WHNP-BC cheat sheet

Cervical cancer screening: start at 21; ages 21-29 cytology every 3 years; ages 30-65 primary HPV every 5 years, co-testing every 5 years, or cytology every 3 years; stop at 65 with adequate prior negative screening and no high-grade history.

PALM-COEIN classifies abnormal uterine bleeding: structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) and nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified).

Any bleeding after 12 months of amenorrhea is postmenopausal bleeding and requires endometrial evaluation (transvaginal ultrasound and/or endometrial biopsy); an endometrial thickness of 4 mm or less has high negative predictive value but does not replace tissue sampling when bleeding persists or risk factors exist.

Exclude ectopic pregnancy with urine or serum hCG in every reproductive-age patient presenting with pelvic pain, vaginal bleeding, or syncope, regardless of reported contraceptive use.

Simple adnexal cysts in premenopausal patients without septations, solid components, or ascites are usually physiologic and can be followed with imaging rather than immediate surgery.

Iron deficiency anemia in a menstruating patient over 40 years, or when menstrual loss does not explain the severity, warrants evaluation for gastrointestinal blood loss.

Blood pressure 140/90 mm Hg or higher on two occasions confirms hypertension; 160/110 mm Hg or higher, or any elevation with end-organ symptoms, requires same-day evaluation.

Screening for sexually transmitted infections and describing intimate partner violence exposure are part of the assessment, not optional add-ons; both alter the differential and the plan.

Mammography: biennial screening ages 50-74 for average risk; shared decision-making for ages 40-49, with the option to begin at 40 or 45 depending on the guideline framework used.

Colorectal cancer screening begins at age 45 and continues to 75; options include colonoscopy every 10 years or annual stool-based testing with colonoscopy for abnormal results.

Osteoporosis screening: DXA for all women 65 and older; earlier for postmenopausal women under 65 with elevated FRAX risk (10-year major osteoporotic fracture risk of 9.3% or greater).

Chlamydia and gonorrhea screening annually for sexually active women younger than 25 and for older women with risk factors; at least one lifetime HIV and syphilis screen, and both at the first prenatal visit.

HPV vaccination: routine at ages 9-26; shared clinical decision-making at 27-45; two doses if the series starts before age 15, three doses if it starts at 15 or older.

Tdap every 10 years, and once during each pregnancy at 27-36 weeks regardless of prior interval; influenza vaccination annually at any trimester.

Folic acid 400 mcg daily for all patients planning pregnancy; 4 mg daily when there is a prior neural tube defect-affected pregnancy, started at least 1 month before conception.

Breast self-awareness is recommended over structured breast self-examination; routine clinical breast examination is not recommended as a stand-alone screening method.

Screen for type 2 diabetes in adults aged 35-70 with overweight or obesity, and repeat at least every 3 years when results are normal.

Bacterial vaginosis is diagnosed by 3 of 4 Amsel criteria: homogeneous thin discharge, vaginal pH above 4.5, clue cells, positive whiff test; treat with metronidazole 500 mg orally twice daily for 7 days or vaginal metronidazole gel.

Uncomplicated vulvovaginal candidiasis: fluconazole 150 mg orally as a single dose or a short topical azole course; recurrent disease (4 or more episodes/year) requires induction then maintenance therapy.

Trichomoniasis: metronidazole 500 mg orally twice daily for 7 days; treat partners and rescreen at 3 months.

PCOS is diagnosed by 2 of 3 Rotterdam criteria (ovulatory dysfunction, clinical or biochemical hyperandrogenism, polycystic ovarian morphology) after excluding thyroid disease, hyperprolactinemia, and nonclassic congenital adrenal hyperplasia.

Endometriosis is confirmed by laparoscopy, but empiric therapy with NSAIDs, combined hormonal contraceptives, or progestins is appropriate before surgery.

Symptomatic uterine leiomyomas: tranexamic acid, levonorgestrel intrauterine system, GnRH agonists or antagonists, myomectomy, or uterine artery embolization depending on fertility goals.

