Chapter 4 Gynecologic, Reproductive, Sexual, and Menopause Health

Three to five years after menopause, the ovaries are atrophic and are usually not palpable. In a 70-year-old woman, you would expect to find a narrow vaginal canal, a small uterus, thin vaginal walls, and nonpalpable ovaries.

An advantage of continuous-combined HT over continuous-cyclic HT regimen is a lower cumulative dose of progestin.

The FDA-approved indication for the use of HT includes the relief of moderate to severe menopausal symptoms related to estrogen deficiency (vasomotor instability, vulvar/vaginal atrophy), and prevention of osteoporosis.

A transdermal estrogen patch is appropriate for treatment in a woman with a hysterectomy complaining of severe hot flashes and night sweats for the past few months.

If a woman becomes pregnant who has a copper IUD in place, she should have it removed regardless of her plans to continue with the pregnancy or not; removing the IUD reduces the risk for spontaneous abortion. There is no risk of congenital defects from copper exposure. If the IUD is left in place, the woman is at risk for spontaneous abortion as well as preterm delivery.

Testosterone is produced in the adrenal gland, in the ovarian stoma, and through conversion of androstenedione and DHA in peripheral tissues. Testosterone is aromatized to estradiol in peripheral tissues.

The female vaginal condom may be used by individuals with latex allergy.

Estrogen in COCs stabilizes the endometrium for less unscheduled bleeding.

Frequent use of spermicide may cause vaginal changes, making you more susceptible to HIV infection.

The vestibule includes the urethral/vaginal openings, hymen, Skene’s glands, and Bartholin’s glands.

The predominant estrogen after menopause is estrone.

Ospemifine for the treatment of dyspareunia related to vulvovaginal atrophy should be advised that they may experience hot flashes as a side effect of this medication. Osemifine is a SERM taken as a daily oral dose to treat moderate to severe dyspareunia related to vulvovaginal atrophy. Hot flashes are a common side effect. Estrogen should not be used in combination with Ospemifine; no studies have looked at using progestogen with Ospemifne.

The following individual should have an endometrial biopsy/evaluation: An individual on continuous-combined HT regimen with spotting that occurs after several months of amenorrhea. Initially, there will be some unpredictable spotting and bleeding. After several months of use, the endometrium atrophies, and amenorrhea usually results. If spotting or bleeding recurs after several months of amenorrhea, endometrial evaluation is warranted.

The main mechanism of action of misoprostol in medically induced abortion is stimulating uterine contractions. Misoprostol is commonly used in conjunction with mifepristone or methotrexate for medical abortions. Misoprostol, a prostaglandin analogue, softens the cervix and stimulates uterine contractions.

Which of the following statements is true concerning the luteal phase of the menstrual cycle? There is thickened cervical mucus. The phase of the menstrual cycle begins after ovulation occurs, lasts approximately 14 days (give or take 2 days), and ends with the first day of menses. Progesterone secreted from he corpus luteum causes thickened cervical mucus. The luteal phase corresponds with the uterine secretory phase.

During menopause transition, there is an increased FSH, increased LH, and decreased estradiol. The production of estradiol decreases as the number of responsive ovarian follicles decreases. This decrease in estradiol triggers the increased release of FSH and LH from the anterior pituitary gland.

An advantage of the transdermal patch over oral delivery of estrogen for the individual experiencing menopausal symptoms is that the transdermal delivery method has fewer adverse effects on coagulation factors. Estrogen delivered via transdermal patch has no effect on cardiovascular markers (HDL-C, LDL-C, triglycerides, C-reactive protein). There is less effect on coagulation factors and a lower risk of venous thromboembolism with transdermal estrogen compared with oral estrogen in the menopausal woman.

The lymph nodes that drain directly into the infraclavicular nodes are the central nodes. The pectoral, subscapular, and lateral axillary lymph nodes drain into the central nodes that are located high in the axilla between the anterior and posterior axillary nodes and are the most likely to be palpable. The central nodes drain into the infraclavicular and supraclavicular nodes.

The levonorgestrel-releasing IUC may be a better choice than the copper-releasing IUC for a woman who has dysmenorrhea because it can cause reduced menstrual bleeding or amenorrhea and reduced dysmenorrhea. The copper-releasing IUC may increase dysmenorrhea.

