formulation (for contraception or hormone therapy). If she finds this
method useful for contraception, it may be a good option to use a formulation
with lower estrogen content to reduce side effects.

Certain medications used with birth control pills can reduce the contraceptive's efficacy.
Which of the following medications, if taken with birth control pills, could cause this
problem and require back-up contraception or a different method of contraception with
long-term therapy? (Select ALL that apply.)

Drugs that may cause this effect include: many antibiotics (e.g.,
cephalosporins, chloramphenicol, macrolides, penicillins, tetracyclines,
sulfas), aprepitant, bexarotene, bosentan, dapsone, griseofulvin, certain HIV
protease inhibitors (e.g., amprenavir, nelfinavir, ritonavir), modafinil,
nevirapine, rifamycins (e.g., rifampin), many seizure medications (e.g.,
barbiturates, carbamazepine, phenytoin, primidone, topiramate), St. John's
wort. Ask your doctor if you should use additional reliable birth control
methods while taking any of the drugs mentioned above while also taking
birth control pills. Before using this medication, tell your doctor or pharmacist
of all prescription and non-prescription/herbal medications you may use,
especially of: thyroid hormone drugs, certain benzodiazepines (e.g.,
diazepam, chlordiazepoxide), prednisone-like drugs, certain antidepressants
(e.g., tricyclics), beta-blockers (e.g., metoprolol), "blood thinners"
(anticoagulants such as warfarin), insulin.

Actual answer: Mycophenolate, ritonavir, carbamazepine, NOT erythromycin,

azithromycin
In book: Antiboitics: rifampin, rifapentine, rifabutin, some antibotics say to
use 2ndary
Anticonvulsants: barbiturates, carbamazepine, oxcarbazepine, phenytoin,
primidone, topiramate, and lamotrigine
St. Johns wart
Ritonavir-boosted protease inhibitors Bosentan (Tracleer)- PAH,
Mycophenolate (Cellcept, Myfortic)-prophylaxsis for organ transplant
Separte from colesevelam by at least 4 hours. Take at least 1 hour prior to
Byetta injection.
Smoking tobacco.
The HEP C antivirals, Technivie and Viekira Pak, cannot be used with any
formulation with EE due increase in liver toxicity.

Which of the following represent possible advantages of using continuous

birth control formulation such as Jolessa or Amethyst? (Select ALL that apply.)

Amethyst is continuous EE 20mcg/LNG 0.09 mg X 91 days.

Jolessa(levonorgestrel/ethinyl estradiol tablets) is an extended-cycle oral
contraceptive consisting of 84 pink active tablets each containing 0.15 mg of
levonorgestrel, a synthetic progestogen and 0.03 mg of ethinyl estradiol, and
7 white inert tablets (without hormones).

Long period of time without menstrual cycle bleeding and period-related

effects, such as moodiness.

No withdrawl effects, such as physical and emotional symptoms that can

occur during the hormone-free interval.

If a woman takes levonorgestrel emergency contraception (EC) while

pregnant, what is expected to happen?

The EC will not affect her future fertility, cause birth defects or terminate an
established pregnancy.

EC will not end an existing pregnancy or cause birth defects. EC contains the
same hormones as regular birth control pills, and women's bodies also
produce these hormones naturally during pregnancy. Exposure to EC does not
threaten an existing pregnancy.

Which of the following are correct statements concerning missed pills with an
estrogen-progestin birth control pill formulation?

Back-up contraception is generally needed if two or consecutive hormonal

pills are missed.

A young woman went on a weekend trip with her boyfriend and forgot her pill packet.
She missed taking her birth control pills during days 18th-20th. The woman has come
into the pharmacy to get her next month's packet, which is ready for pick-up. Choose the
correct advice the pharmacist should relate to the patient:

Do not use the placebo week (or sugar or dummy pills); go ahead and
begin the new packet.