Pelvic inflammatory disease: ceftriaxone 500 mg IM once plus doxycycline 100 mg twice daily for 14 days plus metronidazole 500 mg twice daily for 14 days; remove an IUD only if no improvement in 48-72 hours.

Lichen sclerosus: ultrapotent topical corticosteroid (clobetasol propionate 0.05%) first-line; biopsy if the lesion does not respond or looks atypical.

Bartholin duct abscess: incision and drainage with Word catheter placement; biopsy the wall if the patient is over 40 years or the cyst recurs.

Typical-use failure rates in the first year: implant 0.1%, IUD under 1%, male sterilization 0.15%, DMPA 4%, combined oral contraceptives 7%, male condom 13%.

Combined hormonal contraceptives carry WHO MEC category 3-4 ratings with migraine with aura, smoking at age 35 or older, prior venous thromboembolism, known thrombogenic mutations, and breast cancer.

Emergency contraception ranked by efficacy: copper IUD within 5 days (most effective), ulipristal acetate 30 mg within 120 hours, levonorgestrel 1.5 mg within 72 hours (reduced efficacy with BMI 30 or higher).

Quick Start: a hormonal method may be started any day if pregnancy is reasonably excluded; use a backup method for 7 days (48 hours with progestin-only pills).

Chlamydia: doxycycline 100 mg twice daily for 7 days (azithromycin 1 g single dose in pregnancy, with test of cure 3-4 weeks later).

Gonorrhea: ceftriaxone 500 mg IM once; increase to 1 g if weight is 150 kg or greater; retest for reinfection at 3 months.

Syphilis: benzathine penicillin G 2.4 million units IM; pregnant patients with penicillin allergy require desensitization and penicillin therapy rather than an alternative agent.

Genital herpes: episodic or suppressive acyclovir or valacyclovir; cesarean delivery is offered when active genital lesions or prodromal symptoms are present at the onset of labor.

HIV preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine is taken daily, with HIV testing every 3 months and screening for kidney dysfunction and hepatitis B.

Estimated due date by Naegele's rule is the first day of the last menstrual period plus 280 days; first-trimester ultrasound is more accurate and supersedes the LMP date when the two differ.

Visit schedule for uncomplicated pregnancy: every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, then weekly until delivery.

In a normal early pregnancy serum hCG rises by at least 50-66% every 48 hours; a suboptimal rise suggests ectopic or nonviable pregnancy and prompts ultrasound and serial hCG monitoring.

Methotrexate for ectopic pregnancy requires hemodynamic stability, unruptured mass generally under 3.5-4 cm, no fetal cardiac activity, and hCG below about 5,000 mIU/mL.

RhD immune globulin is given to unsensitized Rh-negative patients at 28 weeks and within 72 hours of delivery of an Rh-positive infant, and after abortion, ectopic pregnancy, amniocentesis, or significant bleeding.

Gestational diabetes screening at 24-28 weeks with a 50 g glucose challenge; a 1-hour value of 130-140 mg/dL (threshold is laboratory-specific) triggers a 3-hour 100 g diagnostic test.

Preeclampsia: blood pressure 140/90 mm Hg or higher after 20 weeks plus proteinuria or end-organ dysfunction; severe features include 160/110 mm Hg, platelets under 100,000, transaminases over twice normal, creatinine above 1.1 mg/dL, pulmonary edema, or cerebral/visual symptoms.

Group B streptococcus screening at 36 0/7 to 37 6/7 weeks; colonized patients receive intrapartum penicillin G, with cefazolin or clindamycin (susceptibility-confirmed) for allergy.

Postpartum hemorrhage is most often caused by uterine atony; treatment is uterine massage, oxytocin first-line, then additional uterotonics, tranexamic acid within 3 hours, and volume resuscitation.

Menopause is a clinical diagnosis after 12 consecutive months of amenorrhea in a patient over 45; FSH and estradiol testing are not required when the presentation is typical.