A vaginal pH less than 4.5 is an expected finding in a healthy reproductive-age woman. An acidic vagina pH (less than 4.5) is an expected finding in a healthy reproductive woman. This acidic pH is the result of the prevalence of lactobacilli, which in turn reflects the influence of estrogen initiated during puberty. Menopausal women and women who are using the lactational amenorrhea method of contraception may have a more alkaline pH as a result of decreased estrogen levels.

Testosterone can be converted to estradiol. It is produced in the adrenal gland, in the ovarian stroma, and through the conversion of androstenedione and DHA in peripheral tissues. Testosterone is aromatized to estradiol in peripheral tissues.

COCs may potentiate the action of a bronchodilator and some drugs, including benzodiazepines, tricyclic antidepressants, and theophyllines.

Data indicate less uncheduled bleeding and less breast tenderness with conjugated estrogen combined with bazedoxifene (CEE/BZA) than with conjugated estrogen combined with medroxyprogesterone acetate (CEE/MPA).

Prolactin stimulates the synthesis of milk proteins in the mammary glands. Prolactin is secreted by the anterior pituitary gland. During pregnancy, prolactin stimulates the synthesis of milk proteins in the mammary glands. Oxytocin is secreted by the posterior pituitary gland in response to suckling and stimulates the breastmilk ejection reflex.

Non-contraceptive benefits of COCs include all the following except a decrease in risk for cervical cancer. The benefits include decreased risks for benign breast disease, endometrial cancer, and ovarian cancer.

Ovulation occurs within 32-44 hours after the LH surge begins, and urine ovulation prediction tests detect the LH surge.

A woman who plans to use the calendar method for contraception should chart her menstrual cycles for several months. She should subtract 11 days from her longest recorded cycle and 18 days from her shortest cycle to estimate when she would be fertile and infertile. For example, the woman with a 27 to 30 day cycle should abstain from sexual intercourse from day 9 (27 minus 18) through day 19 (30 minus 11).

LH surge, ovulation, rise in BBT, thickened cervical mucus. The LH surge occurs in the follicular phase and peaks about 10 to 12 hours before ovulation occurs. BBT increases at the time of ovulation. After ovulation, the corpus luteum, formed from he ruptured follicle, secretes progesterone, which causes thickening of cervical mucus and a sustained increase in BBT.

A diaphragm should be left in place for at least 6 hours after sexual intercourse and no longer than 24 hours.

The FDA has approved the use of mifepristone and misoprostol for medication abortion for up to 70 days (10 weeks) after an LMP.

Contraindications to use mifepristone and misoprostol include current use of an anticoagulant medication, known or suspected ectopic pregnancy, and use of long-term systemic corticosteroid therapy.

Which structure produces GnRH? The hypothalamus. GnRH is released from the hypothalamus in a pulsatile fashion. GnRH stimulates the anterior pituitary gland to release FSH and LH.

Unexplained vaginal bleeding prior to evaluation is a CDC category 3 condition for initiation of DMPA. Current and/or history of DVT or pulmonary emboli is a category 2 condition; drugs that later affect liver enzymes do not influence the effectiveness of DMPA, and smoking at any age is a category 1 condition for use of DMPA.

Spinnbarkeit refers to the elasticity of cervical mucus (the ability to be stretched between two fingers) seen at ovulation and under the influence of estrogen.

The following statement concerning coitus interruptus is false. There is a decreased chance of the presence of pre-ejaculatory sperm with repeated acts of intercourse. This statement is false. In itself, pre-ejaculatory fluid contains no sperm. However, with repeated acts of intercourse close together, subsequent pre-ejaculatory fluid may have “carryover” sperm from the previous ejaculation.

In the case of a partially expelled IUC, remove the current one, place a new IUC at the current visit, and start doxycycline for 5 to 7 days. The original one needs to come out, and if the woman wants another IUC, it can be placed that same day after ruling out pregnancy. Doxycycline is prescribed to reduce the risk of infection.

An increased production of prostaglandins is associated with primary dysmenorrhea. Prostaglandins act at target sites near areas of secretion. They regulate the contraction and relaxation of smooth muscle. Prostaglandins are produced by the endometrium, with peak levels occurring in the late secretory phase. They stimulate uterine myometrial contractions.

IUDs have the same failure rate in the perfect use and typical use failure rates.

The ovary releases estrogen in response to FSH. FSH is released by the anterior pituitary gland in response to GnRH from the hypothalamus. FSH stimulates follicular growth in the ovary, leading to increased estradiol levelsThe advantage of continuous-combined hormone therapy over continuous cycl.

