Author Archives: npWomensHealthcare

WHNPs in specialty positions: Cultivating a new role in gynecologic oncology

Throughout my graduate education in nursing, I had no doubt that I ultimately wanted to focus my practice on women’s health. However, I did graduate with a fair amount of trepidation about the possibility that I had limited my options in the advanced practice arena, especially after I had chosen to narrow my focus to oncology. Over the next couple of years, I came to realize not only that my options as a women’s health nurse practitioner (WHNP) were more numerous than I had thought, but also that I would be able to help cultivate new roles within the profession as well. Continue reading »

My career as a nurse advocate

When I was 6 years old, I knew I wanted to be a nurse. I followed through on this aspiration and pursued nursing throughout my adult career. At the same time, I’ve always considered myself artsy. I collect art—there are no bare walls in my house—and I have done a lot of needlework and have even won some awards. But my mission, my passion, which I developed early in my nursing career, is patient advocacy and access to care for women and newborns.

Early nursing advocacy

career nurse advocate postI was a master’s-degree nurse working at the bedside and loving the interaction with my patients, but I was also wondering how I could make a difference in more than one life at a time. In the mid-1980s, I was asked casually, “Can you help us develop a phone tree that we can use for statewide legislative advocacy?” Before I knew it, I was involved in state and national health policy issues: family medical leave, the push for affordable malpractice insurance for nurses in Virginia, Medicaid expansion for pregnant women and newborns, and the first sex education program for the county schools.

I decided to learn everything I could about healthcare policy and women’s issues. I even thought about leaving the bedside to focus on health policy full time, but I just couldn’t leave nursing. Being active in my professional nursing organization has provided a way for me to use my voice on behalf of women and newborns. When volunteer and leadership opportunities at local, state, and national levels were presented to me, I seized them. Along the way, I met other nurses, Nancy Sharp and Judy Collins, who were mentors, and who are now colleagues and friends in healthcare advocacy.

Later advocacy as a nurse practitioner

In the mid-1990s, I was considering returning to school—perhaps in health policy, maybe to earn a PhD, or perhaps to become a nurse practitioner (NP). My colleagues at the time supported my decision to remain close to patients, but I also still cared deeply about health policy. I decided to become a women’s health NP and continue my advocacy. In 1998, as a brand-new NP, I became a member of my regional chapter of the Virginia Council of Nurse Practitioners and joined their new Government Relations Committee. Our goal was to develop a two-part plan to develop strong relationships with our elected officials and to start to address the need for prescriptive authority for scheduled drugs for Virginia NPs. The council had been successful in achieving limited prescriptive authority for unscheduled medications in 1991 (HB 1402, Delegate Marshall, and SB 606, Senator Schewel). To achieve our goal, we needed to educate our state legislators about the role and cost effectiveness of NPs as healthcare providers. In 1999, our bill (SB 744, Senator Edwards) was to continue the NP/MD supervision ratio of 4:1 for NPs with prescriptive authority, lifting the sunset clause that would have reverted the ratio to 2:1 in 2000. We succeeded, and the bill became law in July 1999.

Our next challenge was prescriptive authority for controlled substances for Virginia NPs. We initially wanted to include all Schedules, II through V, in our bill, but we were persuaded to include only Schedules III through V by our bill patron. In 2000, HB 818 (Delegate Devolites) passed the House but was stopped in a Senate hearing. We needed to decide quickly whether to pull our bill or accept a compromise that each schedule would be rolled in over a 3-year period, with a progress report due to the General Assembly in 2003. We accepted the compromise and quickly returned to meeting with Senators to inform them of the change to our bill. We succeeded in the Senate and then again in the House. We stayed focused throughout the regulatory process and celebrated our success, which meant we could diagnose and treat shingles and we could write prescriptions for pain medications if our patients needed them.

How did we accomplish all of this? Although social media had not yet come into prominence, we had the Internet and a new means of communication called email. We also spent a lot of time on the phone, encouraging members to join our efforts. We used a toll-free number to call members of the General Assembly about our bill, and encouraged our family, neighbors, and colleagues to call, write, and visit. We met with legislators individually at breakfast, at town hall meetings, in their district offices, after church, or in the grocery store. We started having a legislative reception each year to keep our concerns about our patients and our practices in the spotlight. Slowly but surely, we developed strong relationships with our legislators and educated them about what it means to be an NP. Our other successes during this time included the following1:

  • SB 101, Senator Howell (2002): Allowed NPs to order physical therapy services;
  • HB 855, Delegate Jones (2004): Signature and certification legislation (a first in the United States);
  • SB 456, Senator Devolites (2006): Prescriptive Authority for Schedule II Drugs; and
  • SB 63, Senator Howell (2008): Mandated that at least one of seven Board of Nursing (BON) seats be held by an NP.

Many colleagues shared in all the work that led to our success. I wish I had room to name them all. I know that we changed the face of NP practice in Virginia.

Current advocacy

In 2010, the Institute of Medicine (IOM) published a report, The Future of Nursing: Leading Change, Advancing Health, which was the product of an initiative by the Robert Wood Johnson Foundation (RWJF) and the IOM to assess the need to transform nursing and to develop recommendations that would change the face of nursing. The RWJF and AARP developed a public initiative, The Future of Nursing: Campaign for Action, to increase public awareness. The key recommendation for us as NPs was that nurses should practice to the full extent of their education and training, a primary feature in our advocacy. Other key recommendations were as follows2:

  • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;
  • Nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States; and
  • Effective workforce planning and policy making require better data collection and information infrastructure.

It was an exciting time for us. President Obama was in office, and healthcare and the Affordable Care Act were top headlines. The prospect of Medicaid expansion would lead to many more patients and a need for more providers. As NPs, we wanted to be those providers. However, the opposition against us was strong and focused, and the General Assembly needed to hear from us again and again, to be reminded about our education and training as NPs. Many years of nursing research revealed the quality and safety of the care we provided, as well as the high degree of patient satisfaction with our care. Several times we sponsored legislation, only to be denied in Committee. Some of us were members of Virginia’s Advisory Committee of Joint Boards of Nursing and Medicine or the Virginia BON or we participated in governmental appointments such as the Virginia Prescription Drug Monitoring Program. We continued our yearly legislative receptions across the state and pushed our legislators to hear our stories and visit our clinical practices.

In 2017, a patron who was willing to work with us and with our opponent helped develop a bill that would satisfy everyone. With our off-year wave election, the face of the General Assembly suddenly was more willing to hear us. Our challenge: We needed to educate the newly elected members and shore up endorsements from our long-time supporters and organizational partners. Our elected officials gave us their full-throated support. The 2018 General Assembly acted on our bill. HB-793 (Delegate Robinson), Nurse Practitioner Practice Agreements, passed with nearly unanimous “yea” votes in both chambers and was signed by our new governor, a physician.

This bill, a transition-to-practice bill, has been used in other states to remove the barrier of requiring a practice agreement with a physician to practice as an NP. As many as 50% of our state’s NPs are eligible to transition to practice without such an agreement by filing an attestation form that they meet the criteria. We must now encourage our members to make this advancement part of their practice. While we celebrate our success this year, we are also working to develop regulations, and our opponent continues to try to thwart our success. Once again, we will report to the General Assembly about the implementation of our bill into our practice. Much work remains to be done to continue our journey to full practice authority. We must support our friends in the General Assembly; answer questions about our safety, quality, and clinical practice; and as always, be the advocate for our patients.

Grassroots advocacy: How can you be successful?

  • Consider it essential to be an active member of your professional organization. Start with involvement in short-term projects, such as volunteering to help plan a legislative reception.
  • Learn about your organization’s legislative issues and how best to contact your elected officials. Develop a focused, evidence-based message that everyone can easily discuss. Consider this your “2-minute elevator speech.”
  • Attend town hall meetings, visit your General Assembly, and participate in legislative receptions.
  • Use all forms of communication: emails, phone calls, face-to-face meetings, op-ed pieces, newspaper feature articles, and social media such as Facebook, Twitter, and LinkedIn. Get your message out there!
  • During an election cycle, work on a campaign phone bank or knock on doors. Use this opportunity to discuss your advocacy issues with candidates and with your representatives.
  • When you have a bill pending, visit, call, or email your legislator. Show up at committee meetings. Follow the process all the way to the end. Be relentless; your opponents will be relentless.
  • Celebrate your successes and acknowledge the contributions of your colleagues and legislators who made it possible with thank-you notes and a promise to work on their next campaign.

Implications for nurses

All nurses should expect to work as advocates. In fact, advocacy is now taught as part of our role as a nurse. Advocacy will keep you busy, and you will learn a lot about people and how your government works. It may even change your life’s work. Besides, don’t you want to make a difference for your patients and your practice? As Thomas Jefferson said in 1787, We in America do not have government by the majority. We have government by the majority that participates.

Carola Bruflat is a newly retired WHNP who worked in a private obstetrics/gynecology practice in Northern Virginia. She is an active member of the National Association of Nurse Practitioners in Women’s Health (NPWH) and served as an NPWH Board Member from 2012 through 2015. She is an active member of the Virginia Council of Nurse Practitioners and is the PAC Chair. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


  1. Virginia Council of Nurse Practitioners. History – Legislative. 2018.
  2. Campaign for Action. The Future of Nursing IOM Report. May 23, 2013.

Mycoplasma genitalium-related infection: An STI not quite ready for prime time

Mycoplasma genitalium has been designated by the CDC as an emerging concern among sexually transmitted pathogenic bacteria. Although M. genitalium-related infections are becoming more prevalent worldwide, and more is being learned about them, many questions about the pathogenesis and management of these infections remain unanswered. Until clear clinical guidelines are established, what should healthcare providers know about M. genitalium-related infections? Continue reading »

Male Sexual and Reproductive Health: The Role of Womenʼs Health Nurse Practitioners

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the right of all individuals to quality, evidence-based sexual and reproductive health (SRH) care that is non-judgmental, respectful, and culturally appropriate. SRH is an important component in individuals’ overall physical, emotional, and social well-being. SRH encompasses sexuality, sexual relationships, and all matters related to the function and processes of the reproductive system.1 The SRH of one individual often intertwines with that of another individual or individuals.

Sexual and reproductive healthcare includes health promotion, disease prevention, and identification and treatment of disease. As such, SRH care addresses issues such as sexuality, reproductive life planning, fertility, contraception, preconception health, all pregnancy options, reproductive assistance options, sexually transmitted infections (STIs)/HIV infection, SRH-related vaccinations (e.g., HPV vaccination), sexual dysfunction, reproductive health-related illnesses such as breast and cervical cancers, and violence within relationships.2,3

NPWH asserts that women’s health nurse practitioners (WHNPs) have a uniquely strong educational foundation to provide SRH care for all individuals, inclusive of all gender identities and sexual orientations. The specific purpose of this position statement is to support the role of WHNPs in the provision of SRH care for males. Providing quality SRH care to males not only helps them preserve and promote their own health but also helps optimize SRH outcomes in females. Of note, throughout this position statement, we use the terms male, female, man, and woman to denote both cisgender and transgender individuals.

The role and the competencies of WHNPs are not setting specific. However, the environment in which WHNPs practice may or may not include opportunities for direct interaction with males as patients. WHNPs who provide healthcare in settings that include male and female patients (e.g., family practice offices, family planning clinics, school- and college-based health centers, reproductive endocrinology/fertility centers) can reach males who might not otherwise receive SRH care. WHNPs who provide care in settings where males are generally not seen as patients (e.g., Ob/Gyn offices/clinics) may still have opportunities to reach male partners for a coordinated approach to SRH.


Providing SRH care for males requires attention to removing barriers and innovation to engage them in a variety of settings. Males, as they move into adolescence and young adulthood (and exit pediatric care), are less likely than their female counterparts to seek preventive healthcare that can include SRH services.4,5 In fact, a large proportion of young men do not know where to access SRH care.4,6,7 Even when adolescent or young adult males are seen in a healthcare setting, many healthcare providers (HCPs) do not address SRH.4,8-10 Recent studies indicate that if discussion about SRH with male patients does occur, it is often limited to how to decrease STI risk, and that although males are willing to discuss SRH-related issues, they prefer that the HCP initiate the discussion.7,9

Guidance for HCPs regarding the content and provision of SRH for males is often combined with recommendations for female SRH care. In 2014, the U.S. Office of Population Affairs (OPA) and the CDC developed and published recommendations for providing quality family planning and related preventive health services that include both female and male SRH services.2 Family planning services, as defined in this document, include reproductive life planning, contraception, preconception health, pregnancy testing and counseling, basic infertility services, and STI screening and treatment. Other important SRH care components include screening for reproductive cancers, providing appropriate immunizations, and providing or referring for prenatal and abortion care as needed.3 The audience for these recommendations extends beyond providers at sites dedicated to family planning services to providers in all primary care settings.

To support HCPs in providing male SRH services, the Male Training Center for Family Planning and Reproductive Health (MTC) elaborated on the OPA/CDC document with the publication of Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice.11 The MTC document provides recommendations for eight health history components, three physical examination components, and six laboratory tests, as well as seven recommendations for counseling based on identification of risk.11 Box 1 outlines the MTC’s recommendations for SRH services for males. HCPs can find additional guidance regarding male SRH care through multiple organizations’ publications—and links to these publications—provided in Box 2.

male sexual reproductive health box1

Box 2. Sample resources for male sexual and reproductive health

The WHNP role in providing SRH care for males is not new. For more than two decades, the NPWH WHNP Guidelines for Practice and Education have included curriculum content on evaluation and management of common SRH problems in males. Likewise, the National Certification Corporation’s WHNP certification exam has included male SRH content for more than two decades. Current NPWH WHNP Guidelines for Practice and Education include comprehensive curriculum content for male SRH addressing all of the MTC recommendations (Box 3).12 The WHNP certification exam includes male SRH issues outlined to include sexuality/sexual dysfunction, contraception, infertility, and STIs.13 WHNPs educationally prepared to provide assessment and management of common male SRH concerns are qualified to provide this care in the variety of clinical settings where they work.

male sexual reproductive health box3

Implications for WHNP practice

WHNPs provide SRH care for males directly (or indirectly) as primary care providers or as specialty care providers in areas such as reproductive endocrinology/fertility and breast health.

  • WHNPs who provide healthcare solely for females can give their patients information on male SRH to share with their male partners. The goal is to support male SRH that enhances the health of female patients and optimizes family planning, pregnancy outcomes, and the physical and emotional health of relationships.
  • WHNPs who provide healthcare solely for females may consider incorporating male SRH care in a couple’s approach in the clinical setting. Again, the goal is to support male SRH, which enhances the health of female patients and optimizes family planning, pregnancy outcomes, and the physical and emotional health of relationships.
  • WHNPs providing care in settings where males are routinely seen (e.g., family practice offices, family planning clinics, school- and college-based health centers, reproductive endocrinology/fertility centers) have opportunities to provide direct male SRH care in such settings. The goal expands beyond enhancing the health of female patients to enhancing the SRH of males.
  • WHNPs are educationally prepared to provide SRH care for individuals inclusive of all gender identities and sexual orientations. WHNPs provide SRH care based on the individual needs of each patient.


NPWH recommends that WHNPs do the following:

  • Engage in learning opportunities to maintain, update, and/or expand knowledge and skills that enable them to provide and promote SRH care for all individuals and couples within the context of their clinical setting.
  • Include provision of SRH care for individuals inclusive of all gender identities in collaborative practice agreements in states where such written agreements are required.
  • Establish referral resources for SRH concerns to meet the needs of patients and partners.

NPWH will provide leadership to ensure that:

  • Faculty of WHNP programs have resources to continue to provide up-to-date, evidence-based male SRH content in the curriculum.
  • Continuing education programs and resources are available for WHNPs to maintain, update, and/or expand their knowledge and skills with regard to male SRH care.
  • WHNPs have SRH informational resources to share with both male and female patients.
  • WHNPs’ scope of practice regulations do not restrict them from providing male SRH care within the parameters of their education and competency.


  1. World Health Organization. Defining Sexual Health: Report of a Technical Consultation on Sexual Health, 28-31 January 2002. Geneva, Switzerland: WHO Press, 2006.
  2. Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep. 2014;63(RR04):1-54.
  3. United Nations Population Fund. Sexual and Reproductive Health. 2016.
  4. Chabot M, Lewis C, de Bocanegra H, Darney P. Correlates of receiving reproductive health care services among U.S. men aged 15 to 44 years. Am J Mens Health. 2011;5(4):358-366.
  5. Bersamin M, Fisher DA, Marcell AV, Finan LJ. Defi cits in young men’s knowledge about accessing sexual and reproductive health services. J Am Coll Health. 2017;65(8):579-584.
  6.  Bersamin M, Fisher DA, Marcell AV, Finan LJ. Reproductive health services: barriers to use among college students. J Community Health. 2017;42(1):155-159.
  7. Tyler C, Warner L, Gavin L, Barfield W. Receipt of reproductive health services among sexually experienced persons aged 15-19 years—National Survey of Family Growth, United States, 2006-2010. MMWR Suppl. 2014;63(2):89-98.
  8. Choiriyyah I, Sonenstein FL, Astone NM, et al. Men aged 15-44 in need of preconception care. Matern Child Health J. 2015;19(11):2358-2365.
  9. Same RV, Bell DL, Rosenthal SL, Marcell AV. Sexual and reproductive health care: adolescent and adult men’s willingness to talk and preferred approach. Am J Prev Med. 2014;47(2):175-181.
  10.  Warner JN, Frey KA. The well-man visit: addressing a man’s health to optimize pregnancy outcomes. J Am Board Fam Med. 2013;26(2):196-202.
  11. Marcel AV, Male Training Center for Family Planning and Reproductive Health. Preventive Male Sexual and Reproductive Health Care: Recommendations for Clinical Practice. 2014.
  12. NPWH/AWHONN. Women’s Health Nurse Practitioner: Guidelines For Practice and Education. 7th ed. Washington DC: NPWH/AWHONN; 2014.
  13. National Certifi cation Corporation. 2018 Candidate Guide Women’s Health Nurse Practitioner. Chicago, IL: National Certifi cation Corporation; 2018.

Men with breast conditions: The role of the WHNP specializing in breast care

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the role of the women’s health nurse practitioner (WHNP), as a member of a multidisciplinary breast care specialty team, in providing specialized breast care for women and men. Furthermore, NPWH supports the removal of any restrictions to the provision of male breast care that are based on the WHNP credential. Continue reading »

Editor-in-chief ’s message

Dear Colleagues,

The National Association of Nurse Practitioners in Women’s Health (NPWH) strives to continuously improve the accessibility and quality of healthcare for women. This improvement is accomplished by promoting innovation and excellence in continuing education and professional development; leadership in policy, practice, and research areas; and support and services for our members. Achieving all these goals is our organization’s vision. Continue reading »

Editor-in-Chief’s message

Dear Colleagues,

As we wrap up 2018, I am pleased to report on some of our fourth-quarter accomplishments and to introduce member opportunities for 2019. First, I am happy to share that our 21st Annual NPWH Premier Women’s Healthcare Conference in San Antonio, Texas, was spectacular, with more than 700 attendees! The success of the conference is the result of extraordinary teamwork by the Planning Committee, Education Committee, Research Committee, Membership Committee, NPWH Board of Directors, staff members, CEO Gay Johnson, and RSG Consulting.

editor chiefs message 7 postI always love the opportunity to meet newcomers and to reconnect with colleagues I have met over the years. As usual, the presentations and posters provided cutting-edge, evidence-based information relevant to providing healthcare for women. If you attended the conference, you may have faced the same difficulty I did in terms of choosing among the breakout sessions. Fortunately, these sessions were recorded and are available free to conference attendees on the NPWH website E-Learning Portal. If you were unable to attend the conference, you can purchase individual sessions and obtain CE credit. Please plan to join us for the 22nd Annual NPWH Premier Women’s Healthcare Conference in Savannah, Georgia, on October 16-19, 2019.

Second, on behalf of NPWH, I extend a sincere thank you to everyone who completed the 2018 NPWH WHNP Workforce Demographics and Compensation Survey. The survey invitation was sent to 11,319 certified WHNPs. We received 2,374 completed surveys, for a response rate of 21%. A summary report will be available at the NPWH website in January 2019. An article in the journal will follow soon after with a more extensive survey report and description of how NPWH plans to use the survey data to support and advocate for WHNPs.

As editor-in-chief of Women’s Healthcare and NPWH director of publications, I hope we are reaching all 11,319 WHNPs who received the survey. NPWH is the national organization for WHNPs. If you are a WHNP who has chosen to focus your expertise and passion on providing healthcare for women and are not a member of NPWH, please join us. If you are a member, please consider becoming active in the organization. You have much to offer NPWH and all of its members.

Here are some ideas for becoming involved in NPWH in the coming year. We offer opportunities for new WHNP graduates as well as seasoned WHNPs, and for those who are involved in clinical practice, academe, research, administration, policy, or some combination thereof.

Submit a manuscript for publication consideration. See our Guidelines for Authors for the different formats you might consider and the submission process.

Apply to be a peer reviewer for the journal. We need content experts, practice experts, and research methodology experts. Click on our peer reviewer application form.

Participate in writing or reviewing position statements.

Explore information on the work of NPWH committees and become involved.

Apply for a board position.

Submit an abstract to present your research or quality improvement project at the next conference.

Take a look at the NPWH blog, Women’s Health Wisdom. Contact Julia Knox at NPWH (jknox@npwh. org) if you have a topic you’d like to see on the blog or if you would like to contribute to the blog.

View a full list of articles and vote for your top two favorites at SurveyMonkey

Past 2018 issues (i.e., March, June, and September) are available at journal website archives

Now is the time to choose your favorite articles from our four 2018 issues: March, June, September, and December. This is a great way to recognize the articles (and their authors) that you found the most interesting and informative. You can view a full list of articles and vote for your top two favorites at SurveyMonkey. If you need to refresh your memory about the articles you read in the March, June, and September issues, you can find them in our journal website archives. Please submit your choices by January 11, 2019. We will announce the winners in the next issue of the journal. I wish all of you happy holidays shared with family and friends!





Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

WHNP1218_EIC Message

The ABCDs of bacterial vaginosis: Abnormal flora, Bothersome symptoms, Chronicity, and Differential diagnosis


Alisa Pascale, DNP, WHNP-BC, is a women’s health nurse practitioner at the Vulvovaginal Disorders Program & Gynecology at Massachusetts General Hospital and Clinical Instructor at MGH Institute of Health Professions, both in Boston, Massachusetts.

Intended audience: This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners who provide care for women of any age.

CE approval period: Now through December 31, 2019

Estimated time to complete this activity: 1 hour CE approval hours: 1.0 contact hours, including 0.5 contact hours of pharmacology credit (NCC code 2A)

Goal statement: To understand the abnormal vaginal ecosystem in women prone to bacterial vaginosis (BV) and to use current evidence and guidelines in treating single episodes of BV and in reducing chronic/recurrent episodes of BV.

Needs assessment: This activity for Women’s Healthcare is based on a CE presentation developed by the author and presented at the NPWH annual conference held in Seattle, Washington, in October 2017. In this article, the author provides background information on BV (e.g., prevalence, risk factors, adverse sequelae, characteristics of a healthy vagina) and then focuses on the ABCDs of BV: abnormal flora, bothersome symptoms, chronicity, and the differential diagnosis.

Educational objectives: At the conclusion of this educational activity, participants should be able to:

  1. Describe normal vaginal flora and the alterations that result in episodic/chronic/recurrent BV.
  2. Discuss adverse sequelae of BV in nonpregnant and pregnant women.
  3. Differentiate between BV and other conditions that cause alterations of vaginal flora.
  4. List treatment options for episodic/chronic/recurrent BV.

Accreditation statement: This activity has been evaluated and approved by the Continuing Education Approval Program of the National Association of Nurse Practitioners in Women’s Health (NPWH), and has been approved for 1.0 contact hours, including 0.5 contact hours of pharmacology credit.

Faculty disclosures: NPWH policy requires all faculty to disclose any affiliation or relationship with a commercial interest that may cause a potential, real, or apparent conflict of interest with the content of a CE program. NPWH does not imply that the affiliation or relationship will affect the content of the CE program. Disclosure provides participants with information that may be important to their evaluation of an activity. Faculty are also asked to identify any unlabeled/unapproved uses of drugs or devices made in their presentation.

Alisa Pascale, DNP, WHNP-BC, disclosed that she served as a consultant and speaker for Symbiomix Therapeutics in 2016.

Disclosure of unlabeled use: NPWH policy requires authors to disclose to participants when they are presenting information about unlabeled use of a commercial product or device or an investigational use of a drug or device not yet approved for any use.

Disclaimer: Participating faculty members determine the editorial content of the CE activity; this content does not necessarily represent the views of NPWH. This content has undergone a blinded peer review process for validation of clinical content. Although every effort has been made to ensure that the information is accurate, clinicians are responsible for evaluating this information in relation to generally accepted standards in their own communities and integrating the information in this activity with that of established recommendations of other authorities, national guidelines, FDA-approved package inserts, and individual patient characteristics.

Successful completion of the activity: Successful completion of this activity, J-18-04, requires participants to:

  1. Log on to and “Sign In” at the top right-hand corner of the page if you have an NPWH account. You must be signed in to receive credit for this course. If you do not remember your username or password, please follow the “Forgot Password” link and instructions on the sign-in page. If you do not have an account, please click on “Create an Account.”*
  2. Read the learning objectives, disclosures, and disclaimers on the previous page.
  3. Study the material in the learning activity during the approval period (now through December 31, 2019).
  4. Complete the post-test and evaluation. You must earn a score of 70% or better on the post-test to receive CE credit.
  5. Print out the CE certificate if successfully completed.

*If you are an NPWH member, were once a member, or have taken CE activities with NPWH in the past, you have a username and password in our system. Please do not create a new account. Creation of multiple accounts could result in loss of CE credits as well as other NPWH services. If you do not remember your username or password, please either click on the “Forgot Username” or “Forgot Password” link or call the NPWH office at (202) 543-9693, ext. 1.

Commercial support: The content for this article was supported by an educational grant from Symbiomix Therapeutics.

Alterations in vaginal microflora cause a vaginal dysbiosis that can lead to asymptomatic or symptomatic bacterial vaginosis (BV). Because the underlying mechanism of BV is not well understood and long-term restoration of the normal vaginal flora can be challenging, BV often recurs or becomes chronic despite initially successful treatment. Healthcare providers (HCPs) caring for women should be familiar with the diagnosis and treatment of BV, as well as the management of recurrent BV. Because BV is sometimes mistaken for other vaginal conditions, HCPs should be alert for these other diagnoses, particularly in women with chronic or recurrent symptoms.

Bacterial vaginosis (BV) is a common condition that results from a shift in the balance of a woman’s vaginal microflora. BV is manifested by a decrease in predominantly hydrogen peroxide-producing lactobacilli and an increase in anaerobic bacteria. The depletion of lactobacilli leads to a rise in vaginal pH, and enzymes produced by the anaerobes lead to some of the classic symptoms associated with BV. Before the article’s main focus on the ABCDs of BV—abnormal flora, bothersome symptoms, chronicity, and differential diagnosis—background information on BV prevalence, risk factors, and adverse sequelae is provided and the characteristics of a healthy vaginal environment are described.