Systemic hormone therapy is first-line for vasomotor symptoms in symptomatic patients younger than 60 or within 10 years of menopause who have no contraindications.

A progestogen is mandatory with systemic estrogen in any patient with a uterus to prevent endometrial hyperplasia and carcinoma; estrogen alone is used only after hysterectomy.

Absolute contraindications to systemic hormone therapy: unexplained vaginal bleeding, known or suspected breast cancer, active venous thromboembolism, coronary heart disease, stroke, and active liver disease.

Use the lowest effective dose and reassess benefits and risks at least annually; transdermal estradiol is preferred when venous thromboembolism risk or hypertriglyceridemia is present.

Genitourinary syndrome of menopause responds to low-dose vaginal estrogen, which does not require a progestogen and has minimal systemic absorption.

Nonhormonal options for vasomotor symptoms include SSRIs/SNRIs (paroxetine, venlafaxine), gabapentin, fezolinetant, cognitive behavioral therapy, and clinical hypnosis.

Bone health after menopause: calcium 1,200 mg daily (diet plus supplement), vitamin D 800-1,000 IU daily, weight-bearing exercise, and DXA at 65 or earlier with risk factors.

Hormone therapy is not indicated for primary prevention of cardiovascular disease or dementia; it should be prescribed for symptom relief and fracture prevention in appropriate candidates.

Chronic hypertension in pregnancy is present before 20 weeks or persists beyond 12 weeks postpartum; new elevation at 20 weeks or later defines a gestational hypertensive disorder.

Screen for depression with the PHQ-2, followed by the PHQ-9 when positive; a PHQ-9 score of 10 or higher warrants further evaluation and a treatment plan.

Sertraline is generally the preferred SSRI in pregnancy and lactation because of extensive data and low milk transfer; untreated maternal illness carries its own substantial risk.

Asymptomatic bacteriuria in pregnancy is screened for and treated with a short susceptibility-guided course to prevent pyelonephritis and preterm birth.

Uncomplicated cystitis: nitrofurantoin for 5 days or trimethoprim-sulfamethoxazole for 3 days; avoid trimethoprim-sulfamethoxazole in the first trimester and nitrofurantoin at term.

Migraine with aura contraindicates combined hormonal contraception because of elevated ischemic stroke risk; progestin-only or nonhormonal methods are preferred.

Preconception diabetes goal is hemoglobin A1c below 6.5% to reduce congenital anomaly risk; metformin is generally continued through pregnancy.

Weight loss of 5-10% of body weight restores ovulation in a substantial proportion of patients with PCOS and obesity.

Screen all reproductive-age patients for intimate partner violence at well-woman, prenatal, and family planning visits, using a validated tool in private and with a trained interpreter when needed.

Informed consent requires the diagnosis or condition, the nature of the proposed intervention, material risks and benefits, reasonable alternatives including no treatment, and the consequences of declining.

Mandatory reporting duties typically include suspected child abuse or neglect, elder and dependent adult abuse, and specified communicable diseases; thresholds and timelines are set by state statute.

Confidentiality for adolescent reproductive care varies by state; clinicians should verify state minor-consent laws and Title X requirements before promising or denying confidentiality.

Teach-back-asking the patient to restate the plan in her own words-is more effective than asking whether she has questions for confirming comprehension.

Patient education materials should be written at approximately a 5th-6th grade reading level and offered in the patient's preferred language.

Use trained medical interpreters rather than family members, and document interpreter use, to preserve accuracy and confidentiality in consent discussions.

Nurse practitioner scope of practice-full, reduced, or restricted-is determined by state law, and prescribing authority depends on DEA registration and state requirements.

Document shared decision-making, including when a patient declines recommended care, so that the informed refusal and follow-up plan are visible in the record.

Closed-loop referral communication means confirming that the referral was scheduled, that the patient attended, and that the result was received and acted upon.