The hormone that is dominant during the proliferative phase of the menstrual cycle is estrogen. Estrogen is the predominant hormone during the uterine proliferative phase of the menstrual cycle, which correlates with the ovarian follicular phase. Under the influence of estrogen, the endometrium grows/thickens in the proliferative phase.

Progestin-only methods are classified as CDC category 1 for lactating women 30 or more days postpartum. CHCs are classified as CDC category 3 for the first 42 days postpartum for women with other venous thromboembolism risk factors, which include obesity. Fertility awareness methods are not recommended until the woman has resumed regular menses. If she is weaning her baby, she will not be able to rely on the lactational amenorrhea method for contraception.

According to the CDC recommendations, a category 4 condition for the indicated contraceptive method would be a vaginal contraceptive ring for a woman older than 35 years who smokes one pack of cigarettes per day, which falls under category 4 conditions for all of the CHCs.

Potential disadvantages of progestin-only implants include irregular bleeding and spotting, prolonged and more frequent bleeding, especially in the first few months of use. Progestin-only implants do not cause any decrease in bone mineral density, and most users ovulate within 6 weeks after removal.

Estriol is the least potent of the estrogens. It is derived from the conversion of estrone and estradiol in the liver, uterus, placenta, and fetal adrenal gland. It is the estrogen known as the “estrogen of pregnancy”.

A 52-year-old female with a hysterectomy 2 years ago for uterine bleeding caused by fibroids is complaining of severe hot flashes and night sweats for the past few months. The most appropriate treatment for her vasomotor symptoms at this time would be a transdermal estrogen patch. HT is indicated for the treatment of moderate to severe vasomotor symptoms.

A menopausal patient is experiencing discomfort during sexual intercourse related to vaginal dryness. What is some information regarding lubricants and moisturizers that she can use? Vaginal lubricants have an immediate effect and are intended to reduce friction on atrophic vulvovaginal structures during sex. Vaginal moisturizers are applied several times weekly for longer-term relief of vaginal dryness. Moisturizers help maintain vaginal moisture and lower vaginal pH. Lubricants do not take several weeks of use to become effective.

Correct info regarding the contraceptive vaginal ring: The ring is worn in the vagina for 3 weeks, followed by 1 week without the ring, when women will have a withdrawal bleed. The exact position of the ring in the vagina is not important to effectiveness. The male condom can be used with the contraceptive vaginal ring.

Incorrect info includes: a new ring should be inserted every 7 days.

Activin is a polypeptide hormone produced by the ovaries that stimulates FSH production. Inhibin, which is also a polypeptide hormone, inhibits FSH production. Pollistatin binds with activin to inactivate it, thereby inhibiting FSH production.

Which phase of the menstrual cycle is the most variable? The follicular phase begins on day 1 of menses and ends with ovulation. This phase is more variable in terms of time frame than the luteal phase, which is normally 14 days (+ or - 2 days).

The USPSTF recommends against routine clinical breast examination at any age and recommends biennial mammograms from age 50 to 74. Therefore, an 80-year-old patient should have neither a clinical breast exam nor a screening mammogram.

Non-contraceptive benefits of COCs include decreased risks for benign breast disease, endometrial cancer, and ovarian cancer. There is no decrease in the risk of cervical cancer.

Important instructions for use of progestin-only oral contraceptive users should include: if you are more than 3 hours late taking a pill, use a backup method for 48 hours. The major mechanism of action of the progesterone-only pills is the thickening of cervical mucus. Progestin-only pills must be taken at the same time each day to maintain adequate progestin for this effect. Progestin levels peak shortly after taking a pill and decline to nearly undetectable levels 24 hours later.

An advantage of the female condom is that it may be used by individuals with latex allergy.

Cognitive behavioral therapy is supported for managing mild-moderate vasomotor symptoms related to menopause by way of Level I evidence.

A 58-year-old with vaginal dryness causing irritation and dyspareunia has no problem with hot flashes. The following would be a good treatment option for her low-dose estrogen vaignal ring. The menopausal woman who has symptoms related to vulvovaginal atrophy and no vasomotor symptoms is best treated with local low-dose vagina estrogen.

The diaphragm should not be left in place for more than 24 hours, and the cervical cap may be left in place for up to 48 hours.

Frequent spermicide use (2+ times per day) may cause vulvovaginal epithelium disruption and increase susceptibility to HIV infection. Spermacide should be placed deep in the vagina close to the cervix and left there for at least 6 hours after sexual intercourse. When spermacide is used along with a condom, there is increased contraceptive efficacy, but it will not further decrease the risk for STIs.