Background information

Prevalence of BV varies widely from country to country, from region to region within the same country, and even within similar population groups.1 Five decades of intense research have established many risk factors for BV acquisition, but because of the condition’s complexity and the lack of a reliable animal model for studying it, its exact etiology remains elusive.2


A systematic review by Kenyon et al.3 suggested that BV prevalence ranged from 6% to 51% in the United States, depending on race, ethnicity, and geographic area. Based on a representative sample of U.S. women who participated in the National Health and Nutrition Examination Survey (NHANES) 2001-2004, overall BV prevalence in this country was 29% among women aged 14-49 years,4,5 making it the most common vaginal infection in this age group.6 According to this NHANES survey, non-Hispanic white women had lower rates of BV (23%) than did African American women (51%) or Mexican American women (32%).4

Risk factors

A systematic review and meta-analysis showed that BV was significantly associated with sexual contact with new and multiple male and/or female partners.7 The precise relationship between sexual activity and BV development is not known.8 General consensus among vaginitis experts is that BV can be sexually associated, but that it is not considered to be sexually transmitted at this time. Two studies showed that women with genital herpes or HIV infection had an increased risk of developing BV.9,10 Also, BV acquisition has been associated with douching.5

Adverse sequelae

Many studies have shown BV to be a risk factor for acquiring HIV infection, herpes, gonorrhea, chlamydia, and trichomoniasis.11-14 BV also may play a role in the development of pelvic inflammatory disease and cervicitis,15,16 as well as in the persistence of human papillomavirus infection17 and in the development of cervical precancerous lesions.18 In pregnant women, BV may increase the risk for miscarriage, chorioamnionitis, preterm birth, and postpartum endometritis.19-23 BV was reported to be 3 times more prevalent among infertile women than fertile women, and it doubled the risk for pregnancy loss following in vitro fertilization-embryo transfer. 24 Of note, Nasioudis et al.25 posited that most links between BV and adverse pregnancy outcomes have been derived from inadequately designed studies that did not fully evaluate other causes of pregnancy-related pathology.

Because BV is asymptomatic in many cases and because its presence increases the risk for a variety of adverse sequelae in pregnant women, healthcare providers (HCPs) may wonder about screening routinely for BV in this population. At present, the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the CDC do not recommend routine screening for BV in asymptomatic pregnant women.26-28

This recommendation is based on evidence indicating that although treatment of BV in pregnant women can eradicate the infection, it has not been shown to decrease preterm birth rates.29 Early screening and treatment for BV may be considered in women at high risk for preterm birth, although no clear criteria/characteristics have been defined. Pregnant women with any vulvovaginal complaints or symptoms should be evaluated for BV and treated if BV is present.

Characteristics of a healthy vagina

A healthy vagina’s microbiota is characterized by a dominance of lactobacilli, which maintain the acidic vaginal pH at 4.0-4.5. The makeup of a healthy vagina in one woman may diff er from that in another. The vagina may be colonized by one or more species of lactobacilli, including Lactobacillus crispatus, L. gasseri, L. iners, and L. jensenii.30 Furthermore, the composition of the vaginal microbiota is not static; many women experience large variations within a single menstrual cycle or between successive cycles, as well as over time.25 Hydrogen peroxide and lactic acid produced by these lactobacilli and other vaginal flora enhance the antimicrobial immune response.

Some healthy women have low numbers of vaginal lactobacilli and high numbers of other lactic acid-producing bacteria and/or variable concentrations of anaerobic bacteria that have been associated with BV.30 The percentage of apparently healthy asymptomatic women with a vaginal microbiota not dominated by lactobacilli is higher among women with African and/or Hispanic heritage, who also have a higher vaginal pH than do white or Asian women.30

Abnormal vaginal flora

Although Gardnerella vaginalis is the best known pathogen linked to BV, the condition is associated with at least a dozen other species (spp) as well, including Atopobium vaginae, Ureaplasma urealyticum, Mycoplasma spp, and others.31 Absence of localized inflammation associated with infection by any of these bacteria is the basis for the term vaginosis rather than vaginitis.

Vaginal biofi lms are well-described microbial communities embedded in a self-produced extracellular matrix to which other species also can adhere.32,33 In one study, G. vaginalis comprised 90% of bacteria in the biofilm and A. vaginae accounted for most of the remainder.34 This biofilm makes abnormal flora more resistant both to the vagina’s own natural defenses and to antibiotics, likely accounting for the frequency with which women have persistent and recurrent infections.35

Bothersome symptoms

Many women with BV are asymptomatic8 and do not learn of this diagnosis until they undergo a routine gynecologic examination by an HCP who notes the typical signs. But many women with BV do have signs and symptoms, typically a thin white or gray vaginal discharge; itching or burning in the vagina; a strong fish-like odor, especially after sex; burning when urinating; and/or itching around the outside of the vagina.8 Many women associate BV onset with recent sexual activity,36 which can cause embarrassment and self-consciousness and prompt some to change or limit their sexual relationships or activities. Self-help remedies such as douching may only exacerbate the problem.37

Making the diagnosis

The telephone is not an effective tool for diagnosis of BV. Because patient self-diagnosis and telephone triage diagnosis are notoriously inaccurate,38 women experiencing any of the aforementioned vaginal signs/symptoms, particularly recurrent symptoms, should see their HCP for an evaluation and clinical diagnosis.

Physical examination

On physical exam of women who may have BV, the external genitalia usually appear normal, although a thin milky discharge may be present at the introitus. The characteristic vaginal discharge is thin, homogeneous, and white, gray, or even yellow. A fishy/amine-positive odor may be perceptible. In many women with BV, physical exam findings can appear normal.

Office-based testing

In the clinical setting, BV diagnosis is made based on Amsel criteria39:

  • Vaginal pH >4.5;
  • Homogeneous white, gray, or even yellow (milky) discharge;
  • Release of an amine (fi shy) odor after addition of 10% potassium hydroxide (KOH) solution to the vaginal fluid; and
  • Presence of clue cells on saline wet prep microscopy.

At least three of these four criteria must be met to make the diagnosis. Vaginal pH paper, saline, KOH, slides, and a microscope are all that are needed to make a quick office diagnosis of BV. This testing is inexpensive and can often yield a diagnosis at the time of the visit, facilitating treatment.

Other laboratory tests

Several commercial products such as the BD Affirm™ VPIII Microbial Identification System and the OSOM® BVBlue® point-of-care testing can identify the microbes present in a patient’s vaginal fluid. Use of such a product adds cost to the visit and can delay diagnosis. Of note, BV diagnosis should not be made solely on the basis of a positive G. vaginalis culture because this bacterium is present in ~50%- 80% of healthy, asymptomatic women.40,41 Positive test results should be interpreted in the context of the entire clinical picture to make the diagnosis.

Treating symptoms and infection

According to the CDC, the benefits of BV therapy in nonpregnant women are symptom relief and infection cure.42 Another potential benefit is a reduction of the risk of acquiring a sexually transmitted infection.

Multiple-dose regimens

For a single episode of BV, the CDC recommends these regimens42:

  • metronidazole 500 mg orally twice daily for 7 days OR
  • metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally, once daily for 5 days OR
  • clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days.

Alternative regimens include the following42:

  • tinidazole 2 g orally once daily for 2 days OR
  • tinidazole 1 g orally once daily for 5 days OR
  • clindamycin 300 mg orally twice daily for 7 days OR
  • clindamycin ovules 100 mg intravaginally once at bedtime for 3 days.

With regard to treatment with nitroimidazoles such as metronidazole and tinidazole, users should abstain from alcohol use for 24 hours after completion of the antibiotic regimen to avoid the chance of a disulfi ram-like reaction. Clindamycin cream and ovules are oil based and might weaken latex condoms and diaphragms for 3-5 days after the regimen is completed.

Single-dose regimens

Because a medication regimen requiring fewer doses may improve adherence, four different single-dose regimens are available. Single-dose intravaginal regimens include clindamycin 2% cream (Clindesse®) and metronidazole gel 1.3% (Nuvessa®); these intravaginal products are not recommended for pregnant women and are less effective than multiple-dose regimens. 43,44 New in 2018 is secnidazole 2g (Solosec™), a novel, single-dose oral product. Secnidazole is formulated as a packet of granules that are sprinkled onto applesauce, yogurt, or pudding and then consumed. 45,46 Unlike metronidazole, this product has no warning to avoid alcohol consumption. An FDA pregnancy category has not yet been assigned for secnidazole. Although single-dose treatments are well liked by patients, they tend to increase out-of-pocket cost.

Chronic/recurrent BV

Chronic or recurrent BV is defined as three or more episodes per year.47 The recurrence rate may be as high as 80% in some populations.48 As discussed previously, the underlying mechanism of the shift to abnormal flora in BV is not well understood. In addition, to date, no treatments target the biofilm, leading to challenges in resolving chronic cases. Women express considerable frustration, embarrassment, and distress with recurrences and the need for repeated or ongoing treatment.37 Until novel treatment options come along, treatment regimens for recurrent BV aim to first treat the current infection and then suppress recurrence(s). HCPs should treat the current infection as per CDC guidelines—that is, with one of the recommended or alternative regimens.

Some experts suggest extending the initial course of oral metronidazole from 7 to 10 days in patients with recurrent BV.49 The addition of boric acid (compounded 600 mg vaginally x21 days) to the initial course of oral nitroimidazole may improve results.49,50 Another option is high-dose metronidazole (compounded 750 mg vaginally x 7 days), which has a higher cure rate than does the 500-mg dose.51 Once the current infection is treated, a regimen of metronidazole vaginal gel 2%, 1 applicator intravaginally twice weekly for 4-6 months, has shown efficacy in suppressing or preventing recurrences.31 All of the regimens discussed in this paragraph are prescribed off label.

Because BV is a sexually associated infection, condom use may prevent BV recurrences and should be suggested to patients with recurrent BV. Probiotics are popular with patients; two particular lactobacilli strains—L. rhamnosus and L. reuteri—taken orally for 30 days, may help reduce BV recurrences.52 However, strong evidence of lactobacilli benefit for the treatment or prevention of recurrent BV is lacking. Novel agents that disrupt the vaginal biofilm, including antiseptics, probiotics/prebiotics, plant-derived compounds, natural antimicrobials, acidifying/buffering agents, and DNases, are being investigated as treatments for recurrent BV.53 Marrazzoetal.54 have described a novel boric acid-based vaginal anti-infective with enhanced anti-biofilm activity (TOL-463) that may show promise for treating recurrent BV in the future.

Differential diagnosis

Bacterial vaginosis is distinctive in terms of the characteristics of the vaginal discharge, the fi shy odor, the elevated vaginal pH, and the presence of clue cells on wet prep. Nevertheless, other conditions and diseases bear similarities to BV and may need to be ruled out. For example, the genitourinary syndrome of menopause may present with an elevated vaginal pH and a shift in vaginal flora. Correction of the underlying low estrogen state with local estrogen or acidic vaginal moisturizers may sometimes correct the vaginal dysbiosis without a need for antibiotics. Coexistence of candidiasis along with BV, or as a result of antibiotic treatment for BV, should be considered. Desquamative inflammatory vaginitis is a less well known condition that can be confused with BV because it causes pH elevation, vaginal discharge, and loss of lactobacilli. Disease entities and conditions that may need to be considered because of their overlapping symptomatology or their coexistence with BV are listed in the Table, along with recommended treatments.55-58

bacterial vaginosis abnormal flora table


Many woman are unfamiliar with the condition of BV, which is far more common than women or their HCPs may realize. BV involves a disruption in healthy vaginal microflora and is not always symptomatic, but it can have major adverse sequelae. In addition, recurrence rates are high and are quite bothersome for many women. Standard treatment includes metronidazole or clindamycin, although new treatments are emerging. More research is needed for both better understanding of BV pathogenesis and new and novel treatment options.

References appear in the downloadable PDF above and below.


Fears surrounding pregnancy and motherhood among women with cystic fibrosis

Recent advances in science and clinical care have changed the characteristics of the population with cystic fibrosis (CF). Half of patients with CF are now adults who want to achieve milestones that were impossible in the past; for women with CF, this may include motherhood. However, these women may have concerns and fears about getting pregnant, being pregnant, and becoming mothers that go beyond those that otherwise healthy women experience. This qualitative study was conducted to ascertain the reproductive health concerns of a small group of women with CF.

Cystic fibrosis (CF) is an autosomal-recessive, multisystem disease affecting about 70,000 persons worldwide.1 In the United States, 1 in 31 persons of Caucasian European descent carries the CF trait, making it the most common genetic disorder in this group.1 A defect on chromosome 7 results in an alteration in the structure and function of the CF transmembrane conductance regulator (CFTR) protein that controls movement of ions across cell membranes.2 As a result of the impaired CFTR protein, the body produces tenacious mucus that obstructs certain organs, particularly the lungs, intestines, and those of the reproductive tract.2

Recent advances have improved overall survival and quality of life (QOL) of patients with CF. For the first time since the CF gene was identified in 1989, about half of patients with the disease survive to adulthood.1 Average life expectancy has risen from 14 years in 1969 to 40+ years today.1,3 Women, who account for about half of the CF population,4 experience poorer health-related QOL than their male counterparts.5 In women with CF, hormonal fluctuations across the lifespan may compromise their overall health.6 Nevertheless, many women with CF wish to experience all of the adult developmental milestones that may not have been possible in the past, when CF was considered a life-limiting disease of childhood.7 One of these milestones is becoming a mother.

The wide variability in disease presentation means that some women with CF can conceive a child naturally and easily, whereas others have impaired fertility or infertility. Thickened cervical mucus can obstruct the Fallopian tubes and/or the cervix, preventing sperm from reaching the egg for fertilization.1 The thickened mucus in the gastrointestinal tract impedes proper absorption of nutrients.1 Adequate body fat and weight are needed for a regular menstrual cycle; as a result, some women with CF who have a suboptimal body mass index (BMI) have irregular ovulation.1 In general, good pulmonary function and a normal BMI predict reproductive success in women with CF.8

Great strides have been made since 1960, when it was reported that a successful pregnancy in a woman with CF ended with maternal death from CF complications 6 weeks after delivery.9 Although exact fertility data are unknown, the CF Foundation Patient Registry indicated that the number of women with CF who became pregnant more than doubled in 24 years, from 116 in 1992 to 270 in 2016.4 With recent CF drug discoveries that target specifi c CF mutations, the personalized approach to care will likely lead to improved patient outcomes, including the ability to become pregnant and deliver healthy infants.

fears pregnancy motherhood cystic fibrosis imageDespite these promising developments, Korzeniewska et al10 reported that only 33% of their sample of women with CF (n = 64) understood how CF affects fertility. Based on semi-structured interviews with 22 women aged 18-30 years with CF, Kazmerski et al11 found that misinformation regarding how CF could affect fertility and pregnancy abounded. In a separate report, Kazmerski et al12 indicated that the women with CF were disappointed by the lack of support from their CF care team when the topic of reproductive health was raised, usually by patients themselves. Both patients and care team members agreed that improvements in this area were needed.

The purpose of the current study was to ascertain the reproductive health concerns of a group of women with CF. These women were part of a larger mixed-methods study (the parent study) that investigated their knowledge of basic fertility concepts and how CF affects the reproductive system, and explored their perceptions regarding whether new CFTR-modulating drugs could affect their reproductive health.7

Parent study

The parent study evaluated broad reproductive health implications of targeted therapy for young women with CF.7 It was approved by the University of Alabama at Birmingham Institutional Review Board and conducted in Alabama in 2015-2016. In brief, 10 women aged 25-34 years with a confirmed diagnosis of CF homozygous F508del mutation and a forced expiratory volume in 1 second ≥40% participated.7 They were recruited from an adult CF center located in a large academic medical center in the southeastern United States.

Participants completed a demographic survey and two questionnaires related to their knowledge of fertility and CF and sat for an audio-recorded, semi-structured interview about the processes of becoming pregnant and a mother. Individual interviews lasting 30-45 minutes were conducted in person or by telephone by two of the authors, who also completed the qualitative analysis for the current study. Participants were asked whether they had been pregnant, whether they felt that CF aff ected their fertility, how and when they learned that CF might affect fertility, what they knew about the effects of the CFTR-modulating drug lumacaftor/ivacaftor (LUM/ IVA) on fertility, and whether they knew about available resources on pregnancy and fertility. Thematic saturation was reached after the eighth interview. Findings from the parent study showed that participants reported needing comprehensive reproductive and sexual health counseling and education from their CF care team, as well as support for their desire to become mothers even though they suspected that their fertility might be impaired.

Current study

Among the 10 women, 7 elaborated on their concerns and possible challenges to becoming pregnant, with 2 also describing their experiences with past or current pregnancies. Qualitative data were analyzed using Braun and Clarke’s approach to thematic analysis, which included these steps: (1) Interview transcripts were read multiple times to look for patterns; (2) Data about fears related to pregnancy and motherhood were coded with descriptive labels; (3) Codes were grouped into preliminary themes; and (4) The final thematic schema was identified.13 Two authors independently reviewed all transcripts and coded the data, and collaborated in developing the final coding schema. Both authors had >90% inter-rater agreement during the coding phase and easily arrived at consensus during the thematic development phase. HyperRESEARCH, a qualitative analysis software, was used to manage and analyze the data.14


Participants (mean age, 29 years) were Caucasian and highly educated, with 80% having a 4-year college degree. Most were married and had never been pregnant. They hoped that new targeted therapeutics in CF care would help them conceive and carry a healthy pregnancy to term. They expressed different layers of fears as they contemplated their future on the pregnancy continuum. (Pseudonyms are used to protect their identities.) The main theme that emerged from this qualitative analysis was Fears surrounding pregnancy and motherhood. Although most participants said they desired children, they had fears related to getting pregnant, being pregnant, and becoming new mothers— the three subthemes.

Fears before pregnancy

Five participants reported having fears even before attempting pregnancy. One fear was bearing a child with CF. Carly said that it was critical to have her partner tested for the CF gene prior to exploring her options for motherhood because she did not want to risk having a child with CF: We decided [that] if he was a CF carrier, we would adopt. If he was not a CF carrier, we would try [to get pregnant]. Being a mother with a child with CF, it just scared the living crap out of me. Experiencing the daily struggles and treatment burden of CF, Carly did not want the same hardships for her child. Debby echoed the sentiment about her partner carrying the CF gene: We are interested in confirming that he’s not a carrier because if he is a carrier, we know our chance of having a CF baby would be definitely increased. If that is the case, we would want to look at alternative situations, like adoption.

Two participants described financial concerns related to becoming pregnant. Ella said that if she could not get pregnant, she wanted to explore using a gestational carrier. However, she stated: I just don’t think we can afford surrogacy. Anna, who has a school-age child, feared having another child: My fears would be financial concerns, just making sure I can cover all the bases so that my next pregnancy is as smooth, or as close to as smooth, as the first one.

Gia shared concerns related to LUM/IVA, a part of her regimen that benefited her overall health and functioning. Because LUM/IVA’s safety during pregnancy has not been established, Gia feared that she would need to stop her medication if she were to become pregnant. She stated: My biggest concern is how I would feel going off lumacaftor/ ivacaftor. [I would] take a hit to my health, my lung health, [and worry] if that is going to impact the health of a fetus….and [if] somehow I wasn’t able to carry the baby to term.

Fears during pregnancy

Five participants conveyed fears about the pregnancy itself. Most fears centered on keeping themselves as healthy as possible in order to deliver a healthy baby. Betty and Carly described how maintaining their health during pregnancy and afterward was critical in order to care for their infants. Carly, a natural athlete who enjoyed exercise as part of her health regimen, said: My biggest fear with having CF is how uncomfortable [pregnancy] is, and I worry that my athleticism, working out, is gonna have to decrease….that [it] may lead to lower lung function. That scares me. I don’t care about what I look like on the outside for the most part; I care about the lungs.

Ella feared that a pregnancy could compromise her pulmonary status: I worry about [pregnancy] impacting my lung function in a way that could be permanent. When lung function goes down, there could be scarring, and things that occur that make it irreversible. Fran worried about her pulmonary health but had a more positive outlook on pregnancy’s potential effects: I think I’m strong enough to handle it. If I did lose lung function, I would be dedicated to getting it back. That would be a top priority for me. It [having a baby] would be worth a short-term setback. Debbie described how she was proactive about maintaining her treatment regimen and staying healthy to avoid getting sick and harming the baby.

Fears as new mothers

Six participants reported potential fears as new mothers, most of which related to balancing the demands of CF with work, family, and motherhood. Ella reported: I do worry about being able to balance doing all of my treatments and caring for a newborn. Debbie described her fear of being able to care for both herself and a baby: I wanna make sure that I’m able to take care of the baby as well as myself. Gia expressed her worry about being able to balance her job and CF with being a mom: I guess it’s more of the balance of, “Could I keep working and how much?” and maybe needing to downshift. I sometimes worry about CF, [which] is already such a time suck that it’s like, “Oh, let’s throw a baby into the mix and see what happens.”

Two participants expressed worry about their child going to daycare and bringing home contagious infections. Carly said that she was always vigilant about possible infection sources to keep herself healthy: I’m a total germophobe. My biggest fears are just me getting sick and not being able to take care of my baby, because of whatever bugs [he or she] might have. She went on to discuss not being able to be around or care for her baby when he or she got sick: I’m gonna have to quarantine myself into a room… [and not] get sick so I can take care of my baby. Betty discussed getting sick from her baby as a result of going to daycare: They [babies] go there and they get sick. They come back, I get sick.

In thinking about their futures, two participants mentioned the often unspoken fear of dying early of their incurable disease and not being able to be there for their children. Ella said: I think about not being healthy, or putting my child through the trauma of losing a parent. I think about how wonderful my husband is, and my family. If that [death] were to happen, it wouldn’t be as though [my baby] would be left alone in the world. Anna spoke of the fear of dying in a more positive light, as a source of motivation: Yeah, dying early. That’s a big fear. That also keeps me motivated. Other participants voiced the positive aspects of becoming pregnant and being mothers with CF. Anna, who had CF-related diabetes, stated: My A1Cs stayed in the 6’s during my entire pregnancy—the best they’ve been in my life. Carly reflected on her determination to remain healthy despite the daily challenges of having CF: I don’t feel that CF has held me back in any other aspect of my life. I’m certainly not expecting it to here [pregnancy].


These study participants wanted to experience pregnancy and motherhood, but they had certain fears about these life experiences. Even before contemplating becoming pregnant, some expressed concerns about the genetic transmission of CF. They did not want any children they bore to experience a life-limiting disease. They wanted their partners to be tested for CF to rule out the possibility of having a child with CF and to help inform their decision-making with regard to the use of gestational carriers, adoption, or living a child-free life.

Concerns about genetic transmission of CF are understandable; young women with breast cancer who carry the BRCA gene have expressed similar fears. In response, the American Society of Reproductive Medicine has recommended pre-implantation genetic diagnosis (PGD) testing on embryos to look for a specific genetic disorder such as the BRCA mutation.15 In fact, CF is one of the most common indications for PGD testing, enabling couples to transfer an embryo without the CF gene and avoid the difficult decision to terminate a pregnancy.16

The physical stress of pregnancy, combined with potential adverse effects of a medication regimen (or temporarily stopping such a regimen), is challenging for women with a chronic illness such as cancer or diabetes or a history of childhood cancer. They have concerns about potential health setbacks such as a recurrence or the development of secondary cancers or pregnancy-associated cardiomyopathy.17-21 Despite having similar fears, the women with CF in this study expressed hope and determination to experience pregnancy and motherhood.

Many survivors of childhood cancer who are at risk for infertility related to gonadotoxic therapy have misperceptions regarding their personal risk for infertility.22-26 The American Society of Clinical Oncology recommends discussing potential infertility, as well as fertility preservation options, with all young individuals diagnosed with cancer.27 Multidisciplinary programs to address fertility preservation in children and adolescents are emerging.28 The Cystic Fibrosis Foundation aims to provide resources to educate patients, families, and healthcare providers (HCPs) regarding fertility and reproductive health options.29

A sobering challenge of future motherhood for women with CF is the potential for early mortality, which forces them to face an uncertain future for themselves as parents and for their children, who could suffer the loss of their mother at a young age. Confronting these uncertainties appeared to strengthen the resolve of some of the study participants with CF, and could potentially motivate them to remain engaged in health-promoting activities and to maintain strong relationships with their partners and family members.


A limitation of the current study was the small and homogenous (all Caucasian) sample, although this demographic characteristic is representative of the CF population. Another limitation is that these women had the same genetic mutation (F508del homozygous), which may have influenced their responses because of the moderate/severe phenotypic presentation of this mutation. Finally, 80% of the participants held a 4-year college degree, compared with 30% of persons with CF nationally, which could limit the generalizability of the findings.4

Implications for practice and future research

Childbearing-age women with CF may benefit from a collaborative care eff ort between the CF care team and reproductive health specialists who can provide individualized education and counseling. All of these HCPs can address patients’ fears and assist them with their reproductive health decisions. Kazmerski et al12 reported that women with CF considered their disease a major factor in deciding whether to become pregnant, and that they were disappointed by the lack of support from their CF care team when the topic of reproductive health was raised, usually by the women themselves. HCP and patient discomfort in initiating reproductive and sexual health discussions may hinder provision of comprehensive care; hence, HCP training and educational resources for reproductive health services, as well as standardization in CF care models, are warranted.11

Additional research is needed to investigate how women with CF decide to pursue a pregnancy versus use a gestational carrier or adopt a child. The different paths to motherhood for women with CF is not well documented; in fact, in the larger (parent) study, these women self-reported a lack of knowledge related to alternative options and their associated costs, both tangible and intangible.7 These findings are consistent with those of Cherven et al,26 who found that only 36% of childhood cancer survivors reported receiving education about the risk for infertility at diagnosis and 39% received it at the end of therapy. Nearly all of these survivors reported that they would have preferred receiving fertility education at diagnosis. However, education at one time point alone may be insufficient. Continuing discussions about fertility need to be targeted to young cancer survivors’ needs and developmental stage, which change over time. Findings from previous work with young cancer survivors may help improve the conversation with patients with CF, who require ongoing education and counseling about reproductive health and fertility options, as well as their associated costs.


Attempting and carrying a pregnancy is a complex challenge for women with CF. If these women can conceive, then they worry about being able to be a full partner in caring for a newborn—while still sustaining their own daily care for CF. As mean survival of patients with CF extends into the fifth decade of life, findings from this current study suggest that women with CF would benefit from individualized education and counseling regarding reproductive health as part of their comprehensive clinical care.

Sigrid Ladores is Associate Professor at the School of Nursing, Leigh Ann Bray is Assistant Professor at the School of Nursing, Wendy Landier is Associate Professor at the School of Medicine, Brooke Cherven is a PhD student at the School of Nursing, and Karen Meneses was Professor and Associate Dean for Research at the School of Nursing, all at the University of Alabama at Birmingham. The authors state that they do not have a fi nancial interest in or other relationship with any commercial product named in this article.


