Item: 1 of 2 ~ 1 • Mark -<] C> Jill ~· ~J

QID: 24220 .1 Previous Next Lab'V!I!ues Notes Calculator

• 1
A 22-year-old woman comes to the physician's office requesting contraception . She has a history of pelvic inflammatory
disease diagnosed 8 months ago, and she had toxic shock syndrome 3 years ago . Upon further questioning, she states
that she has been experiencing abnormal vaginal bleeding for the past 6 months . She reports smoking half a pack of
cigarettes per day. Her temperature is 37°C (98 .6°F), blo,od pressu re is 129/85 mm Hg, pulse is 70/min, and respiratory rate is
14/min .

Which of the following is an absolute contraindication to the use of ora l contraceptive pills?

A. Current cigarette smoking

B. Current hypertension
C. History of pelv ic inflammatory disease

D. History of toxic shock syndrome

E. Undiagnosed abnormal vaginal bleeding

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Item: 1 of 2 ~ 1 • Mark -<] C> Jill ~· ~J
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1
•2

The correct answer is E. 49% chose this.

Undiagnosed vaginal bleeding is an absolute contraindication to the use of oral contraceptive pills (OCPs) . A work-up to find
the underlying cause of bleed ing must be pursued before OCPs can be prescribed. Other absolute contraindications are
pregnancy, history of thromboembolic disorders, history of stroke or coronary artery disease, breast cancer, estrogen-
dependent cancer, a benign or malignant tumor of the liver, and ciga rette smoking in a woman >35 years old .
Absolute Contraindications to the use of OCPs
1. Undiagnosed vaginal bleeding
2 . Pregnancy
3. Thromboembolic disorders
4. h/o CVA/Stroke
5.CAD
6. Breast cancer
7. Any estrogen-dependent cancer
8. Any tumor of the liver
9. Tobacco use in a woman over the age of 35 years

Coronary artery disease Estrogen Breast cancer Oral contraceptive pill Contraindication Neoplasm Liver Vaginal bleeding Birth control Tobacco smoking Stroke

Combined oral contraceptive pill Thrombosis Malignancy Smoking Cancer Pregnancy Coronary circulation

A is not correct. 230/o chose this.

Cigarette smoking is an absolute contraind ication to the use of oral contraceptive pills (OCPs) in women >35 years old.
However, smoking does not preclude the use of OCPs in younger patients . This patient should, however, be counseled about
smoking cessation .
Smoking cessation Cigarette Tobacco smoking Contraindication

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Item: 1 of 2 ~ 1 • Mark -<] C> Jill ~· ~J
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Combined oral contraceptive pill Thrombosis Malignancy Smoking Cancer Pregnancy Coronary circulation
1
•2 A is not correct. 230/o chose this .
Cigarette smoking is an absolute contraindication to the use of oral contraceptive pills (OCPs) in women >35 years old.
However, smoking does not preclude the use of OCPs in younger patients . This patient should, however, be counseled about
smoking cessation .
Smoking cessation Cigarette Tobacco smoking Contraindication

B is not correct. 160/o chose this.

Hypertension is not an absolute contraindication to oral contraceptive pills (OCPs), nor does this patient have true
hypertension, as her systolic blood pressure is only 125 mm Hg. However, OCPs may cause hypertension and blood pressure
should be monitored .
Hypertension Contraindication Blood pressure Systole

C is not correct. 6% chose this.

A history of pelvic inflammatory disease is not a contraindication to oral contraceptive pills (OCPs). A recent history of
sexually transmitted infection is a contraindication for the use of an intrauterine device. Patients should be counseled about
the importance of using condoms to prevent sexually transmitted infection and should be informed that OCPs offer no
protection against sexually transmitted infections .
Pelvic inflammatory disease Sexually transmitted infection Intrauterine device Contr aindication Condom Inflammation Pelvis

D is not correct. 6% chose this.