During the luteal phase, this is thickened cervical mucus. The luteal phase of the menstrual cycle begins after ovulation occurs. lasts approx. 14 days, and ends with he first day of menses. Progesterone secreted from the corpus luteum causes thickened cervical mucus. The luteal phase corresponds with the uterine secretory phase.

A physical finding of a 25-year-old nulliparous female includes a uterus of 8 cm in length, right ovary 3 cm x 2 cm, and left ovary not palpable. These findings indicate a normal uterus and normal ovaries. In a reproductive woman, the uterus is approximately 8 cm in length, 5 cm in width, and 2.5 cm in thickness, with slightly larger dimensions in the multiparous woman. Ovaries are approximately 3 cm x 2 cm x 1 cm.

A woman taking UPA for emergency contraception because she was late starting a new pack of COCs and had unprotected sex should be advised to abstain from sex or use a barrier for 5 days and then restart her COCs. She should also use a backup method for the first 7 days after restarting her COCs.

The alveoli within the breast lobules are responsible for milk production.

Emergency contraception pills should be taken as soon as possible after unprotected sex and within 120 hours for maximum effectiveness. If the woman has had previous unprotected sex since her last period and more than 120 hours ago, obtain a urine pregnancy test to rule out an existing pregnancy.

The following is considered to be a category 4 condition for the use indicated contraception method: The use of COC by a 40-year-old woman who has migraine headaches without aura. Because the use of COCs by a woman over 35 years old who has migraines with or without aura is a CDC category 4 condition. The use of COCs by a woman of any age who has migraine headaches with aura is also a CDC category 4 condition.

Healthy sperm can survive in the female reproductive tract and retain the ability to fertilize an egg for 3-5 days. An egg can be fertilized for 12-24 hours after release from the ovary.

The most prevalent contraceptive method among married women in the US is sterilization (female and male).

The Montgomery glands are the sebaceous glands that circle the nipple within the area of the areola.

Estrogen therapy options do not require opposition by a progestin in an individual with an intact uterus, such as the Estring vaignal ring. The Estring vaginal ring has little or no synthetic absorption and does not require opposition by progestogen.

The American Cancer Society recommends yearly mammograms for women starting at age 45.

The area located between the fourchette anteriorly and the anus posteriorly is the perineum.

The following factors may increase levels of SHBG, sex hormone-binding globulin: hyperthyroidism, pregnancy, and use of estrogen-containing oral contraceptives. Factors that decrease SHBG include obesity, hyperinsulinemia, and androgens.

Squamous metaplasia is the process whereby columnar cells of the endocervix are replaced by mature squamous epithelium. The transformation zone is the area around the junction of squamous and columnar cells (squamocolumnar junction) where squamous metaplasia occurs.

Breast development begins with breast budding around the age of 9. The growth of pubic and axillary hair usually starts after breast development begins, and the peak growth spurt occurs around age 12, just prior to the onset of menses.

Alternative contraception should be considered when any of the following occur: menses, regular supplementation, long periods without breastfeeding, or the baby is 6 months old.

Return fertility after discontinuing progestin-only injections may take 6 to 12 months.

Lactobacillus is the predominant vaginal organism responsible for an acidic pH in the preproductive woman.

The rise in BBT occurs at the time of ovulation. BBT cannot be used to predict ovulation, but it can be used to determine whether ovulation has occurred. A statement that would indicate the need for further instruction about this method would be “I know that I am about to ovulate when my temperature rises at least 0.4 degrees.”

If a contraceptive patch is detached for less than 24 hours, it can be reattached if it adheres well, or a new patch can be applied. The client should keep the same patch-change day. As long as it has been less than 48 hours since the patch detached, she does not need to use emergency contraception or a backup method.

A woman taking UPA for emergency contraception because she was late starting a new pack of her COC and had unprotected sex should be advised to abstain from sex or use a barrier method for 5 days and then restart her COCs. She should be advised to refrain from taking her COCs for 5 days after taking an emergency contraception.

Drugs that increase the production of the liver enzyme cytochrome P-450 may cause more rapid clearance of COCs during first-pass metabolism in the liver.

The predominant estrogen after menopause is estrone. Estrone is converted from androstenedione, produced by the adrenal gland and ovarian stroma.