This study was supported by a UAB Faculty Development Grant and the School of Nursing, UAB.

References appear in the downloadable PDF above and below.


Caring for women with disabilities during the perinatal period: Results of a descriptive survey

This study was conducted to describe the education, comfort, and perceived competency of a group of nurse practitioners and midwives who provide perinatal care to women with disabilities. The results are presented and the implications discussed.

Approximately 8 million women of reproductive age report having a disability.1,2 Studies have shown that women with disabilities give birth at rates similar to those of women without disabilities.3-5 Among women with a disabling condition, 51% report being physically disabled, 30% report a mental or developmental disability, and 19% report a sensory disability.6

Regardless of the type of disability, many affected women have limited access to healthcare, resulting in unmet reproductive healthcare needs.7-10 Furthermore, studies suggest that some healthcare providers (HCPs) caring for women lack sufficient knowledge about disabilities, as well as harbor negative stereotypes about the sexuality and the reproductive capability of women who have a disability.3,8,11-13


The term disability has medical, legal, and social definitions.


caring women disabilities perinatal period imageThe CDC defines disability as a condition that impedes activity and the ability to participate in daily activities.2 The World Health Organization (WHO) defines disability as a complex phenomenon that includes impairments, activity limitations, and restrictions on participating in daily life because of one’s body function or structure.14

Disabilities are classified as physical, sensory, neurologic, and/or developmental. Many individuals with one or more types of disability have co-morbid conditions related to the disability or disabilities. Physical disabilities include those occurring from birth (e.g., spina bifida), those caused by trauma (e.g., spinal cord injury), and those related to a health condition (e.g., cancer and/ or its treatment). Sensory disabilities include those involving vision (e.g., myopia), hearing, smell, taste, or tactile perception. Neurologic and developmental disabilities include those that occur during fetal development (e.g., microcephaly), birth (e.g., anoxia), or exposure to toxic substances (e.g., alcohol, lead). Developmental disabilities include spectrum disorders (e.g., autism) and cognitive delays/deficits (e.g., intellectual disability).


The Americans with Disabilities Act (ADA), enacted in 1990, defines disability as a physical or mental impairment that substantially limits one or more major life activities of an individual, a record of such an impairment, and being regarded as having such an impairment.15 The ADA requires reasonable accommodations for patients with disabilities, including access to public services and HCPs.15


According to the Social Model of Disability, people are disabled by barriers (physical or attitudinal) in society, not by their impairment or diff erences.16,17 The Social Model explores and supports the needs of persons with disabilities, as opposed to the limits that a disability may incur. The social defi nition of disability is based not on medical or legal terms but, rather, on an attitudinal construct. Many women with disabilities consider themselves healthy and want to be viewed that way. They need assistance from HCPs to support their health goals, which may include pregnancy.

Review of the literature

Women who have disabilities face social and environmental barriers that increase their risk for experiencing health disparities. Decreased access to high-quality care may lead to lower rates of screening for cervical and breast cancers, as well as unmet sexual and reproductive healthcare needs.3,6,9

Multiple studies have explored the experiences of women with disabilities as they access and receive perinatal care.1,3,7,8,10-12 In a qualitative study, female participants with a physical, sensory, and/or intellectual disability (N = 17) welcomed pregnancy as an experience that would affi rm their identity and worth as women and as mothers.18 However, these same participants reported that their HCPs lacked suffi cient knowledge about disabilities and their impact on pregnancy. They reported a lack of support from their HCP for their goal of motherhood, coupled with a perceived expectation of failure and an unnecessary categorization of themselves as women with high-risk pregnancies. Furthermore, participants reported that postpartum care focused mainly on the infant, and that any attention paid to them was from the perspective of what they weren’t able to do rather than what they were able to do. Participants reported that threats were made to remove their infant from the home if the care they provided to their infant was assessed as suboptimal.

Mitra et al8 interviewed 25 women with a physical disability who had given birth within the past 10 years. Participants reported that physicians and nurses providing perinatal care demonstrated a lack of knowledge and a poor attitude about pregnancy among women with disabilities. In addition, participants reported a lack of assistive devices in the healthcare setting.

In a study focused on the provider’s point of view, Smeltzer et al19 interviewed 14 HCPs—13 physicians and 1 certified nurse-midwife (CNM)—who reported providing care to women with physical disabilities. The investigators found that none of the HCPs reported having formal education or training on how to provide care to women with disabilities during the perinatal period. However, all of them reported having a positive attitude and found the experience rewarding.

The study

Nurse practitioners (NPs) and CNMs are instrumental in providing care during the perinatal period to women with disabilities. However, little is known about the educational preparation, comfort, perceived competency, and practice challenges of NPs and CNMs in delivering perinatal care to this population. The purpose of this study was to describe the education, comfort, perceived competency, and practice challenges of NPs and CNMs in the provision of perinatal care to women with disabilities.


The authors developed a 37-item survey to describe the provision of perinatal care to women with disabilities by these HCPs. Two questions measured recall of educational exposure to disability content and one question ascertained whether participants felt that their education about disabilities was suffi cient for practice. Nine questions measured respondents’ comfort in providing care to women with disabilities. The concept of practitioner comfort in care delivery has been linked to improved healthcare outcomes and patients’ sense of being respected.20,21 Ten questions assessed perceived competency in providing healthcare to women with disabilities. In addition to completing the survey, respondents had an opportunity to provide narrative comments on challenges they faced when providing care to women with disabilities. The remaining questions pertained to demographic data collection.

Prior to distribution, the survey underwent expert review by three advanced practice registered nurses (APRNs), including one CNM, for readability, content, and face validity. Minor changes were made to the survey to clarify the questions. After approval by the institutional review board, the survey was distributed by email to the membership of a leading APRN organization (N = 2,400) using SurveyMonkey. The letter accompanying the survey instrument served as consent. All data were collected anonymously. Members currently practicing as NPs or CNMs were invited to take the survey. Student members, as well as NPs and CNMs not currently practicing, were ineligible to participate. Data were collected between October 2015 and December 2015.

Frequencies and percentages were used to examine the distribution of responses. Chi-square (χ2) statistics were used to test associations among education, comfort, competency, and demographic variables. Statistical tests were considered signifi cant at an alpha of .05. The Cronbach alpha for the survey instrument was 0.92 overall. Data were analyzed using SPSS version 24.


Of the 2,400 surveys emailed, 185 were returned (response rate, 7.8%); of the 185 surveys returned, 150 were eligible for inclusion in the fi nal analysis (final response rate, 150/2,400, or 6.25%). Table 1 provides respondents’ demographic data and education and practice histories. Table 2 lists their levels of education, comfort, and competency in caring for women, including pregnant women, with disabilities.

caring women disabilities perinatal period table1

A significant relationship existed between professional experience (years of education and practice) and educational preparation, comfort, and perceived competency in providing care to women with disabilities (Table 3). NPs/CNMs in practice <10 years reported greater perceived competency providing care to pregnant women with intellectual (χ2 = 5.18, n = 150, P <.05) or developmental (χ2 = 4.14, n = 150, P <.05) disabilities. In addition, NPs/ CNMs who received didactic (χ2 = 8.81, n = 150, P <.001) or clinical (χ2 = 5.81, n = 150, P <.05) education in this area were more likely to feel that they received sufficient education to attain competency in providing care to women with disabilities than did those who reported receiving none of this content.

caring women disabilities perinatal period table 2 3

Respondents’ narrative comments focused on challenges delivering perinatal care to women with disabilities, including inadequate time to provide care, limited access to assistive devices, few referral resources for consultation, communication challenges, and lack of guidelines for care provision. Physical challenges pertained primarily to physical space and equipment—or the lack thereof. Respondents reported a lack of equipment to provide adequate care for patients with physical disabilities or mobility impairments. For example, many reported that their workplace had only one examining table that could be lowered enough to accommodate a woman with a physical disability, resulting in delays in seeing patients if the room with this usable table was occupied.

Communication was the primary challenge when caring for women with sensory disabilities. In particular, working with hearing-impaired patients was diffi cult without an interpreter, profi ciency in sign language, or another way to communicate eff ectively with them. Some respondents reported not having adequate educational materials for visually impaired/blind patients.

Provider-specific challenges addressed individual concerns about being prepared to meet the needs of women with disabilities. Some respondents noted that they did not feel adequately informed about specifi c conditions or how those conditions aff ected pregnancy or general health. Others noted diffi culty in keeping up to date with recommendations, guidelines, and regulations related to disabilities.

Overall, respondents felt that time constraints were a major challenge when providing care to women with disabilities.


The low response rate must be acknowledged. The survey was distributed electronically to members of a national organization that represents APRNs who specialize in women’s health. Some email addresses may not have been active or emails may not have been properly delivered or received. Reminder emails were sent 2 weeks after the initial request. To increase response rates in future studies, researchers might consider off ering an incentive such as a gift card. Another option is to conduct the study at the member organization’s annual conference. The authors are unable to comment or speculate on the delivery of perinatal care that survey non-responders provide to women with disabilities. Generalizability to all APRNs might not be possible because of the low response rate.

Box. Educational resources

American College of Obstetricians and Gynecologists. Women with Disabilities. 2017.

Byrnes L, Hickey M. Perinatal care for women with disabilities: clinical considerations. J Nurse Pract. 2016;12(8):503-509. article/pii/S1555415516303002

Center for Research on Women with Disabilities.

CDC. Disability and Health. Women with Disabilities. disabilityandhealth/women.html

Discussion and clinical implications

Although most survey respondents did not receive formal education or training in providing perinatal care to women with disabilities, this group reported feeling competent and comfortable in delivering such care. The authors ascribe these feelings to respondents’ experience levels. The authors did not ask respondents whether they sought learning opportunities in the form of continuing education (CE) programs or conferences on providing care to women with disabilities. This inquiry is an important consideration for future research, as well as for program development.

The overwhelming majority of respondents reported seeing fewer than 10 patients with a disability per month. This fi nding may be consistent with the data on limited access to and use of healthcare services, particularly reproductive health services, on the part of women with disabilities.3,6

Fewer than 30% of respondents reported having assistive devices and/or equipment to facilitate care in their clinical practice setting, which may present an actual or potential barrier to utilization of care by women with disabilities. According to the ADA, facilities, including healthcare facilities, are required to have accommodations and be accessible to persons with disabilities. Access and accommodations include transportation, ease of maneuverability within the physical space, and appropriate equipment.

Given the estimate of the number of women with disabilities in the population, many are likely not receiving the care they need. Provision of comprehensive care by competent, sensitive HCPs is necessary; however, accomplishing this goal presents challenges. A comprehensive overview of providing perinatal care to women with disabilities is available with CE credit.22 As noted in the current survey, HCPs are not routinely educated on the unique care needs of persons with disabilities. This fi nding is consistent with those of Smeltzer et al19 regarding obstetrical care providers. The Box lists and provides links to educational resources for practitioners and students alike. These resources can be incorporated into existing course work.

Environmental accommodations for patients with disabilities are costly and not necessarily easily implemented. Many HCPs may be unaware of resources and referrals within their geographic location, perhaps because of the limited number of patients they encounter who require these services. Most important, the substantial time required to deliver appropriate, comprehensive care tends not to be allocated in scheduling. HCPs should have not only the necessary physical accommodations for patients with disabilities but also the knowledge about how each disability can aff ect health during the perinatal period and in general.

Advanced practice registered nurses can help bridge the gaps in care and help ensure favorable experiences with the healthcare system. Raising awareness about the unique needs of women with disabilities is one step toward ensuring a more positive experience for them.

Lorraine Byrnes is Associate Professor, Mary Hickey is Clinical Professor, Jin Young Seo is Assistant Professor, and Lorie Goshin is Assistant Professor, all at Hunter Bellevue School of Nursing, Hunter College, City University of New York. The authors state that they do not have a fi nancial interest in or other relationship with any commercial product named in this article.


Female cosmetic genital surgery: In search of the perfect vulva

The United States leads all other countries in the number of female cosmetic genital surgeries (FCGSs) performed each year despite limited evidence of their relevance, safety, and effi cacy. In February 2018, the Cosmetic Surgery Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD) released a report on this topic. Even more recently, the FDA issued a warning about the use of energy-based treatments for vaginal rejuvenation. This column highlights recommendations from the ISSVD report on FCGS, and offers a clinical perspective from a board-certifi ed plastic surgeon. Continue reading »

Recommendations for Well-Woman Care – A Well-Woman Chart

Preventive care visits provide an excellent opportunity for well-woman care, including screening, evaluation of health risks and needs, counseling, and immunizations. Recommendations for Well-Woman Care – A Well-Woman Chart was developed by the Women’s Preventive Services Initiative (WPSI). The Well-Woman Chart outlines preventive services recommended by the WPSI, U.S. Preventive Services Task Force (USPSTF), and Bright Futures based on age, health status, and risk factors. Additional recommendations for immunizations are provided in a separate table from the Advisory Committee on Immunization Practices. Clinical practice considerations, risk assessment methods, and the age and frequency to deliver services are described in the Clinical Summary Tables that accompany the chart.

The Recommendations for Well-Woman Care – A Well-Woman Chart provides a framework for incorporating preventive health services for women into clinical practice. These services may be completed at a single visit or as part of a series of visits that take place over time. The recommendations are not intended as a statement of the standard of care, and do not comprise all proper treatments or methods of care. Providers should use clinical judgment in applying these recommendations to individual patient care, taking into account the needs and resources particular to the locality, the institution, or the type of practice. The Chart is updated annually. The WPSI website ( has the most up-to-date version of the Chart and Clinical Summary Tables.

well woman care

  1. Additional Bright Futures recommendations include: Periodic vision and hearing tests for ages 13-21; risk assessment for anemia for ages 13-21; and fluoride supplementation if needed for ages 13-16 ( Recommendations on services for adolescents under the age of 13 can be found at
  2. Immunizations should be administered according to the most recent ACIP recommendations (


ACIP = Advisory Committee on Immunization Practices; BRCA = breast cancer susceptibility gene; CRC = colorectal cancer; CVD = cardiovascular disease; HIV = human immunodeficiency virus; HCV = hepatitis C virus; HBV = hepatitis B virus; STI = sexually transmitted infection; USPSTF = U.S. Preventive Services Task Force; WPSI = Women’s Preventive Services Initiative.

*Criteria for selective screening

  1. Low-dose aspirin to prevent cardiovascular disease and colorectal cancer: Calculated 10-year risk of a CVD event ≥10%; not at increased risk for bleeding; have a life expectancy of at least 10 years; and are willing to take low-dose aspirin daily for at least 10 years.
  2. Diabetes screening and management: Overweight or obese for age 40-70 years; previous gestational diabetes, but not previously diagnosed with diabetes mellitus when not pregnant for age ≥13 years.
  3. Folic acid supplementation: Sexually active and planning or capable of pregnancy.
  4. Healthful diet and physical activity counseling: Overweight or obese and have additional CVD risk factors (hypertension, dyslipidemia, abnormal blood glucose levels, diabetes).
  5. Lipid screening: Familial dyslipidemia, risk factors, or high-risk conditions for age 13-17 years.
  6. Osteoporosis screening: 10-year fracture risk equivalent to an average-risk 65-year-old woman based on specific risk factors (parental history of hip fracture, smoking, white race, excess alcohol consumption, low body weight).
  7. Statin use to prevent CVD: Age 40 to 75 years; one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and calculated 10-year risk of a CVD event ≥10%.
  8. Urinary incontinence screening: Screen all women age 18 or older and younger women if postpartum.
  9. Gonorrhea and chlamydia screening: New sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI; inconsistent condom use among persons who are not in mutually monogamous relationships; previous or coexisting STI; and exchanging sex for money or drugs. Prevalence is also higher among incarcerated populations, military recruits, and patients receiving care at public STI clinics.
  10. Hepatitis B screening: Born in a country with a prevalence of HBV infection ≥2%; lack of vaccination in infancy in U.S.-born persons with parents from a country or region with prevalence ≥8%; HIV-positive persons; injection drug users; and household contacts or sexual partners of persons with HBV infection.
  11. Hepatitis C screening: One-time screening for adults born between 1945 and 1965. Criteria for others includes past or current injection drug use; receipt of a blood transfusion before 1992; long-term hemodialysis; born to an HCV-infected mother; incarceration; intranasal drug use; getting an unregulated tattoo; and other percutaneous exposures (e.g. healthcare workers).
  12. Latent tuberculosis infection: Persons from countries with increased tuberculosis prevalence; living in high-risk congregate settings (e.g., homeless shelters, correctional facilities); exposure to individuals with active tuberculosis, such as healthcare workers and workers in high-risk congregate settings; immunosuppressed individuals.
  13. Sexually transmitted infection prevention counseling: New sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI; inconsistent condom use among persons who are not in mutually monogamous relationships; previous or coexisting STI; and exchanging sex for money or drugs. Prevalence is also higher among incarcerated populations, military recruits, and patients receiving care at public STI clinics.
  14. Syphilis screening: Women with HIV; high-prevalence communities or populations; history of incarceration; exchanging sex for money or drugs.
  15. Breast cancer screening: No specific criteria; decisions about screening are made on an individual basis through a shared decision-making process.
  16. Lung cancer screening: 30-pack-year smoking history and currently smoke or have quit within the past 15 years.
  17. Medications to reduce breast cancer risk: Major risk factors for breast cancer include increasing age, family history of breast or ovarian cancer (especially among first-degree relatives and onset before age 50 years), history of atypical hyperplasia or other nonmalignant high-risk breast lesions, previous breast biopsy, and extremely dense breast tissue. Models suggest that women with an estimated 5-year breast cancer risk of 3% or greater are likely to have more benefit than harm, although the balance depends on age, race, or ethnicity, the medication used, and whether the patient has a uterus.
  18. Skin cancer counseling: Fair skin, light hair and eye color, freckles, sunburn easily.
  19. Low-dose aspirin to prevent preeclampsia: History of preeclampsia, especially when accompanied by an adverse outcome; multifetal gestation; chronic hypertension; type 1 or 2 diabetes mellitus; renal disease; autoimmune disease (systemic lupus erythematosus, antiphospholipid syndrome).
  20. Diabetes screening after pregnancy: Previous gestational diabetes, but not previously diagnosed with diabetes mellitus when not pregnant.

Detecting women’s cancer with cell phones

Researchers at Louisiana State University are working to turn cell phones into medical diagnostic tools for breast cancer. In the future, this new technology could help women screen for the BRCA gene and mutations at an affordable cost, all from the convenience of their local clinic, without having to travel to a specialist.

Read more.

Educational interventions to increase Tdap vaccination rates among pregnant women

The highly contagious respiratory infection pertussis remains a public health problem for the United States.1 Infants have the highest morbidity and mortality rates from pertussis because of a lack of immunity at birth and an immature immune system. In 2015, a total of 20,762 cases of pertussis were reported in the U.S., with infants accounting for 1,960 cases (9.5% of the total cases).2 Continue reading »

Health policy and the female caregiver: The impact on women’s health

As healthcare providers (HCPs), we are aware of the demographic shift and increased longevity that have resulted in a rise of the aging population in the United States and in many other countries around the world.These changes have increased the need for “informal” caregivers, usually partners or relatives, to provide assistance to individuals at varying levels of healthcare need. Unpaid caregiving by partners, family members, or even friends remains the main source of long-term care for older persons worldwide.This caregiving, usually provided by women, can have an adverse impact on caregivers’ health, quality of life, economic stability, and longevity.2,3 Continue reading »

Challenges of preconception and interconception care: Environmental toxic exposures

This article provides healthcare providers with up-to-date information about the impact of a variety of potentially toxic environmental exposures on reproductive health, specifically with respect to preconception care (PC) and interconception care (IC). PC/IC should include education regarding environmental risks and a discussion about ways to minimize a woman’s exposure to environmental toxins in order to optimize both pregnancy and infant outcomes. Continue reading »

WHNPs in specialty positions: My experience in breast surgical oncology

When I, Caitlyn E. Hull, sought to become a women’s health nurse practitioner (WHNP), I had not considered the variety of roles that might be available. I had imagined myself working as a generalist in an obstetrics/gynecology (Ob/Gyn) private practice or federally funded clinic like many of my professors and preceptors, and I was thrilled with the possibilities that lay ahead of me in this field. When I was offered a position as a WHNP in surgical oncology at the Stefanie Spielman Comprehensive Breast Center (Photograph), which is affiliated with The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital (The James) and Richard J. Solove Research Institute, I had several questions and hesitations. I was curious about how my education and training would be utilized in breast oncology, particularly as a new NP. Continue reading »

Pessary use for pelvic organ prolapse in sexually active women

By Brooke M. Faught, MSN, WHNP-BC, IF

Pelvic organ prolapse (POP), a common condition in women, increases in prevalence with advancing age. Treatment for POP may include pelvic floor exercises, surgery, and/or use of pessaries. Pessaries offer women a nonsurgical, cost-effective, low risk option for treating symptomatic prolapse. This column focuses on what healthcare providers need to know when caring for sexually active women with POP who choose to use a pessary. Continue reading »

Developing and implementing PrEP at your local health center

Pre-exposure prophylaxis (PrEP) is an effective tool in the prevention of HIV acquisition. Advanced practice registered nurses are ideally positioned to introduce and prescribe PrEP, but some may not know how to integrate it into their practice. In this article, the authors describe the logistics of developing and implementing a PrEP program at multiple Planned Parenthood of Illinois (PPIL) health centers. They also discuss the training and support offered to PPIL clinicians during implementation of the program, the evaluation process, and the results. The process from development to implementation and evaluation can be easily adapted to other clinical settings. Continue reading »

Managing women’s health issues across a lifespan: NPWH 2017-2018 regional meetings

Before reading the article, click here to take the pretest.

Over the past year, NPWH sponsored four regional meetings highlighting updates on the management of women’s health issues across a lifespan. The meetings were presented to live audiences using an interactive learning strategy, with several clinical scenarios illustrating issues within four topic areas: contraception, bacterial vaginosis, hypoactive sexual desire disorder, and postmenopausal osteoporosis. The author of this article has chosen one scenario for each topic to demonstrate how this learning strategy can cover important health areas in a way that intrigues and challenges, in this case, our readers. Continue reading »

Checklist for parents planning out-of-hospital births: An evidence-based application

Out-of-hospital births (OHBs) have increased in the United States in recent years. However, available evidence to date shows that OHBs, when compared with in-hospital births, are associated with higher levels of neonatal morbidity and mortality. The authors of this article offer an evidence-based checklist to help maternity care providers and their patients understand these risks and determine whether an in-hospital birth might be a better choice for them. Continue reading »

Monograph: Patient preferences in treatment of recurrent singleton preterm birth

recurrent singleton preterm birth postThis study investigated patient preferences for administration-related attributes of treatments used to reduce the risk of recurrent preterm birth and drivers of treatment adherence propensity and was funded by AMAG Pharmaceuticals, Inc. All materials have undergone peer review according to Women’s Healthcare standards.

Download here to view the full study.

Position Statement: Cervical Cancer Screening

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports a concerted effort to continue to improve cervical cancer screening rates and timely, appropriate follow-up and treatment when screening results are abnormal. The goal is to reduce cervical cancer incidence, morbidity, and mortality. NPWH supports ongoing research to ensure that screening guidelines are based on the best evidence available. Furthermore, NPWH supports policies at the local, state, and federal levels that ensure access to cervical cancer screening services and follow-up as needed. Continue reading »

Women and smoking: Facilitating change

Although smoking may not be a gender-specific practice, females are predisposed to many potentially adverse effects of smoking during the course of their lives. Compared with their male counterparts, they are at higher risk for developing certain smoking-related diseases. In this article, the author describes how women’s healthcare providers can encourage their patients who smoke to quit, both by utilizing the 5As model and by offering them a variety of management options to help them reach their goal. Continue reading »

Mothers’ perceptions regarding mother–daughter sexual communication

The author investigated attitudes, beliefs, and knowledge that a group of mothers perceived as compromising or promoting sexual communication with their adolescent daughters. The results of the study are presented and its implications for women’s healthcare providers are discussed. Continue reading »

Managing postmenopausal dyspareunia: An update


Susan Hoffstetter, PhD, WHNP-BC, FAANP, is a professor at Saint Louis University School of Medicine, Department of Obstetrics, Gynecology & Women’s Health, Division of Uro-Gynecology, in St. Louis, Missouri.

Intended audience: This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners who provide care for menopausal and postmenopausal women. Continue reading »

Editor-in-chief’s message

Dear Colleagues,

What a wonderful time of the year—spring is in full swing, and many of us are planning for summertime events. As we move into summer, I invite you to take a few minutes to reflect on nurse practitioners (NPs) in the world of women’s health who have been an inspiration to you and others. With its Inspiration in Women’s Health Awards, NPWH gives us an opportunity to recognize and celebrate NPs who have inspired us. These awards will be presented at our 21st Annual NPWH PremierWomen’s Healthcare Conference, which will take place in San Antonio, Texas, on October 10-13, 2018. Continue reading »

Implementation of the HSDD process of care into clinical practice

Distressing low sexual desire is the most common sexual complaint among women in the United States. Despite the prevalence of this condition and others like it, many healthcare providers find the diagnosis and treatment of female sexual disorders elusive. In late 2016, a team of sexual health experts from the International Society for the Study of Women’s Sexual Health met to develop a process of care (POC) to streamline the management of women with hypoactive sexual desire disorder (HSDD). In April 2018, Mayo Clinic Proceedings published the HSDD POC, which is summarized here. Continue reading »

Cultivating your inner Wonder Woman: Policy advocacy

By Diana M. Drake, DNP, MSN, APRN, WHNP-BC

The movie Wonder Woman is said to be, in essence, two solid hours of female empowerment. At the start of 2018, while flying to Salvador, Brazil, to lead a practicum entitled Women’s Health in the Context of Environment, Race, Culture and Policy, I was able to watch this blockbuster film. While doing so, I realized that, in the Brazil practicum, I would be asking my NP students to find their own inner Wonder Woman and become powerful advocates and ambassadors for change within an international context. Continue reading »

Editor-in-chief’s message: Reflection on 2017 and the year ahead

Dear Colleagues,

I hope the start of 2018 has been a good one for everyone. I imagine that all of you, like me, are looking forward to spring; it is just around the corner!

