I am a nurse midwife. I have sat for RN boards, taken the GRE (the most meaningless exam I have ever had to spend time on but very hard and necessary to get into grad school), most recently the Boards necessary to certify as a nurse-midwife, and five years ago, took the IBCLE exam. Of all the professional certification type exams I have taken, the IBCLE is by far the most difficult in my opinion. I think the test did cover a reasonable base of knowledge though for someone who wishes to function as a lactation consultant. What I am finding difficult at the present is finding time to figure out how to get all the continuing ed requirements I need as I must have a certain amount for ACNM, a certain amount to maintain my prescriptive authority and additionally, more credits to maintain my IBCLC. It adds up to alot of time and money! I do wish we could get credit for our participation here. Re estrogen patches for ppd: I don't prescribe low dose combined OC's for breastfeeding mothers because estrogen has been well documented to both decrease milk volume and to be one of the things that can indeed alter milk quality. I would think estrogen patches would be unacceptable for the same reason. While optimally, we don't have pregnant moms or breastfeeding moms on medications like antidepressants if we can help it, there are antidepressents that seem fairly acceptable to use, and because I know of no effect of antidepressents on milk quality or quantity, I would be much more inclined to prescribe an antidepresent that there was a good deal of experience with in breastfeeding moms than estrogen (which may not even affect the depression) if it were really needed (counselling and support seem the obvious first choices). Ione Sims, CNM, IBCLC