A history of toxic shock syndrome (TSS) is not a contraindication to oral contraceptive pills (OCPs) . TSS is an acute illness
caused by preformed Staphylococcus aureus toxin (TSST-1) . More than 90% of those affected are women of child-bearing
age, and it often occurs within 5 days of a menstrual period in women who use tampons. Treatment consists of rapid
rehydration, removal of the source of the toxin, and antistaphylococcal drugs. A history of TSS does not preclude OCP use.
Toxic shock syndrome Staphylococcus au reus Toxin Toxic shock syndrome toxin Staphylococcus Tampon Contraindication Menstrual cycle Toxicity Menstruation

Bottom line:

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Item: 1 of 2 ~ 1 • Mark -<] C> Jill ~· ~J
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• I I • • • I I ..
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Hypertension is not an absolute contraindication to oral contraceptive pills (OCPs), nor does this patient have true
•2
hypertension, as her systolic blood pressure is on ly 125 mm Hg . However, OCPs may cause hypertension and blood pressu re
should be monitored .
Hypertension Contraindication Blood pressure Systole

C is not correct. 60/o chose this.

A history of pelvic inflammatory disease is not a contraindication to oral contraceptive pills (OCPs) . A recent history of
sexually transmitted infection is a contraindication for the use of an intrau terine device. Patients should be counseled about
the importance of using condoms to prevent sexually transmitted infection and should be informed that OCPs offer no
protection against sexually transmitted infections .
Pelvic inflammatory disease Sexually transmitted infection Intrauterine device Contr aindication Condom Inflammation Pelvis

D is not correct. 6% chose this.

A history oftoxic shock syndrome (TSS) is not a contraindication to oral contraceptive pills (OCPs) . TSS is an acute illness
caused by preformed Staphylococcus aureus toxin (TSST-1) . More than 90% of those affected are women of child-bearing
age, and it often occurs w ithin 5 days of a menstrual period in women who use tampons. Treatment consists of rapid
rehydration, removal of the source of the toxin, and antistaphylococcal drugs. A history of TSS does not preclude OCP use.
Toxic shock syndrome Staphylococcus au reus Toxin Toxic shock syndrome toxin Staphylococcus Tampon Contraindication Menstrual cycle Toxicity Menstruation

Bottom line:
Undiagnosed vaginal bleeding is an absolute contraindication to the use of oral contraceptive pills.
Oral contraceptive pill Birth control Combined oral contraceptive pill Contraindication Vaginal bleeding

References:
FA Step 2 CK 9th ed p 335
FA Step 2 CK 8th ed p 323

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Item: 2 of 2 ~ 1 • Mark -<] C> Jill ~· ~J
QID: 22965 ..1 Previous Next Lab'V!I!ues Notes Calculator

1
A 21-year-old woman presents to the emergency department because of severe abdominal pa in for the past 6 hours. She
•2
is currently on prophylactic rifampin after her boyfriend was diagnosed w ith bacterial meningitis . The patient has a history
of asthma for which she intermittently uses an albuterol in haler. She is also on oral contraceptives. On exam ination, the
patient is in obvious discomfort with pa in on palpation of the lower left quadrant. Her serum human chorionic gonadotropin level
is elevated and transvagina l ultrasound revea ls free flu id in the cul-de-sac . Laparoscopy reveals a ruptured ectopic pregnancy.

What is the most li kely reason for failure of the patient's oral contraceptive?

A. Albuterol use
B. Bacteria l men ingitis
C. Competition for bind ing sites

D. Malabsorption
E. Rifam pin use

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Item: 2 of 2 ~ 1 • Mark -<] C> Jill ~· ~J
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The correct answer is E. 81% chose this.

Rifampin is commonly used to t reat tuberculosis, leprosy, and Legionnaire disease; it is also given as post-exposure
prophylaxis for men ingococcal disease. Rifampin works by inhibit ing bacteria l DNA-dependent RNA polymerase . It is an
inducer of the cytochrome P-450 enzymes and causes these enzymes to metabolize drugs (such as ora l contraceptives) at a
faster rate . Increased metabolism decreases blood concentrations of the oral contraceptive pills and therefore significantly
decreases the efficacy of these pills. Other common side effects of rifampin include hepatotoxicity and orange-colored tears,
sweat, and urine.
Hepatotoxicity Rifampicin Leprosy Tuberculosis Post-exposure prophylaxis Cytochrome P450 Meningococcal disease Oral contraceptive pill RNA polymerase Metabolism Urine RNA

Preventive healthcare Neisseria meningitidis Adverse drug reaction Combined oral contraceptive pill Birth control Enzyme inducer

A is not correct. 3% chose this.