For now, though, I want to look back at 2017 to celebrate what we have accomplished for the journal, as well as recognize the many individuals who helped us have an excellent year. I’ll start off by announcing the winners of our Women’s Healthcare 2017 Favorite Article Contest: Continue reading »

Interstitial cystitis: Algorithm to simplify diagnosis of chronic urinary symptoms

By Anita L. Booth, DNP, FNP-BC and Jill Harpst Rodgers, DNP, FNP-BC

This pre/post-test study was undertaken to determine whether an algorithm constructed in an electronic health record template would aid in diagnosing interstitial cystitis. The algorithm is presented and the study methods, results, and implications are described here. Continue reading »

Digital assessment of the pelvic floor muscles: A neglected technique

By Helen A. Carcio, MS, MEd, ANP-BC

Clinical evaluation of the pelvic floor muscles (PFMs) should be an integral part of a comprehensive well-woman examination because it can aid in identifying bladder dysfunction and pelvic organ prolapse. Digital assessment of the PFMs, a simple but neglected technique that should be part of every clinical evaluation of the pelvic musculature, is described in detail in this article. Continue reading »

Healthcare for Transgender and Gender Non-Conforming Individuals

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms each individual’s right to quality, evidence-based sexual and reproductive healthcare and encourages each individual to strive for a healthy self-concept of sexuality and gender identity. Although NPWH has historically focused on the care of cisgender women, we recognize the importance of providing quality sexual and reproductive healthcare to all individuals, regardless of gender identity. Table 1 provides gender identity-related terminology and definitions.1  Continue reading »

Assessment of the effect of social influences and personal resilience on preventing repeat adolescent pregnancy

By Nola Holness, PhD, CNM, APRN-Adult

One in five adolescent mothers in the United States has a repeat adolescent pregnancy, which is associated with increased maternal morbidity and mortality and poor birth outcomes. Whereas many adolescent mothers succumb to harmful external pressures, resulting in risky sexual behaviors and possible repeat pregnancy, others are fortunate in having a helpful support system. In addition, many adolescent mothers have an inner resilience and are able to implement measures on their own to prevent a repeat pregnancy. This study investigated how social influences and personal resilience affected African-American and Hispanic adolescent mothers’ planned use of contraception or abstinence to prevent a repeat adolescent pregnancy. Continue reading »

Dense breasts: Cancer risk and supplemental imaging modalities

By Mary Ellen Egger, APN, WHNP, CBPN and Diana L. Lam, MD


Mary Ellen Egger, APN, WHNP, CBPN, is a nurse practitioner in the Breast Center at Vanderbilt University in Nashville, Tennessee.

Diana L. Lam, MD, is an Assistant Professor in the Department of Radiology specializing in Breast Imaging at the University of Washington, Seattle Cancer Care Alliance, in Seattle, Washington.

Intended audience: This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners who provide care for women in any age bracket. Continue reading »

Policy and preventive healthcare services: Women living longer, living well

By Diana M. Drake, DNP, MSN, APRN, WHNP-BC

From the perspective of women’s healthcare providers (HCPs) in the United States, one of the major shifts in their field over the past decade has been a female patient population that is growing older, with an increasing mix of midlife and senior-life patients. Continue reading »

New evidence-based guideline for accurate HPV testing in head and neck cancers

The College of American Pathologists has released its newest evidence-based practice guideline, “Human Papillomavirus Testing in Head and Neck Carcinomas,” now available in Archives of Pathology and Laboratory Medicine. The guideline recommends accurate assessments of a patient’s high-risk HPV status, directly or by surrogate markers. Read more.

The consensus model: What current and future NPs need to know

Editor’s Note: This article originally appeared in American Nurse Today, January 2018.

Acute care vs. chronic care is the key.

By Caroline Lloyd Doherty, AGACNP-BC; Patricia Pawlow, ACNP-BC; and Deborah Becker, PhD, ACNP-BC, CHSE, FAAN

As a current or future advanced practice nurse (APRN), you must understand the Consensus Model and its career implications to practice. The model was developed in 2008 by the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. It was endorsed by more than 40 nursing organizations, including the American Association of Colleges of Nursing, National Organization of Nurse Practitioner Faculties, American Association of Nurse Anesthetists, American College  of Nurse-Midwives, and the American Association of Nurse Practitioners. Continue reading »

Hair or bare?

Many women pose questions to their healthcare provider (HCP) about the removal of pubic hair. Although not medically indicated, removal of hair around the genitals is done for a variety of reasons. Complications may arise as a result of this practice. In this column, the evolution of genital landscaping and considerations for HCPs are discussed. Continue reading »

Message from the CEO

I am proud to announce that the 20th Annual NPWH Premier Women’s Healthcare to date! We had more than 750 attendees, and the viewed our excellent poster presentations. I received comments about the conference that included the following: Inspiring! Great content! Excellent faculty! Fun to be with colleagues in this learning environment. I extend a special thanks to the 2017 Planning Committee, the NPWH Board of Directors, RSG Consulting, and our incredible NPWH staff for making this truly our best conference yet! Continue reading »

Genetic testing for hereditary cancer syndromes in women

What is a hereditary cancer syndrome?

Cancer can be sporadic, familial, or hereditary. A sporadic cancer happens at random, maybe because of a mistake that occurred when cells in the body were dividing or because a person was exposed to toxins (poisons) in their environment—for example, cigarette smoke—over a long period of time. A familial cancer occurs in members of the same family and is likely caused by a combination of genetic and toxic environmental factors. A hereditary cancer syndrome is caused by a specific mutation (change) in a certain gene that can be passed down from parent to child. Continue reading »

Editor-in-chief’s message

Dear Colleagues,

I have a few updates and opportunities regarding the journal that I’d like to share with you. First, there is an erratum in our September 2017 issue’s Focus on Sexual Health article, “Persistent genital arousal disorder: The uninvited guest (Part 2),” by Brooke M. Faught. The first paragraph and a portion of the second paragraph of the article were inadvertently omitted in the print version of the journal. The article is published in its entirety in the online version of the September 2017 issue. Continue reading »

Group visits for management of patients with PCOS: A pilot study

Polycystic ovary syndrome (PCOS), a complex disorder affecting reproductive-aged females, presents challenges for equipping patients with knowledge and tools to manage their condition. The authors examined the feasibility of conducting a group visit program in a college health setting for women with PCOS, and ascertained whether these visits might effectuate favorable changes in these women’s self efficacy and health practices. Continue reading »

On the case…Having the conversation about alcohol as a teratogen: Three women

By Beth Kelsey, EdD, APRN, WHNP-BC, FAANP and Marilyn Pierce-Bulger, MN, FNP-BC, CNM

How do nurse practitioners skillfully handle three challenging scenarios involving young women who are (1) at repeated risk for an unplanned pregnancy, (2) planning a pregnancy, or (3) currently pregnant—and who also drink alcoholic beverages?

JD, a 20-year-old female college student, presents at a student health center for emergency contraception. She reports that she had unprotected sex two nights previously. JD had discontinued her oral contraceptive (OC) 3 months previously because she believed that it was causing her to gain weight. She occasionally uses condoms. JD does not desire a pregnancy at this time. Upon further review of JD’s health history, the nurse practitioner (NP) learns that the patient drinks one or two beers on most weekends and that she has four or five beers at parties about once a month. Continue reading »

Risky dating behavior among women aged 50+: A growing public health concern

Risky dating behavior, often leading to risky sexual behavior, is a growing public health concern because it contributes to the high incidence of sexually transmitted infections (STIs). These behaviors have been the focus of many national educational initiatives targeting persons at greatest risk—typically those in their late teens or 20s. In recent years, a new at-risk group has been identified that has been relatively invisible until now: sexually active women aged 50 years or older. The authors discuss the educational and primary care needs of these women so that their risk for developing STIs can be reduced. Continue reading »

BRCA and beyond: The contribution of genetics to breast and gynecologic cancers (Part 2)


Kate McReynolds, APRN, MSc, MSN, ANP-BC, AGN-BC, is a Genetic Nurse Practitioner at Vanderbilt University Medical Center in Nashville, Tennessee.

Intended audience

This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners who provide care for women in any age bracket.

CE approval period

Now through November 30, 2018

Estimated time to complete this activity

1 hour

CE approval hours

1.0 contact hour of CE credit

Needs assessment

This two-part article focuses on hereditary cancer syndromes associated with breast and gynecologic cancers. In part 1, the author provided background information about hereditary cancer, detailed several specific hereditary breast and gynecologic cancer syndromes (HBGCSs), and explained the gene alterations involved in these syndromes. In part 2, the author describes ways that healthcare providers can identify women who may have one of the two most common syndromes and who could therefore benefit from genetic risk assessment, counseling, and testing—processes she also discusses. The author also explains how to interpret genetic test results and provides management recommendations for the two most common HBGCSs. Continue reading »

Position Statement: Human Papillomavirus Vaccination

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports an intentional and concerted effort to improve human papillomavirus (HPV) vaccination rates—with the goal of ending cancers caused by HPV. All nurse practitioners (NPs) who provide healthcare for adolescents and young adults are crucial to the success of this effort, and are encouraged to take these steps in their clinical practices: Continue reading »

Breast pain: An evidence-based case report

By Kathryn Trotter, DNP, CNM, FNP, FAANP

Should we worry about cancer?

SM, a 38-year-old African-American woman, presents to the office with a complaint of pain in the left breast for the past 6 months. Pointing to the outer lateral breast, she describes intermittent achiness, along with a sharp stabbing pain lasting about 30 seconds if the breast is pressed or palpated. She asks whether this pain might be a symptom of breast cancer. She is also seeking pain relief because her symptoms occasionally interfere with sleep and her exercise routine. On a scale from 1-10, SM rates her overall breast pain a 3 and the sharp stabbing pain a 6. She says that the pain in her left breast does not necessarily worsen prior to menses. However, a few times a year, she reports experiencing premenstrual tenderness in both breasts. She has not noticed nipple discharge or retraction, dimpling, skin color change, nodularity, or a mass. Continue reading »

WHO Factsheet: Sexually transmitted infections (STIs)

What are sexually transmitted infections and how are they transmitted?

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.

STIs are spread predominantly by sexual contact, including vaginal, anal and oral sex. Some STIs can also be spread through non-sexual means such as via blood or blood products. Many STIs—including chlamydia, gonorrhoea, primarily hepatitis B, HIV, and syphilis—can also be transmitted from mother to child during pregnancy and childbirth.

A person can have an STI without having obvious symptoms of disease. Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain.

Click here to read more on the World Health Organization’s Media Centre page.

New book offers evidence-based approach to diagnosis and treatment of vulvar disorders*

the vulva New book offers evidence-based approach to diagnosis and treatment of vulvar disordersBy Susan Hoffstetter, PhD, WHNP-BC, FAANP

The Vulva: A Practical Handbook for Clinicians was written to improve healthcare providers’ (HCPs’) abilities to diagnose, treat, and manage vulvar disorders, including those affecting the pelvic floor. The authors, Australian dermatologist Gayle Fischer and gynecologist Jennifer Bradford, have extensive clinical and research experience in this area. Continue reading »

Chlamydia and gonorrhea rescreening: patient portal reminders

Chlamydia and gonorrhea rescreening: Patient portal remindersBy Megan N. Spiekermeier, DNP, WHNP-BC and Debra L. Ilchak, DNP, RN, FNP-BC, CNE

Chlamydia and gonorrhea, the most commonly reported curable sexually transmitted infections (STIs) in the United States, often present without symptoms.1 If left untreated, these infections can lead to serious health complications in women, including pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain.1 Because reinfections are common and are associated with poor health outcomes, current guidelines from the CDC recommend rescreening for chlamydia and gonorrhea 3 months following treatment.1 Despite this recommendation, rescreening rates remain low nationwide, as well as at the project site.2 Continue reading »

Non-suicidal self-injury: The nurse practitioner’s role in identification and treatment

By Erik P. Southard, DNP, FNP-BC; Renee N. Bauer, PhD, MS, RN; and Andreas M. Kummerow, MS, RN, CNE

Non-suicidal self-injury (NSSI) is an increasingly common way in which adolescents and adults cope with emotional pain. This article covers ways to recognize NSSI behaviors before they cause irreversible damage and to guide patients toward receiving the treatment they need.  Continue reading »

Professional Development: Creating an Award-WInning Poster

first place nurse practioner posterBy Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

Have you recently completed your research study or quality improvement (QI) project, submitted an abstract for conference presentation consideration, and been accepted for a poster presentation? If so, congratulations! Presenting a poster is an excellent venue for disseminating your research and project outcomes to colleagues. Poster presentations, more so than podium presentations, provide an opportunity to interact with individual viewers and with small groups of conference participants. If you are new to presenting, poster format can be less intimidating than standing in front of a large audience. In addition, the one-on-one contacts you can make with a poster presentation are a great way to network with others interested in your topic and to explore possible next steps in your scholarly and professional endeavors. Continue reading »

Effect of physical activity on urinary incontinence in women: Implications for providers

By Kimberly J. Angelini, WHNP-BC, PhD(c)

A growing number of young women are participating in high-intensity, high-impact physical activities that can cause urinary incontinence (UI). Many of these women may not report this problem during routine health examinations, perhaps because of embarrassment or unawareness that it can be treated. The author raises healthcare providers’ awareness of the need to screen this population for UI and then make the diagnosis and treat it when indicated. Continue reading »

Message from the CEO

gary johnson ceo nurse practitioner womens healthcareHappy September and  the beginning of the new fall season!

As you may remember, NPWH was founded in 1980 as a national organization for nurse practitioners (NPs) who were focused on family planning and reproductive health. As the years have progressed, so have we. NPWH now represents all women’s health NPs (WHNPs), as well as family NPs and adult NPs who are providing healthcare to women. In addition, NPWH represents individuals in academia who are educating these women’s health-focused NPs. We have defined ourselves as the premier organization that works tirelessly to develop and produce the absolute best in educational opportunities, as well as new programs, initiatives, and resources that provide expert, up-to-date content in all areas of women’s health. Continue reading »

Treatment of a Bartholin gland abscess: A step-by-step approach using simulation

By Aimee Chism Holland, DNP, WHNP-BC, NP-C, RD and Bonnie Bibb, MSN, NP-C

This article provides novice nurse practitioners (NPs) or NP students, as well as NP students’ instructors and preceptors, with detailed information needed to safely perform an incision and drainage of a Bartholin gland abscess or large symptomatic Bartholin gland cyst with placement of a Word catheter or wound packing. The authors provide a simulation module that can be used to practice this procedure, which is performed to relieve vulvar discomfort and promote wound healing. Continue reading »

Editor-in-chief’s message: Women’s Healthcare: A Clinical Journal for NPs (WH) reader survey

Dear Colleagues,

Thank you to everyone who completed our recent Women’s Healthcare: A Clinical Journal for NPs (WH) reader survey. We received 481 responses. The information you provided is very helpful to us as we continue to strive to bring you articles on topics of the utmost importance and interest. As a team, the WH editing and publishing staff, the WH editorial advisory board, NPWH CEO Gay Johnson, and I do listen to what you, our readers, tell us as we plan content and format.  Continue reading »

Persistent genital arousal disorder: The uninvited guest (Part 2)

Brooke M. Faught, MSN, WHNP-BC, IFBy Brooke M. Faught, MSN, WHNP-BC, IF

Healthcare providers (HCPs) need to understand a patient’s experience of a health condition in order to provide effective care in a holistic manner. This recommendation is especially important in cases of elusive health conditions that may be unfamiliar to most patients and even to some HCPs. In Part 1 of this two-part series, readers learned that persistent genital arousal disorder (PGAD) involves unwanted, unwarranted, persistent symptoms of genital arousal that frequently border on pain. In many cases, these symptoms are debilitating. In part 2 of this series, two women share their personal experiences with PGAD. Two additional accounts of PGAD are available. Continue reading »

Two additional PGAD accounts

By Brooke M. Faught, MSN, WHNP-BC, IF

Healthcare providers (HCPs) need to understand a patient’s experience of a health condition in order to provide effective care in a holistic manner. This recommendation is especially important in cases of elusive health conditions that may be unfamiliar to most patients and even to some HCPs. In Part 1 of this two-part series, readers learned that persistent genital arousal disorder (PGAD) involves unwanted, unwarranted, persistent symptoms of genital arousal that frequently border on pain. In many cases, these symptoms are debilitating. In Part 2 of this series, two women share their personal experiences with PGAD. Two additional accounts of PGAD are shared below.

Patient story 3

In May 2015, I was a 44-year-old woman living a pretty normal life in northern New Jersey with my family. I was a cheerleading and soccer mom who was looking for a job after being a stay-at-home mom for 15 years. On May 3, 2015, my life changed. I woke up one morning with feelings of a urinary tract infection (UTI) and feelings of arousal. I told myself that I must be imagining the arousal part and that those feelings must be from the UTI. I saw my primary care doctor, who said that I did not have a UTI and that, if my symptoms persisted, I should see a urologist. The urologist gave me medicine for overactive bladder, but it didn’t work. I never told the urologist about the arousal symptoms because I was too embarrassed. He did a cystoscopy and a urodynamic study and found nothing wrong.

I started doing my own research. I was taking Cymbalta (duloxetine) for generalized anxiety disorder, which I’ve had my entire life. Otherwise, I was quite healthy. I had mild peripheral neuropathy and arthritis, but neither of these conditions affected my life. Through my research, I learned that antidepressants such as Cymbalta might cause the UTI symptoms and the arousal feelings. I called my psychiatrist, who was treating me for the anxiety, to tell her about what I’d read, but she did not believe me. I felt like I was being tortured by the arousal feelings, but I couldn’t do anything but cry all the time. So I decided to go off Cymbalta on my own. I weaned myself from it very slowly. After a few weeks, the UTI symptoms and arousal feelings disappeared. I could not have been happier. I felt as though I got my life back except for one thing—the anxiety was back.

The psychiatrist recommended trying another antidepressant and convinced me that the arousal feeling was just a quirky reaction to the Cymbalta. I decided to start Lexapro (escitalopram). Two days into the new drug, all the feelings I had in May came back. I had had only 1 month of being arousal free and having no UTI symptoms. I immediately stopped the escitalopram, but this time, the arousal feelings did not go away; I was back to being tortured. I sat in the bath that night and just cried my eyes out. I always felt like a strong person, so I told myself that this problem was not going to beat me.

I started Googling on my phone for answers. I like to call it contacting Dr. Google. To my surprise, there was a name for what I had. I couldn’t believe it. At this point, I knew I had persistent genital arousal disorder, or PGAD. I diagnosed myself. Now the question was, “What do I do?” I was too embarrassed to tell anyone, even a doctor. I felt like a disgusting and filthy human being. How could this be happening? I decided to masturbate, thinking it would relieve the arousal. It didn’t! It just made the feelings stronger. I couldn’t tell my husband about my problem; I thought he would think I was disgusting too. The arousal symptoms were so strong that they would force me to masturbate, even though it actually made me feel worse. Each day I felt as though I was living in agony. I liken it to feeling raped over and over again.

I finally summoned the courage to tell my best friend, who was sympathetic and understanding. I also told my husband, who was concerned. Neither of them looked at me differently, but I was different. I was not the same person I used to be. I thought of killing myself many times. Having two daughters, aged 12 and 15, was the main thing holding me back. Because I was this upset, I tried the urologist again. He did some testing. But I could not hold back the tears. I am a strong person, not a crier, but this problem brought me to my knees. This monster that was inside me made me feel like I was crazy. I actually wished that I had cancer instead. The urologist told me that I needed to see a psychiatrist and that it was all in my head. I sat in the parking lot, crying. I called my friend, who calmed me down enough so that I could drive home.

I then found a urologist who was familiar with PGAD. He put me on Chantix (varenicline), which made me very sick: headaches, dizziness, and an upset stomach. It was December, and I thought that this would be my last Christmas with the girls. I couldn’t help it. I couldn’t live like this. I called my acupuncturist and summoned the courage to tell her about the PGAD. I figured, “What do I have to lose?” I was going to kill myself anyway. She did a treatment on me, which at least calmed me down. She also found a physical therapy center for me, a place that helps people with this issue. I got an appointment right after the first of the new year. I felt hopeful.

Meeting the physical therapist, I did not know what to expect. She was kind and tried her best to make me feel comfortable, but I was shaking. She said that she thought she could help me because my pelvic muscles were extremely tight and having spasms. During these sessions, for the first time in my life, I started having panic attacks. I was afraid that I would have an orgasm if she touched me. However, most of the reason I am alive today is because of her. She gave me hope, and that is what I needed. She tried different methods and relaxation techniques. I could tell that she wanted to help me. I asked her how long it would take to see improvement and she said, “three months.” I thought that I could hold on for that long.

Three months came and went, and I withdrew more and more from my kids, my friends, and my husband. I was alive but not living a life. At this point, my husband and I had no sex life at all. My husband kept looking at me with sad eyes and my poor kids didn’t know what to think. Things were so bad I didn’t even ask them. I completely withdrew from the world except for my Facebook support groups. I didn’t feel as alone then.

My physical therapist sent me to a doctor in New York City. This doctor ran all sorts of tests and said that I might have interstitial cystitis (IC) and PGAD. She gave me gabapentin and aloe vitamins, neither of which helped. The doctor then ordered ileoinguinal nerve injections and Botox injections. At this point, the feelings of arousal extended from my clitoris to my rectum. I had rectal pain too. The Botox helped the rectal pain but nothing else. The doctor put me on Elavil (amitriptyline) too, to no avail.

I was constantly aroused, 24 hours a day. It is like having an itch I couldn’t scratch. I went to bed crying every night. At this point, I began sleeping on the couch. I needed to either masturbate or use two ice packs, one in the front and one in the back, with hope it would numb the area and I would doze off. I also tried meditation and stretching, but nothing worked. I didn’t want my children or husband to know any of this. My younger daughter always wanted to snuggle with me in bed, but I couldn’t do it. She was so confused. We were so close and I didn’t want her near me. I felt isolated, depressed, anxious, and desperate.

After that I tried ArpWave therapy, which is similar to a TENS unit but more powerful. I tried it for a month, along with more vitamins. I was so desperate I would try anything. At the same time, I felt so guilty about the money I was spending; most of the doctors I saw didn’t take insurance. This approach didn’t work either. I was thinking about ways to kill myself so that my family could get my life insurance money. I then tried marijuana. I had capsules made for me; I increased the dosage weekly. Every time I increased the dosage, I was stoned but still aroused. Another failed attempt.

During this time, I was seeing a therapist as well. My depression and desperation intensified. The therapist convinced me to see a psychiatrist and get on an antidepressant. The psychiatrist was so caring, even though I was not an easy patient. She insisted that I overcome my fear of taking medicine. She is the other reason I am still alive and fighting to rid myself of this torment. She was extremely helpful, giving me different techniques to deal with my problems. And she gave me hope.

My therapist recommended another doctor whose office is an hour and a half from my house. He diagnosed me with IC. He gives me bladder instillations and tried me on all different types of medicines. Every time I tried a different one, I lost or gained weight or was sleepy or energetic. He also taught me to do the instillations at home, so I learned to self-catheterize. Acquiring this skill was not on my bucket list. I would sometimes get urethral spasms, which are relieved with oxycodone. I still see this doctor now, but I am not better. I open my pill closet and I see tons of bottles of medicine. It reminds me of my grandmother when she was 80.

It is November now, and I decided to call another doctor whose office is even further away. I would need to travel across the country to possibly get help, using more money that we didn’t have. My relationship with my husband at this point was deteriorating quickly; I don’t even think we had one anymore. I detached from everyone. My only safe places were with my therapist or with my physical therapist. My husband said he felt helpless. We grew further apart because I was not interested in sex. I don’t want to be touched or be with people. My 12-year-old, who is very affectionate, wanted to sit on my lap and I wouldn’t let her. My 15-year-old wanted to hug me goodnight and I just sat there and told her I didn’t feel well. Both of my girls’ faces were so sad. They felt like they had lost their mother. They did lose their mother: I felt too disgusting to have these arousal feelings while holding or hugging them.

I had a phone consult with the new doctor. He told me to get an MRI with contrast done and to send him the results. I went to my chiropractor to get the prescription for the test, but he didn’t believe me. He told me it was stress. My primary care doctor ordered the MRI. After getting the results, I learned that I have pelvic congestion syndrome. I immediately called my physical therapist, who told me to go to an interventional radiologist. In May of that year I had had hemorrhoid surgery (hemorrhoids are common with pelvic congestion syndrome). I made an appointment with an interventional radiologist, who performed an embolization on my veins. I thought for sure this was the answer. I was excited and thought my misery would finally end. After the procedure, the radiologist told me it would take months to see if it worked because my veins were larger than anyone’s he had ever seen. There were also more of them surrounding my pelvis than he had ever seen. However, it gave me hope and it got me through another Christmas.

The arousal feelings are still here. It is impossible to sit, stand, walk, or do any activity for too long. My life as it once was seems gone forever. I was an energetic woman who never stopped moving. I was social and happy. I jogged every day and always ate healthfully. I wished I could have anything else but this problem. I don’t feel comfortable talking about my problem, so I have had no outlet, which has completely turned my life upside down.

I asked my 15-year-old daughter how she felt about everything going on with me. Like most 15-year-old girls in love with their boyfriends, she is pretty self-absorbed. She said, though, that she felt scared when I couldn’t get up because of the pain. (After having the arousal all day, it turns into pain.) I would have urethral spasms that hurt so bad I had to take oxycodone. I could barely walk when this happened. I asked my younger daughter, who has always been a mama’s girl, how she felt. She didn’t answer me. I asked her again and she got angry and said, “I don’t want to talk about it,” and ran to her room. My husband tried to talk to her and she wouldn’t budge. Two hours later, she came into my room sobbing. She said, “You go to the doctor’s and you never get better.” She added, “I want my mommy back.” I was heartbroken. My first thought was that they would be better off without me.

I spent one night scouring the Internet trying to figure this out. I thought that maybe paralyzing myself from the waist down would take away this monster that lived inside of me. I wouldn’t be crazy or in pain. I would just be in a wheelchair, which I felt would be better than this agony. At this point, I had stopped socializing with friends because I didn’t want to have these arousal feelings in front of everyone. If I would go out, all my clothes had to be loose fitting so the symptoms would not get worse. My friends don’t even expect me to come out anymore.

It is now 2 years in, and I went back to check on the varicose veins. The interventional radiologist said they would be gone. To his surprise, I was unique in having a vein on the left side that was still carrying blood. The right side was fine. The only thing he could do was put in a stent to block the blood flow. He told me to think about it, because the procedure is risky; it could cause a blood clot on my left side of my body.

My physical therapist sent me to another doctor in New York City who said I did not have IC. He believes I have pudental neuralgia, which is causing my arousal symptoms. I felt arousal all over from my clitoris to my rectum. After a year of treatment for IC, I came back confused, not knowing whom to believe. I have to go see another interventional radiologist to get a guided pudental nerve block. I am still waiting because it took 6 weeks to get an appointment. Six weeks feels like an eternity when you are just trying to survive. He might send me for another MRI, depending on the results of the block. If I have pudental neuralgia, I have some options of injections and some surgeries but will not know for a few weeks. He does not want me to get the stent put in at this time because the procedure carries many risks and he was not sure it was going to work.

Since the onset of my symptoms, I have seen a total of 17 doctors. At this point, I would like the psychiatric community to know what PGAD is, what causes it, and how to cure it. We need more doctors who believe us and are interested in our cause. We need insurance companies to cover the cost of the treatments. Most insurance companies will not pay, stating that the treatments are experimental. So many people can’t afford treatment or the treatment location is too far away. I feel guilty over the financial burden I have become to my family.