Because: If two or more consecutive pills have been missed > or equal to 48
hours were pills should have been taken.
If hormonal pills were missed in the last week of the cycle (18-20 th):
Omit the hormone-free interval by finishing the hormone pills in the current
pack and start new pack next day. Since next day begin on 21 st, go ahead and
use new packet. Use backup contraception or avoid intercourse for 7 days..
Consider EC if missed pills were during the 1 st week and unprotected
intercourse occurred in the previous 5 days.

A pharmacist will counsel a 39-year old patient beginning a combination oral

contraceptive for pregnancy prevention. The patient smokes. Which of the
following are correct counseling statements?

Estrogen products should be avoided in this patient because of her age and
her smoking status.

The FDA requires that the patient package insert be dispensed every time the
patient receives the medication. There is a boxed warning to avoid estrogen
products in patients > 35 years of age who smoke. Missed pills are a common
cause of unintended pregnancies.

Which combination oral contraceptive product comes in a patch formulation?

Xulane, Ortho Evra

A woman is using Alesse combination oral contraceptive pills. She does not
enjoy getting a monthly menstrual cycle and has heard about new pill
formulations where you get less periods. Choose the formulation/s which
results in menstruation once every 3 months: (Select ALL that apply.)

Quartette, Amethyst, Seasonique, NOT Cyclessa, Trinessa

Oral contraceptives with "Tri" or "Cycl" in the name usually indicate triphasic
pills.

A patient has vomited out the first dose of Plan B One Step (1.5 mg). The
pharmacist should tell her to retake the dose (after taking anti-nausea
medicine first) if she has vomited within this time period after having taken
the EC tablet/s:

2 hours
If the patient vomits within two hours after taking levonorgestrel pills, she
should take an anti-emetic and then take another full dose of levonorgestrel.

A physician is prescribing ulipristal to a young woman. What are the

differences between ulipristal and levonorgestrel?

Ulipristal (Ella)- 5 days

Ulipristal (Ella) requires a prescription. Ulipristal works primarily by delaying

ovulation, but it may also prevent implantation in the uterus; this mechanism
is more controversial than levonorgestrel.

CK has just been at the pharmacy to pick up a new prescription for

combination oral contraceptives. The pharmacist has explained the serious
risks associated with oral contraceptives. What are some of the less serious
adverse effects that CK may experience? (Select ALL that apply.)

Spotting, Nausea, Bloating, Breast Tenderness

RW has started to use the oral contraceptive Sprintec 28. Which of the
following medications would not interact with oral contraceptives?

Levofloxacin

DOES: St. Johns Wort, Smoking, Rifampin, Lamotrigine

Levofloxacin does not interact with birth control pills. Use back-up (condoms
and spermicide) while using an interacting medication.

The following are contraindications to the use of estrogen therapy, in any

dose or formulation. (Select ALL that apply.)
History of MI, DVT, cerebrovascular accident, and unexplained vaginal
bleeding

NOT history of pregnancy

KT is a 25 year-old woman who has been using Micronor for contraception

since she had a baby. KT was breast-feeding, but she stopped when the baby
was seven months. The baby is now eight months old. KT knows that she
needs to be switched to a pill that includes estrogen but she has been too
busy to see the physician. She forgot to take her Micronor this morning and
had intercourse later that evening. Is she at risk for pregnancy?
Yes, pregnancy could result, and pt may consider EC.

Patients must take the pill at the same time of day; if three hours have
elapsed from the regular scheduled time, back up is needed for 48 hours
after taking the late pill. If a dose is missed, and sexual intercourse has taken
place, pregnancy could result, and the patient may desire emergency
contraception.

A young female enters the pharmacy. She is using birth control pills. She asks
if she is protected against HIV and other STIs. Which advice should be
provided?

The method that has 100% success at preventing HIV and sexually
transmitted diseases is abstinence.

Birth control pills, patches and rings are intended to prevent pregnancy. They
do not protect against transmission of HIV (AIDS) or other sexually
transmitted diseases (STIs), including chlamydia, genital herpes, genital
warts, gonorrhea and syphilis. Barrier methods decrease the risk of
transmission but abstinence is the only method that is 100% effective.

ACHES stands for Abdominal pain, Chest pain, Headaches, Eye problems,
Sweling and/or aching in the legs and thighs