A 25-year-old woman who has had an IUC for 2 years has a Pap test showing actinomycosis. She has no symptoms of infection. Appropriate management would include keeping the IUC and repeating the Pap test in 3 years. Actinomyces is a normal organism of the female genital tract. IUC users are more likely to have colonization. Pelvic infection caused by Actinomyces is very rare, but it is a serious infection if it does occur. The Pap test does not diagnose actinomycosis infection. The asymptomatic IUC user should be informed of the Pap test result and advised that the IUC does not need to be removed and that she does not require any antibiotic treatment unless an infection occurs.

Instructions for progestin-only oral contraception users should include… if you are more than 3 hours late taking the pill, use a backup method for 48 hours. The major mechanism of action of pregestin-only pills is the thickening of cervical mucus. Progestin-only pills need to be taken at the same time every day to maintain adequate progestin effect. Progestin levels peak shortly after taking a pill and decline to nearly undetectable levels 24 hours later.

Estrogen is the predominant hormone during the uterine proliferative phase of the menstrual cycle, which correlates with the ovarian follicular phase. Under the influence of estrogen, the endometrium grows/thickens in theproliferative phase.

Asking a patient if they’ve ever engaged in sex to meet any of their basic needs may help the clinician understand more about the patient’s practices.

BBT - use a BBT thermometer, temperature increase of 0.4 degrees F or higher at ovulation, and remains elevated for at least 3 days. Abstain from sex until a 3-day temp increase has occurred.

Testosterone is an androgen that can be converted into estradiol, and it is produced in the adrenal gland, in the ovarian stroma, and through the conversion of androstenedione and DHA in peripheral tissues. Testosterone is aromatized to estradiol in peripheral tissues.

Expected lab values with menopause are increased FSH, increased LH, and decreased estradiol.

Lactational amenorrhea is only effective when breastfeeding every 4 hours during the day and every 6 hours during the night. Another method of contraception should be considered when the infant begins sleeping through the night.

A urine ovulation prediction test detects an LH surge. Ovulation occurs within 32-44 hours after the LH surge begins.

Combined oral contraceptives decrease the risk of benign breast disease, endometrial cancer, and ovarian cancer. It does not decrease the risk of cervical cancer.

Mifepristone and misoprostol for medical abortion for up to 70 days after the LMP.

SHBG levels can increase from estrogen-containing oral contraceptives, hyperthyroidism, and pregnancy. While obesity, hyperinsulinemia, and androgens decrease SHBG.

The advantage of continuous combined hormone therapy over continuous cyclic HT regimens is a lower cumulative dose of progestin. Estrogen and progesterone are taken every day with a continuous combined HT than a continuous cyclic HT regimen in which estrogen is taken every day and larger doses of progestogen are added 10-14 days each month.

The alveoli with the breast lobules are responsible for milk production.

Smoking a pack (15 or more cigarettes/day) at age 35 or older is a CDC category 4 condition for all the CHCs.

The predominant estrogen after menopause is estrone. Estrone is converted from androstenedione produced by the adrenal gland and ovarian stroma.

For the calendar method of contraception, subtract 11 days from the longest recorded cycle and 18 days fromthe shortest cycle to estimate when she would be fertile and infertile. For example, a patient with 27 - 30 day cycles should abstain from sexual intercourse from day 9 (27 minus 18) through day 19 (30 minus 11).

For the calendar (rhythm) method, the rules are ALWAYS:

Earliest fertile day = shortest cycle − 18
Latest fertile day = longest cycle − 11

These numbers never change, no matter what cycle lengths they give you.

“18 comes Early, 11 comes Late.”

18 is the bigger number → subtract from the shortest cycle → gives the earliest fertile day
11 is the smaller number → subtract from the longest cycle → gives the latest fertile day

Or:

“Short − 18, Long − 11.”

Say it like a rhythm — it sticks.

The follicular phase begins on day 1 of menses and ends with ovulation. This phase is more variable in terms of time frame than the luteal phase, which is normally 14 days (± 2 days).

The order of events: LH surge, ovulation, rise in BBT, thickened mucus = The LH surge occurs in the follicular phase and peaks about 10-12 hours before ovulation occurs. BBT increases at the time of ovulation. After ovulation, the corpus luteum, formed from the ruptured follicle, secretes progesterone, which thickens cervical mucus and sustains a sustained increase in BBT.

The ACS recommends yearly mammograms for individuals starting at age 45 with an average risk of breast cancer.

Emergency contraception pills should be taken as soon as possible after unprotected sex and within 120 hours for maximum effectiveness. If more than 120 hours ago obtain a pregnancy test.