PGAD has destroyed not only my life, but also my marriage, my children’s lives, and my relationships with friends. It makes you feel like you’re going insane. I have panic attacks now and it takes all of my energy just to make it through the day. I don’t wish this torture on anyone and that is exactly what this is—torture.

Patient story 4

Editor’s note: In this patient’s account of PGAD, he provided information requested of him in a structured format.

Please include the following information in your story, although you can eliminate questions that you do not want to answer:

  1. Age (<20, 21-25, 26-30, 31-35, 36-40, 41-45, 46-50, 51-60, 61-70, 71-80, 81+): 26-30
  2. Age at time of onset of first PGAD symptoms and age at time of PGAD diagnosis: 18
  3. # of healthcare providers seen before you received the diagnosis of PGAD: >5
  4. Any known cause(s) of your PGAD?: Both pudendal neuralgia and sudden stopping of the SNRI (serotonin/norepinephrine reuptake inhibitor) Effexor (venlafaxine) have been implicated.
  5. Health history (e.g., diabetes, heart disease, anxiety, depression): Depression
  6. Menstrual status (e.g., menopausal, postmenopausal, childbearing age): I am a male.
  7. Region of the U.S. or country in which you reside: London, U.K.
  8. Are you sexually active? No, not for a few years
  9. How do you experience PGAD? What are your symptoms? With an erection, which does not coincide with feelings of arousal, or without one, the extreme discomfort is the same. Symptoms have been ever-present for more than 9 years. Knocks and bumps to the penis bring on symptoms almost immediately, and sitting for more than 10 minutes can exacerbate them unbearably. Sitting in a car is impossible. Even vibrations on public transport (whether standing or sitting) cause my symptoms to erupt. Physical activity, exercise, lifting heavy things, and especially doing exercises affecting the legs and pelvis cause a terrible flare-up that may last a few days. A flare-up consists of painful feelings of physical arousal, an overwhelming feeling of penile pressure, and the desperate need to ejaculate. But no matter how many orgasms I try to knock out, the symptoms do not settle. In the absence of any treatment, I was spending every day lying down or sitting on a toilet seat, needing to masturbate more than 10 times a day—even after rubbing the skin of my penis raw—until I was so exhausted that I would fall asleep. I always wake up with the symptoms. Often in the past, the symptoms awakened me from sleep.

There is no level 0; there is never a time when I do not have some degree of symptoms and an awareness of them. Sometimes I am aware of the symptoms, but they are not yet interfering with my life. They can be soothed by massaging the area, controlling my thoughts, changing position, or getting up if I am sitting down. I can concentrate on cognitively demanding tasks and feel that I am living. My mind can host positive thoughts and things seem good and possible. I avoid sexual thoughts and images as best as I can; otherwise, my symptoms progress to the next level. Stimulating the area while in this state, experiencing knocks and bumps, and submission to a sexual image or thought can all trigger a spike in symptoms.

At the “point of no return,” I become acutely aware that the symptoms have now taken a foothold. Beyond this point, none of the measures previously discussed push the symptoms back. At this level, I experience a sudden intrusion of sexual thoughts and imagery, like a dam bursting. The symptoms begin to interfere with my life and my concentration falters. I feel the desperate need to masturbate but can still push through and get on with tasks without feeling completely incapacitated (similar to being able to read a book despite hearing noise at a nearby construction site). I can still have positive thoughts, but I become acutely aware of my limitations and hope begins to diminish.

At the next level, pain has begun to interfere with my concentration and physical integrity. I cannot concentrate. I feel I can’t be comfortable anywhere, even though the most relatively comfortable position is lying down. I begin to suffer a great deal and become depressed, upset, and terribly frustrated. I cannot perform physically or cognitively demanding tasks such as study or reading academic material. Even watching television or doing light reading is not possible.

At this point, arousal has blurred into pain. It is the only way it can be described. My penis and buttocks, as well as the perineal area, are “angry.” Every moment is hell. I feel as if a single hour is stretched to the limit. I want to die. I feel things would be better if I were dead and then it would all be over. My mind is hostile to any feelings of hope or positive thoughts. The future seems bleak, and I feel as though I will never be able to achieve anything I had planned.

All of this takes place within the space of 4 hours. To reset this clock, I need to masturbate for another 2-3 hours.

  1. How bothersome are your symptoms? They have utterly destroyed me.
  2. How do your symptoms of PGAD affect your daily living? I wake up to the symptoms. Before I can eat, shower, or do anything, I must begin the process of relieving myself. On the days I work, or have an appointment, I must get up at the crack of dawn to begin the masturbation process that will give me the relief I need to go out into the world for a few hours. I am terrified of being out of the house too long. Long trips, particularly on the public transport in London, are excruciating. By the time I get home, I need to masturbate again. It has consumed my life. It obscures my thoughts, my personality, my very being. I live in a world of painful white noise, punctuated only by short periods of peace into which I must fit my entire life.
  3. How has PGAD affected your intimate relationships? I can’t have intimate relationships. I can’t concentrate on a date, or a day out, or just the nonsexual aspects of intimacy, which I usually love, until I have had some kind of relief. I would need to relieve myself before meeting my partner so that I could focus just on her. When we did have sex, once was never enough. When we would usually be “done,” my nightmare was just beginning. The first orgasm would actually make it worse. I would then need to lie there masturbating at least one or two more times before I felt normal, which never looks good. PGAD has poisoned my intimate relationships. In my most recent one, by the end of it, she had become just an object, and I felt I was losing myself in the act. I do not think I will have another intimate relationship until I’m sure I can interact meaningfully with another human being.
  4. How do you cope with PGAD symptoms (e.g., ice, rest, masturbation)? I need to masturbate for hours every day. It is the only way to have any productivity or some semblance of a quality of life. I have had to learn to masturbate with my left arm, because when I had to use my right arm, it would become a dead weight from the exertion to the point that I could not even write with it afterwards. I have to spend a lot of time in my room, lying down and resting. Ice or ice cold water is also an essential part of my routine.
  5. Which medical therapies have you found effective to manage symptoms? Lyrica (pregabalin) is my life. Without 600 mg a day, I know I would be dead. Gabapentin has been prescribed in conjunction with pregabalin and makes a marginal difference on top of it. Amitriptyline in conjunction with the above is also indispensable. Fluoxetine helped for a while but lost its efficacy. Pudendal nerve injections and a hypogastric plexus block, as well as a ganglion of impar block, have all failed or made matters worse. Many more treatments have failed.
  1. What do you want healthcare providers to know about your experience with PGAD? I do not like this. I can never learn to enjoy it. I am not a sex addict. It has nothing to do with sex. The worse PGAD is, the less sex you have. It is more painful than the most painful mainstream condition you can imagine. I want to be taken seriously. I do not want to be treated like an addict. I am not seeking drugs. I just want this unrelenting pain to stop.

NPWH 2016 Conference Abstracts

nurse practitioner womens healthcare journal new orleansThis issue of Women’s Healthcare: A Clinical Journal for NPs features abstracts presented at the 19th annual NPWH conference in New Orleans in October 2016. These abstracts include those of the podium presenters and that of the first-place poster award winner. My heartiest congratulations to all! Each year, the NPWH conference is enriched by these podium presentations and the poster sessions. Please take time to review the abstracts that provide state-of-the-science information about women’s health, and please consider submitting your work for 2018!

Lorraine Byrnes, PhD, CNM, FNP-BC, PMHNP-BC, FAANP
2016 NPWH Research Committee Chair Continue reading »

BRCA and beyond: The contribution of genetics to breast and gynecologic cancers (Part 1) 

BRCA and beyond: The contribution of genetics to breast and gynecologic cancers (Part 1)Faculty
Kate McReynolds, APRN, MSc, MSN, ANP-BC, AGN-BC, is a Genetic Nurse Practitioner at Vanderbilt University Medical Center in Nashville, Tennessee.

Intended audience
This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners who provide care for women in any age bracket.

CE approval period
Now through September 30, 2018 Continue reading »

Laparoscopic vs. Robotic Surgery for Endometriosis

Outcomes can be equally good with either procedure

Contrary to the common expectation that robotic assistance can improve the outcomes of endometriosis surgery, a study found no evidence it is either superior or inferior to traditional laparoscopic technique.

“Both robotic and laparoscopic surgery improve quality of life and relieve pain when the procedures are done by experts in endometriosis,” says Tommaso Falcone, MD, Chairman, Ob/Gyn & Women’s Health Institute at Cleveland Clinic.

This conclusion is the result of a multicenter, randomized clinical trial comparing the use of traditional laparoscopic surgery with robot assisted surgery in women with endometriosis. The primary outcome was operative time. Secondary outcomes included perioperative complications and quality of life. Continue reading »

A PCP’s Guide to Managing Patients at Genetic Risk of Breast Cancer

Hereditary syndromes that increase the risk of breast cancer are not common, but it is critical to recognize and manage them appropriately. This paper reviews the management of patients with the most common hereditary breast cancer syndromes, ie, hereditary breast and ovarian cancer syndrome, hereditary diffuse gastric cancer, Cowden syndrome (PTEN hamartoma tumor syndrome), Peutz-Jeghers syndrome, and Li-Fraumeni syndrome. Continue reading »

Scientists Seek People with Primary Progressive MS and Other Forms of MS to Study Gut Bacteria

Investigators at the University of California in San Francisco are recruiting people with MS for an international study of the gut microbiome – the population of bacteria in the gut – in MS. They are seeking people with primary progressive MS nationwide (there is no need for onsite visits), as well as people with any other type of MS who can make a one-time visit to San Francisco, New York, Boston or Pittsburgh. The overall purpose of these studies is to investigate the potential role of gut bacteria in MS.

Scientists Focus on Gut Flora for Future Treatments of Autoimmune Diseases

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Vaginal Microbiome in Gynaecological Cancer

The vaginal microbiome is comprised of a plethora of bacterial species (ranging from 20 to 140), with the most abundant representation by Lactobacillus species. Next generation sequencing and other modern methods have been used to characterize healthy vaginal microbiome and discern between different “healthy” profiles that keep vaginal homeostasis in check. Continue reading »

Cervical Biopsy more efficient, less painful via new method

Physicians evaluate new device to test for cervical cancer. Comparison of Tissue Yield Using Frictional Fabric Brush Versus Sharp Curettage For Endocervical Curettage.

Women undergoing cervical biopsies might have lower odds of repeat tests with a rotating fabric brush than a sharp instrument because the soft device may capture more cells for analysis, a recent study suggests. Furthermore, biopsies with the softer tool may be less painful, researchers say. Cervical biopsies sometimes fail to collect enough cells from the cervix to accurately test for cancer, in which case another biopsy is needed. Continue reading »

The pelvic health and wellness program: A niche clinical entity

In today’s healthcare climate, women’s health nurse practitioners (WHNPs) and other NPs providing healthcare for women are in a unique position, as front-line providers, to develop and implement a comprehensive, conservative, community-based pelvic health and wellness program (PHWP) within their chosen practice settings. The PHWP provides screening, assessment, and management of pelvic floor disorders (Table 1). These disorders include urinary incontinence (UI), overactive bladder (OAB), pelvic organ prolapse, chronic pelvic pain, and sexual dysfunction.1 The PHWP, an innovative, nontraditional, niche offering, can provide a much-needed clinical service in the community, broaden and enhance an NP’s own practice potential, and create a sound business venture to increase practice revenue. This program is a win-win situation because, with proper diagnosis and treatment, more than 90% of women with bladder or pelvic disorders can experience great improvement or a remission of their symptoms.

The healthcare landscape

The time is right; the need is now! Demographic trends are changing the nature of the healthcare landscape. Although overtaken by the Millennials in population, the number of Baby Boomers (persons born between 1946 and 1964) who are entering the 65+ age group is still increasing; the nation’s 65-and-older population grew from 44.7 million in 2013 to 46.2 million in 2014.2 Although people are living longer than ever before, many of them spend the extra years coping with the burden of chronic conditions such as diabetes and UI.3 However, many active women of today will not settle for wearing diapers or pads as the solution to their bladder problems, and will proactively seek help.4 And many Millennials want to make sure that they won’t suffer the consequences of poor pelvic health that their mothers and grandmothers endured. Prenatal and postpartum programs to restore the pelvic floor muscles (PFMs) are both part of the larger PHWP.

Although many women seek professional care for bladder and pelvic problems, others are too afraid, ashamed, or embarrassed to do so. They feel that they have no place to go, and no one to turn to for help. Instead, they sit at home wearing diapers or pads. They fear that the only treatment is surgery and are unaware that conservative measures are available. But if their healthcare provider’s office offered a PHWP, they could avail themselves of the evaluation and treatment they need. That’s where you come into the picture.

Two models: Intrapreneur and entrepreneur

A PHWP can be developed via an intrapreneurial or an entrepreneurial approach. Intrapreneurial NPs, on their own initiative, approach the physicians/partners in the practice with the idea of establishing a PHWP and outline a plan that would transform the idea into a worthy and profitable undertaking. If the physicians/partners approve the plan, then they take responsibility for providing financial and administrative support for the program’s implementation.5 In these situations, the NPs become the program’s managers and take full responsibility  for implementing all facets of it.

This packaging of existing services into a focused  PHWP enhances overall care. Because of the downstream effect of the presence of the PWHP, the general patient base of the practice will likely increase. The woman with UI who is sitting at home with a pad will see that she is not alone, that she has a place to go, and that she has a provider who can address her  problem. Another plus for the practice is that the PWHP provides an internal surgical referral base for patients who prefer the option of surgery over more conservative approaches. Establishment of a PHWP enables the practice to promote the new program, burnishing the favorable image of the practice and increasing its visibility within the community. As I said, it’s a win-win for everyone.

Entrepreneurs, in contrast to intrapreneurs, not only conceive the innovative ideas surrounding the development and establishment of a PWHP, but they also organize, operate, finance, and assume the ris for the new business venture on their own, working outside an existing organizational structure.6 Entrepreneurship is hard work, but well worth the effort, for individuals with an adventurous spirit and the personal and professional resources to support it. An entrepreneurial independent practice requires more financial resources and time and has more potential risks than does the intrapreneurial model, but it also offers greater potential rewards.

Engaging in an intrapreneurial or entrepreneurial enterprise is not for everyone. As with any business venture, NPs must perform the necessary analysis to determine whether this pursuit is right for them. Table 2 lists potential reimbursements from women who progress through the PHWP, as well as costs associated with setting up a PHWP. The start-up costs are relatively low compared with the dramatically higher practice revenue.7 Understanding the basics of coding is essential to both models.8 Medicare and most insurance companies reimburse for assessments, treatments, and procedures done in a PHWP. ICD-10 changes have had little effect on these billing practices. However, NPs need to learn how to get reimbursed and how to maximize those reimbursements, as well as learn what it takes to operate a business and write grants for startup costs. And they will need to develop and establish a patient base and referral sources—the keys to success.

A PHWP can be established in settings other than offices and clinics. For example, intrapreneurial NPs who work in nursing homes or extended-care facilities can pursuethis goal as well.

Strategic enhancements

Whether NPs choose an intrapreneurial or an entrepreneurial approach, they will find that a PHWP can:

Dramatically increase practice revenue. For example, the program can generate $1,000-$2,500 for each patient who progresses through the program (6-8 visits) and gross $100,000-$250,000 a year per 100 patients (not including advanced procedures/testing such as pessary insertion or urodynamic testing);

Recapture monies lost from Medicare cutbacks by offering a program that is procedurally base with a history of proven reimbursement from Medicare;

Provide a lucrative service line to meet the pelvic health needs of women throughout the lifespan, but particularly of the emerging Baby Boomer generation;

Be current and competitive by offering a PHWP;

Package resources and enhance and merge existing

service lines to create a structured, step-bystep program of pelvic healthcare;

Increase utilization of existing resources such as ultrasonography, bladder scans, and laboratory services;

Provide a portal to other services that the practice may offer;

Establish a niche as the premier source of conservative pelvic healthcare in your area;

Increase the practice’s surgical referral base by recruiting women through the conservative arm who decide on a surgical alternative;

Enhance quality of life for women experiencing pelvic dysfunction; and

Enhance marketing opportunities and increase visibility and viability of your practice by offering an exciting new program that can be promoted in the community.7


Timing is everything. The Affordable Care Act provides two billable opportunities for the integration of pelvic health assessment into a pelvic health practice in the form of preventive teaching and a comprehensive screen. These opportunities are the annual wellness visit under Medicare and the well-woman visit for all other women.

For the first time, two major physician organizations have recommended that first-line therapies for UI and OAB be conservative rather than surgical. The American College of Physicians recommends education, pelvic floor exercises, timed voiding, and fluid managment for UI.9 The American Urological Association offers similar guidelines for OAB.10 These recommendations are well within the scope of practice for NPs.


At the Health & Continence Institute (HCI), gross revenue is $1,000-$2,500 as each woman progresses through the program. This revenue range does not include fees for pessary insertion. An important aspect is that NPs would be recruiting patients not for just a single visit but, rather, for entry into the PHWP, where they would remain for a series of 6-8 visits over 3-4 months. Startup costs are covered after 4-6 patients complete the program.

When you consider the return on investment, startup costs are strikingly low. These costs depend on the type of model you pursue. Intrapreneurs can easily insert their program into the daily routine of their home office. Only one room is needed for 2-3 days a week. Entrepreneurs have the added challenge of setting up a new office and purchasing equipment and supplies.11 Grants for this purpose are available from organizations such as The Simon Foundation for Continence and The National Associationfor Incontinence. Adding only two new patients a week to the program can lead to gross revenue of $100,000-$250,000. But the best news is that the conservative measures implemented in a PHWP greatly enhance quality of life for women who previously had few options.


The number of women who have pelvic health problems will only increase as Baby Boomers age.12 Pelvic health conditions have been neglected for years, even though they comprise 2 of the 10 most common chronic conditions in U.S. women—OAB and UI.13 These two conditions affect a higher percentage of persons of all age groups than do hypertension, depression, and diabetes.13WHNPs and other NPs caring for women are well positioned to champion, initiate, and implement a PHWP within a practice setting as intrapreneurs or entrepreneurs. An NP entrepreneur is no longer an oxymoron! In fact, it is somewhat surprising that there has not been a groundswell of practitioners wanting to provide this niche clinical service. A large part of the problem may be that practitioners have nowhere to turn to for practical advice or training for themselves!

On a more personal level, many NPs have reached out to the HCI to share that, at this point in their careers, they are seeking new challenges and causes to champion. Many of them are also looking for potential opportunities and ways to meet the needs of women with pelvic health concerns who do not know where to turn. Even more NPs are looking for ways to provide a niche service that is also financially advantageous for them.

Whether readers want to proceed as intrapreneurs or entrepreneurs, they are about to embark on an exciting, rewarding, and lucrative career opportunity. Good luck! =

Helen A. Carcio is founder and director of the Health & Continence Institute, where she independently manages her pelvic health center in Deerfield, Massachusetts. Readers can contact her at the HCI website. She was an Associate Professor at the University of Massachusetts at Amherst in the nurse practitioner program. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn.

Sexuality in the aging population: Q&A from a certified sex therapist

The author of the second part of this 2-part series on sexuality in the aging population is a Certified Clinical Specialist in Psychiatric/Mental Health Nursing and an AASECT-Certified Diplomate of  Sex Therapy. She shares her clinical expertise on  this topic in a Q&A format. Readers can access the first part of the series here.

1. What do you see as the biggest myths about sexuality in the over-50 population?

The first myth is that couples are no longer interested in sex after they reach the half-century mark. The second myth is that men lose the ability to have erections, and the third is that women do not enjoy sex after 50. Here are the facts. Although some couples do put sex on the back burner after childrearing ends, others find that with that empty nest comes the opportunity for more sexual playfulness and less worry about being discovered by others in the home. Men do experience changes in erectile function as they age, but, even into their 70s, only about a third of men regularly have difficulty getting and keeping erections. Many women find they become more adventuresome and finally have the time to discover their own sexual potential after age 50. The biggest risk to good sex in later life is boredom.

2. How does sexuality change for women during the postmenopausal years?

The body’s sexual signals change as women age. Whereas younger women become lubricated as one of the signs of sexual arousal, older women do not get as wet. If women have not learned to notice other arousal signs, they may think that they are not turned on. A lot depends on whether a woman has had a surgically induced menopause and whether she is able to take replacement estrogen. Without hormonal support, vaginal tissue becomes thin and dry, causing vaginal containment (of a penis, a finger, a tongue, a dildo, or the like) to be painful. To ameliorate the situation, many older women find they enjoy using lubricating oils such as coconut oil as a part of their sexual warmup. Some women may also need to use a vaginal moisturizer if penetration is uncomfortable.

3. Which techniques do you advise older couples to incorporate into their sexual repertoire?

I coined the phrase true oral sex to describe the absolute need for couples to communicate with their mouths and not just with their bodies. This practice is especially true for older couples, whether in long-term relationships or in newer ones. In addition, the sexual experience during later years requires a true hands-on approach. The body’s biological system is not going to be activated just by thoughts and hormones now—t must be physically coaxed. And both partners need to make sure that they are breathing—holding one’s breath is the biggest single reason most women at any age do not get sexually aroused.

4. How did your practice change after the FDA approved Viagra in the late 90s?

I had practiced for two decades before erectile dysfunction (ED) medications were approved by the FDA. I have found these agents to be a huge boost to what I could offer to men because they are actual treatments for the physical problems men experience. The downside was that although many men gained benefits from Viagra, their spouse or partner was not necessarily interested in resuming sexual activity. So, negotiations needed to take place—prompting an even greater need for true oral sex.

5. Is there an age when many women stop having sex?

Studies have shown that women stop having sex when they can no longer find interesting partners. For some women, this situation may occur when they are in their 50s and for others, this situation never occurs. Is there an age when women should stop having sex? Unless there are medical contraindications, a woman can have sex as long as she wants to do so.

6. What barriers prevent intercourse in the older couple?

Declining or compromised state of health of one or both partners is the greatest risk to good sexual health. However, even if one or both partners have minor or major health problems, many older couples find that, even without intercourse, they can enjoy many other sexual activities—what I call outercourse. Outercourse encompasses all sexual activities other than penis-invagina intercourse, including finger, tongue, and/or vibrator  stimulation of the clitoris, for instance, as well as cuddling and caressing of any and all body parts.

7. How can couples maintain their sexuality if intercourse (or vaginal penetration of any kind) is not an option?

Sexuality is a state of both feeling and being sexual. Couples who maintain their sexual vitality for a long time share traits of having fun, being open minded, and flirting and “dating” even if they are a long-time couple. Such couples take the time to touch and caress each other, even if not for sexual warm-up per se. Many couples find that after 20 minutes of non-sexual caressing, they begin to feel sexual yearnings. Couples who experiment with direct stimulation of a flaccid penis, with or without assistance of an ED medication, sometimes find that this “wakes up” the nerves and helps start an erection, which can then lead to some form of sexplay. Many couples do not have intercourse or even orgasm as a goal, as might have been the case earlier in their lives, but find great satisfaction in exploring other options.

8. Which resources do you recommend for older women seeking answers to their questions about sexual dysfunction?

These women should get the best help available regarding their state of physical and sexual health, including advice on hormone replacement, urinary incontinence, and pelvic floor evaluation. They should read age-related materials about sexuality. My book, Assisted Loving: The Journey through Sexuality and Aging, is written in question-and-answer format. The book addresses actual concerns expressed by my readers over the 6 years during which I wrote a column on the topic.

9. How do you counsel postmenopausal women who are entering into a new romantic relationship?

Most older women have had lots of life experiences and have developed common sense about keeping themselves safe, but romance can throw all that knowledge out the door. I suggest that these women move forward using their heads and their intuition—f something doesn’t feel quite right, don’t go there. If they are using an online dating service, for example, they should have several people they trust in the loop so they don’t take unnecessary chances. Until they are 100% sure of a partner’s sexual history, they should not trust that the potential mate does not have a sexually transmitted infection. If the partner is a male, they should insist that he use a condom. These women should also get checkups themselves and tell their healthcare provider that they are beginning a new sexual relationship. They should also be encouraged to enjoy the experience! =

Ginger T. Manley is a Certified Clinical Specialist in Psychiatric/Mental Health Nursing and an AASECTCertified Diplomate of Sex Therapy. She retired in 2015 from her faculty position as Associate in Psychiatry, Division of Addictive Medicine, at Vanderbilt Medical School in Nashville, Tennessee. Her website is The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


Message from the CEO

I am proud to say that, with this November 2015 issue, Women’s Healthcare: A Clinical Journal for NPs, is turning 2 years old! When we introduced the journal 2 years ago, we provided quarterly online issues. Now, as an added benefit, we provide our active NPWH members with both the electronic version and a complimentary print copy of each issue.

Since Women’s Healthcare began, we have added more departments such as On the case…, DNP projects: Spotlight on practice, Focus on sexual health, and Commentary. We have always offered one continuing education (CE) article per issue, along with two or three additional feature articles. Our goals for the future are to continue offering these articles and departments, to increase the number of issues per year, and to add more case studies, scientific studies, and clinical updates.

Our journal continues to grow, and is fast becoming a highly valuable asset to nurse practitioners (NPs) caring for women. The open rate – that is, the proportion of people on an email list who open (or view) a given email – for each issue of Women’s Healthcare is rising, and averages more than 30%. To put this statistic in perspective, the industry gold standard is an open rate of 20%. Even more stats support what our readers are discovering with respect to our journal’s content:

• 75% find the information in the journal “useful” to “very useful”;

• 83% engage in the journal’s CE articles;

• 58% utilize the journal’s “How to” and Case study articles;

• 54% find the journal’s research news useful; and

• 50% utilize the journal’s Clinical resources department.

NPWH takes great pride in providing a variety of tools that promote high-quality, evidence-based women’s healthcare. With regard to our 2-year-old journal, our goal moving forward is to ensure that all advanced practice nurses caring for women recognize Women’s Healthcare as the specialty go-to journal for expert women’s health content.

I want to mention a few of NPWH’s other accomplishments in 2015:

NPWH celebrated its 35th anniversary this year, a milestone marked at our 18th Annual NPWH PremierWomen’s Healthcare Conference in Salt Lake City, Utah, in October.

The 2nd Annual Women’s Sexual Health Course for NPs was a great success this year; we sold out of space! We are increasing the number of registrations next year to enable more NPs to participate. Save the Date: June 23-26, 2016.

We added a new component to our mobile app, a women’s cardiovascular health preventative screening tool, which we launched at our annual conference in October.

NPWH proudly welcomed our second class of Student Reporters to participate in our annual conference.

We partnered with Bedsider to provide grants to six clinical sites to measure and improve contraceptive practices for women aged 17-29.

Stay tuned for more CE opportunities, toolkits, and programs for NPs. Our main objective is to continue to provide more services and support for our members. We invite those of you who are not yet members to join NPWHA! And we thank all of you who supported our organization this year. All of us look forward to a wonderful 2016!

– Gay Johnson

Chief Executive Officer, NPWH



Editor-in-chief’s message

Dear Colleagues,

Are you looking for a challenging but rewarding opportunity to participate in enhancing advanced practice nursing (APN) knowledge? If the answer is yes, I hope you will consider becoming a peer reviewer for our journal. Here are some answers to frequently asked questions.