Albuterol is a ~ 2 -receptor agonist that is used to treat asthma, bronchospasm and chronic obstructive pulmonary disease v ia
smooth muscle relaxation and bronchial dilation . Side effects are related to ~rreceptor stimulation and include tremor,
anxiety, headache, hypokalemia, and tachycard ia. Since it is an inhaled medication , another side effect includes oral thrush
caused by improper use of the inhaler. Albuterol does not affect the metabolism of oral contraceptive pills.
Bronchospasm Hypokalemia Chronic obstructive pulmonary disease Asthma Tachycardia Salbutamol Smooth muscle tissue Agonist Headache Tremor Side effect Inhaler

Oral candidiasis Anxiety Metabolism Candidiasis Bronchus Adverse effect Adverse drug reaction Muscle ~1uscle relaxant Vasodilation Respiratory disease

Combined oral contraceptive pill

B is not correct. 10/o chose this.

Bacteria l men ingit is is caused by bacteria such as Neisseria meningitidis and Streptococcus pneumoniae. The patient would
present with symptoms such as headache, fever, and nuchal rigidity--none of which this patient has. Furthermore, bacterial
meningit is as a disease is not known to interfere with oral contraceptives in the body.
Neisseria meningitidis Streptococcus pneumoniae ~1eningitis Bacterial meningitis Streptococcus Bacteria Headache Neisseria Fever Oral contraceptive pill

C is not correct. 9% chose this.

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Item: 2 of 2 ~ 1 • Mark -<] C> Jill ~· ~J
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1
Bacteria l meningit is is caused by bacteria such as Neisseria meningitidis and Streptococcus pneumoniae. The patient would
2 present with symptoms such as headache, fever, and nuchal rigidity--none of which this patient has. Furthermore, bacterial
meningit is as a disease is not known to interfere with oral contraceptives in the body.
Neisseria meningitidis Streptococcus pneumoniae Meningitis Bacterial meningitis Streptococcus Bacteria Headache Neisseria Fever Oral contraceptive pill

C is not correct. 9% chose this.

Drug binding to t issue receptors and other plasma proteins such as albumin and lipoproteins may affect the efficacy of the
drug. Protein binding can influence the drug's biological half-life in the body, affecting the drug's efficacy. Neither rifampin nor
albuterol shar e binding sites with estrogen or progesterone, the components of combined oral contraceptive medications.
Estrogen Progesterone Rifampicin Biological half-life Human serum albumin Blood plasma Albumin Half-life Protein Oral contraceptive pill lipoprotein Combined oral contraceptive pill

Receptor (biochemistry) Blood proteins Salbutamol Birth control

D is not correct. 6% chose this.

While intestinal malabsorption of oral contraceptive pills { OCPs) is a cause of decreased OCP efficacy, this patient has no
history of malabsorptive disease, such as celiac disease . Furthermore, while she does have abdom inal pain, she has not
reported any concomitant diarrhea or vomit ing w hich would suggest malabsorption . Therefore, this answer choice is unlikely.
Coeliac disease Malabsorption Diarrhea Oral contraceptive pill Abdominal pain Vomiting Birth control Combined oral contraceptive pill Digestion

Bottom line:
Rifampin is an inducer of the P-450 system and causes these enzymes to metabolize drugs, such as oral contraceptives, at a
faster rate . This decreases the blood concentrations of these drugs and in this patient's case, could lead to a surprise
pregnancy.
Rifampicin Oral contraceptive pill Combined oral contraceptive pill Metabolism Pregnancy Enzyme Birth control Enzyme inducer

References:
FA Step 2 CK 9th ed pp 514; 335

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