Estrogen delivered via a transdermal patch does not affect cardiovascular markers (HDL, LDL, triglycerides). There is less effect on coagulation factors and a lower risk of venous thromboembolism with transdermal estrogen compared with oral estrogen in the menopausal patient.

Data indicates less unscheduled bleeding andless breast tenderness with conjugated estrogen combined with bazedoxifene CEE/BZA than with conjugated estrogen combined with medroxyprogesterone acetate CEE/MPA.

A patient calls because her contraceptive patch fell off, but was easily reapplied. states that it was fully attached last night during sex, the appropriate advice would include keeping the same patch on if it adheres well, and keeping the same patch change day.

A patient receiving ulipristal acetate (UPA) for emergency contraception because she was late starting a new pack of combined oral contraceptive (COC) and then had unprotected sex should be advised to abstain from sex or use a barrier method for 5 days and then restart her COCs. There is concern that hormonal contraceptives may reduce the effectiveness of UPA. The patient should be advised not to start hormonal contraception for at least 5 days after taking UPA. The patient should also use a backup method for the first 7 days after restarting COCs.

An advantage of continuous-combined hormone therapy over continuous cyclic HT regimens is a lower cumulative dose of progestin. Estrogen and progesterone are taken every day with continuous with a lower cumulative dose of progestin than continuous-cyclic, in which estrogen is taken every day, and larger doses of progestogen are added 10-14 days each month.

It is recommended that no further cervical cancer screening be performed in women 65 and older following adequate negative prior screening and no history of CIN2 or more serious diagnosis. Screening should not be resumed even if the patient reports a new sexual partner.

Individuals using continuous-combined HT may initially have some unpredictable spotting and bleeding, but after several months of use, the endometrium atrophies, and amenorrhea usually results. If spotting or bleeding recurs after several months of amenorrhea, an endometrial evaluation is warranted.

The lubricant to avoid when using a polyurethane barrier method is silicone because it is not compatible, whereas oil and water-based lubricants are. Petroleum-based products should not be used as they are associated with infection.

The contraceptive vaginal ring is worn in the vagina for 3 weeks, followed by 1 week without, where the patient will havea withdrawal bleed. The exact position does not matter for effectiveness, and a male condom can be used along with it. A patient should not insert a new one every 7 days.

Internal vaginal condoms are made of nitrile and can be safely used by those with a latex allergy.

The diaphragm can not be left in place for more than 24 hours, while the cervical cap can be left in place for up to 48 hours.

New users of COCs starting their BC on Sunday should use a backup method for 7 days of the first pack of pills.

The Estring vaginal ring has little or no systemic absorption and does not require opposition by a progestogen.

Non-contraceptive benefits of COCs include decreased risks for benign breast disease, endometrial cancer, and ovarian cancer.

The pectoral, subscapular, and lateral axillary lymph nodes drain into the central nodes that are located high in the axilla between the anterior and posterior axillary nodes and are the most likely to be palpable. The central nodes drain into the infraclavicular and supraclavicular nodes.

BBT teaching for a patient includes: taking the temperature at the same time each day before getting out of bed, using a special thermometer to obtain basal body temperature, and a rise of 0.4 degrees F above the baseline for 3 days indicates that it is safe to have sex.

Osemifene is taken daily to treat moderate to severe dyspareunia related to vulvovaginal atrophy. Hot flashes are a common side effect. Estrogen should not be used in combination with Osemifene. No studies have looked at progesterone used in conjunction.

A transdermal estrogen patch is appropiate fo an individual who has had a hysterectomy because they do not need progestogen; only estrogen is appropriate. The estrogen Osepmifene and vaginal estrogen cream are indicated for vulvovaginal atrophy and related symptoms, but do not relieve vasomotor symptoms.

HT is indicated for moderate to severe vasomotor symptoms.

Estrogen in COCs stabilizes the endometrium for less unscheduled bleeding. Estrogen contributes to the inhibition of ovulation through suppression of FSH, but mainly potentiates the action of progestin, which has the most contraceptive effect.

Disadvantages of progestin-only implants are that they may cause irregular, prolonged, or more frequent bleeding bleeding especially in the first few months of use. It does not decrease bone mineral density, and most users ovulate within 6 weeks after removal.

LH surge, ovulation, rise in BBT, and thickened cervical mucus are the stages of ovulation.

Estring vaignal ring has little to no systemic absorption and does not require opposition by progestogen.

Progesterone secreted from the corpus luteum causes thickened cervical mucus.