What is the role of a peer reviewer?

Peer reviewers are important consultants to journal editors and authors. Their major role may be content expert, practice expert, or research methodology expert, although one peer reviewer need not fill all these roles. We match the skills of a peer reviewer with the needs of a given manuscript. When a manuscript has a clinical focus, we try to choose reviewers with expertise in the content or practice area covered in the manuscript. When we receive a qualitative or quantitative research manuscript, we try to choose reviewers who have expertise in that research methodology.

Most important, we strive to identify and maintain a strong cadre of thoughtful and thorough reviewers who are willing to provide truthful and constructive critiques. Diversity among our peer reviewers is also important; we are looking for reviewers who vary in terms  of their role (academic or clinical practice), years of experience,  areas of expertise, and populations served.

What is in it for me?

APNs in the academic world reap the benefits of adding peer reviewer contributions to their CVs and promotion documents. Novice authors may find the process of doing peer reviews helpful in improving the quality of their own writing. Seasoned authors may enjoy fostering the professional growth of novice authors through constructive peer reviews that identify both the positive features of a manuscript and the areas that need improvement. All peer reviewers can take satisfaction in knowing that they are contributing to the APN profession by supporting the publication of high-quality, relevant, evidence-based articles that can help their colleagues provide the best possible care for their patients.

What happens when I receive a manuscript for review?

First, you will receive a request from us that informs you of the topic of the manuscript and our turnaround time (3-4 weeks). This information will help you decide whether you are interested and whether you have time to do the review. (If, after making the commitment, you find that you need a small extension, we are almost always able to grant it.) Next, if you accept our offer, we will send you the blinded manuscript with a peer reviewer evaluation form. The entire review process is completed electronically and takes about 4 hours.

The peer reviewer evaluation form includes a list of questions about the content and about your general impression regarding whether the manuscript merits publication in our journal. You can provide comments and suggestions on the evaluation form, but we encourage you to make them right on the manuscript.

We do not ask you to correct grammar or spelling errors;  in many, if not most, cases, we will have edited the  manuscript before we send it to you. We do ask that you  read the manuscript to determine whether the information is accurate, supported by evidence, relevant, and clearly presented, and to make suggestions for improvement. We also ask you to check the references for timeliness and appropriateness and to identify any important resources that might be missing. For research manuscripts, we ask for a thorough review of methodology.

How can I learn to do a good peer review?

At your request, Dory Greene, our managing editor, and I would be happy to provide feedback on your review. Even for novices, though, if your review is thoughtful, thorough, and truthful, it will be useful and very much appreciated.

How do I sign up to be a peer reviewer?

Click Here! I hope to hear from you soon!

Beth Kelsey, EdD, APRN, WHNP-BC


Formation of a peer review group for advanced practice nurses: Learning from and with colleagues

In 1996, Dr. Els Borst, former Minister of Health of the Netherlands, proposed that specially trained master’s-prepared nurses assume certain tasks of physicians in order to help meet the growing need for healthcare in the midst of a physician shortage. In light of the increased number of elderly and chronically ill patients today, this need is even more pressing.1  The consequence of Dr. Borst’s proposal was the inauguration of the first Master’s in Advanced Nursing Practice (MANP) program in Groningen, the Netherlands, at the Hanze University of Applied Sciences in 1997.

Since that time, the training and the work accountability of advanced practice nurses (APNs) in the Netherlands have been extended. A major change occurred in March 2009, when Dutch APNs were granted official registration numbers and legal title protection. Nurses can be registered as APNs only after earning a master’s degree from a certified university and undergoing training on the job at a certified healthcare institute with a certified medical and nursing trainer.

Dutch APNs can be registered in one of five nursing specialties: (1) acute care in somatic disorders, (2) intensive care in somatic disorders, (3) chronic care in somatic disorders, (4) preventive care in somatic disorders and (5) mental health. Like physicians, APNs must attend conferences offering staff development workshops and be actively employed for at least 24 hours a week. In 2014, more than 2,500 APNs were registered in the Netherlands.2

After initial registration, APNs must re-register every 5 years to maintain an active license. Since 2010, one of the requisites for re-registration has been participation in peer review (PR). Guidelines of the Dutch Nursing Specialty Registration Board (DNSRB) require APNs to participate in a PR group (PRG) for at least 40 hours per 5-year period.3 In addition, to ensure competence and continuous professional development, periodic self-appraisal and peer feedback must be in place for all levels of nursing.4 

Defining peer review

Peer review is a systematic process by which one assesses, monitors, and makes judgments about the quality of care provided to patients by others, as measured against established standards of practice. 5,6 Nursing PR is an evaluation of one’s professional nursing practice, including identification of opportunities to improve care, by persons with the appropriate expertise to perform the evaluation.7 Because they undergo PR, APNs are a group of healthcare providers (HCPs) whose personal competencies in various nursing specialties are compared— with those of other APNs and with objective criteria—with the aim of improving daily practice.3  PR, recognized as a measure of accountability and a means to evaluate and improve practice,4  enhances development of the APN profession and improves the quality of patient care.

Peer review has multiple benefits for APNs. It facilitates an open and safe learning environment. It provides APNs with an opportunity to reflect on questions and problems together. Because of the interactive setting, APNs invariably learn something new.8PR even offers APNs a break in an otherwise hectic workday. PR can help APNs evaluate the quality of care they have delivered, and gain insight into their greatest strengths and weaknesses as HCPs. With feedback and recommendations from the group, APNs can gain new knowledge and improve their skills.

Creating and working as a PRG

Because the APN profession is relatively new in the Netherlands, the nursing education department of the Erasmus Medical Center Rotterdam had no experience in starting or structuring a PRG. Five years ago, five pioneering APNs working on an internal medicine unit decided to create such a PRG. These APNs found several examples of PRGs in the literature and took the initiative in creating a framework, based on non-empirical research, that took into account the criteria requisites of the DNSRB.

To initiate an effective PRG, some basic steps are essential. The first step is to form a group of 3-5 APNs in the same specialty who have similar interests within their specialty. The next step is to elect a chair to serve a 1-year term. The chair then makes a yearly schedule so that members can plan to attend all PRG meetings. To meet the criterion of spending 40 hours in the PRG over 5 years, the group must meet for about 2 hours every 3 months.

At each meeting, members take turns serving as the contributor, who presents a case related to her work field. One week before the meeting, the contributor sends a recap of the case—along with corresponding literature, protocols, and guidelines—to PRG members so that they can read background material and analyze the case. Each case submitted for PR must have these elements:

• The patient’s presenting complaint, personal and family health history, and physical examination findings;

• An analysis of the case, with corresponding literature or guidelines to clarify or substantiate the diagnosis or the problem;

• A list of dilemmas that can occur or that did occur with the presented case, as well as learning points, and

• Learning objectives extracted from the presented case for discussion.

At the meeting, the contributor uses PowerPoint to present the case and then leads the discussion regarding dilemmas and learning goals. A member who is appointed secretary for each meeting takes notes and creates a report of the thoughts an views exchanged during the meeting. The report includes a summary of the case, the learning goals of the contributor, and feedback/recommendations from the group. After the meeting, the report is sent to the PRG members. Reports of PRG meetings are saved in a digital portfolio.

At the next PRG meeting, notes of the previous meeting are discussed. The chair asks the previous contributor whether she used feedback from the last PRG meeting and applied it to her practice. The process gives the contributor an opportunity to reflect on her own goals and improve the quality of her work.

Choosing the best method to present a case

Within the first year of the PRG’s existence, all five members had submitted a case. The group then met to determine the best format for presenting a case. The PRG considered three options: the testing method, the Balint method, and the research method. These methods were evaluated in terms of whether they enhanced the professionalism  the APN through the sharing of knowledge, expertise, and thoughts. The group was most satisfied with the testing method, which is particularly suitable for case study discussion and for evaluation of clinical guidelines and protocols. With this method, the group works together, sharing ideas and coming to an agreement on how practice can be improved. One downside of the testing method is that the personal learning goals of the APN are not included.

Gaining competencies

In the Netherlands, the focus of learning is to gain competencies. A framework used for the competency- based approach is that of the Canadian Medical Education Directives for Specialists (CanMEDS) (Figure).9 The CanMEDS framework describes seven different roles of an HCP: professional, communicator, collaborator, manager, health advocate, scholar, and, in the center, medical expert. APNs who have gained the first six competencies can become medical experts (the center of the honeycomb), but they cannot become medical experts if they fail to gain one of the six competencies surrounding the central competency. APNs need to enhance themselves in all seven competencies in order to become better HCPs.

Achieving the best practice

A combined framework using both the testing method and the CanMEDS framework was determined to be the best practice. This combined framework was deemed to be the best way to prepare a case for discussion and to give the PRG and the contributor the clearest insight into the question and learning issues provided by the case. The testing method is an ideal way to discuss problems or questions regarding certain procedures and guidelines within the safe confines of a group. In addition, each group member can impart information and share expertise via the group discussions, which can then be absorbed by the other members and translated into their own practices.


The PRG found that, over a 4-year period, a combined approach—the testing method and the CanMEDS framework—constituted the best practice for structuring a case for discussion and determining the contributor’s own learning issues. The DNSRB also recommends use of CanMEDS competencies in this regard. If the combined framework does not work well for a given PRG, it may be related to poor group dynamics, lack of a safe environment, or a tendency for members discussing a case to highlight their feelings rather than their own practice. Some PRG members indicated that they sometimes felt vulnerable. It take courage to learn from colleagues. According to Karas-Irwin and Hoffmann,4 a caring environment imbued with genuine respect enhances PRG interactions. By participating in a PRG, APNs in the Netherlands not only meet the needs and criteria of the DNSRB, but also enhance their professional skills and build their knowledge base.

Implications for APNs in the United States

Although there is no specific requirement to participate in PR as part of APN licensure in the United States, PR is recognized as an important component of practice and professional responsibility. 10,11 The opportunity to come together as a small group of APNs with similar clinical practices and interests on a regular basis to review challenging cases provides a collegial environment for learning from each other. Peer assessments can play an important role in enhancing quality of care for complex patients with multiple interrelated chronic conditions, especially as seen in the U.S. with its aging population and the increasing prevalence of obesity and its co-morbidities. =

Simone J. van der Linden is an APN in the Department of Hematology, Cancer Institute; Leni van Doorn is an APN in the Department of Medical Oncology, Cancer Institute; Judith P. van Eck is an APN in the Department of Medicine, Section of Endocrinology; Wanda Geilvoet is an APN in the Department of Medicine, Section of Endocrinology; and Greta Mulders is an APN in the Department of Hematology, all at Erasmus Medical Centre, Rotterdam, The Netherlands. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.


The authors thank L. Maas, RN, MS, Rotterdam University, Master’s in Advanced Nursing Practice Program, Rotterdam, the Netherlands.


  1. Statistics Netherlands. Dutch population expected to reach 17.5 million in 2038.
  2. Dutch Nursing Association.  2013.
  3.  Dutch Nursing Specialty Registration Board. Intercollegiale Toetsing Verpleegkundig Specialisten. 2010.

  4. Karas-Irwin BS, Hoffmann RL. Facing the facts: in-person peer review. Nurs Manage. 2014;45(11):14-17.
  5.  Sherwood GD, Brown M, Fay V, Wardell D. Defining nurse practitioner scope of practice: expanding primary care services. Internet J Adv Nurs Pract. 1997;1(2).

  6. Smith MA, Atherly AJ, Kane RL, Pacala JT. Peer review of the quality of care. Reliability and sources of variability for outcome and process assessments. JAMA. 1997;278(19):1573-1578.

  7.  Spiva LA, Jarrell N, Baio P. The power of nursing peer review. J Nurs Adm. 2014;44(11):586-590.

  8. de Haan E. Leren met Collega’s.  Uitgeverij Van Gorcum;2009.
  9.  Frank JR, Jabbour M, Fréchette D, et al. Report of the CanMEDS Phase IV Working Groups. Ottawa, Canada:The Royal College of Physicians and Surgeons of Canada;2005.
  10. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies. 2012.

  11. National Association of Nurse Practitioners in Women’s Health/Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.


Lung cancer screening: Low-dose computed tomography

In the United States this year, more than 200,000 individuals will be diagnosed with lung cancer and close to 160,000 individuals will die of lung cancer. Women represent half of both of these numbers. More than 50% of lung cancers will have distant metastasis at the time of diagnosis. The 5-year survival rate for these individuals is less than 5%, as compared with a 58% survival rate if cancer is detected while still localized to the lung.1,2 A screening program that can detect lung cancer at an early stage—when surgery can be curative—and that is designed to minimize harms associated with screening is highly desirable.

Findings from the National Lung Screening Trial (NLST) support the use of helical low-dose computed tomography (LDCT) for lung cancer screening in individuals at high risk for lung cancer.3 The NLST was an 8-year National Cancer Institute-funded randomized controlled trial conducted from 2002 through 2009 to compare the effects of the use of LDCT versus standard chest radiography on lung cancer mortality rates in high-risk individuals.3 Participants were adults aged 55-74 years who had a 30-pack-year smoking history and currently smoked or had quit within the previous 15 years. More than 50,000 participants were screened with LDCT or chest radiography annually for 3 years. Data were collected on lung cancer occurrences and lung cancer-related deaths through 2009. The data demonstrated a 20% reduction in mortality from lung cancer among participants screened with LDCT versus those screened with chest radiography.

The U.S. Preventive Services Task Force (USPSTF) used modeling based on the NLST data to assess the potential benefits and harms of screening with LDCT for varying populations.4 In 2013, the USPSTF issued a recommendation for annual screening for lung cancer using LDCT in adults aged 55-80 years who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years.4 The American Cancer Society and the American College of Chest Physicians issued similar lung cancer screening recommendations in 2013.5,6 The only variance from the USPSTF recommendations was an upper age limit of 74 years instead of 80.

LDCT uses much less radiation than does standard CT. With LDCT, the x-ray sources follow a helical or spiral path around the patient, taking less than 1 minute to scan the entire chest. Computers create multiple thinly-sliced 2-dimensional images of the lungs from the x-ray information. Further evaluation is needed if LDCT reveals a pulmonary nodule. Nodules with low probability of cancer may be followed with repeat LDCT scans over a period of time to watch for nodule growth. Higher-dose LDCT, positron emission tomography, and biopsies are used to evaluate nodules with moderate or high probability for cancer.7,8

The USPSTF has recommended standardization of LDCT screening and follow-up of abnormal findings, as well as development of a registry to collect data needed to enable continuous improvement in screening program quality over time.4 Several organizations have recommended that lung cancer screening and follow-up be conducted as part of a structured, high-volume, high-quality program involving a multidisciplinary team skilled in evaluation and treatment of lung cancer. Such programs would use eligibility criteria consistent with USPSTF recommendations, have American College of Radiology (ACR) certification in CT, and participate in the ACR data registry program.7 In addition, these programs would include use of smoking cessation strategies and informed and shared decision making with patients before initial screening.

Benefits of lung cancer screening can be maximized and harms minimized when healthcare provider (HCPs) do the following:

  • Limit screening to persons at high risk;
  • Discontinue screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or ability to have lung surgery;
  • Use healthcare facilities that have ACR certification in CT and a multidisciplinary team with access to clinical resources to provide diagnosis, follow-up treatment, and long-term patient management related to lung cancer screening; and
  • Avoid invasive follow-up procedures in patients with nodules identified as low probability. Instead, follow with repeat LDCT scans over a period of time to watch for nodule growth.7,8

The Patient Protection and Affordable Care Act requires most health insurance plans to cover preventive services with no deductible or co-payment for the patient if the USPSTF grades the recommendation as A (strongly recommended) or B (recommended).9 Both tobacco cessation (graded A) and lung cancer screening with LDCT (graded B) would qualify for insurance coverage at no additional cost.

Medicare covers annual lung cancer screening with LDCT for beneficiaries aged 55-77 years who are asymptomatic (no signs or symptoms of lung cancer), have at least a 30-pack-year smoking history, and currently smoke or have quit smoking within the past 15 years. HCPs must document an initial lung cancer screening counseling visit that includes the following:

  • Determination of eligibility for screening;
  • Shared decision making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false-positive rate, and total radiation exposure;
  • Counseling on the importance of annual lung cancer screening; and
  • Counseling on the importance of maintaining smoking abstinence if a former smoker and smoking cessation if a current smoker; and, if appropriate, providing information about smoking cessation interventions.10

In Talking With Your Patients about Screening for Lung Cancer, the USPSTF provides discussion points using three patient scenarios: patients who fit all screening criteria; patients who are outside the screening criteria; and patients who fit all screening criteria but have a significant co-morbid condition.11 The National Comprehensive Cancer Network provides a booklet, NCCN Guidelines for Patients®: Lung Cancer Screening that can facilitate informed and shared decision making about screening.12 The Association of Health Research and Quality’s Treating Tobacco Use and Dependence: 2008 Update is a good resource on smoking cessation for HCPs.13

Annual lung cancer screening with LDCT cannot prevent cancer but can reduce lung cancer mortality through earlier diagnosis in individuals at high risk based on age and smoking history. Such screening is recommended along with continued efforts to prevent smoking and exposure to other lung cancer risk factors and to assist individuals with smoking cessation.

Beth Kelsey is Assistant Professor and DNP Program Director at the School of Nursing, Ball State University, in Muncie, Indiana. She is editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


1. National Cancer Institute. SEER Stat Fact Sheets: Lung and Bronchus Cancer. 2015.

2. American Cancer Society. Cancer Facts & Figures: 2015.

3. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.

4. U.S. Preventive Services Task Force. Lung Cancer: Screening. December 2013.

5. Wender R, Fontham ET, Barrera E Jr, et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107-117

6. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer; diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e78S-e92S.

7. Richards TB, White MC, Caraballo RS. Lung cancer screening with low-dose computed tomography for primary care providers. Prim Care. 2014;41(2):307-330.

8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening. 2015.

9. Preventive Health Services for Adults.

10. Centers for Medicare & Medicaid Services. Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). February 5, 2015.

11. U.S. Preventive Services Task Force. Talking With Your Patients About Screening for Lung Cancer. Rockville, MD: USPSTF; 2013.

12. National Comprehensive Cancer Network. NCCN Guidelines for Patients: Lung Cancer Screening. 2015.

13. Agency for Healthcare Research and Quality. Treating Tobacco Use and Dependence: 2008 Update.

Strategies for collecting the family history to assess risk for inherited cancer

Collection of a patient’s family history (FH) is an important tool for establishing her risk levels for certain inherited cancers. Time constraints and other barriers challenge the ability of healthcare providers to collect a complete and detailed FH, which can result in inadequate risk assessment. The author presents strategies to improve FH collection and documentation and briefly reviews guidelines for assessing patterns of risk for inherited cancers within the history.

Key words: family history, inherited cancer, genetic testing, breast cancer

In clinical practice, a patient’s family history (FH) helps establish patterns of risk for hereditary disease and serves as a component of the general health history. Collection of an FH that reflects three or more generations (siblings, parents, grandparents) is recommended to assess a patient’s genetic risk for hereditary cancers. In many cases, FHs are limited to information about first-degree relatives; these histories are rarely updated to reflect newly discovered disease in family members.1 Lack of availability or inadequate review of the FH is a missed opportunity for risk stratification for hereditary cancers, referral for genetic testing, and provision of recommendations for early screening and risk reduction strategies if needed.

Healthcare providers (HCPs) should take a complete FH at each patient’s annual well-woman visit and be able to recognize patterns of risk for inherited cancers. A woman’s genetic predisposition to hereditary cancer will have implications for screening, disease prevention, and treatment options.2 The purpose of this article is to improve the quality of FH documentation by presenting strategies to streamline collection of FH information and to review guidelines for assessing patterns of risk for inherited cancers—specifically breast cancer, reproductive cancers, and colon cancer—within the history.

Inherited genetic mutations that increase cancer risk

Although generally recognized as a risk factor for breast cancer, a mutation of breast cancer gene 1 or 2 (BRCA 1/2) imparts substantial risk for the development of other cancers as well. A mutation in BRCA 1/2 disables the ability of the gene to affect cellular repair of damaged DNA, a condition particularly associated with breast, ovarian, prostate, and pancreatic cancers.3 The pattern of inheritance is autosomal-dominant; inheritance of the BRCA 1/2 mutation may arise from either the maternal or the paternal side of the family. Women who carry a mutation on BRCA 1/2 have a 40%-80% risk of developing breast cancer and a 11%-40% risk of developing ovarian cancer in their lifetime.4 Mutations on other genes (TP53, PTEN, STK11) have been linked to high risk for breast cancer in young women, but these mutations are less common.5

Lynch syndrome (hereditary nonpolyposis colon cancer [HNPCC]), another autosomal-dominant genetic condition, places individuals at high risk for cancer by inactivating the DNA repair function coded by MSH2, a DNA mismatch repair protein, or by the gene MLH1.6 Women with Lynch syndrome have lifetime risks of 40%-60% of developing endometrial cancer and of 4%-12% of developing ovarian cancer.7,8 Women and men with this genetic condition have an 80% lifetime risk of developing colon cancer.9

Importance and implications of the family history review

For young women with no personal history of cancer (unaffected women), an FH review is an opportunity to provide anticipatory guidance. When an FH may indicate an inherited cancer, testing for the suspected genetic mutation in the affected family member(s) is recommended. Once a particular genetic mutation is identified in the family member(s), other members can be offered early screening and specific testing for the mutation.5 Early awareness is important; women who test positive for a genetic mutation that imparts cancer risk should be counseled about early screening and consideration of preventive options.

For example, emerging data have associated the BRCA1 mutation with the development of cancers caused by the deleterious effect of estrogen metabolites on DNA synthesis. This link is noteworthy in that medications that decrease or halt estrogen production (e.g., luteinizing hormone-releasing agonists) could be offered as a preventive option against breast cancer for some women.10 Studies evaluating the effectiveness of aromatase inhibitors and selective estrogen receptor modulators for cancer prevention in these groups are under way. New evidence suggests that women with BRCA1 mutations who undergo oophorectomy before age 35 have decreased mortality rates from ovarian cancer (women who have BRCA2 mutations may be able to delay this surgery until their 40s).11 Oral contraceptive use and oophorectomy are recommended for prevention of HNPCC-related cancers.8

Of note, mutations in cancer predisposition genes other than BRCA1/2 and those that cause HNPCC can place women at high risk of developing breast cancer and/or reproductive cancers. Women who test negative for BRCA or HPNCC mutations but have a strong familial picture for cancer risk should begin screening early, and options for preventive treatment should still be considered.12

Family history collection methods

Many HCPs recognize the value of the FH but cite lack of time and limited patient knowledge of their own FH as major barriers to collection of an accurate FH.13 Several studies have established that a self-collected instrument is an effective and time-efficient method of collecting FH data and identifying risk for hereditary cancers.1,14,15 Individuals who self-collect may have access to family members with better recall for third- or fourth-degree relatives.14,15 Although initiatives to develop and improve access to self-collected and archived FHs are under way, adoption of this method has been slow.16,17

The Table lists some available FH tools. The Surgeon General’s Family History Initiative advocates use of an online tool, My Family Health Portrait (MFHP), which allows individuals to collect and upload accurate FH information. The MFHP facilitates creation of a table that can be populated online and downloaded for storage and periodic updating on a computer. The printed output can be shared with HCPs to help identify specific risk patterns within the family.16,18 Although few studies have been published on the efficacy of MFHP, evidence suggests that this tool is particularly useful as a means of recording FHs of breast and ovarian cancers.19,20Table


Family Healthware, developed by the CDC, is a Web-based tool that integrates familial risk assessment with generation of specific health screening recommendation messages based on risk.21 Although the results of a randomized trial conducted on 3283 primary care patients that compared the clinical usefulness of the Family Healthware tool versus general cancer prevention messages were equivocal,21 the authors suggested that better engagement with the clinician and integration with a health record and decision support might improve clinical outcomes and should be incorporated in future iterations of the tool. As this issue goes to press, the CDC website for Family Healthware indicates that the Web-based tool remains in testing but may be available for research purposes by contacting the CDC.22

Myriad Genetics created the Hereditary Cancer Quiz, a four-item online assessment that purports to identify flags for hereditary breast and ovarian cancer (HBOC) and HNPCC risks.23 Individuals whose answers trigger risk flags are invited to complete a detailed online Family History Tool (FHT). The FHT is similar to the MFHP in that individuals who complete the FHT can identify patterns showing risk for hereditary cancers within their family.24 The table and pedigree generated by the FHT can be shared with a specified HCP via encrypted email. The Web interface is intuitive, and results are both easy to understand and visually attractive. Individuals can choose to create a personal account maintained on the website or use the site via a guest account. The privacy statement for the website stipulates that individuals who create an account remain guard­ians of the data, meaning that account creators control all access. However, individuals using this site should read and review the privacy statement before setting up a personal account.25 Myriad Genetics makes no statements regarding the product’s efficacy or bias.

Paper-based instruments are an effective alternative if online access or privacy is a concern. Several such instruments are available. Hughes et al26 successfully deployed a self-administered paper-based FH instrument for patients in an internal medicine practice, resulting in 6% (51/567) being referred for additional services because of high risks suggested by the FH. A Family History Collection Form created by the National Coalition for Health Professional Education in Genetics is available for download and use.27 The download site includes supplementary instructions for completing and interpreting the collected data.

Barriers for providers and patients

According to HCPs, barriers to performing an FH review include a lack of familiarity with screening recommendations for inherited cancers and a lack of knowledge regarding which patients to refer to geneticists.13 Evidence suggests that low-risk, affluent women are over-referred for genetic counseling and genetic screening tests,28,29 whereas minorities are disproportionately under-referred for these same services.30 Over-referral for genetic testing of low- to average-risk women is associated with use of patient inquiry about FH as a determinant in the decision to refer for genetic screening.29 Barriers to routine collection of FH information also include low patient reading level and privacy concerns. Special efforts may need to be extended to women with low literacy. Some cultural groups may find “keeping it on paper” problematic.31 Protocols and education programs about protections provided by the Genetic Information Nondiscrimination Act will need to be developed and communicated broadly.

Recommendations for risk assessment and referral

In an FH, presence of any of these indicators is a red flag that warrants further investigation and possible referral to a genetics counselor32:

  •  Several family members with the same or related cancers
  • Early age of onset for cancer
  • Male breast cancer
  • Ashkenazi Jewish descent

The American College [now Congress] of Obstetricians and Gynecologists (ACOG) recommends genetic counseling and screening for unaffected women with a close relative who has been diagnosed with ovarian cancer or a BRCA1/2 mutation.33 In addition, women who have male relatives with breast cancer, multiple cases of breast cancer among close relatives, or close relatives diagnosed with breast cancer at an early age should be offered genetic screening.33 The most recent screening/genetics referral recommendations by the National Comprehensive Cancer Network are similar to those of ACOG, with an additional recommendation to offer genetic risk assessment for unaffected individuals who have more than one family member on the same side affected by any of these cancers: endometrial cancer, pancreatic cancer, aggressive prostate cancer, brain tumors, leukemia/lymphoma, thyroid cancer, or diffuse gastrointestinal cancer.34


Under the Affordable Care Act, coverage was extended for preventive health services, including genetic counseling and BRCA testing if a woman’s FH shows evidence of risk for deleterious mutations.35 Commencement of screening for cervical cancer is an opportune time to introduce the idea of FH data collection to young women. A few minutes could be used to discuss the benefits of FH awareness and to pre­sent options for data collection (online or paper tool). Women can choose to begin collecting FH data prior to their next scheduled annual visit, which will allow them and their families to discuss family members’ health histories and have adequate time to gather missing details. Interventions and screening should start early; beginning the process in a woman’s early 20s allows adequate time to collect information, determine risk, and, if necessary, refer for screening.


The information and resources provided in this article are intended to facilitate collection and interpretation of the FH during the annual well-woman visit. Hereditary patterns of disease are most readily identified by review of a comprehensive FH. As such, HCPs need to develop skills in collecting and interpreting FHs. Improved collection and documentation skills for HCPs may have a profound impact on decisions about further screening, disease prevention, and treatment options for inherited cancer.

Mary Elizabeth “Betsy” Guimond is Assistant Professor of Nursing at Robert Morris University in Pittsburgh, Pennsylvania. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Suggested reading
Cancer Genetics Risk Assessment and Counseling–for health professionals (PDQ®). Updated July 17, 2015.

1. van Altena AM, van Aarle S, Kiemeney LA, et al. Adequacy of family history taking in ovarian cancer patients: a population-based study. Fam Cancer. 2012;11(3):343-349.

2. Nilsson MP, Hartman L, Idvall I, et al. Long-term prognosis of early-onset breast cancer in a population-based cohort with a known BRCA1/2 mutation status. Breast Cancer Res Treatment. 2014;144(1):133-142.

3. Yoshida K, Miki Y. Role of BRCA1 and BRCA2 as regulators of DNA repair, transcription, and cell cycle in response to DNA damage. Cancer Science. 2004;95(11):866-871.

4. Petrucelli N, Daly MB, Feldman GL. BRCA1 and BRCA2 hereditary breast and ovarian cancer. GeneReviews®. 2013.

5. Woodson AH, Profato JL, Muse KI, Litton JK. Breast cancer in the young: role of the geneticist. J Thorac Dis. 2013;(5 suppl 1):S19-S26.

6. Vasen HF. Clinical description of the Lynch syndrome [hereditary nonpolyposis colorectal cancer (HNPCC)]. Fam Cancer. 2005;4(3):219-225.

7. Auranen A, Joutsiniemi T. A systematic review of gynecological cancer surveillance in women belonging to hereditary nonpolyposis colorectal cancer (Lynch syndrome) families. Acta Obstet Gynecol Scand. 2011; 90(5):437-444.

8. Lu K, Daniels M. Endometrial and ovarian cancer in women with Lynch syndrome: update in screening and prevention. Fam Cancer. 2013; 12(2):273-277.

9. Kohlmann W, Gruber SB. Lynch syndrome. In: Pagon RA, Adam MP, Ardinger HH, et al, eds. GeneReviews®. Seattle, WA: University of Washington; 2014.

10. Savage KI, Matchett KB, Barros EM, et al. BRCA1 deficiency exacerbates estrogen-induced DNA damage and genomic instability. Cancer Res. 2014;74(10):2773-2784.

11. Finch APM, Lubinski J, Møller P, et al. Impact of oophorectomy on cancer incidence and mortality in women with a BRCA1 or BRCA2 mutation. J Clin Oncol. 2014;32(15):1547-1553.

12. Berliner J, Fay A, Cummings S, et al. NSGC practice guideline: risk assessment and genetic counseling for hereditary breast and ovarian cancer. J Genet Couns. 2013;22(2):155-163.

13. Wood ME, Stockdale A, Flynn BS. Interviews with primary care physicians regarding taking and interpreting the cancer family history. Fam Pract. 2008;25(5):334-340.

14. Vogel TJ, Stoops K, Bennett RL, et al. A self-administered family history questionnaire improves identification of women who warrant referral to genetic counseling for hereditary cancer risk. Gynecol Oncol. 2012;125(3):693-698.

15. Armel SR, McCuaig J, Finch A, et al. The effectiveness of family history questionnaires in cancer genetic counseling. J Genet Couns. 2009; 18(4):366-378.

16. Carmona RH, Wattendorf DJ. Personalizing prevention: the US Surgeon General’s family history initiative. Am Fam Physician. 2005;71(1):36-39.

17. Owens K, Marvin M, Gelehrter T, et al. Clinical use of the surgeon general’s “My Family Health Portrait” (MFHP) tool: opinions of future health care providers. J Genet Couns. 2011;20(5):510-525.

18. Flynn B, Wood M, Ashikaga T, et al. Primary care physicians’ use of family history for cancer risk assessment. BMC Fam Pract. 2010;11(1):45.

19. U.S. Surgeon General. My family health portrait. U.S. Department of Health & Human Services, Office of the Surgeon General; 2007.

20. Facio FM, Feero WG, Linn A, et al. Validation of My Family Health Portrait for six common heritable conditions. Genet Med. 2010;12(6):370-375.

21. Rubinstein WS, Acheson LS, O’Neill SM, et al. Clinical utility of family history for cancer screening and referral in primary care: a report from the Family Healthware Impact Trial. Genet Med. 2011;13(11):956-965.

22. Centers for Disease Control and Prevention. Public Health Genomics. Family History. Family History Collection Tools. Family healthware™. June 20, 2013.

23. Myriad Genetic Laboratories. Heriditary Cancer Quiz™. 2014.

24. Myriad Genetic Laboratories. Family History Tool™.

25. Myriad Genetic Laboratories. Terms of Use/Privacy policy.

26. Hughes KS, Roche C, Campbell CT, et al. Prevalence of family history of breast and ovarian cancer in a single primary care practice using a self-administered questionnaire. Breast J. 2003;9(1):19-25.

27. National Coalition for Health Professional Education in Genetics. The Jackson Laboratory. Family History Tool. 2014.

28. White DB, Bonham VL, Jenkins J, et al. Too many referrals of low-risk women for BRCA1/2 genetic services by family physicians. Cancer Epidemiol Biomarkers Prev. 2008;17(11): 2980-2986.

29. Bellcross CA, Kolor K, Goddard KA, et al. Awareness and utilization of BRCA1/2 testing among U.S. primary care physicians. Am J Prev Med. 2011;40(1):61-66.

30. Trivers KF, Baldwin LM, Miller JW, et al. Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians: a vignette-based study. Cancer. 2011; 117(23):5334-5343.

31. Thompson T, Seo J, Griffith J, et al. “You don’t have to keep everything on paper”: African American women’s use of family health history tools. J Community Genet. 2013;4(2):251-261.

32. National Coalition for Health Professional Education in Genetics. The Jackson Laboratory. Interpreting the Family History. 2014.

33. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 103: Hereditary breast and ovarian cancer syndrome. Obstet Gynecol. 2009;113(4):957-966.

34. Daly MB, Pilarski R, Axilbund JE, et al. Genetic/familial high-risk assessment: breast and ovarian, version 1.2014. J Natl Compr Canc Netw. 2014; 12(9):1326-1338.

35. Centers for Medicare & Medicaid Services. Affordable Care Act Implementation FAQs – Set 12.

From practice to policy: The WHNP as advocate

As most of our readers know, the National Association of Nurse Practitioners in Women’s Health (NPWH) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) released the 7th edition of the Women’s Health Nurse Practitioner: Guidelines for Practice and Education in December 2014. Many women’s health nurse practitioners (WHNPs) use this document to outline their clinical competencies, and faculty use it as a framework in developing WHNP program curricula. But the guidelines go beyond describing clinical practice components and educational requirements; they also include policy and advocacy competencies. In particular, the guidelines enumerate participating in legislative/policy-making activities that influence women’s health and serving as “a consultant and trusted source of information on women’s health for healthcare systems and policy-makers” as key WHNP leadership competencies.1

As core WHNP competencies, policy and advocacy align well with NPWH’s mission and values. NPWH’s mission is to “ensure the provision of quality primary and specialty healthcare to women of all ages by women’s health and women’s health-focused nurse practitioners.” This mission includes protecting and promoting a woman’s right to make her own choices regarding her health within the context of her personal, religious, cultural, and family beliefs. As a professional membership organization, NPWH strives to continuously improve access and quality of healthcare for women through excellence and innovation in continuing education and professional development; to demonstrate leadership in policy, practice, and research; and to provide support and services for our members. These policy-related values are key to achieving our mission:

  • To advocate for healthcare policies that support women and advanced practice registered nurses (APRNs) who care for them; and,
  • To collaborate with strategic partners to enhance the effectiveness and timeliness of our efforts in the policy arena.2

How do these competencies affect clinical practice?

So, what does all of this mean in the real world of clinical practice? As most of our readers witness every day, policy decisions related to everything from reimbursement for healthcare service delivery to state-based APRN scope of practice regulations to decisions regarding availability of services, medications, or new technologies can affect women’s health—and the realization of NPWH’s mission. The following discussion provides just a few examples.

The Patient Protection and Affordable Care Act seeks to increase access to affordable health insurance, with the ultimate goal of increasing access to healthcare. One way that it does this is by providing a mechanism for federally supported Medicaid expansion to cover most low-income adults (i.e., those earning up to 138% of the federal poverty level). Yet, to date, approximately 20 states have not expanded Medicaid to this level of coverage.3 Most states provide Medicaid coverage during pregnancy; however, in non–Medicaid-expansion states, this coverage stops shortly after delivery. Although coverage of prenatal care facilitates a favorable pregnancy outcome, lack of coverage for care needed before and between pregnancies can have devastating effects on women and their children.

Consider the reproductive-aged woman with type 1 diabetes mellitus (T1DM). Diabetes in pregnancy can adversely affect both maternal and infant outcomes. Women with T1DM have higher rates of maternal mortality and morbidity, including increased rates of pre-eclampsia and cesarean section. Likewise, maternal T1DM increases the risks for fetal and neonatal loss, congenital anomalies, macrosomia, and a host of other neonatal complications. A patient with T1DM who qualifies for Medicaid during pregnancy but loses coverage soon after delivery will not have access to care for her chronic disease prior to her next pregnancy. This gap in care can allow her T1DM to spiral out of control, contributing to increased maternal and infant health problems or even death during subsequent pregnancies.4

In June 2015, the House Labor, Health and Human Services (LHHS) Subcommittee marked up its fiscal year 2016 spending bill, which contained a complete elimination of Title X. The following week, the Senate released a funding bill proposing $257.8 million for Title X, a decrease from the prior year’s $286.5 million budget.5 By the time this article goes to press, we should know how the Title X program fares in the 2016 budget. It is estimated that publicly funded healthcare providers, such as those funded through Title X, met an estimated 42% of the need for publicly supported contraceptive services and supplies in 2013.6 Cuts to, or elimination of, the Title X program would effectively bar many of these women from accessing similar services in the future. In the case of the patient with T1DM discussed earlier who has already lost access to care for her chronic disease, she will also lose family planning services, which may contribute to a shortened pregnancy interval and may increase the potential for a poor pregnancy outcome. Furthermore, because Title X clinics are staffed primarily by NPs, cuts to Title X could decrease women’s access to quality care by WHNPs and other NPs who provide family planning services.

Professional competencies plus organizational values in action

Although many of our readers in clinical practice may have little time to “participate in legislative and policy-making activities that influence women’s health” in the traditional sense, they are our greatest asset in terms of bringing women’s stories to the forefront. NPWH staff keep our fingers on the pulses of policy-makers with power to make decisions about how, where, and from whom each woman can access care that is “within the context of her personal, religious, cultural, and family beliefs,” but our organization’s members provide the stories that give life to the policy. It is through our organization’s members that we at NPWH learn about the challenges that women face in accessing woman-centric care to meet their needs, as well as the barriers faced by WHNPs in attempting to provide that care.


In keeping with the NPWH/AWHONN guidelines, WHNPs possess the leadership competencies to serve as trusted sources of information on women’s health. As NPWH Policy Director, I invite all of our readers to collaborate with NPWH as “strategic partners to enhance the effectiveness and timeliness of our efforts in the policy arena.” Please contact me at to share your stories about policy issues affecting your practice and your patient population at the local, state, or national level. In this way, we can work together to become a collective voice for the women we serve in moving the policy needle to a place that supports women’s full access to the care that they need delivered by the providers they choose.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri-St. Louis; a consultant at Health Policy Advantage, LLC, in St. Louis, Missouri; and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH).


  1. National Association of Nurse Practitioners in Women’s Health/Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.
  2. NPWH. Mission, Vision, and Values. Mission. 2015.
  3. Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions. July 20, 2015.
  4. Negrato CA, Mattar R, Gomes MB. Adverse pregnancy outcomes in women with diabetes. Diabetol Metab Syndr. 2012;4(1):41.
  5. National Family Planning & Reproductive Health Association. Title X: Budget & Appropriations.
  6. Frost JJ, Frohwirth L, Zolna MR. Contraceptive Needs and Services, 2013 Update. Washington, DC: Guttmacher Institute; July 2015.

Lung cancer screening*

Tests are used to screen for different types of cancer.

Some screening tests are used because they have been shown to be helpful both in finding cancers early and in decreasing the chance of dying from these cancers. Other tests are used because they have been shown to find cancer in certain people; however, it has not been proven in clinical trials that use of these tests will decrease the risk of dying from cancer.

Scientists study screening tests to find those with the fewest risks and most benefits. Cancer screening trials also are meant to show whether early detection (finding cancer before it causes symptoms) decreases a person’s chance of dying from the disease. For some types of cancer, finding and treating the disease at an early stage may result in a better chance of recovery. Clinical trials that study cancer screening methods are taking place in many parts of the country. Information about ongoing clinical trials is available from the National Cancer Institute website.

Three screening tests have been studied to see if they decrease the risk of dying from lung cancer.

Low-dose spiral CT scan (LDCT scan): A procedure that uses low-dose radiation to make a series of very detailed pictures of areas inside the body. It uses an x-ray machine that scans the body in a spiral path. The pictures are made by a computer linked to the x-ray machine. This procedure is also called a low-dose helical CT scan.

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Sputum cytology: Sputum cytology is a procedure in which a sample of sputum (mucus that is coughed up from the lungs) is viewed under a microscope to check for cancer cells.

Screening with low-dose spiral CT scans has been shown to decrease the risk of dying from lung cancer in heavy smokers.

The National Lung Screening Trial studied people aged 55 years to 74 years who had smoked at least 1 pack of cigarettes per day for 30 years or more. Heavy smokers who had quit smoking within the past 15 years were also studied. The trial used chest x-rays or LDCT scans to check for signs of lung cancer.

The scientists found that LDCT scans were better than chest x-rays at finding early-stage lung cancer.  Screening with LDCT also decreased the risk of dying from lung cancer in current and former heavy smokers. A Guide is available for patients and healthcare providers to learn more about the benefits and harms of LDCT screening for lung cancer.

Screening with chest x-rays and/or sputum cytology does not decrease the risk of dying from lung cancer.

Chest x-ray and sputum cytology are two screening  tests that have been used to check for signs of lung cancer. Screening with chest x-ray, sputum cytology,  or both of these tests does not decrease the risk of dying from lung cancer.

  • National Cancer Institute. Updated April 27, 2015. Readers are invited to photocopy Patient education pages in the journal and distribute them to their patients.




Female sexual dysfunction: Why is it so difficult to treat?

Many healthcare providers avoid addressing and treating sexual problems in women for a multitude of reasons, including the paucity of FDA-approved medications for female sexual dysfunction (FSD), concern about the additional time required during the patient visit, and confusion over billing and coding, leading to challenges regarding reimbursement. In this column, I describe the common barriers and misconceptions that impede successful evaluation and treatment of FSD.

Over recent years, multiple studies have demonstrated the high prevalence of sexual complaints in women. In fact, more women than men report problems with sexual functioning, including problems related to libido, arousal, orgasm, and pain. In the National Health and Social Life Survey, 43% of women reported one or more sexual problems, compared with 31% of men.1 Nearly 10 years later, the PRESIDE study demonstrated a 44% prevalence of female sexual dysfunction (FSD) in the United States.2 Despite these compelling statistics, research regarding treatments for sexual dysfunction and marketing for products designed to improve sexual function have been primarily geared toward men, not women. Although the focus may finally be shifting to women, why is FSD still so difficult to treat?

#1: Few FDA-approved treatments for FSD

In 1998, the FDA approved sildenafil (Viagra®) as the first medication for the treatment of erectile dysfunction (ED) in men, initiating a new kind of sexual revolution. Men with ED who had previously been rendered virtually abstinent were now able to resume satisfying sexual activity. Since that time, 27 medications have been approved by the FDA for the direct or indirect enhancement of sexual functioning in men. Until 2 months ago, the total number of FDA-approved medications for the treatment of low sexual desire in women was zero. But on August 18, 2015, the FDA made history by approving flibanserin (Addyi™), the first-ever medication for the treatment of hypoactive sexual desire disorder in women.3

#2: Too time consuming to address

One of the biggest complaints that I hear from healthcare providers (HCPs) regarding addressing their female patients’ sexual concerns is that it takes too much time in an already busy clinic setting. I recommend the use of any of the following validated questionnaires, which can facilitate discussions about this sensitive and complicated topic.

  • Sexual Function Questionnaire4
  • Female Sexual Function Index5
  • Female Sexual Distress Scale-Revised6
  • Decreased Sexual Desire Screener7
  • Hypoactive Sexual Desire Disorder Screener8
  • Abbreviated Sexual Function Questionnaire9
  • Sexual Quality of Life-Female10

#3: Not a profitable specialty

Although billing based on time spent face-to-face with a patient is not typically a lucrative method for running a practice, HCPs do have ways to enhance reimbursement when treating female patients with sexual complaints. For instance, offering services such as colposcopy, vulvovaginal biopsy, biothesiometry, perineometry, and trigger-point injections can provide a major increase in revenue when utilizing procedural modifiers. Even minor tests such as urinalysis, wet preps, and vaginal pH analysis can add profit to a patient encounter. When applicable, providing urogynecologic services such as urodynamics, tibial nerve stimulation and pessary placement/maintenance can further boost clinic revenue.

#4: Prevalence versus “distress”

Although nearly half of all surveyed women in the two aforementioned studies reported sexual complaints,1,2 only 12% reported experiencing distress related to their sexual problems.2 In order for a woman to meet criteria for an FSD diagnosis, she needs to be bothered by her condition. If she does not experience such distress, then treatment is unnecessary and unlikely to prove beneficial. HCPs need not create a diagnosis where none exists. At the same time, FSD is a true entity that deserves attention when warranted.

#5: Multifactorial etiology of FSD

Many factors affect female sexual functioning, including overall health, medication use, stress, pregnancy, menopause, drug and alcohol abuse, mental health, relationship status, and socioeconomic status. Existence of all these contributing factors necessitates that history taking in women with FSD be thorough. Although this list is not exhaustive, relevant health conditions for which to screen in women reporting sexual complaints include depression, diabetes, thyroid disease, hyperprolactinemia, cardiovascular disease, neurologic disease, androgen insufficiency, and estrogen deficiency.11 The Table lists commonly prescribed medication classes that can increase
FSD risk.11


#6: Lack of provider training

In 2010, the Journal of Sexual Medicine published proceedings from the International Consultation in Sexual Medicine, which included this quote: Current sexual health education for undergraduate and practicing physicians is inadequate to meet the advancing science and technology and increasing patient demand for high-quality sexual health care.12 That being said, many academic programs for prospective physicians, nurse practitioners, and physician assistants are beginning to incorporate more sexual health training into their curricula, which will arm HCPs with the knowledge and confidence needed
to manage patients’ sexual problems or refer them to another provider when appropriate.

#7: Social stigma and patient unwillingness to discuss sensitive topics

In a study presented in 2010, Parish et al13 evaluated 75 videotaped patient–provider interactions regarding distressing low desire (DLD). HCPs underestimated the prevalence of distress in 82% of women who described themselves as very distressed with respect to their low desire. In this same study, 69% of women minimized their distress during the encounter with the provider but then acknowledged their distress after the visit. Although the impact of DLD was not addressed in any of the 75 interactions, after the visit, 95% of the patients reported that DLD affected their relationship and 98% reported that it affected their partners.


Considering the high prevalence of FSD, and the likelihood that it is distressing to at least a sizable minority of women who have it, HCPs must aim to identify it and treat it—despite the barriers that still exist. Addressing patients’ concerns in a holistic manner, establishing rapport, and providing a nonjudgmental environment for discussion about sensitive topics is the best method to facilitate success in this patient population.

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

1. Laumann, EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;

2. Shifren, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970-978.

3. FDA News Release. FDA Approves First Treatment for Sexual Desire Disorder. August 18, 2015.

4. Quirk FH, Heiman JR, Rosen RC, et al. Development of a sexual function questionnaire for clinical trials of female sexual dysfunction. J Womens Health Gend Based Med. 2002;11(3):277-289.

5. Quirk F, Haughie S, Symonds T. The use of the sexual function questionnaire as a screening tool for women with sexual dysfunction. J Sex Med. 2005;2(4):469-477.

6. Derogatis L, Clayton A, Lewis-D’Agostino D, et al. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5(2):357-364

7. Clayton AH, Goldfischer ER, Goldstein I, et al. Validation of the decreased sexual desire screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6(3):730-738.

8. Leiblum S, Symonds T, Moore J, et al. A methodology study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2006;3(3):455-464.

9. Williams K, Abraham L, Symonds T. Psychometric validation of an abbreviated version of the sexual function questionnaire (ASFQ). Value in Health. 2010;13(7):A381.

10. Symonds T, Boolell M, Quirk F. Development of a questionnaire on sexual quality of life in women. J Sex Marital Ther. 2005;31(5):385-397.

11. Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urol Clin North Am. 2007;34(4):497-506.

12. Parish SJ, Rubio-Aurioles E. Education in sexual medicine: proceedings from the international consultation in sexual
medicine, 2009. J Sex Med. 2010;7(10):3305-3314.

13. Parish SJ, Hahn SR, Kingsberg SA, et al. Doctor-patient communication about desire with women who have distressing low desire in primary care and general OB/GYN practice. Presented at: The International Society for the Study of Women’s Sexual Health; 2010; St. Petersburg, Florida.

Reproductive life plans among Spanish-speaking Hispanic women in the U.S.

Pregnancy and pre-conception care (PCC) are major concerns for reproductive-aged women. Although researchers are beginning to find an association between women’s intendedness of pregnancy and their reproductive health-related behaviors, little is known about this topic with respect to Hispanic women in the United States who speak only Spanish. The authors report findings from interviews with 263 members of this population to ascertain their thoughts regarding reproductive life plans and two other topics of interest—PCC and the danger of oral contraceptive use versus pregnancy.

Key words: reproductive life plan, Hispanic women, intendedness of pregnancy, pre-conception care

The ability to choose whether and when to bear children is a fundamental aspect of reproductive health. Yet for more than a decade, about one-half of all pregnancies in the United States have been unintended.1 This statistic represents an average; the proportion of unintended pregnancies varies substantially by demographic group. For example, when compared with non-Hispanic white women, Hispanic women have higher rates of unintended pregnancy, unintended births, and abortions and lower rates of contraception use.2 Rates of unintended pregnancy are substantially increased among poor and low-income women and decreased among higher-income women.2 Poor women are more likely than other women to have unprotected intercourse, and when they do use contraception, they report markedly higher rates of method failure.3,4

Although the reasons are not fully understood and are likely complex, ethnicity, race, culture, and
socioeconomic status all affect decision making about pregnancy and contraceptive use. These factors, alone or in combination, can facilitate or compromise a woman’s ability to formulate a reproductive life plan (RLP) and to meet her RLP goals. These factors can also affect a woman’s knowledge and decisions about pursuing pre-conception care (PCC).


Between 2000 and 2010, the Hispanic population in this country grew by 43% and now comprises 16% of the total U.S. population.5 Compared with non-Hispanic women, Hispanic women have higher rates of unintended pregnancy and lower rates of contraception use. The growing Hispanic population in the U.S. means that healthcare providers (HCPs) will see more and more Hispanic women in their practices and need to know how to help these women make informed decisions about RLPs, use effective contraception when pregnancy is not desired, and obtain PCC to optimize pregnancy outcomes.

Several studies have sought to provide insight into the factors that influence Hispanic women’s decisions about and effective use of contraception. These factors include knowledge about contraception, level of acculturation, attitudes toward planning a pregnancy and toward unintended pregnancy, and attitudes and biases of their HCPs.1,6-8 However, these studies have not focused on Hispanic women who speak only Spanish, or on factors that might influence their RLPs and related decision making about contraceptive use and PCC.

The State of California provides comprehensive family planning and reproductive health services to low-income residents through Family Planning, Access, Care, and Treatment (Family PACT), a federally funded program. In 2010, Family PACT provided services to 1.8 million women and men.9

A sizable proportion of Family PACT clients are Hispanic women who speak only Spanish because they are recent immigrants to this country. This study was conducted with a sample of Spanish-speaking Hispanic women seen at a Family PACT clinic for contraceptive care to explore various aspects of the participants’ RLPs. This study was the first to use CDC guidelines on RLPs and PCC10 as a basis to explore these practices in female members of this ethnic group.

Purpose of study

With the ultimate goal of optimizing women’s health and knowledge before conceiving, the investigators designed a structured interview to determine whether a convenience sample of reproductive-aged, Spanish-speaking women seeking care in a family planning clinic had formulated RLPs. Definitions used by the American College [now Congress] of Obstetricians and Gynecologists (ACOG)11 and in the CDC guidelines for RLPs and PCC10 provided the basis for the interview questions posed in this study.

  • A reproductive life plan is defined as a strategy based on a woman’s values and resources to achieve a set of goals about having children, including whether to get pregnant, when to get pregnant, and how many children to have in her lifetime.10 The RLP includes a strategy for effective contraceptive use and options if pregnancy is not desired at all.
  • Core pre-conception care involves assessment of a woman’s undiagnosed, untreated, or poorly controlled health conditions; immunization history; medication use; nutritional concerns; genetic risks; substance use; and occupational or environmental exposures prior to conception.11

The investigators sought to answer three questions: (1) Do these women have RLPs? (2) Do they think that women should plan and prepare for pregnancy? and (3) How do they compare the health risks posed by use of birth control pills versus those posed by pregnancy?

Methods and materials

Approval to conduct this study was obtained from the John F. Wolfe Human Subjects Committee and the Research Committee of the Los Angeles Biomedical Research Institute. A 3- to 5-minute interview tool was developed and piloted with 25 potentially eligible women to determine understandability in Spanish and to correct questions that might be confusing. Questions about personal information and RLPs had single answers, and those about pregnancy planning and preparation were open ended (Box).

Neither the term reproductive life plan nor the abbreviation RLP was used when interviewing study participants. Instead, the investigators asked participants how many children they wanted to have and when they wanted to have them. Provision of answers to these questions was considered evidence that a woman had envisioned some form of an RLP for herself. With regard to the question about risks posed by oral contraceptive (OC) use versus pregnancy, the investigators chose to use the term birth control pill as a proxy not only for OCs but for all hormonal contraceptives because they believed that participants would be most familiar with this term.

Interviews were conducted from January 2013 through November 2013 by one of the authors whose first language is Spanish (PX). Prospective participants were approached in the waiting area of the Women’s Health Care Clinic at Harbor UCLA, which provides all types of birth control products to low-income women for free. Women were eligible for the study if they were non-pregnant, Spanish speaking, at least 18 years of age but premenopausal, and at risk for pregnancy. Exclusion criteria were prior hysterectomy or tubal sterilization and lack of ability to give consent. An explanation of the study—including any risks or benefits, assurances of confidentiality, and an option to withdraw at any time without consequences—was read to prospective participants in Spanish. Because the project was an interview with no personal identifiers and no interventions, the Institutional Review Boards approved a waiver of informed consent signature. If a woman gave verbal consent to participate, she was taken to an adjacent private area for the interview. The interviewer used a standard script to ensure uniformity of interview administration and to enable all the data to be merged.

Demographic information was solicited to characterize the study sample. Questions were read aloud and participants’ answers documented verbatim. Participants who did not mention any medical measures in their answer to the question of whether a woman should plan and prepare herself for pregnancy were asked a follow-up question about anything they thought a woman should do medically to plan and prepare for a pregnancy. Medical measures, as described in the CDC guidelines, entail pre-conception screening for health conditions and practices associated with adverse pregnancy outcomes (e.g., obesity, hypertension, smoking).10 The intent of the guidelines is to identify and modify risks before conception occurs. If a participant did not mention any of these medical measures or others, she was asked, Is there any reason for a woman to see a healthcare provider before getting pregnant?

Three investigators placed the participants’ answers to the question about the content of PCC into one of five categories: social, personal, financial, psychological, or medical. Of note, although social, financial, and psychological planning are parts of PCC, this study was designed, at least in part, to find out whether women would include medical measures as part of PCC. If the participants responded with answers that fell into more than one category, each category was tallied. The three investigators had 100% agreement on all category assignments.


A total of 265 women whose primary spoken language was Spanish were approached to participate in the survey. No woman declined, but 2 were excluded because they were surgically infertile; therefore, data for this study were derived from 263 women.

Mean age of the sample was 34 years (range, 18-50 years). Among 263 participants, 4 (1.5%) were younger than 20, 54 (20.5%) were aged 20-25, 42 (15.9%) were aged 26-30, 48 (18.2%) were aged 31-35, and 115 (43.7%) were older than 35. Mean duration of formal education was 10 years (range, 0-18 years). Parity ranged from 0 to 7 births (mode, 2). The time that each woman took to respond to the question about her age was used as the comparator for the speed with which she answered questions about her RLP. Answers to questions were classified as “rapid” if a woman’s response time was at least as fast as when she answered the question about her age, “delayed” if they were more slowly provided, or “unsure” if a woman was unable to provide an answer.

Reproductive life plan

A total of 239 (91%) of the participants said that they knew how many children they wanted to have in their lifetime; among this group, nearly half wanted at least 3 children. A total of 226 women (85.9%) answered this question rapidly, 35 (13.3%) delayed their answers, and 2 (0.8%) were unsure. The 122 women who said that they wanted more children were asked how soon they wanted to become pregnant. Their responses and the speed/assurance of their responses (rapid, delayed, unsure) appear in Table 1.

Table 1

Birth control methods used by these participants were grouped by tiers of efficacy as defined by first-year failure rates in typical use.12Tier I methods include implants, intrauterine devices, and abstinence. Tier 2 methods include pills, patches, vaginal rings, and injections. Tier 3 methods include barrier methods and behavioral methods. Fewer than 20% of women who wanted to delay pregnancy for at least 3 years reported use of tier I methods (Table 2).

Table 2

Pre-conception care

A total of 252 participants (95.8%) said that a woman should plan and prepare for pregnancy. But when asked how a woman should prepare, only 10.7% provided answers that fell into the category of medical care. More than half of the answers related to financial preparation (26.4%) or mental preparation (26.7%). The remainder of the answers pertained to social preparation (6.3%) or other concerns (13.3%). Even when asked Do you think that there is anything the woman should do to prepare medically for pregnancy? only 2% of the women who had not initially spoken of the need for any medical preparation mentioned PCC at this second opportunity.

Hazards of OC use versus pregnancy

In the last section of the interview, 188 (71.5%) of the participants said that birth control pills were at least as hazardous to a women’s health as pregnancy, whereas only 56 (21.3%) knew that pregnancy was more dangerous than taking birth control pills. Nineteen subjects (7.2%) reported that they did not know which situation was more hazardous.


Results of this study suggest that these traditional Hispanic women tended to prize relatively larger families—as compared with the average number of children in U.S. families (~2.4, depending on various definitions of a family by the 2010 Census Bureau).13 Most participants appeared certain about the number of children they wanted and how soon they wanted their next pregnancy. Nevertheless, fewer than one-fifth of those who wanted to delay their next pregnancy for 3 or more years were using a Tier 1 contraceptive method. About one-third were using the least effective Tier 3 methods.

Hispanic women, relative to their non-Hispanic counterparts, know less about reproduction and contraception use, which may partly account for their significantly lower rates of contraceptive use.3,4 Although the findings regarding the use of less effective contraceptive methods by Hispanic women are consistent with other existing research, the purported causes demonstrate that pregnancy planning and contraceptive decision making go beyond simple knowledge. A recent study conducted in Texas, another state with a large Hispanic population, related Hispanic women’s use of less effective contraceptive methods or inconsistent use of methods to their ambivalence about pregnancy.6 In this study, as many as one-third of participants who claimed they wanted no more children still said they would feel very happy or somewhat happy about becoming pregnant in the next 3 months.6 Another study on contraceptive use among young Hispanic women conducted in southeast Texas showed that women low in acculturation (defined by the language portion of the Short Acculturation Scale for Hispanics), compared with women high in acculturation, were more likely to use no contraception or cyclic contraception rather than Tier 1 methods.7 A study by the National Latina Institute for Reproductive Health showed that a large majority of Hispanic women do not use contraception consistently because of economic barriers and deeply rooted cultural and religious influences.2

When asked whether a woman should plan and prepare herself for pregnancy, nearly 96% of the participants responded in the affirmative. However, when asked how a woman should do so, fewer than 11% mentioned anything related to medical aspects of planning and preparation even when prompted. More than 89% gave answers related to psychological, financial, or social planning and preparation. Monitoring a woman’s pre-conception health was not mentioned. Based on these women’s responses, this study population seemed relatively unfamiliar with the importance of medical care prior to becoming pregnant to identify, intervene with, and monitor pre-conception risk to improve pregnancy outcomes. No other studies looking specifically at Hispanic women’s knowledge or attitudes related to PCC were found.

When asked whether they thought birth control pills or pregnancy was more hazardous to a woman’s health, more than 70% of participants chose the former—even though pregnancy is far more dangerous than use of any of the hormonal contraceptives.14 These women, like most U.S. wom­en, believe that pregnancy is a natural process that could not possibly be riskier to their health than hormonal contraceptive use. In fact, a study of English-speaking, reproductive-aged women’s knowledge of the health risks of pregnancy versus those risk of OC use showed the same misconceptions.14 Even the more highly educated, affluent women in this study considered OC use more hazardous than pregnancy.

Study limitations

Generalizability of these study findings is limited. The data were derived from an interview of Hispanic women, many of whom were recent immigrants to the U.S., at a single clinic for low-income women. The results do not represent women in general or Spanish-speaking Hispanic women. Another concern is that more than half (53.6%) of these participants had completed their families and wanted no more pregnancies. However, this subgroup provided the investigators with important insights into the mismatch between their pregnancy plans and their selection of less effective contraceptive methods.

Practice implications

This survey revealed three important points. First, HCPs need to be aware that many Spanish-speaking women may not have clearly defined their fertility goals. Rather than asking a woman whether she plans to get pregnant in the next year, HCPs should ask, How would you feel if you were to get pregnant in the next year? Her answer may reveal her commitment or ambivalence regarding pregnancy prevention, which is important to know when prescribing a user-dependent birth control method. For women seeking contraception who are ambivalent about pregnancy prevention, HCPs may want to plan for follow-up to address any concerns that might arise during early use of the method.15

Second, HCPs need to directly address women’s concerns about contraceptive safety.7,12 HCPs should assess each woman’s contraceptive experiences and preferences. This assessment may help uncover misconceptions, fears, or the influences of others on her contraceptive decision making.15 Use of less effective contraceptive methods (i.e., those in Tier 3) may reflect her concerns about the safety of using more effective methods (i.e., those in Tiers 1 and 2). Every time HCPs prescribe a particular method, a patient should be informed that this method is safer for her than pregnancy.

Third, to address a Spanish-speaking, reproductive-aged woman’s lack of familiarity with the importance of PCC, HCPs should routinely remind her that, if and when she wants to get pregnant, she should return to have her health status evaluated and to learn what she can do to improve the outcome of the intended pregnancy. Every family planning visit provides an opportunity for pre-conception counseling on healthy lifestyle behaviors and pre-pregnancy management of risk factors and medical conditions that influence pregnancy outcomes.


Lack of pregnancy planning and inconsistency between stated pregnancy plans and effective contraceptive use are common among U.S. women.16 The findings of this study reflect the need to continue to expand HCPs’ understanding of the causes for this inconsistency in both the general population and in specific populations.

Pamela E. Xandre is Assistant Professor at the School of Nursing, California State University, Long Beach. Salma Shabaik is a physician at Family Practice in Long Beach, California. Anita L. Nelson is Professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine, University of California at Los Angeles. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006; 38(2):90-96.

2. Ranjit N, Bankole A, Darroch JE, Singh S. Contraceptive failure in the first two years of use: differences across socioeconomic subgroups. Fam Plann Perspect. 2001;33(1):19-27.

3. Sangi-Haghpeykar H, Ali N, Posner S, Poindexter AN. Disparities in contraceptive knowledge, attitudes, and use in Hispanic and non-Hispanic whites. Contraception. 2006;74(2): 125-132.

4. Schwarz EB, Smith R, Steinauer J, et al. Measuring the effects of unintended pregnancy on women’s quality of life. Contraception. 2008;78(3): 204-210.

5. Humes KR, Jones NA, Ramirez RR. Overview of race and Hispanic origin, 2010. Census Briefs. March 2011.

6. Aiken AR, Potter JE. Are Latina women ambivalent about pregnancies they are trying to prevent? Evidence from the Border Contraceptive Access Study. Perspect Sex Reprod Health. 2013;45(4):196-203.

7. Roncancio AM, Ward KK, Berenson AB. The use of effective contraception among young Hispanic women: the role of acculturation. J Pediatr Adolesc Gynecol. 2012;25(1):35-38.

8. Rocca CH, Harper CH. Do racial and ethnic differences in contraceptive attitudes and knowledge explain disparities in method use. Perspect Sex Reprod Health. 2012;44(3):150-158.

9. California Department of Healthcare Services. Fact Sheet on Family PACT: An Overview. Updated January 2012.

10. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR Preconception Work Group and the Select Panel on Preconception Care. Morbid Mortal Weekly Rep. 2006;55(RR-06):1-23.

11. American College of Obstetricians and Gynecologists. ACOG Committee Opinion number 313, September 2005. The importance of pre-conception care in the continuum of women’s health care. Obstet Gynecol. 2005;106(3):665-666.

12. Wysocki S. The state of hormonal contraception today: enhancing clinician/patient communications. Am J Obstet Gynecol. 2011;205(4 suppl):S18-S20.

13. United States Census Bureau. America’s Families and Living Arrangements: 2010.

14. Nelson AL, Rezvan A. A pilot study of women’s knowledge of pregnancy health risks: implications for contraception. Contraception. 2012;85(1):78-82.

15. Gavin L, Moskosky S, Carter M, et al; Centers for Disease Control and Prevention. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep. 2014;63(RR-04):1-54.

16. Morgan SP, Rackin H. The correspondence between fertility intentions and behavior in the United States. Popul Dev Rev. 2010;36(1):91-118.

PrEP for prevention: Practice update

According to the Centers for Disease Control and Prevention (CDC), about 1.2 million persons are living with HIV in the United States, and about 20% of them are unaware of it.1 Lack of awareness of HIV status contributes to viral transmission. Healthcare providers (HCPs) play a vital role in the screening, diagnosis, and treatment of HIV infection, but they can also play an important role in HIV prevention. This article focuses on pre-exposure prophylaxis (PrEP), a safe and effective intervention that is rapidly becoming a major tool in HIV transmission prevention. The article also provides an overview of the assessment and management of patients prior to and during the use of PrEP.

The CDC estimates that 50,000 persons in the United States are newly infected with HIV every year.1 Most of the new cases involve men who have sex with men (MSM) (n = 30,689), but African-American women represent a disproportionate number of new infections (n = 5,300) when compared with white non-Hispanic women (n = 1,300) and Hispanic/Latina women (1,200).2

The birth rate among HIV-infected women has increased from 6,000-7,000 live births in 2000 to 8,700 live births in 2006, the last year reported.3 This increase in births may be related to the increased availability and use of antiretroviral medications, which significantly decrease mother-to-child transmission risk. Other factors are also in play. Study data suggest that women who are HIV positive and desire children, including those who disclose their seropositive status to their partners, may not be using condoms consistently.4,5 Little is known about birth rates in women who are HIV negative, desire children, and are in a relationship with an HIV-positive partner.

Pre exposure prophylaxis is the most recent intervention in the effort to fight the HIV epidemic. PrEP is a combination of two antiretrovirals, tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg, taken once daily. This treatment has been shown to reduce transmission risk by upwards of 92%.6 PrEP is available to adult men and women who are HIV negative but have an increased risk of exposure to HIV through sexual and/or injection drug use. PrEP is not approved for use in children or adolescents. Guidelines for PrEP were released in 2014 by the U.S. Public Health Service.<sup.6


Health history
To identify and reduce their patients’ risk for contracting HIV infection, HCPs need to take a sexual history as part of primary care and specialty care services. Studies have shown that many HCPs do not ask about risky sexual behaviors and many patients do not disclose them.4,5,7 Assessment of patients’ sexual behaviors and their potential contribution to HIV risk should be part of every healthcare encounter. The 5 P’s of sexual health—partners, practices, protection from sexually transmitted infections (STIs), past history of STIs, and prevention of pregnancy—provide a framework to assess each patient.8

Many patients are not comfortable talking about their sexual practices, partners, and history. HCPs can facilitate this discussion by informing patients that they routinely take a sexual history so that they can provide appropriate sexual health care, and that all information provided is confidential. HCPs can begin by asking these questions, as recommended in the 2014 PrEP guidelines.6 In the past 6 months:

  • Have you had sex with men, women, or both?
  • How many men/women have you had sex with?
  • How many times did you have vaginal or anal sex when neither you nor your partner wore a condom?
  • How many of your sex partners were HIV-positive?
  • If you did have sex with HIV-positive partners, how many times did you have vaginal or anal sex without a condom?
  • Do you have sex with partners who do not know their HIV status?

Next, HCPs need to inquire about any past history of STIs, treatment, past or current symptoms, their partner(s)’ history of STIs, and whether they would like to be tested for HIV during this healthcare encounter. In addition, HCPs can ask patients if they have ever injected drugs not prescribed by their HCP. If the answer is yes, patients are asked whether they have shared injection or drug preparation equipment or been in a drug treatment program in the past 6 months.

If this assessment suggests that a given patient is at high risk for HIV infection, the HCP initiates a discussion about PrEP. Adult MSM who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative man are potential candidates if they have had anal sex with a male (receptive or insertive) without a condom and/or have had an STI diagnosed in the past 6 months. Adult men and women who are heterosexually or bisexually active who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative partner are potential candidates if they infrequently use condoms during sex with partner(s) of unknown HIV status who are at substantial risk for HIV infection. Any individual who is HIV negative and in an ongoing sexual relationship with an HIV-positive partner is a potential candidate. In addition, individuals who have used illicit injection drugs in the past 6 months that included sharing injection and drug preparation equipment or who have been in a drug treatment program in the past 6 months are potential candidates. If a patient found to be a potential candidate is interested in PrEP, then further evaluation is needed to determine whether this intervention is appropriate for him or her.

Physical examination and lab screening/testing
No specific physical examination is required prior to initiation of PrEP. However, HCPs should recognize and further investigate fever, rash, and cervical adenopathy as potential clinical signs of acute HIV infection. These findings are especially relevant if a patient reports having experienced viral infection symptoms such as fatigue, myalgia, headache, night sweats, and diarrhea in the prior 4 weeks.

Laboratory tests for prospective PrEP recipients include HIV testing, hepatitis B virus (HBV) screening, and renal function tests. HIV testing is done within 1 week of initiating PrEP. If the test result is positive, PrEP is not initiated because it does not provide adequate therapy for HIV; in addition, there is some concern about the development of drug resistance. If the test result is indeterminate, PrEP initiation is postponed until further testing determines HIV status.

Both TDF and FTC suppress replication of HBV as well as HIV, so the PrEP intervention may offer an additional benefit if a patient has active HBV infection. Reactivation of HBV infection may occur if PrEP is discontinued or taken inconsistently. If screening indicates that a patient is not infected by HBV or immune to it, HBV vaccination is recommended. Patients who have significantly reduced renal function should not take PrEP.

Pregnancy testing is done if indicated. Although data regarding the use of TDF/FTC in terms of fetal health and growth are limited, the FDA has approved PrEP use during pregnancy. No evidence exists of harm to fetuses exposed to TDF or FTC when used for treatment of HIV during pregnancy.6


PrEP must be taken on a consistent basis for maximum prevention benefit. PrEP is safe and effective but may cause a loss of appetite, mild gastric upset, or mild headaches initially. HCPs need to counsel patients about these side effects and inform them about over-the-counter drugs that may lessen these effects. Patients are asked to contact their HCP if the side effects do not subside. PrEP reaches maximum intracellular concentrations in about 20 days; therefore, patients should be advised that effectiveness is not immediate.

All other medications that patients are taking should be reviewed. Drug interaction data are available for TDF, but not for FTC. TDF has no significant effect on oral contraceptive hormone levels. Serum concentrations of some drugs (e.g., acyclovir, valacyclovir, aminoglycosides) or of TDF may be increased when these agents are combined.6

Regardless of whether or not a patient decides to take PrEP, HCPs and patients need to discuss other ways to reduce HIV infection risk (e.g., limiting the number of sexual partners, always using a condom). For some individuals, multi-session behavioral counseling may be required. Women who have the potential to become pregnant should receive counseling and provision of contraception if they do not want to become pregnant, and pre-conception counseling if they are considering a pregnancy. Patients who report substance abuse should receive referrals for appropriate treatment.

Patients should receive information on the signs and symptoms of acute HIV infection and should be advised to contact their HCP if these occur. In addition, those patients who are taking PrEP need to know that they should not discontinue the regimen without first discussing it with their HCP.

Patients taking PrEP are seen for follow-up at least every 3 months. At these visits, HCPs need to assess them for side effects, medication adherence, and HIV risk behaviors, as well as for signs and symptoms of acute HIV infection. HIV testing is repeated at each follow-up visit. A pregnancy test is performed for women who could become pregnant, and STI tests are done as indicated. Renal function tests are conducted every 6 months.

These follow-up visits provide an important opportunity to reinforce the need for consistent medication use and to support HIV risk-reduction behaviors. Discussion about continuing PrEP should take into account personal preference, change in risk profile, and ability to adhere to the daily dosing regimen. PrEP must be discontinued if a patient’s HIV test result is positive or if renal function is significantly impaired.


PrEP is a safe and effective pharmacologic intervention for women and men at high risk for HIV infection. HCPs have the opportunity to improve the lives of their patients and provide preventive care in the fight against HIV.

Lorraine Byrnes is Associate Professor at Hunter Bellevue School of Nursing, Hunter College, City University of New York, in New York City. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


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1. Centers for Disease Control and Prevention. CDC Vital Signs: New Hope for Stopping HIV. 2011.

2. Centers for Disease Control and Prevention. Fact Sheets: HIV/AIDS. 2013.

3. Centers for Disease Control and Prevention. HIV among Pregnant Women, Infants, and Children. 2015.

4. Sanders LB. Sexual behaviors and practices of women living with HIV in relation to pregnancy. J Assoc Nurses AIDS Care. 2009;20(1):62-68.

5. Sullivan K, Voss J, Li D. Female disclosure of HIV-positive serostatus to sex partners: a two-city study. Womens Health. 2010;50(6):506-526.

6. Centers for Disease Control and Prevention. Pre-Exposure Prophylaxis (PrEP). 2015.

7. Bernstein KT, Liu KL, Begier EM, et al. Same sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches. Arch Intern Med. 2008;168(13):1458-1464.

8. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History.

Not your mother’s WHNP guidelines

In the past, and even continuing into the present day, low-income women and children have encountered barriers in accessing healthcare. Fifty years ago, to help overcome these barriers, Loretta Ford, RN, and Henry Silver, MD, created the first nurse practitioner (NP) program at the University of Colorado; it was there, in 1965, that the NP role first emerged. This certificate education program, which built on the knowledge and skills of the public health nurse, prepared pediatric NPs (PNPs) to work in collaboration with physicians to care for underserved low-income pediatric populations.1

Inspired by the success of the PNP role, innovative nurses and physicians expanded the registered nurse role to include provision of care to underserved pregnant women. The evolution of the obstetric/gynecologic (OB/GYN) nurse’s role from maternity care to women’s healthcare throughout the lifespan, in what would become an advanced practice role, drove the need for uniform standards for education and practice.

To serve this need, the first guidelines, Obstetric-Gynecologic Women’s Health Nurse Practitioner: Role Definition, Role Description, and Guidelines for Educational Development, were published in 1979. These guidelines, updated in 1984 and 1990, remained in effect until 1996. Reflecting the spirit of cooperation inherent in women’s healthcare, the National Association of Nurse Practitioners in Women’s Health (NPWH) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) collaborated to develop and publish Women’s Health Nurse Practitioner: Guidelines for Practice and Education (hereafter called the Guidelines) in 1996. This 4th edition and two subsequent editions have delineated the emerging skills and competencies necessary for WHNPs to meet women’s healthcare needs.

The 7th edition of the Guidelines

The evolving national healthcare scene, the changing policies/guidelines affecting NP education and practice, and multiple emerging population health concerns have driven the need for periodic comprehensive reviews and revisions of the Guidelines. The 7th edition of the Guidelines provides a clarification of the WHNP role, without expanding the role.1 This edition articulates and differentiates the women’s health population focus by:

• Strengthening language regarding the WHNP’s role in primary care, and;
• Describing key areas of specialty practice consistent with WHNP education and identified competencies, including high-risk pregnancy, infertility, urogynecology, gynecologic oncology, menopause, and gynecologic office-based procedures.

The revision process for the Guidelines

In April 2013, a joint NPWH/AWHONN task force of WHNPs, with equal representation from the two associations, was convened to revise the Guidelines under the leadership of a chairperson with dual NPWH/AWHONN membership. Task force members were selected for their knowledge and experience in women’s health, nursing education, and clinical practice. In addition, the National Certification Corporation (NCC), the only nationally recognized certifying body for WHNPs, was invited to name a representative to participate on the task force.

Over the course of 18 months, the task force took steps to ensure that the updated document would reflect not only current WHNP practice but also the an­ticipated WHNP role of the future. First, the task force reviewed key documents guiding NP practice and education, as well as women’s healthcare, to ensure alignment. Upon completion of the draft document, key WHNP stakeholders were asked to review the document and provide comments to strengthen it. Following this review, NPs in other population foci, along with representatives from the American Association of Nurse Practitioners, the Gerontological Advanced Practice Nurses Association, the National Association of Pediatric Nurse Practitioners, and the National Organization of Nurse Practitioner Faculties (NONPF), participated in a second review. The second review hinged on these questions:

• Do these Guidelines align with key NP guidance documents regarding NP practice and education?
• When, and for what services, would you refer to a WHNP?
• Is the reason that you would refer to a WHNP adequately reflected in the Guidelines document?

All comments were reviewed by the task force and incorporated into the document.

During development of the Guidelines, all NCC-certified WHNPs were invited to complete a survey regarding their current practice, including work setting, skills utilized in practice, content learned in WHNP programs, and content and skill building in the workplace. Survey results indicated that approximately 82% of WHNPs practice in primary care settings, including OB/GYN and family practice offices, family planning clinics, governmental health departments, college health departments, sexually transmitted disease clinics, and prenatal care clinics.2 The other respondents reported working in specialty and sub­specialty practices such as gynecologic oncology, urogynecology, infertility, and maternal–fetal medicine. The survey results, combined with input from non-WHNP colleagues, underscored the broad reach of WHNP practice.

Revisions include alignment with Licensure, Accreditation, Certification & Education (LACE), NONPF NP Core Competencies, American Association of Colleges of Nursing MSN and DNP Essentials, other NP population focus guidelines, and the Institute of Medicine’s (IOM’s) The Future of Nursing: Leading Change, Advancing Health, as well as key documents pertaining to women’s health.

Key differences from prior editions

The 7th edition of the Guidelines represents a comprehensive view of WHNP practice today, emphasizing a lifespan approach to care extending from menarche through senescence. Written within the framework of the LACE consensus model for advanced practice nursing and consistent with the IOM’s groundbreaking report on the future of nursing, the Guidelines, compared with earlier editions, reflect a broader description of WHNP assessment, diagnostic, and treatment activities within the context of general competencies, gynecology, male sexual and reproductive healthcare (SRH), nongynecologic primary care, and obstetrics. WHNP education concepts reflect the practice competencies necessary to partner with women to meet their healthcare needs. The Guidelines elaborate on the WHNP role in male SRH, take a gender-focused approach to women’s health concerns, and recognize WHNPs’ expertise in performing selected office-based procedures. In further clarifying the components of WHNP practice, the Guidelines reflect WHNPs’ expertise and value as care providers, leaders, and consultants in the areas of women’s health and male SRH.


The writing team and reviewers for the Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition spent countless hours bringing this final document to fruition. Guideline development and publication by NPWH and AWHONN included a review of interdisciplinary documents and input from family NP, adult-gerontology NP, PNP, and faculty colleagues in addition to a team of WHNPs. This multifaceted approach exemplifies the collaborative nature of women’s healthcare providers as partners with their female patients in promoting health, preventing disease, and optimizing health outcomes.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri-St. Louis; a consultant at Health Policy Advantage, LLC, in St. Louis, Missouri; and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH). She can be reached at 314-629-2372 or at

1. National Association of Nurse Practitioners in Women’s Health/ Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.

2. Kelsey B and the National Association of Nurse Practitioners in Women’s Health. NPWH Women’s Health NP Role and Competencies Survey. 2013. Unpublished data.